Pneumonia is an inflammation of the lung parenchyma that is most commonly caused by infectious agents like bacteria and viruses. It is a leading cause of death among children under 5 years old globally. Symptoms include cough, fever, tachypnea, and respiratory distress. Diagnosis involves physical exam findings and chest x-ray. Treatment depends on the suspected cause and severity of illness, and may involve hospitalization, antibiotics, oxygen support, and fluid resuscitation. Prognosis is generally good with appropriate treatment, but complications can occur.

1. PNEUMONIA
By Saba Sadeghpour

2. Pneumonia defined as inflammation of the lung parenchyma.
Definition

3. Definition

4. Epidemiology
◦ Mortality is closely linked to poverty.( more than 99% of pneumonia
death)
◦ The highest pneumonia mortality rate occurring in poorly developed
countries. (in Africa and South Asia)

5. pneumonia…
diarrhea
19%
neonatal sepsis
15%
malaria
11%
measles…
meningitis…
HIV/AIDS…
other infections
12%
Infectious cause of death
Pneumonia is the leading
infectious cause of death
globally among children
younger than 5 yr (920,000
death each year)
Epidemiology

6. The introduction of pneumococcal conjugate vaccines (PCVs)
،has been an important contributor to the further reductions in
pneumonia-related mortality achieved over the past 15 yr.

7. Etiology
*Although most cases of pneumonia are caused by microorganisms.
noninfectious causes include:
Aspiration (food or gastric acid, foreign bodies)
Hypersensitivity reactions
Drug
Radiation

8. The cause of pneumonia in an individual patient is often difficult to
determine:
✔Direct sampling of lung tissue is invasive and rarely performed.
✔Bacterial cultures of sputum or upper respiratory tract samples from
children typically do not accurately reflect the cause of lower
respiratory tract infection.
Etiology

9. ✗Pneumococcus(the most common in 3 wk to 4 yr )
✗Mycoplasma pneumoniae (the most frequent in 5 yr and older)
✗Chlamydophila pneumoniae (the most frequent in 5 yr and older)
✗Group A streptococcus (Streptococcus pyogenes )
✗Staphylococcus aureus
Etiology (bacterial pathogen)

10. RSV (in younger than 5 yr)
Parainfluenza (1,2,3)
Influenza (A.B)
Etiology (viruses)

11. ❏Fungal (Histoplasma capsulatum, Blastomyces dermatitidis,
Coccidioides immitis, Cryptococcus neoformans, Aspergillus
species, Mucormycosis, Pneumocystis jiroveci)
❏Rickettsial (Rickettsia rickettsiae)
❏Parasitic (Eosinophilic pneumonia)
Etiology

12. The major causes of hospitalization and death from bacterial pneumonia
among children (in developing countries):
❀S. pneumoniae
❀H. influenzae
❀S. aureus
Etiology

13. ✽Viral pathogens are the most common causes of lower respiratory tract
infections. (in infants and children older than 1 mo but younger than 5
yr of age)
✽Lower respiratory tract viral infections are much more common in the
fall and winter .(in relation to the seasonal epidemics of respiratory
viruses that occur each year)
Etiology

14. ☞Infection with more than one respiratory virus occurs in up to 20% of
cases.
☞The age of the patient can suggest the likely pathogens.
Etiology

15. Pathogenesis
The lower respiratory tract possesses a number of defense mechanisms
against infection:
Mucociliary clearance
Macrophages
Secretory immunoglobulin A
Coughing

16. Viral pneumonia
Usually results from spread of infection along the airways, accompanied
by direct injury of the respiratory epithelium. (which results in airway
obstruction from swelling, abnormal secretions, and cellular debris)

18. Bacterial pneumonia
Often occurs when respiratory tract organisms colonize the trachea
and subsequently gain access to the lungs. (pneumonia may result
from direct seeding of lung tissue after bacteremia)

19. Group A streptococcus lower respiratory tract infection includes:
✦Local hemorrhage (extension into the interalveolar septa)
✦Necrosis of tracheobronchial mucosa
✦Formation of large amounts of exudate
✦Edema
✦Involvement of lymphatic vessels

20. S. aureus pneumonia confluent:
✧Irregular areas of cavitation of the lung parenchyma
✧Bronchopneumonia (often unilateral)
✧Extensive areas of hemorrhagic necrosis
✧Bronchopulmonary fistulas

21. Recurrent pneumonia
2 or more episodes in a single year or 3 or more episodes ever, with
radiographic clearing between occurrences.

