Pneumonia

Question 1

Definition of pneumonia

Answer 1

Inflammation of the lungs with consolidation or interstitial lung infiltrates, characterised by the causative organism. Can be classified as community-acquired or hospital-acquired.

Question 2

Peak age of incidence of pneumonia

Answer 2

• The incidence of pneumonia peaks in infancy and old age, but is also relatively high in childhood
• More than 600,000 children die from pneumonia worldwide

Question 3

Causes of pneumonia

Answer 3

• In more than 50% of cases no causative pathogen is identified
• Viruses are the most common cause in young children beyond the neonatal period, whereas bacteria are more common in neonates and older children

Question 4

Most common causative pathogens of pneumonia in newborns

Answer 4

Generally organisms from the mother’s genital tract, particularly Group B Streptococcus, as well as gram-negative enterococci and bacilli
* E.Coli, klebsiella, pseudomonas, H.influenzae

Question 5

Most common causative pathogens of pneumonia in infants and young children

Answer 5

Respiratory viruses such as RSV are most common. Bacterial infections include Streptococcus pneumonia, H.influenzae and Staphylococcus Aureus. Bordetella pertussis and chlamydia trachomatis can also cause pneumonia at this age

Question 6

Most common causative pathogens of pneumonia in children > 5 years old

Answer 6

Mycoplasma pneumoniae, Streptococcus pneumoniae and Chlamydia pneumoniae are the main causes.
Mycobacterium tuberculosis should be considered at all ages

Question 7

Presentation of pneumonia in children

Answer 7

• The most common presenting symptoms are fever, cough and shortness of breath, generally preceded by a URTI
• Other symptoms include lethargy, poor feeding and appearing unwell
• Localised chest, abdominal, or neck pain is a feature of pleural irritation

Examination will show:
* Tachypnoea (most sensitive), decreased Sp02 and increased work of breathing
* Signs of consolidation including localized dullness on percussion, decreased breath sounds, bronchial breathing and end-inspiratory coarse crackles (often absent in young children)
* The percussion note will be ‘stony dull’ if there is an accompanying effusion or empyema

Question 8

What is empyema

Answer 8

When a pleural effusion associated with pneumonia has become infected-> becomes viscous (i.e pus in the pleural cavity)

Question 9

Investigations for pneumonia

Answer 9

A chest X-ray is only necessary if there is doubt about the diagnosis. Neither a chest X-ray nor blood tests, including full blood count and CRP, are able to reliably differentiate between a viral and bacterial cause

Question 10

How can we determine the severity of pneumonia in children

Answer 10

Measure the temperature, examine the chest, RR, pulse, BP, Sp02, note the degree of agitation and consciousness, look for exhaustion, cyanosis, respiratory distress and dehydration

Question 11

When should a child be admitted to hospital with pneumonia

Answer 11

• Persistent oxygen saturation of less than 92% when breathing air
• Grunting, marked chest recession, or a respiratory rate of over 60 breaths/minute
• Cyanosis (indicated by pale/mottled/ashen/blue skin, lips or tongue)
• Pneumonia complicated by pleural effusion (reduced breath sounds and dullness to percussion
• Child looks seriously unwell, does not wake, or if roused does not stay awake, or does not respond to normal social cues.
• A temperature of 38°C or higher in a child aged three months or less.
• Should consider if signs of respiratory distress (nasal flaring, change in behaviour), pallor, decreased intake, A temperature of 39°C or higher in a child aged 3–6 months

Question 12

Hospital management of pneumonia

Answer 12

• While awaiting admission to hospital, give controlled supplementary oxygen to all children whose oxygen saturation is persistently less than 92%.
• If hospital admission is required:
  o Give PO Abx if tolerated (otherwise IV and review after 48hr to consider switching it to PO)

Question 13

Management of pneumonia in secondary care

Answer 13

• Prescribe Abx- Amoxicillin is recommended as first choice for oral antibiotic therapy. Alternatively can give co-amoxiclav, cefaclor, or a macrolide such as clarithromycin
• Macrolide antibiotics may be added at any age if there is no response to first-line empirical therapy
• Prescribe antibiotics for 5 days, depending on the response to treatment
• Advise the parents/carers to use paracetamol or ibuprofen to treat a child who is distressed due to fever as well as adequate fluid intake. Advise to check on child regularly
• Advise to seek medical help if their child’s condition deteriorates (signs of respiratory distress, change in behaviour, reduced fluid intake etc)