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PEDIATRICS > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

annual incidence in developed countries is:

A
  • 40 / 1000 children per year for children under 5 years
  • 20 /1000 children per year for children over 5 years of age
  • Developing countries:
    -more frequent than in Europe / North America;
    -more severe
    -leading cause of mortality in children along with diarrheal
    diseases
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2
Q

MORPHOLOGY:

A
  • inflammation of the lung parenchyma
    (alveoli, interstitial, small caliber lower respiratory tract - small bronchi, bronchioles) most often due to infection
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3
Q

Clinical practice - term pneumonia

A
  • Child with fever and respiratory signs and symptoms who has evidence af consolidation (parenchymal infiltrates) on CXR (chest X-Ray)
  • where a CXR is not performed / the diagn is based on
    symptoms and signs alone – the term acute LRTI (lower
    respiratory tract infection) is prefered.
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4
Q

PNEUMONIA - DEFINITION

A

Chest- X-Ray is essential for:
- Supporting diagnosis
- Clinical and radiological accurate form
- in practice it is not always recommended (guidelines)

  1. alveolary infiltrate / consolidation – lobar or segmental
    = alveolar disease (pneumococcal pneumonia

characteristics)
2. Interstitial infiltrate= interstitial pneumonia

-characteristic for viral infections, mycoplasma,

Chlamydia
3. bronchopneumonia type – multifocal/multilobar pneumonia

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5
Q

PATOPHYSIOLOGY

A

The development of pneumonia requires a causative pathogen to reach the alveoli / to overcome the hosts protective immunity
1. most pneumonia is acquired by inhalation of infected particles
* from exogenous sources
* from colonization of the nasopharynx or sinuses
2. most rarely - following aspiration
3. hematogenous spread (10-15%) / generalized infection(sepsis)
4. contiguity (rarely)
Lower respiratory airway - are normally sterile
Filtering and fixing of pathogens in the environment in upper respiratory airway → first barrier

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6
Q

Local host defence mechanisms include:

A
  • innate responses
  • mucociliary clearance and coughing,
  • mucus layer, IgAs,
  • phagocytosis by alveolar macrophages and neutrophils
  • antiviral and antibacterial molecules: defensins,
    interferons, lysosime- produced by the airway epithelium
  • acquired immunity:
    surface antibodies and rapid T-cell responses
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7
Q

Inflammatory response

A

Neutrophils influx
The release of mediators of inflammatory reaction
Oxidative enzymes
Plasma transudation
The loss of surfactant

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8
Q

MECHANISMS

A
  1. The deficit means of defense of the lung
    A. Shorting upper airway (intubation, tracheostomy)
    B. Depressed epiglottis reflex / ineffective ⇒ suction
    (oral secretions, gastric contents - neurology disease)
    C. Alteration of mucociliary clearance
    (chronic pulmonary disease : FC, PCD)
    D. Depression / inefficiency of cough reflex
    E. Cell immunodeficiency / humoral immunodeficiency local or general
    F. Immunosuppression (drugs, illness)
  2. Viral infection - facilitates bacterial invasion
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9
Q

Factors that predispose to pneumonia are:

A
  • exposure to virulent organisms
  • high inoculum
  • impaired innate response
  • impaired acquired immunity
  • Viral infections are more infectious and transmissible than bacterial pneumonias
  • most community - acquired bacterial pneumonias arise
    following the endogenous spread of organisms from the upper airway, after local host responses have been damaged by a recent / concurrent viral respiratory infection!
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10
Q

CLASIFICATION CRITERIA

A

Most times - etiologyc diagnosis is made on the basis of
probability criteria:
- Age group
- Presence / absence of comorbidities
- Clinical exam
- Radiological appearance
- Biological status / reactivity
- Epidemiological context, vaccination status

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11
Q

ETIOLOGY

A
  • Viruses
    Respiratory syncytial virus
    Parainfluenza viruses 1,2,3,4
    Influenza A and B viruses
    Human- Metapneumovirus
    Adenoviruses, Enteroviruses
    Rhinoviruses
    Measles virus, VZV, CMV
  • Bacterial atypical
    Mycoplasma - Mycoplasma pneumoniae
    Chlamydia - Chlamydia trachomatis (neonates)

Chlamydia pneumoniae
Legionella pn., Moraxella sp.