22. Clinical Manifestations
☑Rhinitis
☑Cough
☑Fever (specially)
☑Tachypnea
☑Use of the accessory respiratory muscles
☑Cyanosis (severe infection)
☑Lethargy (severe infection and infants)

24. Auscultation :crackles and wheezing
*It is often difficult to localize the source of these adventitious sounds in very
young children with hyperresonant chests.
Clinical Manifestations

25. Bacterial pneumonia (in older children & adults) typically begins suddenly
with high fever, cough, and chest pain. Other symptoms:
➣Drowsiness (with intermittent periods of restlessness)
➣Rapid respirations
➣Anxiety
➣Occasionally
➣Delirium
➣Splinting (minimize pleuritic pain and improve ventilation)
Clinical Manifestations

27. Physical findings
It depend on the stage of pneumonia:
✓Early in the course =diminished breath sounds, scattered crackles,
rhonchi (over the affected lung field)
✓The development of increasing consolidation or complications of
pneumonia such as pleural effusion or empyema, dullness on
percussion is noted and breath sounds may be diminished.

28. ✓Abdominal distention may be prominent because of gastric dilation from
swallowed air or ileus.
✓Abdominal pain is common in lower-lobe pneumonia.
✓The liver may seem enlarged (downward displacement of the diaphragm
secondary to hyperinflation of the lungs or congestive heart failure)
Physical findings

29. In infants, there may be a prodrome of upper respiratory tract infection
and:
❁Poor feeding
❁The abrupt onset of fever
❁Restlessness
❁Apprehension
❁Respiratory distress
Physical findings

30. Respiratory distress
✪Nasal flaring
✪Retractions of the supraclavicular, intercostal, and subcostal areas
✪Tachypnea
✪Tachycardia
✪Air hunger
✪Often cyanosis
*Auscultation may be: misleading, particularly in young infants, with meager findings
disproportionate to the degree of tachypnea.

31. Diagnosis
CXR (PA & lateral) supports the diagnosis of pneumonia.

32. CXR
⚐It identify a complication such as a pleural effusion or empyema.
⚐Hyperinflation with bilateral interstitial infiltrates and peribronchial
cuffing (viral)
⚐Confluent lobar consolidation is typically seen with pneumococcal
pneumonia.

33. ⚑The radiographic appearance alone does not accurately identify
pneumonia etiology, and other clinical features of the illness must be
considered.
⚑Repeat chest radiographs are not required for proof of cure for patients
with uncomplicated pneumonia.
CXR

34. *Chest radiograph didn’t performed for children with suspected
pneumonia (cough, fever, localized crackles, or decreased breath sounds)
who are well enough to be managed as outpatients because imaging in
this context only rarely changes management.
CXR

35. Ultrasonography is highly sensitive and specific in diagnosing
pneumonia in children by determining lung consolidations and air
bronchograms or effusions.
Diagnosis

36. The peripheral WBC count can be useful in differentiating viral from
bacterial pneumonia:
⚛Viral pneumonia= WBC count is normal /elevated (but is usually not higher
than 20,000/mm3 +lymphocyte predominance)
⚛Bacterial pneumonia= often elevated WBC count (15,000-40,000/mm3) +
polymorphonuclear leukocytes
Diagnosis

37. A large pleural effusion, lobar consolidation, and a high fever at the
onset of the illness are also suggestive of a bacterial etiology.
Diagnosis

38. Factors Suggesting Need for Hospitalization of
Children With Pneumonia:
1. Age <6 mo
2. Immunocompromised state
3. Toxic appearance
4. Moderate to severe respiratory distress
5. Hypoxemia (O 2 sa <90% breathing room air, sea level)

39. Bronchopleural fistula
Factors Suggesting Need for Hospitalization of
Children With Pneumonia:
6. Complicated pneumonia(pleural effusion, empyema, fistula, distress,
abscess, necrotizing pneumonia, extrapulmonary infection, hemolytic
uremic syndrome, or sepsis.)
7. Sickle cell anemia with acute chest syndrome
8. Vomiting or inability to tolerate oral fluids or medications

