This document discusses pneumonia in children. It defines pneumonia as an inflammation of the lungs and notes it is a leading cause of death in children worldwide. The document covers clinical presentation, classification, diagnosis and treatment of pneumonia in various pediatric populations. It discusses complications such as parapneumonic effusion/empyema and approaches to management including supportive care, antibiotic treatment and drainage if needed. Non-resolution of pneumonia is also addressed.

1. Kassahun D, MD+

2. Definition;
 It is an inflammation of the parenchyma of
the lungs—is a substantial cause of morbidity
and mortality in childhood throughout the
world, rivaling diarrhea as a cause of death
in developing countries
 The leading causes of death
 75% of cases of ART are due to pneumonia
 Higher mortality in infants

3. Clinically
1. Community acquired pneumonia
 Typical
 Atypical pneumonia
 Aspiration pneumonia
2. Nosocomial pneumonia ;
 is usually caused by gram-negative bacilli or
S. aureus and occurs in ICU where mechanical
ventilation, indwelling catheters, and
administration of broad-spectrum antibiotics
are common
3. Pneumonia in immunocompromized

4. Radiologic classfication
1. Alveolar pneumonia
 Air bronchogram is a x-stic
 Lobar type of consolidation
 S.pneumonia,klepsella, HiB
2. Bronchopneumonia
 With evidence of localised or generalised patchy
infiltrates on chest x-ray
 Primary involvement of airways and surrounding
interstitium
 S.pneumonia, S pyrogens,HiB, viruses
3. Interstitial pneumonia
 Patchy or homogeneous opacity
 Atypical pneumonia, non infectious
causes

5. Newborns ;
 Group B streptococcus, Escherichia coli, Klebsiella
species,
1- 3 months
 Chlamydia trachomatis
 RSV, other respiratory viruses (parainfluenza viruses,
influenza viruses, adenovirus),
 S. pneumoniae, H. influenzae type b

6. Preschool
 Streptococcus pneumoniae, Haemophilus
influenzae type b,Staphylococcal aureus,
 Less common: group A streptococcus, Moraxella
catarrhalis,Pseudomonas aeruginosa
School
 Mycoplasma pneumoniae, Chlamydia
pneumoniae,H. influenzae, influenza viruses,
adenovirus, other respiratory viruses, Legionella
pneumophila

7.  Direct spread from the upper respiratory
tract
 Commonest
 Segmental pneumonia
 Bactermia/hematogenous dissemination/
 Usually multifocal, bronco pneumonia

8. A series of pathologic changes;
1. Edema, is the initial phase
 the presence of a proteinaceous exudate and
bacteria in the alveoli.
2. Red hepatization phase; the presence of
erythrocytes and neutrophils in the cellular
intraalveolar exudate.

9. 3. Gray hepatization-
 no new erythrocytes are extravasating, and
those already present have been lysed and
degraded.
 The neutrophil is the predominant cell, fibrin
deposition is abundant, and bacteria have
disappeared.
4. Resolution
 the macrophage is the dominant cell type
 the debris of neutrophils, bacteria, and fibrin
has been cleared, as has the inflammatory
response..

10.  Neonates and young infants
 Non specific symptoms - fever, poor feeding,
lethargy
 fast breathing-age-related definitions of
tachypnea ;
 Younger than two months: >60 breaths/min
 2-12 months: >50 breaths/min
 1-5 years: >40 breaths/min
 ≥ 5 years: >20 breaths/min
 Grunting,, apnea
 Chest indrawing, cyanosis
 Older children
 Respiratory distress

11.  Signs of respiratory distress
 tachypnea,
 hypoxemia, and
 increased work of breathing (
 intercostal,
 subcostal, or
 suprasternal retractions;
 nasal flaring;
 grunting;
 use of accessory muscles

12.  Physical findings;
 Early in the course of illness,
 diminished breath sounds, scattered crackles, and
rhonchi
 Progressively signs of
 consolidation or complications of pneumonia such as
effusion, empyema, and pyopneumothorax
 Abdominal distention /swallowed air or ileus
 Hepatomegaly / 2 to hyperinflation, CHF?
 Abdominal pain

