Pneumonia Araya Satdhabudha, MD. Division of Pediatric Pulmonology & Critical Care Thammasat University

Pneumonia

Araya Satdhabudha, MD.

Division of Pediatric Pulmonology & Critical Care Division of Pediatric Pulmonology & Critical Care

Thammasat University Thammasat University

Epidemiology • Pneumonia is a common problem in children • Particularly in children under 5 years• Incidence 156 million children/year

– 95% in developing country– 7-13% faced with severe pneumonia

• 0.29 episode/child-year in developing country• 0.05 episode/child-year in developed country• Pneumonia is the leading cause of death in

developing country

Bull World Health Organ 2008

Epidemiology and etiology of childhood pneumoniaWorld Health Organization

Bulletin of the World Health Organization 2004

Epidemiology : developing countries In 1998• 10 million of children < 5 yrs were died each year

– 3 million child died from pneumonia (most from measles, pertussis)

Recent data• Pneumonia still cause around 2 million children’s

death annually – About 20% of all child death– 70% in Africa and Asia– Africa and Asia record 2-10 times more children with

pneumonia than in USA

Bull World Health Organ 2008

Epidemiology : Thailand

• 45-50 % of LRTI in children under 5 years are diagnosis as pneumonia

• Pneumonia is the leading cause of death in children under 5 years

• 19% of fatal children are caused by pneumonia (2 million children/year)

J Med Assoc Thai 2002Lancet 2005

ข้�อมู�ลจาก สำ��นั�กระบ�ดวิ�ทย� กรมควิบค�มโรค กระทรวิงสำ�ธ�รณสำ�ข ปี� 2548-2553





Pneumonia

Bulletin of the World Health Organization 2004

Risk factors• Low birth weight (premature, SGA)

– 20% of children born in developing countries have birth weight under 2,500 gm.

• Under- nutrition, hypovitaminosis A, Zinc def.– W/A Z score of <-2 to -3 had 2-3 higher risk of death due to

ALRI (Am J Epidemilo 1996)

• Lack of breastfeeding– Motality rate associated with both ALRI and diarrhoae was

increased 6 times by not breastfeeding

• Air pollution : – Household use of fuels – ETS : RR of 1.2 for ARI in maternal smoking (J Infect Dis 1988)

• Overcrowding : day-care centers Paediatric Respiiratory reviews 2005

Etiology

Age (years) Pathogen

Neonatal period GBS, Gram negative enteric bacteria, CMV, L. monocytogenes

1 mo – 3 mos Virus : RSV, PIFBacterial : S. pneumoniae, H. influenzae, B. pertussis, S. aureus

C. trachomatis 3 mos – 5 yrs Virus : RSV, PIF, influenza, adenovirus, hMPV, rhinovirus

Bacteria: S. pneumoniae, H. influenzae

5 – 15 yrs M. pneumoniae, C. pneumoniae, S. pneumoniae

•15-60% : cannot identify the pathogen

•Age is a good predictor of the likely causative agent

JID 2004Kendig’s Disorders of Resp Tract in Children 2012

N Engl J Med 2002

Clinical evaluation

• Fever• Cough

• Dyspnea

Atypical pneumonia : may be no fever

Tachypnea

Nasal flaring, Retractions, Chest indrawing

Grunting

Crepitation

Wheezing

May be absent in early stage of LRI

: the most sensitive sign sensitivity 74% specificity 67%

: impending respiratory failure

: auscultation may not be present in early pneumonia

Paediatric respiratory reviews 2000Arch Dis child 2000

WHO’s age - specific criteria for tachypnea

Age < 2 mo : RR > 60/min

Age 2-12 mo : RR > 50/min

Age 1 – 5 yrs : RR > 40/min

Age > 5 yrs : RR > 30/min

Clinical clue for CAP• Daycare attendance :Viral infection, DRSP• Exposure to infectious diseases : Viral or

Mycoplasma infection, Tb• Hospitalization : Nosocomial infection• Missing immunizations : H. influenzae, pertussis,

measles• Antibiotic therapy within previous month : Infection with resistant bacterial strains• Recent travel : influenza, SARS

Investigations

NP aspirate for virus in all children aged < 18 months (highly specific and sensitive)

J Infection 2004; 48: 134-8.

•blood culture in all hospitalized children but low blood culture yield (< 10%) J Infection 2004; 48: 134-8

•Blood culture in child with high fever or looked sepsis. BTS guidelines for CAP in children.thorax 2011

Investigation for CAP in children

Am Fam Physician 2004; 70:899-908.

Clinical clue Suggested Dx or interpretationLabs CBC ESR CRP G/S and cultureChest radiograph

Not helpful in distinguish etiologyNot helpful in distinguish etiologyNot helpful in distinguish etiologyHelpful if specimen is adequateNot helpful in distinguish etiology

CXR

– CXR may not be abnormal at the start of classical pneumonia

– If all the physical signs of pneumonia are not present, CXR are unlikely to be helpful.

– The child should be perform CXR, when• Age < 5 yrs without localizing sign• Complicated pneumonia : pleural effusion, atelectasis• Atypical presentation• Not respond to antibiotic with in 48-72 hr.

