Good Morning 
Morning Report
July 23, 2013
Semantic Qualifiers
Symptoms
Acute /subacute
Chronic
Localized
Diffuse
Single
Multiple
Static
Progressive
Constant
Intermittent
Single Episode
Problem Characteristics
Ill-appearing/
Toxic
Well-appearing/
Non-toxic
Recurrent
Localized problem
Systemic problem
Abrupt
Gradual
Acquired
Congenital
Severe
Mild
New problem
Recurrence of old
problem
Painful
Nonpainful
Bilious
Nonbilious
Sharp/Stabbing
Dull/Vague
Illness Script
 Predisposing Conditions
 Age, gender, preceding events
(trauma, viral illness, etc),
medication use, past medical history
(diagnoses, surgeries, etc)
 Pathophysiological Insult
 What is physically happening in the
body, organisms involved, etc.
 Clinical Manifestations
 Signs and symptoms
 Labs and imaging
Predisposing Conditions
 Incidence: 35-40/1000 in <5yo, 7/1000 in older
children and adolescents
 Boys > girls
 List 2 environmental risk factors for PNA
Lower socioeconomic status
 Smoke exposure-cigarette smoke or wood smoke
 Cold weather
 Alcohol

 Question
 B….aspiration
Predisposing Conditions
 Name 4 medical conditions that increase PNA risk
 Medical history
 Sickle
cell
 BPD
 GERD
 Cystic
Fibrosis
 Heart disease
 Immunodeficiency

Increased aspiration
 Neuromuscular
disorder
 Seizure disorder
 Question
 E. Viral agents are the most common cause of PNA in

infants and young children
Pathophysiology
 What method of transmission is reponsible for the
spread of PNA?

Spread by droplets
 Typically follows URI
 Mechanism
 Colonization of nasopharynx with further inhalation of

microorganisms, leading to a pulmonary focus of

infection
 Less commonly…bacteremia results from the initial upper

airway colonization with subsequent seeding of lungs
Pathophysiology
 What is the most common organism causing bacterial
PNA?

Streptococcus pneumonia
 What are 3 additional pathogens that cause bacterial
PNA?

S. aureus, Group A Strep, GNR (<3mo), anaerobes
 6 week old, afebrile infant with tachypnea, cough, and
CXR showing interstitial changes?

Chlamydia pneumoniae
 What are 2 viral causes of PNA?

RSV, Parainfluenza, Influenza, Metapneumovirus, etc.
Pathophysiology
 Question
 C. Mycoplasma pneumoniae
 Microbiology of PNA
changes based on the age
of the patient, and this
should be kept in mind
when making management
decisions!
Clinical Manifestations
Bacterial PNA
 Abrupt onset
 High fever
 Cough

Sometimes productive
 Focal findings on lung exam
 Crackles
 Diminished breath sounds
 Bronchial breath sounds
 Egophany
 Toxic appearance
 Respiratory distress
 Tachypnea (most sensitive/specific)
 Retractions
 Nasal Flaring
 Grunting
 Hypoxia
 Chest pain
 Emesis and abdominal pain
Clinical Manifestations
Atypical PNA
 School age or older
 Constitutional symptoms
Fever
 Malaise
 Myalgias
 Headache

 Gradual development of dry cough later in the illness as
other symptoms improve
Clinical Manifestations
Bacterial
Atypical
Tuberculosis
Clinical Manifestations
 Question

C. Development of an empyema
 Name 3 possible complications of pneumonia
Lung abscess
 Pleural effusion
 Empyema
 Necrotizing pneumonia
 Pneumothorax
 Sepsis
 Bronchopulmonary fistula
 Pneumatoceles

Complications
 Lung abscess
 Often develop following aspiration
 Thick-walled cavity with

air/fluid level
 TB should be considered
 Needle aspiration for culture
 Necrotizing pneumonia
 Rare complication of bact PNA
 Liquefaction/necrosis caused by

toxins of virulent organisms
 VERY ill
 IV abx for at least 4 weeks
Complications
 Sterile para-pneumonic effusion
 Purulent effusions with resultant empyema
 Persistent fever, ill-appearing, tachypnea, increased WOB,

chest pain and splinting
 Dullness to percussion/decreased air entry
 CXR with decubitus, US, CT
Treatment
 Question

C. Outpatient treatment with high dose Amoxicillin
 Outpatient therapy (7-10days total)


First line: High dose Amoxicillin at 80-100mg/kg/day
Penicillin allergy?
Cephalosporin (non-type 1)
 Clindamycin/Azithromycin (type 1 allergy)



Atypical organisms: Azithromycin x 5 days
Aspiration PNA: Augmentin or Clindamycin
 Inpatient therapy (duration varies)


Ceftriaxone or Ampicillin
More extensive disease/failed treatment


Vancomycin, Clindamycin
Azithromycin (adjunctive coverage sometime given)
Treatment
Admission
 Criteria for admission





<3 months
Respiratory distress
Hypoxemia
Dehydrated
Highly febrile/toxic
Underlying disease
 Testing (once admitted)
 CBC
 Blood culture
 CXR
 +/- Sputum culture
Treatment
 Tests to consider for patient who is not improving clinically?

Bronchoscopy, lung aspiration, open lung biopsy
 MORE CONTENT SPECS 

Recurrent PNA: >1 episode/year, >3 episodes in lifetime
Anatomic lesions: vascular rings, cysts, pulmonary sequestration
 Respiratory tract disorders: CF, GERD, aspiration
 Immunodeficiency: HIV, CGD, hypogammaglobulinemia
 **REFER if documented




Congenital lesions of the lung (CCAM, sequestration, etc) can
mimic PNA
Prevention of PNA
Good handwashing, personal respiratory hygeine, proper

immunization, breastfeeding, limiting sick contacts, decrease

smoke exposure

Thanks!!
Almost every content spec 

“Pneumonia.” Pediatrics in Review. 2008, volume 29,
p147
Class Housestaff Today!
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2nd years – Board Room A
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 He’s headed to Indonesia on a medical service trip!!!