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    Pneumonia: Presented By: DR Aakrit Dahal Intern, Shree Birendra Hospital Department of Paediatrics

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    Akrit Dahal
    Pneumonia is a major cause of illness and death in children worldwide. It is defined as inflammation of lung parenchyma and is most commonly caused by viruses or bacteria through droplet transmission. Clinical features include fever, cough, tachypnea and respiratory distress. Diagnosis is based on clinical features, chest x-ray and lab tests like CBC, CRP. Treatment involves antibiotics, oxygen and hydration. Prognosis depends on factors like age, nutrition, underlying illness and development of complications. Prevention strategies include breastfeeding, immunization and reducing risk factors like indoor air pollution.

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    Pneumonia: Presented By: DR Aakrit Dahal Intern, Shree Birendra Hospital Department of Paediatrics

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    Akrit Dahal
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    Pneumonia is a major cause of illness and death in children worldwide. It is defined as inflammation of lung parenchyma and is most commonly caused by viruses or bacteria through droplet transmission. Clinical features include fever, cough, tachypnea and respiratory distress. Diagnosis is based on clinical features, chest x-ray and lab tests like CBC, CRP. Treatment involves antibiotics, oxygen and hydration. Prognosis depends on factors like age, nutrition, underlying illness and development of complications. Prevention strategies include breastfeeding, immunization and reducing risk factors like indoor air pollution.

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    Pneumonia in Children

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    Pnemonia

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    Pneumonia is a major cause of illness and death in children worldwide. It is defined as inflammation of lung parenchyma and is most commonly caused by viruses or bacteria through droplet transmission. Clinical features include fever, cough, tachypnea and respiratory distress. Diagnosis is based on clinical features, chest x-ray and lab tests like CBC, CRP. Treatment involves antibiotics, oxygen and hydration. Prognosis depends on factors like age, nutrition, underlying illness and development of complications. Prevention strategies include breastfeeding, immunization and reducing risk factors like indoor air pollution.

    Copyright:

    © All Rights Reserved
    137 views65 pages

    Pneumonia: Presented By: DR Aakrit Dahal Intern, Shree Birendra Hospital Department of Paediatrics

    Uploaded by

    Akrit Dahal
    Pneumonia is a major cause of illness and death in children worldwide. It is defined as inflammation of lung parenchyma and is most commonly caused by viruses or bacteria through droplet transmission. Clinical features include fever, cough, tachypnea and respiratory distress. Diagnosis is based on clinical features, chest x-ray and lab tests like CBC, CRP. Treatment involves antibiotics, oxygen and hydration. Prognosis depends on factors like age, nutrition, underlying illness and development of complications. Prevention strategies include breastfeeding, immunization and reducing risk factors like indoor air pollution.

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    Pneumonia

    Presented By:
    Dr Aakrit Dahal
    Intern, Shree Birendra Hospital
    Department of Paediatrics
    Contents
    Quiz
    Definition
    Epidemology
    Classification
    Etiology
    Pathogenesis
    Clinical feature
    Diagnosis
    Treatment
    Prognosis
    Complication
    Prevention
    Quiz 1
    What illness is the number one killer of children?

    • A. Diarrheal Disease
    • B. HIV/AIDS
    • C. Malaria
    • D. Pneumonia
    Quiz 2
    What is the most sensitive and specific sign of pneumonia in children?

    • A. Difficulty breathing
    • B. Fever
    • C. Tachypnea
    • D. Tachycardia
    Quiz 3
    If available, a chest x-ray should be done for children with possible
    pneumonia:

    • A. When a diagnosis is made


    • B. When a history of tachypnea is present
    • C. When antibiotics are started
    • D. When complications are suspected
    Quiz 4
    Which of the following immunization effectively reduce pneumonia mortality in
    children?

    • A. Haemophilus influenzae b Vaccine


    • B. Pneumococcal Conjugate Vaccine
    • C. Measles Vaccine
    • D. All of the above
    Definition
    • Pneumonia is defined as inflammation of Lung Parenchyma
    Epidemiology
    • Incidence of Pneumonia

    is 10 fold higher and


    death from pneumonia is 2000 fold more in developing country then
    in developed countries

    • Incidence has decreased in recent few years due to Antibiotic and


    vaccine
    Types of Pneumonia
    • 1.Anatomical Basis
    • 2.Etiological basis
    • 3.Clinical Basis
    Anatomical Basis
    Etiological causes (infectious)

    1. Bacteria
    2. Virus
    3. Fungal
    4. Rickettsial
    5. Mycobacterial
    6. Parasitic
    Non Infectious Causes
    1. Aspiration(food,foreign bodies,Hydrocarbons and gastric content)
    2. Hypersensitivity
    3. Drug/Radiation induced Pnemonitis
    Clinically
    • 1.Community Acquired Pneumonia
    • 2.Hospital Acquired Pneumonia
    Do all children acquire Pneumonia???
    Risk Factor
    1. Low Birthweight
    2. Malnutrition
    3. Vitamin A Deficiency
    4. Lack of Breast Feeding
    5. Large family
    6. Advance birth order
    7. Overcrowding
    8. Air pollution
    9. Passive Smoking
    Mode of transmission

