PNEUMONIA

JI NGILAY, NADJIMIN E

CASE
NN, 5mos male Chief complaint: cough x 4 days

History of present illness

3 days PTC
(+) cough productive, whitish phlegm (+) colds, stuffy nose (-) fever (-) vomiting good suck and activity (-) consult/ medication given

History of present illness

1 day PTC
(+) cough productive, whitish phlegm, (+) colds, watery nasal disharge (-) fever (+) vomiting 2x, NP,PIF (-) consult/ medication

History of present illness

1hr PTC
(+) cough productive, distressing (+) colds, watery nasal disharge (-) fever (+) perioral cyanosis (+) fast breathing (+) vomiting 2x PIF (+) consult at your clinic

Pertinent physical examination

CR- 144/min

RR- 67/min

temp 37C

Chest : symmetrical chest expansion, with

intercostal and subcostal retractions, crackles and wheezes all over, fair air entry.

Pneumonia
Inflammation of the parenchyma of the lungs

Risk factors for the development of pneumonia

(1) lung disease (2) anatomic problems (3) gastroesophageal reflux disease with aspiration (4) neurologic disorders
Interfere protection of the airway compromise clearing

(5) diseases that alter the immune system

Pathogenesis
lower respiratory tract normally kept sterile by physiologic defense

mechanisms
mucociliary escalator

normal secretions (secretory IgA)

Cough reflex Immunologic defense mechanisms macrophages that are present in alveoli and bronchioles

IN NNs case
Possible risk factors?

Epidemiology
viral pneumonia = peak attack rate 2 - 3 yrs < 3 yr - RSV common pathogen > 5 yr
S. pneumoniae

M. pneumoniae
Chlamydia pneumoniae

In NNs case
Most probable organism?

Pathogenesis
Viral pneumonia
spread of infection along the airways direct injury of the respiratory epithelium Results to: airway obstruction Swelling abnormal secretions cellular debris predispose to secondary bacterial infection disturbing normal host defense altering secretions modifying bacterial flora

Pathogenesis
Bacterial infection varies according to organism: M. pneumoniae
attaches to the respiratory epithelium inhibits ciliary action cellular destruction inflammatory response

(submucosa)

Pathogenesis
S. pneumoniae
local edema proliferation of organisms spread adjacent portions characteristic focal

lobar involvement

Pathogenesis
Group A Streptococcus
diffuse infection necrosis of tracheobronchial mucosa Forms large exudate, edema, and local hemorrhage Extends to interalveolar septa Involves of lymphatic vessels Increased pleural involvement

Pathogenesis
S. aureus
confluent bronchopneumonia often unilateral extensive areas of hemorrhagic necrosis irregular areas of cavitation pneumatoceles, empyema, or bronchopulmonary fistulas

INTERSTITIAL

LOBAR

Pneumatocoele

Clinical Manifestations
preceded by several days of an URTI Tachypnea is the most consistent clinical

manifestation

Clinical Manifestations
Increased work of breathing
intercostal, subcostal, and

suprasternal retractions nasal flaring use of accessory muscles

Severe infection :
cyanosis

Auscultation
crackles and wheezing

Clinical Manifestations
Bacterial pneumonia older children
high fever with shaking chill chest pain drowsiness Restlessness

rapid respirations
dry, hacking, productive cough Anxiety occasionally delirium Circumoral cyanosis

Clinical Manifestations
pleuritic pain
lie on their side with their knees drawn up to their

chest (affected side ) Minimize pain and improve ventilation

Physical examination
lag in respiratory excursion -affected side Abdominal distention -gastric dilation
swallowed air ileus

liver may seem enlarged

downward displacement of the diaphragm hyperinflation superimposed congestive heart failure

Nuchal rigidity

Physical examination
In infants

prodrome of URTI diminished appetite fever Restlessness respiratory distress

Grunting nasal flaring retractions supraclavicular intercostal, subcostal areas

Physical examination
Stage of illness Early
diminished breath sound Crackles rhonchi

development of
consolidation or complications (effusion, empyema, or

pyopneumothorax)
dullness breath sounds diminished

 In infants

Tachypnea Tachycardia air hunger Cyanosis

Some infants may have associated gastrointestinal

disturbances secondary -paralytic ileus

Vomiting Anorexia Diarrhea abdominal distention

Respiratory Distress

Respiratory Distress

Diagnosis
chest radiograph
confirms the diagnosis indicate a complication pleural effusion empyema

viral pneumonia
hyperinflation interstitial infiltrates peribronchial cuffing

Diagnosis
pneumococcal pneumonia

lobar consolidation

Diagnosis
Definitive diagnosis

isolation
Viruses-requires 5-10 days

detection of viral antigens Serologic techniques

require testing serum Acute & convalescent rise in antibodies

Not clinically useful

Diagnosis
Blood cultures
positive in 10-30%

cold agglutinins
M. pneumoniae at titers >1:64 nonspecific

anti-streptolysin O (ASO) titer

group A streptococcal pneumonia

Criteria for Admission

Oxygen requiring

No reliable caretaker

Treatment
mildly ill children not hospitalized
amoxicillin

penicillin-resistant pneumococci
high doses of amoxicillin (80-90 mg/kg/24 hr)

alternatives
cefuroxime axetil amoxicillin/clavulanate

school-aged children
M. pneumoniae macrolide

Treatment
Hospitalized child
cefuroxime (75-150 mg/kg/24 hr) mainstay of therapy

Staphylococcal pneumonia
Include vancomycin clindamycin

Treatment
Oxygen therapy Nebulization
creates a mist of fine fluid droplets small enough to penetrate down into the lung used to moisten lower airway secretions Last 5-10 minutes flow rates of at least 6 L/minute

Complications
Pleural effusion Empyema Pericarditis Bacteremia Hematologic spread
Rare complications Meningitis suppurative arthritis osteomyelitis

IMCI

Integrated Management of Childhood Illnesses

Look for the ff: DANGER SIGNS

Child not be able to breastfeed or drink? Vomit everything Convulsion Abnormally sleepy or difficult to awaken

Chief complaint: cough or difficulty of breathing

Ask for how long?
Look, listen, and feel for

Count breaths in one minute Look for chest indrawing

Look and listen for stridor

SIGNS

CLASSIFY AS

TREATMENT

Any general danger sign Chest indrawing Stridor in a calm child

SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Give first dose of an appropriate antibiotic Give Vitamin A Treat the child to prevent Low blood sugar Refer urgently
Give appropriate antibiotic for 5 days Soothe the throat and relieve the cough with a safe remedy Advise the mother when to return immediately Follow up in 2 days If coughing more than 30 days refer for assessment Advise the mother when to return immediately Follow up if no signs of improvement

Fast breathing

PNEUMONIA

No signs of Pneumonia or very severe disease

No pneumonia, Cough or cold

APPROPRIATE ORAL ANTIBIOTIC

First line:
Co-trimoxazole 250/40/5

Second line:
Amoxicillin 250/5

FOLLOW-UP
After 2 days:
Check for general danger signs Assess for cough and difficulty of breathing.

Ask

Child breathing slower Less fever Eating better

WHEN TO RETURN IMMEDIATLEY

Fast breathing
Difficulty of breathing