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Pneumonia in children: etiology, diagnosis and treatment

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Title: Pneumonia in children: etiology, diagnosis and treatment


1
Pneumonia in children etiology, diagnosis and
treatment
  • Prof. Galyna Pavlyshyn

2
Plan
  • 1. Discuss the common causes of pneumonia in
    children of various ages
  • 2. Classifications of pneumonia in children
  • 3. Clinical manifestations of pneumonia in
    children
  • 4. Outline the approach to the diagnosis of
    pneumonia in children
  • 5. Select appropriate antibiotic therapy for a
    child with pneumonia based on childs age and
    severity of illness
  • 6. Discuss the diagnosis and management of common
    complications of pneumonia

3
Pneumonia in pediatric patients
  • Basic facts
  • Childhood pneumonia remains an important cause
    of morbidity and mortality in developing world
    4 million deaths annually in the developing
    world
  • About 20 of all deaths in children under 5 ys
  • are due to Acute Lower Respiratory Infections
  • (ALRIs - pneumonia, bronchiolitis and
    bronchitis)
  • 90 of these deaths are due to pneumonia.
  • Annual incidence in the U.S. in
  • Children under 5 yo is 40 cases/1000
  • Children age 12-15 7 cases/1000
  • Mortality rate lt 1/1.000 in the U.S.

4
Disease Pattern
Causes of 10.5 million deaths among children lt
5 in developing countries
One in every two child deaths in developing
countries are due to just five infections
diseases and malnutrition
5
Pneumonia in pediatric patients
  • Early recognition and prompt treatment of
    pneumonia is life saving.
  • Low birth weight, malnourished and non-breastfed
    children and those living in overcrowded
    conditions are at higher risk of getting
    pneumonia.
  • These children are also at a higher risk of
    death from pneumonia.
  • About one-half of all children lt 5 yo with
    community-acquired pneumonia will require
    hospitalization

6
What is pneumonia (PNA)?
  • Has been defined as inflammation of lung
    parenchyma the portion of the lower respiratory
    tract consisting of the respiratory bronchioles,
    alveolar ducts, alveolar sacs, alveoli

7
Pneumonia
  • is an acute infectious inflammatory disease of
    various nature with involving of lower
    respiratory tract into pathologic process and
    intra-alveolar inflammatory exudation

8
Possible causes of Pneumonia
  • Bacterial streptococcus pneumonia, mycoplasma
    (atypical)
  • And any other
  • Viral RSV (respiratory syncytial virus)
  • In children younger than 2 years, viral
    infections were found in 80 of children with
    pneumonia in children older than 5 years, viral
    infections were detected only 37 of the time.
  • Aspiration
  • Depends on patient age, immune status, and
    location (hospital vs. community)

9
Etiology Age-dependent
  • Neonates
  • Group B Streptococci
  • GN Enterics - Esherichia coli, Klebsiella
    pneumoniae,
  • Listeria monocytogenes
  • rare St. aureus
  • 2 w- 2mo
  • Chlamydia
  • Viruses
  • Str. Pneumoniae, St. aureus, H. influenzae

10
Children 2-6 mo
  • Esherichia coli, Klebsiella pneumoniae
  • Strep. Pneumoniae and Hemophylus influenzae type
    ß
  • Chlamydia pneumoniae
  • rare St. aureus

11
6 mo -6 yrs
  • Strep. Pneumoniae - 50
  • Viruses - RSV, parainfluenza, influenza,
    adenovirus, rhinovirus, coronavirus, herpesvirus,
    human metapneumovirus
  • Hemophylus inf. type ß - 10
  • Mycoplasma pneumoniae - 10
  • Rare St. aureus, Chlamydia pneumoniae

12
7-18 yrs
  • Strep. Pneumonie - 35-40
  • Atypical pneumonia (Mycoplasma pneumoniae) -
    30-50
  • Moraxella catarrhalis, Hemophylus influezae
  • Viruses
  • hospital (nosocomial)
  • Ps. aeruginosa,
  • rare Kl. pneumoniae, St. aureus, Proteus

