15.3.1 Breathing Difficulty In Children : Upper Resp Tract

Question 1

Clinical importance of Pneumonia

Answer 1

• Pneumonia is the single greatest cause of death in children worldwide .
• Each year, 2 million children younger than 5 years die of pneumonia, representing 20% of all deaths in children within this age group .
• 155 million cases of pneumonia occur in children every year worldwide
• In many children with LRTI, diagnostic testing may identify 2 or 3 pathogens, including combinations of both viruses and bacteria, making it difficult to determine the significance of any single pathogen

Question 2

CAP
Def
Common organism

Answer 2

Community acquired pneumonia

Def:
- CAP can be defined as acute infection (of less than 14 days’ duration), acquired in the community, of the lower respiratory tract leading to cough or difficult breathing, tachypnoea or chest-wall indrawing
- Most of cases of pneumonia is CAP
- CAP accounts for between 30% and 40% of hospital admissions, with associated case fatality rates of between 15% and 28%.
- Mixed bacterial and viral infections may occur in 30 - 40% of cases of childhood CAP.

Organism
- S.pneumoniae as the most common documented bacterial pathogen, occurring in 4%–44% of all children
- Viral etiologies of CAP have been documented in up to 80% of children younger than 2 years; in contrast, older children, 10–16 years, who had both clinical and radiographic evidence of pneumonia, documented a much lower percentage of viral pathogens
- RSV is consistently the most frequently detected, representing up to 40%of identified pathogens in those younger than 2 years, but rarely identified in older children with CAP.
- Epidemiologic investigations of hospitalized children with CAP document that 2%–33% are simultaneously infected by 2 or more viruses

Question 3

Define Hospital acquired pneumonia

Answer 3

• 24-48 hrs after being admitted to hospital get infection with pneumonia
• Complicated by underlying conditions
• different than CAP organisms (antibiotic resistant!)

Question 4

Define ventilator acquired pneumonia

Answer 4

• If on ventilator; few days later raised infec markers and pneumonia symptoms
• different than CAP organisms (antibiotic resistant!)

Question 5

Define simple pneumonia

Answer 5

• either bronchopneumonia (primary involvement of airways and surrounding interstitium), or lobar pneumonia involving a single lobe.

Question 6

Define complicated pneumonia

Answer 6

defined as a pulmonary parenchymal infection complicated by parapneumonic effusions, multilobar disease, abscesses or cavities, necrotizing pneumonia, empyema, pneumothorax or bronchopleural fistula

Question 7

CAP
Causes

Answer 7

Slide 9

Bacteria
- Strep pneumonia (declined in past years because of injection)
- Haemophilus influenza (disappeared because of vac)
- Stap Aureus (Became more prevalent; more complications {emphyema})
- TB (not acute pneumonia; but pneumonia signs)

Atypical bac
- Mycoplasma pneumonia (school age, hostels)

Viruses
- RSV (young age)
- human metaoneumonia
- parainfluenza virus types 1 & 3
- adenovirus
- Influenza A & B
- Rhinovirus
- measles
- Covid

Question 8

CAP
Etiology (why is age important?)

Answer 8

Different organism

<3months
– Gram negative organisms – Group B streptococcus
– Staphylococcus aureus
– Haemophilus influenzae
– Other atypical
• chlamydia, ureoplasma

3months-5years
– Streptococcus pneumoniae
– Haemophilus influenzae
– Staphylococcus aureus

>5years
– Streptococcus pneumoniae
– Mycoplasma pneumoniae
– Staphylococcus aureus

Question 9

Mycoplasma

Answer 9

Atypical pneumonia caused by Mycoplasmais characteristically slowly progressing, with malaise, sore throat,low-grade fever, and cough developing over 3–5 days

Question 10

Causes of CAP in HIV positive children

Answer 10

Slide 13
- immunosupressed
- most NB cause of death in children <6 months

Bac
- non-typical salmonella
- klebsiella pneumonia
- streptococcus milleri
- E. coli

