Morning ReportJuly 23, 2013

Good Morning

Symptoms

Acute /subacute Chronic

Localized Diffuse

Single Multiple

Static Progressive

Constant Intermittent

Single Episode Recurrent

Abrupt Gradual

Severe Mild

Painful Nonpainful

Bilious Nonbilious

Sharp/Stabbing Dull/Vague

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem

Systemic problem

Acquired Congenital

New problem Recurrence of old problem

Semantic Qualifiers

Illness Script

Predisposing Conditions Age, gender, preceding events

(trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)

Pathophysiological Insult What is physically happening in

the body, organisms involved, etc.

Clinical Manifestations Signs and symptoms Labs and imaging

Predisposing Conditions

Incidence: 35-40/1000 in <5yo, 7/1000 in older children and adolescents

Boys > girlsList 2 environmental risk factors for PNA

Lower socioeconomic status Smoke exposure-cigarette smoke or wood smoke Cold weather Alcohol

Question B….aspiration

Predisposing Conditions

Name 4 medical conditions that increase PNA risk Medical history

Sickle cell BPD GERD Cystic Fibrosis Heart disease Immunodeficiency

Increased aspiration Neuromuscular disorder Seizure disorder

Question E. Viral agents are the most common cause of PNA

in infants and young children

Pathophysiology

What method of transmission is reponsible for the spread of PNA? Spread by droplets

Typically follows URI

Mechanism Colonization of nasopharynx with further inhalation

of microorganisms, leading to a pulmonary focus of infection Less commonly…bacteremia results from the initial

upper airway colonization with subsequent seeding of

lungs

Pathophysiology

What is the most common organism causing bacterial PNA? Streptococcus pneumonia

What are 3 additional pathogens that cause bacterial PNA? S. aureus, Group A Strep, GNR (<3mo),

anaerobes6 week old, afebrile infant with tachypnea,

cough, and CXR showing interstitial changes? Chlamydia pneumoniae

What are 2 viral causes of PNA? RSV, Parainfluenza, Influenza, Metapneumovirus,

etc.

Pathophysiology

Question C. Mycoplasma

pneumoniae

Microbiology of PNA changes based on the age of the patient, and this should be kept in mind when making management decisions!

Clinical Manifestations

Bacterial PNAAbrupt onsetHigh feverCough

Sometimes productiveToxic appearanceRespiratory distress

Tachypnea (most sensitive/specific) Retractions Nasal Flaring Grunting Hypoxia

Chest painEmesis and abdominal pain

Focal findings on lung exam Crackles Diminished breath sounds Bronchial breath sounds Egophany

Clinical Manifestations

Atypical PNASchool age or olderConstitutional symptoms

Fever Malaise Myalgias Headache

Gradual development of dry cough later in the illness as other symptoms improve

Clinical Manifestations

Bacterial Atypical Tuberculosis

Clinical Manifestations

Question C. Development of an empyema

Name 3 possible complications of pneumonia Lung abscess Pleural effusion Empyema Necrotizing pneumonia Pneumothorax Sepsis Bronchopulmonary fistula Pneumatoceles

Complications

Lung abscess Often develop following aspiration Thick-walled cavity with air/fluid level TB should be considered Needle aspiration for culture

Necrotizing pneumonia Rare complication of bact PNA Liquefaction/necrosis caused by toxins of virulent organisms VERY ill IV abx for at least 4 weeks

Complications

Sterile para-pneumonic effusionPurulent effusions with resultant empyema

Persistent fever, ill-appearing, tachypnea, increased WOB,

chest pain and splinting Dullness to percussion/decreased air entry

CXR with decubitus, US, CT

Treatment

Question C. Outpatient treatment with high dose Amoxicillin

Outpatient therapy (7-10days total) First line: High dose Amoxicillin at 80-100mg/kg/day Penicillin allergy?

Cephalosporin (non-type 1) Clindamycin/Azithromycin (type 1 allergy)

Atypical organisms: Azithromycin x 5 days Aspiration PNA: Augmentin or Clindamycin

Inpatient therapy (duration varies) Ceftriaxone or Ampicillin More extensive disease/failed treatment

Vancomycin, Clindamycin Azithromycin (adjunctive coverage sometime given)

Treatment

Admission

Criteria for admission <3 months Respiratory distress Hypoxemia Dehydrated Highly febrile/toxic

Underlying diseaseTesting (once admitted)

CBC Blood culture CXR +/- Sputum culture

Treatment

Tests to consider for patient who is not improving clinically? Bronchoscopy, lung aspiration, open lung biopsy

MORE CONTENT SPECS Recurrent PNA: >1 episode/year, >3 episodes in lifetime

Anatomic lesions: vascular rings, cysts, pulmonary sequestration

Respiratory tract disorders: CF, GERD, aspiration Immunodeficiency: HIV, CGD, hypogammaglobulinemia **REFER if documented

Congenital lesions of the lung (CCAM, sequestration, etc) can

mimic PNA Prevention of PNA

Good handwashing, personal respiratory hygeine, proper immunization, breastfeeding, limiting sick contacts,

decrease smoke exposure

Thanks!!

Almost every content spec “Pneumonia.” Pediatrics in Review. 2008, volume

29, p147

Class Housestaff Today!1st years – Board Room B2nd years – Board Room A

3rd years – 2 center

Bon Voyage Rocky!

He’s headed to Indonesia on a medical service trip!!!