Updates

1. Dr. Abdullahel Amaan
Dr. Mohtarama Mostari
Resident Phase-A (Neonatology)
Current Placement: Pediatric Pulmonology

2.  Pneumonia is defined as inflammation of the lung parenchyma.
(Ref: Nelson Text Book of Pediatrics 20th)

3. Epidemiology
 The incidence of pneumonia in U5 children is 0.22 e/child year with 11.5%
progressing to severe episodes.
(Ref:

4. Epidemiology ..
 This means, in each year, about 156 million new episodes of
pneumonia occur world wide, among which 151 million episodes in
developing countries & Bangladesh is in 4th position (after India,
China & Pakistan), about 6 million episodes occuring each year.
(Ref: Epidemiology and Etiology of Childhood Pneumonia. Rudan I, Campbell, et al. Bull World
Health Organ 2008, May; 86(5):408-16.)

5.  The cost of diagnosis & antibiotic treatment of was estimated at around US$
109 million/year.
 It is the leading cause of U5 mortality, globally accounting 16% of all U5
deaths, killing 9,20136 children in 2015.
(Ref: WHO Fact sheet on Pneumonia. Updated on September 2016)
Epidemiology ..

6. Risk factors
1. Malnutrition (W-A Z <-2)
2. LBW-(<2500gm)
3. Non exclusive BF
4. Lack of Immunization-(Measles,
Pentavalent Hib, Varicella)
5. Indoor air Pollution
6. Parental smoking
7. Overcrowding
8. Zinc deficiency
9. Poor care giving practice
10. Concomitant diseases (Diarrhoea,
Heart Diseases, Asthma etc.)

7. Pneumonia : Classification
Clinical
classification
Etiological
classification
Anatomical
classification
Infectous
Non-
Infectous1. Community acquired
2. Nosocomial pneumonia.
3. Pneumonia
in immunocompromised
Typical
Atypical
Pneumonia developed within
48 hours of hospital admission

8. Etiological Classification
 Infectious:
 Bacteria
 Virus
 Fungus(Histoplasma,
Blastomyces,Aspergillus,
Coccidiodes, Cryptococcus.
 Parasites:Ascaris,
Srongiloides.
 Non-infectious :
 Aspiration of food, gastric acid, foreign
body, hydrocarbons, lipoid substances.
 Hypersensitivity reactions,
 Drugs/radiation induced pneumonitis.

9. Etiology according to age
Age group Frequent pathogens
Neonates
( < 3 wk )
Group B streptococcus, E. coli & other Gram -ve bacilli,
S. pneumoniae, H. influenziae type b.
3 wk – 3 mo RSV & other respiratory viruses, S. pneumoniae, H.
influenziae type b, Chlamydia trachomatis.
4 mo – 4 yr RSV & other respiratory viruses, S. pneumoniae, H.
influenziae type b, Mycoplasma pneumoniae, GAS.
≥ 5 yr Mycoplasma, Chlamydophila pneumoniae, Legionella, Str
pneumoniae, H. influenzae type b, Respiratory viruses.

10.  Recurrent pneumonia is defined as 2 or more episodes in a single
year or 3 or more episodes ever, with radiographic clearing between
occurrences.
 An underlying disorder should be considered if a child experiences
recurrent pneumonia:

11. Recurrent pneumonia causes:
A. Hereditary disorders: Cystic Fibrosis, Sickle Cell Disease.
B. Disorders of Immunity: HIV/AIDS, Brutons agammaglobinemia,
Selective Ig deficiency, SCID, Chronic Granulomatous disease,
Leucocyte adhesion defect.
C. Disorders of cilia: Kartagener syndrome, Immotile cilia syndrome.
D. Anatomic Disorders: Pulmonary sequestration, Lobar emphysema,
GER, TEF (H type), Bronchiectasis.

12. Mode of Transmission
1. Droplet Nuclei
2. Nosocomial
3. Endogenous
4. Blood Borne

13. Pathogenesis
•Inhalation of droplet nuclei
•Hematogenous seeding
•Aspiration
Colonization of organism in
respiratory passage
Inflammatory reaction in
respiratory tract including lung
parenchyma

14. Stages of pneumonia
 Stage of congestion: Lung parenchyma filled with inflammatory
exudate.
 Stage of red hepatization: massive exudation with red cells,
neutrophil & fibrin in alveoli.
 Stage of grey hepatization: progressive disintegration of RBC with
greyish brown discoloration.
 Stage of resolution: Progressive removal of exudate from alveolar
space.

15. Clinical Manifestations

16.  In viral pneumonia, low grade fever is usually present, along with
other features of respiratory distress:
1. Tachypnea ( most consistent C/F),
2. Increased work of breathing evident by intercostal, subcostal, and
suprasternal retractions, nasal flaring, and use of accessory muscles,
3. cyanosis and lethargy in case of severe infection,
4. hyper resonant chests with crackles & wheezing.

17.  Bacterial pneumonia is characterized by:
1. sudden high grade fever, cough, and chest pain.
2. drowsiness , occasionally with, delirium,
3. along with rapid progression of usual signs of respiratory distress,
i.e. tachypnea, grunting, nasal flaring; retractions of the
supraclavicular, intercostal, and subcostal areas & often cyanosis.

18. IMCI (2m – 5y)

20. IMCI: Day1 – 2m
 Fast breathing,
 Severe chest indrawing ,
 grunting,
 hypo/ hyperthermia,
 not feeding well,
 convulsion.
Any of these is classified as very severe disease.

