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    Pneumonia Pneumonia Presentation Transcript

      • Is an inflammation of the parenchyma of the lungs
      • Most cases of pneumonia are caused by microorganism
      • noninfectious causes- aspiration of food or gastric acid; foreign bodies; hydrocarbons; lipoid substances; hypersensitivity reactions and drug 0r radiation-induced pneumonitis
      • Specific risk factors:
      • Lung disease
      • anatomic problems
      • Gastroesophageal reflux disease with aspiration
      • 4. Neurologic disorders that interfere with protection of the airway or compromise clearing of the airway
      • 5. Diseases that alter the immune system, such immunodeficiency diseases or hemoglobinopathies
    • Etiology
      • Viral - peak attack is between 2-3 y.o.
      • S.pneumoniae, M.pneumoniae – older than 5 y.o.
      • other bacterial causes: group A strep, S.pyogenes, Staph aureus, H.influenzae type B
    • Clinical manifestation
      • Viral and bacterial pneumonias are most often preceded by several days of symptoms of an upper respiratory tract infection, typically rhinitis and cough
      • Viral pneumonia, fever -temp.- is generally lower than bacterial.
      • Tachypnea is the most consistent clinical manifestation
      • Increased working breathing accompanied by intercostal retractions, nasal flaring and use accesory muscles
      • Bacterial pneumonia in older children typically begins suddenly with shaking chill followed by high fever, cough and chest pain
    • Predictors of CAP in a Patient with cough
      • 1. ages 3-5 y.o.- tachypnea and/or chest indrawing
      • 2. ages 5-12 y.o. – fever, tachypnea
        • & crackles
        • 3. > 12 y.o. fever, tachypnea, tachycardia
        • at least 1 abnormal chest findings
        • ronchi, crackles, wheezes, ↓breath sounds
      • Reliable indicators- either tachypnea and/or chest indrawing among infants and preschool children
      • Tachypnea is still the best predictor
      • Age specific criteria for tachypnea:
      • 2-12 mos. – 50 breaths/min.
      • 1-5 years. – 40 breaths/min.
      • > 5 years – 30 breaths/min.
      • Patients with CAP are 2-3 times more likely to have the following signs and symptoms:
      • nasal flaring, grunting, tachypnea, rales and pallor
      • Diagnosis of an adolescent suspected to have CAP:
      • cough
      • tachypnea (RR .20 breaths/min.)
      • tachycardia (HR .100bpm)
      • fever (temp > 37.8 ºC)
      • at least 1 abnormal chest findings
      • CXR with infiltrates
    • Criteria for admission
      • A patient who is moderate to high risk to develop pneumonia-related mortality should be admitted
      • A patient who is at minimal to low risk can be managed on OPD basis
    • RISK CLASSIFICATION FOR PNEUMONIA-RELATED MORTALITY VARIABLES PCAP A Minimal risk PCAP B Low risk PCAP C Moderate risk PCAP D High risk co-morbid illness none present present Present Compliant care giver Yes yes no no Ability to ff-up possible possible Not possible Not possible Presence of dehydration none mild moderate severe Ability to feed able able unable unable age >11 mo. >11 mo. <11 mo. <11 mo.
    • VARIABLES PCAP A Minimal risk PCAP B Low risk PCAP C Moderate risk PCAP D High risk resp rate 2-12mo. 1-5 yrs. >5 yrs. >50/min >40/min >30/min >50/min >40/min >30/min >60/min >50/min >35/min >70/min >50/min >35/min Signs of resp failure a.Retraction b. Head bobbing c. Cyanosis d. Grunting none none Intercostal/subcostal Present present none Supraclavicular/intercostal/subcostal present
    • VARIABLES PCAP A Minimal risk PCAP B Low risk PCAP C Moderate risk PCAP D High risk Signs of resp failure e. apnea f. sensorium None awake None awake None irritable Present Lethargic,stuporous/comtose Complications none none present present Action plan OPD OPD Admit to regular ward Admit to ICU
      • Parameters to be evaluated when considering admission:
      • 1. Host factors
      • a. ability to feed
      • b. age
      • c. signs of resp failure
      • d. pulmonary complications
      • e. respiratory rate
      • f. state of dehydration
      • g. presence of comorbid factors
      • 2. External factors
      • a. compliant caregiver
      • b. ability to ff-up
      • Grunting and apnea are manifestations
      • of acute respiratory failure requiring admission to critical care unit
      • compared with older children, an infant younger than one year has higher risk of contracting sever pneumonia
      • Age from 2-11 mos. was associated with death
      • Presence of retraction on admission was the best single predictor of death
      • Subcostal, intercostal, supraclavicular retractions were associated with mortality
      • Chest retraction has been considered to be an excellent sign for selecting children needing admission for more intensive treatment.
      • Tachypnea, chest retraction, somnolence and young age, chronic illness & malnutrition were independently associated with hospitalization
      • Cyanosis and head bobbing corelates well with hypoxemia
      • Inability to cry, head nodding and a resp rate of >60/min. were best predictors of hypoxemia.
