I is slide prepared for medical students

1. PNEUMONIA
BY Dr. BIRHANU A.

2. OUTLINES
• OBJECTIVES
• PNEUMONIA
– Ethiology,
– Epidemiology,
– C/Manifestation,
– Pathogenesis,
– Diagnosis And
– Management

3. Objectives
• At the end of this lecture you should
understand the etiology, epidemiology,
pathogenesis, c/manifestation, diagnosis and
management of pneumonia in children.

4. Pneumonia
• Is inflammation of the lung parenchyma
• Etiology
– Infectious
– Noninfectious and aspiration
– Hypersensitivity and reaction
– Drugs or radiation-induced pneumonitis

5. Bacteria
• S.pnuemonia-commonest 3wk-4yr
• C.pneumoniaeand M.pnuemoniae-
commonest above ≥5years of age
• S.aureus-commonest after influenza viruse
• S.pyogenes

6. Conti……….
AGE GROUP FREQUENT PATHOGENS (IN ORDER OF FREQUENCY)
Neonates (<3 wk) GBS, E.coli, other Gram-negative bacilli, S.pneumoniae,
H.influenzae (type b, nontypeable)
3 wk-3 mo RSV, other respiratory viruses (rhinoviruses, parainfluenza
viruses, influenza viruses, human metapneumovirus,
adenovirus), S. pneumoniae, H. influenzae (type b,
nontypeable); if patient is afebrile, consider C. trachomatis
4 mo-4yr RSV, other respiratory viruses (rhinoviruses, parainfluenza
viruses, influenza viruses, human metapneumovirus,
adenovirus), S. pneumoniae, H. influenzae (type b,
nontypeable), M.pneumoniae, group A streptococcus
≥5 yr M. pneumoniae, S. pneumoniae, C.pneumoniae, H. influenzae
(type b,* nontypeable), influenza viruses, adenovirus, other
respiratory viruses

7. • S. pneumoniae, H. influenzae, and S. aureus
are the major causes of hospitalization and
death from bacterial pneumonia.
• The incidence of pneumonia caused by H.
influenzae or S.pneumoniae has been
significantly reduced in areas where routine
immunization has been implemented.

8. EPIDEMIOLOGY
• Is the leading infectious cause of death globally
• Among children younger than 5 yr, accounting for
an estimated 920,000 deaths each year.
• Pneumonia mortality is closely linked to poverty.
• More than 99% of pneumonia deaths are in low-
and middle-income countries.
• The highest pneumonia mortality rate occurring
in poorly developed countries.

10. PATHOGENESIS
• Defence mechanisms of respiratory tract
– Mucociliary clearance
– Macrophages
– Secretory immunoglobulin A
– Coughing refelex

11. Viral pneumonia
• Usually results from spread of infection along the
airways.
• Then causes a direct injury of the respiratory
epithelium.
• Airway obstruction occurs from swelling, abnormal
secretions, and cellular debris.
• The small caliber of airways in young infants makes
such patients particularly susceptible to severe
infection.
• Atelectasis, interstitial edema, and hypoxemia from
ventilation–perfusion mismatch often accompany
airway obstruction.

12. • Viral infection of the respiratory tract can also
predispose to secondary bacterial infection by
– Disturbing normal host defence mechanisms
– Altering secretions
– Through disruptions in the respiratory microbiota.

13. Bacterial pneumonia
• Most often occurs when respiratory tract
organisms colonize the trachea and
subsequently gain access to the lungs
• Pneumonia may also result from direct
seeding of lung tissue after bacteremia.
• When bacterial infection is established in the
lung parenchyma, the pathologic process
varies according to the invading organism.

14. M. pneumoniae
• Attaches to the respiratory epithelium, inhibits ciliary
action, and leads to cellular destruction and an
inflammatory response in the submucosa.
• As the infection progresses, sloughed cellular debris,
inflammatory cells, and mucus cause airway obstruction,
with spread of infection occurring along the bronchial tree,
as is seen in viral pneumonia.
S. pneumoniae
• produces local edema that aids in the proliferation of
organisms and their spread into adjacent portions of lung,
often resulting in the characteristic focal lobar involvement.

15. Group A streptococcus
• Lower respiratory tract infection typically results
in more diffuse lung involvement with interstitial
pneumonia.
• The pathology includes
– Necrosis of tracheobronchial mucosa
– Formation of large amounts of exudate
– Edema and local hemorrhage, with extension into the
interalveolar septa; and involvement of lymphatic
vessels with frequent pleural involvement.

16. S. aureus pneumonia
• Manifests as confluent bronchopneumonia,
often unilateral and characterized by
– the presence of extensive areas of hemorrhagic
necrosis and irregular areas of cavitation of the
lung parenchyma, resulting in pneumatoceles,
empyema, and bronchopulmonary fistulas.