21. Investigations
 X-Ray Chest
 CBC
 ESR, C-Reactive Proteins.
 Blood culture.
 Mantoux Test

22. Chest X-Ray
 Viral pneumonia is usually characterized by:
1. hyperinflation with bilateral interstitial infiltrates and
2. peribronchial cuffing .
 Confluent lobar consolidation &/or pleural effusion is typically seen
with pneumococcal pneumonia .

23. Viral vs Bacterial Pneumonia

24. CBC
 In viral pneumonia: the WBC count can be normal or elevated
but is usually not higher than 20,000/mm3, with a lymphocyte
predominance.
 In bacterial pneumonia: is often associated with an elevated
WBC count, in the range of 15,000-40,000/mm3, and a
predominance of granulocytes.

25.  Acute phase reactants (ESR, CRP):
Higher in bacterial, normal or slightly raised in viral pneumonia.
Blood culture: Blood culture results are positive in only 10%.

26. TREATMENT
 Treatment of suspected bacterial pneumonia is based on the presumptive
cause,age and clinical appearance of the child.
 For mildly ill children who do not require hospitalization, amoxicillin is
recommended.
 With the emergence of penicillin-resistant pneumococci, high doses of
amoxicillin (80-90 mg/kg/24 hr) should be prescribed.
 Therapeutic alternatives include cefuroxime axetil and amoxicillin/clavulanate.

27.  For school-aged children and in children with suggested infection of
M. Pneumoniae or C. pneumoniae , a macrolide antibiotic such as
azithromycin is an appropriate choice.
 In adolescents, a respiratory fluoroquinolone (levofloxacin,
moxifloxacin) may be considered as an alternative.

28.  The empiric treatment of suspected bacterial pneumonia in a hospitalized
child start on the clinical manifestations at the time of presentation.

29. Indications for admission to hospital
 Young age - < 6 months of age;
 Toxic appearance
 Moderate to severe respiratory distress
 Inability of family to provide care at home;
 Failure of outpatient therapy;
 Complicated pneumonia
 Vomiting or inability to tolerate oral fluid or medications.
 Immunocompromised state

30. Treatment after hospital admission
 Supportive care for children
 Oxygen, if needed (SpO2-<92%)
 Fluids and ensure hydration
 Antipyretics, analgesics
 Antibiotics

31. 1. In areas without substantial high-level penicillin resistance among S.
pneumoniae,
2. children who are fully immunized against H. influenzae type b and S.
pneumoniae and
3. are not severely ill should receive ampicillin or penicillin G.
 For children who do not meet these criteria, ceftriaxone or cefotaxime should be
used.
 If clinical features suggest staphylococcal pneumonia initial antimicrobial
therapy vancomycin or clindamycin.

32.  If viral pneumonia is suspected, it is reasonable to withhold
antibiotic therapy, especially for those patients
 who are mildly ill,
 have clinical evidence suggesting viral infection and
 are in no respiratory distress.

33.  The optimal duration of antibiotic treatment for pneumonia has not been well-
established in controlled studies.
 Antibiotics should generally be continued until the patient has been afebrile for
72 hr, and the total duration should not be < 10 days (or 5 days for azithromycin).
 Shorter courses (5-7 days) may also be effective, particularly for children
managed on an outpatient basis.
 In developing countries, oral zinc (10 mg/day for <12 mo, 20 mg/day for ≥12 mo)
is advised to reduce mortality among children.

34. Complications
 Pleural effusion
 Empyema
 Lung abscess
 Pneumothorax
 Pneumatocele
 Delayed Resolution
 Respiratory Failure
 Metastatic Septic lesions
 Activation of latent TB

35. Complicated pneumonia

36. Prognosis
 Typically, patients with uncomplicated community-acquired bacterial
pneumonia show improvement in clinical symptoms (fever, cough,
tachypnea, chest pain), within 48-96 hours of initiation of antibiotics.
 Radiographic evidence of improvement lags substantially behind clinical
improvement. It may take 6 to 8 weeks to return to normal.

37.  When a patient does not improve with appropriate antibiotic therapy
complications, such as
1. empyema
2. bacterial resistance
3. nonbacterial etiologies such as viruses or fungi and aspiration of foreign
bodies or food
4. preexisting diseases such as immuno deficiencies, ciliary dyskinesia, cystic
fibrosis, pulmonary sequestration or congenital pulmonary airway
malformation and
5. other noninfectious causes including bronchiolitis obliterans,
hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration and
granulomatosis with polyangitis are suspected.

38.  A repeat chest X-ray is done to determine the reason for delay in response to
treatment.
 Bronchoalveolar lavage may be indicated in children with respiratory failure.
 High-resolution CT scans may better to identify complications or an anatomic
reason.

39. Prevention
1.Exclusive Breastfeeding up to 6 months of age .
2.Immunization against with-- Hib, PCV, Measles,
Pertussis, Varicella.
3.Adequete Nutrition---Under nutrition causes >1 millions death under 5
due to Pneumonia.
4.Hand washing, safe water drinking & prevention of Diarrhoea.
5.Avoidance of parental or other sorts of secondary & tertiary smoking.
6.Free from indoor air pollution.
7.Zinc supplementation.

42. Viral vs Bacterial Pneumonia

43. Staphylococcal vs Streptococcal pneumonia