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12
Q

Bacterial typical

A

Streptococcus pneumoniae
Haemophilus influenzae type b/ nontypable strains
Staphylococcus aureus
Streptococcus pyogenes (group A)
Klebsiella sp
Mycobacterium tuberculosis
Atypical mycobacteria (M.avium intracellulare complex, M.abscessus,
M. kansasii and several others)

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13
Q

ETIOLOGY

  • New born - intrauterine or intrapartum origin
  • etiology ≈
A

early neonatal sepsis
Group B Streptococcus
Listeria monocytogenes
Haemophilus influenzae type b
Gram-negative bacilli

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14
Q

Etiology * < 3 wk

A
  • increased risk of nosocomial pneumonia
  • favorable factors :
    small weight new born ,
    peripartum complications
    (respiratory distress, mechanical
    ventilation, invasive maneuvers, etc)
    E.coli and other enteric gram-negative bacilli
    Staphylococcus aureus /S. epidermidis
    Streptococcus pneumoniae
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15
Q

Etiology
3 wk - 4 mo

A
  • viruses (RSV, influenza, parainfluenza, adenovirus)
    -S.pneumoniae, H. influenzae b,
  • Staph.aureus, Staph.epidermidis, Chlamydia trachomatis, Bordetella pertussis
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16
Q

Etiology
4 mo - 5 years -

A
  • viruses (RSV, influenza, parainfluenza, adenovirus)
  • S.pneumoniae, H. influenzae b / non-typable
  • Streptococi Gr A, Staph. aureus
  • Bordetella pertussis
  • Moraxella catarrhalis
  • Klebsiella pneumoniae
  • enteric bacilli, anaerobic
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17
Q

ETIOLOGY

> 5 years

A

Viruses (influenza, parainfluenza, adenoviruses)
Mycoplasma pneumoniae
Chlamydia pneumoniae
Streptococcus pneumoniae
H. influenzae b (unvaccinated), non-typable H. influenzae
Legionella pneumophilla

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18
Q

most important bacterial
cause in all age group

A

Streptococcus pneumoniae
In all age groups - etiology is dominated by viruses
The high incidence of mixed infections is usually a combination of viral and bacterial pathogens, reflecting the prior role that viral infection has in establishing bacterial pneumonia
* The contribution of viral infection to pneumonia will increase significantly during influenza epidemics

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19
Q

CLINICAL MANIFESTATION

A

It differs by:
- age
- etiology
- presence / absence of comorbidity

In infants the clinical signs may be less relevant or even missing

It is possible a normal clinical exam, but with chest X-Ray changes / and the reverse situation

20
Q

CLINICAL EXAM

A
  • The likely symptoms and signs of pneumonia depend on the age and the extent of the disease
  • Widespread bilateral disease is more likely to cause breathlessness and signs of respiratory distress
  • Focal infection may cause fever and lethargy/ often - nothing specific to find on examination to suggest a pneumonia
21
Q

Abnormal respiratory rate by age group:

A

> 60 breaths / min in infants less than 2 months
50 breaths / min in infants between 2 - 12 months
40 breaths / min in children 1-5 years
˃30 breaths / min in children over 5 years

22
Q

CLINICAL MANIFESTATION
Infant / toddler

A
  • fever, tachycardia
  • irritability
  • anorexia
  • decreased activity / lethargy
  • drowsiness
  • vomiting / diarrhea,
  • tachypnea, cough, chest wall recession, wheeze

=> General non-specific symptoms in infant!

23
Q

CLINICAL MANIFESTATION
older child

A
  • fever, chills
  • productive cough
  • chest pain (twinge or pleuritic)
  • tachypnea, shortness of breathe
  • headache, tachycardia
  • abdominal pain-usually- lower lobe ( may be severe, mimic appendicitis),
  • nausea,vomitting
24
Q

CLINICAL EXAMINATION
in general

A
  • The presence of:
  • respiratory distress syndrome
  • tachypnea, chest wall recession
  • expiratory groan, nasal flaring, use of accesory muscle of
    respiration, dyspnea, cough , cyanosis +/-
  • dullness on percussion, localized decreased breath sounds ,bronchophony
  • abnormal findings on ascultation: bronchial breathing , crackles (crepitations), wheeze
  • Crepitations- indicates small airway or alveolar disease
25
Q

CLINICAL MANIFESTATION

  • Other possible signs:
A
  • neurological
  • cardiovascular
  • digestive (flatulence, diarrhea, toxic ileus)
  • stigmata of viral infection(rash)

Hypoxemia
- tachypnea, chest recession
- Nasal flaring
- central type of cyanosis
- lethargy

Bacteriemia
- high fever > 39 o and persistent
- Sensory alteration (low reactivity, not feeding, no longer receives liquid p.o.)
Possible - “toxic” abdominal ileus, seizures

26
Q

BACTERIAL PNEUMONIA

A
  • Rapid onset, high fever, chills
  • Signs / symptoms of sepsis ± severe respiratory symptoms localized chest pain (pleural effusion)
  • crackles or decreased breath sounds in the setting of
    consolidation
  • Evidence of infection of other sites - due to the same
    organism causing their pneumonia :meningitis, otitis media, sinusitis, pericarditis, epiglotitis, abscess
27
Q

