Pneumonia

PEDIATRIC COMMUNITY PEDIATRIC COMMUNITY ACQUIRED PNEUMONIAACQUIRED PNEUMONIA

PNEUMONIAPNEUMONIA

Is an inflammation of the parenchyma of Is an inflammation of the parenchyma of the lungsthe lungs

Most cases of pneumonia are caused by Most cases of pneumonia are caused by microorganismmicroorganism

noninfectious causes- aspiration of food or noninfectious causes- aspiration of food or gastric acid; foreign bodies; hydrocarbons; gastric acid; foreign bodies; hydrocarbons; lipoid substances; hypersensitivity lipoid substances; hypersensitivity reactions and drug 0r radiation-induced reactions and drug 0r radiation-induced pneumonitispneumonitis

Specific risk factors:Specific risk factors:

1.1. Lung diseaseLung disease

2.2. anatomic problemsanatomic problems

3.3. Gastroesophageal reflux disease with Gastroesophageal reflux disease with aspirationaspiration

4. Neurologic disorders that interfere with 4. Neurologic disorders that interfere with protection of the airway or compromise protection of the airway or compromise clearing of the airwayclearing of the airway

5. Diseases that alter the immune system, 5. Diseases that alter the immune system, such immunodeficiency diseases or such immunodeficiency diseases or hemoglobinopathieshemoglobinopathies

EtiologyEtiology

Viral - peak attack is between 2-3 y.o.Viral - peak attack is between 2-3 y.o.

S.pneumoniae, M.pneumoniae – S.pneumoniae, M.pneumoniae – older older than 5 y.o.than 5 y.o.

other bacterial causes: group A strep, other bacterial causes: group A strep, S.pyogenes, Staph aureus, H.influenzae S.pyogenes, Staph aureus, H.influenzae type Btype B

Clinical manifestationClinical manifestation

Viral and bacterial pneumonias are most Viral and bacterial pneumonias are most often preceded by several days of often preceded by several days of symptoms of an upper respiratory tract symptoms of an upper respiratory tract infection, typically rhinitis and coughinfection, typically rhinitis and cough

Viral pneumonia, fever -temp.- is generally Viral pneumonia, fever -temp.- is generally lower than bacterial.lower than bacterial.

Tachypnea is the most consistent clinical Tachypnea is the most consistent clinical manifestationmanifestation

Increased working breathing accompanied Increased working breathing accompanied by intercostal retractions, nasal flaring and by intercostal retractions, nasal flaring and use accesory muscles use accesory muscles

Bacterial pneumonia in older children Bacterial pneumonia in older children typically begins suddenly with shaking chill typically begins suddenly with shaking chill followed by high fever, cough and chest followed by high fever, cough and chest painpain

Predictors of CAP in a Patient with coughPredictors of CAP in a Patient with cough

1. ages 3-5 y.o.- tachypnea and/or chest 1. ages 3-5 y.o.- tachypnea and/or chest indrawing indrawing

2. ages 5-12 y.o. – fever, tachypnea2. ages 5-12 y.o. – fever, tachypnea

& crackles& crackles

3. > 12 y.o. fever, tachypnea, tachycardia3. > 12 y.o. fever, tachypnea, tachycardia

at least 1 abnormal chest findingsat least 1 abnormal chest findings

ronchi, crackles, wheezes, ronchi, crackles, wheezes, ↓breath ↓breath soundssounds

Reliable indicators- either tachypnea and/or Reliable indicators- either tachypnea and/or chest indrawing among infants and preschool chest indrawing among infants and preschool childrenchildren

Tachypnea is still the best predictorTachypnea is still the best predictor Age specific criteria for tachypnea:Age specific criteria for tachypnea: 2-12 mos. – 50 breaths/min.2-12 mos. – 50 breaths/min. 1-5 years. – 40 breaths/min. 1-5 years. – 40 breaths/min. > 5 years – 30 breaths/min.> 5 years – 30 breaths/min.