    1. Droplet Nuclei
    2. Nosocomial
    3. Endogenous
    4. Blood Borne
    Pathogenesis

    1.Loss/Suppression of Cough
    reflex
    2.Injury to Muco-ciliary
    Apparatus
    3.Accumulation of Secretion
    4.Interferance with Action of
    alveolar macrophage
    5.Pulmonary Congestion
    Clinical Feature
    1. Preceded by URTI(rhinitis and cough)
    2. Fever(Higher in Bacterial than viral)
    3. Tachypnea
    4. Cough
    5. Dyspnea
    6. Chest pain
    7. Cyanosis and lethargy (in infants with severe infection)
    8. Signs of Respiratory Distress
    • In Viral Pneumonia, Low grade fever is usually present ,along with
    other feature of respiratory Distress:

    1. Tachypnea
    2. Increased work of breathing evident by intercostal,subcoastal,and
    suprasternal retratction,nasal flaring and use of accessory muscle
    3. Cyanosis and lethargy in case of severe infection
    4. Hyper resonant with crackles and wheezing
    Clinical Feature
    Bacterial pneumonia is characterized by :
    1. Sudden high grade fever, cough and chest pain
    2. Drowsiness, occasionally with delirium
    3. Along with Rapid progression of usual sign of respiratory distress
    • Tachypnea
    • Grunting
    • Nasal flaring
    • Retraction of the supraclavicular, intercoastal and subcoastal area
    • Cyanosis
    Infant Presenting Complain

    1. Prodrome of upper respiratory tract infection


    2. Diminished appetite,
    3. Abrupt onset of fever,
    4. Restlessness, apprehension, and respiratory distress.
    5. Ill looking,
    6. Respiratory distress manifested as (grunting; nasalflaring;
    retractions of the supraclavicular, intercostal, and subcostal)
    7. Tachypnea; Tachycardia; air hunger; and often cyanosis.
    Physical signs
    • Decreased breath sound
    • Crackles
    • Lag in respiratory excursion in affected side
    • If complication: Dull on percussion
    • Abdominal distention
    • Abdominal pain (common in lower lobe pneumonia)
    Sign of pneumonia -Indrawing

    out---breathing---in
    Lower chest wall indrawing: with inspiration,
    the lower chest wall moves in
    Sign of pneumonia - Nasal Flare

    Nasal flaring: with inspiration, the side of the


    nostrils flares outwards
    Diagnosis
    1. Clinically
    2. CBC
    3. Acute Phase Reactants(ESR,CRP)
    4. Chest X-ray
    5. USG
    6. Test for Viral Pneumonia
    7. Blood culture
    8. Test for Mycoplasma(Cold Agglutinin,PCR)
    Clinically
    Bacterial etiology is suspected when

    1.High fever
    2.Lobal consolidation
    3.Pleural effusion
    Complete Blood Count

    • In Viral Pneumonia is normal or elevated but usually not higher


    than 20,000/mm3,with a lymphocyte predominance

    • In Bacterial Pneumonia: WBC count range of 15,000-40,000/mm3,


    and a predominance of Granulocyte
    Acute Phase Reactants
    1. ESR,CRP
    2. Raised in case of Pneumonia
    3. Higher in bacterial, normal or slightly raised in viral Pneumonia
    Chest X-ray
    1.Viral Pneumonia:
     Peri-bronchial cuffing
     Bilateral interstitial infiltrates

    2.Pneumococaal Pneumonia: Lobar consolidation

    3.Stapylococcal Pneumonia: Pneumatocele


    Viral Pneumonia
    Pneumococcal Pneumonia
    IS USG HELPFUL???
    USG
    • Portable or handheld ultrasonography is Highly Sensitive and
    Specific in diagnosing Pneumonia in children.

    • USG may shows lung consolidation or effusion


    Viral Pneumonia
    • Viral isolation, antigen detection, or detection of Viral Genome

    • Rapid DNA,RNA test are available and are reliable

    • Serological technique can be applied by but not usually done

    • Peripheral cell gene expression pattern by microarray RT-PCR is


    Emerging modality
    Blood Culture
    1. Its only positive in 10 percent of patient
    2. Usually not done
    3. Done in case of complicated pneumonia
    Test for Mycoplasma
    • Cold agglutinins Titers> 1:64 is found in 50 % of patient infected
    with M pneumoniae
    • PCR is also positive
    Treatment
    Treatment is based of

    1. Presumptive cause.
    2. Age
    3. Clinical appearance of children
    • For Mildly ill Children who doesn’t require Hospitalization

    • Amoxicillin is prescribed(high dose of 80-90 mg/kg/24 hour)


    • Therapeutic alternatives include Cefuroxime Axetil and
    Amoxycillin/clavulanate

    • For school going children and children suspected with M pneumoniae


    and C pneumoniae , Macrolide antibiotic is prescribed(Azithromycin)

