Pneumonia

1
Pneumonia

• Araya Satdhabudha, MD.
• Division of Pediatric Pulmonology Critical Care
  
• Thammasat University

2
(No Transcript)
3
Epidemiology

• Pneumonia is a common problem in children
• Particularly in children under 5 years
• Incidence 156 million children/year
• 95 in developing country
• 7-13 faced with severe pneumonia
• 0.29 episode/child-year in developing country
• 0.05 episode/child-year in developed country
• Pneumonia is the leading cause of death in
  developing country

Bull World Health Organ 2008
4
Epidemiology and etiology of childhood
pneumoniaWorld Health Organization
Bulletin of the World Health Organization 2004
5
Bulletin of the World Health Organization 2004
6
Epidemiology developing countries

• In 1998
• 10 million of children lt 5 yrs were died each
  year
• 3 million child died from pneumonia (most from
  measles, pertussis)
• Recent data
• Pneumonia still cause around 2 million childrens
  death annually
• About 20 of all child death
• 70 in Africa and Asia
• Africa and Asia record 2-10 times more children
  with pneumonia than in USA

Bull World Health Organ 2008
7
Epidemiology Thailand

• 45-50 of LRTI in children under 5 years are
  diagnosis as pneumonia
• Pneumonia is the leading cause of death in
  children under 5 years
• 19 of fatal children are caused by pneumonia (2
  million children/year)

J Med Assoc Thai 2002 Lancet 2005
8
????????? ??????????????? ????????????
???????????????? ?? 2548-2553
9
????????? ??????????????? ????????????
???????????????? ?? 2548-2553
10
????????? ??????????????? ????????????
???????????????? ?? 2548-2553
11
????????? ??????????????? ????????????
???????????????? ?? 2548-2553
12
????????? ??????????????? ????????????
???????????????? ?? 2546-2555
13
Pneumonia
14
Bulletin of the World Health Organization 2004
15
Risk factors

• Low birth weight (premature, SGA)
• 20 of children born in developing countries have
  birth weight under 2,500 gm.
• Under- nutrition, hypovitaminosis A, Zinc def.
• W/A Z score of lt-2 to -3 had 2-3 higher risk of
  death due to ALRI (Am J Epidemilo 1996)
• Lack of breastfeeding
• Motality rate associated with both ALRI and
  diarrhoae was increased 6 times by not
  breastfeeding
• Air pollution
• Household use of fuels
• ETS RR of 1.2 for ARI in maternal smoking (J
  Infect Dis 1988)
• Overcrowding day-care centers

Paediatric Respiiratory reviews 2005
16
Etiology

• 15-60 cannot identify the pathogen
• Age is a good predictor of the likely causative
  agent

Age (years) Pathogen
Neonatal period GBS, Gram negative enteric bacteria, CMV, L. monocytogenes
1 mo 3 mos Virus RSV, PIF Bacterial S. pneumoniae, H. influenzae, B. pertussis, S. aureus C. trachomatis
3 mos 5 yrs Virus RSV, PIF, influenza, adenovirus, hMPV, rhinovirus Bacteria S. pneumoniae, H. influenzae
5 15 yrs M. pneumoniae, C. pneumoniae, S. pneumoniae
Kendigs Disorders of Resp Tract in Children 2012
JID 2004
N Engl J Med 2002
17
Clinical evaluation
Atypical pneumonia may be no fever

• Fever
• Cough
• Dyspnea

May be absent in early stage of LRI
Tachypnea Nasal flaring, Retractions, Chest
indrawing Grunting Crepitation Wheezing
the most sensitive sign sensitivity 74
specificity 67
impending respiratory failure
auscultation may not be present in early
pneumonia
Paediatric respiratory reviews 2000 Arch Dis
child 2000
18

• WHOs age - specific criteria for tachypnea

Age lt 2 mo RR gt 60/min Age 2-12 mo RR gt
50/min Age 1 5 yrs RR gt 40/min Age gt 5 yrs
RR gt 30/min
19
Clinical clue for CAP

• Daycare attendance Viral infection, DRSP
• Exposure to infectious diseases Viral or
  Mycoplasma infection, Tb
• Hospitalization Nosocomial infection
• Missing immunizations H. influenzae, pertussis,
  measles
• Antibiotic therapy within previous month
• Infection with resistant bacterial strains
• Recent travel influenza, SARS

20
Investigations

• blood culture in all hospitalized children but
  low blood culture yield (lt 10) J Infection 2004
  48 134-8
• Blood culture in child with high fever or looked
  sepsis.
• BTS guidelines for CAP in children.thorax 2011

NP aspirate for virus in all children aged lt 18
months (highly specific and sensitive)
J Infection 2004 48 134-8.
21
Investigation for CAP in children
Clinical clue Suggested Dx or interpretation
Labs CBC ESR CRP G/S and culture Chest radiograph Not helpful in distinguish etiology Not helpful in distinguish etiology Not helpful in distinguish etiology Helpful if specimen is adequate Not helpful in distinguish etiology
Am Fam Physician 2004 70899-908.
22
CXR

• CXR may not be abnormal at the start of classical
  pneumonia
• If all the physical signs of pneumonia are not
  present, CXR are unlikely to be helpful.
• The child should be perform CXR, when
• Age lt 5 yrs without localizing sign
• Complicated pneumonia pleural effusion,
  atelectasis
• Atypical presentation
• Not respond to antibiotic with in 48-72 hr.

