2. PNEUMONIA
• Pneumonia is an inflammation of the parenchyma of
the lung.
- Most cases of pneunomin are
caused by microorganism.
- non infectious causes include
aspiration of food or
gastric acid foreign bodies
hydrocarbons and lipoid.
substances hypersensitivity
reaction and drug or radiation
induced pneumonitis.
3. PNEUMONIA
• Classification .
1 : Anatomical classification.
A – lobar pneumonia .
The consolidalion involves all or part of lobe
B – Bronchopneumonia
the consolidation involves scattered lobules
C - Interstitial pneumonia .
As in viral pneumonia where inflammatory .
Infiltrate involve mainly interstitial tissue between alveli.
4. PNEUMONIA
2 : Etiological classfication.
the cause of pneumonia in patient is often difficult to
determine because direct culture of lung tissue
invasive and rarely performed.
- culture obtained from upper respiratory tract or
sputum genenally not accurately.
5. PNEUMONIA
• Causes of infectious pneumonia.
Bacterial.
Common.
- streptococcus pneumoniae
Group B streptococci
Group A streptococci .
- Mycoplasma pneumoniae
- chlamydia pneumoniae Adolescent.
- chlamydia trachomatis infant.
-Mixed anaerobes Aspiration pneumonia
- Gram-negative enteric.
10. PNEUMONIA
Age group Frequent Pathogens
Neonate <1mo Group B straptococcus – E coli
streptococcus Pneumoniae – H influeza.
1-3 mo Rsv . Influenza viruses para fluenza viruses – adenovirus
febrile Pneu S. pneumoniae . H . influenza
Afebrile Pneu Chlamydia trachomatis Mycoplasma hominis cytomegalovirus.
3 – 12 mo R.S.V Influenza viruses para fluenza viruses adenovirus
S. pneumoniae H . Influenza Chlamydia trachomatis Mycoplasma
pneumoniae Group A straptococcus
2 – 5 yr Influenza viruses para fluenza viruses adenovirus S. pneumoniae
H . Influenza Mycoplasma pneumoniae Chlamydia pneumoniae
Group A straptococcus S . Aureus.
5 – 18 yr Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae
H . Influenza Influenza viruses adenovirus
> 18 yr Mycoplasma pneumoniae S. pneumoniae Chlamydia pneumoniae
H . Influenza Influenza viruses adenovirus.
12. PNEUMONIA
• Hospitalization of children with pneumonia
Age > 6 month -
- Sickle cell anemia with acute chest syndrom.
.- Multiple lobe involvement
Immunocompromised-
. Toxic appearance-
Sever respiratory distress -
.Requirement for supplemental oxygen-
Dehydration-
.Vomiting-
.No response to oral antibiotic-
.Non compliant parent -
13. PNEUMONIA
• Recurrent pneumonia
-Hereditary disorder
Cystic fibrosis
Sickle cell disease
-Disorders of immunity
Aids
Bruton agammaglobulemia
Selective IgG subclass deficiencies
Common variable immunodeficiency syndrom
Sever combined immunodeficiency syndrom
-Disorders of leukocytes
Chronic granulomatous diseaseٍ
Hyperimmunoglobulin E syndrome
Leukocyte adhesion defect
14. PNEUMONIA
- Disorders of cilia
Immotile cilia syndrom
Kartagener syndrom
-Anatomic disorder
Sequestration
Lobar emphysema
Esophageal reflux
Foreign body
Tracheo esophageal fistula ( H type )
Gastroesophageal reflux
Bronchietasis
Aspiration ( oro pharyngeal in coordination )
15. PNEUMONIA
• Pathogenesis
The lower respiratory tract is normally sterile by
-Physiologic defense mechanisms including
-Mucociliary clearance
-ProPerties of normal secretion such as secretory immunoglobulin A IgA
- Clearing of air way by coughing
Immunologic defense mechanism of lung limit invasion by pathogenic
organisms
Includes macrophages are present in alveoli and bronchioles secretory IgA
and others immunoglobulins
17. PNEUMONIA
•Viral pneumonia
usually result from spread of infection along the air way. Accompanied by
direct injury of respiratory epithelium resulting in air way obstruction from
swelling abnormal secretion and cellular debris small calibar of air way in
young infant makes them particularly susceptible to sever infection.
Viral infection predispose to secondary bacterial infection by disturbing
normal host defense mechanism altering secretion and modifying bacterial flora.
18. PNEUMONIA
•Bacterial infection
In bacterial infection pathologic process varies according
to the invading organism
M . Pneumoniae attaches to
the respiratory epithelium inhibit ciliary action and
Lead to cellular destruction and an inflammatory response in the submucosa
as the infection progresses sloughed cellular debris inflammatory cell and mucus
Cause airway obstruction with spread of infection occuriang along the bronchial
Tree as in viral pneumoia.
- S . Pneumoniae
Produce local edema that aids in the proliferation of organism and their spread
Into adjacent portion of lung often resulting in the characteristic focal lobar
Involvement
19. PNEUMONIA
-Grop A . Streptococcus
pathology Includes necrosis of tracheobronchial mucosa formation
-of large
amount of exudate edema and local hemorrhage with extension into the
Interalveolar septa and involvement of lymphatic vessel and pleura.
