Jan 18th 2011
A 2year old male came into ED at OSH with a 2
week history of cough, fevers and URI
symptoms . Per Mom, patient had been
diagnosed with the Flu 3 weeks earlier but had
show no improvement. He began to have more
severe and frequent fevers, decreased appetite
and an episode of febrile seizure. At PCP office
patient was febrile with cough, nasal congestion
and malaise with decreased breath sounds over
Right Lung. Mother was instructed to bring him
to the ED with suspected pneumonia. Patient has
no significant past birth or medical history, no
known allergies and Immunizations were up to
date.
Exam
 Admit Vitals: Temp: 100.4
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Pulse: 138
RR: 32
BP: 119/83
Admit PE: Gen- Fever, chills, increased fussiness and
malaise
HEENT: OP clear, TM clear bilat, PERRLA, EOMI,
Rhinorrhea
CV: Tachycardic, Reg Rate, no Murmurs
Resp: ↑WOB, +Rales on L and RLL; ↓BS over RUL.
ABD: SNTND, +BS
Ext: CR< 3 sec, +2DP at bilateral UE and LE
Labs
 Labs: CBC, UA, Blood and Urine Cultures, Continuous Pulse
Ox
 Radiology: CXR A-p and Lateral
Admit CXR A-P 1/5/2011
MICHAEL BLANCANEAUX
KISHORE GANDLA
ERIC PRICE
HOLLIE STEWART
150 million cases per year
20 million requiring hospitalization
Boys > Girls
Incidence
birth to 5 years old – 40 per 1,000
12 to 15 years old – 7 per 1,000
Mortality
<1 per 1,000 (developed countries)
Barriers
Saliva
Nasal hair
Epiglottis
Cough reflex
Mucociliary apparatus
Humoral immunity
http://doktermudatrader.blogspot.com/2010/05/acute-respiration-infection-in-children.html
Transmission
Transmission
Transmission
Inhalation of aerosolized droplets
Aspiration
Bacteremia seeding lung tissue (rare)
http://nowthatsnifty.blogspot.com/2009/12/12-people-sneezing-in-slowmo.html
Deficits in Host Resistance
Compromised immune system
preceding URI, neutropenia,
HIV/AIDS
Excessive secretions
Anatomic abnormalities
Overwhelming pathogen load
Virulent pathogen
Acute inflammation
Migration of neutrophils into air spaces
Degradative enzymes
Chromatin meshwork for pathogens
http://www.aurorabaycare.com/health-info/display.aspx?URL=11617.html
Four stage Inflammatory Response
Congestion – Vascular engorgement,
alveolar fluid
Red Hepatization – RBC’s, leukocytes, fibrin
Gray Hepatization – leukocytes, fibrin
Resolution – Enzymatic digestion,
expulsion,
reabsoroption of debri
Clinical features
 Hallmark symptoms
1. Cough
2. Fever

All children who have cough
and fever does not have
Pneumonia.
Clinical features
 Chills
 Malaise
 Pleuritic chest pain
 Retractions
Clinical exam
 Tachypnea is the most sensitive and specific sign
of pneumonia.
 Resp rate
1. >50 (2-12 mo)
2. >40 (1-5 Y)
3. >20 (>5 Y)
(Note: Substract 10 if child is febrile)
Clinical exam
 Important things to assess
1. Temperature
2. Pulse
3. Respiratory rate
4. Pulse oximetry
Clinical exam
 Examine lungs while child is in parents’s arms to
hear better.
 Common signs:
1. Dullness to percussion
2. Crackles
3. Decreased breath sounds
4. Bronchial breath sounds with egophony
Clinical pneumonia syndromes
Labs
 Outpatient- Not usually indicated
 If highly febrile- Blood cx ( 10% +ve)
 If dense consolidation or effusion suspected- CXR
 PPD- In selected patients
Treatment
 Outpatient
 Inpatient
Outpatient Treatment
Antibiotic treatment
 First line: high-dose amoxicillin (age 60 days to 5
years) or azithromycin (Zithromax®) (age 5
years or older)
 Second-line (cephalosporin or macrolide):
ceftriaxone (Rocephin®), cefuroxime (Ceftin®),
cefprozil (Cefzil®), clarithromycin (Biaxin®).
 Combination of macrolide and beta-lactam agent
for severe disease
Duration of therapy
 7-10 days
 If not better in 48-72 hrs, other pathogens or
complications should be considered.
Consolidation: Infection of air spaces (air
bronchograms) and/or interstitium of the lung.
Findings:
Depends upon amount and distribution of
airspaces involved, presents as confluent
parenchymal (lobar or segmental) opacity or
patchy opacity(atypical).
If the Interstitium is predominantly involved, it
may appear as a reticulonodular pattern.
Radiology
Air bronchograms would confirm an alveolar
process
The lung volume should not be lost (may even
be increased).
 **Usually radiographic abnormalities should
disappear after 6 weeks of appropriate
antibiotic therapy but radiographic findings
may trail clinical resolution**
Consolidation Right Upper Lobe / Air Bronchogram
Lobar Pneumonia
Consolidated Pneumonia CT: large left lower lobe pneumonia
with bilateral pleural effusion.
Round Pneumonias are found typically in the child. Most often
the organism is pneumococcus
Atypical pneumonia: Bilateral reticular/nodular interstitial
infiltrates, focal patchy alveolar opacity in the right middle lobe
right upper lobe
Atypical pneumonias frequently caused a centrilobular shadow (64%), an
acinar shadow (71%), and/or airspace consolidation (57%) and ground-glass
attenuation (86%) with a lobular distribution on CT.
Viral pneumonia caused by RSV: Hyperinflation, mild peribronchial cuffing,
increased parahilar markings, and patchy lingular opacity
Pneumonia Complications: Empyema on left
Pneumonia Complications: Lung abcess on left
Inpatient Treatment
 When to hospitalize for PNA
 If patient's have:
 Respiratory distress

