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Unit 2 68 > Ch 19 PEDS Community Acquired Pneumonia (B/V), Parapneumonic effusion and empyema, Bronchiolitis, Mycoplasma pneumonia, Aspiration pneumonia > Flashcards

Ch 19 PEDS Community Acquired Pneumonia (B/V), Parapneumonic effusion and empyema, Bronchiolitis, Mycoplasma pneumonia, Aspiration pneumonia Flashcards

1
Q

Children less than 2 years old with community-acquired pneumonia is often _______

A

Viral

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2
Q

What are viral pathogen causes of community-acquired pneumonia?

(PHIR)

A

Parainfluenza
Human metapneumonvirus
Influenza A/B
RSV

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3
Q

What is the MOST common bacterial cause of Community-acquired pneumonia in children?

What are some less common causes? (newborn, atypical)

A

S. pneumoniae (bacterial usually follows viral lower respiratory tract infection)

Other bacteria less common:
Chlamydia trachomatis (newborns to 12 weeks)
C. pneumoniae,
C. pittaci
B. pertussis
M. pneumonia (often referred to as “atypical pneumonia”, more common in children > 5yr)
Legionella

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4
Q

What kinds of children are at high risk for bacterial community-acquired pneumonia?

(I AM A)

A

Compromised pulmonary defense system:

Immunocompromised
Aspirates own secretions or while eating
Malnourished children
Abnormal mucociliary clearance

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5
Q

What are NOT reliable findings or diagnostic tools that may distinguish viral from bacterial pneumonia?

A

Findings:
Fever
Severity of illness
Character of cough

Diagnostic:
CBC
Chest XRAY (some differences, cannot determine severity, may show improvements overtime)

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6
Q

What may the CBC show for bacterial community-acquired pneumonia in a child? What about overwhelming infection?

A

WBC elevated with left shift

Overwhelming infection - WBC < 5000

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7
Q

What treatment should the NP institute for Community-acquired pneumonia?

A 
General supportive measures:
   Antipyretics
   Increased fluids (hydrate/electrolytes)
   Nutrition
   O2 if hypoxic

Viral or Bacterial:
PO Amoxicillin 5 - 10 days (unless you know the cause ie viral influenza = O,Z / bacterial M. Pneum = macrolide (azirthryomycin)

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8
Q

List the patients that should be hospitalized for Community-acquired pneumonia (viral or bacterial, does not make a difference):

(_____ and ____ with M-CHEAP)

A

all infants < 3 months for abx (IV or PO)
(note: consider hospitalization for 3 - 6 months old, greater than 6 months with no RDS can be treated PO amoxcillin)

any child with: 
   Moderate or Severe respiratory distress
   Clinical deterioration on treatment
   Hypoxemia
   Effusion of CXR
   Apnea
   Poor feeding
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9
Q

If patient is managed outpatient, what is the treatment for Bacterial Community-acquired pneumonia with the S. Pneumoniae pathogen? Follow-up?

(know drug, dose, frequency, duration)

A

Empiric antibiotic -
Treat S. Pneumoniae
AMOXICILLIN 80 - 90 mg/kg/day BID for 5-10 days

Close follow-up within 12 hours to 5 days

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10
Q

If the patient is managed outpatient, what is the treatment for Bacterial Community-acquired pneumonia with the M. Pneumoniae pathogen? (drug, dose, frequency, duration)

What class of medications should be considered?

Follow-up?

A

Children > 5 years old higher incidence of M.Pneumoniae
AMOXICILLIN 80 - 90 mg/kd/day BID for 5 - 10 days

Consider Macrolide antibiotics for M. Pneumonia

Close follow up within 12 hours to 5 days

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11
Q

What is the best treatment option for a child with viral RSV pneumonia? A Child with a history of congenital heart disease with RSV pneumonia, what should be considered for this child?

A

General supportive care

Any child with BPD or any severe pulmonary/heart conditions or immunocompromised =
hospitalized
possible Ribavirin
rapid viral diagnostic tests

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12
Q

What medications can be given to a child with Influenzae A/B pneumonia?

OZ

A

Start within 48 hours of symptoms, give for 5 days

Oseltamvir (Tamiflu)
Zanamivir (Relenza) must be > 5 years old

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13
Q

What two medications are not recommended for influenzae A/B community-acquired pneumonia

A

Amantadine
Rimantadine

Both are ANTIVIRALS
High resistance

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14
Q

What class of medications is best for bacterial community-acquired pneumonia with S. Pneumoniae for children allergic to penicillins?