13. WHO classification
1. No pneumonia-common cold
2. Pneumonia
 Cough and fast breathing
3. Severe pneumonia
 Chest indrawing and grunting
4. Very severe pneumonia
 Sever respiratory distress, cyanosis, vomit
everything, inability to feed, convulsion,
unconscious

14.  Clinical
 infants and children with respiratory complaints,
particularly fever, cough, tachypnea, retractions, and
abnormal lung examination
 CXR
 confirms the diagnosis of pneumonia
 is necessary when the diagnosis is uncertain and in
patients with severe, complicated, or recurrent
pneumonia
 early in the 1st 36 hours-negative
 Resolution-4-6 weeks, some may take few months
 Blood culture
 Ag detection

17.  Recurrent pneumonia
 2 or more episodes in a one year or 3 or more
episodes ever, with radiographic clearing between
occurrences.
 An underlying disorder should be considered if a child
experiences recurrent pneumonia.
 Cong. ID
 Selective immunoglobulin G subclass deficiencies
 Severe combined immunodeficiency syndrome
 Chronic granulomatous disease
 Hyperimmunoglobulin E syndrome (Job syndrome)
 Leukocyte adhesion defect
 Aquired ID
 AIDS
 Maligancy
 Drugs….

18. 1. Indication for admission
 Young infants
 Hypoxemia saturation 92%
 Dehydration,
 inability to feed in an infant

19. Indication for admission….
 Moderate to severe respiratory distress:
 Tachypnea
 difficulty breathing, apnea, grunting
 Toxic appearance
 Underlying conditions
 Presence of complications
(effusion/empyema/
 Failure of outpatient therapy
 worsening or no response in 24 to 72 hours

20. 2.Supportive treatment
 Antipyretics and analgesia
 Respiratory support
 monitor carbon dioxide via blood gas analysis
 oxygen saturation by oximetry;
 <95% percent in room air should be supplemented
 Airway clearance-gentle suction of the nares
 Adequate hydration
 If wheezing……bronchodilator

21. 3.Antibiotic treatment
Depends on
 Age of the patient
 Host immune condition
 Severity of the disease
 Type of pneumonia
 CAP, HAP, Aspiration pneumonia
 Out patient
 Cotrimoxazole
 Amoxacillne,
 Ampicillne

22. Impatient Management
 Neonates
 Amp and gentamycin or 3rd gen cephalosporin
 Children
 Crystalline Penicillin and Chloramphenicol
 3rd gen cephalosporin
 Very toxic cases
 Cloxacilline and gentamycin/ceftriaxone

23. Wide coverage should be done for
 Malnourished children
 Ampicillin and gentamycin
 Hospital acquired
 Cloxacilline and gentamycin/ceftriaxone
 Immune deficiency disorders and underlining
disorders
 Aspiration pneumonia
 Antibiotic againest Anaeobes and streptocoocus
 Penicillin and metronidazole/clindamycine

24.  Parapneumonic effusion/empyema
 Prolonged course of antibiotic
 Drainage of abscess
 Necrotizing pneumonia
 For 4 weeks or two weeks after the patient is afebrile/clinical
improvement.
 Percutaneous drainage catheter replacement

25.  Lung abscess
 For 4 weeks or two weeks after the patient is
afebrile/clinical improvement.
 Fever disappear in 4-8 days
 Eighty to 90 percent of lung abscesses in children resolve
with antibiotic therapy alone
 Pneumatocele
 Most pneumatoceles involute spontaneously.
 on occasion, pneumatoceles result in pneumothorax

26.  Close follow up in the 1st 24-48 hour
 If no improvement within 48-96 hours;
consider
 Alternative or coincident diagnoses like foreign
body aspiration
 Ineffective antibiotic coverage
 Development of complication
 Pre-existing diseases such as immunodeficiencies,
ciliary dyskinesia, cystic fibrosis
 Control CXR
 For those complicated pneumonia

27.  Non resolving pneumonia
 Pneumonia that progress, resolve slowly, or fail to
achieve complete resolution despite appropriate
therapy
 Usual duration of findings :
 subjective improvement within three to five days of Rx
 CRP 1-3 days, fever 2-4days, leukocytosis 2-4 days,
crackles 3-6 days ,cough 4-9 days
 Slow resolution" often being defined as the
persistence of radiographic abnormalities for greater
than one month in a clinically improved host.

