Ch 19 PEDS Community Acquired Pneumonia (B/V), Parapneumonic effusion and empyema, Bronchiolitis, Mycoplasma pneumonia, Aspiration pneumonia Flashcards
Children less than 2 years old with community-acquired pneumonia is often _______
Viral
What are viral pathogen causes of community-acquired pneumonia?
(PHIR)
Parainfluenza
Human metapneumonvirus
Influenza A/B
RSV
What is the MOST common bacterial cause of Community-acquired pneumonia in children?
What are some less common causes? (newborn, atypical)
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
What kinds of children are at high risk for bacterial community-acquired pneumonia?
(I AM A)
Compromised pulmonary defense system:
Immunocompromised
Aspirates own secretions or while eating
Malnourished children
Abnormal mucociliary clearance
What are NOT reliable findings or diagnostic tools that may distinguish viral from bacterial pneumonia?
Findings:
Fever
Severity of illness
Character of cough
Diagnostic:
CBC
Chest XRAY (some differences, cannot determine severity, may show improvements overtime)
What may the CBC show for bacterial community-acquired pneumonia in a child? What about overwhelming infection?
WBC elevated with left shift
Overwhelming infection - WBC < 5000
What treatment should the NP institute for Community-acquired pneumonia?
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)
List the patients that should be hospitalized for Community-acquired pneumonia (viral or bacterial, does not make a difference):
(_____ and ____ with M-CHEAP)
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
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)
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
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?
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
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?
General supportive care
Any child with BPD or any severe pulmonary/heart conditions or immunocompromised =
hospitalized
possible Ribavirin
rapid viral diagnostic tests
What medications can be given to a child with Influenzae A/B pneumonia?
OZ
Start within 48 hours of symptoms, give for 5 days
Oseltamvir (Tamiflu)
Zanamivir (Relenza) must be > 5 years old
What two medications are not recommended for influenzae A/B community-acquired pneumonia
Amantadine
Rimantadine
Both are ANTIVIRALS
High resistance
What class of medications is best for bacterial community-acquired pneumonia with S. Pneumoniae for children allergic to penicillins?
Cephlasporins or macrolides (S. Pneumoniae may be resistant to macrolides*)
_______ is an atypical pneumonia that is the most serious acute respiratory illness in infants and young children.
Bronchiolitis - this is an atypical pneumonia (pg527Hays)
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:
Bronchiolitis
What pathogens are commonly associated with Bronchiolitis?
HARP
Viral: Human Metapneumovirus Adenovirus RSV Parainfluenza / Influenza
(bacterial causes are less common)
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)
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)
What findings are typical for RSV Bronchiolitis?
1 - 2 days of fever
Rhinorrhea and Cough
then progresses to: Wheezing, Tachypnea, or Respiratory distress
breathing will be shallow with rapid respirations
Current recommendations via AAP for Bronchiolitits instructs the NP to not utilize what diagnostic tools?
(include diagnostic tools and medication classes)
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)
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?
Non-specific hyperinflation
Increased interstitial markings
(both are common viral caused findings on XRAY)
Children that are severely ill from Bronchiolitis/severe RSV infections and have a cardiopulmonary or immune defect should be given what antiviral therapy?
Ribavirin (ANTIVIRAL) aerosol treatment
high-risk patients or severely ill patients should be hospitalized and given this antiviral
Palivizumab injection is _____ and is only given to what types of individuals? When is this vaccine offered?
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)
T/F Most children with RSV bronchiolitis are treated as outpatients
TRUE! - hospitalization is only necessary for severely ill or have high risk life-threatening risk factor
A child with RSV bronchiolitis that needs to be hospitalized will present as:
(HAMM)
Hypoxic on room air
history of Apnea
Moderate tachypnea with feeding difficulties/poor oral hydration
Marked respiratory distress with retractions
What three pathogens are found in Empyema?
Which one is the most common?
Streptococcus Pneumonia (most common)
Haemophilus Influenzae
Staphylococcus Aureus
What kind of chest XRAY should you order on a child with suspected Empyema?
Lateral Decubitus (remember, this helps visualize pleural fluid - unless the fluid is loculated)
What should the NP expect on exam in a child with empyema during the percussion assessment?
Dullness via percussion on the affected side
The child will also prefer to lie on the affected side (easier to breathe)
A large effusion may have what specific finding on exam?
Tracheal deviation to the contralateral side
What are three expected findings in lab work and diagnostic tools for an empyema?
Elevated WBC with left shift
Positive blood cultrure
Thoracentesis - Neutrophils present in pleural fluid
Bacterial thoracentesis results - pH < 7.2 and low glucose
The thoracentesis for parapnuemonic effusion/empyema has identified your patient’s causative organism, what should you order for treatment?
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
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?
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.
What pathogen is commonly associated with Mycoplasma Pneumonia?
M. Pneumoniae
incubation is 2 - 3 weeks long with slow onset of symptoms
What are three expected findings in lab work and diagnostic tools for Mycoplasma Pneumonia?
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.
What life-threatening hematologic disorder may accompany M pneumoniae infection?
Direct Coombs-positive autoimmune hemolytic anemia
What treatment is considered for the child with Mycoplasma pneumonia?
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
What is the common cause of aspiration pneumonia?
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)
In aspiration pneumonia, what part of the lung is commonly affected?
right upper lobe in a supine patient
T/F Children with underlying medical conditions are more at risk for developing aspiration pneumonia
TRUE! - table 19-6 pg. 529 Hays
What underlying medical conditions place a child at a greater risk for aspiration pneumonia?
(ASCENDING-M)
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
T/F Aspiration pneumonia is an acute illness
FALSE - aspiration pneumonia may be acute or chronic
What findings may only present in chronic aspiration pneumonia versus acute aspiration pneumonia?
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)
What are expected findings on a chest XRAY in a child with acute aspiration pneumonia?
Lobar CONSOLIDATION or Atelectasis
Focal or generalized alveolar or interstitial INFILTRATES
What are expected findings on a chest XRAY in a child with chronic aspiration pneumonia?
PERIHILAR INFILTRATES with or without
Bilateral AIR TRAPPING
_________ diagnostic can best delineate complications such as bronchiectasis in chronic aspiration or empyema in acute aspiration
Chest CT
Patients with chronic aspiration pneumonitis, should be evaluated for ________
Dysphagia - impaired swallowing (see diagnostic tools related to the respiratory tract - rigid bronchoscopy, FEES, VFSS, UGI)
What are some differential diagnosis related to aspiration pneumonia? (acute vs chronic)
(chronic - FLICC)
Acute:
Bacterial or viral pneumonias
Chronic: (common recurrent pneumonia disorders) Immunodeficiencies Ciliary dysfuncion Foreign body Chronic wheezing Interstitial lung disorders
What is the treatment plan for an acutely ill aspiration pneumonia child?
Supportive: antipyretics, hydration, o2 if hypoxic
Antimicrobial therapy Clindamycin initial coverage
What is the treatment plan for chronic aspiration pneumonitis?
(STOIC S)
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
