Dr.Osama Felemban MBBS DCH CABP AFSA CPPF

Consultant Pediatric Pulmonology

Clinical Assistant Professor

Pediatric Department

King Abdulaziz University Hospital

Faculty of Medicine

KAU

1. Over view

2. Epidemiology

3. Pathophysiology

4. Clinical Presentation

5. Clinical Approach

6. Differential diagnosis

7. Investigations

8. Management

9. Complication & prognosis

10. Prevention

11. Take Home massages

12. References

1- Over view LRTI : infection below the level of larynx

Larynogotracheobronchitis

Bronchitis

Bronchiolitis

Pneumonia

2- Epidemiology

The estimated incidence of LRTI is 30 per 1,000 children

per year in the UK.

Boys affected > than girls, (children born between 24-28

weeks compared to born at term.)

Haemophilus influenzae infection is uncomon because of

immunization.

3 - Pathophysiology Essentially, it is inflammation of the airways/pulmonary

tissue, due to viral or bacterial infection, below the level

of the larynx.

Gastro-oesophageal reflux may cause a chemical

pneumonitis.

Smoke and chemical inhalation may cause pulmonary

inflammation

Etiology Viral infections : e.g

Influenza A

Respiratory syncytial virus (RSV)

Human metapneumovirus (hMPV)

Varicella-zoster virus (VZV)

Chickenpox

Bacterial infection :

Streptococcus pneumoniae (the majority of bacterial

pneumonias)

H. influenzae

Staphylococcus aureus

Klebsiella pneumoniae

Enterobacteria - eg, Escherichia coli

Anaerobes

Atypical organisms

Mycoplasma pneumoniae

Legionella pneumophila,

Chlamydophila pneumoniae

Secondary bacterial infection

relatively common following viral upper respiratory tract infection (URTI)

or LRTI.

4 - Clinical Presentation typical viral URTI

Fever

Bacterial pneumonia :++ in children (persistent or repetitive

fever > 38.5°C) with chest recession and a raised resp.rate

Audible wheezing is not seen very often in LRTI (common

with more diffuse infections ; M. pneumoniae and

bronchiolitis).

Stridor or croup suggests URTI, epiglottitis or foreign body

inhalation.

5 – Clinical Approach History :symptoms of LRTI is variable with age

Newborn and neonates present with: Grunting

Poor feeding

Irritability or lethargy

Tachypnoea ±

Fever (±Hypothermia) Cyanosis (in severe infection)

Cough (±)

In this age group beware: Particularly of streptococcal sepsis and pneumonia in the first 24 hours

of life

Chlamydial pneumonia, which may be accompanied by chlamydialconjunctivitis (presents in the second or third week)

History Infants present with:

Cough (the most common symptom after the first four weeks)

Tachypneic (according to severity)

Grunting

Chest indrawing

Feeding difficulties

Irritability and poor sleep

Breathing, which may be described as 'wheezy' (but usually upper airway noise)

History of preceding URTI (very common)

Atypical and viral infections (especially pneumonia) may have only low-grade fever or no fever

Toddlers/pre-school children:

Preceding URTI is common

Cough is the most common symptom

Fever occurs most noticeably with bacterial organisms

Pain (chest and abdominal)

Vomiting with coughing is common (post-tussive vomiting)

Lower lobe pneumonias can cause abdominal pain

Older children:

There will be additional symptoms to those above

More expressive and articulate children will report a wider

range of symptoms

Constitutional symptoms may be variable described

Atypical organisms are more likely in older children

Physical Examination General points:

Examination can be difficult in young children

(particularly auscultation)

A careful routine of observation is essential to identify

respiratory distress

Pulse oximetry can be very useful in evaluation.

High fever over 38.5°C may occur often

signs of respiratory distress:

Cyanosis in severe cases

Grunting

Nasal flaring. In children aged under 12 months this can

be a useful indicator of pneumonia

Marked tachypnoea

Chest indrawing (intercostal and suprasternal recession)

Other signs ;subcostal recession, abdominal 'see-saw'

breathing and tripod positioning

Reduced oxygen saturation (less than 95%)

Observation:

In good light, with the chest and abdomen uncovered, is essential

Count respirations and note the respiratory rate (RR)

Newborn 30-60/minute

Infant 20-30/minute

Toddler 20-30/minute

Child 15- 20/ minute

Observe the infant's feeding (to uncover decompensation during

feeding)

Observe the chest movements (for example, looking for splinting of

the diaphragm)

Auscultation:

Examine with warm hands and a stethoscope

Take the opportunity to examine a quiet sleeping child

Upper respiratory noises can be identified by listening at

the nose and chest

Crepitations in the chest may indicate pneumonia, +

when accompanied by fever

Percussion:

Identifies consolidation

Consolidation is a later and less common finding than

the crepitation of a pneumonia

Later in older children there may be dullness to

percussion over zones of pneumonic consolidation

Bronchial breathing and signs of effusion occur late in

children and localization of consolidation can be difficult

to diagnose

6 - Differential diagnosis Asthma

Inhaled foreign body

Pneumothorax

Cardiac dyspnoea

Pneumonitis from other causes:

Extrinsic allergic alveolitis

Smoke inhalation

Gastro-oesophageal reflux

7 - Investigations

CBC:

White cell count is often elevated.

Microbiological studies:

Blood cultures are seldom positive in pneumonia (fewer than 10% are bacteraemic in pneumococcal disease).

Sputum culture

Imaging:

Chest radiography (CXR) is not routinely indicated in outpatient management.

CXR cannot differentiate reliably between bacterial and viral infections.

Other tests:

Tuberculin skin testing if tuberculosis is suspected.

Cold agglutinins when mycoplasmal infection is suspected (50% sensitive and specific).

ESR , CRP

Diagnostic procedures:

Drainage and culture of pleural effusions may relieve symptoms and identify the infection.

8 - Management Most children with lower respiratory tract infection

(LRTI) and pneumonia can be treated as outpatients,

with oral antibiotics.

Older children can be managed with close observation

at home if they are not distressed or significantly

dyspnoeic and parents can cope with the illness.

Viral bronchitis and croup do not require antibiotics

and mild cases can be treated at home

Admission of severe LRTI :

Oxygen saturation <92%

Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older

child)

Significant tachycardia for level of fever

Prolonged central capillary refill time >2 seconds

Difficulty in breathing as shown by intermittent apnea, grunting and

not feeding

Presence of comorbidity :

congenital heart disease,

chronic lung disease of prematurity,

chronic respiratory conditions such as

- cystic fibrosis,

- bronchiectasis or

- immune deficiency

Admission should also be considered for:

All children under the age of 6 months

Children in whom treatment with antibiotics has failed (most

children improve after 48 hours of oral, outpatient antibiotics)

Patients with troublesome pleuritic pain

Be sure to offer the patient and parents general support,

explanation and reassurance.

Respiratory support as required, including oxygen

Pulse oximetry to guide management

Severe respiratory distress with ↓level of consciousness

and failure to maintain oxygenation indicates a need for

intubation

Medications Antipyretics

(avoid aspirin due to the danger of Reye's syndrome).

Antibiotic treatment

9 - Complication & prognosis Complete resolution after treatment should be expected in

the vast majority of cases.

Bacterial invasion of the lung tissue can cause pneumonic

consolidation, septicemia, empyema, lung abscess

(especially S. aureus) and pleural effusion.

Respiratory failure, hypoxia and death are rare unless

there is previous lung disease or the patient is

immunocompromised.

10 - Prevention Prevention of pneumococcal pneumonia and influenza by

vaccination, for high-risk individuals with pre-existing

heart or lung disease.

Smoking in the home is a major risk factor for all

childhood respiratory infection.

11 - Take Home massages

Understanding the pathophysiology of LRTI

Conducting proper History

Performing careful physical Examination

Comprehension the Impact of the disease on the family

Close follow up after discharge

Avoidance of bad Habit : Smoking

12 - References Guidelines for the management of community acquired pneumonia in children;

British Thoracic Society (2011)

Pediatric Essntial Nelsom 2011

van Woensel JB, van Aalderen WM, Kimpen JL; Viral lower respiratory tract

infection in infants and young children. BMJ. 2003 Jul 5;327(7405):36-40.

Michelow IC, Olsen K, Lozano J, et al; Epidemiology and clinical

characteristics of community-acquired pneumonia in hospitalized children.

Pediatrics. 2004 Apr;113(4):701-7.

Krilov LR; Respiratory syncytial virus disease: update on treatment and

prevention. Expert Rev Anti Infect Ther. 2011 Jan;9(1):27-32.

Feverish illness in children - Assessment and initial management in children

younger than 5 years; NICE Guideline (May 2013)

Mahabee-Gittens EM, Grupp-Phelan J, Brody AS, et al; Identifying children

with pneumonia in the emergency department. Clin Pediatr (Phila). 2005

Jun;44(5):427-35.

Haider BA, Saeed MA, Bhutta ZA; Short-course versus long-course antibiotic

therapy for non-severe Cochrane Database Syst Rev. 2008 Apr

16;(2):CD005976.