PNEUMONIA

Saadia Sajjad.Roll no. 460

Learning ObjectivesTo describe the presentation of pediatric

pneumoniaTo outline the management of pediatric

pneumoniaTo summarize the complications of pediatric

pneumoniaTo highlight interventions to prevent and protect

against pediatric pneumonia

What is Pneumonia?

Pneumonia: an inflammation of the lung parenchyma and is associated with consolidation of alveloar spaces.The term “Lower Respiratory Tract Infection” (LRTI) may include pneumonia, bronchiolitis and/or Bronchitis.

Types:

Broncho-PneumoniaLobar Pneumonia.

EpidemiologyPneumonia kills more children under the age of five than any other illness in every region of the world.It is estimated that of the 9 million child deaths in 2007, 20% (1.8 million) were due to pneumoniaApproximately 98% of children who die of pneumonia are in developing countries.

Pneumonia - Common Pathogens

Age Group Common Pathogens (in Order of Frequency)

Newborn E.ColiGroup B StreptococciStaph. AureusKlebsiellaPseudomonas

1-3 months Chlamydia trachomatisRespiratory Syncytial virusOther respiratory viruses

3-12 months Respiratory Syncytial virusStaph AureusStreptococcus pneumoniaeHaemophilus influenzaeChlamydia trachomatisMycoplasma pneumoniae

Age Group Common Pathogens (in Order of Frequency)

2-5 years Respiratory VirusesStreptococcus pneumoniaeHaemophilus influenzaeMycoplasma pneumoniaeChlamydia pneumoniae

5-18 years Mycoplasma pneumoniaeStreptococcus pneumoniaeChlamydia pneumoniaeHaemophilus influenzaeInfluenza viruses A and BAdenovirusesOther respiratory viruses

AgePresence of cough, difficulty breathing, shortness of breath, chest painFeverRecent upper respiratory tract infectionsAssociated symptoms Duration of symptoms Immunizations status

TB exposureMaternal Chlamydia, Group B Strep status during pregnancyChoking episodesPrevious episodesPrevious antibiotics

Pneumonia History

Pneumonia HistoryTravel historyDay care attendanceAnimal exposureIll contacts

Past MedicationsBirth HistoryMedicationsAllergiesImmunization StatusHome EnvironmentSocial HistoryFamily History

Recognition of Signs of Pneumonia

Tachypnea is the most sensitive and specific sign of pneumonia

Age Respiratory Rate(breaths/min)

Indication of severe infection (breaths/min)

< 2 months > 60 >70

2 to 12 months > 50

12 months to 5 years

> 40 >50

Greater than 5 years

> 20

Other signs of pneumonia -Indrawing

out---breathing---in Lower chest wall indrawing: with

inspiration, the lower chest wall moves in

Other signs of pneumonia - Nasal Flare

Nasal flaring: with inspiration, the side of the

nostrils flares outwards

Diagnosis in Community Setting

SIGNS Classify AS Treatment

•Tachypnea•Lower chest wall indrawing•Stridor in a calm child

Severe Pneumonia •Refer urgently to hospital for injectable antibiotics and oxygen if needed•Give first dose of appropriate antibiotic

•Tachypnea Non-Severe Pneumonia

•Prescribe appropriate antibiotic•Advise caregiver of other supportive measure and when to return for a follow-up visit

•Normal respiratory rate Other respiratory illness

•Advise caregiver on other supportive measures and when to return if symptoms persist or worsen

Does this infant child have pneumonia?

The Rational Clinical Exam, Journal of the American Medical Association

Observation of the infant is the most important part of the examination – does the child look sick?

Respiratory rate should be calculated over two thirty second intervals, or one minute due to moment to moment variability.

Auscultation is unreliable when examining infants. In older children, examination will show diminished

movements on affected side, dullness on percusion, bronchial breathing. Moist rales on resolution.

