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- 1. PNEUMONIA D R M A H T A B M B B S , D C H , D N B H A M D A R D U N I V E R S I T Y N E W D E L H I , I N D I A
- 2. INTRODUCTION PNEUMONIA DEFINED AS INFLAMMATION OF LUNG PARENCHYMA BIGGEST KILLER WORLDWIDE OF CHILDREN < 5 YR OF AGE MORTALITY HAS REDUCED FROM 4 MILLION(1981) TO JUST OVER 1 MILLION IN 2013 PNEUMONIA STILL ACCOUTS ONE –FIFTHS OF CHILDHOOD DEATH WORLDWIDE
- 3. INTRODUCTION Childhood pneumonia is an important cause of morbidity in the developed world, and morbidity and mortality in the developing world. Incidence — The World Health Organization (WHO) estimates there are 156 million cases of pneumonia each year in children younger than five years, with as many as 20 million cases severe enough to require hospital admission. Mortality — The mortality rate in developed countries is low (<1 per 1000 per year). In developing countries, respiratory tract infections are not only more prevalent but more severe. Immunizations have had a great impact on incidence of pneumonia caused by pertussis, diphtheria, measles, Hib, and S.pneumonia. Where used, BCG for TB has also had a significant impact.
- 4. ETIOLOGY Infectious agents: Bacteria, viruses Non-infectious agents : aspiration of food/gastric acid, foreign bodies, hydrocarbons, hypersensitivity reactions, drug or radiation – induced pneumonitis.
- 5. ETIOLOGY NEONATES <3WK GROUP B STREPTOCOOCUS,E.COLI,OTHERS GRAM –VE BACTERIA,STREPTOCOCCUS,HEMOPHILUS INFLUENZA 3WK-3M RSV OTHER RESPIRATORY VIRUS (RHINOVIRUS,PARAINFLUENZA VIRUS,INFLUENZA,ADENOVIRUS,S.PNEUMONIA,H.INFLUENZA 4M-4YR RSV, OTHER RESPIRATORY VIRUS(RHINOVIRUS,PARAINFLENZA VIRUS,INFLUENZA,MYCOPLASMA _>5YR M.PNEUMONIA,S.PNEUMONIAE,CHLAMYDIA PNEUMONIA,H.INFLUENZA,INFLUENZA,ADENOVIRUS
- 6. ETIOLOGY Infectious agents causing community acquired pneumonia vary by age . Most common cause in infants is RSV Respiratory viruses (RSV, para-influenza and influenza, adenovirus) in children younger than 5 yrs old. S.pneumonia and M.pneumonia is children older than 5 years. M. Pneumonia and C.pneumonia are principal causes of atypical pneumonia. Additional agents occasionally or rarely cause pneumonia as hospital acquired or zoonotic infections, in endemic areas or in immunocompromised individuals.
- 7. Causes of pneumonia in the immunocompromised Gram negative enteric bacteria M.avium complex Fungi (aspergillosis, histoplasmosis) CMV Pneumocystis jirovecii Pneumonia in patients with cystic fibrosis usually caused by: Staph. Aureus in infancy P.aeruginosa or Burkholderia cepacia in older children