VIRAL PNEUMONIA

A
  • Slower onset, upper respiratory tract infection prodrome- coryza, fever, cough, hoarseness !!
  • Moderate fever, irritable child without toxic condition
  • Signs of respiratory distress
  • tachypneea,
    retractions,
    grunting,
    nasal flaring
  • Rales , decreased breath sounds
  • Conjunctivitis, otitis media, rash, stridor , cough
    ± headache, myalgia , +/- wheezing
28
Q

CHEST X- RAY
VIRAL / ATYPICAL PNEUMONIAS

A
  • hyperinflation
  • perihilar streaking
  • increased interstitial markings
  • peribronchial infiltrates
  • patchy bronchopneumonia
  • rare : lobar consolidation/atelectasis, pleural effusion
    It is an etiological orientation element, but there are overlaps !!
  • to be interpreted in the clinical context
  • only chest X-Ray- is not sensitive to etiological differentiation
  • may be “normal” in early stages
29
Q

CHEST X-RAY

A
  • Clinical and radiological aspects do not allow the affirmation of a
    specific etiology other than with a considerable degree of
    approximation!

CT - scan, ultrasound chest – may be useful (confirm
diagnosis, differential diagn,

30
Q

CHEST XRAY
BACTERIAL PNEUMONIA

A
  1. Alveolary consolidation process with lobar / segmental / lobular distribution
  2. Air bronchogram on the pulmonary condensation area
  3. Frequent pleural participation (pleural effusion)
  4. Possible pneumatoceles / abscesses (necrotizing pneumonia)
31
Q

DIAGNOSIS - INVESTIGATION (1)

A

*1. Blood count - WBC / differential white blood cell count ( etiological orientation), intrainfectious anemia
2. ESR, CRP, procalcitonin,
3. Blood cultures ( ˂ 10% are positive)
4. Urea, electrolytes – SIADH
5. Sputum culture , IDR 5uPPD
6. Pleural fluid (smear, chemistry, culture)
7. Pulse oximetry, blood gas dosing, pH
8. Ag microbial detection in urine (limited value)

32
Q

DIAGNOSIS - INVSTIGATIONS (2)

A
  • Determination of specific Ac in serum (viral infections, atypical germs – late diagnosis)
  • Immunological techniques :
    Ag determinations by contraimmunoelectrophoresis, agglutination latex, PCR - polymerase chain reaction- molecular diagnosis –on blood or respiratory secretions for viruses, Mycoplasma, Chlamydia, Pneumococcus
  • nasopharyngeal aspirate - Viral cultures (high cost, results
    belatedly)
33
Q

INVESTIGATIONS (3)

A
  • naso pharyngeal cultures, sputum cultures - bacterial
    superinfection, false pos / neg (not differ by carrier status)
  • if in cultures→-bK germ, Pseudomonas, nosocomial germs →of considered and supplemented by other investigations
  • Bronchoscopy- tracheobronchial aspirate, bronchoalveolar lavage + exam bacteriological and culture (Gram pos / neg, aerobic / anaerobic, fungi, bK)
  • Lung Biopsy (immunosuppressed)
  • Investigations for possible underlying pathologies (sweat test, immunogram, IDR 5u PPD etc) or complications(thoracic US, chest CT)
34
Q

BACTERIAL OR VIRAL (1)

A
  • In many children the diagnosis is made clinically in the primary care setting, investigations is unnecessary
  • For sicker children requiring hospital treatment – poor feeding, oxygen requirement, severe malaise- investigations are indication
  • It is difficult to distinguish bacterial from viral pneumonia in many children
  • Mycoplasma, chlamydia can cause focal consolidation
  • Invasive viruses such as influenza and adenovirus can cause high neutrophil counts and elevated acute phase reactants !
  • Mixed infection occurs in up to 30% of children
35
Q

BACTERIAL OR VIRAL (2)
SOS

A
  • Bilateral wheeze is perhaps the strongest indicator that any LRTI that may be present is atypical or viral in etiology
  • A truly focal disease confined to a single lobe is not likely
    to be due to a virus

SOS * Unilateral pleural effusion with adjacent consolidation indicates a bacterial cause ! SOS

  • Empyema can occur frequently with Staphylococcal, pneumococcal, group A – β hemolytic Streptococcal pneumonia
  • Procalcitonin and C-reactive protein are not specific for
    bacterial pneumonia / but if the values are high may be helpful !!!
36
Q

Evaluating pneumonia severity
INFANTS

A

MILD SEVERE
TEMPERATURE - ˂ 38,5o ˃ 38,5o
RESP RATE -≤ 70 ˃ 70
SpO2 in room air - ˃ 94 % ˂ 90-93
Chest recession - mild moderate to severe
Breathing difficulty nasal flaring,cyanosis,apnea
Other symptoms - taking full meal not eating

