Pediatric Community Acquired

Pneumonia
Mark Nicholas B. Reyes
Medical Intern
 Sample Case

• A.S.
• Male
• 5 y.o.
• Chief complaint: cough
 Sample Case
History of Present Illness

• Productive cough and colds

2 days prior to • Fever (Tmax 38.2C)
admission • 1x vomiting of previously ingested
food
• Poor appetite and activity
• No diarrhea
• No difficulty of breathing
 Sample Case
History of Present Illness

• Persistence of distressing cough

and colds
1 day prior to
• Intermittent fever
admission • 5x vomiting of previously
ingested milk
• Mottling of the skin on upper and
lower extremities
 Sample Case
History of Present Illness

Few hours prior • Still febile at 38C

to admission • Perioral cyanosis during coughing
episodes
• Irritable with poor suck, activity,
and appetite
 Sample Case
Past Medical History

• Pneumonia (2019)
• Complete immunization at par with age
 Sample Case
Family History

• Hypertension - Maternal and paternal side

• No heredofamilial diseases like:
• Diabetes mellitus
• Cancer
• Stroke
• Asthma
• Seizure
• Heart Disease
 Sample Case
Developmental History

• Emotional/Social Milestones
• 12 months: has favorite things and people
• Language/Communication
• 12 months: Responds to simple spoken requests
 Sample Case
Developmental History

• Cognitive (learning, thinking, and problem-solving)

• 12 months: Copies gestures
• Movement/ Physical development
• 18 months: drinks from cup
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Review of Systems

Head and Neck No headache, no head injury

Ears and nose No ear pain, no ringing, no nose bleeds
Throat No bleeding gums, no sore tongue

Eyes No change in vision

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Review of Systems

CVS No chest pain

Renal No difficulty in urinating
Urogenital No discharge

Neurologic No loss of consciousness

Muscular No muscle and joint pains
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Physical Examination

General Survey Awake, irritable, in mild cardiorespiratory

distress
Vital Signs HR: 132 bpm RR: 32 cpm
Temp: 37.6C 02 saturation: 96%
Wt: 8.5kg Ht. 69cms
Eyes Anicteric sclerae, pink palpebral
conjunctiva, no matting, sunken eyeballs
 Sample Case
Physical Examination

Ears Normoset ears, no ear deformity, no

tragal tenderness, no aural discharge
Mouth/throat Moist oral mucosa, moist lips, non
hyperemic pharyngeal wall
Chest Symmetric chest expansion, bibasal
crackles, shallow subcostal retractions, no
wheezes
 Sample Case
Physical Examination
Cardiovascular Adynamic precordium, tachycardic, regular
rhythm, no murmurs
Gastrointestinal Globular, soft abdomen, nondistended,
hyperactive bowel sounds
Extremities Grossly normal extremities, warm
extremities, full equal pulses, CRT <2 secs,
no cyanosis with good skin turgor
Musculoskeletal No limitations of movement
 Sample Case
Neurologic Examination

Sensorium and Awake with good eye contact

affect
Orientation Oriented to the three spheres
Glasgow coma 15/15
scale
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Neurologic Examination

Cranial Nerves I: n/a

II: 2-3mm equally reactive to light
III,IV, and VI: EOMs with full ROM
V: n/a
VII: No fascial asymmetry
VIII: Intact gross hearing
IX, X: Can swallow with intact gag reflex
XII: can moe, shrug shoulders
 Sample Case
Admitting Impression and Plan
Admitting Pediatric Community Acquired
Impression Pneumonia - B
Plan DAT with SAP
D5 0.3NaCl 500cc x 50 cc/hr(30ck6)
Monitor vital signs q4h and record
Diagnostic Examinations
- CBC PC
- CXR (AP-L)
- UA
 Sample Case
Admitting Impression and Plan

Therapeutics Salbutamol 1 neb q8

Cetirizine drops 1ml BID
Paracetamol drops (12mkdose)
s/b O2
 Pneumonia

• Inflammation of the parenchyma of the lungs

• Leading infectious cause of death among children <5 y/o
• Pneumonia mortality is closely linked to poverty
 Etiology

Age Group Frequent Pathogens (in order of frequency)

GBS, [Link], S. Pneumoniae, and Haemophilus

Neonates (< 3 weeks)
influenza

3wk - 3 months RSV, [Link], and [Link]

RSV, [Link], H. influenzae, [Link],

4months - 4 years
GAS

≥ 5 years [Link], [Link], [Link]

 Noninfectious Causes

• Aspiration
• Foreign bodies
• Hypersensitivity reactions
• Drug or radiation induced pneumonitis
What are the defense mechanisms of the lower respiratory
tract against infections?

• Mucociliary clearance
• Macrophages
• Secretory IgA
• Coughing
 Pathogenesis
Viral Pneumonia

• Usually results from spread of infection along the airways, accompanied

by direct injury of the respiratory epithelium → airway obstruction,
abnormal secretion, and cellular debris
 Pathogenesis
Bacterial Pneumonia

• Most often occurs when respiratory tract organisms colonize the trachea and
subsequently gain access to the lungs
• May also result from direct seeding of lung tissue after bacteremia
 Pathogenesis
S. Pneumonia

• Localedema that aids in proliferation of organisms and spread to

adjacent portion leading to characteristic focal lobar involvement
 Pathogenesis
Group A streptococcus

• Results in more diffuse lung involvement

• Pathology includes:
• Necrosis of tracheobronchial mucosa
• Exudates, edema, and local hemorrhage
• Involves lymphatic vessels with pleural involvement
 Pathogenesis
S. Aureus

• Manifests as confluent bronchopneumonia

• Often unilateral
• Presence of extensive areas of hemorrhagic necrosis and irregular areas of
cavitation of the lung parenchyma
 Pathogenesis
Mycoplasma pneumonia

