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: [email protected]
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