Martino PavoneDirigente Medico

Referente Servizio di Polisonnografia e ventilazione meccanica a

lungo termine

UOC Broncopneumologia

Dipartimento Pediatrico Universitario Ospedaliero

Ospedale Pediatrico Bambino Gesù – IRCCS Roma

Piazza S. Onofrio 4, 00165 Roma

e-mail: martino.pavone@opbg.net

CAP DEFINITIONS

79. WHO guidelines on detecting pneumonia in children. Lancet 1991;338(8780): 1453–4.

80. World Health Organization. Technical bases for the WHO recommendations on the management of pneumonia in children at first-level health facilities. Geneva

(Switzerland): WHO; 1991.

43. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax

2011;66(Suppl 2):ii1–23.

33, Bradley JS, Byington CL, Shah SS, et al. The management of community acquired pneumonia in infants and children older than 3 months of age: clinical practice

guidelines by the Pediatric Infectious Diseases Society and the Infectious. Diseases Society of America. Clin Infect Dis 2011;53(7):e25–76.

DEFINITIONS OF CAP IN CHILDREN

ETIOLOGIES BY AGE

Jadavji T, Law B, Lebel MH, Kennedy WA, Gold R, Wang EE. A practical guide for the diagnosis and treatment of pediatric pneumonia. CMAJ. 1997;156(5):S703-S711.

Kumar S, Wang L, Fan J, et al. Detection of 11 common viral and bacterial pathogens causing community-acquired pneumonia or sepsis in asymptomatic patients by using a multiplex reverse transcription-PCR

assay with manual (enzyme hybridization) or automated (electronic microarray) detection. J Clin Microbiol. 2008;46(9):3063-3072.

ETIOLOGIES OF CAP IN CHILDREN

CRITERIA FOR HOSPITALIZATION

Children and infants who have moderate to severe CAP, as defined by several factors, including

respiratory distress and hypoxemia (sustained SpO2 <90 %)

Infants less than 3–6 months of age with suspected bacterial CAP

Children and infants with suspected or documented CAP caused by a pathogen with increased

virulence, (example: CA-MRSA)

Children and infants for whom there is concern about:

- careful observation at home

- who are unable to comply with therapy

- unable to be followed up

CRITERIA FOR HOSPITALIZATION

CRITERIA FOR HOSPITALIZATION

7. Cincinnati Children’s Hospital Medical Center. Evidence-based care guideline. Community acquired pneumonia in children 60 days through 17 years of age.

http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/community-acquired-pneumonia. Accessed February 14, 2012.

26. British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines for the management of community acquired pneumonia in childhood. Thorax. 2002;57(suppl

1):i1-i24.

ROLE OF INVESTIGATIONS

CHEST X-RAY: NO. WHEN?

• Chest radiography should not be considered a routine investigation in children thought

to have CAP

• Children with signs and symptoms of pneumonia who are not admitted to hospital

should not have a chest x-ray

• A lateral x-ray should not be performed routinely

Take Home Message: NO ROUTINELY IN OUTPATIENTS

Chest x-ray, posteroanterior and lateral, should be obtained in

Outpatients:

with suspected or documented hypoxemia or significant respiratory distress

in those with failed initial antibiotic therapy to verify the presence or absence of complications of pneumonia (parapneumonic effusions, necrotizing pneumonia, and

pneumothorax).

Inpatients:

in all patients hospitalized for management of CAP to document the presence, size, and

character of parenchymal infiltrates and identify complications of pneumonia that may

lead to interventions beyond antimicrobial agents and supportive medical therapy.

CHEST X-RAY: YES. WHEN?

THM: YES, IF SUSPECT A COMPLICATION

THM: YES, IN ALL PATIENTS HOSPITALIZED

INFLAMMATORY MARKERS

Acute phase reactants (ESR, CRP, SPC) are not of clinical utility in distinguishing viral

from bacterial infections and should not be tested routinely, in fully immunized children

who are managed as outpatients.

In patients with more serious disease, such as those requiring hospitalization or those

with pneumonia-associated complications, acute-phase reactants may be used in

conjunction with clinical findings to assess response to therapy.