Viral

Question 11

Indications for hospital admission in CAP

Answer 11

• all children younger that 2 months

Children older than 2 months with:
- Impaired level of consciousness
- inability to drink or eat
- cyanosis

Question 12

Impact of HIV infec on clinical diagnosis of CAP

Answer 12

• Clinical signs of CAP are similar in HIV-infected and HIV uninfected children.
• However, pneumonia resulting from opportunistic pathogens should also be considered in HIV infected children.
• Of these, PCP is the most common and serious infection among infants, occurring commonly at 6 weeks - 6 months of age.
• PCP is frequently (20 - 40%) the initial presenting feature of AIDS in HIV- infected children not taking co-trimoxazole prophylaxis.
• Although PCP may present with a tetrad of features comprising tachypnoea, dyspnoea, fever and cough, these are not specific for pneumonia caused by P. jiroveci.
• Hypoxia may be prominent and rapidly progressive.
• Other stigmata of AIDS such as hepatosplenomegaly and generalised lymphadenopathy are not always present and adventitious sounds in the chest may be absent despite clinical signs of severe respiratory distress.

Question 13

Risk for types of pneumonia according to age

Answer 13

• < 2 months risk of gram negative infection
• > 5 years have more infection with Mycoplasma pneumoniae

Question 14

What can determine your immune status

Answer 14

Congenital immundefiency
– T-cell defiency
– B-cell deficiency

Acquired immundefiency
– HIV
– Malnutrition
– Cancer patient

Question 15

Complications of pneumonia

Answer 15

• Empyema
• Lung abscess
• Necrotising pneumonia
  Slide 44

Metastatic
- Meningitis
- CNS abscess
- pericarditis
- endocarditis
- osteomyelitis
- septic arthritis

Question 16

Empyema

Answer 16

• Pus in the thoracic cage
• Byington et al. found, among 540 children admitted to hospital with community-acquired bacterial pneumonia, 153 (28%) had parapneumonic effusions
• Rise in hospital admissions
  – 40/100000 to 120/100000 in Leuven
• Streptococcus pneumonia remains the most important pathogen.

Question 17

Necrotising pneumonia

Answer 17

• Also termed cavitary pneumonia or cavitatory necrosis
• Diagnosis of NP can be suspected on CXR
  ➡️dense lobar consolidation and pleural effusion
• Chest CT is needed for a more definitive diagnosis.
• Loss of normal pulmonary parenchymal architecture and the presence of areas of decreased parenchymal enhancement, representing liquefaction, that are progressively replaced by multiple small air or fluid filled cavities
• The pathophysiology of NP is thought to be one of massive pulmonary gangrene, tissue liquefaction and necrosis

Causes
- Streptococcus pneumoniae
- Staphylococcus aureus
- Mycoplasma pneumoniae

• Children with NP have increased risk for developing a BPF.
• Likely due to the friability of the inflamed pleura abutting the necrotised lung
• All patients who developed BPF in the present series had a chest drain in place for 7 days,
• Length of chest tube drainage is a risk factor for development of BPF
• Necrotising pneumonia should be recognised as an increasingly detected complication of paediatric CAP
• It is distinct from pleural effusion and empyema.
• Conservative management of necrotising pneumonia with antibiotics and ICD for pleural effusions results in good outcomes
• There is no indication that surgical resection is necessary

Question 18

Prevention of Pneumonia

Answer 18

• Pneumococcal conjugate vaccines are extremely effective in preventing radiographically confirmed pneumonia (20 - 37% reduction) in HIV-uninfected children.
• The vaccine also prevents 13% of all clinically diagnosed severe pneumonia in HIV-infected children.
• Furthermore, the vaccine is effective in preventing 85% of invasive pneumococcal disease in HIV-uninfected children and 65% in HIV-infected children
• Influenza vaccine
  ➡️Children with chronic pulmonary, cardiovascular or immunosuppressive disease or those on aspirin should be vaccinated annually at the start of the influenza season.

Question 19

Non-response

Answer 19

Non-response is more often related too local complication than drug resistance