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Dr.Osama Felemban MBBS DCH CABP AFSA CPPF 
Consultant Pediatric Pulmonology 
Clinical Assistant Professor 
Pediatric Depar...
1. Over view 
2. Epidemiology 
3. Pathophysiology 
4. Clinical Presentation 
5. Clinical Approach 
6. Differential diagnos...
1- Over view 
 LRTI : infection below the level of larynx 
 Larynogotracheobronchitis 
Bronchitis 
 Bronchiolitis 
 P...
2- Epidemiology 
 The estimated incidence of LRTI is 30 per 1,000 children 
per year in the UK. 
 Boys affected > than g...
3 - Pathophysiology 
 Essentially, it is inflammation of the airways/pulmonary 
tissue, due to viral or bacterial infecti...
Etiology 
 Viral infections : e.g 
 Influenza A 
 Respiratory syncytial virus (RSV) 
 Human metapneumovirus (hMPV) 
 ...
 Bacterial infection : 
 Streptococcus pneumoniae (the majority of bacterial 
pneumonias) 
 H. influenzae 
 Staphyloco...
 Atypical organisms 
 Mycoplasma pneumoniae 
 Legionella pneumophila, 
 Chlamydophila pneumoniae 
 Secondary bacteria...
4 - Clinical Presentation 
 typical viral URTI 
 Fever 
 Bacterial pneumonia :++ in children (persistent or repetitive ...
5 – Clinical Approach 
 History :symptoms of LRTI is variable with age 
 Newborn and neonates present with: 
 Grunting ...
History 
 Infants present with: 
 Cough (the most common symptom after the first four weeks) 
 Tachypneic (according to...
 Toddlers/pre-school children: 
 Preceding URTI is common 
 Cough is the most common symptom 
 Fever occurs most notic...
 Older children: 
 There will be additional symptoms to those above 
 More expressive and articulate children will repo...
Physical Examination 
 General points: 
 Examination can be difficult in young children 
(particularly auscultation) 
 ...
 signs of respiratory distress: 
 Cyanosis in severe cases 
 Grunting 
 Nasal flaring. In children aged under 12 month...
 Observation: 
 In good light, with the chest and abdomen uncovered, is essential 
 Count respirations and note the res...
 Auscultation: 
 Examine with warm hands and a stethoscope 
 Take the opportunity to examine a quiet sleeping child 
 ...
 Percussion: 
 Identifies consolidation 
 Consolidation is a later and less common finding than 
the crepitation of a p...
6 - Differential diagnosis 
 Asthma 
 Inhaled foreign body 
 Pneumothorax 
 Cardiac dyspnoea 
 Pneumonitis from other...
7 - Investigations 
 CBC: 
 White cell count is often elevated. 
 Microbiological studies: 
 Blood cultures are seldom...
 Other tests: 
 Tuberculin skin testing if tuberculosis is 
suspected. 
 Cold agglutinins when mycoplasmal infection 
i...
8 - Management 
 Most children with lower respiratory tract infection 
(LRTI) and pneumonia can be treated as outpatients...
 Admission of severe LRTI : 
 Oxygen saturation <92% 
 Respiratory rate >70 breaths/minute (≥50 breaths/minute in an ol...
Presence of comorbidity : 
 congenital heart disease, 
 chronic lung disease of prematurity, 
 chronic respiratory cond...
Admission should also be considered for: 
 All children under the age of 6 months 
 Children in whom treatment with anti...
 Be sure to offer the patient and parents general support, 
explanation and reassurance. 
 Respiratory support as requir...
Medications 
 Antipyretics 
(avoid aspirin due to the danger of Reye's syndrome). 
 Antibiotic treatment
9 - Complication & prognosis 
 Complete resolution after treatment should be expected in 
the vast majority of cases. 
 ...
10 - Prevention 
 Prevention of pneumococcal pneumonia and influenza by 
vaccination, for high-risk individuals with pre-...
11 - Take Home massages 
 Understanding the pathophysiology of LRTI 
 Conducting proper History 
 Performing careful ph...
12 - References 
 Guidelines for the management of community acquired pneumonia in children; 
British Thoracic Society (2...
