Paediatric Community Acquired Pneumonia

– Clinical Vignettes
(based on BTS guidelines for the management of community
acquired pneumonia)
Background
• Paediatric pneumonia is the biggest cause of childhood mortality
globally

• In the UK the majority of cases are clinically straightforward and can

be managed safely with oral antibiotics

• In line with the findings of the BTS audit

Learning objectives
• The learning objectives for these clinical case scenarios are to
improve knowledge on:
• How to manage paediatric pneumonia
• Promote discussion of areas for quality improvement in the care of
paediatric pneumonia
• Highlight intersection with NICE sepsis guidelines
• Discuss the diagnosis of severe pneumonia
Vignette – Case 1
• Martha is a three year old girl who has been brought to children’s
A&E by her father, Malcolm. Malcolm has been concerned about
Martha’s breathing for the last two days. While things began with a
cold which seemed milder, he describes it has having become
increasingly laboured, particularly over the evening.
• She seems uncomfortable particularly when coughing, which she
has been doing increasingly. She has been having temperatures for
the last three days.
• At triage her observations are: Heart Rate 155 bpm, Respiratory
Rate 52 bpm, Oxygen Saturation 90% in room air, Temperature 39 oC
Q1
Clinically you suspect an acute bacterial pneumonia.

1.1) What is her sepsis risk & what actions should it trigger?

1.2) Using the BTS guideline as tool do you feel that Martha’s
pneumonia is severe?
A1.1
• Her triage observations meet the high risk criteria using the NICE
sepsis tool

• This should lead to her being:

- Assessed by a senior decision maker
- Having blood taken urgently for blood gas &
lactate/culture/FBC/CRP/U&E
- Starting intravenous antibiotics within 1 hour
A1.2
• In line with the BTS guideline

• Her triage observations suggest her pneumonia is severe and she

should proceed to have a CXR
Vignette – Case 2
• Caroline is a 2 year old girl brought as an emergency appointment to the
afternoon clinic at her local GP practice. She is accompanied by her
mother, Sally.

• Caroline has been unwell for about 24 hours. She came home from nursery
the day before with a temperature and a cough. In between her
temperatures she has been reasonably bright and interactive.

• When you assess her, her heart rate is around 110 bpm and respiratory
rate 25 bpm. On auscultation you hear coarse crackles in the base of the
right lung
Q2.1
• You diagnose Amy with pneumonia

• Using the BTS paediatric pneumonia guideline are blood tests

indicated in this scenario?
Q2.2
• What additional features or findings on examination might change
this decision?
A2.1
• This case should be managed without routine blood investigations.
The annual BTS audit has identified high rates of blood testing in
children with pneumonia, which can with care be reduced with
obvious benefits in terms of resource usage.
A2.2

• Any features not described which trigger on the NICE sepsis tool

• Findings suggestive of complicated pneumonia (absent breath

sounds, dull to percussion, decreased chest expansion) should trigger
blood testing
Vignette – Case 3
• James is a previously well 4 year old boy

• He presents to the Emergency Department with a 4 day history of

fever, cough and shortness of breath

• He has been eating less than usual but is drinking ‘good amounts’ and
passed urine while in the department
Examination – Case 3
• James is alert, has moderate increased work of breathing

• Oxygen saturations are 94% in room air, respiratory rate 20/minute

• Temperature 38.4◦C, heart rate 86/minute, well perfused peripherally

• On auscultation crackles are heard at the left base

Clinical questions
• Based on the BTS Guideline use the QI tool flow chart to answer

Q3.1 Which antibiotic is recommended to be prescribed?

Q3.2 Which route should be used to deliver it?

Q3.3 Should IV co-amoxiclav be prescribed?

Discussion
A3.1 Recommended antibiotic in this case would be amoxicillin (in
case of penicillin allergy then azithromycin, erythromycin or
clarithromycin may be indicated)
A3.2 Recommended route is oral. IV antibiotics should be used if
unable to tolerate oral fluids or absorb oral antibiotics, e.g.
vomiting; or if presents with signs of sepsis or complicated
pneumonia
A3.3 No, see 1 and 2 above
Vignette - Case 4
• Jane is an 8 year old girl she is referred to the Paediatric Assessment
Unit by her GP
• She has a 10 day history of progressive cough and was sent home
from school yesterday due to shortness of breath
• Jane is prescribed a regular steroid inhaler by her GP for asthma
Clinical questions
• Based on the BTS Guideline use the QI tool flow chart
Q4.1 Which criteria would inform your decision about
performing a CXR or not?

• Jane responds to treatment and is discharged home 4 days later with

a diagnosis of ‘right lower lobe pneumonia’
Q4.2 Should she have a follow up CXR?
Discussion
A4.1 A CXR is not routinely indicated, only recommended if:
• There is clinical suspicion of complicated pneumonia
• absent breath sounds, dullness to percussion, decreased chest
expansion
• There are features of severe pneumonia
• see flow chart for detail in summary: signs of significant
respiratory distress, apnoea, SpO2 <92% in air, not feeding or
signs of dehydration/poor perfusion

A4.2 Follow up CXR not routinely recommended, is indicated however in:

• Those with a round pneumonia, collapse or persistent symptoms