BTS guideline for CAP pneumonia in children, Thorax 2011Paediatric respratory review 2000

Suggestive features of bacterial LRI

Kendig and Chernik’s disorders of the respiratory tract in children.2012..

clinical Fever > 38.5○C

abrupt onset

dyspnea

crepitation Am Fam Physician 2004; 70:899-908.

CXR

•alveolar process,

• lobar consolidation

Suggestive features of viral LRI

clinicalInfants and young children

fever < 38.5○C

gradual onset

dyspnea

crepitation, wheeze

CXRHyperinflation

interstitial process

patchy collapse (25%)

Suggestive features of mycoplasma LRI

BTS Guideline. Thorax 2011

clinicalSchool aged children

fever (30%), Cough(90%), rales (62%), wheeze /rhonchi(36%)

Extrapulmonary manifestation

CXRInterstitial infiltrate,

lobar consolidation

and hilar adenopathy

Am Fam Physician 2004; 70:899-908.

Kendig and Chernik’s disorders of the respiratory tract in children.2012..

Microbiological investigations : bacteriaInvestigations Recommendations

Blood culture In children with high fever or looked sepsis

NP aspirate for bacterial c/s Not recommend due to not adequate specimen

Tracheal suction for g/s,c/s Recommened if adequate specimen

Pleural aspirate (if present) Recommened for microscopy, culture and bacterial Ag detection

Serum Ag (bacterial) Not recommend as tests are less sensitive and specific

Serum Ab, immune cpx, paired serum

Recommened, good sensitivity and speificity for S.pneumoniae

PCR (serum, pleural fluid, secretion)

High sensitivity and specificity for S.pneumoniae

Bacterial Ag in urine Not recommend esp in young children due to poor specificity

J Infection 2004BTS guidelines for CAP in children.thorax 2011

Microbiological investigations : atypical pneumonia and virus

Investigations Recommendations

NP aspirate for viral Ag/PCR/culture

highly specific and sensitive for RSV, parainfluenza, influenza and adenovirus

Viral serology Acute and convalescent serum (if diagnosis not made with NP aspirates)

M. pneumoniae Cold agglutinin (PPV 70%), serum IgM (in the 2nd wk) or 4-fold rising of paired serum IgG, +ve PCR of NP secretion

C. pneumoniae Serum IgM or 4-fold rising of paired serum IgG, +ve PCR of NP secretion

C. trachomatis Culture or PCR identification in NP secretion, IgM antibody

J Infection 2004.BTS guidelines for CAP in children.thorax 2011

Management

Severity assessment

BTS guidelines for CAP in children.thorax 2011

Mild Severe

Infants BT < 38.5 C RR < 70 Mild retraction Taking full feed

BT > 38.5 C RR > 70 Moderate to severe retraction Cyanosis, apnea, grunting Not feeding

Older children

BT < 38.5 C RR < 50 Mild breathlessness No vomiting

BT > 38.5 C RR > 50 Difficulty breathing Nasal flaring, cyanosis, grunting Sign of dehydration

Indication for admission• Age < 3 months• Desaturation (SpO2 < 92% in roomair)

• Dyspnea(increase WOB, retraction, grunting• Poor feeding or dehydration• Lethalgy or sign of shock : peripheral cyanosis, poor capillary

refill• S.aureus pneumonia• Underlying disease: CHD, CLD, immune def.• Clinical not improve within 48 hr after Rx• Family not able to provide appropriate observation or

supervision


Indications for PICU admission

• Require FiO2 > 0.6 to maintain SpO2 > 92%

• Shock• Sever respiratory distress, exhaustion (rising

RR and PR ± ↑PaCO2)

• Recurrent apnea• Slow, irregular breathing


General management At home• Supportive and symptomatic treatment for

– Fever– cough – preventing dehydration : force oral fluid as tolerate – identifying any deterioration

• The child should be reviewed by the doctor if– Deteriorating– not improved after 48 hrs of treatment


At hospital • Oxygen therapy:

– In child with dyspnea, cyanosis, desaturation– maintain SpO2 > 92%

• Fluid therapy : – Avoid nasogastric tube– Start iv fluid : mark dyspnea, abdominal distension, dehydration– Avoid volume overload, monitor serum electrolytes

• Managing fever and pain• Bronchodilator inhaled : wheezing or rhonchi• Physiotherapy (no role in distress, acute pneumonia)• Frequent monitoring (vital signs, SpO2, lung signs, respiratory pattern


Specific treatment

Clinical Practice Guideline for Treatment of

Childhood Pneumonia in Thailand

ชมรมโรคระบบห�ยใจและเวิชบ��บ�ดวิ�กฤตในัเด#ก พ.ศ . 2555

2 days

Oral antibiotic for CAP

Intravenous antibiotics for CAP

Antiviral drug

MMWR Jan 2011

Prevention • Promote adequate nutrition including breastfeeding

and zinc intake• Raising immunization rate

– Pneumococcal conjugated vaccine– Hib vaccine– Measles vaccine– Pertussis vaccine– Influenza vaccine

• Reducing indoor pollution– Household use of fuels– Environmental tobacco smoke

• Hand washing BTS guidelines for CAP in children.thorax 2011

Paediatric Respiratory Rewiews 2011

Thank you for your attention

Documents

Pneumonia Araya Satdhabudha, MD. Division of Pediatric Pulmonology & Critical Care Thammasat University