Recurrent pneumonia (RP) is defined as at least 2 pneumonia episodes in a 1-year period or at least 3 episodes at any time, without any clinical symptoms and chest X-ray lesions between pneumonia episodes. It is up to 9% of children with pneumonia will progress to RP. In which, more than 80% of children have an underlying illness. However, to the best of our knowledge, the data on recurrent pneumonia is still insufficient, especially in developing countries.

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Recurrent Pneumonia
Pediatric Symposium
Bach Mai Hospital
November 9, 2018

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Disclosures
• No financial disclosures.
• No off-label use.

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Objectives
• At the end of this presentation, participants will
be able to…
• Include two new questions in their history for
recurrent pneumonia.
• Consider five questions to help focus the
differential.
• Broaden their differential for unilobar and
multi-lobar recurrent pneumonia.

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Outline
• Pneumonia
• Recurrent Pneumonia
• Differential

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Pneumonia – Defense Mechanisms

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Pneumonia
• Defense mechanism breaks down
• Foreign materials and infectious agents reach
the lower airways
• Body responds with secretions and alveolar
fluid, then infiltration of leukocytes
• Pulmonary consolidation and hypoxemia from
ventilation-perfusion mismatch

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Recurrent Pneumonia
• ≥ 2 episodes in a single year
• ≥ 3 episodes ever

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Presentation
• Cough
• Tachypnea
• Dyspnea
• Fever
• Decreased appetite

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History
• Perinatal events
• Premature, intubated, meconium timing
• Feeding difficulties
• Exposures
• Allergens, toxins, pollutants, tobacco smoke,
respiratory infections
• Vaccination status?

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History
• Pattern of previous infections?
• Nocturnal cough?
• Persistent diarrhea? Skin infections? Abscess?
• Meds: Immunosuppressant or steroids?

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History
• Family history
• Asthma, allergies, recurrent infections

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Physical Exam

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Questions
• Does the child have recurrent respiratory tract
infections?
• Are the recurrent respiratory tract infections based in
upper or lower airways?
• Is there any involvement of other organ systems?
• Are the frequency and severity of recurrent lower
respiratory tract infections sufficient to warrant
additional investigations?
• Where in the lung(s) does each episode take place, and
how does this help to plan further investigations?

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Differential

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Recurrent
pneumonia
Unilobar Multi-lobar

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Unilobar
Intraluminal
Obstruction
Extraluminal
Compression
Anatomic
Abnormalities

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f
• Retained foreign body
• Mucoid impaction
• Bronchomalacia or stenosis
• Bronchial adenoma
Intraluminal
Obstruction
Extraluminal
Compression
Anatomic
Abnormalities

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C
• Enlarged lymph nodes
• Infection, lymphoma
• Enlarged or aberrant vessels
• Parenchymal tumors
• Cardiac enlargement
Intraluminal
Obstruction
Extraluminal
Compression
Anatomic
Abnormalities

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• Airway
• Localized bronchial stenosis
• Bronchomalacia
• Isolated areas of bronchiectasis
• Parenchyma
• Pulmonary sequestration
• Congenital cystic adenomatoid malformation
• Bronchogenic cysts
Intraluminal
Obstruction
Extraluminal
Compression
Anatomic
Abnormalities

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Unilobar
Bronchoscopy
Chest CT
(MRI,
angiography)
If not diagnostic...

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Multi-lobar
Aspiration
Asthma
Cystic
Fibrosis
Ciliary
Dyskinesia
Immuno-
deficiency
Other

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• Diffuse wheezing
• Fever (Viral URI)
• Atelectasis --> opacities
• Pulmonary function tests
Multi-lobar Asthma
Aspiration
Cystic
Fibrosis
Ciliary
Dyskinesia
Immuno-
deficiency
Other

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• Abnormal swallowing
• Gastroesophageal reflux
• TE fistula
• Cleft palate
• Video swallow study
• Impedance probe
• BAL (lipid-laden macrophages)
Multi-lobar Asthma
Aspiration
Cystic
Fibrosis
Ciliary
Dyskinesia
Immuno-
deficiency
Other

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• Delayed meconium
• Steatorrhea
• Poor weight gain
• Stasis of secretions
• Sweat test
• Genetic tests
Multi-lobar Asthma
Aspiration
Cystic
Fibrosis
Ciliary
Dyskinesia
Immuno-
deficiency
Other

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• Ciliary dysfunction
• Difficulty mobilizing secretions
• Nasal ciliary biopsy
Multi-lobar Asthma
Aspiration
Cystic
Fibrosis
Ciliary
Dyskinesia
Immuno-
deficiency
Other

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• Unusual/prolonged infections
• Recurrent skin infections
• Failure to thrive
• Family History
Multi-lobar Asthma
Aspiration
Cystic
Fibrosis
Ciliary
Dyskinesia
Immuno-
deficiency
Other

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• Congenital Heart Disease
• Sickle Cell Disease
Multi-lobar Asthma
Aspiration
Cystic
Fibrosis
Ciliary
Dyskinesia
Immuno-
deficiency
Other

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Objectives
• At the end of this presentation, participants will
be able to…
• Include two new questions in their history for
recurrent pneumonia.
• Consider five questions to help focus the
differential.
• Broaden their differential for unilobar and
multi-lobar recurrent pneumonia.

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Questions & Discussion

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References
• Gereige R, Laufer PM. Pneumonia. Pediatrics in Review. 2013;134(10):438-56.
• Owayed A, Campbell D, Wang E. Underlying Causes of Recurrent Pneumonia in
Children. Arch Pediatr Adolesc Med. 2000;154:190-194.
• Patria MF, Esposito S. Paediatric Respiratory Reviews. 2013;13:53-60.
• Sheares B. Recurrent Pneumonia in Children. Pediatr Ann. 2002;312):109-14.
• Yousif TI, Elnazir B. Approach to a child with recurrent pneumonia. Sudan J
Paediatr. 2015;15(2): 71-77.