13
Infectious causes of pneumonia
Age Causative organisms
Perinatal 4 weeks Group B haemolytic streptococci E. coli and other gram negative enteric organisms, Chlamydia trachomatis
Infancy Viruses - RSV Pneumococcus Haemophilus influenzae
14
Pathophysiology
  • Often, follows upper respiratory tract infection
  • Lower respiratory tract invaded by bacteria,
    viruses or other pathogens
  • Preceding viral illness (influenza,
    parainfluenza, RSV, adenovirus) leads to
    increased incidence of pneumococcal pneumonia
  • Bacterial pneumonias usually due to spread of
    invasive organisms from the nasopharynx by
    inhalation or aspiration
  • In children, bacteremia may lead to hematogenous
    seeding of the pulmonary parenchyma and result in
    pneumonia

15
Pathophysiology
  • Immune response leads to inflammation
  • Lung compliance is decreased, small airways
    become obstructed and air space collapse
    progresses
  • Ventilation-perfusion mismatch and decreased
    diffusion capacity leads to hypoxemia

16
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17
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18
CLASSIFICATION
  • ?? Etiology
  • ?? Morphological class
  • - Bronchopneumonia
  • - Lobar pneumonia
  • - Interstitial pneumonia
  • ?? Congenital pneumonia
  • Community acquired pneumonia
  • Nosocomial (hospital acquired) pneumonia
  • Aspiration pneumonia
  • ?? Non complicated pneumonia
  • complicated pneumonia

19
Morphological classification
20
Complications of pneumonia
  • Pulmonary
  • pleuritis, parapneumonic effusions and empyema,
  • pneumothorax,
  • failure of resolution ?
  • intra-alveolar scarring
  • ('carnification') ? permanent loss of
    ventilatory function of affected parts of lung

Pneumonia may be complicated by a pleuritis
21
Complications of pneumonia
  • Pulmonary abscess formation

A thick-walled lung abscess
22
Complications of pneumonia
  • Extrapulmonary
  • - infective endocarditis
  • - cerebral abscess / meningitis
  • - septic arthritis
  • - Infectious-toxic shock
  • - DIC (disseminated intravascular coagulation)
    syndrome

23
Significant Risk Factors
  • younger age (2-6 months),
  • low parental education,
  • smoking at home,
  • prematurity,
  • weaning from breast milk at lt 6 months,
  • anaemia
  • malnutrition
  • Trop Doct 2001 Jul31(3)139-41

24
Clinical case 1
  • 2 y old boy with complaints of fever, cough,
    vomiting, decreased appetite, chest pain,
  • right lower quadrant (RLQ) abdominal pain
  • T 39 C, chills, HR 140, RR 50
  • Retractions, signs of respiratory distress
  • Decreased breath sounds, rales, egophony,
    dullness to percussion rate
  • Symptoms since yesterday afternoon
  • Recent upper respiratory infection

25
Clinical case 1
  • What diagnoses are you considering?
  • What is the most likely diagnosis ?

26
Clinical case 1
  • Why?

27
Clinical case 1
  • What do you want to do?

28
jjj
29
jjj
right upper lobe pneumonia
30
Clinical case 1Physical examination
  • Tachypnea
  • Fever (T 39 C) nonspecific and not 100
    sensitive sign
  • Hypoxemia (pulse oximetry 5th vital sign)
  • Signs of respiratory distress (retractions,
    flaring, grunting)
  • X-ray infiltrates of lung tissue

31
Clinical case 1Physical examination
  • Tachypnea
  • Is the most sensitive and specific sign of
    radiographically confirmed pneumonia in children
  • Is the twice as frequent in children with
    radiographic pneumonia than in those without
  • Absence of tachypnea is the most valuable sign
    for excluding pneumonia

32
Clinical case 1
  • What definition of tachypnea
  • in children do you know?

33
Clinical case 1Physical examination
  • Definition of tachypnea
  • (World Health Org.)
  • lt 2 months gt 60 breaths per minute
  • 2-12 mos gt 50 breaths per minute
  • 1-5 y gt 40 breaths per minute
  • More 5 y gt 20 breath per minute

