Pneumonia

Presented By:
Dr Aakrit Dahal
Intern, Shree Birendra Hospital
Department of Paediatrics
 Contents
Quiz
Definition
Epidemology
Classification
Etiology
Pathogenesis
Clinical feature
Diagnosis
Treatment
Prognosis
Complication
Prevention
 Quiz 1
What illness is the number one killer of children?

• A. Diarrheal Disease
• B. HIV/AIDS
• C. Malaria
• D. Pneumonia
 Quiz 2
What is the most sensitive and specific sign of pneumonia in children?

• A. Difficulty breathing
• B. Fever
• C. Tachypnea
• D. Tachycardia
 Quiz 3
If available, a chest x-ray should be done for children with possible
pneumonia:

• A. When a diagnosis is made

• B. When a history of tachypnea is present
• C. When antibiotics are started
• D. When complications are suspected
 Quiz 4
Which of the following immunization effectively reduce pneumonia mortality in
children?

• A. Haemophilus influenzae b Vaccine

• B. Pneumococcal Conjugate Vaccine
• C. Measles Vaccine
• D. All of the above
Definition
• Pneumonia is defined as inflammation of Lung Parenchyma
Epidemiology
• Incidence of Pneumonia

is 10 fold higher and

death from pneumonia is 2000 fold more in developing country then
in developed countries

• Incidence has decreased in recent few years due to Antibiotic and

vaccine
Types of Pneumonia
• 1.Anatomical Basis
• 2.Etiological basis
• 3.Clinical Basis
Anatomical Basis
Etiological causes (infectious)

1. Bacteria
2. Virus
3. Fungal
4. Rickettsial
5. Mycobacterial
6. Parasitic
Non Infectious Causes
1. Aspiration(food,foreign bodies,Hydrocarbons and gastric content)
2. Hypersensitivity
3. Drug/Radiation induced Pnemonitis
Clinically
• 1.Community Acquired Pneumonia
• 2.Hospital Acquired Pneumonia
Do all children acquire Pneumonia???
Risk Factor
1. Low Birthweight
2. Malnutrition
3. Vitamin A Deficiency
4. Lack of Breast Feeding
5. Large family
6. Advance birth order
7. Overcrowding
8. Air pollution
9. Passive Smoking
Mode of transmission

1. Droplet Nuclei
2. Nosocomial
3. Endogenous
4. Blood Borne
Pathogenesis

1.Loss/Suppression of Cough
reflex
2.Injury to Muco-ciliary
Apparatus
3.Accumulation of Secretion
4.Interferance with Action of
alveolar macrophage
5.Pulmonary Congestion
 Clinical Feature
1. Preceded by URTI(rhinitis and cough)
2. Fever(Higher in Bacterial than viral)
3. Tachypnea
4. Cough
5. Dyspnea
6. Chest pain
7. Cyanosis and lethargy (in infants with severe infection)
8. Signs of Respiratory Distress
• In Viral Pneumonia, Low grade fever is usually present ,along with
other feature of respiratory Distress:

1. Tachypnea
2. Increased work of breathing evident by intercostal,subcoastal,and
suprasternal retratction,nasal flaring and use of accessory muscle
3. Cyanosis and lethargy in case of severe infection
4. Hyper resonant with crackles and wheezing
 Clinical Feature
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 sign of respiratory distress
• Tachypnea
• Grunting
• Nasal flaring
• Retraction of the supraclavicular, intercoastal and subcoastal area
• Cyanosis
 Infant Presenting Complain

1. Prodrome of upper respiratory tract infection

2. Diminished appetite,
3. Abrupt onset of fever,
4. Restlessness, apprehension, and respiratory distress.
5. Ill looking,
6. Respiratory distress manifested as (grunting; nasalflaring;
retractions of the supraclavicular, intercostal, and subcostal)
7. Tachypnea; Tachycardia; air hunger; and often cyanosis.
Physical signs
• Decreased breath sound
• Crackles
• Lag in respiratory excursion in affected side
• If complication: Dull on percussion
• Abdominal distention
• Abdominal pain (common in lower lobe pneumonia)
Sign of pneumonia -Indrawing

out---breathing---in
Lower chest wall indrawing: with inspiration,
the lower chest wall moves in
 Sign of pneumonia - Nasal Flare

Nasal flaring: with inspiration, the side of the

nostrils flares outwards
Diagnosis
1. Clinically
2. CBC
3. Acute Phase Reactants(ESR,CRP)
4. Chest X-ray
5. USG
6. Test for Viral Pneumonia
7. Blood culture
8. Test for Mycoplasma(Cold Agglutinin,PCR)
Clinically
Bacterial etiology is suspected when

1.High fever
2.Lobal consolidation
3.Pleural effusion
Complete Blood Count

• In Viral Pneumonia is normal or elevated but usually not higher

than 20,000/mm3,with a lymphocyte predominance

• In Bacterial Pneumonia: WBC count range of 15,000-40,000/mm3,

and a predominance of Granulocyte
Acute Phase Reactants
1. ESR,CRP
2. Raised in case of Pneumonia
3. Higher in bacterial, normal or slightly raised in viral Pneumonia
Chest X-ray
1.Viral Pneumonia:
 Peri-bronchial cuffing
 Bilateral interstitial infiltrates

2.Pneumococaal Pneumonia: Lobar consolidation

3.Stapylococcal Pneumonia: Pneumatocele

Viral Pneumonia
Pneumococcal Pneumonia
IS USG HELPFUL???
USG
• Portable or handheld ultrasonography is Highly Sensitive and
Specific in diagnosing Pneumonia in children.

