Infectious Pediatric Pneumonia Author: Roberta D. Hood, HBSc, MD, CCFP Lecturer, University of...

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Transcript of Infectious Pediatric Pneumonia Author: Roberta D. Hood, HBSc, MD, CCFP Lecturer, University of...

  • Slide 1
  • Infectious Pediatric Pneumonia Author: Roberta D. Hood, HBSc, MD, CCFP Lecturer, University of Toronto Date Created: December 2011
  • Slide 2
  • Learning Objectives To describe the presentation of pediatric pneumonia To outline the management of pediatric pneumonia To summarize the complications of pediatric pneumonia To highlight interventions to prevent and protect against pediatric pneumonia
  • Slide 3
  • Outline Quiz Epidemiology and Pathophysiology Patient History Presentation and Diagnosis Management and Disposition Further Testing Complications Treatment Interventions to Protect Interventions to Prevent Summary Key Points Case Quiz Results
  • Slide 4
  • Quiz Question 1 What illness is the number one killer of children? A. Diarrheal Disease B. HIV/AIDS C. Malaria D. Pneumonia
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  • Quiz Question 2 What is the most sensitive and specific sign of pneumonia in children? A. Difficulty breathing B. Fever C. Tachypnea D. Tachycardia
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  • Quiz Question 3 If available, a chest x-ray should be done for children with possible pneumonia: A. When a diagnosis is made B. When a history of tachypnea is present C. When antibiotics are started D. When complications are suspected
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  • Quiz Question 4 Which of the following immunization effectively reduce pneumonia mortality in children? A. Haemophilus influenzae b Vaccine B. Pneumococcal Conjugate Vaccine C. Measles Vaccine D. All of the above
  • Slide 8
  • What is Pneumonia? Pneumonia: an acute infection of the pulmonary parenchyma The term Lower Respiratory Tract Infection (LRTI) may include pneumonia, bronchiolitis and/or bronchitis
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  • Epidemiology and Pathophysiology
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  • Epidemiology Pneumonia kills more children under the age of five than any other illness in every region of the world. It is estimated that of the 9 million child deaths in 2007, 20% (1.8 million) were due to pneumonia Approximately 98% of children who die of pneumonia are in developing countries.
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  • Epidemiology Dadaab and Kakuma Refugee Camps (Kenya) Data collected from 2007-2011 revealed that acute respiratory infections are the leading cause of morbidity and mortality in the camps. In Dadaab camp acute respiratory infections were associated with 30% to 40% of deaths of children less than 5 years of age and up to 45% of morbidity in the same age group.
  • Slide 12
  • Millennium Development Goal In 2000, the United Nations Member States committed to Millennium Development Goal 4 to reduce the under five mortality rate by two thirds by 2015, compared to 1990. Millennium Development Goal 4 can only be achieved by an intensified effort to reduce pneumonia deaths.
  • Slide 13
  • Question: Is reducing the incidence, morbidity, and mortality of pneumonia in children a high priority in the region where you practice? What is being done in your area?
  • Slide 14
  • Basic Pathophysiology Most cases of pneumonia are caused by the aspiration of infective particles into the lower respiratory tract. Organisms that colonize a childs upper airway can cause pneumonia. Pneumonia can be caused by person to person transmission via airborne droplets.
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  • Etiology The common pathogens are a function of the patients age. The specific agent causing pneumonia can be determined in 1/3 to 2/3 of cases when cultures, antigen detection and serologic techniques are available. It is helpful to be aware of local outbreaks as clustering of cases is common.
