Pneumonia is inflammation of the lung parenchyma that can be caused by infectious or non-infectious etiologies. Streptococcus pneumoniae is the most common cause of bacterial pneumonia in children aged 3 weeks to 4 years. Pneumonia is the leading infectious cause of death in children under 5 years globally. Clinical manifestations include cough, increased respiratory rate, grunting, and fever. Chest x-ray and laboratory tests are used for diagnosis. Management involves oxygen therapy, fluid therapy, antibiotics, and admission is indicated for young infants or those with respiratory distress. Prevention includes vaccines for pathogens like Streptococcus pneumoniae, influenza, and RSV.

1. PNEUMONIA
BY Dr. BIRHANU A.

2. OUTLINES
• OBJECTIVES
• PNEUMONIA
– Ethiology,
– Epidemiology,
– C/Manifestation,
– Pathogenesis,
– Diagnosis And
– Management

3. Objectives
• At the end of this lecture you should
understand the etiology, epidemiology,
pathogenesis, c/manifestation, diagnosis and
management of pneumonia in children.

4. Pneumonia
• Is inflammation of the lung parenchyma
• Etiology
– Infectious
– Noninfectious and aspiration
– Hypersensitivity and reaction
– Drugs or radiation-induced pneumonitis

5. Bacteria
• S.pnuemonia-commonest 3wk-4yr
• C.pneumoniaeand M.pnuemoniae-
commonest above ≥5years of age
• S.aureus-commonest after influenza viruse
• S.pyogenes

6. Conti……….
AGE GROUP FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)
Neonates (<3 wk) GBS, E.coli, other Gram-negative bacilli, S.pneumoniae,
H.influenzae (type b, nontypeable)
3 wk-3 mo RSV, other respiratory viruses (rhinoviruses, parainfluenza
viruses, influenza viruses, human metapneumovirus,
adenovirus), S. pneumoniae, H. influenzae (type b,
nontypeable); if patient is afebrile, consider C. trachomatis
4 mo-4yr RSV, other respiratory viruses (rhinoviruses, parainfluenza
viruses, influenza viruses, human metapneumovirus,
adenovirus), S. pneumoniae, H. influenzae (type b,
nontypeable), M.pneumoniae, group A streptococcus
≥5 yr M. pneumoniae, S. pneumoniae, C.pneumoniae, H. influenzae
(type b,* nontypeable), influenza viruses, adenovirus, other
respiratory viruses

7. • S. pneumoniae, H. influenzae, and S. aureus
are the major causes of hospitalization and
death from bacterial pneumonia.
• The incidence of pneumonia caused by H.
influenzae or S.pneumoniae has been
significantly reduced in areas where routine
immunization has been implemented.

8. EPIDEMIOLOGY
• Is the leading infectious cause of death globally
• Among children younger than 5 yr, accounting for
an estimated 920,000 deaths each year.
• Pneumonia mortality is closely linked to poverty.
• More than 99% of pneumonia deaths are in low-
and middle-income countries.
• The highest pneumonia mortality rate occurring
in poorly developed countries.

10. PATHOGENESIS
• Defence mechanisms of respiratory tract
– Mucociliary clearance
– Macrophages
– Secretory immunoglobulin A
– Coughing refelex

11. Viral pneumonia
• Usually results from spread of infection along the
airways.
• Then causes a direct injury of the respiratory
epithelium.
• Airway obstruction occurs from swelling, abnormal
secretions, and cellular debris.
• The small caliber of airways in young infants makes
such patients particularly susceptible to severe
infection.
• Atelectasis, interstitial edema, and hypoxemia from
ventilation–perfusion mismatch often accompany
airway obstruction.

12. • Viral infection of the respiratory tract can also
predispose to secondary bacterial infection by
– Disturbing normal host defence mechanisms
– Altering secretions
– Through disruptions in the respiratory microbiota.

13. Bacterial pneumonia
• Most often occurs when respiratory tract
organisms colonize the trachea and
subsequently gain access to the lungs
• Pneumonia may also result from direct
seeding of lung tissue after bacteremia.
• When bacterial infection is established in the
lung parenchyma, the pathologic process
varies according to the invading organism.

14. M. pneumoniae
• Attaches to the respiratory epithelium, inhibits ciliary
action, and leads to cellular destruction and an
inflammatory response in the submucosa.
• As the infection progresses, sloughed cellular debris,
inflammatory cells, and mucus cause airway obstruction,
with spread of infection occurring along the bronchial tree,
as is seen in viral pneumonia.
S. pneumoniae
• produces local edema that aids in the proliferation of
organisms and their spread into adjacent portions of lung,
often resulting in the characteristic focal lobar involvement.

15. Group A streptococcus
• Lower respiratory tract infection typically results
in more diffuse lung involvement with interstitial
pneumonia.
• The pathology includes
– Necrosis of tracheobronchial mucosa
– Formation of large amounts of exudate
– Edema and local hemorrhage, with extension into the
interalveolar septa; and involvement of lymphatic
vessels with frequent pleural involvement.

