pneumonia report

8/12/2019 Pneumonia Report

1/66


2/66

+VIRAL PNEUMONIA

preceded by several days of symptoms of an upper

respiratory tract infection, typically rhinitis and cough

Low Grade Fever: usually present; temperatures are

generally lower than in bacterial pneumonia.

Tachypnea: most consistent clinical manifestation of

pneumonia


3/66

+VIRAL PNEUMONIA

Increased work of breathing: accompanied by intercostal,

subcostal, and suprasternal retractions, nasal flaring, and use

of accessory muscles

Cyanosis and respiratory fatigue: for severe infection

especially in infants


4/66

+VIRAL PNEUMONIA

Crackles and wheezing: often difficult to localize the source

of these adventitious sounds in very young children with

hyperresonant chests


5/66

+BACTERIAL PNEUMONIA

Sudden onset of chills in adults or older children

followed by a high fever, cough, and chest pain

In older children and adolescents: brief URTIfollowed by the abrupt chills and high fever

accompanied by:

drowsiness with intermittent periods of

restlessness rapid respirations

dry, hacking, unproductive cough

anxiety

occasionally, delirium


6/66

+BACTERIAL PNEUMONIA

Circumoral cyanosis may be

observed

Splinting: noted on the affected sideto minimize pleuritic pain and

improve ventilation. They may lie on

their side with their knees drawn upto their chest.


7/66

+PNEUMOCOCCAL PNEUMONIA IN

INFANTS

Prodrome of URTI and decreased appetite

Sudden onset of fever

Restlessness, apprehension

Respiratory distress

GI manifestations: Vomiting, anorexia, diarrhea and

abdominal distention


8/66

+PHYSICAL EXAMINATION

Depends on the stage of pneumonia

Early stage:

diminished breath sounds scattered crackles

rhonchi


9/66


Dullness on percussion and decreased breath sounds due

to consolidation or complications of pneumonia such as

effusion, empyema, or pyopneumothorax

Lag in respiratory excursion: occurs on the affected side

Abdominal distention: due to gastric dilation from

swallowed air or ileus


10/66


Abdominal pain: common in lower lobe pneumonia

Enlarged liver: due to downward displacement of the

diaphragm secondary to hyperinflation of the lungs or

superimposed congestive heart failure

Nuchal rigidity: especially with involvement of the right

upper lobe or if with meningitis or hematogenous spread of

disease


11/66

+PCAP CLASSIFICATION

CLASSIFICATIO

N PROVIDED

BY

Philippine Academy

of Pediatric

Pulmonologists

Philippine Health

Insurance Corp

World Health

Organization

pCAP A or B

---

Nonsevere

pCAP C

Pneumonia I

Severe

pCAP D

Pneumonia II

Very severe

Variable

CLINICAL

1. Dehydration None Mild Moderate Severe

2. Malnutrition None Moderate Severe

3. Pallor None Present Present


12/66


4. Respiratory Rate

3-12months

1-5 years

>5years

50/min to

60/min

40/min to

50/min

30/min to40/min

>60/min to

70

>50/min

>35/min

>70/min

>50/min

>35/min

5. Signs of

respiratory failure

a. Retraction

b. Head

bobbingc. Cyanosis

d. Grunting

e. Apnea

f. Sensorium

None

None

NoneNone

None

None

IC/Subcostal

Present

PresentNone

None

Irritable

Supraclaviclular/

SC

PresentPresent

Present

Present

Lethargic/Stupor

ous/ Comatose


13/66


DIAGNOSTIC AID

AT SITE-OF-CARE

pCAP A or B

---

Nonsevere

pCAP C

Pneumonia

I

Severe

pCAP D

Pneumonia II

Very severe

1. Chest xray

findings of any ofthe following:

effusion; abscess;

air leak; lobar

consolidation

None Present Present

2. Oxygensaturation at room

air using pulse

oximetry

95%


14/66

+ATYPICAL PNEUMONIA

MANIFESTATIONS

Cough and copious purulent sputum production


15/66

+ATYPICAL PNEUMONIA

PHYSICAL EXAM

Crackles localized in the affected area

Wheezing and digital clubbing

In severe cases: dyspnea and hypoxemia


16/66

+

DIAGNOSTIC TESTS*Recommendations from PAPP*


17/66

+DIAGNOSTIC TESTS

for pCAP A or B

Chest Radiograph

May be requested to rule outpneumonia-related complications

or pulmonary conditions

simulating pneumonia


18/66

+DIAGNOSTIC TESTS

for pCAP A or B

Chest Radiograph

Should not be routinely requested

to predict end-of-treatment clinical

outcome


19/66

+

To determine appropriateness of

antibiotic usage (but not routinelyrequested):

