Transcript Treatment of out-of-hospital pneumonia

CHAIR OF PEDIATRY WITH
MEDICAL GENETICS
SUBJECT OF LECTURE:
“Pneumonias of newborns. Hemorrhagic
disease of newborns”.
Definition
Pneumonia is an acute infectious disease of
the pulmonary parenchyma, that is
diagnosed in case of presence of breathing
violation syndrome, physical data and
infiltrative changes at roentgenogram.
Variant of pneumonia
Depending on period of infection:
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Intrauterine transplacental (causative agent entered
from mother through placenta) and antenatal (causative
agent penetrates fetus through amniotic fluid);
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Intranatal (child is infected during delivery through
infected maternal passages);
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Postnatal (infection happens after birth):
hospital;
“street”, “home”, acquired pneumonias (out of hospital);
children have ventilation associated pneumonias at the first
72 hours of being on artificial pulmonary ventilation.
Pneumonias etiology
Intrauterine pneumonias: streptococcus of В, G and
D groups, Кl. pneumoniae, St. aureus, Listeria
monocytogenes, E.coli.
Out of hospital pneumonias: Staphilococcus aureus,
Streptococcus epidermidis, Str. Рneumoniae,
Chlamidia pneumoniae, Mycoplasma
pneumoniae,
Hospital pneumonias: Pseudomonas aeruginosa, Кl.
pneumoniae, E. coli, Proteus spp., St. aureus,
anaerobic flora – Acinetobacter, Serratia.
Ventilation associated pneumonias: pneumococcus,
Hem. Influenzae..
Risk factors of pneumonia development
at newborns
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Somatic and/or obstetric pathology during pregnancy
(it causes chronic antenatal hypoxia of fetus and
suppression immunologic reactivity).
Mother’s chronic infection pathology (especially of
urogenital system).
Acute infectious diseases during pregnancy.
Complications of intranatal period (choreoamnionitis,
premature membranes rupture, long waterless period,
plural manual researches).
Pneumopathies.
Congenital violations of lungs development.
Susceptibility to regurgitates.
Prematurity, intrauterine growth retardation.
Pathogenesis
Passes of lungs contamination by the pathogenic flora:
Bronchogenic-droplet pass is typical for postnatal pneumonia and pass
through infected amniotic fluid is typical for intranatal pneumonia;
microaspiration of oral pharynx content;
Hematogenic – causative agent entering from extrapulmonary infection
source;
Lymphogenic – infection spread from the nearby organs.
Pathogenic phases:
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Entering of the causative agent to the pulmonary tissue, hydropic –
inflammatory obstruction of respiratory tract, function violations of
ciliated epithelium with spread of the agent through tracheobronchial
tree to alveoles and between alveoles through Kon’s pores;
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Primary alteration of pulmonary tissue with development of
morphologic substrate of pneumonia (of the focus, segment, lobe or
intersticium );
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Activation of processes of lipid peroxidation with damaging not only
causative agent but also structures of own organism, function violations
of surfactant, destabilization of cell membranes –increase in size of the
injured pulmonary tissue;
Pathogenesis
Pathogenic phases (continue):
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Violation of perfusion through alveole – capillary membrane –
respiratory hypoxia, development of complex dyspnea, tachycardia,
increase of stroke volume (SV), cardiac output (CO);
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As a result of hypoxia the increase of pressure in the system of
pulmonary artery causes overload of right heart, dystrophic changes in
myocardium – circulatory hypoxia;
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Respiratory and circulatory hypoxia cause centralization of blood
circulation and violation of perfusion of peripheric tissues, that causes
accumulation of suboxides, acidosis and hystotoxic hypoxia
development;
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In condition of acidosis О2-connecting function of erythrocytes is
violated - hemic hypoxia. Toxicosis appears: exogenous – as a result of
action of microbal toxins, and endogenous – as a result of metabolism
violations. Violations of other organs and systems, all types of exchange
and immunologic homeostasis appear.
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Brain is mostly sensitive to hypoxemia and hypoxia, that’s why function
violations of CNS are irreplaceable concomitants of newborns.
Classification
By the periods of origin: intrauterine (antenatal and transplacental), intranatal,
postnatal (by the location of origin: out-of-hospital, hospital).
