Pneumonia in children + LONG CASE

• Define Community Acquired Pneumonia

• Describe the clinical presentation of CAP in different age groups

• List the causative organisms of CAP in these age groups

• List the investigations that are needed for diagnosis and management community acquired pneumonia (CAP)

• Discuss the management of CAP including the choice of antibiotics

• Pneumonia is an infection of the lungs

• It is characterised by inflammation of the alveoli

• Alveolar space are filled with secretions

• interferes with air exchange

• Causes hypoxia

• Invasion of alveoli and terminal air spaces by microorganisms - inhaled or via the blood stream

• Inflammatory cascade triggers leakage of plasma and loss of surfactant resulting in air loss and consolidation

• Activated inflammatory cascade results in

• injury to host tissues

• alter endothelial and epithelial integrity

• alter the vascular tone and intravascular haemostasis

• Presence of signs and symptoms of pneumonia in a previously healthy child due to an infection that has been acquired in the community

• Paediatric pneumonia is a killer

• Pneumonia claims the life of a child every 20 seconds.

• According to UNICEF 3 million children die of pneumonia evert year

• 98 percent of pneumonia-induced deaths occur in developing countries

• These deaths are more likely in children with underlying conditions such as congenital heart disease, chronic lung disease of prematurity or immunodeficiency

• -Highest in infancy

• -Relatively high in childhood

• greater risk of contracting the disease

• their immune system is not fully developed.

• Most are caused by viruses or bacteria

• Approximately 1/3rd of paediatric pneumonias are due to a combination of viral and bacterial infections (mixed infection)

• Age is a very important factor in the ethology

• Viruses are more common in younger children, while bacteria become commoner in older children

• But in about 50% no pathogen is identified

• organisms acquired from the maternal genital tract e.g. GBS, E coli, Klebsiella and Listeria monocytogenus

• Most common virus - RSV

• Respiratory viruses – RSV, Influenza and Parainfluenza, Adeno, Entero and Corona viruses

• Bacteria – Streptococcus Pneumoniae, Staphylococcus aureus (rare, but serious), non-typable Haemophilus influenzae [contribution by Hib depends on immunisation status]

• Mycoplasma pneumoniae

• Streptococcus pneumoniae

• Chlamydia pneumoniae

• Myco and Clamy different antibiotics than strep

• Consider Mycobacterium tuberculosis at all ages.

• Clinical presentation varies with age

• The younger the child symptoms are non-specific

• Cough and fever which are hallmarks of pneumonia in adults may be absent in younger children

• “Unwell” child

• Fever

• Poor feeding

• Cough

• Tachuypnoea and chest recessions- noticed by parents - used as a feature to diagnose CAP

• “Unwell” child - poor feeding, lethargy

• Fever

• Cough!

• Tachypnoea

• Difficulty in breathing

• Constitutional symptoms - headache, vomiting, diarrhoea

• Chest, abdominal or neck pain - pleuritic pain

• May be difficult to appreciate in neonates and very young children

• Tachypnoea is the most easily appreciated sign

• Respiratory rate

• Respiratory effort - chest recessions / working of accessory muscles of respiration

• Oxygen saturation

• Presence of cyanosis

• Chest xray (consolidation, pleural effusion) - poor indicators of aetiology and severity - do not perform routinely in mild uncomplicated acute LRTI

• Ultrasonography - this has been shown to accurately diagnose pneumonia in infants and children. May eventually replace xrays.

• CT / MRI if indicated

• FBC (hint at bacterial neutrophilic leucocytosis vs viral)

• CRP (do not distinguish between bacterial and viral infections in children and should not be measured routinely)

• PCR of nasopharyngeal aspirate

• Cultures (colonised organisms!) - sputum / blood (younger infants) / nasopharyngeal aspirate / pleural fluid / bronchial aspirate (When facilities are available blood cultures should be performed in children suspected of having bacterial pneumonia [B]. Acute serum samples for antibodies may be saved and a convalescent sample taken in cases where a microbiological diagnosis was not reached during the acute illness [B]. When significant pleural fluid is present, it could be aspirated for diagnostic purposes and sent for microscopic examination and culture. Another specimen could be saved for bacterial antigen detection [B].)

• Serology (esp for mycoplasma) - acute and convalescent

• SaO2 < 93%

• Severe tachypnoea

• Difficulty in breathing

• Grunting

• Apnoea

• Not feeding

• Family unable to provide appropriate care (relative)

• Respiratory support for those having grunting, flaring, severe tachypnea, and retractions - HIgh flow oxygen via face mask /Nasal canulae (Oxygen should be administered to children who are restless, tachypnoeic with severe chest indrawing (Oxygen saturation < 92%))

• Those unable to maintain oxygenation by above means or develop decreasing level of consciousness and hypercapnia may need PPV /CPAP

• General supportive care

• Analgesic for pain, headache etc.

• Antipyretics

• IV fluids if not drinking adequately (When a child is in severe respiratory distress oral intake may be impaired. Intravenous fluid can be administered, but should be done cautiously, since syndrome of inappropriate ADH secretion is a possibilit)

• Attention to nutrition - NG feeds if needed

• where the disease was acquired - Community vs hospital

• age

• severity of illness

• appearance of chest x ray

• Broad spectrum IV antibiotics to cover both  gram positive and negative organisms

• Combination therapy (ampicillin and either gentamicin or cefotaxime) is typically used in the initial treatment of newborns and young infants

• Second- or third-generation cephalosporins and macrolide antibiotics such as azithromycin (older children - myco and clamy!) are acceptable alternatives.

• For staphylococcal and resistant pneumococcal infections Vancomycin may be needed

• Pulmonary

• Metastatic

• Systemic

• Pleural effusion

• Empyema

• Lung abscess

• Pneumothorax

• Broncho-pleural fistula

• Necrotizsng pneumonia

• Acute respiratory failure

• Meningitis

• Cerebral abscess

• Pericarditis

• Endocarditis

• Osteomyelitis

• Septic arthritis

• Systemic inflammatory response syndrome or sepsis

• Haemolytic ureamic syndrome

• Pleural effusions - usually these are sympathetic effusions and resolve with appropriate antibiotic therapy

• Empyema and lung abscess

• -May require drainage with a chest drain

• -Installation of a fibrinolytic agent in the intrapleural space (e.g. urokinase)

• -Surgical decortication may be needed

• Overall, the prognosis is good.

• Most cases of viral pneumonia resolve without treatment

• Common bacterial pathogens and atypical organisms respond to antimicrobial therapy

• Staphylococcal pneumonia although rare, can be very serious despite treatment

• Long-term alteration of pulmonary function is rare, even in children with pneumonia that has been complicated by empyema or lung abscess.

• Counsel parents

• -prevent exposure of infants to tobacco smoke

• -Importance of hand washing / (? face covering) regarding later infectious exposures in daycare centers, schools, and similar settings

• - benefit of pneumococcal immunization and annual influenza immunizatin

• lobar pneumonia (most likely strep pneu)

• developin into a bronchoneumona maybe viral developing into bacterial? more severe

• right mid zone consolidation (not that symptomatic!)

• consolidation right upper lobe (lower border convex downwards - very small children -classical klebsiella - high power anti)

• Mycoplasma pneumoniae

• Chlamydia pneumoniae

• Legionella pneumophila

• A dry cough,confusion or diarrhoea

• Lymphopenia without marked leukocytosis

• Hyponatraemia

• Aspiration

• Intubation

• Bacteraemia

• Pseudomonas aeruginoa

• Klebsiella pneumoniae

• E.coli

• Serratia

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