Pneumonia Severity Assessment

Mild Severe

Infants Temperature <38.5 CRR < 50 breaths/minMild recessionTaking full feeds

Temperature >38.5 CRR > 70 breaths/minModerate to severe recessionNasal FlaringCyanosisIntermittent ApneaGrunting RespirationsNot feeding

Older Children Temperature <38.5 CRR < 50 breaths/minMild breathlessnessNo vomiting

Temperature >38.5 CRR > 50 breaths/minSevere difficulty in breathingNasal FlaringCyanosisGrunting RespirationsSigns of dehydration

Indications for Admission - IMCI

All Children with Very Severe Pneumonia need admission

Very Severe Pneumonia includes any of: Cough or difficult breathing plus at least one of the

following: Central cyanosis Inability to breastfeed or drink, or vomiting everything Convulsions, lethargy or unconsciousness Severe respiratory distress (e.g. head nodding) Some or all of the other signs of pneumonia (tachypnea,

grunting, nasal flare, indrawing, changes in auscultation)

Age Group Indications for Admission to Hospital

Infants Oxygen Saturation <= 92%, cyanosisRR > 70 breaths /minDifficulty in breathingIntermittent apnea, gruntingNot feedingFamily not able to provide appropriate observation or supervision

Older Children Oxygen Saturation <= 92%, cyanosisRR > 50 breaths /minDifficulty in breathingGruntingSigns of DehydrationFamily not able to provide appropriate observation or supervision

Indications for Admission

Investigations

Chest X-rayWBC Count

Blood CultureGram Staining of expectorated sputum

Pleural fluid examinationASO titre

Tuberculin skin test

Chest X-ray

Consider if available and: Infection is severe Diagnosis is otherwise inconclusive To exclude other causes of shortness of

breath (e.g.. foreign body, heart failure) To look for complications of pneumonia

unresponsive to treatment (e.g.. empyema, pleural effusion)

To exclude pneumonia in an infant less than three months with fever

Complications of Pneumonia

Pleural effusionEmpyemaParapneumonic effusions Lung abscessPneumothoraxPneumatoceleDelayed ResolutionRespiratory FailureMetastatic Septic lesionsActivation of latent TB

Treatment – IMCI Guidelines

Antibiotic therapyChloramphenicol (25 mg/kg IM or IV every 8 hours) until the child has improved. Then continue orally 3 x/ day for a total course of 10 days. If chloramphenicol is not available, give benzylpenicillin (50 000 units/kg IM or IV every 6 hours) and gentamicin (7.5 mg/kg IM once a day) for 10 days.

If the child does not improve within 48 hours, Switch to gentamicin (7.5 mg/kg IM once a day) and cloxacillin (50 mg/kg IM or IV every 6 hours), for staphylococcal pneumonia.When the child improves, continue cloxacillin (or dicloxacillin) orally 4 times a day for a total course of 3 weeks.

Supportive Treatment – IMCI Guidelines

Oxygen therapyIf fever (=>39oC) causing distress, give paracetamolIf wheeze is present, give a rapid-acting broncho-dilatorGentle suction any thick secretions in the throat, which the child cannot clear.

Ensure that the child receives daily maintenance fluids for the child's age - avoid overhydration. Encourage breastfeeding and oral fluids. If the child cannot drink, insert a NG tube and give maintenance fluids in frequent small amounts. If the child is taking fluids adequately by mouth, do not use a NG tube as it increases the risk of aspiration pneumonia. If oxygen is given by nasopharyngeal catheter at the same time as NG fluids, pass both tubes through the same nostril.Encourage the child to eat as soon as food can be taken.

Prevention Strategies

Vaccination against measles, Streptococcus pneumoniae, and Haemophilus influenzae type bPublic awarenessInterventions to protect against pneumoniaZinc supplementationPrevention of HIV in ChildrenCo-trimoxazole prophylaxis for HIV-infected children

Prevention - Vaccination

Haemophilus Influenzae type B (Hib) vaccine Pneumococcal conjugate vaccinePneumonia is a possible complication of Measles, thus prevention of measles would decrease the incidence of pneumonia.

A Complicated Case from Gambia

Based on a true story

Case – Chief Complaints

A 1 year old child is brought in for fever, cough, lethargy, and mild respiratory distress increasing over 2 weeks.

You take a focused medical history from the child’s mother.

What are the patient’s vital signs?