THM: NOT ROUTINELY IN OUTPATIENTS WITH UNCOMPLICATED CAP

THM: YES, IF SUSPECT A SERIOUS DISEASE OR COMPLICATION

Routine measurement of the cBCC is not necessary in all children with suspected CAP

managed in the outpatient setting.

A cBCC should be obtained for patients with severe pneumonia, to be interpreted in

the context of the clinical examination and other laboratory and imaging studies.

COMPLETE BLOOD CELL COUNT (cBCC)

THM: NOT ROUTINELY IN OUTPATIENTS WITH UNCOMPLICATED CAP

THM: YES, IN SEVERE PNEUMONIA

• Microbiological investigations should not be considered routinely in those with milder

disease or those treated in the community.

• Microbiological diagnosis should be attempted in children with severe pneumonia

sufficient to require paediatric intensive care admission, or those with complications of

CAP.

MICROBIOLOGY

THM: NOT ROUTINELY IN MILDER CAP OR OUTPATIENTS

THM: YES, IN SEVERE PNEUMONIA OR PICU-Adm

Tests for the rapid diagnosis of influenza virus and other respiratory viruses should be used.

A positive influenza test may:

- decrease the need for additional diagnostic studies

- decrease antibiotic use,

- guide appropriate use of antiviral agents (in both out/inpatient)

Antibacterial therapy is not necessary for children (out/inpatients), with a positive test for

influenza virus in the absence of clinical, laboratory, or radiographic findings that suggest

bacterial coinfection.

TESTING FOR VIRAL PATHOGENS

THM: YES, RAPID INFLUENZA AND OTHER RESPIRATORY VIRUSES

Children with signs and symptoms suspicious for Mycoplasma pneumoniae should be tested to help guide antibiotic selection.

Diagnostic testing for Chlamydophila pneumoniae is not recommended as reliable and

readily available diagnostic tests do not currently exist.

TESTING FOR ATYPICAL BACTERIA

THM: YES, TESTS FOR MYCOPLASMA PN. IF SUSPECTED

CLINICAL OBSERVATION

Re-assessment:

- for persistent fever

- if symptoms persist

- and/or they are not responding to treatment

Children who have SpO2 <92% should be referred to hospital for assessment and

management.

Families of children who are well enough to be cared for at home should be giveninformation on managing fever, preventing dehydration and identifying any

deterioration.

SEVERITY ASSESSMENT

ANTIBIOTIC MANAGEMENT

Al children with a clear clinical diagnosis of pneumonia should receive antibiotics as

bacterial and viral pneumonia cannot reliably be distinguished from each other.

Children aged < 2 years presenting with mild symptoms of lower respiratory tract

infection do not usually have pneumonia and need not be treated with antibiotics but

should be reviewed if symptoms persist. A history of conjugate pneumococcal

vaccination gives greater confidence to this decision.

Amoxicillin is recommended as first choice for oral antibiotic therapy in all children

because it is effective against the majority of pathogens which cause CAP in this group,

is well tolerated and cheap.

Alternatives are co-amoxiclav, cefaclor, erythromycin, azithromycin and clarithromycin.

AMOXICILLIN

THM: AMOXICILLIN, FIRST CHOICE

Macrolide antibiotics may be added at any age:

- if there is no response to first-line empirical therapy

- if either mycoplasma or chlamydia pneumonia is suspected

- in very severe disease.

MACROLIDES

In pneumonia associated with influenza, co-amoxiclav is recommended.

Antibiotics administered orally are safe and effective for children presenting with

even severe CAP and are recommended.

Treatment courses of 10 days have been best studied, although shorter courses may

be just as effective, particularly for more mild disease managed on an outpatientbasis.

OTHER

Influenza antiviral therapy should be administered as soon as possible to children with

moderate to severe CAP consistent with influenza virus infection during widespread

local circulation of influenza viruses, particularly for those with clinically worsening

disease documented at the time of an outpatient visit.

Because early antiviral treatment has been shown to provide maximal benefit, treatment should not be delayed until confirmation of positive influenza test results.

