Peadiatric pneumonia by Teo Yan
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Transcript of Peadiatric pneumonia by Teo Yan
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Definition
Pneumonia is an inflammation of the pulmonary parenchyma
Most caused by microorganisms, noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions, and drug- or radiation-induced pneumonitis
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classified as community-acquired, hospital-acquired, or ventilator-associated
-40–80% of children with
community-acquired pneumonia.-Streptococcus pneumoniae
(pneumococcus) is the most common bacterial pathogen
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Epidemiology
Pneumonia is substantial cause of morbidity and mortality in childhood (particularly among children <5 yr of age)
Estimated approximately 4 million deaths children among worldwide
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Global distribution of deaths among children
under age 5, by cause, 2010
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Organisms of pneumonia
bacterial or viral cause of pneumonia can be identified in 40–80% of children with community-acquired pneumonia. Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen, followed by Chlamydia pneumoniae and Mycoplasma pneumoniae
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Leading Etiologic Agents of Pneumonia Infants and Children
S.aureus
S.aureus
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Pathophysiology
Virusairbornedropletsmouth or noselungsvirus incaded cells
lining airway and alveoli cell death(protective process) immune system responds more lung damage fluid leak into alveoli(due to WBC,lymphocytes activate) interrupts normal transportation of oxygen
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Bacterial invasion triggers the immune system to send neutrophils kill the offending organisms, and also releasecytokines fever, chills, and fatigue
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Types of pneumonia
Classify by clinically:
Lobar pneumonia-infection that only involves a single lobe, or section.
Bronchopneumonia - affects the lungs in patches around the tubes (bronchi or bronchioles)
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Clinical features
Fever Dyspnoea Cough ( productive or non-
productive) Lethargy Poor feeding
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Physial examination
Tachypnoea,nasal flaring and chest indrawing
Consolidation with dullness on percussion
End –inspiratory respiratory coarse carckles over the effeted area
Decreased breath sounds and bronchial breathing
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Assessment of severity of pneumonia The predictve value of respiratory
rate for the diagnosis of pneumonia Tachypnoea is defined as follows : < 2 months age: > 60 /min 2- 12 months age: > 50 /min 12 months – 5 years age: > 40
/min
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Assessment the severity of pneumonia
AGE < 2months AGE>2 months – 5yrs old
Severa pneumonia severe chest indrawing or fast breathing
Very severe pneumonia not feeding convulsion abnormally sleepy or difficult to wake fever/low body temperature hypopnoea with slow irregular breathing
Mild pneumonia fast breathing
Severe pneumonia chest indrawing
Very severe pneumonia not able to drink convulsions drowsiness malnutrition
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Investigations
Chest X-ray White blood cell count Blood culture Pleural fluid analysis Serology Nasopharyngeal aspirate
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Chest X-ray
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Investigations
elevated WBC count in the range of 15,000-40,000/mm and a predominance of granulocytes
erythrocyte sedimentation rate (ESR)
C–reactive protein (CRP) anti-streptolysin O (ASO) titer
useful in the diagnosis of group A streptococcal pneumonia
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Viral pneumonia
several days of symptoms of an upper respiratory tract infection eg: rhinitis and cough
Fever, lower than in bacterial pneumonia
Tachypnea intercostal, subcostal, and
suprasternal retractions, nasal flaring, and use of accessory muscles
cyanosis
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Investigations
Reliable DNA or RNA tests for the rapid detection of RSV
PCR test seroconversion in an IgG assay
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Myocoplasma pneumonia
Headaches and malasia
precede the chest symptoms by 1-5 days
Cough may not obvious
chest may be scanty
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chest X-ray - one lobe is involved but sometimes may shadowing in both lungs
frequently no correlation between the X-ray appearances and the clinical state of the patient.
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Investigation
Serology : acute phase serumtitre > 1:160 or
paired samples taken 2-4 weeks apart showing a
4 fold rise is a good indicator of Mycoplasma pneumoniae infection
This test should be considered for children aged five years or older
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Management
Assessment of oxygenation
The best objective measurement of hypoxia is by pulse oximetry which avoids the need
for arterial blood gases. It is a good indicator of the severity of pneumonia
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Criteria for hospitalization community acquired pneumonia can
be treated at home it is crucial to identify indicators of
severity in children who may need admission.
Failure to recognise the severity of pneumonia may lead to death.
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The following indicators can be used as a guide for admission:
children aged 3 months and below, whatever the severity of pneumonia.
fever ( more than 38.5 ⁰C ), refusal to feed and vomiting
fast breathing with or without cyanosis associated systemic manifestation failure of previous antibiotic therapy recurrent pneumonia severe underlying disorder ( i.e.
immunodefi ciency )
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Antibiotics Bacterial pathogens of children and the recommended antimicrobial agents to be used:
Pathogen Antimicrobial agentBeta-lactam susceptible Streptococcus pneumonia penicillin, cephalosporins Haemophilus influenzae type b ampicillin, chloramphenicol,
cephalosporinsStaphylococcus aureus cloxacillinGroup A Streptococcus penicillin, cephalosporinMycoplasma pneumoniae macrolides , e.g. erythromycin,
azithromycinChlamydia pneumoniae macrolides , e.g. erythromycin,
azithromycinBordetella pertussis macrolides , e.g. erythromycin,
azithromycin
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Children with severe pneumonia, the following antibiotics are recommended:
Suggested antimicrobial agents for inpatient treatment of pneumonia
1st line beta-lactam drugs : benzylpenicillin, amoxycillin, ampicillin, amoxycillin-clavulanate2nd line cephalosporins : cefotaxime, cefuroxime, ceftazidime3rd line carbapenem: imipenamOthers aminoglycosides: gentamicin, amikacin
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• second line antibiotics need to be considered when :
- there are no signs of recovery - patients remain toxic and ill with spiking
temperature for 48 - 72 hours • a macrolide antibiotic is used if Mycoplasma
or Chlamydia are the causative agents • a child admitied to hospital with severe
community acquired pneumonia must receive parenteral antibiotics. As a rule, in severe cases of pneumonia, combination therapy using a second or third generation cephalosporins and macrolide should be given.
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Supportive treatment
Fluids Oxygen Temperature control Chest physiotherapy
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Complications of pneumonia Pleural effusion Empyema Pericarditis Lung abscess Respiratory failure Meningitis Suppurative arthritis Osteomyelitis
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Comparism of common organisms causing pneumonia in Paed population
Org Strep Staph Mycoplasma
RSV
Commonest com -acq
Iv drugs users or with cental venous catheters
Age 3mth -childhood Noenatal-- infancy
>5yrs <3mths
Clinical Feature
Broncho in young child Lobar/consolidation in olderF,Rusty sputumHaemoptysisPleuritic painO/E-
Fever TachypneaCyanosis Extremely ill
Headaches,Malaise,Chest symptoms.
upper respiratory tract infection, Fever,tachypnea
Inv- CXR multi lobar consolidati on, cavitation, pneumatocoeles
Not correlate with clinical state
Infiltr ate In affect- ed area
Tx 1st line 2nd line
Iv flucloxacillin (200mg/kg/d)
Erythromycin,Clarithromycin
HIV(PCP)
Any age
high fever, breathlessness and dry cough
diffuse bilateral alveolar and interstitial shadowing perihilar regions spread out in a butterfly patternHAART
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The End