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Pediatric Community Acquired Pneumonia


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Pediatric Community Acquired Pneumonia
PPS Clinical Practice Guideline

Pediatric Community Acquired Pneumonia

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