Understanding pneumonia in children

1. PNEUMONIA IN
CHILDREN

2. LECTURE OUTLINE
1. Introduction
2. Definition
3. Epidemiology
4. Risk factors
5. Classification
6. Etiology
7. Pathogenesis
8. History and Clinical features
9. Investigations
10. Complications
11. Management
12. Prevention

3. INTRODUCTION
Globally, pneumonia is a significant cause of morbidity and
mortality in children younger than 5 years throughout the world,
particularly in developing countries.
The introduction of immunisation ( Hib and Pneumococcal) has
drastically reduced the incidence and mortality due to
pneumonia.

4. DEFINITION
Pneumonia is an inflammation of the parenchyma of
the lungs.
Most cases of pneumonia are caused by
microorganisms, but there are several noninfectious
causes

5. EPIDEMIOLOGY
An estimated 120 million cases of pneumonia occur annually
worldwide, resulting in1.3 millions deaths.
Children below the age of 2 years in the developing world, account
for nearly 80% of Paediatric deaths secondary to pneumonia.
The introduction of vaccines ( Hib and pneumococcal) has to a
certain degree reduced the risk of pneumonia in developing
countries

7. Classification
 Etiological( organism)
 Anatomical ( lobar, bronchopneumonia,)
 Clinical setting( CAP,HAP,VAP)
 Clinical presentation

8. Etiology
Infectious
 Bacteria
 Viruses (influenza,
RSV.parainfluenza,adenoviruses)
 Fungi-rare, high risk in
immunocompromised patients-
aspergillosis,histoplasmosis
Non- infectious
 Aspiration
 Hydrocarbons
 Foreign body
 Hypersensitivity reactions
 Drug/radiation induced
pneumonitis

9. ETIOLOGY
Causes of pneumonia in children can be classified by age-specific versus
pathogen-specific organisms
1. Neonates:
Early-Onset: 2-5 years
• Group B streptococci . Streptococcus pneumoniae
• Klebsiella pneumoniae . Hemophilus influenzae
• Escherichia coli . Respiratory viruses
• Listeria monocytogenes
Late onset: 5 years and above
• Streptococcus pneumoniae . S. pneumoniae
• Streptococcus pyogenes . Mycoplasma pneumoniae
• Staphylococcus aureus
S. Pneumoniae is still the most commonly identified organism in children of 5 years and above.

10. Congenital infections
 TORCH infections can potentially cause pneumonia
in newborn babies
 Toxoplasmosis
 Others –HIV
 Rubella
 CMV
 Herpes simplex

11. Normal Chest x-ray

12. PATHOGENESIS
Pneumonia is due to an invasion of the lower respiratory tract, below the larynx
by pathogens either by inhalation, aspiration, respiratory epithelium invasion or
hematogenous spread.
The infection breaches the anatomical barriers, humoral and cellular immunity
either by fomite/droplet spread ( mostly viral) or nasopharyngeal colonisation
( mostly bacterial). This leads to inflammation causing an exudative process,
which in turns impairs oxygenation.
There are 4 stages of lobar pneumonia:
1. Alveolar oedema and vascular congestion: within 24 hours
2. Red hepatisation: consolidation due to RBCs, neutrophils and
desquamated epithelial cells associated with fibrin deposits in the alveoli
3. Gray hepatisation: 2 -3 days later. Lung appear dark brown. There
accumulation of hemosiderin and hemolysis of RBCs
4. Resolution: cellular infiltrate is resorbed and the pulmonary architecture is

13. Pathogenesis

14. Anatomical classification

15. Lobar pneumonia Bronchopneomonia

16. Interstitial pneumonia

17. HISTORY
 Duration of symptoms
 Exposures, travel,
 Sick contacts
 Baseline health of the child
 Chronic diseases
 Recurrent symptoms
 Immunisation history
 Maternal health
 Birth complications in neonates.

18. CLINICAL FEATURES
1. Symptoms:
 Cough
 Body hotness
 Fast and difficult breathing
 Feeding difficulty in infants
2. Signs:
 Tachypnoea
 Inter and sub-costal recessions
 Nasal flaring
 Cyanosis
 Sa O2 < 90% on room air

19. PHYSICAL EXAMINATION
Inspection
• ill-looking
• chills/rigors
• Inter and sub-costal recessions
• Nasal flaring
• cyanosis
Palpation
• decreased chest expansion or
asymetry
• lymphadenopathy
• increased tactile fremitus
creaPercussion
• dull
• Stony dull, Hyperresonant
Auscultation
• bronchial breath sounds in periphery
• decreased air entry, crepitations
( coarse crackles )
• bronchophony -voice heard
abnormally clearly over consolidated
lung
• egaphony - listen to patient's chest as
they make "e" sound, if +'ve will hear
an "a" sound
• whispering pectoriloquay - pt
whispers "1, 2, 3, 4", if clear then
extreme consolidation

20. Definition of tachypnea
Age Respiratory rate b/min
Neonate >60
>2 months-12 months >50
1-5yrs >40
5-15yrs >30
>15yrs >20

21. INVESTIGATIONS
1. FBC + Acute phase reactants ( ESR and CRP)
2. CXR
3. Blood culture
4. Serology is being used to determine the presence
of mycoplasma, legionella, and chlamydia
species.
5. Sputum mcs

