Pneumonia in children: etiology, diagnosis and treatment

1. Pneumonia in children: etiology, diagnosis and treatment Prof. Galyna Pavlyshyn

2. Plan • 1. Discuss the common causes of pneumonia in children of various ages; • 2. Classifications of pneumonia in children; • 3. Clinical manifestations of pneumonia in children; • 4. Outline the approach to the diagnosis of pneumonia in children; • 5. Select appropriate antibiotic therapy for a child with pneumonia based on child’s age and severity of illness; • 6. Discuss the diagnosis and management of common complications of pneumonia

3. Pneumonia in pediatric patients Basic facts Childhood pneumonia remains an important cause of morbidity and mortality in developing world – 4 million deaths annually in the developing world; About 20% of all deathsin children under 5 ys are due to Acute Lower Respiratory Infections (ALRIs - pneumonia, bronchiolitis and bronchitis); 90% of these deathsare due to pneumonia. Annual incidence in the U.S. in: Children under 5 yo is ~ 40 cases/1000 Children age 12-15 ~ 7 cases/1000 Mortality rate < 1/1.000 in the U.S.

4. Disease Pattern Causes of 10.5 million deaths among children < 5 in developing countries One in every two child deaths in developing countries are due to just five infections diseases and malnutrition

5. Pneumonia in pediatric patients Early recognition and prompt treatment of pneumonia is life saving. Low birth weight, malnourished and non-breastfed children and those living in overcrowded conditions are at higher risk of getting pneumonia. These children are also at a higher risk of death from pneumonia. About one-half of all children < 5 yo with community-acquired pneumonia will require hospitalization;

6. Has been defined as inflammation of lung parenchyma – the portion of the lower respiratory tract consisting of the respiratory bronchioles, alveolar ducts, alveolar sacs, alveoli; What is pneumonia (PNA)?

7. Pneumonia • is an acute infectious inflammatory disease of various nature with involving of lower respiratory tract into pathologic process and intra-alveolar inflammatory exudation;

8. Possible causes of Pneumonia • Bacterial – streptococcus pneumonia, mycoplasma (atypical) • And any other • Viral – RSV (respiratory syncytial virus) • In children younger than 2 years, viral infections were found in 80% of children with pneumonia; in children older than 5 years, viral infections were detected only 37% of the time. • Aspiration • Depends on patient age, immune status, and location (hospital vs. community)

9. Etiology Age-dependent Neonates: • Group B Streptococci • GN Enterics - Esherichia coli, Klebsiella pneumoniae, • Listeria monocytogenes • rareSt. aureus 2 w- 2mo: • Chlamydia • Viruses • Str. Pneumoniae, St. aureus, H. influenzae

10. Children 2-6 mo • Esherichia coli, Klebsiella pneumoniae; • Strep. Pneumoniae and Hemophylus influenzaetypeβ; • Chlamydia pneumoniae; • rareSt. aureus

11. 6 mo -6 yrs • Strep. Pneumoniae - 50 % • Viruses - RSV, parainfluenza, influenza, adenovirus, rhinovirus, coronavirus, herpesvirus, human metapneumovirus • Hemophylus inf.typeβ- 10 % • Mycoplasma pneumoniae- 10 % • Rare St. aureus, Chlamydia pneumoniae

12. 7-18 yrs • Strep. Pneumonie - 35-40 % • Atypical pneumonia (Mycoplasma pneumoniae) - 30-50 % • Moraxella catarrhalis, Hemophylus influezae • Viruses; • hospital (nosocomial) • Ps. aeruginosa, • rareKl. pneumoniae, St. aureus, Proteus;

13. Infectious causes of pneumonia

14. Pathophysiology • Often, follows upper respiratory tract infection; • Lower respiratory tract invaded by bacteria, viruses or other pathogens; • Preceding viral illness (influenza, parainfluenza, RSV, adenovirus) leads to increased incidence of pneumococcal pneumonia; • Bacterial pneumonias usually due to spread of invasive organisms from the nasopharynx by inhalation or aspiration; • In children, bacteremia may lead to hematogenous seeding of the pulmonary parenchyma and result in pneumonia

15. Pathophysiology • Immune response leads to inflammation; • Lung compliance is decreased, small airways become obstructed and air space collapse progresses; • Ventilation-perfusion mismatch and decreased diffusion capacity leads to hypoxemia;

18. CLASSIFICATION: 􀂙 Etiology 􀂙 Morphological class - Bronchopneumonia -Lobarpneumonia - Interstitial pneumonia 􀂙 Congenital pneumonia Community acquired pneumonia Nosocomial (hospital acquired) pneumonia Aspiration pneumonia 􀂙 Non complicated pneumonia complicated pneumonia

19. Morphological classification

20. Complications of pneumonia Pneumonia may be complicated by a pleuritis • Pulmonary: • pleuritis, parapneumonic effusions and empyema, • pneumothorax, • failure of resolution  intra-alveolar scarring ('carnification')  permanent loss of ventilatoryfunction of affected parts of lung;

21. Complications of pneumonia • Pulmonary: abscess formation A thick-walled lung abscess

22. Complications of pneumonia • Extrapulmonary: - infective endocarditis - cerebral abscess / meningitis - septic arthritis - Infectious-toxic shock - DIC (disseminated intravascular coagulation) syndrome

23. Significant Risk Factors • younger age (2-6 months), • low parental education, • smoking at home, • prematurity, • weaning from breast milk at < 6 months, • anaemia • malnutrition Trop Doct 2001 Jul;31(3):139-41

