Definition

Pneumonia is an inflammation of the pulmonary parenchyma

Most caused by microorganisms, noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions, and drug- or radiation-induced pneumonitis

classified as community-acquired, hospital-acquired, or ventilator-associated

-40–80% of children with

community-acquired pneumonia.-Streptococcus pneumoniae

(pneumococcus) is the most common bacterial pathogen

Epidemiology

Pneumonia is substantial cause of morbidity and mortality in childhood (particularly among children <5 yr of age)

Estimated approximately 4 million deaths children among worldwide

Global distribution of deaths among children

under age 5, by cause, 2010 

Organisms of pneumonia

bacterial or viral cause of pneumonia can be identified in 40–80% of children with community-acquired pneumonia. Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen, followed by Chlamydia pneumoniae and Mycoplasma pneumoniae

Leading Etiologic Agents of Pneumonia Infants and Children

S.aureus

S.aureus

Pathophysiology

Virusairbornedropletsmouth or noselungsvirus incaded cells

lining airway and alveoli cell death(protective process) immune system responds more lung damage fluid leak into alveoli(due to WBC,lymphocytes activate) interrupts normal transportation of oxygen

Bacterial invasion triggers the immune system  to send neutrophils kill the offending organisms, and also releasecytokines  fever, chills, and fatigue

Types of pneumonia

Classify by clinically:

Lobar pneumonia-infection that only involves a single lobe, or section.

Bronchopneumonia - affects the lungs in patches around the tubes (bronchi or bronchioles)

Clinical features

Fever Dyspnoea Cough （ productive or non-

productive） Lethargy Poor feeding

Physial examination

Tachypnoea,nasal flaring and chest indrawing

Consolidation with dullness on percussion

End –inspiratory respiratory coarse carckles over the effeted area

Decreased breath sounds and bronchial breathing

Assessment of severity of pneumonia The predictve value of respiratory

rate for the diagnosis of pneumonia Tachypnoea is defined as follows : < 2 months age: > 60 /min 2- 12 months age: > 50 /min 12 months – 5 years age: > 40

/min

Assessment the severity of pneumonia

AGE < 2months AGE>2 months – 5yrs old

Severa pneumonia severe chest indrawing or fast breathing

Very severe pneumonia not feeding convulsion abnormally sleepy or difficult to wake fever/low body temperature hypopnoea with slow irregular breathing

Mild pneumonia fast breathing

Severe pneumonia chest indrawing

Very severe pneumonia not able to drink convulsions drowsiness malnutrition

Investigations

Chest X-ray White blood cell count Blood culture Pleural fluid analysis Serology Nasopharyngeal aspirate

Chest X-ray

Investigations

elevated WBC count in the range of 15,000-40,000/mm and a predominance of granulocytes

erythrocyte sedimentation rate (ESR)

C–reactive protein (CRP) anti-streptolysin O (ASO) titer

useful in the diagnosis of group A streptococcal pneumonia

Viral pneumonia

several days of symptoms of an upper respiratory tract infection eg: rhinitis and cough

Fever, lower than in bacterial pneumonia

Tachypnea intercostal, subcostal, and

suprasternal retractions, nasal flaring, and use of accessory muscles

cyanosis

Investigations

Reliable DNA or RNA tests for the rapid detection of RSV

PCR test seroconversion in an IgG assay

Myocoplasma pneumonia

Headaches and malasia

precede the chest symptoms by 1-5 days

Cough may not obvious

chest may be scanty

chest X-ray - one lobe is involved but sometimes may shadowing in both lungs

frequently no correlation between the X-ray appearances and the clinical state of the patient.

Investigation

Serology : acute phase serumtitre > 1:160 or

paired samples taken 2-4 weeks apart showing a

4 fold rise is a good indicator of Mycoplasma pneumoniae infection

This test should be considered for children aged five years or older

Management

Assessment of oxygenation

The best objective measurement of hypoxia is by pulse oximetry which avoids the need

for arterial blood gases. It is a good indicator of the severity of pneumonia

Criteria for hospitalization community acquired pneumonia can

be treated at home it is crucial to identify indicators of

severity in children who may need admission.

Failure to recognise the severity of pneumonia may lead to death.

The following indicators can be used as a guide for admission:

children aged 3 months and below, whatever the severity of pneumonia.

fever ( more than 38.5 ⁰C ), refusal to feed and vomiting

fast breathing with or without cyanosis associated systemic manifestation failure of previous antibiotic therapy recurrent pneumonia severe underlying disorder ( i.e.

immunodefi ciency )

Antibiotics Bacterial pathogens of children and the recommended antimicrobial agents to be used:

Pathogen Antimicrobial agentBeta-lactam susceptible Streptococcus pneumonia penicillin, cephalosporins Haemophilus influenzae type b ampicillin, chloramphenicol,

cephalosporinsStaphylococcus aureus cloxacillinGroup A Streptococcus penicillin, cephalosporinMycoplasma pneumoniae macrolides , e.g. erythromycin,

azithromycinChlamydia pneumoniae macrolides , e.g. erythromycin,

azithromycinBordetella pertussis macrolides , e.g. erythromycin,

azithromycin

Children with severe pneumonia, the following antibiotics are recommended:

Suggested antimicrobial agents for inpatient treatment of pneumonia

1st line beta-lactam drugs : benzylpenicillin, amoxycillin, ampicillin, amoxycillin-clavulanate2nd line cephalosporins : cefotaxime, cefuroxime, ceftazidime3rd line carbapenem: imipenamOthers aminoglycosides: gentamicin, amikacin

• second line antibiotics need to be considered when :

- there are no signs of recovery - patients remain toxic and ill with spiking

temperature for 48 - 72 hours • a macrolide antibiotic is used if Mycoplasma

or Chlamydia are the causative agents • a child admitied to hospital with severe

community acquired pneumonia must receive parenteral antibiotics. As a rule, in severe cases of pneumonia, combination therapy using a second or third generation cephalosporins and macrolide should be given.

Supportive treatment

Fluids Oxygen Temperature control Chest physiotherapy

Complications of pneumonia Pleural effusion Empyema Pericarditis Lung abscess Respiratory failure Meningitis Suppurative arthritis Osteomyelitis

Comparism of common organisms causing pneumonia in Paed population

Org Strep Staph Mycoplasma

RSV

Commonest com -acq

Iv drugs users or with cental venous catheters

Age 3mth -childhood Noenatal-- infancy

>5yrs <3mths

Clinical Feature

Broncho in young child Lobar/consolidation in olderF,Rusty sputumHaemoptysisPleuritic painO/E-

Fever TachypneaCyanosis Extremely ill

Headaches,Malaise,Chest symptoms.

upper respiratory tract infection, Fever,tachypnea

Inv- CXR multi lobar consolidati on, cavitation, pneumatocoeles

Not correlate with clinical state

Infiltr ate In affect- ed area

Tx 1st line 2nd line

Iv flucloxacillin (200mg/kg/d)

Erythromycin,Clarithromycin

HIV(PCP)

Any age

high fever, breathlessness and dry cough

diffuse bilateral alveolar and interstitial shadowing perihilar regions spread out in a butterfly patternHAART

The End