Daniel Tawfik, MD PGY-3Morning report

6 June 2014

icky breathing

HPISetting: EDPatient: 7mo maleHPI:

Rhinorrhea, cough x 3 daysIncreased cough with post-tussive emesis

this AMOne episode of perioral cyanosis with

retractionsNo improvement noted with 2.5mg albuterol

at homeNo fevers at home

PMHRight congenital diaphragmatic hernia

V-V ECMO DOL 0-4Repaired DOL 5Revised at 3mo age

History of adrenal insufficiencyHistory of pulmonary hemorrhageChronic lung diseaseFeeding problems, NG dependent with

thickened PO feedsRecent hospitalization 1wk ago for RSV with

reactive component

PMHMeds: MVI, Albuterol PRN (finished

prednisolone 6 days ago)Allergies: NKDAImms: UTDFHx: No chronic or childhood illnessesSHx: Lives with parents and 6 older

siblings. One brother with cough x 4 days.

Physical examVS: T 39.9, P 209, R 54, BP 105/63, SpO2 78% RAGEN: awake, alert, cryingHEENT: NG in place, TM’s clear, no oropharyngeal

lesionsRESP: Increased work of breathing, subcostal and

intercostal retractions, coarse breath sounds throughout, scattered end-expiratory wheeze

CV: Tachycardic, perioral cyanosis, no murmurs or gallops appreciated, heart sounds more prominent on right.

GI: soft, nontender, nondistended, no HSMEXT: warm, well-perfused, CRT 2 secSKIN: No rashes or lesions

DDxRESPIRATORY

AsthmaAspiration pneumonitisForeign body aspirationCDHLung hypoplasiaCCAM/CPAMPneumothoraxHemidiaphragm paralysis

CARDIOVASCULARVSDASDTOFTAPVR/PAPVRHLHSSVTVascular ringPulmHTN

INFECTIOUSbronchiolitisCAPHAPInfluenzapertussis

ENTTEFLaryngeal clefttracheomalacia

HEME/ONCAnemiaLeukemic lung infiltrate

NEUROstrokeSeizure

OTHERPregnancyLupus

StudiesPertinent labs:

WBC 46 (33% bands, 56% PMNs)VRP: negativeBlood culture: negative

Pertinent imaging:CXR: New focal LLL opacity. Unchanged

hypoplastic right lung and mediastinal shift to the right.

Community-acquired pneumonia>150 million cases per year1.2 to 2 million deaths per year

18% of U5MLeading cause of childhood mortality

worldwide40% hospitalization rateStrep pneumo, H. flu, Mycoplasma most

commonMoraxella, Chlamydia, Staph less common

DispositionInpatient

Hypoxemic<6moBad pathogen (MRSA, etc)Compliance concerns

Diagnostic testingBlood culture

If inpatientIf not improving or deteriorating

VRPMycoplasma

Test if suspiciousCBC

If inpatientESR/CRP

Response to therapyCXR

If inpatientIf hypoxemic

TreatmentOral

Immunized -> Amoxicillin +/- AzithromycinAlternatives: clindamycin, cephalosporin,

levofloxacinUnimmunized -> Augmentin +/- Azithromycin

Alternatives: clindamycin, cephalosporin, levofloxacin

IVImmunized -> Ampicillin +/- Azithromcyin

Alternatives: clindamycin, cephalosporinUnimmunized -> Ceftriaxone +/-

AzithromycinAlternatives: clindamycin

DosingAmoxicillin 90 mg/kg/day divided TID x 10

days

Augmentin 90 mg/kg/day divided BID x 10 days

Ampicillin 200 mg/kg/day divided Q6hCeftriaxone 75 mg/kg Q24h

Clindamycin 40 mg/kg/day divided TID x 10 days

Azithromycin 10 mg/kg Q24h x 3 days

ResourcesIntermountain CAP guidelines

https://intermountainhealthcare.org/ext/Dcmnt?ncid=522578601

Intermountain CAP flashcardhttps://intermountainhealthcare.org/ext/Dcm

nt?ncid=522833243

Empyema1-2% of pneumonias (closer to 28% in

Utah)Treatment affected by size

< 25% of hemithoraxAntibiotics (Cefotax/Ceftriaxone/Ceftaroline +

Clindamycin)25-50% of hemithorax

CT + TPA or VATS> 50% of hemithorax

CT + TPA or VATSIf drainage >2 days, may need open debridement

Ibuprofen and empyema?OR 4 (2.5-6.5) if Ibuprofen used prior to

hospitalization (p <0.0001)Ibuprofen caused empyema?

Pro-inflammatory at low doses (3 mg/kg) Increased neutrophils and cytokines

Also associated wth increased necrotizing fasciitis with Strep pyogenes

Ibuprofen result of empyema?Increased pain with empyema -> more medsDelay in hospitalization if more comfortable

ReferencesGereige RS, Laufer PM. Pneumonia. Peds in Rev. 2013; 34(10):438-56.Bradley JS et al. The management of community-acquired pneumonia in

infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011; 53(7):e25-76.

Byington CL et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: Risk factors and microbiological associations. Clin Infect Dis. 2002; 34:434-40.

Rinaldo JE, Pennock B. Effects of ibuprofen on endotoxin-induced alveolitis: biphasic dose response and dissociation between inflammation and hypoxemia. Am J Med Sci 1986; 291:29-38.

Konstan MW et al. Effect of ibuprofen on neutrophil migration in vivo in cystic fibrosis and healthy subjects. J Pharmacol Exp Ther 2003; 306(3):1086-91.

Peterson CL et al. Risk factors for invasive group A streptococcal infections in children with varicella: a case-control study. Pediatr Infect Dis J 1996; 15:151-6.