Pneumonia

Question 1

Define

Answer 1

Incidence peaks in infancy and old age; no causative organism found in 50%

Young children = virus;

Newborn
* Organisms from the mother’s genital tract
* Particularly group B streptococcus
* Gram-negative enterococci and bacilli (E. coli)
* Listeria

Infants and Young Children
* Respiratory viruses (particularly RSV)
* Bacterial causes include S. pneumoniae and H. influenzae, Bordetella pertussis or Chlamydia trachomatis
* Staphylococcus aureus is a RARE but SERIOUS cause of pneumonia

Children > 5 years
* Mycoplasma pneumoniae
* Streptococcus pneumoniae
* Chlamydia pneumoniae

AT ALL AGES: Mycobacterium tuberculosis should be considered

NOTE: since the introduction of the Hib vaccine, there has been a marked reduction in the incidence of pneumonia from H. influenzae

SIADH may be associated with pneumonia - low Na

Question 2

Signs and symptoms

Answer 2

Fever, couch, SoB, preceding URTI
Other symptoms:
* Lethargy
* Poor feeding
* Unwell child

Signs

Auscultation: consolidation (stony dull, bronchial breathing, decreased breath sounds), coarse crackles

Examination Findings
* Tachypnoea
* Nasal flaring
* Chest indrawing

IMPORTANT: increased respiratory rate is the most sensitive clinical sign of pneumonia in children
* End-inspiratory coarse crackles can sometimes be heard
* NOTE: in young children, the classical pneumonia signs of consolidation with dullness on percussion, decreased breath sounds and bronchial breathing are often absent
* Oxygen saturations may be decreased

Question 3

Investigation

Answer 3

1. Cardiorespiratory examination
   * (N.B. bronchiolitis = fine crackles; pneumonia = coarse crackles)
2. Basic observations in A to E approach
3. Basic obs: temperature, O2 saturations, RR, respiratory exam
4. FBC, U&Es
5. Cyanosis and hydration status
6. VBG
7. XCR
   may confirm diagnosis (but CANNOT differentiate between viral and bacterial)
   * A pleural effusion may be seen in some patients
   * Some of these effusions may develop into empyema and fibrin strands may form, leading to septations
   * Nasopharyngeal aspirate may identify viral causes

o Tuberculosis (if exposure…):

Ix: manteaux test (if -ve, excludes) -> IGRA test (if -ve, prophylaxis; if +ve, treat)

· Manteaux >5mm = +ve in at-risk groups (child <4yo, healthcare workers, IVDU)

· Manteaux >15mm = +ve in normal population

Mx: RIPE, RiCES or prophylaxis:

· (MTB) RIPE = 6m Rifampicin, 6m Isoniazid, 2m Pyrazinamide, 2m Ethambutol

· (NTM) RiCES = Rifampicin, Clarithromycin, Ethambutol ± Streptomycin/amikacin

· Prophylaxis = isoniazid

Question 4

Management

Answer 4

Determine severity:
* Measure temperature
* Examine chest
* Record BP, HR and RR
* Note degree of agitation and consciousness
* Note signs of exhaustion
* Note cyanosis and accessory muscle use
* Assess hydration status (cap refill, skin turgor, dry mucous membranes and urine output)

Hospital admission if… (this is the same for any respiratory condition)
* SpO2 <92% on air
* Grunting
* Marked chest recession
* RR >60/min (severe tachypnoea)
* Cyanosis
* T >38C
* Child <3months
* Low feeding
* Low consciousness

Consider admission if:
* dehydration, decreased activity, nasal flaring, predisposing diseases (e.g. CLD)
* Whilst awaiting hospital admission à supplemental oxygen if SpO2 <92%

Antibiotics (cannot distinguish viral from bacterial, so give anyway):
1. Child <2yo with mild LRTI -> do not have pneumonia usually (so, no ABx)
2. 1st line / mild CAP = amoxicillin, 7-14 days
3. 2nd line / severe CAP = Co-amoxiclav + macrolides (clarithromycin)
* Alternative = cefaclor
* Macrolides for pen-allergic patients (i.e. clarithromycin)
* In pneumonia associated with influenzae, co-amoxiclav is recommended

Question 5

Complications

Answer 5

Effusions

Lobar collapse or atelectasis

CAP is the leading cause of death in children < 5 years

Advice

Paracetamol or ibuprofen if the child is distressed by fever (should NOT be given simultaneously but may be interchanged)

Advise adequate fluid intake

Advise parents not to smoke at home

Check on child regularly through day and night

Seek medical advice if they are unable to cope or child’s condition deteriorates (e.g. signs of increased respiratory effect/ distress, reduced fluid intake, reduced responsiveness, worsening or unresolving fever)

• Small effusions may occur in some children but most will resolve with appropriate antibiotics
• However, a persistent fever despite 48 hours of antibiotics suggests a pleural collection that requires drainage (with USS)
• NOTE: patients with evidence of lobar collapse or atelectasis should have a repeat CXR after 4-6 weeks to check whether the lung fields look normal

Question 6

PACES

Answer 6

Explain the diagnosis (chest infection)

Explain whether admission is needed

Explain treatment (antibiotics)

Advise paracetamol used if distressed

Advise adequate fluid intake

Advise against parental smoking

Check the child regularly during the day and night

Safety net → ↑RR, apnoea, cyanosis, ↑WOB, dehydration, fever does not settle 48h+ of ABX, ↑drowsy