    In adolescent respiratory fluoroquinolones(Levofloxacin, Moxifloxacin)


    How long should the Antibiotic be used???
    Duration of therapy
    • Not well established

    • However, it is generally continued until the patient has been afebrile


    for 72 hours and the total duration should not be less than 10 days(5
    days for azithromycin)

    • Shorter course(5-7days) ,especially in patient treated on out patient


    basis can be used
    Should all children with Pneumonia be Admitted ???
    Criterial for Hospital Admission
    Treatment after Hospital Admission
    • 1.Oxygen Therapy
    • 2.Fluids and ensuring of hydration
    • 3.Antipyretics/Analgesic
    • 4.Antibiotic
    Hospital Treatment
    • Empirical treatment of Suspected bacterial Pneumonia in Hospitalized
    patient. The following criteria should be considered

    1. Without substantial high level of penicillin resistance among S


    pneumoniae
    2. Immunization against H influenzae type b and S pnemoniae
    3. Not severely ill

    • If Above criteria meet: Ampicillin or penicillin G


    • If criteria Don’t meet: Cefotaxime or Ceftriaxone should be used
    • If clinical feature suggest Staphylococcal pneumonia (Empyema,
    Pneumatocele) initial therapy should contain vancomycin or
    clindamycin
    If VIRAL pneumonia is suspected:
    It is reasonable to withheld Antibiotic if
    1. Mild illness
    2. Without respiratory distress

    However 30% of viral Pneumonia coexist with superimposed


    bacterial infection; and which can be suspected by rapid clinical
    deteriorating such same Antibiotic therapy should begun
    Role of Zinc
    • Oral Zinc (10mg if <12 month and 20mg >= 12 month) reduces the
    mortality
    Prognosis
    • Uncomplicated Pneumonia respond in 48-96 hours after initiation of
    Antibiotic therapy(clinically)

    • Radiological Evidence of improvement lags substantially behind


    clinical improvement

    • 45% hospitalized patient of pneumonia develops Bronchial Asthma


    after 5 years
    Prognostic Factors
    • 8 years old child with a diagnosis of Pneumonia was kept of oral
    Amoxycillin with Clavulanic Acid for 4 days, however the
    patient didn’t improve.

    WHAT MAY BE THE POSSIBLE CAUSES??


    Prognosis
    1. Complication
    2. Bacterial resistance
    3. Non bacterial etiology
    4. Bronchial Obstruction
    5. Pre-existing disease
    6. Non infective causes
    Complication
    • Pleural effusion
    • Empyema
    • Lung Abscess
    • Bronchopleural fistula
    • Necrotizing pneumonia
    • ARDS
    • Extra Pulmonary Complication
    • (Meningitis,Artharitis,Pericarditis,Osteomyelitis,Endocarditis)
    • Sepsis
    Recurrent Pneumonia
    • 2 or more Episodes in a single year
    OR
    • 3 or more episode ever with radiographical clearing between
    occurrences
    Causes
    1. Hereditary: Cystic Fibrosis ,Sickle cell disease
    2. Disorder of Immunity: HIV/AIDS, Chronic Granulomatous
    disease. Selective IG deficiency, Leucocyte Adhesion defect
    3. Disorder or Cilia: Kartagener syndrome/Immotile cilia syndrome
    4. Anatomical Disorder: Pulmonary Sequestration, Lobar emphysema,
    GERD, TEF, Bronchiectasis
    Prevention
    1. Exclusive breast feeding upto 6 month
    2. Immunization against with Hib,PCV,Measeles
    3. Adequate Nutrition
    4. Handwashing,safe drinking water and prevention of diarrhea
    5. Avoidance of parenteral smoking
    6. Free from indoor air pollution
    7. Zinc Supplementation
    Quiz 1
    What illness is the number one killer of children?

    • A. Diarrheal Disease
    • B. HIV/AIDS
    • C. Malaria
    • D. Pneumonia
    Quiz 2
    What is the most sensitive and specific sign of pneumonia in children?

    • A. Difficulty breathing
    • B. Fever
    • C. Tachypnea
    • D. Tachycardia
    Quiz 3
    If available, a chest x-ray should be done for children with possible
    pneumonia:

    • A. When a diagnosis is made


    • B. When a history of tachypnea is present
    • C. When antibiotics are started
    • D. When complications are suspected
    Quiz 4
    Which of the following immunization effectively reduce pneumonia mortality in
    children?

    • A. Haemophilus influenzae b Vaccine


    • B. Pneumococcal Conjugate Vaccine
    • C. Measles Vaccine
    • D. All of the above
    Reference
    • 1.Ghai Essential Pediatrics 8th Edition
    • 2.Neelson Textbook of Pediatrics 20th edition
    • 3.Davidson Principles of Medicine 23rd edition
    • 4.Robbins Basis of Pathology 8th edition
    • 5.Harrison Texbook of Medicine 18th Edition
    • 6.WHO manual
    Thank You

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