Pediatric Community Acquired Pneumonia

Pediatric Community Acquired Pneumonia - Presentation Transcript

1. PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA http://crisbertcualteros.page.tl
2. PNEUMONIA
   • Is an inflammation of the parenchyma of the lungs
   • Most cases of pneumonia are caused by microorganism
3. • noninfectious causes- aspiration of food or gastric acid; foreign bodies; hydrocarbons; lipoid substances; hypersensitivity reactions and drug 0r radiation-induced pneumonitis
4. • Specific risk factors:
   • Lung disease
   • anatomic problems
   • Gastroesophageal reflux disease with aspiration
5. • 4. Neurologic disorders that interfere with protection of the airway or compromise clearing of the airway
   • 5. Diseases that alter the immune system, such immunodeficiency diseases or hemoglobinopathies
6. Etiology
   • Viral - peak attack is between 2-3 y.o.
   • S.pneumoniae, M.pneumoniae – older than 5 y.o.
   • other bacterial causes: group A strep, S.pyogenes, Staph aureus, H.influenzae type B
7. Clinical manifestation
   • Viral and bacterial pneumonias are most often preceded by several days of symptoms of an upper respiratory tract infection, typically rhinitis and cough
   • Viral pneumonia, fever -temp.- is generally lower than bacterial.
8. • Tachypnea is the most consistent clinical manifestation
   • Increased working breathing accompanied by intercostal retractions, nasal flaring and use accesory muscles
9. • Bacterial pneumonia in older children typically begins suddenly with shaking chill followed by high fever, cough and chest pain
10. Predictors of CAP in a Patient with cough
    • 1. ages 3-5 y.o.- tachypnea and/or chest indrawing
    • 2. ages 5-12 y.o. – fever, tachypnea
    • & crackles
    • 3. > 12 y.o. fever, tachypnea, tachycardia
    • at least 1 abnormal chest findings
    • ronchi, crackles, wheezes, ↓breath sounds
11. • Reliable indicators- either tachypnea and/or chest indrawing among infants and preschool children
    • Tachypnea is still the best predictor
    • Age specific criteria for tachypnea:
    • 2-12 mos. – 50 breaths/min.
    • 1-5 years. – 40 breaths/min.
    • > 5 years – 30 breaths/min.
12. • Patients with CAP are 2-3 times more likely to have the following signs and symptoms:
    • nasal flaring, grunting, tachypnea, rales and pallor
13. • Diagnosis of an adolescent suspected to have CAP:
    • cough
    • tachypnea (RR .20 breaths/min.)
    • tachycardia (HR .100bpm)
    • fever (temp > 37.8 ºC)
    • at least 1 abnormal chest findings
    • CXR with infiltrates
14. Criteria for admission
    • A patient who is moderate to high risk to develop pneumonia-related mortality should be admitted
    • A patient who is at minimal to low risk can be managed on OPD basis
15. RISK CLASSIFICATION FOR PNEUMONIA-RELATED MORTALITY <11>11 mo. >11 mo. age unable unable able able Ability to feed severe moderate mild none Presence of dehydration Not possible Not possible possible possible Ability to ff-up no no yes Yes Compliant care giver Present present present none co-morbid illness PCAP D High risk PCAP C Moderate risk PCAP B Low risk PCAP A Minimal risk VARIABLES
16. Supraclavicular/intercostal/subcostal present Intercostal/subcostal Present present none none none Signs of resp failure a.Retraction b. Head bobbing c. Cyanosis d. Grunting >70/min >50/min >35/min >60/min >50/min >35/min >50/min >40/min >30/min >50/min >40/min >30/min resp rate 2-12mo. 1-5 yrs. >5 yrs. PCAP D High risk PCAP C Moderate risk PCAP B Low risk PCAP A Minimal risk VARIABLES
17. Admit to ICU Admit to regular ward OPD OPD Action plan present present none none Complications Present Lethargic,stuporous/comtose None irritable None awake None awake Signs of resp failure e. apnea f. sensorium PCAP D High risk PCAP C Moderate risk PCAP B Low risk PCAP A Minimal risk VARIABLES
18. • Parameters to be evaluated when considering admission:
    • 1. Host factors
    • a. ability to feed
    • b. age
    • c. signs of resp failure
    • d. pulmonary complications
19. • e. respiratory rate
    • f. state of dehydration
    • g. presence of comorbid factors
    • 2. External factors
    • a. compliant caregiver
    • b. ability to ff-up
20. • Grunting and apnea are manifestations
    • of acute respiratory failure requiring admission to critical care unit
    • compared with older children, an infant younger than one year has higher risk of contracting sever pneumonia
21. • Age from 2-11 mos. was associated with death
    • Presence of retraction on admission was the best single predictor of death
    • Subcostal, intercostal, supraclavicular retractions were associated with mortality
22. • Chest retraction has been considered to be an excellent sign for selecting children needing admission for more intensive treatment.
    • Tachypnea, chest retraction, somnolence and young age, chronic illness & malnutrition were independently associated with hospitalization
23. • Cyanosis and head bobbing corelates well with hypoxemia
    • Inability to cry, head nodding and a resp rate of >60/min. were best predictors of hypoxemia.
24. DIAGNOSTICS
    • No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting (Grade D).