DIAGNOSTIC TESTS

for pCAP A or B

Chest Xray

Completeblood count

C-reactive

protein


20/66

+

To determine appropriateness of

antibiotic usage (but not routinelyrequested):

DIAGNOSTIC TESTS

for pCAP A or B

Erythrocyte

sedimentation

rate

Procalcitonin

Blood culture


21/66

+

SHOULD BE DONE

To determine the etiology: Gram

stain and/or culture and sensitivity

of pleural fluid when available

DIAGNOSTIC TESTS

for pCAP C or D


22/66

+

SHOULD BE DONE

To assess gas exchange: Oxygen

saturation using pulse oximetry,

Arterial blood gas

DIAGNOSTIC TESTS

for pCAP C or D


23/66

+

MAY BE DONE

Chest x-ray PA-lateral: to confirmclinical suspicion of multilobar

consolidation, lung abscess,

pleural effusion, pneumothorax orpneumomediastinum

DIAGNOSTIC TESTS

for pCAP C or D


24/66

+

MAY BE DONE

To determine appropriateness ofantibiotic usage: C-reactive

protein, Procalcitonin, Chest x-ray

PA-lateral, White Blood Cell count,

Gram stain of sputum or

nasopharyngeal aspirate

DIAGNOSTIC TESTS

for pCAP C or D


25/66

+

MAY BE DONE

To determine etiology: Sputum

culture and sensitivity, Blood

culture and sensitivity

DIAGNOSTIC TESTS

for pCAP C or D


26/66

+

MAY BE DONETo predict clinical outcome: Chest

x-ray PA-lateral, Pulse oximetry

DIAGNOSTIC TESTS

for pCAP C or D


27/66

+

MAY BE DONE

To determine the presence oftuberculosis if clinically suspected:Mantoux test (PPD 5-TU), Sputumsmear for aid fast bacilli

DIAGNOSTIC TESTS

for pCAP C or D


28/66

+

MAY BE DONE

To determine metabolic

derangement: Serum electrolytes,

Serum glucose

DIAGNOSTIC TESTS

for pCAP C or D


29/66

+

MANAGEMENT OFPNEUMONIA

*Recommendations from PAPP*


30/66

+WHEN IS ANTIBIOTIC

RECOMMENDED?

For pCAP A or B,

>2 y/o

with high grade fever without wheeze


31/66

+WHEN IS ANTIBIOTIC

RECOMMENDED?

For pCAP C,

alveolar consolidation on chest x-raywith any of the following:

Elevated serum CRP, PCT or WBC

High grade fever without wheeze

> 2 y/o


32/66

+WHEN IS ANTIBIOTIC

RECOMMENDED?

For pCAP D,a specialist should be consulted.


33/66

+WHAT EMPIRIC TREATMENT SHOULD

BE ADMINISTERED IF A BACTERIAL

ETIOLOGY IS STRONGLY CONSIDERED?

For pCAP A or B without previous

antibiotic,

DOC:AMOXICILLIN

[40-50 mg/kg/day, maximum dose of 1500

mg/day in 3 divided doses for at most 7 days]


34/66




Alternative Drugs for pCAP A or B

without previous antibiotic,

AZITHROMYCIN

[10 mg/kg/day OD for 3 days or 10mg/kg/day at

day 1 then 5 mg/kg/day for days 2 to 5,maximum dose of 500 mg/day]


35/66


36/66




For pCAP C, without previous

antibiotic,

Completely immunized againstHib

DOC: PENICILLIN G [100,000

units/kg/day in 4 divided doses]


37/66





antibiotic,

Incomplete/unknown immunization status

DOC:AMPICILLIN [100 mg/kg/day in

4 divided doses]


38/66





antibiotic (>15 y/o),

parenteral non-antipseudomonal -

lactam + extended macrolide

parenteral non-antipseudomonal -lactam + respiratory fluoroquinolones


39/66




For pCAP C, without previous antibiotic,

and who can tolerate oral feeding and does

not require oxygen support,

AMOXICILLIN

[40-50 mg/kg/day, maximum dose of 1500 mg/dayin 3 divided doses for at most 7 days]


40/66




For a patient classified as pCAP Cwho

is severely malnourished or

suspected to have MRSA, or classified

as pCAP D,

referral to a specialist


41/66




For a patient who has been

established to haveMycobacterium

tuberculosis infection or disease,

antituberculous drugs


42/66

+WHAT TREATMENT SHOULD BE

INITIALLY GIVEN IF A VIRAL ETIOLOGY

IS STRONGLY CONSIDERED?