28.  DDx of non resolving pneumonia
 Tuberculosis
 Fungal infection
 Resistant pathogens
 Complicated pneumonia
 Non infectious
 Malignancy
 Systemic vasculitis
 Collagen Vascular disease
 Pulmonary embolism

29.  Improvement of vital signs
 Ability to feed
 oxygen saturation ≥90 percent in room air
 Improvement in respiratory distress (tachypnea,
retractions, nasal flaring, use of accessory muscles)
 Clinical improvement including level of activity,
appetite, and decreased fever for at least 12 to 24 hrs
 Stable and/or baseline mental status
 Reliable attendant to take home antibiotic regimen
 Safe and compliant home environment

30.  Parapneumonic effusion
 Defined as pleural effusion associated with
pneumonia.
 These effusions result from the spread of
inflammation and infection to the pleura.
 Empyema is a collection of purulent exudates
in the pleural space.

31.  Empyema is most frequently encountered in
infants and preschool children.
 70% in < 2 years.
 It occurs in 5-10% of children with bacterial
pneumonia and in up to 86% of children with
necrotizing pneumonia.

32. Common causes
 Streptococcus pneumoniae, although
 Staphylococcus aureus
 Haemophilus influenzae
 Group A streptococcus
Less common causes; gram-negative organisms,
tuberculosis, fungi, and malignancy.
other risk
 rupture of a lung abscess into the pleural space,
 trauma or thoracic surgery, or
 mediastinitis or
 the extension of intra-abdominal abscesses.

33. 3 stages:
1. Exudative; fibrinous exudate forms on the
pleural surfaces
2. Fibrinopurulent;
 causing loculation of the fluid and thickening of
the parietal pleura. If the pus is not drained
 bronchopleural fistulas and pyopneumothorax, or
 empyema necessitatisi
 into the abdominal cavity
3. organizational
 there is fibroblast proliferation; pockets of
loculated pus may develop into thick-walled
abscess cavities

34.  Primarily those of bacterial pneumonia.
 Most patients are
 febrile,
 sign of respiratory distress, and
 often appear more ill.

35.  Leukocytosis and high ESR
 Blood culture
 CXR
 Chest U/S-loculated empyema
 PFA
 PH <7.2
 Cell count >10,000 PMN
 Glucose <40mg/dl
 LDH >1000units
 Culture---------high yield

37.  Local complications include
 bronchopleural fistulas
 pyopneumothorax
 purulent pericarditis
 pulmonary abscesses
 peritonitis
 osteomyelitis
 Septic complications such as
 meningitis,
 arthritis, and
 osteomyelitis

38. Supportive care
 Antipyretics
 Early mobilization
Antibiotics
 intravenous antibiotics for 3-6 weeks .
 Coverage based on etiologic dx
 Oral antibiotics should be continued at discharge
for one to four weeks or longer if there is
residual disease.
Chest drainage

39. Fibrinolytic agents
 Instillation into the pleural cavity via the chest
tube may promote drainage, decrease fever, lessen
need for surgical intervention
 Streptokinase 15,000 U/kg in 50 mL of 0.9% saline
daily for 3-5 days and
 Urokinase 40,000 U in 40 mL saline every 12 hr for
6 doses
Open thoracotomy/surgical decortication
 Febrile and dyspneic >72 hr after initiation of
therapy with intravenous antibiotics and
thoracostomy tube drainage