Patients with CAP are 2-3 times more Patients with CAP are 2-3 times more likely to have the following signs and likely to have the following signs and symptoms:symptoms:

nasal flaring, grunting, tachypnea, nasal flaring, grunting, tachypnea, rales and pallorrales and pallor

Diagnosis of an adolescent suspected to Diagnosis of an adolescent suspected to have CAP:have CAP:

coughcough tachypnea (RR .20 breaths/min.)tachypnea (RR .20 breaths/min.) tachycardia (HR .100bpm)tachycardia (HR .100bpm)

fever (temp > 37.8fever (temp > 37.8ºC)ºC) at least 1 abnormal chest findingsat least 1 abnormal chest findings CXR with infiltratesCXR with infiltrates

Criteria for admissionCriteria for admission

A patient who is moderate to high risk to A patient who is moderate to high risk to develop pneumonia-related mortality develop pneumonia-related mortality should be admittedshould be admitted

A patient who is at minimal to low risk can A patient who is at minimal to low risk can be managed on OPD basisbe managed on OPD basis

RISK CLASSIFICATION FOR RISK CLASSIFICATION FOR PNEUMONIA-RELATED MORTALITYPNEUMONIA-RELATED MORTALITY

VARIABLESVARIABLES PCAP APCAP A

Minimal riskMinimal risk

PCAP BPCAP B

Low riskLow risk

PCAP CPCAP C

Moderate Moderate riskrisk

PCAP DPCAP D

High riskHigh risk

co-morbid co-morbid illnessillness

nonenone presentpresent presentpresent PresentPresent

Compliant Compliant care givercare giver

YesYes yesyes nono nono

Ability to ff-upAbility to ff-up possiblepossible possiblepossible Not possibleNot possible Not possibleNot possible

Presence of Presence of dehydrationdehydration

nonenone mildmild moderatemoderate severesevere

Ability to feedAbility to feed ableable ableable unableunable unableunable

ageage >11 mo.>11 mo. >11 mo.>11 mo. <11 mo.<11 mo. <11 mo.<11 mo.

VARIABLESVARIABLES PCAP APCAP A

Minimal riskMinimal risk

PCAP BPCAP B

Low riskLow risk

PCAP CPCAP C

Moderate Moderate riskrisk

PCAP DPCAP D

High riskHigh risk

resp rateresp rate

2-12mo.2-12mo.

1-5 yrs.1-5 yrs.

>5 yrs.>5 yrs.

>50/min>50/min

>40/min>40/min

>30/min>30/min

>50/min>50/min

>40/min>40/min

>30/min>30/min

>60/min>60/min

>50/min>50/min

>35/min>35/min

>70/min>70/min

>50/min>50/min

>35/min>35/min

Signs of resp Signs of resp failurefailure

a.Retractiona.Retraction

b. Head b. Head bobbingbobbing

c. Cyanosisc. Cyanosis

d. Gruntingd. Grunting

nonenone nonenone Intercostal/Intercostal/subcostalsubcostal

PresentPresent

presentpresent

nonenone

Supraclavicular/Supraclavicular/intercostal/intercostal/subcostalsubcostal

presentpresent

VARIABLESVARIABLES PCAP APCAP A

Minimal riskMinimal risk

PCAP BPCAP B

Low riskLow risk

PCAP CPCAP C

Moderate Moderate riskrisk

PCAP DPCAP D

High riskHigh risk

Signs of resp Signs of resp failurefailure

e. apneae. apnea

f. sensoriumf. sensoriumNoneNone

awakeawake

NoneNone

awakeawake

NoneNone

irritableirritable

PresentPresent

Lethargic,stuporLethargic,stuporous/comtoseous/comtose

ComplicationsComplications nonenone nonenone presentpresent presentpresent

Action planAction plan OPDOPD OPDOPD Admit to Admit to regular wardregular ward

Admit to ICUAdmit to ICU

Parameters to be evaluated when Parameters to be evaluated when considering admission:considering admission:

1. Host factors1. Host factors

a. ability to feeda. ability to feed

b. ageb. age

c. signs of resp failurec. signs of resp failure

d. pulmonary complicationsd. pulmonary complications

e. respiratory ratee. respiratory rate

f. state of dehydrationf. state of dehydration

g. presence of comorbid factorsg. presence of comorbid factors

2. External factors2. External factors

a. compliant caregivera. compliant caregiver

b. ability to ff-up b. ability to ff-up

Grunting and apnea are manifestationsGrunting and apnea are manifestations

of acute respiratory failure requiring of acute respiratory failure requiring admission to critical care unitadmission to critical care unit

compared with older children, an infant compared with older children, an infant younger than one year has higher risk of younger than one year has higher risk of contracting sever pneumoniacontracting sever pneumonia

Age from 2-11 mos. was associated with Age from 2-11 mos. was associated with deathdeath

Presence of retraction on admission was Presence of retraction on admission was the best single predictor of death the best single predictor of death

Subcostal, intercostal, supraclavicular Subcostal, intercostal, supraclavicular retractions were associated with mortality retractions were associated with mortality

Chest retraction has been considered to Chest retraction has been considered to be an excellent sign for selecting children be an excellent sign for selecting children needing admission for more intensive needing admission for more intensive treatment.treatment.

Tachypnea, chest retraction, somnolence Tachypnea, chest retraction, somnolence and young age, chronic illness & and young age, chronic illness & malnutrition were independently malnutrition were independently associated with hospitalizationassociated with hospitalization

Cyanosis and head bobbing corelates well Cyanosis and head bobbing corelates well with hypoxemiawith hypoxemia

Inability to cry, head nodding and a resp Inability to cry, head nodding and a resp rate of >60/min. were best predictors of rate of >60/min. were best predictors of hypoxemia. hypoxemia.

DIAGNOSTICSDIAGNOSTICS

No diagnostic aids are initially requested No diagnostic aids are initially requested for a patient classified as either PCAP A or for a patient classified as either PCAP A or PCAP B who is being managed in an PCAP B who is being managed in an ambulatory setting (Grade D).ambulatory setting (Grade D).

Recommendations for PCAP C & D:Recommendations for PCAP C & D:Routine exams:Routine exams:a.a. CXR-PA LateralCXR-PA Lateralb.b. WBC countWBC countc.c. Culture and sensitivity of:Culture and sensitivity of:

blood,pleural fluid, & tracheal blood,pleural fluid, & tracheal aspirate for PCAP D, sputum for older aspirate for PCAP D, sputum for older children children

The following should not be requested:The following should not be requested:

1.1. ESRESR

2.2. C-reactive proteinC-reactive protein

ANTIBIOTIC RECOMMENDATIONANTIBIOTIC RECOMMENDATION

1. for patient classified as either PCAP A or 1. for patient classified as either PCAP A or B and is B and is

a. beyond 2 years of agea. beyond 2 years of ageb. having high grade fever without b. having high grade fever without

wheezewheeze2. For a patient classified as PCAP C and is 2. For a patient classified as PCAP C and is

a. beyond 2 years of agea. beyond 2 years of age

b. having high grade fever without b. having high grade fever without wheezewheeze

c. having alveolar consolidation in the c. having alveolar consolidation in the CXRCXR

d. having WBC count > 15,000d. having WBC count > 15,000

3. For a patient classified as PCAP D 3. For a patient classified as PCAP D

Practice guidelines cited as Practice guidelines cited as AGE AGE as the as the best predictor of underlying etiology of best predictor of underlying etiology of pediatric pneumoniapediatric pneumonia

First 2 years of life First 2 years of life VIRUSESVIRUSES are most are most frequently implicatedfrequently implicated

As age increases, bacterial pathogens As age increases, bacterial pathogens become more prevalentbecome more prevalent

