PNEUMONIA

Reference:
1. Buku Ajar Respirologi Anak
2. Nelson Textbook of Pediatrics

K. Yangtjik
Fifi Sofiah
Yusmala Helmy
Myrna Alia
 Magnitude of the Problem
in Indonesia
Pneumonia in children (< 5 years of age)
Morbidity Rate 10-20 %
Mortality Rate 6 / 1000
Pneumonias kill
50.000 / a year
12.500 / a month
416 / a day = passengers of 1 jumbo jet plane
17 / an hour
1 / four minutes
 RISK FACTORS FOR PNEUMONIA
OR DEATH FROM ARI
Malnutrition, poor
breast feeding
practices
Lack of immunization Vitamin A deficiency

Young age Low birth weight

Increase
risk of
ARI
Cold weather
Crowding or chilling

High prevalence Exposure to air pollution

of nasopharyngeal Tobacco smoke
carriage of Biomass smoke
pathogenic bacteria Environmental air pollution
 Etiology
Age Common causes Less common causes
Birth to 20 days Bacteria Bacteria
Escherichia coli Anaerobic organisms
Group B streptococci Group D streptococci
Listeria monocytogenes Haemophilus influenzae
Streptococcus pneumoniae
Ureaplasma urealyticum

Viruses
Cytomegalovirus
Herpes simplex virus
3 weeks to 3 Bacteria Bacteria
months Chlamydia trachomatis Bordetella pertussis
S. pneumoniae H. influenzae type B and
nontypeable
Moraxella catarrhalis
Staphylococcus aureus
U. urealyticum

Viruses Virus
Adenovirus Cytomegalovirus
Influenza virus
Parainfluenza virus 1, 2, and 3
Respiratory syncytial virus
 Etiology
4 months to 5 years Bacteria Bacteria
Chlamydia pneumoniae H. influenzae type B
Mycoplasma pneumoniae M. catarrhalis
S. pneumoniae Mycobacterium
tuberculosis
Neisseria meningitis
S. aureus
Viruses Virus
Adenovirus Varicella-zoster virus
Influenza virus
Parainfluenza virus
Rhinovirus
Respiratory syncytial virus
5 years to adolescence Bacteria Bacteria
C. pneumoniae H. influenzae
M. pneumoniae Legionella species
S. pneumoniae M. tuberculosis
S. aureus
Viruses
Adenovirus
Epstein-Barr virus
Influenza virus
Parainfluenza virus
Rhinovirus
Respiratory syncytial
virus
Varicella-zoster virus
PATOFISIOLOGI
STADIUM I: HIPEREMIA/ KONGESTI

Inokulasi mikroorganismerespon peradanganakumukasi sel MN pada

submukosa dan ruang perivaskuler obstruksi parsial pada jalan nafas.
Penyakit bertambah berat jika sel alveolar tipe II kehilangan integritas strukutralnya
produksi surfaktan berkurang, sehingga terjadi edema

STADIUM II: HEPATISASI MERAH

RBC, fibrin, PMNs fills the alveoli

STADIUM III: HEPATISASI KELABU

Leucocytes and fibrin consolidated in infected alveoli

STADIUM IV: RESOLUTION

Exudate absorbed by macrophage

 Clinical Manifestation
General symptoms
Fever
Headache
Irritable
Anorexia
GIT symptoms: nausea, vomiting or diarrhoea
 Clinical Manifestation
Respiratory symptoms
Cough
Dyspnea: nasal flaring, chest indrawing,
grunting
Tacypnea
Cyanosis
 Physical Findings
Tachpnea

Normal RR
Normal RR (WHO)
Age Range Av. Rate during Age RR
asleep
< 2 mo < 60 x/m

Neonates 30 60 35 2 mo-12mo < 50x/m

1 mo 1 y.o 30 60 30
1-5 y.o < 40x/m
1 2 y.o 25 50 25
5-8 y.o < 30 x/m
3 4 y.o 20 30 22
5 y.o 9 y.o 15 30 18
10 y.o 15 30 15
 Physical Findings

Nasal flaring

Chest indrawing/retractions
 Physical Findings

Cyanosis
Rales/ ronchi
 Laboratory Findings
Peripheral WBC (White Blood Cells):
In viral pneumonianormal or elevated usually
not higher than 20,000/mm3, with a lymphocyte
predominance.
Bacterial pneumonia (occasionally, adenovirus
pneumonia) is often associated with an elevated
WBC count in the range of 15,000-40,000/mm3
and a predominance of granulocytes
Low WBC count/ leucopenia poor prognosis
 Laboratory Findings
CRP ( C-reactive protein)
lower in viral infection
No conclusive evident to distinguish viral or
bacterial infection
 Radiological exam
Not a routine procedure indicated for:
Severe clinical symptom
Poor response to therapy
Deterioration in clinical symptoms
 Radiological exam
Interstitial infiltrate increased
bronchovasculature, peribronchial cuffing,
hyperaerated
Alveolar infiltrate consolidation with air
bronchogram
Consolidation in one lobe lobar pneumonia
Bronchopneumonia infiltrate spreading to
peripheral area, increased peribronchial
vasculature
 Radiological exam
Consolidation in upper right lobe
 Management
Causative
Proper and rapid antibiotic administration
key to succesful management
Empirical antibiotic therapy no rapid
microbiology test early identification of
causative microorganism not possible
Mild symptoms treat in outpatient care,
oral antibiotic
 Management
Causative inpatient
Broad spectrum antibiotic (Example in Moh. Hoesin
Hospital):
Ampicillin 100 mg/BW/day div. in 3-4 doses +
Chloramphenicol (div in 3-4 doses):
< 6 mo : 25-50 mg/BW/day
> 6 mo : 50-75 mg/BW/day OR
Gentamycin 3 5 mg/BW/day(in 2 doses),
Severe clinical symptoms or laboratory finding
suggesting sepsis ceftazidime 50-100 mg/BW/day
(div 2-3 doses)
Antibiotic recommendations for community acquired pneumonia
(AAFP)
Patie Outpatient Inpatient Critically ill
nt age
Birth Admit Ampicillin IV or IM: Ampicillin IV or IM, in same dosages
to 20 Age <7 days: as for inpatients
days Weight <2 kg (4.4 lb): 50 to 100 mg per kg per day in plus
divided doses every 12 hours Gentamicin IV or IM, with or without
Weight >=2 kg: 75 to 150 mg per kg per day in divided cefotaxime IV, in same dosages as
doses every 8 hours for inpatients
Age >=7 days:
Weight <1.2 kg (2.6 lb): 50 to 100 mg per kg per day
divided every 12 hours
Weight 1.2 to 2 kg: 75 to 150 mg per kg per day in divided
doses every 8 hours
Weight >2 kg: 100 to 200 mg per kg per day in divided
doses every 6 hours
plus
Gentamicin IV or IM:
>=37 weeks of gestation
and
Age zero to 7 days: 2.5 mg per kg every 12 hours
Age >7 days: 2.5 mg per kg every 8 hours
with or without
Cefotaxime (Claforan) IV:
Age <=7 days:
100 mg per kg per day in divided doses every 12 hours
Age >7 days:
150 mg per kg per day in divided doses every 8 hours
Antibiotic recommendations for community acquired pneumonia
(AAFP)