34
Clinical case 1Physical examination
  • Wheezing is rare with bacterial pneumonia more
    common in pneumonia caused by atypical bacterial
    or viruses
  • less than 5 of children with wheezing had
    pneumonia
  • only 2 of children without fever in the ED had
    pneumonia
  • hypoxemia (SpO2 lt 92 ) increased risk

35
Clinical case 2
  • Patient 1 yo is transferred to the ED after 1
    week of fever and respiratory symptoms
  • Child is in moderate respiratory distress, pale
    appearing and quiet
  • T 39.7 C, RR 65, HR 158, SpO2 91.
  • Marked decrease in breath sounds on right side,
    moderate subcostal and intercostal retractions.
  • Appears dehydrated

36
Clinical case 2
  • Signs and symptoms include failure to improve
    with treatment of pneumonia, persistent fever,
    malaise, chest pain, respiratory distress
  • Physical exam reveals decreased breath sounds,
    dullness to percussion and pleural rub
  • CXR shows white out of right chest
  • Decubitus X-rays suggest presence of loculations
  • Ultrasound detects early loculations and
    septations

37
  • This radiograph reveals progression of pneumonia
    into the right middle lobe and the development of
    a large parapneumonic pleural effusion

38
Clinical case 2
  • Diagnosis
  • Complicated right lobal pneumonia - parapneumonic
    pleural effusion
  • Draining large effusions may provide symptomatic
    relief
  • Aspiration of pleural fluid may provide an
    etiologic agent to direct therapy

39
Congenital pneumonia
  • Tachypnea
  • Irregular respiratory movements (paradoxic)
  • Apnea
  • Flaring of alae nostril
  • Grunting (expiration sound)
  • Involving chest muscles
  • Temperature may be present in some term babies

40
Congenital pneumonia
  • Poor feeding
  • Lethargy or irritability
  • Temperature instability
  • Poor color, cyanosis
  • Abdominal distention
  • tachycardia

41
Congenital pneumonia
  • Late onset of CP (after 7-14 days of life).
  • Mainly Chlamidia or Urea- and Mycoplasma
  • Onset usually is preceded by upper respiratory
    tract symptoms and/or conjunctivitis
  • Nonproductive cough
  • Fever is absent afebrile pneumonia syndrome

42
Physical sings
  • The sings such as dullness to percussion, change
    in breath sounds, and the presents of rales or
    rhonchi are virtually to appreciate in a neonate
  • Weakened breathing during auscultation
  • Moist or bubbly sounds, crepitating
  • Respiratory failure develops gradually

43
CXR in
  • Atypical Pneumonia
  • Chlamydia
  • Diffuse intersitial markings
  • hyperinflation
  • Mycoplasma
  • Normal, or can look like viral or typical
    bacterial PNA

44
Viral pneumonia
  • Respiratory syncytial virus is the most common
    viral cause other common causes include
    parainfluenza virus, adenovirus, enterovirus
  • Clinical features- begin with several days of
    rhinitis, cough, followed by fever and more
    pronounced respiratory tract symptoms, such as
    dyspnea, intercostal retraction.

45
Viral pneumoniaDiagnosis
  • Laboratory findings preponderance of
    lymphocytes observed on CBC
  • Diffuse or bilateral infiltrates visible on
    chest ragiograph
  • Rapid test for viral antigen, culturing
    nasopharyngeal specimens for viruses

46
CXR in viral PNA
47
CXR in Aspiration
  • opacification in right upper lobes of infants and
    in the posterior or bases of the lung in older
    children
  • Specific testing
  • barium swallow
  • pH probe, and
  • flexible endoscopic evaluation of swallowing and
    sensory testing

48
Possible Exam Signs of PNA
  • Tachypnia
  • gt 50/min if younger than 1 year, gt 40/min if
    older than 1 year.
  • Cyanosis
  • Retractions
  • Inspiratory crackles
  • Bronchial breath sounds
  • Egophany ( E to A)
  • Bronchophany (99)
  • Whispered pectoriloquy (pectorophony)
  • Dullness to percussion
  • Tactile fremitus