Negative results of influenza diagnostic tests, especially rapid antigen tests, do not

conclusively exclude influenza disease. Treatment after 48 hours of symptomatic

infection may still provide clinical benefit to those with more severe disease.

INFLUENZA ANTIVIRAL THERAPY

If a child remains feverish or unwell 48 - 72 h after treatment has commenced, re-

evaluation (and further investigations) should be performed (considered) for possible

complications.

COMPLICATIONS

ICU, if a child:

Requires invasive ventilation via a nonpermanent artificial airway

Pulse oximetry measurement is <92% on inspired oxygen of ≥ 0.50.

ICU or UCCRM, if a child:

Acutely requires use of noninvasive positive pressure ventilation

Has an impending respiratory failure.

Has sustained tachycardia, inadequate blood pressure, or need for pharmacologic support

of blood pressure or perfusion.

Has altered mental status, whether due to hypercarbia or hypoxemia as a result of pneumonia.

IDSA, ADMISSION CRITERIA TO ICU OR UCCRM

UCCRM: Unit with continuous cardiorespiratory monitoring capabilities

Two main scenarios:

(1) when the pneumonia is so severe that the child is developing severe respiratory failure

requiring assisted ventilation;

(2) a pneumonia complicated by septicaemia.

Key features that suggest a child requires transfer include:

Failure to maintain oxygen saturation >92% in fractional inspired oxygen of > 0.6

Shock

Rising respiratory and pulse rate with clinical evidence of severe respiratory distress and

exhaustion, with or without a raised arterial carbon dioxide tension

Recurrent apnoea or slow irregular breathing.

BTS, ADMISSION CRITERIA TO ICU

BREAKING NEWS

Community-Acquired Pneumonia Requiring Hospitalization among U.S. Children. Seema Jain, et Al. N Engl J Med 2015;372:835-45.

ETIOLOGIES OF CAP IN CHILDREN

Utility of inflammatory markers in predicting the aetiology of pneumonia in children. Elemraid MA et Al. Diagnostic Microbiology and Infectious

Disease 79 (2014) 458–462

area under the curve of 0.894 with 75.7% sensitivity and 89.4% specificity.

INFLAMMATORY MARKERS IN PREDICTING ETIOLOGY

Risk factors of progressive community acquired pneumonia in hospitalized children: A prospective study. Huang C-Y, et Al. Journal of Microbiology,

Immunology and Infection (2015) 48, 36-42

PREDICTING SEVERITY

Predicting Severe Pneumonia Outcomes in Children. Derek JW et Al. Pediatrics. 2016; 138(4):e20161019

2319 children

Pneumoniae Severity scale:

Severe (mechanical ventilation, shock, or death),

Moderate (intensive care admission only),

Mild (non–intensive care hospitalization) outcomes.

20 predictors, evaluated in 3 models:

a full model included all 20 predictors,

a reduced model included 10 predictors based on expert consensus,

and an electronic health record (EHR) model included 9 predictors

21% had a moderate or severe outcome (14% moderate, 7% severe).

Each of the models accurately identified risk for moderate or severe pneumonia

(concordance index across models 0.78–0.81). Age, vital signs, chest indrawing, and

radiologic infiltrate pattern were the strongest predictors of severity. The reduced and EHR

models retained most of the strongest predictors and performed as well as the full model.

PREDICTING SEVERITY

Lung ultrasound in the diagnosis and monitoring of community acquired pneumonia in children. Urbankowska E, et Al. Respiratory Medicine 109

(2015) 1207-1212

76/71 Chest X-Ray/LUS.

5 LUS false negative results (patients with parahilar pulmonary infiltrates by CXR).

Almost perfect overall agreement between LUS and CXR (Cohen kappa coefficient of 0.89).

The diagnostic performance of LUS in demonstration of lung involvement was as follows:

sensitivity of 93.4%,

specificity of 100%,

positive predictive value of 100%,

negative predictive value of 85.7% accuracy of 95.3%.

LUNG ULTRASOUNDS

LINEE GUIDA CINESI