Lower respiratory tract infection (LRTI) in
Lower respiratory tract infection (LRTI) in
Lower respiratory tract infection (LRTI) in
Lower respiratory tract infection (LRTI) in
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  1. 1. Dr.Osama Felemban MBBS DCH CABP AFSA CPPF Consultant Pediatric Pulmonology Clinical Assistant Professor Pediatric Department King Abdulaziz University Hospital Faculty of Medicine KAU
  2. 2. 1. Over view 2. Epidemiology 3. Pathophysiology 4. Clinical Presentation 5. Clinical Approach 6. Differential diagnosis 7. Investigations 8. Management 9. Complication & prognosis 10. Prevention 11. Take Home massages 12. References
  3. 3. 1- Over view  LRTI : infection below the level of larynx  Larynogotracheobronchitis Bronchitis  Bronchiolitis  Pneumonia
  4. 4. 2- Epidemiology  The estimated incidence of LRTI is 30 per 1,000 children per year in the UK.  Boys affected > than girls, (children born between 24-28 weeks compared to born at term.)  Haemophilus influenzae infection is uncomon because of immunization.
  5. 5. 3 - Pathophysiology  Essentially, it is inflammation of the airways/pulmonary tissue, due to viral or bacterial infection, below the level of the larynx.  Gastro-oesophageal reflux may cause a chemical pneumonitis.  Smoke and chemical inhalation may cause pulmonary inflammation
  6. 6. Etiology  Viral infections : e.g  Influenza A  Respiratory syncytial virus (RSV)  Human metapneumovirus (hMPV)  Varicella-zoster virus (VZV)  Chickenpox
  7. 7.  Bacterial infection :  Streptococcus pneumoniae (the majority of bacterial pneumonias)  H. influenzae  Staphylococcus aureus  Klebsiella pneumoniae  Enterobacteria - eg, Escherichia coli  Anaerobes
  8. 8.  Atypical organisms  Mycoplasma pneumoniae  Legionella pneumophila,  Chlamydophila pneumoniae  Secondary bacterial infection  relatively common following viral upper respiratory tract infection (URTI) or LRTI.
  9. 9. 4 - Clinical Presentation  typical viral URTI  Fever  Bacterial pneumonia :++ in children (persistent or repetitive fever > 38.5°C) with chest recession and a raised resp.rate  Audible wheezing is not seen very often in LRTI (common with more diffuse infections ; M. pneumoniae and bronchiolitis).  Stridor or croup suggests URTI, epiglottitis or foreign body inhalation.
  10. 10. 5 – Clinical Approach  History :symptoms of LRTI is variable with age  Newborn and neonates present with:  Grunting  Poor feeding  Irritability or lethargy  Tachypnoea ±  Fever (±Hypothermia)  Cyanosis (in severe infection)  Cough (±) In this age group beware:  Particularly of streptococcal sepsis and pneumonia in the first 24 hours of life  Chlamydial pneumonia, which may be accompanied by chlamydial conjunctivitis (presents in the second or third week)
  11. 11. History  Infants present with:  Cough (the most common symptom after the first four weeks)  Tachypneic (according to severity)  Grunting  Chest indrawing  Feeding difficulties  Irritability and poor sleep  Breathing, which may be described as 'wheezy' (but usually upper airway noise)  History of preceding URTI (very common)  Atypical and viral infections (especially pneumonia) may have only low-grade fever or no fever
  12. 12.  Toddlers/pre-school children:  Preceding URTI is common  Cough is the most common symptom  Fever occurs most noticeably with bacterial organisms  Pain (chest and abdominal)  Vomiting with coughing is common (post-tussive vomiting)  Lower lobe pneumonias can cause abdominal pain
  13. 13.  Older children:  There will be additional symptoms to those above  More expressive and articulate children will report a wider range of symptoms  Constitutional symptoms may be variable described  Atypical organisms are more likely in older children
  14. 14. Physical Examination  General points:  Examination can be difficult in young children (particularly auscultation)  A careful routine of observation is essential to identify respiratory distress  Pulse oximetry can be very useful in evaluation.  High fever over 38.5°C may occur often
  15. 15.  signs of respiratory distress:  Cyanosis in severe cases  Grunting  Nasal flaring. In children aged under 12 months this can be a useful indicator of pneumonia  Marked tachypnoea  Chest indrawing (intercostal and suprasternal recession)  Other signs ;subcostal recession, abdominal 'see-saw' breathing and tripod positioning  Reduced oxygen saturation (less than 95%)
  16. 16.  Observation:  In good light, with the chest and abdomen uncovered, is essential  Count respirations and note the respiratory rate (RR)  Newborn 30-60/minute  Infant 20-30/minute  Toddler 20-30/minute  Child 15- 20/ minute  Observe the infant's feeding (to uncover decompensation during feeding)  Observe the chest movements (for example, looking for splinting of the diaphragm)
  17. 17.  Auscultation:  Examine with warm hands and a stethoscope  Take the opportunity to examine a quiet sleeping child  Upper respiratory noises can be identified by listening at the nose and chest  Crepitations in the chest may indicate pneumonia, + when accompanied by fever
  18. 18.  Percussion:  Identifies consolidation  Consolidation is a later and less common finding than the crepitation of a pneumonia  Later in older children there may be dullness to percussion over zones of pneumonic consolidation  Bronchial breathing and signs of effusion occur late in children and localization of consolidation can be difficult to diagnose
  19. 19. 6 - Differential diagnosis  Asthma  Inhaled foreign body  Pneumothorax  Cardiac dyspnoea  Pneumonitis from other causes:  Extrinsic allergic alveolitis  Smoke inhalation  Gastro-oesophageal reflux
  20. 20. 7 - Investigations  CBC:  White cell count is often elevated.  Microbiological studies:  Blood cultures are seldom positive in pneumonia (fewer than 10% are bacteraemic in pneumococcal disease).  Sputum culture  Imaging:  Chest radiography (CXR) is not routinely indicated in outpatient management.  CXR cannot differentiate reliably between bacterial and viral infections.
