Jan 18 th 2011. A 2year old male came into ED at OSH with a 2 week history of cough, fevers and URI symptoms. Per Mom, patient had been diagnosed with.

Jan 18th 2011

A 2year old male came into ED at OSH with a 2 week history of cough, fevers and URI symptoms . Per Mom, patient had been diagnosed with the Flu 3 weeks earlier but had show no improvement. He began to have more severe and frequent fevers, decreased appetite and an episode of febrile seizure. At PCP office patient was febrile with cough, nasal congestion and malaise with decreased breath sounds over Right Lung. Mother was instructed to bring him to the ED with suspected pneumonia. Patient has no significant past birth or medical history, no known allergies and Immunizations were up to date.

ExamAdmit Vitals: Temp: 100.4 Pulse: 138 RR: 32

BP: 119/83Admit PE: Gen- Fever, chills, increased fussiness and

malaise HEENT: OP clear, TM clear bilat, PERRLA, EOMI,

Rhinorrhea CV: Tachycardic, Reg Rate, no Murmurs Resp: ↑WOB, +Rales on L and RLL; ↓BS over RUL. ABD: SNTND, +BS Ext: CR< 3 sec, +2DP at bilateral UE and LE

LabsLabs: CBC, UA, Blood and Urine Cultures, Continuous Pulse

OxRadiology: CXR A-p and Lateral

Admit CXR A-P 1/5/2011

MICHAEL BLANCANEAUXKISHORE GANDLAERIC PRICEHOLLIE STEWART

150 million cases per year20 million requiring hospitalization

Boys > GirlsIncidence

birth to 5 years old – 40 per 1,00012 to 15 years old – 7 per 1,000

Mortality<1 per 1,000 (developed countries)

BarriersSaliva Nasal hairEpiglottisCough reflexMucociliary apparatusHumoral immunity

http://doktermudatrader.blogspot.com/2010/05/acute-respiration-infection-in-children.html

Transmission

Transmission

Transmission

Inhalation of aerosolized dropletsAspirationBacteremia seeding lung tissue (rare)

http://nowthatsnifty.blogspot.com/2009/12/12-people-sneezing-in-slow-mo.html

Deficits in Host ResistanceCompromised immune system

preceding URI, neutropenia, HIV/AIDSExcessive secretionsAnatomic abnormalities Overwhelming pathogen loadVirulent pathogen

Acute inflammationMigration of neutrophils into air spaces

Degradative enzymesChromatin meshwork for pathogens

http://www.aurorabaycare.com/health-info/display.aspx?URL=11617.html

Four stage Inflammatory ResponseCongestion – Vascular engorgement,

alveolar fluidRed Hepatization – RBC’s, leukocytes, fibrinGray Hepatization – leukocytes, fibrinResolution – Enzymatic digestion, expulsion,

reabsoroption of debri

Clinical featuresHallmark symptoms1.Cough2.Fever

All children who have cough and fever does not have Pneumonia.

Clinical features

ChillsMalaisePleuritic chest painRetractions

Clinical exam

Tachypnea is the most sensitive and specific sign of pneumonia.

Resp rate1.>50 (2-12 mo)2.>40 (1-5 Y)3.>20 (>5 Y)(Note: Substract 10 if child is febrile)

Clinical examImportant things to assess1.Temperature2.Pulse3.Respiratory rate4.Pulse oximetry

Clinical exam

Examine lungs while child is in parents’s arms to hear better.

Common signs:1.Dullness to percussion2.Crackles3.Decreased breath sounds4.Bronchial breath sounds with egophony

Clinical pneumonia syndromes

Labs

Outpatient- Not usually indicatedIf highly febrile- Blood cx ( 10% +ve)If dense consolidation or effusion suspected- CXRPPD- In selected patients

TreatmentOutpatientInpatient

Outpatient Treatment

Antibiotic treatment

First line: high-dose amoxicillin (age 60 days to 5 years) or azithromycin (Zithromax®) (age 5 years or older)

Second-line (cephalosporin or macrolide): ceftriaxone (Rocephin®), cefuroxime (Ceftin®), cefprozil (Cefzil®), clarithromycin (Biaxin®).

Combination of macrolide and beta-lactam agent for severe disease

Duration of therapy7-10 daysIf not better in 48-72 hrs, other pathogens or

complications should be considered.

Consolidation: Infection of air spaces (air bronchograms) and/or interstitium of the lung. Findings:   Depends upon amount and distribution of airspaces involved, presents as confluent parenchymal (lobar or segmental) opacity or patchy opacity(atypical).