25. • Recommendations for PCAP C & D:
    • Routine exams:
    • CXR-PA Lateral
    • WBC count
    • Culture and sensitivity of:
    • blood,pleural fluid, & tracheal aspirate for PCAP D, sputum for older children
26. • The following should not be requested:
    • ESR
    • C-reactive protein
27. ANTIBIOTIC RECOMMENDATION
    • 1. for patient classified as either PCAP A or B and is
    • a. beyond 2 years of age
    • b. having high grade fever without wheeze
    • 2. For a patient classified as PCAP C and is
    • a. beyond 2 years of age
28. • b. having high grade fever without wheeze
    • c. having alveolar consolidation in the CXR
    • d. having WBC count > 15,000
    • 3. For a patient classified as PCAP D
29. • Practice guidelines cited as AGE as the best predictor of underlying etiology of pediatric pneumonia
    • First 2 years of life VIRUSES are most frequently implicated
    • As age increases, bacterial pathogens become more prevalent
30. • Literature review showed the following pattern of microbial etiology:
    • PCAP managed as an outpatient
    • a. bacterial pathogen is more common than a viral pathogen
    • b. Streptococcus pneumoniae is the pathogen in more than half of the patients
31. • Less common pathogens include M. pneumoniae and C. pneumoniae
    • 2. PCAP managed as an in patient
    • a. bacterial pathogen is more common than a viral pathogen
    • b. S.pneumoniae is the pathogen in little more than half of the patients
32. • H. influenzae type B should be considered in a patient below 5 y.o. who has not completed the primary series of Hib immunization
33. • certain features that suggest the presence of a bacterial and viral pathogen
    • Demonstration of either alveolar infiltrates in CXR or elevated WBC favors bacterial pathogen
    present absent Wheeze <38.5>38.5 ºC Fever Viral Bacterial FEATURES
34. EMPIRIC TREATMENT
    • 1. for patient classified as PCAP A or B without previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided doses
    • 2. for a patient classified as PCAP C w/o previous antibiotic & who has completed the primary immunization against H. influenzae type B, Pen G 100,000 u/kg/day in 4 divided doses.
35. • if a primary immunization against Hib has not been completed,and below 5 y.o., IV ampicillin (100mg/kg/day in 4 divided doses
    • 3. for a patient classified as PCAP D, a specialist should be consulted
36. INITIAL TREATMENT GIVEN WITH VIRAL ETIOLOGY
    • Antiviral agents such as amantadine and the newer neuraminidase inhibitors zanamivir and oseltamivir
    • -reduces the duration of illness by 1-1.5 days
    • -to reduce the duration of viral shedding among patients with influenza
37. • For influenza A infection – amantadine (4.4-4.8 mg/kg/day) can be given for 3-5 days
    • - Discontinue the drug within 24-48 hrs. after resolution of symptoms
38. • For influenza A or B infection – oseltamivir (2mg/kg/dose BID) can be given for 5 days
    • In case proven epidemics of influenza, oseltamivir may be given
    • Its use for treatment & prophylaxis of household contacts has been effective for >12 y.o.
39. RESPONSE TO CURRENT ANTIBIOTICS
    • 1. decrease in respiratory signs (tachypnea) & defervescence within 72 hrs. after initiation of antibiotic
    • 2. persistence of symptoms beyond 72 hrs after initiation of antibiotics requires reevaluation
40. • 3. end of treatment CXR, WBC, ESR or CRP should not be done to assess therapeutic response to antibiotic
41. • 1. if an out patient classified as either PCAP A or PCAP B is not responding to the current antibiotic within 72 hrs.
    • - change the initial antibiotic
    • - start oral macrolide
    • - reevaluate diagnosis
42. • possibility of penicillin resistant S.pneumoniae
    • Course of action: change amoxicillin to any of the ff.: cefuroxime, co-amoxiclav, sultamicillin or cepfodoxime
43. • Possibility of Mycoplasma sp or Chlamydia sp.
    • Course of action: start an oral macrolide, such as erythromycin
44. • 2. if an inpatient classified as PCAP C is not responding to the current antibiotic within 72 hrs. consider consultation with a specialist
    • following possibilities:
    • - penicillin resistant S.pneumoniae
    • - presence of complications
45. • If an inpatient classified as PCAP D is not responding within 72 hrs., consider immediate re-consultation with a specialist
46. WHEN CAN SWITCH THERAPY IN BACTERIAL PNEUMONIA
    • Switch from IV antibiotics to oral form 2-3 days after initiation of antibiotic is recommended in patients:
    • a. responding to initial antibiotic therapy
    • b. able to feed with intact GI absorption
    • c. does not have any pulmonary or extrapulmonary complications
47. ANCILLARY TREATMENT
    • 1. cough preparations, chest physiotherapy, bronchial hygiene, nebulization using NSS, steam inhalation, topical solution, bronchodilators and herbal medicine are not routinely given
48. • 2. among patients, oxygen and hydration should be given if needed
    • 3. in the presence of wheezing, a bronchodilator may be given
49. PREVENTION
    • 1. vaccines recommended by the Phil. Pediatric Society should be routinely administered
    • 2. Zinc supplementation
    • 3. Vitamin A, immunomodulators and Vitamin C should not be routinely given
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