PNEUMONIA

BALUYUT, ARVY D.
General Data
Name: David, John Luis
Age: 1 month old, male
Birthday: May 18, 2014
Address: Sto. Cristo Mexico Pampanga
Informant: Mother
Reliability: 95% reliability
Date of admission: June 30, 2014
Chief Complaint
Difficulty of breathing
PRENATAL HISTORY
Irregular pre-natal Check up- started on the 20
th

week of pregnancy at a health center
Multivitamins, FeSO4 at 28
th
week AOG

PRENATAL HISTORY
(-) Cough and colds
(-) UTI
No history of gestational hypertension, gestational
diabetes mellitus or gestational thyrotoxicosis
PRENATAL HISTORY
Mother is a non-smoker, non-alcoholic beverage
drinker or non-illicit drug user
No exposure to other medications
No roentgen exposure
NATAL HISTORY
Patient was born to an 18 year old G2P2 (2002)
mother via normal spontaneous delivery
Birth weight unrecalled
NEONATAL HISTORY

Apgar score good cry
No resuscitative effort done
No cyanosis, jaundice, anemia, convulsions,
congenital anomalies or infection
FAMILY HISTORY
(-) Hypertension or cardiac problem
(-) Diabetes Mellitus
(-) Bronchial Asthma
(-) Convulsions/Seizure disorder
(-) Infection, PTB
History of Present Illness
6 days PTA
(+) cough and colds, (-) fever, no consult done, no
medications given
4 days PTA
(+) DOB, (+) cough, dry, (+) colds, (-) fever
Few hours PTA
(+) productive cough, (-) colds, (-) fever, (-) vomiting, (-)
diarrhea
Sought consult at DPMMH
Referred to JBL


Past Medical History
No allergies
No viral exanthems
Family History
(-) Diabetes mellitus
(-)PTB
(-) Hypertension
(-) Asthma
(-) Allergies
(-) Thyroid disease
(-) Kidney Disease
(-) Cancer
Immunization History
BCG at birth
Hepatitis B vaccine at birth
Physical Examination
General: Awake, good cry, good suck

Vital Signs:
PR: 133 bpm
RR: 65 cpm
Temp: 37.2 C
Physical Examination
Anthropometrics:
Weight: 3.5 kgs
Height: 18.9 inches (48 cm)
BMI: 15.21kg/m2 (Normal)

Physical Examination
Skin: (-) pallor, (-) jaundice, (-) cyanosis
HEENT: anicteric sclera, pink palpebral conjuctiva,
no ear discharge, no nasal discharge, (-) CLAD
Chest: symmetrical chest expansion, with subcostal
retractions, with rales on both lung field
Heart: adynamic precordium, normal rate & regular
rhythm, no murmur
Physical Examination
Abdomen: flat, soft, normoactive bowel sounds,
non-tender
Extremities: Full and equal pulses, (-) clubbing, CRT
<2 secs,
Plan
IVF: D5IMB 130cc x 22 ugtts/min or 4 doses
Ceftazidime 100 mkday q8
Gentamicin 5mkday OD

DIAGNOSTICS
ABO Blood
Type
A WBC count 18.9
RH Type + Neutrophil 0.30
Hemoglobin 93 Lymphocyte 0.70
Hematocrit 0.28 Platelet count 197
Chest X-ray
IMPRESSION
Hazy infiltrates are seen in both lungs due to
pneumonia
Pulmonary hyperaeration is noted
Heart and great vessels are normal in size and
configuration
Other chest structures are not remarkable
CASE DISCUSSION
SALIENT FEATURES
1 month old
Male
History of cough
Tachypnea
Rales on both lung fields
With infiltrates on both lung fields as seen in chest
x-ray

APPROACH TO DIAGNOSIS
Difficulty of Breathing
Cardiovascular System
Respiratory System
Ruled out:
No history of congenital heart
disease
No murmurs
Cardiac rate regular and
normal rhythm
No edema

Ruled in:
History of cough and colds
Tachypnea
With subcostal retractions
Rales on both lung fields



DIFFERENTIAL DIAGNOSIS
Acute Bronchitis
- Non-specific bronchial inflammation, usually viral in origin,
with cough as a prominent feature.

RULED IN
Colds
Dry cough

RULED OUT
Tachypnea
Rales on both lung fields

DIFFERENTIAL DIAGNOSIS
Bronchiolitis
- Acute inflammatory injury of the bronchioles that is usually
caused by viral infection.

RULED IN
Most common cause of lower respiratory tract infection in the 1
st

year of life
Colds
Dyspnea
Tachypnea

RULED OUT
Usually common in 1 y/o



DIFFERENTIAL DIAGNOSIS
Tuberculosis
-Multisystemic disease with myriad presentations and
manifestations.