17. Recurrent pneumonia
• Is defined as 2 or more episodes in a single
year or 3 or more episodes ever, with
radiographic clearing between occurrences.
• An underlying disorder should be considered if
a child experiences recurrent pneumonia.
• Differential diagnosis of recurrent pneumonia
are the following

18. HEREDITARY DISORDERS
– Cystic fibrosis
– Sickle cell disease
DISORDERS OF IMMUNITY
– HIV/AIDS
– Primary immunodeficiencies

19. DISORDERS OF CILIA
– Primary ciliary dyskinesia
– Kartagener syndrome
ANATOMIC DISORDERS
– Pulmonary sequestration
– Lobar emphysema
– Congenital cystic adenomatoid malformation
– Gastroesophageal reflux
– Foreign body aspiration
– Tracheoesophageal fistula (H type)
– Bronchiectasis
– Aspiration (oropharyngeal incoordination)
– Aberrant bronchus

20. CLASSIFICATION
Criteria used for classification
• Etiologic
• Anatomic
• severity

21. Anatomic
• Lobar
• Bronchial
• interstitial
Severity
• Sever pneumonia
• Pneumonia
• No pneumonia
Ethiology
• Viral
• Bacterial
• Fungal

22. COMPLICATIONS
LOCAL COMPLICATIONS
• Pleural effusion,
• empyema, abscess,
• Bronchopleural fistula,
• Necrotizing pneumonia,
acute
• Acute respiratory
distress syndrome
• Respiratory failure
DISTANT COMPLICATIONS
• Meningitis
• Arthritis
• Pericarditis
• Osteomyelitis
• Endocarditis
• Haemolytic uremic
syndrome
• Sepsis

23. Clinical Manifestations
• Frequently preceded by several day symptoms of URTI
• Cough: chief symptom
• Increased respiratory rate:
– > 60/minute infants younger than 2 months old
– >50/minute infants 2-12 months old
– > 40/minute children 1-5 years old
• Grunting (keeps narrow airways open)
• Sign of severe distress and impending respiratory
failure
• Nasal flaring (air hunger)

24. • In infants
– vomiting, anorexia, diarrhea, and abdominal
distention secondary to a paralytic ileus.
– may have a prodrome of URTI and poor feeding,
leading to the abrupt onset of fever, restlessness,
apprehension, and respiratory distress.
• In older children sudden onset high fever,
cough, and chest pain may presentation.

25. • Retractions: intercostal, supraclavicular,
subcostal
• Increased effort to breathe, decreased lung
compliance
• Hypoxemia: normal >95%
• Fever

26. Diagnosis
• Chet x-ray
• Chest U/S
• CBC
• ESR/CRP
• PCR
• Blood culture (fail to improve, have clinical
deterioration, complicated pneumonia, or require
hospitalization)
• ASO and anti-DNase B titers

27. MANAGEMENT
• INDICATION FOR ADMISSION
– Age <6 mo
– Immunocompromised state
– Toxic appearance
– Moderate to severe respiratory distress
– Hypoxemia (oxygen saturation <90% breathing room air, sea level)
– Complicated pneumonia
– Sickle cell anemia with acute chest syndrome
– Vomiting or inability to tolerate oral fluids or medications
– Severe dehydration
– No response to appropriate oral antibiotic therapy
– Social factors (e.g., inability of caregivers to administer medications at
home or follow-up appropriately)

28. 1. Oxygen Therapy: IN o2, CPAP, MV
2. Fluid Therapy: MF, dehydration mgt.
3. Antipyretics: paracetamol
4. Antibiotics
5. Oral Zinc for 7days

29. ANTIBIOTICS
• Empiric antibiotic choice for hospitalised
suspected pneumonia patient depends on
– local epidemiology,
– the immunization status of the child, and
– the clinical manifestations at the time of
presentation

30. Ampicillin or penicillin G for inpatient
GIVEN
– without substantial high-level penicillin resistance for
s.pneumoniae
– Fully immunized for H.influenzae type b and
s.pneumoniae
– Not severely ill child
– Ceftriaxone or cefotaxime can be given for those that
don’t fulfil the above criteria.
– Total duration continued upto 10days

31. • Outpatient
– High dose amoxacillin
– Macrolides for pencillin allegy and suspected
antipical bacteria
– Total duration 5-7days if azithromycin for 5days

32. PROGNOSIS
• Tachycardia and hypotension- Within two days
• Fever, tachypnea, chest and arterial
oxygenation (PaO2)- Within three days
• Cough and fatigue- ≥14 days
• Radiographic improvement up to 1month

33. PREVENTION
• Vaccination that prevent pneumonia are
– PCV
– Influenza vaccine
– H.influenza type b vaccine
– Pertussis vaccine
– Measles vaccine
– RSV vaccine