49
Symptoms and signs 5 categories
  • Nonspecific and toxicity
  • Signs of lower respiratory disease
  • Signs of pneumonia
  • Sign of pleural effusion and empyema
  • Extrapulmonary disease

50
Symptoms signs non-specific
  • Fever, malaise, headache
  • GI complaints
  • Apprehension
  • restlessness

51
Symptoms-lower respiratory
  • Tachypnea, dyspnea
  • Shallow or grunting respiration
  • Cough
  • Nasal flaring, intercostal retraction

52
Symptoms-pleuritic
  • Referred pain to neck and back
  • Abdominal pain if diaphragmatic involvement

53
Symptoms-extrapulmonary
  • Disseminated disease
  • Skin and soft tissue involvement arising from
    bacteremia, meningitis

54
Plan of examination
  • CBC - so called septic investigation -
  • blood analysis (? WBC more than 20109/l or
  • ?WBC less than 5109/l)
  • Increased WBC with left stiff strongly suggests
    bacterial process
  • Pneumococcus associated with marked leukocytosis
  • Leukocyte index gt 0.2 (immature forms general
    count of neutrophils)
  • Trombocytopenia (lt 150000)

55
Examination Laboratory
  • Biochemical blood test acidosis,
    hypoproteinemia
  • Increased inflammatory markers (C-reactive
    protein)
  • Bacteriological examination of sputum (tracheal),
    blood (gold standard)
  • Blood culture rarely give organism, but this
    test is necessary
  • Examination for viruses

56
Examination Radiology X-ray
  • Infiltrates, bilateral involvement or pleural
    effusion - suggest more serious disease
  • Focal or diffuse interstitial pneumonitis may
    reveal
  • Infiltrates may be less obvious in dehydrated
    patients

57
Bronchopneumonia - intensified (increased)
pulmonary picture, diffuse focal infiltration
58
Interstitial pneumonia
59
CXR in Bacterial PNA
60
CXR in Bacterial PNA
Right lower lobe consolidation in a patient with
bacterial pneumonia
61
-
Lobar pneumonia
62
Acute community-acquired pneumonia with
complicated parapneumonic effusion
63
Complicating pneumonia and empyema
64
  • Bilateral necrotising pneumonia complicated by
    right pneumothorax

Bilateral consolidation with scarring and early
cavitation in the lower lung fields
65
Pneumococcal pneumonia complicated by lung
necrosis and abscess formation
                          A lateral chest
radiograph shows air-fluid level characteristic
of lung absces
66
  • Lung abscess in the posterior segment of the
    right upper lobe
  • CT scan shows a thin-walled cavity with
    surrounding consolidation

67
What indications for disposition
(hospitalization) patient with pneumonia do you
know?
  • Most children can be treated
  • as outpatients.

68
Disposition
  • Admit if
  • Toxic appearance
  • Respiratory compromise, including marked
    tachypnea (gt60 breaths/min in infant and
  • gt 40-50 breaths/min in older children)
  • Hypoxemia (SpO2 lt 92-94 in room air)
  • Dehydration or inability to maintain oral
    hydration or tolerate oral medications
  • Indications of severe disease

69
Disposition
  • Admit if
  • Young age - lt 4-6 months of age
  • Underlying diseases
  • - cardiac disease
  • - renal disease
  • - hematological disease
  • Inability of family to provide care at home
  • Failure of outpatient therapy

70
Treatment
  • Supportive care for children
  • Oxygen if needed
  • Fluids and insure hydration
  • Antipyretics, analgesics
  • Antitussives are NOT indicated

71
Antibiotic therapy
  • I beta-lactam
  • Penicillin
  • Cephalosporin
  • Carbopenem
  • Aminoglycoside
  • Macrolide
  • Linkozamide linkomycin, clindomycin
  • Vancomycin