24. Clinical case 1 • 2 y old boy with complaints of fever, cough, vomiting, decreased appetite, chest pain, right lower quadrant (RLQ) abdominal pain; • T 39 C, chills, HR 140, RR 50; • Retractions, signs of respiratory distress; • Decreased breath sounds, rales, egophony, dullness to percussion rate; • Symptoms since yesterday afternoon; • Recent upper respiratory infection;

25. Clinical case 1 • What diagnoses are you considering? • What is the most likely diagnosis ?

26. Clinical case 1 • Why?

27. Clinical case 1 • What do you want to do?

28. jjj

29. jjj right upper lobe pneumonia

30. Clinical case 1Physical examination • Tachypnea • Fever (T 39 C) – nonspecific and not 100% sensitive sign; • Hypoxemia (pulse oximetry – 5th vital sign) • Signs of respiratory distress (retractions, flaring, grunting) • X-ray: infiltrates of lung tissue

31. Clinical case 1Physical examination • Tachypnea • Is the most sensitive and specific sign of radiographically confirmed pneumonia in children • Is the twice as frequent in children with radiographic pneumonia than in those without; • Absence of tachypnea is the most valuable sign for excluding pneumonia;

32. Clinical case 1 • What definition of tachypnea in children do you know?

33. Clinical case 1Physical examination Definition of tachypnea (World Health Org.) • < 2 months: > 60 breaths per minute • 2-12 mos: > 50 breaths per minute • 1-5 y: > 40 breaths per minute • More 5 y: > 20 breath per minute

34. Clinical case 1Physical examination • Wheezing is rare with bacterial pneumonia – more common in pneumonia caused by atypical bacterial or viruses • less than 5% of children with wheezing had pneumonia; • only 2% of children without fever in the ED had pneumonia; • hypoxemia (SpO2 < 92 %) increased risk;

35. Clinical case 2 • Patient 1 yo is transferred to the ED after 1 week of fever and respiratory symptoms; • Child is in moderate respiratory distress, pale appearing and quiet; • T 39.7 C, RR 65, HR 158, SpO2 91%. • Marked decrease in breath sounds on right side, moderate subcostal and intercostal retractions. • Appears dehydrated

36. Clinical case 2 • Signs and symptoms include failure to improve with treatment of pneumonia, persistent fever, malaise, chest pain, respiratory distress; • Physical exam reveals decreased breath sounds, dullness to percussion and pleural rub; • CXR shows white out of right chest; • Decubitus X-rays suggest presence of loculations; • Ultrasound detects early loculations and septations;

37. This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic pleural effusion

38. Clinical case 2 • Diagnosis: • Complicated right lobal pneumonia - parapneumonic pleural effusion • Draining large effusions may provide symptomatic relief; • Aspiration of pleural fluid may provide an etiologic agent to direct therapy

39. Congenital pneumonia • Tachypnea • Irregular respiratory movements (paradoxic) • Apnea • Flaring of alae nostril • Grunting (expiration sound) • Involving chest muscles • Temperature may be present in some term babies

40. Congenital pneumonia • Poor feeding • Lethargy or irritability • Temperature instability • Poor color, cyanosis • Abdominal distention • tachycardia

41. Congenital pneumonia • Late onset of CP (after 7-14 days of life). Mainly Chlamidia or Urea- and Mycoplasma • Onset usually is preceded by upper respiratory tract symptoms and/or conjunctivitis • Nonproductive cough • Fever is absent “afebrile pneumonia syndrome”

42. Physical sings • The sings such as dullness to percussion, change in breath sounds, and the presents of rales or rhonchi are virtually to appreciate in a neonate • Weakened breathing during auscultation • Moist or bubbly sounds, crepitating • Respiratory failure develops gradually

43. CXR in: Atypical Pneumonia • Chlamydia – • Diffuse intersitial markings • hyperinflation • Mycoplasma – • Normal, or can look like viral or typical bacterial PNA

44. Viral pneumonia • Respiratory syncytial virus is the most common viral cause; other common causes include parainfluenza virus, adenovirus, enterovirus; • Clinical features- begin with several days of rhinitis, cough, followed by fever and more pronounced respiratory tract symptoms, such as dyspnea, intercostal retraction.

45. Viral pneumoniaDiagnosis • Laboratory findings – preponderance of lymphocytes observed on CBC; • Diffuse or bilateral infiltrates visible on chest ragiograph; • Rapid test for viral antigen, culturing nasopharyngeal specimens for viruses;

46. CXR in viral PNA

47. CXR in Aspiration: • opacification in right upper lobes of infants and in the posterior or bases of the lung in older children Specific testing: • barium swallow • pH probe, and • flexible endoscopic evaluation of swallowing and sensory testing

48. Tachypnia > 50/min if younger than 1 year, > 40/min if older than 1 year. Cyanosis Retractions Inspiratory crackles Bronchial breath sounds Egophany ( E to A) Bronchophany (99) Whispered pectoriloquy (pectorophony) Dullness to percussion Tactile fremitus Possible Exam Signs of PNA

49. Symptoms and signs5 categories • Nonspecific and toxicity • Signs of lower respiratory disease • Signs of pneumonia • Sign of pleural effusion and empyema • Extrapulmonary disease

50. Symptoms & signs non-specific • Fever, malaise, headache • GI complaints • Apprehension • restlessness