Literature review showed the following Literature review showed the following pattern of microbial etiology:pattern of microbial etiology:

1.1. PCAP managed as an outpatientPCAP managed as an outpatienta. bacterial pathogen is more common a. bacterial pathogen is more common than a viral pathogenthan a viral pathogenb. b. Streptococcus pneumoniaeStreptococcus pneumoniae is the is the pathogen in more than half of the pathogen in more than half of the patientspatients

Less common pathogens include Less common pathogens include M. M. pneumoniae pneumoniae and and C. pneumoniaeC. pneumoniae

2. 2. PCAP managed as an in patientPCAP managed as an in patienta. bacterial pathogen is more a. bacterial pathogen is more

common than a viral pathogencommon than a viral pathogenb. b. S.pneumoniae S.pneumoniae is the pathogen in is the pathogen in

little more than half of the patientslittle more than half of the patients

H. influenzae H. influenzae type B should be type B should be considered in a patient below 5 y.o. who considered in a patient below 5 y.o. who has not completed the primary series of has not completed the primary series of Hib immunizationHib immunization

certain features that suggest the presence of a bacterial certain features that suggest the presence of a bacterial and viral pathogenand viral pathogen

Demonstration of either alveolar infiltrates in CXR or Demonstration of either alveolar infiltrates in CXR or elevated WBC favors bacterial pathogen elevated WBC favors bacterial pathogen

FEATURESFEATURES BacterialBacterial ViralViral

FeverFever >38.5>38.5ºCºC <38.5<38.5ºCºC

WheezeWheeze absentabsent presentpresent

EMPIRIC TREATMENTEMPIRIC TREATMENT

1. for patient classified as PCAP A or B without 1. for patient classified as PCAP A or B without previous antibiotic, oral Amoxicillin (40-50 previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided dosesmg/kg/day in 3 divided doses

2. for a patient classified as PCAP C w/o 2. for a patient classified as PCAP C w/o previous antibiotic & who has completed the previous antibiotic & who has completed the primary immunization against primary immunization against H. influenzae H. influenzae type type B, Pen G 100,000 u/kg/day in 4 divided doses.B, Pen G 100,000 u/kg/day in 4 divided doses.

if a primary immunization against Hib has if a primary immunization against Hib has not been completed,and below 5 y.o., IV not been completed,and below 5 y.o., IV ampicillin (100mg/kg/day in 4 divided ampicillin (100mg/kg/day in 4 divided dosesdoses

3. for a patient classified as PCAP D, a 3. for a patient classified as PCAP D, a specialist should be consultedspecialist should be consulted

INITIAL TREATMENT GIVEN WITH VIRAL INITIAL TREATMENT GIVEN WITH VIRAL ETIOLOGYETIOLOGY

Antiviral agents such as amantadine and Antiviral agents such as amantadine and the newer neuraminidase inhibitors the newer neuraminidase inhibitors zanamivir and oseltamivir zanamivir and oseltamivir

-reduces the duration of illness by 1--reduces the duration of illness by 1-1.5 days 1.5 days

-to reduce the duration of viral -to reduce the duration of viral shedding among patients with influenzashedding among patients with influenza

For influenza A infection – amantadine For influenza A infection – amantadine (4.4-4.8 mg/kg/day) can be given for 3-5 (4.4-4.8 mg/kg/day) can be given for 3-5 daysdays

- Discontinue the drug within 24-48 hrs. after - Discontinue the drug within 24-48 hrs. after resolution of symptomsresolution of symptoms

For influenza A or B infection – oseltamivir For influenza A or B infection – oseltamivir (2mg/kg/dose BID) can be given for 5 days(2mg/kg/dose BID) can be given for 5 days

In case proven epidemics of influenza, In case proven epidemics of influenza, oseltamivir may be givenoseltamivir may be given

Its use for treatment & prophylaxis of household Its use for treatment & prophylaxis of household contacts has been effective for >12 y.o.contacts has been effective for >12 y.o.

