Paediatric Pneumonia : Summarized

Pneumonia

Dr Nimrah Shehzadi

The inflammation of lung parenchyma is called pneumonia .

Etiology :

1.infectious(40-80%)

Bacterial : streptococcus pneumoniae(most common ),mycoplasma pneumoniae,chlamydoph pneumoniae,streptococcus pyogenes,staphyloccus aureus.

Viral : RSV, Rhinovirus (most common),influenza,parainfluenza, adenovirus,enterovirus.

2.hypersensitivity

3.aspiration(food,foreign body,hydrocarbons,lipoid substances)

4.drug or radiation induced

Clinical manifestations:

Symptoms :

Infant :  

Preceding URTI (rhinitis ,cough )

Increased respiratory rate (most consistent feature )

Lethargy

Older children :

High grade fever

Cough

Chest pain

Respiratory distress

Drowsiness

Anxiety

Delirium

Abdominal pain ( lower lobar pneumonia)

Signs :

Tachypnea

Increased work of breathing in the form of nasal flaring ,subcostal,suprasternal and intercostal recessions )

Cyanosis,grunting, head nodding,

Tachycardia ( due to hypoxia or due to septicemia)
Tracheal Shift/with mediastinal shift to opposite side(of diseased lung) in case of pneumothorax and pleural effusion ,and to the same side of disease in case of lung collapse. No mediastinal shift in case of consolidation.

On percussion :dull note in case of consolidation, stony dull note in case of empyema and pleural effusion, hyperresonant in case of underlying pneumothorax.

Auscultation: Assess for B/L air entry and compare both sides, there may be coarse crepitations heard over affected lung sites, if there is consolidation airentry may be markedly reduced over that lung zone , with no air entry in case of collapse of pneumothorax, while in case of pleural effusion the intensity of breath sounds may be reduced and pleural rub auscultated.
Liver (and/or spleen) may be descended in due to tachypnea . So take total span of liver and don’t confuse with hepatomegaly.

Investigations :

CBC ( wbc count useful to differentiate viral from bacterial pneumonia ,

Viral  :wbc normal or elevated but not more than 20,000/mm3 lymphocyte predominant, Bacterial :wbc :15-40,000/mm3,granulocyte predominant).

ABGs

CXR(PA and lateral view ): infiltrates,pleural effusion,empyema,hyperinflation and peribronchial cuffing.

CRP :raised

ESR:raised

Isolation of pathogen from blood ,pleural fluid or lung(cultures)

 MANAGEMENT

Admit the patient if danger signs present.

Keep cleared airway, Nasal secretion may need frequent clearing.

Expose and tepid water sponging to lower the temp.

O2 inhalation @ 1-1.5L/min via NG  (if tachypnea; clinical cyanosis, irritability,

poor respiratory  effort, O2 Sats < 92%). Regarding oxygen inhalation, always confirm that if you are giving O2 inhalation via NG then NG should not be blocked by secretions in the nose.

Look for adequate Breathing. There should be good/B/L comparable chest rise .
If Oxygen is given via face mask in older child, may increase flow to 6-8 L/min.
Maintain Circulation, ( Patient may need to be rehydrated as severely tachypneic patient show reluctance to feed)

Maintain IV Line

Give Maintenance fluids if not allowed orally due to tachypnea.

Monitor Vital Signs ( PR , RR, BP, spO2, temp ) x 4 hourly ( or more frequently if indicated)

I/V Antibiotics  in case of bacterial pneumonia.        

Age 0-2 months

Inj. Amikacin (15mg/kg/day IV in 2 DD +                                      

Inj. Cefotaxime (150mg/kg/day IV in 3 DD)

     Age 02 – 24 months

            Inj. Ampicillin (100mg/kg/day IV in 4 DD) +

            Inj Ceftriaxone (100 mg.kg/day in 4 DD)

    Age above 02 years

            Inj. Benzyl – Penicillin 200,000 IU/kg/day I/V in 4 DD       after test dose.

            inj Ceftriaxone

Second line Antibiotics : Vancomycin, Clarithromycin,, Meropenem.         Consult seniors.

·         Syp. Paracetamol (10-15 mg/kg/dose Q 6hr)

·         If baby is very sick, keep NPO - give IV N/5 saline 100ml/kg/day

·         Give frequent small feeds via NG (If tolerated)

·         Chest Physiotherapy if needed

·         If wheezing and spasm present, nebulize with ventolin solution 1-4 hourly.

In case of viral cause, antibiotics are not indicated. Duration of antibiotic therapy :

Oral zinc (10mg/day for <12 mo,20mg/day for >12 mo)

Complications :

Pleural effusion (treatment: antibiotics and drainage with tube thoracostomy)

Empyema

Pneumothorax

Meningitis

DIC

FITS

Differential diagnosis of recurrent pneumonia :

Malnutrition

Congenital heart disease

Unvaccinated Children/ Immunodeficiency

Cystic fibrosis

Kartagener syndrome

Foreign body

Tracheoesophagal fistula

Aspiration(as in CP children)

The value of experience is not in seeing much, but in seeing wisely.