Transcript Lecture_03_Pneumonia in children

Pneumonia in children:
etiology, diagnosis and
treatment
Prof. Galyna Pavlyshyn
Plan
1. Discuss the common causes of pneumonia in
children of various ages;
 2. Classifications of pneumonia in children;
 3. Clinical manifestations of pneumonia in
children;
 4. Outline the approach to the diagnosis of
pneumonia in children;
 5. Select appropriate antibiotic therapy for a child
with pneumonia based on child’s age and severity
of illness;
 6. Discuss the diagnosis and management of
common complications of pneumonia
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Pneumonia in pediatric patients
Basic facts
 Childhood pneumonia remains an important cause of
morbidity and mortality in developing world – 4 million
deaths annually in the developing world;
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About 20% of all deaths in children under 5 ys
are due to Acute Lower Respiratory Infections
(ALRIs - pneumonia, bronchiolitis and bronchitis);
90% of these deaths are due to pneumonia.
Annual incidence in the U.S. in:
Children under 5 yo is ~ 40 cases/1000
Children age 12-15 ~ 7 cases/1000
Mortality rate < 1/1.000 in the U.S.
Disease Pattern
Causes of 10.5 million deaths among
children < 5 in developing countries
One in every
two child
deaths in
developing
countries are
due to just
five infections
diseases and
malnutrition
Pneumonia in pediatric patients
Early recognition and prompt treatment of
pneumonia is life saving.
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Low birth weight, malnourished and nonbreastfed children and those living in
overcrowded conditions are at higher risk of
getting pneumonia.
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These children are also at a higher risk of death
from pneumonia.
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About one-half of all children < 5 yo with
community-acquired pneumonia will require
hospitalization;
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What is pneumonia (PNA)?
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Has been defined as inflammation of lung
parenchyma – the portion of the lower respiratory
tract consisting of the respiratory bronchioles,
alveolar ducts, alveolar sacs, alveoli;
Prevalence /1000 Patient age (yrs)
35-40
<1
30-35
2-4
15
5-9
<10
>9
Pneumonia
 is
an acute infectious inflammatory
disease of various nature with
involving of lower respiratory tract
into pathologic process and intraalveolar inflammatory exudation;
Possible causes of Pneumonia
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Bacterial – streptococcus pneumonia,
mycoplasma (atypical)
– And any other
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Viral – RSV (respiratory syncytial virus)
– In children younger than 2 years, viral infections
were found in 80% of children with pneumonia;
in children older than 5 years, viral infections
were detected only 37% of the time.
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Aspiration
Depends on patient age, immune status, and
location (hospital vs. community)
Etiology
Age-dependent
Neonates:
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Group B Streptococci
GN Enterics - Esherichia coli, Klebsiella pneumoniae,
Listeria monocytogenes
rare St. aureus
2 w- 2mo:
- Chlamydia
- Viruses
- Str. Pneumoniae, St. aureus, H. influenzae
Children 2-6 mo
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Esherichia coli, Klebsiella pneumoniae;
Strep. Pneumoniae and Hemophylus
influenzae type β;
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Chlamydia pneumoniae;
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rare St. aureus
6 mo -6 yrs
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Strep. Pneumoniae - 50 %
Viruses - RSV, parainfluenza, influenza,
adenovirus, rhinovirus, coronavirus,
herpesvirus, human metapneumovirus
Hemophylus inf. type β - 10 %
Mycoplasma pneumoniae - 10 %
Rare St. aureus, Chlamydia pneumoniae
7-18 yrs
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Strep. Pneumonie - 35-40 %
Atypical pneumonia (Mycoplasma
pneumoniae) - 30-50 %
Moraxella catarrhalis, Hemophylus
influezae
Viruses;
hospital (nosocomial)
– Ps. aeruginosa,
– rare Kl. pneumoniae, St. aureus, Proteus;
Infectious causes of
pneumonia
Age
Causative organisms
Perinatal + Group B haemolytic streptococci
4 weeks
E. coli and other gram negative enteric
organisms,
Chlamydia trachomatis
Infancy
Viruses - RSV
Pneumococcus
Haemophilus influenzae
Pathophysiology
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Often, follows upper respiratory tract infection;
Lower respiratory tract invaded by bacteria,
viruses or other pathogens;
Preceding viral illness (influenza, parainfluenza,
RSV, adenovirus) leads to increased incidence of
pneumococcal pneumonia;
Bacterial pneumonias usually due to spread of
invasive organisms from the nasopharynx by
inhalation or aspiration;
In children, bacteremia may lead to
hematogenous seeding of the pulmonary
parenchyma and result in pneumonia
Pathophysiology
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Immune response leads to inflammation;
Lung compliance is decreased, small airways
become obstructed and air space collapse