RULED IN
Cough
Dyspnea
Tachypnea

RULED OUT
No CLAD
No fever
Patchy or nodular infiltrate in the chest x-ray


COMMUNITY ACQUIRED
PNEUMONIA
EPIDEMIOLOGY
Inflammation of the lung parenchyma
Substantial cause of morbidity and mortality in
childhood throughout the world
158 million episode of pneumonia per year
154 million in developing countries
3 million deaths (29%- less than 5 years old)
ETIOLOGY
Infectious causes
Non-infectious causes
Aspiration of food or gastric acid
Foreign bodies
Hydrocarbons
Lipoid substances
Hypersensitivity reactions
Drug or radiation induced pneumonitis

ETIOLOGY
Streptococcus pnumoniae
Most common bacterial pathogen in children 3 weeks to
4 yr of age

Mycoplasma pneumonia & Chlamydophila
pneumonia
Most frequent pathogens in children 5 yr and older
ETIOLOGY
S. pneumonia, H. influenza, S. aureus
Major causes of hospitalization and death from bacterial
pneumonia among children in developing countries
ETIOLOGIC AGENTS GROUPED BY
AGE OF PATIENT
AGE GROUP FREQUENT PATHOGENS
Neonates Group B streptococcus, E. coli, other gram negative
bacilli, S. pneumonia, H influenza, (type B)
3 wks-3 months RSV, other respiratory viruses (parainfluenza, influenza,
adenovirus), S. pneumonia, H. influenza, if patient is
afebrile, consider Chlamydia trachomatis
4 mo-4 yr RSV, other respiratory viruses (parainfluenza, influenza,
adenovirus), S. pneumonia, H. influenza, M. pneumonia,
Group A streptococcus
>5 yr M. pneumonia, S. pneumonia, C. pneumonia, H.
influenza, influenza viruses, adenovirus, other
respiratory viruses, Legionella pneumophila
PATHOGENESIS

*Defense mechanism of the lower respiratory tract
includes:
1. mucocillary clearance

2. secretory IgA

3. clearing of airway by coughing

4. immunologic defense mechanism that
limit invasion (macrophages, secretory
IgA,and other immunoglobulins)

PATHOGENESIS

the small caliber of airways in young infants makes
them particularly susceptible to severe infections.

viral infections predispose to secondary bacterial
infection

severity of symptoms varies according to the invading
organism



PATHOGENESIS
M. Pneumoniae cellular destruction and inflammatory
response in the submucosa

S. Pneumoniae local edema aids in proliferation of the
organism and focal lobar involvement

Grp A streptococcus more diffuse infection with
interstitial pneumonia

S. Aureus extensive areas of hemorrhagic necrosis and
irregular areas of cavitation of the lung parenchyma


CLINICAL MANIFESTATIONS
Tachypnea
Fever
Alar flaring
Cyanosis, respiratory fatigue
Crackles
Wheezing
Decrease breath sound
Dullness on percussion
Intercostal, subcostal, suprasternal retractions

DIAGNOSIS

Chest X-ray- not diagnostic although confirmatory
Viral: hyperinflation with bilateral interstitial infiltrates
and peribronchial cuffing
Pneumococcal: confluent lobar consolidation

Peripheral White blood cell count
Viral: Normal or elevated (not >20,000/mm3,
lymphocyte predominance)
Bacterial: Elevated, 15,000-40,000/mm3, predominance
of granulocytes

DIAGNOSIS

ESR
C-reactive protein
Tissue culture - isolation of organism
Serologic Tests

FACTORS SUGGESTING NEED
FOR HOSPITAL ADMISSION
Age <6 mos
Sickle cell anemia with acute chest syndrome
Multiple lobe involvement
Toxic appearance
Severe respiratory distress
Requirement for supplemental oxygen
Dehydration
Vomiting
No response to oral antibiotic therapy
Social factors
TREATMENT
Mildly ill children who do not require
hospitalization
Amoxicillin
Alternatives: Cefuroxime, Amoxicillin/Clavulanate

School-aged children and in children whom
infection with M. pneumonia, C pneumonia
Macrolide

Adolescents
Respiratory fluoroquinolone
TREATMENT
Empiric treatment of suspected bacterial
pneumonia in a hospitalized child
Cefotaxime or ceftriaxone

Staphylococcal pneumonia
Vancomycin, Clindamycin

PROGNOSIS

Treatment with uncomplicated community
acquired bacteria pneumonia respond to therapy
with improvement in clinical symptoms within 48
to 96 hr of initiation of antibiotics.