40. Factors Suggesting Need for Hospitalization of
Children With Pneumonia:
9. Severe dehydration
10. No response to appropriate oral antibiotic therapy
11. Social factors (e.g., inability of caregivers to administer medications at
home or follow-up appropriately)

41. Treatment
In bacterial pneumonia is based on:
◉Presumptive cause
◉Age
◉Clinical appearance of the child

42. ♻Amoxicillin (<5 yr)_ 90 mg/kg/day orally divided twice daily
♻Cefuroxime + amoxicillin/clavulanate
♻Macrolide (school-aged/ adolescents)
♻Azithromycin (8 yr or older)
♻Clarithromycin /doxycycline
♻Fluoroquinolone (adolescents)
♻Erythromycin (40 mg/kg/day in 4doses)
Treatment (Outpatient)

43. The treatment of suspected bacterial pneumonia in a hospitalized child is
based on:
⚠ local epidemiology
⚠immunization status of the child
⚠clinical manifestations at the time of presentation
Treatment

44. ♲Ampicillin /penicillin G (not severely ill)
♲Ceftriaxone /cefotaxime (who do not meet these criteria)
♲Vancomycin /clindamycin (pneumatoceles,empyema)
♲Macrolide (M. pneumoniae or C. pneumoniae)
Treatment (hospitalized)

45. Antibiotic therapy especially for
=
preschool aged + mildly ill + no distress
*However, up to 30%of patients with known viral infection, particularly influenza viruses,
may have coexisting bacterial pathogens.
Treatment (viral pneumonia)

46. Supportive care in hospital
• Respiratory support:
o mechanical ventilation
o supplemental oxygen
o continuous positive airway pressure (CPAP)
• Vasoactive medications (for hypotension or sepsis physiology)

47. Duration of antibiotic therapy
⚡Antibiotics should generally be continued until the patient has been
afebrile for 72 hr.
⚡The total duration should not be less than 10 days. (or 5 days if
azithromycin is used)

48. Prognosis
*Uncomplicated bacterial pneumonia show response to 48-72 hr
antibiotic therapy.

49. Some possibilities must be considered when patient doesn’t improve:
1. Complications( pleural effusion / empyema)
2. Bacterial resistance
3. Nonbacterial etiologies (viruses , fungi , aspiration of foreign bodies)
empyema
aspiration of foreign
bodies
pleural effusion

50. Some possibilities must be considered when patient doesn’t improve:
4. Noninfectious causes (including bronchiolitis obliterans, hypersensitivity
pneumonitis, eosinophilic pneumonia, Wegener granulomatosis)
5. Preexisting diseases (immunodeficiencies, ciliary dyskinesia, cystic fibrosis,
pulmonary sequestration, congenital malformation)
6. Bronchial obstruction

51. Determining the reason for a lack of response to
initial treatment:
☢CXR
☢Bronchoalveolar lavage (in children with respiratory failure)
☢CT scans (may better identify complications)

52. ✷Mortality from community-acquired pneumonia is rare.
✷most children with pneumonia do not experience long-term
pulmonary sequelae.
✷Up to 45% of children have symptoms of asthma 5 yr after
hospitalization for pneumonia.
Prognosis

53. Complications
It usually the result of:
☺Bacteremia
☺Direct spread of bacterial infection within the thoracic cavity (pleural
effusion, empyema, and pericarditis)
☺Hematologic spread (Meningitis, endocarditis, suppurative arthritis,
osteomyelitis)

54. ✍Vaccine ( like PCV7, influenza, RSV vaccines) for children >6 mo of age
✍For infants <6 mo of age, household contacts and other primary
caregivers should be immunized.
Prevention

55. References
✉http://www.hkjpaed.org/details.asp?id=684&show=1234
✉http://brownemblog.com/blog-1/2019/5/31/tuberculous-pleural-effusion
✉https://www.frontiersin.org/articles/10.3389/fimmu.2018.01403/full
✉Nelson Textbook of Pediatrics, 21th edition 2020
✉Uptodate
✉Medscape

56. For Your Attention