Transcript Lower respiratory tract infections

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Mostafavi SN. MD
Pediatric infectious disease departement
Isfahan University of Medical Science
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Lower respiratory tract infections
 Pneumonia:
– Viral
– Bacterial
– Afebrile
– Atypical
– Aspiration
– Nosocomial
 Bronchiolitis
 Empyema
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Case 1
A 6 months old boy brought with
high fever and cough. On physical
exam tachypnea and bilateral
coarse rales were found. What’s
your diagnosis?
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Diagnosis of pneumonia
 What's suggestive symptoms and signs
of pneumonia?
 Which patient has definite diagnosis of
pneumonia?
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Symptoms/signs of pneumonia
 All respiratory infections: fever, cough,
 Lower respiratory involvement: respiratory
distress, tachypnea, cyanosis
 Pneumonia: fine rales, decreasing breath
sounds, bronchophonia, …
 Definite: new pulmonary infiltration in CXR
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Case 1-1
 A 6 months old boy
brought with high
fever and cough. On
physical exam
tachypnea and
bilateral coarse rales
were found. What’s
your diagnosis?
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Case 1-2
 A 6 months old boy
brought with high
fever and cough. On
physical exam
tachypnea and
bilateral coarse rales
were found. What’s
your diagnosis?
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Case 1-2
Has the infant need admission?
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Admission criteria in pneumonia
 Inability to intake fluid or medications
 Cyanosis( o2 sat< 92%)
 Severe respiratory distress( apnea, …)
 Toxic appearance
 Pleural effusion
 Sometimes < 1 year
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Case 1-2
Has the patient need antibiotic?
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Type of
pneumonia
History
Physical
exam
X ray
infiltrates
ESR, CRP,
WBC, PMN
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Viral
bacterial
Age< 5, gradual
onset, mild fever,
cough, respiratory
distress
Bilateral rales, high
pitched breath
sounds,
Bilateral interstitial ,
peribronchiolar,
parenchymal,
hyperinflation
Abrupt onset, high
fever, severe cough,
significant respiratory
distress
Focal rales
NL to mild increase
Significant increase
Lobar, lobular
consolidation , dense
parenchymal
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Case 1-3
 A 6 months old boy
brought with high
fever and cough. On
physical exam
tachypnea and
bilateral coarse rales
were found. If he
need any antibiotic?
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Case 1-2
 A 6 months old boy
brought with high
fever and cough. On
physical exam
tachypnea and
bilateral coarse rales
were found. If he
need any antibiotic?
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Which antibiotic should be
prescribed for the infant?
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Microorganism Outpatient
Inpatient
S. pneumonia
High dose
penicilline(85%),
high dose
ampicilline( 85%),
Ceftriaxone( > 95%),
ceftriaxon+
vancomycine( 100%)
High dose
amoxicillin( 85%),
macrolides(6080%)
H. Inluenza ( < 5 Low dose
Low dose
yr)
amoxicillin( 50%), ampicillin(50%),
low dose co
ceftriaxone( 100%)
Amoxiclav (>95%),
macrolids(> 90%)
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Case 1-2
 What's the clinical course of the
patient?
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Clinical course of bacterial
pneumonia
 Improve in fever and respiratory signs
in 48-72 hours
 Clearing CXR in 4-8 weeks
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Case 2
 A 7 years old girl brought
with high fever, malaise,
protracted cough, mild
diarrhea since 5 days ago.
On PE she had bilateral
fine rales without
significant respiratory
distress. She received
coamoxiclave since 72
hour ago. Whats your
diagnosis?
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Atypical pneumonia
What's the suggestive symptoms
and signs of atypical pneumonia?
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Atypical pneumonia
 Age 5-15 yr
 Severe constitutional signs: high fever, prolonged


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fever, anorexia, malaise
Mild respiratory signs: coryza, protracted prolonged
cough, no/mild distress, bilateral mild rales
Prominent extrapulmonary signs: rash, diarrhea,
abdominal pain, CNS, …
Prominent x ray abnormalities: bilateral interstitial,
lobar infiltrates specially in lower lobes
No response to beta-lactams and dramatic response to
azithromycine, clarithromycine, erythromycine
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Case 3
 A 2 month old boy brought with severe
cogh since two days ago and coryza and
mild cough since five days ago. His
mother has signs of URTI since 7 days
ago. On PE RR=70/min, mild cyanosis
and diffuse wheezing were found.
What's your diagnosis?
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Main clues in bronchiolitis
 Age:<1 yr ( 2-6 mo), peak admission: 1-3 mo
 Epidemic in Day to Farvardin months
 Initially coryza, cough then severe cough,
wheezing, dyspnea
 Sometimes fever
 Hyperinflation, perihilar infiltration in x ray
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Case 3- x ray
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 A 2 month old boy
Case 3
brought with severe cogh
since two days ago and
coryza and mild cough
since five days ago. His
mother has signs of URTI
since 7 days ago. On PE
RR=70/min, mild
cyanosis and diffuse
wheezing were found.
Has the patient need
admission?
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Admission in bronchiolitis
 O2 saturation< 90-92
 Age< 6 wk
 Reduced intake
 Underlying heart, lung, immunological
disease
 Severe respiratory distress including apnea
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What's the outpatient management
of bronchiolitis?
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Out patient management of
bronchiolitis
 No effect of salbutamol, theophylline G,
corticosteroids, cough suppressants
 Supine position with the head elevated
 Small frequent feeding
 Nose drops and clearing
 Warning signs
 Mist therapy
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