      • No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting (Grade D).
      • Recommendations for PCAP C & D:
      • Routine exams:
      • CXR-PA Lateral
      • WBC count
      • Culture and sensitivity of:
      • blood,pleural fluid, & tracheal aspirate for PCAP D, sputum for older children
      • The following should not be requested:
      • ESR
      • C-reactive protein
      • 1. for patient classified as either PCAP A or B and is
      • a. beyond 2 years of age
      • b. having high grade fever without wheeze
      • 2. For a patient classified as PCAP C and is
      • a. beyond 2 years of age
      • b. having high grade fever without wheeze
      • c. having alveolar consolidation in the CXR
      • d. having WBC count > 15,000
      • 3. For a patient classified as PCAP D
      • Practice guidelines cited as AGE as the best predictor of underlying etiology of pediatric pneumonia
      • First 2 years of life VIRUSES are most frequently implicated
      • As age increases, bacterial pathogens become more prevalent
      • Literature review showed the following pattern of microbial etiology:
      • PCAP managed as an outpatient
      • a. bacterial pathogen is more common than a viral pathogen
      • b. Streptococcus pneumoniae is the pathogen in more than half of the patients
      • Less common pathogens include M. pneumoniae and C. pneumoniae
      • 2. PCAP managed as an in patient
      • a. bacterial pathogen is more common than a viral pathogen
      • b. S.pneumoniae is the pathogen in little more than half of the patients
      • H. influenzae type B should be considered in a patient below 5 y.o. who has not completed the primary series of Hib immunization
      • certain features that suggest the presence of a bacterial and viral pathogen
      • Demonstration of either alveolar infiltrates in CXR or elevated WBC favors bacterial pathogen
      FEATURES Bacterial Viral Fever >38.5 ºC <38.5 ºC Wheeze absent present
      • 1. for patient classified as PCAP A or B without previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided doses
      • 2. for a patient classified as PCAP C w/o previous antibiotic & who has completed the primary immunization against H. influenzae type B, Pen G 100,000 u/kg/day in 4 divided doses.
      • if a primary immunization against Hib has not been completed,and below 5 y.o., IV ampicillin (100mg/kg/day in 4 divided doses
      • 3. for a patient classified as PCAP D, a specialist should be consulted
      • Antiviral agents such as amantadine and the newer neuraminidase inhibitors zanamivir and oseltamivir
      • -reduces the duration of illness by 1-1.5 days
      • -to reduce the duration of viral shedding among patients with influenza
      • For influenza A infection – amantadine (4.4-4.8 mg/kg/day) can be given for 3-5 days
      • - Discontinue the drug within 24-48 hrs. after resolution of symptoms
      • For influenza A or B infection – oseltamivir (2mg/kg/dose BID) can be given for 5 days
      • In case proven epidemics of influenza, oseltamivir may be given
      • Its use for treatment & prophylaxis of household contacts has been effective for >12 y.o.
      • 1. decrease in respiratory signs (tachypnea) & defervescence within 72 hrs. after initiation of antibiotic
      • 2. persistence of symptoms beyond 72 hrs after initiation of antibiotics requires reevaluation
      • 3. end of treatment CXR, WBC, ESR or CRP should not be done to assess therapeutic response to antibiotic
      • 1. if an out patient classified as either PCAP A or PCAP B is not responding to the current antibiotic within 72 hrs.
      • - change the initial antibiotic
      • - start oral macrolide
      • - reevaluate diagnosis
      • possibility of penicillin resistant S.pneumoniae
      • Course of action: change amoxicillin to any of the ff.: cefuroxime, co-amoxiclav, sultamicillin or cepfodoxime
      • Possibility of Mycoplasma sp or Chlamydia sp.
      • Course of action: start an oral macrolide, such as erythromycin
      • 2. if an inpatient classified as PCAP C is not responding to the current antibiotic within 72 hrs. consider consultation with a specialist
      • following possibilities:
      • - penicillin resistant S.pneumoniae
      • - presence of complications
      • If an inpatient classified as PCAP D is not responding within 72 hrs., consider immediate re-consultation with a specialist
      • Switch from IV antibiotics to oral form 2-3 days after initiation of antibiotic is recommended in patients:
      • a. responding to initial antibiotic therapy
      • b. able to feed with intact GI absorption
      • c. does not have any pulmonary or extrapulmonary complications
      • 1. cough preparations, chest physiotherapy, bronchial hygiene, nebulization using NSS, steam inhalation, topical solution, bronchodilators and herbal medicine are not routinely given
      • 2. among patients, oxygen and hydration should be given if needed
      • 3. in the presence of wheezing, a bronchodilator may be given
      • 1. vaccines recommended by the Phil. Pediatric Society should be routinely administered
      • 2. Zinc supplementation
      • 3. Vitamin A, immunomodulators and Vitamin C should not be routinely given