progresses;
Ventilation-perfusion mismatch and decreased
diffusion capacity leads to hypoxemia;
CLASSIFICATION:
􀂙 Etiology
􀂙 Morphological class
- Bronchopneumonia
- Lobar pneumonia
- Interstitial pneumonia
􀂙 Congenital pneumonia
Community acquired pneumonia
Nosocomial (hospital acquired) pneumonia
Aspiration pneumonia
􀂙 Non complicated pneumonia
complicated pneumonia
Morphological classification
Complications of pneumonia
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Pulmonary:
pleuritis, parapneumonic
effusions and empyema,
pneumothorax,
failure of resolution 
intra-alveolar scarring
('carnification') 
permanent loss of
ventilatory function of
affected parts of lung;
Pneumonia may be
complicated by a pleuritis
Complications of pneumonia
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Pulmonary: abscess formation
A thick-walled lung abscess
Complications of pneumonia
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Extrapulmonary:
- infective endocarditis
- cerebral abscess / meningitis
- septic arthritis
- Infectious-toxic shock
- DIC (disseminated intravascular coagulation)
syndrome
Significant Risk Factors
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younger age (2-6 months),
low parental education,
smoking at home,
prematurity,
weaning from breast milk at < 6 months,
anaemia
malnutrition
Trop Doct 2001 Jul;31(3):139-41
Clinical case 1
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2 y old boy with complaints of fever, cough,
vomiting, decreased appetite, chest pain,
right lower quadrant (RLQ) abdominal pain;
T 39 C, chills, HR 140, RR 50;
Retractions, signs of respiratory distress;
Decreased breath sounds, rales, egophony,
dullness to percussion rate;
Symptoms since yesterday afternoon;
Recent upper respiratory infection;
Clinical case 1
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What diagnoses are you considering?
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What is the most likely diagnosis ?
Clinical case 1
 Why?
Clinical case 1
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What do you want to do?
right upper lobe pneumonia
Clinical case 1
Physical examination
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Tachypnea
Fever (T 39 C) – nonspecific and not 100%
sensitive sign;
Hypoxemia (pulse oximetry – 5th vital sign)
Signs of respiratory distress (retractions,
flaring, grunting)
X-ray: infiltrates of lung tissue
Clinical case 1
Physical examination
 Tachypnea
 Is the most sensitive and specific sign
of radiographically confirmed
pneumonia in children
 Is the twice as frequent in children with
radiographic pneumonia than in those
without;
 Absence of tachypnea is the most
valuable sign for excluding pneumonia;
Clinical case 1
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What definition of tachypnea
in children do you know?
Clinical case 1
Physical examination
Definition of tachypnea
(World Health Org.)
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< 2 months: > 60 breaths per minute
2-12 mos: > 50 breaths per minute
1-5 y: > 40 breaths per minute
More 5 y: > 20 breath per minute
Clinical case 1
Physical examination
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Wheezing is rare with bacterial pneumonia –
more common in pneumonia caused by
atypical bacterial or viruses
less than 5% of children with wheezing had
pneumonia;
only 2% of children without fever in the ED
had pneumonia;
hypoxemia (SpO2 < 92 %) increased risk;
Clinical case 2
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Patient 1 yo is transferred to the ED after 1
week of fever and respiratory symptoms;
Child is in moderate respiratory distress, pale
appearing and quiet;
T 39.7 C, RR 65, HR 158, SpO2 91%.
Marked decrease in breath sounds on right
side, moderate subcostal and intercostal
retractions.
Appears dehydrated
Clinical case 2
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Signs and symptoms include failure to improve with
treatment of pneumonia, persistent fever, malaise,
chest pain, respiratory distress;
Physical exam reveals decreased breath sounds,
dullness to percussion and pleural rub;
CXR shows white out of right chest;
Decubitus X-rays suggest presence of loculations;
Ultrasound detects early loculations and
septations;
This radiograph reveals progression of pneumonia into the right
middle lobe and the development of a large parapneumonic
pleural effusion
Clinical case 2
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Diagnosis:
Complicated right lobal pneumonia parapneumonic pleural effusion
Draining large effusions may provide
symptomatic relief;
Aspiration of pleural fluid may provide an
etiologic agent to direct therapy
Congenital pneumonia
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Tachypnea
Irregular respiratory movements (paradoxic)
Apnea
Flaring of alae nostril
Grunting (expiration sound)
Involving chest muscles
Temperature may be present in some term
babies
Congenital pneumonia
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Poor feeding
Lethargy or irritability
Temperature instability
Poor color, cyanosis
Abdominal distention
tachycardia
Congenital pneumonia
Late onset of CP (after 7-14 days of life).
