Pneumonia
Araya Satdhabudha, MD.
Division of Pediatric Pulmonology & Critical Care
Thammasat University
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
Epidemiology and etiology of childhood pneumonia
World Health Organization
Bulletin of the World Health Organization 2004
Epidemiology : developing countries
In 1998
• 10 million of children < 5 yrs were died each year
– 3 million child died from pneumonia (most from measles,
pertussis)
Recent data
• Pneumonia still cause around 2 million children’s
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
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
ข้อมูลจาก สำนักระบำดวิทยำ กรมควบคุมโรค กระทรวงสำธำรณสุ ข ปี 2548-2553
ข้อมูลจาก สำนักระบำดวิทยำ กรมควบคุมโรค กระทรวงสำธำรณสุ ข ปี 2548-2553
ข้อมูลจาก สำนักระบำดวิทยำ กรมควบคุมโรค กระทรวงสำธำรณสุ ข ปี 2548-2553
ข้อมูลจาก สำนักระบำดวิทยำ กรมควบคุมโรค กระทรวงสำธำรณสุ ข ปี 2548-2553
ข้อมูลจาก สำนักระบำดวิทยำ กรมควบคุมโรค กระทรวงสำธำรณสุ ข ปี 2546-2555
Pneumonia
Bulletin of the World Health Organization 2004
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 <-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
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
Kendig’s Disorders of Resp Tract in Children 2012
JID 2004
N Engl J Med 2002
Clinical evaluation
• Fever
• Cough
• Dyspnea
Atypical pneumonia : may be no fever
May be absent in early stage of LRI
Tachypnea : the most sensitive sign sensitivity 74% specificity 67%
Nasal flaring, Retractions, Chest indrawing
Grunting
: impending respiratory failure
Crepitation
Wheezing
: auscultation may not be present in early pneumonia
Paediatric respiratory reviews 2000
Arch Dis child 2000
WHO’s age - specific criteria for tachypnea
Age < 2 mo : RR > 60/min
Age 2-12 mo : RR > 50/min
Age 1 – 5 yrs : RR > 40/min
Age > 5 yrs : RR > 30/min
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
Investigations
•blood culture in all hospitalized children but low blood
culture yield (< 10%) J Infection 2004; 48: 134-8
•Blood culture in child with high fever or looked sepsis.
BTS
CAPvirus
in children.thorax
2011
NP guidelines
aspirateforfor
in all children
aged < 18 months (highly
specific and sensitive)
J Infection 2004; 48: 134-8.
Investigation for CAP in children
Clinical clue
Labs
 CBC
 ESR
 CRP
 G/S and culture
Chest radiograph
Suggested Dx or interpretation
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; 70:899-908
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 < 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
Suggestive features of bacterial LRI
clinical
CXR
Fever > 38.5○C
•alveolar process,
 abrupt onset
• lobar consolidation
 dyspnea
 crepitation
Kendig and Chernik’s disorders of the respiratory tract in children.2012..
Am Fam Physician 2004; 70:899-908.
Suggestive features of viral LRI
clinical
 CXR
Infants and young children
Hyperinflation
 fever < 38.5○C
 interstitial process
 gradual onset
patchy collapse (25%)
 dyspnea
 crepitation, wheeze
Suggestive features of mycoplasma LRI
clinical
CXR
School aged children
Interstitial infiltrate,
 fever (30%), Cough(90%), rales
(62%), wheeze /rhonchi(36%)
lobar consolidation
and hilar adenopathy
Kendig and Chernik’s disorders of the respiratory tract in children.2012..
Extrapulmonary manifestation
BTS Guideline. Thorax 2011
Am Fam Physician 2004; 70:899-908.
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
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.
Management
Severity assessment
Mild
Infants
 BT
< 38.5 C
RR < 70
 Mild retraction
 Taking full feed

Older
children
BT < 38.5 C
 RR < 50
 Mild
breathlessness
 No vomiting

Severe
BT > 38.5 C
 RR > 70
 Moderate to severe retraction
 Cyanosis, apnea, grunting
 Not feeding

BT > 38.5 C
 RR > 50
 Difficulty breathing
 Nasal flaring, cyanosis, grunting
 Sign of dehydration

BTS guidelines for CAP in children.thorax 2011
Indication for admission
•
•
•
•
•
•
•
•
•
Age < 3 months
Desaturation (SpO2 < 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
Indications for PICU admission
• Require FiO2 > 0.6 to maintain SpO2 > 92%
• Shock
• Sever respiratory distress, exhaustion (rising
RR and PR ± ↑PaCO2)
• Recurrent apnea
• Slow, irregular breathing
BTS guidelines for CAP in children.thorax 2011
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
At hospital
• Oxygen therapy:
– In child with dyspnea, cyanosis, desaturation
– maintain SpO2 > 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
Specific treatment
Clinical Practice Guideline for
Treatment of Childhood Pneumonia
in Thailand
ชมรมโรคระบบหำยใจและเวชบำบัดวิกฤตในเด็ก
พ.ศ. 2555
Mild pneumonia
1-3 mos
3 mo-15 yrs
Amoxycillin/macrolides
amoxycillin
macrolides
Improve
Not improve
Improve
Admit
Continue
ATB 5-7
days
Rx as severe
pneumonia
Continue ATB
7-10 days
Not improve
Improve
Continue ATB
Worse
Worse
Admit Rs as
severe
pneumonia
Not improve
Not worse
- No
complication :
Rx atypical or
DRSP
-complication :
admit
Admit Rx as
severe
pneumonia
Not worse
Rx
complication
Severe
pneumonia
< 1 month
1 mo – 15 yr
Ampicillin or
PGS/ampicillin + aminoglycoside
or 3rd gen cephalosporin
3rd generation cephalosporin if
suspected DRSP
Or cloxacillin if suspected
S.aureus
±macrolide if suspected atypical
pathogen
2 days
Not improve
Improve
Reevaluate
Continue ATB total coruse 7-10 days
CXR
Oral antibiotic for CAP
Intravenous antibiotics for CAP
Antiviral drug
MMWR Jan 2011
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
Thank you for your attention