RESPONSE TO CURRENT ANTIBIOTICSRESPONSE TO CURRENT ANTIBIOTICS

1. decrease in respiratory signs 1. decrease in respiratory signs (tachypnea) & defervescence within 72 (tachypnea) & defervescence within 72 hrs. after initiation of antibiotichrs. after initiation of antibiotic

2. persistence of symptoms beyond 72 hrs 2. persistence of symptoms beyond 72 hrs after initiation of antibiotics requires after initiation of antibiotics requires reevaluation reevaluation

3. end of treatment CXR, WBC, ESR or 3. end of treatment CXR, WBC, ESR or CRP should not be done to assess CRP should not be done to assess therapeutic response to antibiotictherapeutic response to antibiotic

1. if an out patient classified as either 1. if an out patient classified as either PCAP A or PCAP B is not responding to PCAP A or PCAP B is not responding to the current antibiotic within 72 hrs.the current antibiotic within 72 hrs.

- change the initial antibiotic- change the initial antibiotic

- start oral macrolide- start oral macrolide

- reevaluate diagnosis- reevaluate diagnosis

possibility of penicillin resistant possibility of penicillin resistant S.pneumoniaeS.pneumoniae

Course of action: Course of action: change amoxicillin to any change amoxicillin to any of the ff.: cefuroxime, co-amoxiclav, of the ff.: cefuroxime, co-amoxiclav, sultamicillin or cepfodoxime sultamicillin or cepfodoxime

Possibility of Possibility of Mycoplasma sp or Mycoplasma sp or Chlamydia sp.Chlamydia sp.

Course of action: Course of action: start an oral macrolide, start an oral macrolide, such as erythromycinsuch as erythromycin

2. if an inpatient classified as PCAP C is 2. if an inpatient classified as PCAP C is not responding to the current antibiotic not responding to the current antibiotic within 72 hrs. consider consultation with a within 72 hrs. consider consultation with a specialist specialist

following possibilities: following possibilities:

- penicillin resistant - penicillin resistant S.pneumoniaeS.pneumoniae

- - presence of complicationspresence of complications

If an inpatient classified as PCAP D is not If an inpatient classified as PCAP D is not responding within 72 hrs., consider responding within 72 hrs., consider immediate re-consultation with a specialist immediate re-consultation with a specialist

WHEN CAN SWITCH THERAPY IN BACTERIAL WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIAPNEUMONIA

Switch from IV antibiotics to oral form 2-3 days Switch from IV antibiotics to oral form 2-3 days after initiation of antibiotic is recommended in after initiation of antibiotic is recommended in patients:patients:

a. responding to initial antibiotic therapya. responding to initial antibiotic therapy

b. able to feed with intact GI absorptionb. able to feed with intact GI absorption

c. does not have any pulmonary or c. does not have any pulmonary or extrapulmonary complicationsextrapulmonary complications

ANCILLARY TREATMENTANCILLARY TREATMENT

1. cough preparations, chest 1. cough preparations, chest physiotherapy, bronchial hygiene, physiotherapy, bronchial hygiene, nebulization using NSS, steam inhalation, nebulization using NSS, steam inhalation, topical solution, bronchodilators and topical solution, bronchodilators and herbal medicine are not routinely givenherbal medicine are not routinely given

2. among patients, oxygen and hydration 2. among patients, oxygen and hydration should be given if neededshould be given if needed

3. in the presence of wheezing, a 3. in the presence of wheezing, a bronchodilator may be givenbronchodilator may be given

PREVENTIONPREVENTION

1. vaccines recommended by the Phil. 1. vaccines recommended by the Phil. Pediatric Society should be routinely Pediatric Society should be routinely administeredadministered

2. Zinc supplementation2. Zinc supplementation

3. Vitamin A, immunomodulators and 3. Vitamin A, immunomodulators and Vitamin C should not be routinely givenVitamin C should not be routinely given