-S – aureus pneumonia
produces Toxin and enzymes as hemolysin coagulase and
staphylo kinase-
It causes broncho pneumonia often unilateral characterized by
prensence of
Hemorrhagic necrosis and irregular areas of cavitation of
lung parenchyma
Resulting in pneumatoceles empyema or broncho pulmonary fistula
.Pyopneumothorax
20. PNEUMONIA
Following changes stages:
1- congestion alveoli are failed with edema fluid and organism.
2- red hepatization alveoli contain polymorph RBCs fibrin edema and organism.
3-grey hepatization deposition of fibrin over the pleural surface phagocytosis
starts inside the alveoli which are now filled with polymorph and fibrin.
4-resolution: neutrophil degenerate fibrin thread and remaining bacteria and
digested and removed by phagocyte
Clinical Manifestation
Viral & bacterial pneumonia are often preceded by several day of symptoms
of URTI typically rhinitis and cough.
In viral pneumonia:
fever is usually present lower than in bacteria.
Tachypnea increased work of breathing accompanied by intercostal, subcostal
and suprasternal retraction nasal flaring and use of accessory muscle.
Severe infection accompanied by cyanosis and respiratory fatigue in infant.
Auscultation of chest wheezing and crackle
21. PNEUMONIA
In bacterial pneumonia:
Sudden shaking chill followed high fever, cough, grunting, chest pain,
drowsiness, rapid respiration, dry cough, anxiety circumoaral cyanosis.
Physical finding:
Depends on the stage of pneumonia diminished breath sound scattered crackels
and rhonchi over affected lung.
Increasing consolidation or complication.
As effusion empyema or pyopneumothorax dullness on percussion and breath
Sound.
Diminished abdominal distension because of gastric dilation from swallowed
air or ileus. Abdominal pain in lower lobe pneumonia
Liver may seem enlarged because downward of diaphragm secondary to hyper
inflation of lung
Neck rigidity without meningitis in right upper lobe.
22. PNEUMONIA
Diagnosis:
Chest X-ray diagnosis of pneumonia may indicate complication pleural
effusion or empyema.
Viral pneumonia X-ray hyper inflation with bilateral interstitial infiltrate
pneumococcal pneumonia lobar consolifation
repeat chest x-ray are not required for proof of cure for ratient with
uncomplicated pneumonia.
- WBC can differentiating viral from bacterial in virtual WBC normal or
elevated but usually not highert han 20,000/mm3 with lymphocyte predominance
Bacterial 15,000- 40,000 predominance granulocyte.
-Pleural effusion – lobar consolidation and high fever at onset of illness suggestive
of bacterial.
-Atypical pneumonia due to C.pneumoniae or M.pneumoniae is difficult to
distinguish from pneumococal pneumonia by X-ray and other lab.
-pneumococcal pneumonia higher in WBC count ESR-CRP.
- Isolation of organism from blood-pleural fluid or lung culture of sputum blood culture.
positive PCR in viruses
24. PNEUMONIA
Treatment:
Treatment based on cause and clinical appearance of child.
Children do not require hospitalization.
-Amoxicillin ( 80-90mg/kg/24 hrs )
- cefuroxime = Zinnat or Amoxicillinclavulante = ogmin.
- For school age children with M-pneumonia.
-C.pneumonia (atypical pneumonia)
mcrolide antibiotic such as azilhromjcin
Bacterial pneumonia in hostpitalized child
cefuroxime (150 mg/kg/24 hrs) = Zinnat
cefotaxime = claforan
cefftriaxone = Rocephin
- If staphylococcal pneumatotocele empyema
Vancomycin or clindamycin
Viral pneumonia
no respiratory distress with hold antibiotic therapy
- Up to 30% of patient wih known viral infection may have coexisting
bacterial pathogen.
25. PNEUMONIA
Deterioration in clinical status antibiotic therapy should be initiated
Response to treatment:
Patient with uncomplicated bacterial pneumonia respond to therapy with improvement
in clinical symptom (fever, cough, tachypnea, chest pain) within 48-96 hrs.
Slowly resolving pneumonia
1- complication as empyema.
2- bacterial resistance.
3- non bacterial etiology as viruses and aspiration of foreign bodies or food.
4- bronchial obstruction from endobronchial lesion foreign body or mucus plug.
5- pre-existing diseases such as immunodeficiencies- ciliary dyskinesia- cysticfibrosis
pulmonary sequestration cystic adenomatoid malformation.
6- non infectious causes:
- bronchoilitis obliterans.
- hypersensitivity pneumonitis
- eosinophils pneumonia
- aspiration
- wegener granulomatosis
26. PNEUMONIA
Complication:
Usually result of direct spread of bacterial infection within thoracic cavity.
(pleural effusion- empyema- pericarditis)
or bacteremia and hematologic spread meningitis suppurative arthritis osteomyelitis