FACTORS TO CONSIDER WHEN THE
PATIENT DOES NOT IMPROVE WITH
ANTIBIOTIC THERAPY
Complications (empyema)
Bacterial resistance
Non-bacterial etiologies
Pre-existing diseases
Other non-infectious causes

**Repeat chest radiograph- 1
st
step in determining
the reason for delay in response to treatment
COMPLICATIONS
Pleural effusion
Empyema
Pericarditis
Bacteremia
Hematologic spread
2012 PAPP UPDATE IN THE
EVALUATION AND
MANAGEMENT OF
PEDIATRIC COMMUNITY-
ACQUIRED PNEUMONIA


WHO SHALL BE CONSIDERED AS
HAVING COMMUNITY-ACQUIRED
PNEUMONIA?

The presence of pneumonia may be considered
even without a chest radiograph in a patient
presenting with cough and/or respiratory difficulty

plus any of the following:


WHO SHALL BE CONSIDERED AS
HAVING COMMUNITY-ACQUIRED
PNEUMONIA?

At the Out-Patient Clinic as the site-of-care
> tachypnea
> fever at any age

At the emergency room
>tachypnea
>fever
>02 sat less than or equal to 92% in the absence of
co-existing illness


WHO SHALL BE CONSIDERED AS
HAVING COMMUNITY-ACQUIRED
PNEUMONIA?

The presence of pneumonia should be determined
using a chest radiograph in a patient presenting
with cough and/or respiratory difficulty in the
following situations:

Presence of dehydration aged 3 months to 5
years
Presence of severe malnutrition aged less
than 7 yrs
High grade fever and leukocytosis aged 3 to 24
months without respiratory symptoms

Predictors of PCAP in a patient
with cough

A. For ages 3 mos to 5 yrs:
- tachypnea and/or chest indrawing

B. For ages 5-12 yrs:
- tachypnea and rales

C. Beyond 12 yrs of age are presence of the ff:-
-Fever, tachypnea, and tachycardia and;
-At least one abnormal chest findings of diminished breath
sounds, rhonchi, rales or wheezes
Presence of retractions on admission was the best
single predictor of death

Inability to cry, head nodding & RR >60min were
the best predictor of hypoxemia
Risk Classification
VARIABLES PCAP A/B
Non Severe
PCAP C
Moderate risk
PCAP D
High risk
1. Dehydration None/mild Moderate

Severe

2.Malnutrition None Moderate Severe
3. Pallor None Present Present
4. Respiratory
Rate
- 3-12 months >50 to <60 >60 t0 <70 >70
-1-5 years old >40 to <50 >50 >50
- 5 years above >30 to <35 >35 >35
Risk Classification
VARIABLES PCAP A/B
Non Severe
PCAP C
Moderate risk
PCAP D
High risk
Signs of Respiratory
Failure




a. Retraction None IC/SC SupraC/IC/SC
b. Head Bobbing None Present Present
c. Cyanosis None

Present Present
d. Grunting None None Present
e. Apnea None None Present
f. Sensorium None Irritable Lethargic/Stupurous
Risk Classification
VARIABLES PCAP A/B
Non Severe
PCAP C
Moderate risk
PCAP D
High risk
Diagnostic at
site of Care




1. Chest Xray
Findings
None Present Present
2. 02 Sat 95% <95% <95%
Risk Classification
VARIABLES PCAP A/B
Non Severe
PCAP C
Moderate risk
PCAP D
High risk
D. Action Plan



1. Site of Care Out Patient Admit to ward Admit to
critical care
facility
2. Follow Up End of
Treatment
Patients under 5 years old and more than 5 years
old who are classified as PCAP C but whose Chest
xray is without any of the following:

Effusion, lung abscess, air leak or multi lobar
consolidation, and whose Oxygen saturation is
>95% at room temperature can be managed
initially on an outpatient basis
DIAGNOSTICS
To determine etiology:
Gram stain and/or culture and sensitivity of pleural
fluid when available

To assess gas exchange:
Oxygen saturation using pulse oximetry
Arterial blood gas
to confirm clinical suspicion of multilobar
consolidation, lung abscess, pleural effusion,
pneumothorax or pneumomediastinum:
Chest x-ray PA-lateral

to determine appropriateness of antibiotic
usage:
C-reactive protein (CRP) A
Procalcitonin (PCT) B
Chest x-ray PA-lateral C
White Blood Cell (WBC) D
Gram stain of sputum or nasopharyngeal aspirate

to determine etiology
Sputum culture and sensitivity
Blood culture and sensitivity

to predict clinical outcome:
Chest x-ray PA-lateral
Pulse oximetry

to determine the presence of tuberculosis if
clinically suspected:
Mantoux test (PPD 5-TU)
Sputum smear for aid fast bacilli

to determine metabolic derangement:
Serum electrolytes
Serum glucose

For PCAP D, a referral to a specialist should be
done
CBC
In viral pneumonia,
normal or elevated but usually not higher than
20,000/mm
3
with a lymphocyte predominance.