- 8. TYPE OF PNEUMONIA Lobar Pneumonia – Involvement of a single lobe or segment of a lobe (classic pattern of S. pneumoniae pneumonia). Bronchopneumonia – refers to inflammation of the lung that is centered in the bronchioles and leads to production of mucopurulent exudate that obstructs some of these small airways and causes patchy consolidation of the adjacent lobules. Interstitial pneumonitis (IP) – refers to inflammation of the interstitial, which is composed of the walls of the alveoli, alveolar sacs and ducts, and the bronchioles. IP is characteristic of viral infections, but may also be a chronic process. Necrotizing pneumonia (associated with aspiration pneumonia and pneumonia resulting from S. pneumoniae, S. pyogenes, and S. aureus
- 9. RISK FACTOR LOW BIRTH WEIGHT MALNUTRITION VITAMIN A DEFICIENCY LACK OF BREAST FEEDING PASSIVE SMOKING LARGE FAMILY SIZE F/O BRONCHITIS OVERCROWDING AIR POLLUTION (INDOOR IN ALSO IMPORTANT IN DEVELOPING COUNTRY)
- 10. SYMPTOM Fever, chills Tachypnea( MOST CONSISTENT CLINICAL MANIFESTATION) Cough Malaise Pleuritic chest pain Retractions Difficulty breathing / SOB INCREASED WORK OF BREATING ( INTERCOSTAL,SUBCOSTAL,SUPRACOSTAL RETRACTION,NF,USE OF ACCESSORY MUSCLES) SEVERE INFECTION MAY HAVE CYANOSIS AND LETHARGY
- 11. CLINICAL MANIFESTAION VIRAL PNEUMONIA ; TEMPERATURE IS LOWER THAN BACTERIAL PNEUMONIA BACTERIAL PNEUMONIA; BEGIN WITH HIGH GRADE FEVER,COUGH AND CHEST PAIN,OTHERS DROWSINESS AND INTERMITTENT PERIOD OF RESTLESSNESS,SPLINTING ON AFFECTED SIDE TO MINIMIZE PAIN Neonates may have fever with only subtle or no physical findings of pneumonia
- 12. EXAMINATION FINDING The examination findings vary depending on the site of infection: Inspiratory crackles (rales, crepitations) – more common in lobar pneumonia and bronchiolitis/pneumonia Decreased breath sounds – may be noted in areas of consolidation Coarse, low-pitched continuous breath sounds (ronchi) – more common in bronchopneumonia Expiration wheezes, high-pitched breath sounds – more common in bronchiolitis and interstitial pneumonitis. Viral pneumonia are associated more often with cough, wheezing or stridor; fever is less
- 13. DIAGNOSIS BASED ON HISTORY,PHYSICAL EXAMINATION,X RAYS FINDING AND LEUKOCYTOSIS CXR PA AND LATERAL VIEW SUPPORT DIAGNOSIS AND INDICATE COMPLICATION EG VIRAL PNEUMONIA; HYPERINFLATION WITH B/L INTERSTITIAL INFILTRATES AND PERIBRONCHIAL CUFFING LOBAR CONSOLIDATION TYPICALLY PNEUMOCOCACCAL PNEUMONIA USG CHEST; LUNG CONSOLIDATION,AIR BRONCHOGRAM AND EFFUSION
- 14. BLOOD INVESTIGATION CBC IN VIRAL WBC MAY NORMAL OR ELEVATED BUT NOT MORE THAN 20000/MM3 WITH LYMPHOCYTOSIS BACTERIAL PNEUMONIA ELEVATED WBC 15-40K/MM3 WITH PREDOMINENCE OF GRANULOCYTOSIS LARGE PLEURAL EFFUSION ,LOBAR CONSOLIDATION AND HIGH FEVER SUGGEST BACTERIAL ETIOLOGY
- 15. DEFINITE DIAGNOSIS OF VIRAL INFECTION REST ON ISOLATION OF A VIRUS OR DETECTION OF VIRAL GENOME OR ANTIGEN IN RESPIRATORY TRACT SECRETION DEFINITE DIAGNOSIS OF BACTERIAL INFECTION REQUIRE ISOLATION OF ORGANISM BY BLOOD,PLEURAL FLUID AND LUNG