BTS guideline for CAP pneumonia in children,
Thorax 2011 Paediatric respratory review 2000
23
Suggestive features of bacterial LRI

• clinical
• Fever gt 38.5?C
• abrupt onset
• dyspnea
• crepitation

• CXR
• alveolar process,
• lobar consolidation

Kendig and Cherniks disorders of the respiratory
tract in children.2012..
Am Fam Physician 2004 70899-908.
24
Suggestive features of viral LRI

• clinical
• Infants and young children
• fever lt 38.5?C
• gradual onset
• dyspnea
• crepitation, wheeze

• CXR
• Hyperinflation
• interstitial process
• patchy collapse (25)

25
Suggestive features of mycoplasma LRI

• CXR
• Interstitial infiltrate,
• lobar consolidation
• and hilar adenopathy

• clinical
• School aged children
• fever (30), Cough(90), rales (62), wheeze
  /rhonchi(36)
• Extrapulmonary manifestation

Kendig and Cherniks disorders of the respiratory
tract in children.2012..
BTS Guideline. Thorax 2011
Am Fam Physician 2004 70899-908.
26
Microbiological investigations bacteria
Investigations Recommendations
Blood culture In children with high fever or looked sepsis
NP aspirate for bacterial c/s Not recommend due to not adequate specimen
Tracheal suction for g/s,c/s Recommened if adequate specimen
Pleural aspirate (if present) Recommened for microscopy, culture and bacterial Ag detection
Serum Ag (bacterial) Not recommend as tests are less sensitive and specific
Serum Ab, immune cpx, paired serum Recommened, good sensitivity and speificity for S.pneumoniae
PCR (serum, pleural fluid, secretion) High sensitivity and specificity for S.pneumoniae
Bacterial Ag in urine Not recommend esp in young children due to poor specificity
BTS guidelines for CAP in children.thorax 2011
J Infection 2004
27
Microbiological investigations atypical
pneumonia and virus
Investigations Recommendations
NP aspirate for viral Ag/PCR/culture highly specific and sensitive for RSV, parainfluenza, influenza and adenovirus
Viral serology Acute and convalescent serum (if diagnosis not made with NP aspirates)
M. pneumoniae Cold agglutinin (PPV 70), serum IgM (in the 2nd wk) or 4-fold rising of paired serum IgG, ve PCR of NP secretion
C. pneumoniae Serum IgM or 4-fold rising of paired serum IgG, ve PCR of NP secretion
C. trachomatis Culture or PCR identification in NP secretion, IgM antibody
BTS guidelines for CAP in children.thorax 2011
J Infection 2004.
28
Management
29
Severity assessment
Mild Severe
Infants BT lt 38.5 C RR lt 70 Mild retraction Taking full feed BT gt 38.5 C RR gt 70 Moderate to severe retraction Cyanosis, apnea, grunting Not feeding
Older children BT lt 38.5 C RR lt 50 Mild breathlessness No vomiting BT gt 38.5 C RR gt 50 Difficulty breathing Nasal flaring, cyanosis, grunting Sign of dehydration
BTS guidelines for CAP in children.thorax 2011
30
Indication for admission

• Age lt 3 months
• Desaturation (SpO2 lt 92 in roomair)
• Dyspnea(increase WOB, retraction, grunting
• Poor feeding or dehydration
• Lethalgy or sign of shock peripheral cyanosis,
  poor capillary refill
• S.aureus pneumonia
• Underlying disease CHD, CLD, immune def.
• Clinical not improve within 48 hr after Rx
• Family not able to provide appropriate
  observation or supervision

BTS guidelines for CAP in children.thorax 2011
31
Indications for PICU admission

• Require FiO2 gt 0.6 to maintain SpO2 gt 92
• Shock
• Sever respiratory distress, exhaustion (rising RR
  and PR ?PaCO2)
• Recurrent apnea
• Slow, irregular breathing

BTS guidelines for CAP in children.thorax 2011
32
General management

• At home
• Supportive and symptomatic treatment for
• Fever
• cough
• preventing dehydration force oral fluid as
  tolerate
• identifying any deterioration
• The child should be reviewed by the doctor if
• Deteriorating
• not improved after 48 hrs of treatment

BTS guidelines for CAP in children.thorax 2011
33
At hospital

• Oxygen therapy
• In child with dyspnea, cyanosis, desaturation
• maintain SpO2 gt 92
• Fluid therapy
• Avoid nasogastric tube
• Start iv fluid mark dyspnea, abdominal
  distension, dehydration
• Avoid volume overload, monitor serum electrolytes
• Managing fever and pain
• Bronchodilator inhaled wheezing or rhonchi
• Physiotherapy (no role in distress, acute
  pneumonia)
• Frequent monitoring (vital signs, SpO2, lung
  signs,
• respiratory pattern

BTS guidelines for CAP in children.thorax 2011
34
Specific treatment

• Clinical Practice Guideline for Treatment of
  Childhood Pneumonia in Thailand

?????????????????????????????????????? ?.?. 2555
35
(No Transcript)
36
2 days
37
Oral antibiotic for CAP
38
Intravenous antibiotics for CAP
39
Antiviral drug
MMWR Jan 2011
40
Prevention

• Promote adequate nutrition including
  breastfeeding and zinc intake
• Raising immunization rate
• Pneumococcal conjugated vaccine
• Hib vaccine
• Measles vaccine
• Pertussis vaccine
• Influenza vaccine
• Reducing indoor pollution
• Household use of fuels
• Environmental tobacco smoke
• Hand washing

BTS guidelines for CAP in children.thorax
2011 Paediatric Respiratory Rewiews 2011
41
Thank you for your attention