16. S. aureus pneumonia
• Manifests as confluent bronchopneumonia,
often unilateral and characterized by
– the presence of extensive areas of hemorrhagic
necrosis and irregular areas of cavitation of the
lung parenchyma, resulting in pneumatoceles,
empyema, and bronchopulmonary fistulas.

17. Recurrent pneumonia
• Is defined as 2 or more episodes in a single
year or 3 or more episodes ever, with
radiographic clearing between occurrences.
• An underlying disorder should be considered if
a child experiences recurrent pneumonia.
• Differential diagnosis of recurrent pneumonia
are the following

18. HEREDITARY DISORDERS
– Cystic fibrosis
– Sickle cell disease
DISORDERS OF IMMUNITY
– HIV/AIDS
– Primary immunodeficiencies

19. DISORDERS OF CILIA
– Primary ciliary dyskinesia
– Kartagener syndrome
ANATOMIC DISORDERS
– Pulmonary sequestration
– Lobar emphysema
– Congenital cystic adenomatoid malformation
– Gastroesophageal reflux
– Foreign body aspiration
– Tracheoesophageal fistula (H type)
– Bronchiectasis
– Aspiration (oropharyngeal incoordination)
– Aberrant bronchus

20. CLASSIFICATION
Criteria used for classification
• Etiologic
• Anatomic
• severity

21. Anatomic
• Lobar
• Bronchial
• interstitial
Severity
• Sever pneumonia
• Pneumonia
• No pneumonia
Ethiology
• Viral
• Bacterial
• Fungal

22. COMPLICATIONS
LOCAL COMPLICATIONS
• Pleural effusion,
• empyema, abscess,
• Bronchopleural fistula,
• Necrotizing pneumonia,
acute
• Acute respiratory
distress syndrome
• Respiratory failure
DISTANT COMPLICATIONS
• Meningitis
• Arthritis
• Pericarditis
• Osteomyelitis
• Endocarditis
• Haemolytic uremic
syndrome
• Sepsis

23. Clinical Manifestations
• Frequently preceded by several day symptoms of URTI
• Cough: chief symptom
• Increased respiratory rate:
– > 60/minute infants younger than 2 months old
– >50/minute infants 2-12 months old
– > 40/minute children 1-5 years old
• Grunting (keeps narrow airways open)
• Sign of severe distress and impending respiratory
failure
• Nasal flaring (air hunger)

24. • In infants
– vomiting, anorexia, diarrhea, and abdominal
distention secondary to a paralytic ileus.
– may have a prodrome of URTI and poor feeding,
leading to the abrupt onset of fever, restlessness,
apprehension, and respiratory distress.
• In older children sudden onset high fever,
cough, and chest pain may presentation.

25. • Retractions: intercostal, supraclavicular,
subcostal
• Increased effort to breathe, decreased lung
compliance
• Hypoxemia: normal >95%
• Fever

26. Diagnosis
• Chet x-ray
• Chest U/S
• CBC
• ESR/CRP
• PCR
• Blood culture (fail to improve, have clinical
deterioration, complicated pneumonia, or require
hospitalization)
• ASO and anti-DNase B titers

27. MANAGEMENT
• INDICATION FOR ADMISSION
– Age <6 mo
– Immunocompromised state
– Toxic appearance
– Moderate to severe respiratory distress
– Hypoxemia (oxygen saturation <90% breathing room air, sea level)
– Complicated pneumonia
– Sickle cell anemia with acute chest syndrome
– Vomiting or inability to tolerate oral fluids or medications
– Severe dehydration
– No response to appropriate oral antibiotic therapy
– Social factors (e.g., inability of caregivers to administer medications at
home or follow-up appropriately)

28. 1. Oxygen Therapy: IN o2, CPAP, MV
2. Fluid Therapy: MF, dehydration mgt.
3. Antipyretics: paracetamol
4. Antibiotics
5. Oral Zinc for 7days

29. ANTIBIOTICS
• Empiric antibiotic choice for hospitalised
suspected pneumonia patient depends on
– local epidemiology,
– the immunization status of the child, and
– the clinical manifestations at the time of
presentation

30. Ampicillin or penicillin G for inpatient
GIVEN
– without substantial high-level penicillin resistance for
s.pneumoniae
– Fully immunized for H.influenzae type b and
s.pneumoniae
– Not severely ill child
– Ceftriaxone or cefotaxime can be given for those that
don’t fulfil the above criteria.
– Total duration continued upto 10days

31. • Outpatient
– High dose amoxacillin
– Macrolides for pencillin allegy and suspected
antipical bacteria
– Total duration 5-7days if azithromycin for 5days

32. PROGNOSIS
• Tachycardia and hypotension- Within two days
• Fever, tachypnea, chest and arterial
oxygenation (PaO2)- Within three days
• Cough and fatigue- ≥14 days
• Radiographic improvement up to 1month

33. PREVENTION
• Vaccination that prevent pneumonia are
– PCV
– Influenza vaccine
– H.influenza type b vaccine
– Pertussis vaccine
– Measles vaccine
– RSV vaccine