22. Radiological pictures of
pneumonia
Non homogenous opacity in
the right mid-zone

23. Homogenous opacity in the
right lower zone

24. CLINICAL Classification
 Pneumonia- cough fever breathing difficulties
 Severe Pneumonia- fever, cough, breathing
difficulties, crepitations
 Very severe Pneumonia- above symptoms PLUS
cyanosis, head bobbing, inability to take orally

25. COMPLICATIONS
Local
1. Empyema: a collection of pus in
the pleural cavity
2. Pleural effusion: build-up of
excess fluid between the layers
of the pleura outside the lungs
3. Lung abscess
4. Necrotizing pneumonia*
5. Respiratory failure
Systemic
 Sepsis
 SiADH
 Hypoxic injury to vital organs-
Brain,heart,kidneys

26. Complications
Pleural effusion Empyema thoracis

27. Complications- lung abscess
and empyema thoracis

28. TREATMENT
Treatment should be targeted to a specific pathogen
that is suspected based on information obtained from
history and physical exam.
1. Supportive and symptomatic management is key
and includes supplemental oxygen for hypoxia,
antipyretics for fever, and fluids for dehydration.
2. Specific antibiotics
3. Promote good nutrition + breastfeeding
4. Treat complications-

29. Viral pneumonias
 Viruses that can lead to pneumonia include:
 Influenza (flu) A and B viruses, the most common causes in adults
 Respiratory syncytial virus (RSV), which is more common in infants and
children than in adults
 Coronaviruses, including SARS-CoV-2, the new virus that causes
COVID-19
 Rhinoviruses, parainfluenza viruses, and adenoviruses

30. Symptoms
 Similar to bacterial pneumonia except:
 Dry cough
 Low grade fever
 Running nose
 myalgia

31. Treatment
 A-clear airway, B-oxygen, C-IV access
Supportive –
 Analgesia, antipyretic, NS nasal drops
 Hydration
 If you have an influenza virus, medications such as oseltamivir (Tamiflu),
zanamivir (Relenza), or peramivir (Rapivab). These drugs keep flu viruses
from spreading in your body.
 If RSV is the cause of your pneumonia, a medication such as ribavirin (
Virazole) may be given, especially vulnerable patients with CHD,
immunocpmromisation. This helps to limit the spread of viruses.

32. Clinical setting-HAP/VAP
 Hospital-acquired pneumonia (HAP) or nosocomial pneumonia refers
to any pneumonia contracted by a patient in a hospital at least 48–
72 hours after being admitted.
 It is thus distinguished from community-acquired pneumonia.
 It is usually caused by a bacterial infection, rather than a virus.

33. HAP
 Accounts for 15–20% of the total.
 It is the most common cause of death among nosocomial infections
and is the primary cause of death in intensive care units
 HAP typically lengthens a hospital stay by 1–2 weeks.

34. Causes of HAP
 The majority of cases, rod shaped gram-negative organisms (52%)
 Staphylococcus aureus (19%), usually of the MRSA type.
 Others are Haemophilus spp. (5%).
 In the ICU results were S. aureus (17.4%), Pseudomonas aeruginosa
(17.4%), Klebsiella pneumoniae and Enterobacter spp. (18.1%), and
Haemophilus influenzae (4.9%).
 Viral pneumonia: influenza and respiratory syncytial virus and, in the
immunocompromised host, cytomegalovirus – cause 10–20% of
infections.[2]

35. Clinical features of HAP
 New or progressive infiltrate on the chest X-ray with one of the
following:[3]
 Fever > 37.8 °C (100 °F)
 Purulent sputum
 Leukocytosis > 10,000 cells/μl

36. Risk factors for HAP
 Among the factors contributing to contracting HAP are
mechanical ventilation (ventilator-associated pneumonia)
 Old age,
 Decreased filtration of inspired air, intrinsic respiratory, neurologic, or
other disease states that result in respiratory tract obstruction,
 Trauma, (abdominal) surgery, medications, or decreased clearance
of secretions may diminish the defenses of the lung.
 Also, poor hand-washing and inadequate disinfection of respiratory
devices cause cross-infection and are important factors.

37. VAP
 Ventilator-associated pneumonia (VAP) is a sub-type of hospital-acquired
pneumonia (HAP) which occurs in people who are receiving mechanical
ventilation.
 A positive culture after intubation is indicative of ventilator-associated
pneumonia and is diagnosed as such.
 In order to appropriately categorize the causative agent or mechanism it is
usually recommended to obtain a culture prior to initiating mechanical
ventilation as a reference.

38. Investigations-Diagnostic and
detection of complications
 FBC/DC( neutrophilia suggest bacterial/lymphocytosis suggests viral
etiology)
 Sputum /gastric lavage/pleural aspirate for mcs
 Bronchioaveolar lavage mcs-VAP
 Blood culture
 CXR
 Arterial blood gases
 Electrolytes -Sodium

39. Treatment
 A-clear airway, B-oxygen, C-IV access D- check RBS
 Usually, initial therapy is empirical.
 Then titrated to culture specific antibiotics
 Supportive- Antipyretic/analgesis, feeds, fluids,
 Treat complications e.g,drain empyema thoracis, thoracocentesis for
symptomatic effusions

40. PREVENTION
1. Avoid overcrowding
2. Immunisation:
 Pneumococcal conjugate (PCV)
 Haemophilus influenzae type b (Hib)
 Pertussis (whooping cough)
 Measles
3. Observe general hygiene, hand hygiene by HCW to
prevent cross infection
4. Breastfeeding during the first 6 months of life
5. Promote good nutrition

41. END