- 16. LOBAR PNEUMONIA
- 17. VIRAL PNEUMONIA
- 18. HISTORY Age Presence of cough, difficulty breathing, SOB Chest pain Fever Recent URTI Associated symptoms and duration of symptoms Immunization status TB exposure Maternal chlamydia, GBS during pregnancy Choking episodes Previous episodes Previous antibiotics
- 20. TREATMENT SEVERE PNEUMONIA; DIAGNOSIS; 1. CENTRAL CYANOSIS SPO2<90% 2. SEVERE RESPIRATORY DISTRESS (GRUNTING ,SEVERE CHEST INDRAWING 3. SIGN OF GENERAL DANGER SIGN (INABILITY TO BREAST FEED OR DRINK,LETHARGY OR UNCONSIOUSNESS,CONVULSION. 4. OTHER SIGN OF PNEUMONIA EG FAST BREATHING 5. CHEST INDRAWING 6. CHEST AUSCULTATION ( DECREASED BREATH SOUND,BRONCHIAL BREATH SOUND,CRACKLES,,ABNORMAL VOCAL RESONANCE,PLEURAL RUB
- 21. INVESTIGATION; 1.MEASURE SPO2 2.CXR TO IDENTIFY (PLEURAL EFFUSION,EMPYEMA,PNEUMOTHORAX,PNEUMOTACELE,INTERSTITIAL PNEUMONIA) TREATMENT 1. O2 SUPPLIMENT WHEN SPO2 <90% (NASAL PRONG IS PREFFERED METHOD IF NOT AVALEBLE THAN NASAL OR NASOPHARENGEAL CATHETOR MAY USED 2. IF PULSE OXIMETER IS NOT AVALIEBLE CONTINUE O2 SUPPLIMENT UNTIL SIGN OF HYPOXIA (INABILITY TO BF OR RR >70 ARE PRESENT 3. NURSE SHOULD CHECK NASAL PRONG EVERY 3 HR TO CHECK BLOCKAGE AND CORRECT POSITION
- 22. ANTIBIOTIC THERAPY ; IV AMPICILLIN/BENZYLPENICILLIN AND GENTAMYCIN (AMPICILLIN 50MG/KG OR BENZYLPENICILLIN 50000U/KG IM/IV EVERY 6HRLY ATLEAST 5 DAYS GENTAMYCIN 7.5MG/KG IM/IV OD ATLEAST FR 5 DAYS IF CHILD DOESN’T SHOW SIGN OF IMPROVEMENT WITHIN 48 HR AND STAPHYLOCOCCAL PNEUMONIA SUSPECTED SWITCH GENTAMYCIN +CLOXACILLIN 50MG/KG IV/IM 6HRLY USE CEFTRIAXONE 80MG/KG IM/IV OD IN CASE OF FAILURE OF FIRST LINE TREATMENT
- 23. Supportive care 1. GENTLE SUCTION OF THICK SECRETION 2.FEVER >38*(102.28F GIVE PARACETAMOL 3 IF WHEEZE GIVE RAPID ACTING BRONCHODILATOR AND STEROID WHEN APPROPRIATE 4 ENSURE CHILD RECEIVE DAILY MAINTENANCE FLUID 5. ENCOURAGE BREAST FEEDING AND ORAL FLUID 5. IF CHILD CANNOT DRINK INSERT NG TUBE GIVE MAINTENANCE FLUID IN SMALL AMOUNT 6. ENCOURAGE CHILD TO EAT FOOD
- 24. MONITORING CHILD SHOULD BE CHECK BY NURSE EVERY 3 HRLY AND BY DR TWICE A DAYS WITHIN 2 DAYS THERE SHOULD BE SIGN OF IMPROVEMENT IF CHILD DON’T IMPROVE IN 2 DAYS LOOK FOR COMPLICATION AND ALTERNATE DIAGNOSIS
- 25. DISCHARGE RD HS RESOLVED THERE IS NO HYPOXIA THEY ARE FEEDING WELL THEY ARE ABLE TO TAKE TAKE ORAL MEDICATION OR COMPLETED A COURSE OF PARENTERAL ANTIBIOTICS PARENTS UNDERSTAND SIGN OF PNEUMONIA,RISK FACTORS AND WHEN TO RETURN FOLLOW-UP GIVE VACCINATION THAT ARE DUE AND ARRANGE FOLLOWUP IN 2 WEEKS
- 26. PNEUMONIA COUGH OR DIFFICULT BREATHING PLUS ONE OF FOLLOWING 1.FAST BREATHING 2. LOWER CHEST INDRAWING IN ADDUTION EITHER CRAKLES OR PLEURAL RUB MAY BE PRESENT ON AUSCULTATION