Mainly Chlamidia or Urea- and Mycoplasma
Onset usually is preceded by upper
respiratory tract symptoms and/or
conjunctivitis
Nonproductive cough
Fever is absent “afebrile pneumonia
syndrome”
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Physical sings
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The sings such as dullness to
percussion, change in breath sounds,
and the presents of rales or rhonchi are
virtually to appreciate in a neonate
Weakened breathing during auscultation
Moist or bubbly sounds, crepitating
Respiratory failure develops gradually
CXR in:
Atypical Pneumonia
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Chlamydia –
– Diffuse intersitial markings
– hyperinflation
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Mycoplasma –
– Normal, or can look like viral or typical bacterial PNA
Viral pneumonia
Respiratory syncytial virus is the most
common viral cause; other common causes
include parainfluenza virus, adenovirus,
enterovirus;
 Clinical features- begin with several days of
rhinitis, cough, followed by fever and more
pronounced respiratory tract symptoms, such
as dyspnea, intercostal retraction.
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Viral pneumonia
Diagnosis
Laboratory findings – preponderance of
lymphocytes observed on CBC;
 Diffuse or bilateral infiltrates visible on chest
ragiograph;
 Rapid test for viral antigen, culturing
nasopharyngeal specimens for viruses;
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CXR in viral PNA
CXR in Aspiration:
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opacification in right upper lobes of infants
and in the posterior or bases of the lung in
older children
Specific testing:
barium swallow
pH probe, and
flexible endoscopic evaluation of swallowing
and sensory testing
Possible Exam Signs of PNA
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Tachypnia
– > 50/min if younger
than 1 year, > 40/min if
older than 1 year.
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Cyanosis
Retractions
Inspiratory crackles
Bronchial breath
sounds
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Egophany ( E to A)
Bronchophany (99)
Whispered
pectoriloquy
(pectorophony)
Dullness to
percussion
Tactile fremitus
Symptoms and signs
5 categories
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Nonspecific and toxicity
Signs of lower respiratory disease
Signs of pneumonia
Sign of pleural effusion and empyema
Extrapulmonary disease
Symptoms & signs
non-specific
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Fever, malaise, headache
GI complaints
Apprehension
restlessness
Symptoms-lower
respiratory
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Tachypnea, dyspnea
Shallow or grunting respiration
Cough
Nasal flaring, intercostal retraction
Symptoms-pleuritic
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Referred pain to neck and back
Abdominal pain if diaphragmatic
involvement
Symptomsextrapulmonary
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Disseminated disease
Skin and soft tissue involvement
arising from bacteremia, meningitis
Plan of examination
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CBC - so called “septic investigation” blood analysis (↑ WBC more than 20*109/l or
↓WBC less than 5*109/l)
Increased WBC with left stiff strongly
suggests bacterial process;
Pneumococcus associated with marked
leukocytosis;
Leukocyte index > 0.2 (immature forms:
general count of neutrophils)
Trombocytopenia (< 150000)
Examination: Laboratory
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Biochemical blood test – acidosis,
hypoproteinemia
Increased inflammatory markers (Creactive protein);
Bacteriological examination of sputum
(tracheal), blood (gold standard);
Blood culture rarely give organism, but
this test is necessary;
Examination for viruses
Examination: Radiology
X-ray
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Infiltrates, bilateral involvement or pleural
effusion - suggest more serious disease
Focal or diffuse interstitial pneumonitis
may reveal
Infiltrates may be less obvious in
dehydrated patients;
Bronchopneumonia - intensified (increased)
pulmonary picture, diffuse focal infiltration
Interstitial pneumonia
CXR in Bacterial PNA
CXR in Bacterial PNA
Right lower lobe consolidation in a patient with bacterial pneumonia
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Lobar pneumonia
Acute community-acquired pneumonia with
complicated parapneumonic effusion
Complicating pneumonia and empyema
Bilateral necrotising
pneumonia complicated
by right pneumothorax
Bilateral consolidation with
scarring and early cavitation
in the lower lung fields
Pneumococcal pneumonia
complicated by lung necrosis
and abscess formation
A lateral chest radiograph shows air-fluid
level characteristic of lung absces
Lung abscess in the posterior segment of the right upper lobe
CT scan shows a thin-walled cavity with surrounding consolidation
Most
children can be treated
as outpatients.
What indications for
disposition (hospitalization)
patient with pneumonia
do you know?