Vital signs are as follows: Temperature 38.7, Pulse 150, Respiratory Rate 54, Oxygen Saturation 94% on room air.

What is observed on physical examination?

On observation the patient clearly appears septic. Mild respiratory distress is present. Skin is mottled.

What is the likely diagnosis?

What other physical examination information is immediately relevant to forming an initial treatment plan for this patient?

Weight and Hydration Status

The child is malnourished

The patient appears mildly dehydrated.

What interventions should be started?

Initial Treatment

A presumptive diagnosis of pneumonia is made. The patient is admitted to the hospital and started on broad spectrum IV antibiotics and appropriate hydration and re-feeding.

The patient does not seem to improve initially.

What is your differential diagnosis?

Differential Diagnosis includes:

Pneumonia +/- complications (e.g. Empyema)Pneumonia in a patient with HIVTuberculosis

What is the first investigation you would order? (assume first choice investigation is available).

The chest x-ray reveals a right sided lobar infiltrate.

What is the clinical correlation?

The patient begins to improve clinically.Fever, cough and respiratory distress resolve.

However, over the next few weeks of appropriate re-feeding, the patient fails to gain weight despite remaining on broad spectrum antibiotics.

What other investigations would you Consider?

HIV test – negativeTB skin test – unreactiveSputum culture – unable to induce sputum

*Important Note: The mother is no longer with the patient. Another family member reports that she is sick with a cough, fever, and weight loss.*

What other courses of treatment should be considered in this case?

The patient was started on treatment for tuberculosis and began to improve and gain weight.

This patient did well. The mother and other close contacts were also treated for tuberculosis.

This patient’s x-ray revealed a lobar infiltrate.Pneumonia commonly presents as a lobar infiltrate. Reactivation of TB tends to be apical, but acute TB can present as a lobar infiltrate.TB should remain as a differential diagnosis and be reconsidered if there is a poor response to treatment, or a possible exposure history.

Summary

1)What is the most sensitive and specific sign of

pneumonia in children?A. Difficulty breathingB. FeverC. TachypneaD. Tachycardia

2)Which of the following immunizationeffectively reduce pneumonia mortality inchildren?A. Haemophilus influenzae b VaccineB. Pneumococcal Conjugate VaccineC. Measles VaccineD. All of the above

3)Which of the following bacterial pathogens most commonly cause bacterial infections in neonates?

A. E. coli, S. pneumoniae, H. influenzaB. Group B Streptococci, E. coli, L. monocytogenesC. Group B Streptococci, H. influenzae, E. coliD. S. pneumoniae, H. influenzae, N. meningitidesE. S. pneumoniae, N. meningitides, L. monocytogenes

4)Which of the following pneumonia-causing pathogens is the most common cause of pneumonia in immunized children?

A. Bordetella pertussisB. Group A streptococcusC. Haemophilus influenzae type BD. InfluenzaE. Streptococcus pneumoniae

5) Which organism is NOT likely to cause pneumonia with parapneumonic effusion or empyema?

A. Group A streptococcusB. Mycoplasma pneumoniaeC. Staphylococcus aureusD. Streptococcus pneumonia

6)Which organism is the most likely organism to cause pneumonia in a 2 year old child? A. InfluenzaB. MetapneumovirusC. Mycoplasma pneumoniaeD. Streptococcus pneumoniaeE. Respiratory syncytial virus

7) Which combination of signs and symptoms is typical of community acquired pneumonia?

A. Clear lung exam, fever, coughB. Crackles, normal respiratory rate, coughC. Tachypnea, cough, feverD. Tachypnea, vomiting and rashE. Wheezes, retractions, nasal flaring

8)Which patient would be the most likely to have bacterial Pneumonia?

A. 1 year old boy with 1 day history of low grade fever, barky cough, RR of 30 in OctoberB. 3 year old male with 3 day history of fever, rhinorrhea, and faint rash in MayC. 4 year old male with 5 day history of fever, cough, retractions and fatigue in FebruaryD. 5 year old female with asthma, and now 1-2 day history of fever and wheezing in MarchE. 8 year old female with 3 day history of fever, cough, sore throat and myalgias in January