37
Q

Evaluating pneumonia severity

OLDER CHILDREN

A

MILD SEVERE
TEMPERATURE - ˂ 38,5o ˃ 38,5o
RESP RATE -≤ 50 ˃ 50
SpO2 in room air - ˃ 94 % ˂ 90-93%
Chest recession- mild breathlessness severe difficulty
Breathing difficulty nasal flaring,cyanosis,apnea
Other symptoms-no vomiting grunting respiration signs of
dehydration

38
Q

COMPLICATIONS

A
  • Pleural effusion, Empyema – SA, SP, STR
  • Pneumatocelle – SA
  • Pericarditis- SA, SP
  • Bacteremia –SA, SP, HI
  • Meningitis, suppurative arthritis, osteomielitys – SP, HI
  • Sepsis, shoc septic
  • ARDS- acute respiratory distress syndrome (viral, bacterial)
  • SIADH – innapropriate secretion antidiuretic syndrome
  • SHU (hemolytic uremic syndrome) – acute renal failure, anemia,
    thrombocytopenia
  • CID (coagulation intravascular diseminate)
39
Q

TREATMENT

A
  • Whether a child should be hospitalised depends – age, the severity of ilness, the suspected organism
  • All children younger than 3 months are generally admitted to the hospital
  • Children older than 3 months with febrile pneumonia require admission
  • moderate to severe respiratory distress , apnea, hypoxemia, poor feeding, clinical deterioration on treatment
  • Associated complications- large effusions, empyema, abscess
40
Q

SUPORTIVE TREATMENT

A
  • Keep upper airways clear – frequent suctioning nasal and oral
    secretions
  • Oxygenotherapy
  • Hydration po / parenteral fluids/ electrolyte supplementation
  • Infants with severe disease – should not be fed
  • The decision to use antibiotics or not, depends on the clinical
    picture and the age of the child
  • It is important
    – epidemiological context
  • chest X-Ray
  • imunisation
41
Q

TREATMENT
Bacterial pneumonia

A
  • If a bacterial pneumonia is suspected – empiric antibiotic
    therapy should be considered
  • Children less than 5 years old an abnormal chest X-Ray,
    suggestive clinical findings- the most likely bacterial pathogen is S.
    Pneumoniae and the antibiotic of choice is amoxicillin for
    outpatient management
  • second generation cephalosporins or macrolide – for children allergic to penicillin
  • Children older than 5 years are more likely to have atypical pneumonia and a macrolide might be the best empiric antibiotic choice
  • When its posible - therapy can be guided by the antibiotic
    sensitivity of the organisms isolated
42
Q

TREATMENT
Bacterial pneumonia
BIRTH - 1 month

A

– ampicillin i.v + aminoglycoside i.v
or
- cefotaxime i.v. + ampiciln i.v. +/- antistaphilococal MRSA

43
Q

TREATMENT
BACTERIAL PNEUMONIA
1- 3 months

A

ampicillin i.v. or oral amoxicilin (90-100 mg/kg/day, 7- 10 days
- amoxicillin – clavulanate (90 mg/kg /day for amoxi)
- erythromycin – 40 mg/kg/day
- ceftriaxone – 100 - 150 mg/kg/day
- cefotaxime - 100-150 mh/kg/day

44
Q

TREATMENT
BACTERIAL PNEUMONIA
* 4 months – 4 years

A

– oral amoxicillin or ampicillin i.v.
- oral amoxicillin – clavulanate (90 mg/kg/day)
- oral or parenteral clarithromycin (15mg/kg/day)
- oral azithromycin
- cefuroxime oral 30 mg/kg/day
- benzylpenicilin i.v. 200 000 units/kg/day
- ceftriaxone i.v. 50-100 mg/kg/day
- cefotaxime i.v. + vancomicyn i.v. / linezolid i.v.
- cefotaxime i.v. + clindamycin

45
Q

TREATMENT
BACTERIAL PNEUMONIA
* 5 – 18 years

A
  • Oral amoxicillin or ampicillin i.v.
  • Erythromycin oral or parenteral
  • Clarithromycin oral or parenteral
  • Oral Azithromycin
  • Ceftriaxone i.v.
  • Cefotaxime i.v. +/- vancomycin, cloxacilin, cephazoline i.v.
  • Bezylpencillin i.v.
46
Q

CONCLUSIONS

A
  • In developed countries, for the immunocompetent host in whom bacterial pneumonia is adequately recognised and treated, the survival rate is high
  • LRTI are a major cause of childhood mortality in disadvantaged areas of the world
  • In developed countries the majority are caused by viral agents and bacterial pneumonias is a less common cause
  • The most common cause of bacterial pneumonia in children of all ages is S.pneumoniae
  • Children at high risk for bacterial pneumonia are those with compromised pulmonary defense systems

PEDIATRICS (12 decks)

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