Pneumonia in peadiatrics


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Hey guys. I'm a final year med student...just made this presentation recently for my peads class. Hope u guys find it useful.

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Pneumonia in peadiatrics

  1. 1. PNEUMONIA Saadia Sajjad. Roll no. 460
  2. 2. Learning Objectives  To describe the presentation of pediatric pneumonia  To outline the management of pediatric pneumonia  To summarize the complications of pediatric pneumonia  To highlight interventions to prevent and protect against pediatric pneumonia
  3. 3. 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-Pneumonia Lobar Pneumonia.
  4. 4. Epidemiology Pneumonia 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 pneumonia Approximately 98% of children who die of pneumonia are in developing countries.
  5. 5. Pneumonia - Common Pathogens Age Group Common Pathogens (in Order of Frequency) Newborn E.Coli Group B Streptococci Staph. Aureus Klebsiella Pseudomonas 1-3 months Chlamydia trachomatis Respiratory Syncytial virus Other respiratory viruses 3-12 months Respiratory Syncytial virus Staph Aureus Streptococcus pneumoniae Haemophilus influenzae Chlamydia trachomatis Mycoplasma pneumoniae
  6. 6. Age Group Common Pathogens (in Order of Frequency) 2-5 years Respiratory Viruses Streptococcus pneumoniae Haemophilus influenzae Mycoplasma pneumoniae Chlamydia pneumoniae 5-18 years Mycoplasma pneumoniae Streptococcus pneumoniae Chlamydia pneumoniae Haemophilus influenzae Influenza viruses A and B Adenoviruses Other respiratory viruses
  7. 7. Age Presence of cough, difficulty breathing, shortness of breath, chest pain Fever Recent upper respiratory tract infections Associated symptoms Duration of symptoms Immunizations status TB exposure Maternal Chlamydia, Group B Strep status during pregnancy Choking episodes Previous episodes Pneumonia History
  8. 8. Pneumonia History Travel history Day care attendance Animal exposure Ill contacts Past Medications Birth History Medications Allergies Immunization Status Home Environment Social History Family History
  9. 9. 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
  10. 10. Other signs of pneumonia - Indrawing out---breathing---in Lower chest wall indrawing: with inspiration, the lower chest wall moves in
  11. 11. Other signs of pneumonia - Nasal Flare Nasal flaring: with inspiration, the side of the nostrils flares outwards
  12. 12. 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
  13. 13. 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.
  14. 14. Pneumonia Severity Assessment Mild Severe Infants Temperature <38.5 C RR < 50 breaths/min Mild recession Taking full feeds Temperature >38.5 C RR > 70 breaths/min Moderate to severe recession Nasal Flaring Cyanosis Intermittent Apnea Grunting Respirations Not feeding Older Children Temperature <38.5 C RR < 50 breaths/min Mild breathlessness No vomiting Temperature >38.5 C RR > 50 breaths/min Severe difficulty in breathing Nasal Flaring Cyanosis Grunting Respirations Signs of dehydration
  15. 15. 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)
  16. 16. Age Group Indications for Admission to Hospital Infants Oxygen Saturation <= 92%, cyanosis RR > 70 breaths /min Difficulty in breathing Intermittent apnea, grunting Not feeding Family not able to provide appropriate observation or supervision Older Children Oxygen Saturation <= 92%, cyanosis RR > 50 breaths /min Difficulty in breathing Grunting Signs of Dehydration Family not able to provide appropriate observation or supervision Indications for Admission
  17. 17. Investigations Chest X-ray WBC Count Blood Culture Gram Staining of expectorated sputum Pleural fluid examination ASO titre Tuberculin skin test
  18. 18. 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
  19. 19. Complications of Pneumonia Pleural effusion Empyema Parapneumonic effusions Lung abscess Pneumothorax Pneumatocele Delayed Resolution Respiratory Failure Metastatic Septic lesions Activation of latent TB
  20. 20. Treatment – IMCI Guidelines Antibiotic therapy Chloramphenicol (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.
  21. 21. Supportive Treatment – IMCI Guidelines Oxygen therapy If fever (=>39oC) causing distress, give paracetamol If wheeze is present, give a rapid-acting broncho-dilator Gentle suction any thick secretions in the throat, which the child cannot clear.
  22. 22. 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.
  23. 23. Prevention Strategies Vaccination against measles, Streptococcus pneumoniae, and Haemophilus influenzae type b Public awareness Interventions to protect against pneumonia Zinc supplementation Prevention of HIV in Children Co-trimoxazole prophylaxis for HIV-infected children
  24. 24. Prevention - Vaccination Haemophilus Influenzae type B (Hib) vaccine Pneumococcal conjugate vaccine Pneumonia is a possible complication of Measles, thus prevention of measles would decrease the incidence of pneumonia.
  25. 25. A Complicated Case from Gambia Based on a true story
  26. 26. 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?
  27. 27. 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?
  28. 28. What other physical examination information is immediately relevant to forming an initial treatment plan for this patient?
  29. 29. Weight and Hydration Status The child is malnourished The patient appears mildly dehydrated. What interventions should be started?
  30. 30. 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?
  31. 31. Differential Diagnosis includes: Pneumonia +/- complications (e.g. Empyema) Pneumonia in a patient with HIV Tuberculosis What is the first investigation you would order? (assume first choice investigation is available).
  32. 32. The chest x-ray reveals a right sided lobar infiltrate. What is the clinical correlation?
  33. 33. 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?
  34. 34. HIV test – negative TB skin test – unreactive Sputum 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?
  35. 35. 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.
  36. 36. 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
  37. 37. 1)What is the most sensitive and specific sign of pneumonia in children? A. Difficulty breathing B. Fever C. Tachypnea D. Tachycardia 2)Which of the following immunization effectively reduce pneumonia mortality in children? A. Haemophilus influenzae b Vaccine B. Pneumococcal Conjugate Vaccine C. Measles Vaccine D. All of the above
  38. 38. 3)Which of the following bacterial pathogens most commonly cause bacterial infections in neonates? A. E. coli, S. pneumoniae, H. influenza B. Group B Streptococci, E. coli, L. monocytogenes C. Group B Streptococci, H. influenzae, E. coli D. S. pneumoniae, H. influenzae, N. meningitides E. 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 pertussis B. Group A streptococcus C. Haemophilus influenzae type B D. Influenza E. Streptococcus pneumoniae
  39. 39. 5) Which organism is NOT likely to cause pneumonia with parapneumonic effusion or empyema? A. Group A streptococcus B. Mycoplasma pneumoniae C. Staphylococcus aureus D. Streptococcus pneumonia 6)Which organism is the most likely organism to cause pneumonia in a 2 year old child? A. Influenza B. Metapneumovirus C. Mycoplasma pneumoniae D. Streptococcus pneumoniae E. Respiratory syncytial virus
  40. 40. 7) Which combination of signs and symptoms is typical of community acquired pneumonia? A. Clear lung exam, fever, cough B. Crackles, normal respiratory rate, cough C. Tachypnea, cough, fever D. Tachypnea, vomiting and rash E. Wheezes, retractions, nasal flaring
  41. 41. 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 October B. 3 year old male with 3 day history of fever, rhinorrhea, and faint rash in May C. 4 year old male with 5 day history of fever, cough, retractions and fatigue in February D. 5 year old female with asthma, and now 1-2 day history of fever and wheezing in March E. 8 year old female with 3 day history of fever, cough, sore throat and myalgias in January