  21. 21.  Other tests:  Tuberculin skin testing if tuberculosis is suspected.  Cold agglutinins when mycoplasmal infection is suspected (50% sensitive and specific).  ESR , CRP  Diagnostic procedures:  Drainage and culture of pleural effusions may relieve symptoms and identify the infection.
  22. 22. 8 - Management  Most children with lower respiratory tract infection (LRTI) and pneumonia can be treated as outpatients, with oral antibiotics.  Older children can be managed with close observation at home if they are not distressed or significantly dyspnoeic and parents can cope with the illness.  Viral bronchitis and croup do not require antibiotics and mild cases can be treated at home
  23. 23.  Admission of severe LRTI :  Oxygen saturation <92%  Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older child)  Significant tachycardia for level of fever  Prolonged central capillary refill time >2 seconds  Difficulty in breathing as shown by intermittent apnea, grunting and not feeding
  24. 24. Presence of comorbidity :  congenital heart disease,  chronic lung disease of prematurity,  chronic respiratory conditions such as - cystic fibrosis, - bronchiectasis or - immune deficiency
  25. 25. Admission should also be considered for:  All children under the age of 6 months  Children in whom treatment with antibiotics has failed (most children improve after 48 hours of oral, outpatient antibiotics)  Patients with troublesome pleuritic pain
  26. 26.  Be sure to offer the patient and parents general support, explanation and reassurance.  Respiratory support as required, including oxygen  Pulse oximetry to guide management  Severe respiratory distress with ↓level of consciousness and failure to maintain oxygenation indicates a need for intubation
  27. 27. Medications  Antipyretics (avoid aspirin due to the danger of Reye's syndrome).  Antibiotic treatment
  28. 28. 9 - Complication & prognosis  Complete resolution after treatment should be expected in the vast majority of cases.  Bacterial invasion of the lung tissue can cause pneumonic consolidation, septicemia, empyema, lung abscess (especially S. aureus) and pleural effusion.  Respiratory failure, hypoxia and death are rare unless there is previous lung disease or the patient is immunocompromised.
  29. 29. 10 - Prevention  Prevention of pneumococcal pneumonia and influenza by vaccination, for high-risk individuals with pre-existing heart or lung disease.  Smoking in the home is a major risk factor for all childhood respiratory infection.
  30. 30. 11 - Take Home massages  Understanding the pathophysiology of LRTI  Conducting proper History  Performing careful physical Examination  Comprehension the Impact of the disease on the family  Close follow up after discharge  Avoidance of bad Habit : Smoking
  31. 31. 12 - References  Guidelines for the management of community acquired pneumonia in children; British Thoracic Society (2011)  Pediatric Essntial Nelsom 2011  van Woensel JB, van Aalderen WM, Kimpen JL; Viral lower respiratory tract infection in infants and young children. BMJ. 2003 Jul 5;327(7405):36-40.  Michelow IC, Olsen K, Lozano J, et al; Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004 Apr;113(4):701-7.  Krilov LR; Respiratory syncytial virus disease: update on treatment and prevention. Expert Rev Anti Infect Ther. 2011 Jan;9(1):27-32.  Feverish illness in children - Assessment and initial management in children younger than 5 years; NICE Guideline (May 2013)  Mahabee-Gittens EM, Grupp-Phelan J, Brody AS, et al; Identifying children with pneumonia in the emergency department. Clin Pediatr (Phila). 2005 Jun;44(5):427-35.  Haider BA, Saeed MA, Bhutta ZA; Short-course versus long-course antibiotic therapy for non-severe Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005976.
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