If the Interstitium is predominantly involved, it may appear as a reticulonodular pattern.

RadiologyAir bronchograms would confirm an alveolar

process

The lung volume should not be lost (may even be increased).

**Usually radiographic abnormalities should disappear after 6 weeks of appropriate antibiotic therapy but radiographic findings may trail clinical resolution**

Consolidation Right Upper Lobe / Air BronchogramLobar Pneumonia

Consolidated Pneumonia CT: large left lower lobe pneumonia with bilateral pleural effusion.

Round Pneumonias are found typically in the child. Most often the organism is pneumococcus

Atypical pneumonia: Bilateral reticular/nodular interstitial infiltrates, focal patchy alveolar opacity in the right middle lobe right upper lobe

Atypical pneumonias frequently caused a centrilobular shadow (64%), an acinar shadow (71%), and/or airspace consolidation (57%) and ground-glass attenuation (86%) with a lobular distribution on CT.

Viral pneumonia caused by RSV: Hyperinflation, mild peribronchial cuffing, increased parahilar markings, and patchy lingular opacity

Pneumonia Complications: Empyema on left

Pneumonia Complications: Lung abcess on left

Inpatient TreatmentWhen to hospitalize for PNAIf patient's have:

Respiratory distress Grunt, tachypneic, hypoxemia, increased WOB

Significant dehydration or risk thereofHigh fever with toxic appearanceFailed to improve with outpatient treatmentDeveloped complications

Effusion

Inpatient TreatmentWhen to hospitalize

Underlying illness that increase risk of decompensation Cardiac Pulmonary Metabolic Immunologic Hematologic Neoplastic

Inpatient TreatmentInitial diagnostic workup

Chest xray shows character and extentBlood culture to investigate secondary

bacteremiaCBC can reassure or point to suppurative

processYou can also consier

Basic/complete metabolic panel Viral panel Sputum for gram stain and culture when practicle

Inpatient TreatmentSupportive care

OxygenSuctioningIVFFever/pain control

Antibiotic therapy

Inpatient TreatmentChoice of antibiotic therapy

For suppurative, empiric treatment with a broad spectrum, typically IV ceftriaxone or amp, cover pneumococcus, GAS, and

Then broaden coverage based on Failure to improve on empiric coverage Severity --> vanc or clinda for S. aureus and

pneumococcus and GAS Effusion Pneumatocele

Inpatient TreatmentSpecial considerations

Macrolide for atypical pneumonia Azithromycin Levofloxacin

Doxycycline

Inpatient TreatmentLength of Treatment

7 to 10 days totalOral therapy

Clinically stable Afebrile

5 days for azithromycin

ComplicationsMajor suppurative complications

Parapneumonic effusionLung abscessNecrotizing pneumonia

ComplicationsNecrotizing pneumonia

liquefaction and necrosis of lung tissue cause by toxins

Ill or toxic appearing childCXR reveals airspace consolidation with

central cavitationTreatment

Vancomycin or clindamycin first-line agents Organism specific

ComplicationsLung abscess

Radiographic finding thick-walled cavity with air-fluid level

Inciting aspiration eventOrganisms

Mouth flora Strep, staph, anaerobes, GNR, TB

ComplicationsTreatment

Clinda Needle aspiration Several weeks IV + PO CXR

ComplicationParapneumonic effusion

CommonUsually resolve with initially therapyPurulent effusion empyema

Ill-appearing, febrile, tachypneic, in pain Dullness to percusion and decreased breathsounds

ComplicationsParapneumonic effusion management

CXR AP Lateral decubitus

Ultrasounography Location, amount, quality

CT - may enhance USPleural fluid aspiration

Complications

Send pleural fluid for Gram stain & cultures Cell count PH Glucose concentration LDH Acid fast bacillus and fungal culture

Surgical intervention controversialInstitutional preference

Medical management alone Thoracentesis – free flowing fluid Chest tube Video assisted thorascopic surgery (VATS) with chest tube

– loculated or purulent Intrapleural fibrinolytic therapy (less impressive) thoracotomy

Complications

ComplicationsAntipyretics/analgesiaIVFCPT contraindicated Appropriate antiobiotics Poorly defined time interval

PreventionImmunizationAvoid smoke exposureGood handwashing

SummaryPNA less frequent than asthmas and

bronchiolitisClinical findings usually sufficient to dx

Fever, cough, tachypnea, inc WOB, ausculatory findings

Radiographs and labs not requiredUncomplicated treated outpatientYoung patients, severally ill, or if

complications, treat inpatient