Disposition
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Admit if:
Toxic appearance;
Respiratory compromise, including marked
tachypnea (>60 breaths/min in infant and
> 40-50 breaths/min in older children);
Hypoxemia (SpO2 < 92-94% in room air);
Dehydration or inability to maintain oral
hydration or tolerate oral medications;
Indications of severe disease;
Disposition
 Admit
if:
Young age - < 4-6 months of age;
 Underlying diseases:
- cardiac disease
- renal disease
- hematological disease
 Inability of family to provide care at
home;
 Failure of outpatient therapy;
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Treatment
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Supportive care for children
Oxygen if needed;
Fluids and insure hydration
Antipyretics, analgesics
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Antitussives are NOT indicated;
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Antibiotic therapy
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I – beta-lactam:
Penicillin;
Cephalosporin;
Carbopenem;
Aminoglycoside
Macrolide
Linkozamide –
linkomycin, clindomycin
Vancomycin
Treatment
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• Bacterial
1 month Ampicillin 75–100 mg/kg/day and
Gentamicin 5 mg/kg d
1–3 months Cefuroxime (75–150
mg/kg/day) or
co-amoxiclav (40 mg/kg/day)
3 months Benzylpenicillin or erythromycin
(change to cefuroxime or amoxycillin if no
response)
Treatment
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Supportive for atypical pneumonia
• Chlamydia and mycoplasma
should be treated with erythromycin
40–50 mg/kg/day usually orally.
• If pneumocystis carinii pneumonia
is suspected co-trimoxazole 18–27
mg/kg/day IV should be prescribed.
Treatment
Patients are treated as an outpatient:
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Children < 5 yo:
- high dose amoxicillin (80-90 mg/kg/d) for 7-10 d
 Children > 5 yo:
- increased prevalence of M. pneumoniae and
C. pneumoniae
- macrolide is reasonable choice
 Older children with signs most consistent with
S. pneumoniae infection (lobar infiltrate,
increased wbc or inflammatory markers) –
AMOXICILLIN may be used;
Treatment
Patients requiring admission:
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IV AMPICILLIN 150-200 mg/kg/d
May used 2-nd or 3-rd generation
cephalosporins;
Choice guided by local resistance
patterns;
Consider combining beta-lactam and
macrolide;
Treatment
Children with more severe disease:
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Consider other organisms including
Methicillin-resistant S. aures (MRSA)
3-rd generation cephalosporin, plus
Clindamycin or
Vancomycin;
Treatment
Age
6 mo.-6 yr
Start
Ampicillin 100
mg/kg/day
Or amoksiklav 20-40
mg/kg
(Amoxicillin/clavulanate)
Alternative
Cefotaxime (Claforan)
Cefuroxime (Zinacef)
100-150 mg/kg/day
Clarithromycin
Azithromycin
Treatment
Age
6 mo.-6 yr
Complicated
Start
Ceftazidime 150 mg/kg/day or
Cefotaxime or ceftriaxone
+ netilmicin (6-7.5 mg/kg)
(amikacinum 15 mg/kg)
Treatment
Age
Start
6 mo – 6 yo
atypical
-Clarithromycin 15-30 mg/kg/day or
6 mo – 6yo
atypical
complicated
Rovamycine 1500000 IU per 10 kg
Azithromycin 10 mg/kg
Suggested Drug Treatment
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Birth to 20 days:
Admission
3 weeks to 3 months:
– Afebrile: oral
erythromycin
– Febrile: add
cefotaxime
NEJM Volume 346:429-437
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4 months to 5 years:
Amoxycillin
80mg/kg/dose
6-14 years:
Erythromycin
Causative Agents
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The most often isolated bacteria
pneumonia - Streptococcus
pneumoniae (33%)
Haemophilus influenzae (21%)
Braz J Infect Dis 2001 Apr;5(2):87-97
Haemophilus influenzae
Treatment with a combination of amoxicillin and
clavulanic acid (Augmentin) is effective against
þ-lactamase-producing strains
Streptococcus pneumoniae
Penicillin is drug of choice for susceptible
organisms
Summary
• Pneumonia is a common infection condition
in children;
• Significant cause of morbidity and hardships
for patients and families;
•Pneumonia is the commonest cause of
mortality;
•Pneumonia in absence of cough is rare.
Summary
•Fast breathing in a child with cough or difficulty
breathing is highly sensitive and specific for
diagnosis
• Tachypnea is the most useful physical sign.
• Most children can be treated as outpatients
• Therapy should be guided by probable etiology
and severity of disease.
Test-control
What are the most common
etiological agents of pneumonia
in neonatal period?
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Test-control
What are the most valuable
signs of pneumonia in children?
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Test-control
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What signs are auxiliary methods
of diagnosis of pneumonia?