• Attaches to the respiratory epithelium

• Inhibits ciliary action
• Cellular destruction and inflammatory response in the submucosa
• Airway obstruction
• Spread of infection along the bronchial tree
 Clinical Manifestations

• Fever
• Tachypnea
• Cyanosis and fatigue in infants
• Diminished appetite
• Increased worked of breathing
• Crackles and wheezing
 Tachypnea

Normal Respiratory Respiratory Rate

Age
Rate Threshold
< 2months old 35-55 breaths/min ≥ 60 breaths/min

2 months - 11 months
25-40 breaths/min ≥ 50 breaths/min
old
12 months - 59 months
20-30breaths/min ≥ 40 breaths/min
old
≥ 5 years old 15-25 breaths/min ≥30 breaths/min
Who shall be considered as having Community Acquired Pneumonia?

• A patient presenting initially with cough and/or respiratory difficulty may

be evaluated for possible presence of pneumonia
Who shall be considered as having Community Acquired Pneumonia?

• Pneumonia may be considered if any of the following positive predictors

of radiographic pneumonia is present:
O2 saturation ≤94% Wheezing or crackles

Decreased breath
Age-specific tachypnea
sounds
Chest wall retraction Nasal Flaring

Fever Consolidations as
visualized in lung
Grunting ultrasound
Who will require admission?
 Who will require admission?

• Patient
classified as pCAP C may be managed initially as outpatient
provided that all of the following are not present:
• < 2 years old
• Convulsions
• CXR with effusion, lung abscess, air leaks, or multilobar pneumonia
• O2 sat ≤ 95% at room
 When is antibiotic recommended?
pCAP A or pCAP B

• Antibiotic may be administered if a patient is:

• Beyond 2 years of age or
• With high grade fever without wheeze
 When is antibiotic recommended?
pCAP C

• Empiric antibiotic may be started if any of the following is present:

• Elevated biomarkers:
• CRP • Alveolar consolidation on
CXR
• Serum procalcitonin
• WBC count • Persistent high-grade fever
without wheeze
• Lipocalin-2
What empiric treatment should be administered ?
Bacterial Etiology - pCAP A or B

• Amoxicillin
• 40-50 mg/kg/day TID
• 90mg/kg/day TID
• Azithromycin 10mg/kg/day OD
• Clarithromycin 15mg/kg/day BID
What empiric treatment should be administered ?
Bacterial Etiology - pCAP C

• Pen G 100,000 units/kg/day in 4 divided doses

• Ampicillin 100 mg/kg/day in 4 divided doses
• Amoxicillin 40-50 mg/kg/day or 90 mg/kg/day
What empiric treatment should be administered ?
Viral Etiology (pCAP C or D clinically suspected Influenza virus)

• Infants 3-8 months

• Oseltamivir 3mg/kg/dose BID x 5 days
• Infants 9-11 months
• Oseltamivir 3.5mg/kg/dose BID x 5 days
What empiric treatment should be administered ?
Viral Etiology (pCAP C or D clinically suspected Influenza virus)

• ≥12 months, <15kg

• Oseltamivir 30mg BID x 5 days
• ≥ 12 months, > 15 kg but <23kg
• Oseltamivir 45mg BID x 5 days
• ≥ 12 months, > 23kg but < 40kg
• Oseltamivir 60mg BID x 5 days
• ≥ 12 months, > 40kg
• Oseltamivir 75mg BID x 5 days
When can a patient be considered as responding to treatment?
pCAP A or B

• Clinical stability may be assessed within 24-48 hours after consultation if

cough has improved or body temperature has returned to normal
When can a patient be considered as responding to treatment?
pCAP C

• Stability may be assessed within 24-48 hours after admission if any of the
following parameters has significantly improved or returned to normal:
• Respiratory rate
• O2 sat at room air
• Body temp
• Work of breathing
When can a patient be considered as responding to treatment?
pCAP D

• Clinicalstability may be assessed within 48-72 hours if ALL of the

following parameters have significantly improved:
• Respiratory rate
• O2 sat at room air
• Body temp
• Work of breathing
What should be done if patient is not responding to current treatment?
pCAP A or B

• If not improving, or clinically worsening, within 72 hours, diagnostic

evaluation to determine if any of the following is present may be
considered
• Coexisting illness
• Antibiotic resistance
• Other diagnosis:
• PTB
• Asthma
What should be done if patient is not responding to current treatment?
pCAP C
• If not improving, or clinically worsening, within 48 hours, diagnostic
evaluation to determine if any of the following is present may be
considered
• Coexisting illness or other etiologic agent
• Antibiotic resistance
What should be done if patient is not responding to current treatment?
pCAP C
Other diagnosis:

• Asthma • PTB • Sepsis • Pleural effusion

• Necrotizing
• Acute
• Pneumothorax • Lung abscess
pneumonia
respiratory
failure
 When can switch therapy be started?
pCAP C

• Switch from intravenous antibiotic administration to oral form may be

beneficial to reduce length of hospital stay provided ALL of the following
are present:
 When can switch therapy be started?
pCAP C

• Current parenteral antibiotic has been given for at least 24 hours

• Afebrile within the last 8 hours
• Responsive to current antibiotic therapy
• Able to feed, and without vomiting or diarrhea
• Without any current pulmonary or extrapulmonary complications
• O2 sat ≥ 95% at room air
 How can pneumonia be prevented?

• Vaccine against:
• S. pneumonia
• H. influenzae type B
• Breastfeeding
• Avoid cigarette smoke
 References

• Nelson Textbook of Pediatrics 21st Ed.

• 3rd PAPP Update [2016] in Evaluation and Management of Pediatric Community-
Acquired Pneumonia
THANK YOU!