72
Treatment
  • Bacterial
  • 1 month Ampicillin 75100 mg/kg/day and
  • Gentamicin 5 mg/kg d
  • 13 months Cefuroxime (75150 mg/kg/day) or
  • co-amoxiclav (40 mg/kg/day)
  • 3 months Benzylpenicillin or erythromycin (change
    to cefuroxime or amoxycillin if no response)

73
Treatment
  • Supportive for atypical pneumonia
  • Chlamydia and mycoplasma should be treated with
    erythromycin
  • 4050 mg/kg/day usually orally.
  • If pneumocystis carinii pneumonia is suspected
    co-trimoxazole 1827 mg/kg/day IV should be
    prescribed.

74
Treatment Patients are treated as an outpatient
  • Children lt 5 yo
  • - high dose amoxicillin (80-90 mg/kg/d) for 7-10
    d
  • Children gt 5 yo
  • - increased prevalence of M. pneumoniae and
  • C. pneumoniae
  • - macrolide is reasonable choice
  • Older children with signs most consistent with
  • S. pneumoniae infection (lobar infiltrate,
    increased wbc or inflammatory markers)
  • AMOXICILLIN may be used

75
TreatmentPatients requiring admission
  • IV AMPICILLIN 150-200 mg/kg/d
  • May used 2-nd or 3-rd generation cephalosporins
  • Choice guided by local resistance patterns
  • Consider combining beta-lactam and macrolide

76
TreatmentChildren with more severe disease
  • Consider other organisms including
    Methicillin-resistant S. aures (MRSA)
  • 3-rd generation cephalosporin, plus Clindamycin
    or
  • Vancomycin

77
Treatment
Age Start Alternative
6 mo.-6 yr Ampicillin 100 mg/kg/day Or amoksiklav 20-40 mg/kg (Amoxicillin/clavulanate) Cefotaxime (Claforan) Cefuroxime (Zinacef) 100-150 mg/kg/day Clarithromycin Azithromycin
78
Treatment
Age Start
6 mo.-6 yr Complicated Ceftazidime 150 mg/kg/day or Cefotaxime or ceftriaxone netilmicin (6-7.5 mg/kg) (amikacinum 15 mg/kg)
79
Treatment
Age Start
6 mo 6 yo atypical -Clarithromycin 15-30 mg/kg/day or Azithromycin 10 mg/kg
6 mo 6yo atypical complicated Rovamycine 1500000 IU per 10 kg
80
Suggested Drug Treatment
  • 4 months to 5 years
  • Amoxycillin 80mg/kg/dose
  • 6-14 years
  • Erythromycin
  • Birth to 20 days Admission
  • 3 weeks to 3 months
  • Afebrile oral erythromycin
  • Febrile add cefotaxime

NEJM
Volume 346429-437
81
Causative Agents
  • The most often isolated bacteria pneumonia -
    Streptococcus pneumoniae (33)
  • Haemophilus influenzae (21)
  • Braz J Infect Dis 2001 Apr5(2)87-97

82
Haemophilus influenzaeTreatment with a
combination of amoxicillin and clavulanic acid
(Augmentin) is effective against
þ-lactamase-producing strains
Streptococcus pneumoniae Penicillin is drug of
choice for susceptible organisms
83
Summary
  • Pneumonia is a common infection condition in
    children
  • Significant cause of morbidity and hardships for
    patients and families
  • Pneumonia is the commonest cause of mortality
  • Pneumonia in absence of cough is rare.

84
Summary
  • Fast breathing in a child with cough or
    difficulty breathing is highly sensitive and
    specific for diagnosis
  • Tachypnea is the most useful physical sign.
  • Most children can be treated as outpatients
  • Therapy should be guided by probable etiology
    and severity of disease.

85
Test-control
  • What are the most common etiological agents of
    pneumonia
  • in neonatal period?

86
Test-control
  • What are the most valuable signs of pneumonia in
    children?

87
Test-control
  • What signs are auxiliary methods of diagnosis of
    pneumonia?

88
Thank You For Attention
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