3 weeks If patient is afebrile: Erythromycin, 40 mg per kg per Cefotaxime, 200 mg per kg per day IV in
to 3 Azithromycin (Zithromax), 10 mg per day IV in divided doses every 6 divided doses every 8 hours plus cloxacillin
months kg orally on day 1, then 5 mg per kg hours* (Tegopen), 150 to 200 mg per kg per day IV
per day on days 2 through 5 If patient is febrile, add one of in divided doses every 6 hours*
or these agents: or
Erythromycin, 30 to 40 mg per kg per Cefotaxime, 200 mg per kg per Cefuroxime alone, 150 mg per kg per day IV
day orally in divided doses every 6 day IV in divided doses every 8 in divided doses every 8 hours*
hours for 10 days hours*
Admit if patient is febrile or hypoxic.or
Cefuroxime (Ceftin), 150 mg per
kg per day IV in divided doses
every 8 hours*
4 months Amoxicillin, 90 mg per kg per day Cefotaxime, 150 mg per kg per Cefuroxime, 150 mg per kg per day IV in
to 5 orally in divided doses every 8 hours day IV in divided doses every 6 divided doses every 8 hours, plus
years for 7 to 10 days hours* erythromycin, 40 mg per kg per day IV or
Consider initial dose of ceftriaxone or orally in divided doses every 6 hours for 10
(Rocephin), 50 mg per kg per day IM, Cefuroxime, 150 mg per kg per to 14 days*
up to 1 g per day. Follow with oral day IV in divided doses every 8 or
therapy for full course. hours* Cefotaxime, 200 mg per kg per day IV in
Alternatives: amoxicillin-clavulanic If the patient has pneumococcal divided doses every 8 hours, plus cloxacillin,
acid (Augmentin), azithromycin, infection: 150 to 200 mg per kg per day IV in divided
cefaclor (Ceclor), clarithromycin Ampicillin alone, 200 mg per kg doses every 6 hours for 10 to 14 days
(Biaxin), erythromycin per day IV in divided doses every
8 hours*
Antibiotic recommendations for community acquired pneumonia
(AAFP)

5 years Azithromycin, 10 mg per kg Cefuroxime, 150 mg per kg per day IV in Cefuroxime, 150 mg per kg per
and older (maximum of 500 mg) orally on divided doses every 8 hours day IV in divided doses every 8
day 1, followed by 5 mg per kg per plus hours
day on days 2 through 5 Erythromycin, 40 mg per kg per day IV or plus
or orally in divided doses every 6 hours for 10 to Erythromycin, 40 mg per kg per
Clarithromycin, 15 mg per kg per 14 days day IV or orally in divided doses
day orally in divided doses every If pneumococcal infection is confirmed: every 6 hours for 10 to 14 days
12 hours for 7 to 10 days Ampicillin alone, 200 mg per kg per day IV in
or divided doses every 8 hours
Erythromycin, 40 mg per kg per
day orally in divided doses every 6
hours for 7 to 10 days
If the patient has pneumococcal
infection:
Amoxicillin alone, 90 mg per kg per
day orally in divided doses every 8
hours
 Management
Supportive
Mild symptoms
Inpatient :
IVFD
Oxygen
Analgetic/ antipyretic
 Complications
Empyema
Pericarditis
Pnemothorax
Hematologic spread
Meningitis
Osteomyelitis
Suppurative arthritis
 IMCI (Integrated Management of
Childhood Illness)/
MTBS (Managemen Terpadu Balita Sakit)
 IMCI (Integrated Management of Childhood Illness)/MTBS
(Managemen Terpadu Balita Sakit)
Offer simple and effective methods to prevent & manage the
leading causes of serious illness and mortality in young
children
IMCI (Integrated Management of Childhood Illness)/MTBS
(Managemen Terpadu Balita Sakit)

Aimed for:
Young infant aged 1 day-2 months
Children aged 2 months-5 years
To be practiced by:
Paramedic and medical practitioner in primary
health care (puskesmas & pustu):
Paramedic (midwives & nurses)
Physician in primary healthcare (Puskesmas)
Not for inpatient care / ward