By the etiology: viral, bacterial, fungous, mixed.
By the morphologic substrate: focal, segmental, lobal (croupous), interstitial.
By the localization: one-side, two-side, injured lobe and segment.
By the course: acute (till 6 weeks), prolonged.
By the severity: moderate, severe, over severe.
By the degree of respiratory insufficiency: І, ІІ, ІІІ degrees.
By the period: starting, height, resolution, recovery.
By the presence of complications:
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Toxic (cardio- vascular syndrome, syndrome of neurotoxicosis, DICsyndrome, gastric- intestinal syndrome, acute epinephros insufficiency).
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Purulent: pulmonary (abscess, destruction), pulmonary- pleural (pleuritis,
pneumothorax), extrapulmonary (meningitis, osteomielitis, pyelonephritis,
otitis).
Examples of diagnosis:
Antenatal interstitial pneumonia, severe form, acute course, starting period,
uncomplicated, RI of the third degree
Intranatal small- focal bronchopneumonia, medium difficult, acute course, period
of height, uncomplicated, RI of the second degree
Clinical and diagnostic criteria
of pneumonia
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Pulmonary (respiratory) complaints
Intoxication symptoms
Signs of respiratory insufficiency
Local physical data
Roentgenologic changes
Laboratory data
Clinical and diagnostic criteria of
antenatal pneumonia
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Symptoms of respiratory insufficiency (dyspnea,
tachypnea, dilated nostrils, additional muscles’ part in
the act of breathing, cyanosis, expiratory sounds) are
shown up in the first minutes of life.
Often it connects with difficult hypoxia and it is one of
the component of generalized intrauterine infection.
Intoxication symptoms (depression, temperature
instability, appetite decreases, tolerance to enteral
feeding decreases, haemodynamics violations, jaundice,
haemorrhagic symptom, tachycardia, deafness of heart
sounds) prevail in clinic.
Physical data is informative: dullness on percussion,
small- vesicle and crackling rales during inspiration.
Clinical and diagnostic criteria of
intranatal pneumonia
Light interval is typical (2-3 days of life);
 Often it connects with purulent conjunctivitis
and local purulent skin injures;
 Physical data is informative: dullness on
percussion, small- vesicle and crackling rales
during inspiration.
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Clinical and diagnostic criteria of postnatal
pneumonia
Out-of-hospital:
The beginning is acute, it starts with catarrhal processes
in epipharynx, temperature increase with
consequential RI. Processes of toxicosis prevail at the
beginning of disease (flaccidity, refusal of food,
decrease of muscle tonus). Physical data of lungs are
small informative: tympanic resonance at periapical
areas, rales are rare.
Hospital:
Difference between hospital and out-of-hospital
pneumonias is: spectrum of causative agents,
resistance of agents to antibacterial therapy, difficulty
and frequency of complications, high lethality.
Features of pneumonia course at
premature children:
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Dominating of symptoms of RI and toxicosis in clinics.
Fever is not constant, it also can be hypothermia.
The frequency of complications is high: pulmonary
(pneumothorax, atelectasis , pleuritis) and extrapulmonary
(otitis, enteroparesis, haemorrhagic symptom, metabolic
violations- mixed acidosis, hypoglycemia, hypo-calcium, sodium, - potassiumemia, hyperbilirubinemia).
Aspiration pneumonia is more frequent at premature children in
comparison with mature ones.
The following order is characteristic: RDS – pneumonia- sepsis,
as opposed to mature children that in case of sepsis don’t have
lungs as site of entry of infection.
The frequency of connecting with other diseases is high.
The frequency of remote consequences is high, it causes
recidivation of bronchopulmonary diseases.
Plan of examination of the newborn
with suspicion on pneumonia
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Roentgenography of chest in 2 projections (interspersed
peribronchial focal infiltration or focal shadows at the
background of increased bronchovascular pattern and
hyperpneumotization).
Clinical blood analysis with calculating of thrombocytes
(leucopenia or leucocytosis are typical, increase of total amount
of stab neutrophils, leukogram shift to the left, total
neutrophillosis, increase of leucocytic index,
thrombocytopenia).
Determination of gas content of blood and indices of acid-base
balance.