A

Cephlasporins or macrolides (S. Pneumoniae may be resistant to macrolides*)

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15
Q

_______ is an atypical pneumonia that is the most serious acute respiratory illness in infants and young children.

A

Bronchiolitis - this is an atypical pneumonia (pg527Hays)

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16
Q

A young child with a previous upper respiratory infection that has progressed to a cough, tachypnea, respiratory distress, and crackles or wheeze on physical exam is most likely:

A

Bronchiolitis

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17
Q

What pathogens are commonly associated with Bronchiolitis?

HARP

A 
Viral:
   Human Metapneumovirus
   Adenovirus
   RSV
   Parainfluenza / Influenza

(bacterial causes are less common)

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18
Q

What are known risk factors that increases the likelihood of severe Bronchiolitis development? (who are high risk children)

What should you consider in terms of treatment for these children?

(P-CONS)

A 
Infants < 6 months old
Premature < 35 weeks gestation history
Congential heart disease
Other severe pulmonary conditions (BPD, Pulm. HTN)
Neuromuscular disease
Significant immunocompromise

RSV prophylaxis therapy (Palivizumab vaccine - must qualify for treatment)

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19
Q

What findings are typical for RSV Bronchiolitis?

A

1 - 2 days of fever
Rhinorrhea and Cough

then progresses to: Wheezing, Tachypnea, or Respiratory distress

breathing will be shallow with rapid respirations

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20
Q

Current recommendations via AAP for Bronchiolitits instructs the NP to not utilize what diagnostic tools?

(include diagnostic tools and medication classes)

A

Diagnostic tool:
Viral Nasal Swab for routine RSV testing (only use this if an infant has been on prophylaxis with Palivizumab)
Chest XRAY (must have respiratory distress)

Medications:
Albuterol/salbutamol (no evidence for effectiveness)
Corticosteroids (no evidence for effectiveness)
Antibiotics (unless bacterial pathogen is strongly suspected)

21
Q

A child with suspected Bronchiolitis presents in your office. Respiratory distress is found on exam, the NP orders a chest XRAY.

What will the NP expect to see on XRAY for a child with Bronchiolitis?

A

Non-specific hyperinflation
Increased interstitial markings

(both are common viral caused findings on XRAY)

22
Q

Children that are severely ill from Bronchiolitis/severe RSV infections and have a cardiopulmonary or immune defect should be given what antiviral therapy?

A

Ribavirin (ANTIVIRAL) aerosol treatment

high-risk patients or severely ill patients should be hospitalized and given this antiviral

23
Q

Palivizumab injection is _____ and is only given to what types of individuals? When is this vaccine offered?

A

used to help prevent RSV - a RSV prophylaxis therapy

Give to: < 2 year olds who are at high risk for getting RSV
(prematurely born, CHD or lung diseases)

offered during RSV season, followed by a dose every 38 - 30 days throughout RSV season (Nov. - April)

24
Q

T/F Most children with RSV bronchiolitis are treated as outpatients

A

TRUE! - hospitalization is only necessary for severely ill or have high risk life-threatening risk factor

25
Q

A child with RSV bronchiolitis that needs to be hospitalized will present as:

(HAMM)

A

Hypoxic on room air
history of Apnea
Moderate tachypnea with feeding difficulties/poor oral hydration
Marked respiratory distress with retractions

26
Q

What three pathogens are found in Empyema?

Which one is the most common?

A

Streptococcus Pneumonia (most common)
Haemophilus Influenzae
Staphylococcus Aureus

27
Q

What kind of chest XRAY should you order on a child with suspected Empyema?

A

Lateral Decubitus (remember, this helps visualize pleural fluid - unless the fluid is loculated)

28
Q

What should the NP expect on exam in a child with empyema during the percussion assessment?

A

Dullness via percussion on the affected side

The child will also prefer to lie on the affected side (easier to breathe)

29
Q

A large effusion may have what specific finding on exam?

A

Tracheal deviation to the contralateral side

30
Q

What are three expected findings in lab work and diagnostic tools for an empyema?

A

Elevated WBC with left shift
Positive blood cultrure
Thoracentesis - Neutrophils present in pleural fluid

Bacterial thoracentesis results - pH < 7.2 and low glucose

31
Q

The thoracentesis for parapnuemonic effusion/empyema has identified your patient’s causative organism, what should you order for treatment?

A

IV Antibiotics
Drainage of fluid/effusion (large effusions may require chest tube drainage and/or video-assisted thoracoscopic surgery)
Early use of Fibrinolytics - becoming standard of care in pediatrics

32
Q

A 5 year old child presents to your clinic bracing his chest with a fever, dry cough, that the mom reports it has been 3 weeks of this. Now her child has ‘mucous when he coughs.’ On auscultation, rales are present. What should you suspect?