Bacterial pneumonia:
15,000-40,000/mm
3
and a predominance of
granulocytes.

TREATMENT
When is antibiotic recommended?
PCAP A or B and
>2 years old, or
High grade fever without wheeze

PCAP C
alveolar consolidation on chest x-ray is present
Elevated serum C-reactive protein [CRP]
Elevated serum procalcitonin level [PCT]
Elevated white cell count
High grade fever without wheeze
Beyond 2 years of age
PCAP D, a specialist should be consulted
TREATMENT
What empiric treatment should be administered if a
bacterial etiology is strongly considered?

PCAP A or B without previous antibiotic: AMOXICILLIN
PO 40-50 mg/kg/day in 3 divided doses for 7days (min of
3days, or BID min 5days)

azithromycin [10 mkday OD for 3 days or 10mkday at day 1
then 5 mkday for days 2 to 5, maximum dose of 500mg/day],
clarithromycin [15 mkday, maximum dose of 1000 mg/day in
2 divided doses for 7 days] may be given to those patients
with known hypersensitivity to amoxicillin

PCAP C requiring hospitalization:
without previous antibiotic and who has

completed Hib v: PENICILLIN G 100,000
U/kg/day in 4 divided doses

incomplete Hib v: AMPICILLIN IV 100 mkday in
4 divided doses
above15 years
parenteral non-antipseudomonal, cephalosporin or
carbapenem + extended macrolide [azithromycin or
chlarithromycin]
OR
parenteral non-antipseudomonal -
lactam,cephalosporin or carbapenem] +
respiratory fluoroquinolones [levofloxacin or
moxifloxacin] administered as combination
therapy.

Those who can tolerate oral feeding and
does not require oxygen support

Amoxicillin[40-50 mkday, maximum dose of
1500 mg/day in 3 divided doses for at most 7
days] may be given on an outpatient.


For a patient classified as pCAP C who is
severely malnourished or suspected to have
methicillin-resistant Staphylococcus aureus,
or classified as pCAP D
Referral to a specialist is highly recommended

For a patient who has been established to
have Mycobacterium tuberculosis infection
or disease
antituberculous drugs should be started.
TREATMENT
What treatment should be initially given if a viral
etiology is strongly considered?

Oseltamivir
30 mg twice a day for 15 kg body weight
45 mg twice a day for >15-23 kg
60 mg twice a day for >23-40 kg
75 mg twice a day for >40 kg
Drug of choice for laboratory confirmed or clinically
suspected cases of influenza.
Pneumonia
Treatment
VIRAL ETIOLOGY
Ancillary treatment
Oseltamivir (2mkdose in 2 divided doses for 5
days) OR

Amantadine (4.4-8.8 mkday for 3-5 days)
may be given for influenza that is either
confirmed by laboratory or occurring as an
outbreak
TREATMENT

When can a patient be considered as responding to
the current antibiotic?

Decrease in respiratory signs and/or
defervescense within 72 hours after
initiation of antibiotic are predictors of
favorable response
TREATMENT
What should be done if a patient is not responding to
current antibiotic therapy within 72 hours?

PCAP A or B (outpatient)
Check for Coexisting illness and
conditions simulating pneumonia.
Add an oral macrolide if atypical
organism is highly considered.
May change to another antibiotic if
microbial resistance.
PCAP C (inpatient)
Check for Coexisting illness and
conditions simulating pneumonia.
Add an oral macrolide if atypical
organism is highly considered.
May change to another antibiotic if
microbial resistance.
Refer to specialist

PCAP D
Immediate consultation with a specialist

TREATMENT
What ancillary treatment can be given?

For pCAP A or B,
cough preparation, elemental zinc, vitamin A,
vitamin D, probiotic and chest physiotherapy
should not be routinely given during the course
of illness.
Bronchodilator in the presence of wheezing

For pCAP C,
Oxygen and hydration
Bronchodilators only in the presence of
wheezing.
Steroid may be added to a bronchodilator
Probiotic, Cough preparation, elemental zinc,
vitamin A, vitamin D and chest physiotherapy
should not be routinely given during the course
of illness.

For pCAP D, referal to a specialist should be
considered

Failure of Treatment
Alternative or coincident diagnoses

Lack of coverage for the actual etiology

Inadequate dosage

Poor compliance

Development of complications
PROGNOSIS
Overall, the prognosis is good. Most cases of viral
pneumonia resolve without treatment
Common bacterial pathogens and atypical
organisms respond to antimicrobial therapy.

PREVENTION
Vaccinination:
Streptococcus pneumonia (conjugate type)
Influenza
Diphtheria, Pertussis, Rubeola, Varicella, Haemophilus
Influenzae type b

Micronutrient.
Elemental zinc for ages 2 to 59 months to be given for 4
to 6 months