Virologic and bacteriological research.
Blood examination on its sterility.
Urine clinical analysis.
Cerebrospinal puncture by indications..
Treatment of pneumonias at newborns
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Main directions of therapy:
Keeping the therapy- protective, hygiene and
sanitary regimen.
Infusion therapy.
Treatment of respiratory insufficiency.
Etiotropic therapy.
Pathogenic therapy (anticoagulant and
antienzyme therapy).
Increase of child’s resistance (immunesubstitutive and vitamins therapy).
Physical therapy and exercise therapy.
Treatment of pneumonias at newborns
Volume and type of feeding is determined by age, maturity
and condition of the newborn.
Indication for enteral feeding:
-absence of vomiting and regurgitations;
-absence of bloating;
-absence of decompensation of circulation and RI II- III
degrees.
Purpose of infusion therapy is: absorption of toxins and its
excretion from the organism, correction of acid-base
balance violations and water-electrolytes exchange
violations, improve of rheological properties of blood.
The fluid volume is counted individually and it
depends on daily needs in fluid, condition of heartvascular system, signs of dehydration, presence or
absence of pathologic loss.
Treatment of pneumonias at newborns
Solutions that are used for infusions: 10% solution of
glucose, 5% solution of albumin, fresh frozen plasma.
The fluid is injected through infusator droply.
Features of infusion therapy:
Using of osmose diuretics and volemic preparations is
forbidden (10% solution of albumin, reopolyglycin).
5% albumin can be used not often than 1 time a day.
Infusion therapy is carrying under obligatory control by the
hour diuresis and water-saline balance.
Using the lazix by 1mg/kg 2 times a day is obligate.
Plasmapheresis and hemosorption can be used for
detoxication.
Treatment of pneumonias at newborns
Methods of oxygen therapy in case of pneumonia
Through mask or funnel – speed of oxygen giving is 2-3 l/min., it
allows to make oxygen concentration around 25-34%.
Through oxygen tent – speed of oxygen giving is 3-4 l/min., it allows
to make oxygen concentration around 25-40%.
Through the nasal cannulas (“moustache”) – speed of oxygen giving
is 0,2-0,5 l/min., it allows to make oxygen concentration around
40-50%.
Oxygen therapy that is carrying directly in the baby’s place – speed
of oxygen giving is 3-4 l/min., it allows to make oxygen
concentration around 30%.
An indispensable condition of oxygen therapy is warming-up and
humidification of oxygen.
Treatment of pneumonias at newborns
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Indications for spontaneous breathing under permanent positive
pressure (SBUPPP) : augmenting of RI symptoms on the
background of usage of oxygen therapy by free oxygen flow,
rating by the Silverman’s or Down’s scale is > 4 points, frequent
and long attack of apnea, bradycardia.
Indications for artificial lung ventilation (ALV): clinical symptoms
of severe RI (rating by the Silverman’s or Down’s scale is > 7
points), on the background of SBUPPP Ра О2 is <50 mm.
mercury column, Ра СО2 is >60 mm. mercury column, рН is <7.2;
shock, prolonged apnea with bradycardia and cyanosis; persistent
central cyanosis on the background of SBUPPP arterial
hypotension; violations of the peripheral haemodynamics.
Inhalation therapy (lazolvan, euphylin, hydrocortizon, vit C, 2%
solution of chlorides or hydrocarbonate of sodium), ultrasonic
inhalator is used.
Treatment of pneumonias at newborns
Treatment of intrauterine pneumonia:
1. Penicillins:
Natural – benzylpenicillin by 25 000 UA/kg/day 2 times parenteraly;
Semisynthetic:
- ampicillin, oxacillin by 25 mg/kg/day 2 times parenteraly;
- amoxicillin by 30 mg/kg/day 2 times parenteraly;
- “protected” penicillins (amoxyclav, ampysulbin) - 30 mg/kg/day 2
times parenteraly.
2. Cephalosporins of the І generation (cephalexin, cephazolin) or ІІ
generation (cephuroxim) by 20-50 mg/kg/day 2 times parenteraly.
3. Aminoglycosides of the ІІ generation (gentamycin) or the III
generation (amicacyn) by 5-7,5 mg/kg/day 2 times parenteraly.