• USG may shows lung consolidation or effusion

Viral Pneumonia
• Viral isolation, antigen detection, or detection of Viral Genome

• Rapid DNA,RNA test are available and are reliable

• Serological technique can be applied by but not usually done

• Peripheral cell gene expression pattern by microarray RT-PCR is

Emerging modality
Blood Culture
1. Its only positive in 10 percent of patient
2. Usually not done
3. Done in case of complicated pneumonia
Test for Mycoplasma
• Cold agglutinins Titers> 1:64 is found in 50 % of patient infected
with M pneumoniae
• PCR is also positive
Treatment
Treatment is based of

1. Presumptive cause.
2. Age
3. Clinical appearance of children
• For Mildly ill Children who doesn’t require Hospitalization

• Amoxicillin is prescribed(high dose of 80-90 mg/kg/24 hour)

• Therapeutic alternatives include Cefuroxime Axetil and
Amoxycillin/clavulanate

• For school going children and children suspected with M pneumoniae

and C pneumoniae , Macrolide antibiotic is prescribed(Azithromycin)

In adolescent respiratory fluoroquinolones(Levofloxacin, Moxifloxacin)

How long should the Antibiotic be used???
Duration of therapy
• Not well established

• However, it is generally continued until the patient has been afebrile

for 72 hours and the total duration should not be less than 10 days(5
days for azithromycin)

• Shorter course(5-7days) ,especially in patient treated on out patient

basis can be used
Should all children with Pneumonia be Admitted ???
Criterial for Hospital Admission
Treatment after Hospital Admission
• 1.Oxygen Therapy
• 2.Fluids and ensuring of hydration
• 3.Antipyretics/Analgesic
• 4.Antibiotic
 Hospital Treatment
• Empirical treatment of Suspected bacterial Pneumonia in Hospitalized
patient. The following criteria should be considered

1. Without substantial high level of penicillin resistance among S

pneumoniae
2. Immunization against H influenzae type b and S pnemoniae
3. Not severely ill

• If Above criteria meet: Ampicillin or penicillin G

• If criteria Don’t meet: Cefotaxime or Ceftriaxone should be used
• If clinical feature suggest Staphylococcal pneumonia (Empyema,
Pneumatocele) initial therapy should contain vancomycin or
clindamycin
If VIRAL pneumonia is suspected:
It is reasonable to withheld Antibiotic if
1. Mild illness
2. Without respiratory distress

However 30% of viral Pneumonia coexist with superimposed

bacterial infection; and which can be suspected by rapid clinical
deteriorating such same Antibiotic therapy should begun
Role of Zinc
• Oral Zinc (10mg if <12 month and 20mg >= 12 month) reduces the
mortality
Prognosis
• Uncomplicated Pneumonia respond in 48-96 hours after initiation of
Antibiotic therapy(clinically)

• Radiological Evidence of improvement lags substantially behind

clinical improvement

• 45% hospitalized patient of pneumonia develops Bronchial Asthma

after 5 years
Prognostic Factors
• 8 years old child with a diagnosis of Pneumonia was kept of oral
Amoxycillin with Clavulanic Acid for 4 days, however the
patient didn’t improve.

WHAT MAY BE THE POSSIBLE CAUSES??

Prognosis
1. Complication
2. Bacterial resistance
3. Non bacterial etiology
4. Bronchial Obstruction
5. Pre-existing disease
6. Non infective causes
Complication
• Pleural effusion
• Empyema
• Lung Abscess
• Bronchopleural fistula
• Necrotizing pneumonia
• ARDS
• Extra Pulmonary Complication
• (Meningitis,Artharitis,Pericarditis,Osteomyelitis,Endocarditis)
• Sepsis
Recurrent Pneumonia
• 2 or more Episodes in a single year
OR
• 3 or more episode ever with radiographical clearing between
occurrences
Causes
1. Hereditary: Cystic Fibrosis ,Sickle cell disease
2. Disorder of Immunity: HIV/AIDS, Chronic Granulomatous
disease. Selective IG deficiency, Leucocyte Adhesion defect
3. Disorder or Cilia: Kartagener syndrome/Immotile cilia syndrome
4. Anatomical Disorder: Pulmonary Sequestration, Lobar emphysema,
GERD, TEF, Bronchiectasis
Prevention
1. Exclusive breast feeding upto 6 month
2. Immunization against with Hib,PCV,Measeles
3. Adequate Nutrition
4. Handwashing,safe drinking water and prevention of diarrhea
5. Avoidance of parenteral smoking
6. Free from indoor air pollution
7. Zinc Supplementation
 Quiz 1
What illness is the number one killer of children?

• A. Diarrheal Disease
• B. HIV/AIDS
• C. Malaria
• D. Pneumonia
 Quiz 2
What is the most sensitive and specific sign of pneumonia in children?

• A. Difficulty breathing
• B. Fever
• C. Tachypnea
• D. Tachycardia
 Quiz 3
If available, a chest x-ray should be done for children with possible
pneumonia:

• A. When a diagnosis is made

• B. When a history of tachypnea is present
• C. When antibiotics are started
• D. When complications are suspected
 Quiz 4
Which of the following immunization effectively reduce pneumonia mortality in
children?

• A. Haemophilus influenzae b Vaccine

• B. Pneumococcal Conjugate Vaccine
• C. Measles Vaccine
• D. All of the above
Reference
• 1.Ghai Essential Pediatrics 8th Edition
• 2.Neelson Textbook of Pediatrics 20th edition
• 3.Davidson Principles of Medicine 23rd edition
• 4.Robbins Basis of Pathology 8th edition
• 5.Harrison Texbook of Medicine 18th Edition
• 6.WHO manual
Thank You