A

Mycoplasma Pneumonia -

affects children > 5 years old, presents with fever and dry cough at onset. Develops into sputum production cough, headache, and malaise. Rales and chest pain are also present.

33
Q

What pathogen is commonly associated with Mycoplasma Pneumonia?

A

M. Pneumoniae

incubation is 2 - 3 weeks long with slow onset of symptoms

34
Q

What are three expected findings in lab work and diagnostic tools for Mycoplasma Pneumonia?

A

Normal total WBC with differential
Enzyme Immunoassay (EIA) and Complement fixation are sensitive and specific for M Pneumoniae (esp. asymptomatic children)
Chest XRAY - infiltrates

PCR - gold standard for diagnosis - however, the EIA and complement fixation are more specific for M. Pneumoniae bacteria.

35
Q

What life-threatening hematologic disorder may accompany M pneumoniae infection?

A

Direct Coombs-positive autoimmune hemolytic anemia

36
Q

What treatment is considered for the child with Mycoplasma pneumonia?

A

Supportive measures: hydration, antipyretics, bedrest

Antibiotic class: MACROLIDES 7 - 10 days
Azithromycin 10mg/kg (MAX 500mg) PO, then 5mg/kg/day (MAX 250mg)

Alternate med: Ciprofloxacin

37
Q

What is the common cause of aspiration pneumonia?

A

Bacteria/gram-negative anaerobes in the mouth

(chronic aspiration causes recurrent bouts of acute febrile pneumonia with “rattling” cough, wheezing, chronic chest infiltrates, failure to thrive)

38
Q

In aspiration pneumonia, what part of the lung is commonly affected?

A

right upper lobe in a supine patient

39
Q

T/F Children with underlying medical conditions are more at risk for developing aspiration pneumonia

A

TRUE! - table 19-6 pg. 529 Hays

40
Q

What underlying medical conditions place a child at a greater risk for aspiration pneumonia?

(ASCENDING-M)

A

Anatomic Abnormalities (cleft, TE fistula, Vocal cord paralysis)
Seizures
CNS malformations/mass/TBI
Encephalopathy
Near-drowning
Delayed maturation (down syndrome/prematurity)
Iatrogenic (anesthesia, NG tube, tracheostomy tube)
Neuromuscular disorders
GI disease (reflux, achalasia, obstruction)

Medications - depressed sensorium

41
Q

T/F Aspiration pneumonia is an acute illness

A

FALSE - aspiration pneumonia may be acute or chronic

42
Q

What findings may only present in chronic aspiration pneumonia versus acute aspiration pneumonia?

A 
Chronic:
  *** "chest rattling" *** cough or wheezing
   chronic chest infiltrates
   bronchiectasis
   failure to thrive

Acute:
typical pneumonia syndrome (acute onset of fever, cough, RD, hypoxemia, asymmetric auscultation findings, and asymmetric imaging findings)

43
Q

What are expected findings on a chest XRAY in a child with acute aspiration pneumonia?

A

Lobar CONSOLIDATION or Atelectasis

Focal or generalized alveolar or interstitial INFILTRATES

44
Q

What are expected findings on a chest XRAY in a child with chronic aspiration pneumonia?

A

PERIHILAR INFILTRATES with or without

Bilateral AIR TRAPPING

45
Q

_________ diagnostic can best delineate complications such as bronchiectasis in chronic aspiration or empyema in acute aspiration

A

Chest CT

46
Q

Patients with chronic aspiration pneumonitis, should be evaluated for ________

A

Dysphagia - impaired swallowing (see diagnostic tools related to the respiratory tract - rigid bronchoscopy, FEES, VFSS, UGI)

47
Q

What are some differential diagnosis related to aspiration pneumonia? (acute vs chronic)

(chronic - FLICC)

A

Acute:
Bacterial or viral pneumonias

Chronic: (common recurrent pneumonia disorders)
Immunodeficiencies
Ciliary dysfuncion
Foreign body 
Chronic wheezing
Interstitial lung disorders
48
Q

What is the treatment plan for an acutely ill aspiration pneumonia child?

A

Supportive: antipyretics, hydration, o2 if hypoxic

Antimicrobial therapy Clindamycin initial coverage

49
Q

What is the treatment plan for chronic aspiration pneumonitis?

(STOIC S)

A

Surgical correction of any anatomical abnormality
Thickened liquids/Pacing systems or bottles
Oral hygiene
Inhaled Corticosteroids
Chest PT
Swallowing therapy

Compromised CNS? = gastrostomy exclusively fed

Unit 2 68 (32 decks)

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