DOC: OSELTAMIVIR

30 mg BID for 15 kg body weight,45 mg BID for >15-23 kg,

60 mg BID for >23-40 kg, and

75 mg BID for >40 kg

for laboratory confirmed, or clinically

suspected cases of influenza


43/66

+WHAT TREATMENT SHOULD BE

INITIALLY GIVEN IF A VIRAL ETIOLOGY

IS STRONGLY CONSIDERED?

The use of immunomodulators for

the treatment of viral pneumonia isNOT recommended

Ancillary treatment


44/66

+WHEN CAN A PATIENT BE CONSIDERED

AS RESPONDING TO THE CURRENT

ANTIBIOTIC?

Decrease in respiratory signs and/or

defervescense within 72 hours afterinitiation of antibiotic are predictors of

favorable response.


45/66

+WHEN CAN A PATIENT BE CONSIDERED

AS RESPONDING TO THE CURRENT

ANTIBIOTIC?

If clinically responding, further

diagnostic aids to assess responsesuch as CXR, CRP AND CBC should

not be routinely requested.


46/66

+WHAT SHOULD BE DONE IF A PATIENT

IS NOT RESPONDING TO CURRENT

ANTIBIOTIC THERAPY?

If an outpatient classified as either

pCAP A or pCAP B, consider any ofthe following:

Other diagnosis.

Coexisting illness. Conditions simulating pneumonia.


47/66



ANTIBIOTIC THERAPY?

If an outpatient classified as either pCAP A

or pCAP B, consider any of the following: May add an oral macrolide if atypical

organism is highly considered.

May change to another antibiotic if microbial

resistance is highly considered.

+


48/66



ANTIBIOTIC THERAPY?

If an outpatient classified as pCAP C,

consider any of the following:

Other diagnosis.

Coexisting illness.

Conditions simulating pneumonia.

+


49/66



ANTIBIOTIC THERAPY?

If an outpatient classified as pCAP C,

consider any of the following: May add an oral macrolide if atypical

organism is highly considered.

May change to another antibiotic if microbial

resistance is highly considered.

+


50/66



ANTIBIOTIC THERAPY?

If an outpatient classified as either

pCAP C, consider any of the following:

May refer to a specialist.

+


51/66



ANTIBIOTIC THERAPY?

If an inpatient classified as pCAP D,

immediate consultation with a specialist

should be done.

+


52/66

+WHEN CAN SWITCH THERAPY IN

BACTERIAL PNEUMONIA BE STARTED?

For pCAP C,

recommended in a patient who should

fulfill all of the following: Responsive to current antibiotic therapy

Tolerance to feeding and without vomiting

or diarrhea


53/66

+


54/66



For pCAP C,

switch therapy from three [3] days of

parenteral ampicillin to:Amoxicillin [40-50 mg/kg/day for 4 days]

+


55/66



For pCAP D,

referral to a specialist should be considered

+


56/66

+WHAT ANCILLARY

TREATMENT CAN BE GIVEN?

For pCAP A or B,

cough preparation, elemental zinc, vitamin

A, vitamin D, probiotic and chestphysiotherapy should not be routinely

given during the course of illness


57/66

+


58/66

+WHAT ANCILLARY


For pCAP C,

oxygen and hydration should be

administered whenever applicable. Oxygen delivery through nasal catheter

is as effective as using nasal prong

+


59/66

+WHAT ANCILLARY


For pCAP C,

a bronchodilator may be administered

only in the presence of wheezing. Steroid may be added to a

bronchodilator

+


60/66

+WHAT ANCILLARY


For pCAP C,

a probiotic may be administered

cough preparation, elemental zinc, vitaminA, vitamin D and chest physiotherapy

should not be routinely given during the

course of illness.

+


61/66

+WHAT ANCILLARY


For pCAP D, referral to a specialist

should be considered

+


62/66

+HOW CAN PNEUMONIA BE PREVENTED?

The following should be given to

prevent pneumonia:

Vaccine against Streptococcus pneumonia (conjugate

type)Influenza

Diphtheria, Pertussis, Rubella, Varicella,

Haemophilus Influenzae typeb

+


63/66


The following should be given to

prevent pneumonia:

Elemental zinc for ages 2 to 59 months tobe given for 4 to 6 months

+


64/66


The following may be given to

prevent pneumonia:

Vitamin D3 supplementation

+


65/66


The following should not be given to

prevent pneumonia:

Vitamin A

+


66/66

+

THANK YOU!

pneumonia report

Documents