Treatment of pneumonias at newborns
Treatment of out-of-hospital pneumonia:
1. Amoxyclav - 30 mg/kg/day 2 times parenteraly;
2. Cephuroxim - 50 mg/kg/day 3 times parenteraly.
3. Aminoglycosides of the ІІ generation (gentamycin) or
the III generation (amicacyn) by 5-7,5 mg/kg/day 2
times parenteraly.
Penicillins and cephalosporins are effective at
treatment of out-of-hospital pneumonia that are
caused by Str. рneumoniae, H.influenzae, at
pneumonia that are caused by Chlamidia
pneumoniae, Mycoplasma pneumoniae macrolides
should be used (erythromycin, azitromycin – 10
mg/kg/day by the scheme).
Treatment of pneumonias at newborns
Treatment of hospital pneumonia:
1. Semisynthetic penicillins: carbopenicillins (carbenicillin) by 100
mg/kg/day, ureidopenicillins (azlocillin, mezlocillin) by 50
mg/kg/day, “protected” penicillins (amoxiclav) by 30 mg/kg/day.
2. Cephalosporins of the IIІ generation (cephtriaxon, cephoperazon,
cephotaxim) or the IV generation (cephepim) by 50 mg/kg/day.
3. Aminoglycosides of the ІІ generation (gentamycin, tobramycin,
sizomycin by 4-8 mg/kg/day or the III generation (amycacin by
7,5 mg/kg/day, nethilmycin by 2,5 mg/kg/day).
4. Fluoroquinolones of the II (ciprofloxacin), the III (levofloxacin) or
the IV generation (gatifloxacin) by 15 mg/kg/day in 2 doses.
5. Carbopenems (imipenem, meropenem) by 60 mg/kg/day.
The 4th and the 5th groups of antibiotics are prescribed according to
live indications.
Haemorrhagic disease of newborns.
Definition
Haemorrhagic disease of newborns (HmDN) is a disease of
newborns that is connected with the low rate of vit Kassociated factors of blood coagulation.
At the first days of life healthy mature newborns have the
low rate of vit K- associated factors of blood
coagulation, that is caused not by vit K deficiency, but it
is caused by transient insufficiency of liver function.
2-5% of children have more low level of vit K- associated
factors of blood coagulation in comparison with healthy
mature children, and exactly they have HmDN.
Variants of HmDN
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Early HmDN. It develops at the first day of life. It occurs
rarely. Clinically it is characterized by skin and mucous layers
hemorrhages, intracranial hemorrhages, hemorrhage from the
umbilical wound, melena (intestinal hemorrhage). Risk
factors: applying medical therapy (anticoagulants,
anticonvulsant preparations, antibiotics, sulfanilamides,
acetylsalicylic acid) at the late periods of pregnancy.
Classical HmDN. It develops at the 2nd- 6th day of life.
Clinically it is characterized by melena, skin and mucous
layers hemorrhages, hemorrhage from the umbilical wound.
Risk factors: gestosis of pregnancy, deficiency of vegetables in
the feeding of pregnant woman, liver diseases, bile-excreting
pass diseases, intestinal disbacteriosis, prematurity,
intrauterine growth retardation.
Late HmDN. It develops after the 1st week of life during 3-8
weeks. Clinically it is characterized by intracranial
hemorrhages, skin hemorrhagic syndrome, melena. Risk
factors: artificial feeding, absence of prophylaxys prescription
of vit K.
Diagnostics and treatment of HmDN
Diagnostics is based on anamnesis and typical clinical data. Among
laboratory methods test of Apt is used. Also prolongation of
prothrombin time and shortening of prothrombin index are
typical.
Treatment:
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Treatment- protected regimen;
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Adequate feeding;
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Prophylactical intramuscularly injection of vit K (1% solution of
vicasol by 0,3-0,5 ml 1-2 mg) after birth;
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Local therapy in case of melena is 0,5% of sodium chlorides per
os by 1 tea spoon 3 times a day, solution of thrombin in
epsilonaminocapron acid per os by 1 tea spoon 3 times a day.
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In case of difficult course using of fresh frozen plasma by 15
ml/kg and concentrate of factors of prothrombin complex PPSB
by 15-30 UA/kg is possible.