- 27. TREATMENT TREAT AS OUT PATIENT 1. NORMAL FLUID REQUIREMENT +BREAST FEEDING OR FLUID IN FREQUENT SMALL AMOUT 2.ANTIBIOTICS; GIVE FIRST DOSE OF AMOXICILLIN THAN TEACH HOW TO GIVE OTHER DOSE * SETTING HIGH HIV RATE ORAL AMOXICILLIN 40MG/KG/DOSE TWICE FOR 5 DAYS ++LOW HIV PREVALENCE 40MG/KG/DOSE TWICE A DAYS FR 3 DAYS 3. AVOID UNNECESSARY HARMFUL MEDICATION EG ATROPINE,CODEINE DERIVATIVES OR ALCOHAL 4. PCM
- 28. FOLLOWUP IN PNEUMONIA ENCOURAGE FEEDING BRING BACK AFTER 3 DAYS EARLIER IF CHILD BECOME SICKER (REFUAL TO FEED,LETHARGY,SEVERE RD ETC)
- 29. PROGNOSIS Overall, the prognosis is good. Most cases of viral pneumonia resolve without treatment common bacterial pathogens and atypical organisms respond to antimicrobial.(IMPROVEMENT IN CLINICAL SYMPTOM GENERALLY 48-96 HR) Long-term alteration of pulmonary function is rare, even in children with pneumonia that has been complicated by empyema or lung abscess. Patients placed on a protocol-driven pneumonia clinical pathway are more likely to have favorable outcomes. Staphylococcal pneumonia, although rare, can be very serious despite treatment
- 30. POSSIBILITIES WHEN PT NOT RESPONDING 1. COMPLICATION EG EMPYEMA 2. BACTERIAL RESISTENCE 3. NON BACTERIAL ETIOLOGY EG VIRAL,FUNGAL,ASPIRATION OF FOREIGN BODY 4. PREEXISTING DISEASE EG IMMUNODEFICIENCY,CILIARY DYSKINESIA,CF,PULMONARY SEQUESTRATION 5. OTHER NON INFECTIOUS ETIOLOGY EG BRONCHIOLITIS OBLITERANCES,HYPERSENSITIVITY PNEUMONITIS,EOSINOPHILIC PNEUMONIA
- 31. COMPLICATION Pleural effusion Empyema , Parapneumonic effusions (STAPHYLOCCUS) Lung abscess Pneumothorax Pneumatocele Respiratory failure Metastatic septic lesions (MENINGITIS,SUPPURATIVE ARTHRITIS AND OSTEOMYELITIS) Activation of latent TB
- 32. PNEMOTHORAX
- 33. LUNG ABSCESS
- 34. PLEUMOTHORAX
- 35. PLEURAL EFFUSION
- 36. ATELECTASIS
- 37. RECURRENT PNEUMONIA 2 OR MORE IN A SINGLE YEAR OR 3 OR MORE EPISODE EVER WITH RADIOLOGICE CLEARING IN BETWEEN UNDERLYING DISORDER FOR RECURRENT PNEUMONIA HEREDITORY DISORDER; SCD,CF DISOERDER OF IMMUNITY; HIV/AIDS,BRUTON AGAMMAGLOBUNIMIA,SCID,LAD DISORDER OF CILIA; KARTAGENER SYNDROME,IMMOTILE CILIA SYNDROME ANATOMIC DISORDER;PULMONARY SEQUESTRATION,LOBAR EMPHYSEMA,GERD,FOREIGN BODY,TOF( H TYPE),BRONCHIECTASIS
- 38. PREVENTION Immunizations (EG PNEUMOCOCCAL,INFLUENZA) RSV infections can be reduced in severity using palivizumab Reduce length of mechanical ventilation and using antibiotic treatment only when necessary Hand washing before and after every patient and using gloves for invasive procedures Hospital staff should use masks (especially those with respiratory illnesses)
- 39. THANK YOU SOURCE NELSON 20TH EDITION GHAI 8TH EDITION WHO GUIDELINE FOR COMMON ILLNESS