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  • Pneumonia - Common Pathogens Age GroupCommon Pathogens (in Order of Frequency) NewbornGroup B Streptococci Gram-negative bacilli Listeria monocytogenes Herpes Simplex Cytomegalovirus Rubella 1-3 monthsChlamydia trachomatis Respiratory Syncytial virus Other respiratory viruses 3-12 monthsRespiratory Syncytial virus Other respiratory viruses Streptococcus pneumoniae Haemophilus influenzae Chlamydia trachomatis Mycoplasma pneumoniae From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
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  • Pneumonia - Common Pathogens Age GroupCommon Pathogens (in Order of Frequency) 2-5 yearsRespiratory Viruses Streptococcus pneumoniae Haemophilus influenzae Mycoplasma pneumoniae Chlamydia pneumoniae 5-18 yearsMycoplasma pneumoniae Streptococcus pneumoniae Chlamydia pneumoniae Haemophilus influenzae Influenza viruses A and B Adenoviruses Other respiratory viruses From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
  • Slide 18
  • Pneumonia History
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  • Pneumonia History Fundamentals Age Presence of cough, difficulty breathing, shortness of breath, chest pain Fever Recent upper respiratory tract infections Associated symptoms (e.g.. headache, lethargy, pharyngitis, nausea, vomiting, diarrhea, abdominal pain, rash) Duration of symptoms
  • Slide 20
  • Pneumonia History Immunizations status TB exposure Maternal Chlamydia, Group B Strep status during pregnancy Choking episodes Previous episodes Previous antibiotics
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  • Pneumonia History Ill contacts Travel history Day care attendance Animal exposure Dehydration is a sign of severe infection that may require hospitalization. Inquire about: Fluid and nutrition intake Urine output
  • Slide 22
  • History Fundamentals Past Medical History Birth History Medications Allergies Immunization Status Home Environment Social History Family History
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  • Diagnosis
  • Slide 24
  • Diagnosis Objectives Recognition of the signs of pneumonia Diagnosis in a community setting Diagnosis in a health care setting Differential Diagnosis RSV and TB Diagnosis in the context of malnutrition, and considering HIV
  • Slide 25
  • Recognition of Signs of Pneumonia Tachypnea is the most sensitive and specific sign of pneumonia Tachypnea had a Sensitivity of 61% and 79% and Specificity of 79% and 65% for pneumonia in malnourished and well- nourished Gambian children respectively
  • Slide 26
  • WHO Definition of Tachypnea AgeRespiratory Rate (breaths/min) Indication of severe infection (breaths/min) < 2 months> 60>70 2 to 12 months> 50 12 months to 5 years > 40>50 Greater than 5 years > 20
  • Slide 27
  • Other signs of pneumonia - Indrawing out---breathing---in Lower chest wall indrawing: with inspiration, the lower chest wall moves in From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000 https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
  • Slide 28
  • Other signs of pneumonia - Nasal Flare Nasal flaring: with inspiration, the side of the nostrils flares outwards From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000 https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
  • Slide 29
  • Diagnosis in Community Setting SIGNS Classify ASTreatment Tachypnea Lower chest wall indrawing Stridor in a calm child Severe Pneumonia Refer urgently to hospital for injectable antibiotics and oxygen if needed Give first dose of appropriate antibiotic TachypneaNon-Severe Pneumonia Prescribe appropriate antibiotic Advise caregiver of other supportive measure and when to return for a follow-up visit Normal respiratory rateOther respiratory illness Advise caregiver on other supportive measures and when to return if symptoms persist or worsen From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Childrens Fund (UNICEF), 2006.
  • Slide 30
  • Infants at Risk of Pneumonia Infants less than 3 months old with signs of pneumonia should be referred immediately to the nearest health facility because they are at high risk of severe illness and death. Infants who were premature, and those with congenital heart disease or chronic lung disease are also at increased risk.
  • Slide 31
  • Diagnosis in a Health Care Setting Vital signs that should routinely be taken in an Emergency Care setting include: Respiratory Rate Heart Rate Temperature Oxygen saturation (if available) Any child with an increased respiratory rate should be immediately identified as having possible pneumonia.
  • Slide 32
  • Vital Signs Both heart rate and respiratory rate are influenced by the presence of fever. Heart rate increases by approximately 10 beats per minute for each 1 degree Celsius. Respiratory Rate has been estimated to vary by 0.5-2 breath per minute to 5-11 breaths per minute for each 1 degree Celsius.
  • Slide 33
  • Does this infant child have pneumonia? The Rational Clinical Exam, Journal of the American Medical Association Observation of the infant is the most important part of the examination does the child look sick? Respiratory rat