Grunt, tachypneic, hypoxemia, increased WOB
 Significant dehydration or risk thereof
 High fever with toxic appearance
 Failed to improve with outpatient treatment
 Developed complications

Effusion
Inpatient Treatment
 When to hospitalize
 Underlying illness that increase risk of decompensation
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Cardiac
Pulmonary
Metabolic
Immunologic
Hematologic
Neoplastic
Inpatient Treatment
 Initial diagnostic workup
 Chest xray shows character and extent
 Blood culture to investigate secondary bacteremia
 CBC can reassure or point to suppurative process
 You can also consier


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Basic/complete metabolic panel
Viral panel
Sputum for gram stain and culture when practicle
Inpatient Treatment
 Supportive care
 Oxygen
 Suctioning
 IVF
 Fever/pain control
 Antibiotic therapy
Inpatient Treatment
 Choice of antibiotic therapy
 For suppurative, empiric treatment with a broad
spectrum, typically IV ceftriaxone or amp, cover
pneumococcus, GAS, and
 Then broaden coverage based on


Failure to improve on empiric coverage
Severity --> vanc or clinda for S. aureus and pneumococcus
and GAS
 Effusion
 Pneumatocele
Inpatient Treatment
 Special considerations
 Macrolide for atypical pneumonia


Azithromycin
Levofloxacin
 Doxycycline
Inpatient Treatment
 Length of Treatment
 7 to 10 days total
 Oral therapy


Clinically stable
Afebrile
 5 days for azithromycin
Complications
 Major suppurative complications
 Parapneumonic effusion
 Lung abscess
 Necrotizing pneumonia
Complications
 Necrotizing pneumonia
 liquefaction and necrosis of lung tissue cause by toxins
 Ill or toxic appearing child
 CXR reveals airspace consolidation with central
cavitation
 Treatment


Vancomycin or clindamycin first-line agents
Organism specific
Complications
 Lung abscess
 Radiographic finding thick-walled cavity with air-fluid
level
 Inciting aspiration event
 Organisms

Mouth flora
 Strep, staph, anaerobes, GNR,
 TB
Complications
 Treatment




Clinda
Needle aspiration
Several weeks IV + PO
CXR
Complication
 Parapneumonic effusion
 Common
 Usually resolve with initially therapy
 Purulent effusion  empyema


Ill-appearing, febrile, tachypneic, in pain
Dullness to percusion and decreased breathsounds
Complications
 Parapneumonic effusion management
 CXR


AP
Lateral decubitus
 Ultrasounography

Location, amount, quality
 CT - may enhance US
 Pleural fluid aspiration
Complications
Send pleural fluid for

Gram stain & cultures

Cell count

PH

Glucose concentration

LDH

Acid fast bacillus and fungal culture
Complications
Surgical intervention controversial
Institutional preference

Medical management alone

Thoracentesis – free flowing fluid

Chest tube

Video assisted thorascopic surgery (VATS) with chest
tube – loculated or purulent

Intrapleural fibrinolytic therapy (less impressive)

thoracotomy
Complications
 Antipyretics/analgesia
 IVF
 CPT contraindicated
 Appropriate antiobiotics
 Poorly defined time interval
Prevention
 Immunization
 Avoid smoke exposure
 Good handwashing
Summary
 PNA less frequent than asthmas and bronchiolitis
 Clinical findings usually sufficient to dx
 Fever, cough, tachypnea, inc WOB, ausculatory findings
 Radiographs and labs not required
 Uncomplicated treated outpatient
 Young patients, severally ill, or if complications, treat
inpatient