Community Acquired Pneumoniarevisedii

COMMUNITYACQUIRED PNEUMONIA

COMMUNITY-ACQUIRED PNEUMONIA Definition  Pneumonia

community

acquired within the

 Standardizing

pneumonia definition

Pneumonia Or Malaria? Raised respiratory rate Plasmodium falciparum parasitemia >100,000/µl

ACUTE PNEUMONIA  Acute

inflammation of the lung parenchyma caused by microorganisms

DEFINITIONS OF SOME TERMS Grunting An expiratory sound, usually low pitched and with musical qualities. In older children, it is frequently a sign of:  chest pain in pneumonia with pleuritis;  pneumonia when many alveoli are affected; Also frequently seen in:  neonatal respiratory distress syndrome and  pulmonary oedema

Flaring Alae Nasi Widening of nostrils.  Occurs in pneumonia complicated by pleuritis. Intercostal Indrawing Retraction of the soft tissue between the ribs during inspiration.  It is a sign of hyperinflation and a flattened diaphragm due to small airway obstruction.

Lower Chest Wall Indrawing Inward movement of the lower chest wall during inspiration (sometimes the xiphisternum is also pulled in). 

Occurs when the intrathoracic pressure is lowered: a) Bronchial asthma; b) Bronchiolitis; and c) Laryngotracheobronchitis. These cause airway obstruction and also reduce the intrathoracic pressure and therefore can cause lower chest wall indrawing.

CLASSIFICATION OF SEVERITY OF PNEUMONIA Non-Severe Pneumonia 

Cough or difficult breathing and fast breathing: – age < 2 months

:

> 60 breaths/min

– age 2 up to 12 months : > 50 breaths/min – age 1 up to 5 years breaths/min

:

> 40

Severe Pneumonia Cough or difficult breathing plus at least one of the following signs:  Lower  Nasal

chest wall indrawing; flaring;

 Grunting

(in young infants).

Very Severe Pneumonia Cough or difficult breathing plus at least one of the following:  Central

cyanosis;

 Inability

to breast feed or drink, or vomiting everything;

 (convulsions,

lethargy or unconsciousness);

 Severe

respiratory distress.

EPIDEMIOLOGY Incidence & Mortality  Burden on the under –5 years olds  Mortality: 1 in 5 deaths among under–5 Risk Factors • Low birth weight • Infancy • Outdoor Air Pollution • Indoor Air Pollution

Risk Factors (contd.) • Crowding -Poor Housing -Large Family Size (> 6)

• Nutrition -Non breast feeding -Vitamin A -Protein Energy Malnutrition • HIV/AIDS -Pneumonia unchanged in children with HIV infection -In symptomatic HIV–infected children: ↑Incidence bacterial pneumonia ↑Severity bacterial pneumonia

AETIOLOGY A. Bacteria Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Haemolytic streptococcus Escherichia coli Klebsiella Sp. Proteus mirabilis Pseudomonas aeruginosa Mycobacterium tuberculosis Non-typhoidal salmonella

Aetiology (contd.) B. VIRUSES  Measles  Respiratory Syncytial Virus (RSV)  Adenovirus  Parainfluenzae  Influenzae A& B  Herpes simplex Type 1

Aetiology (contd.) C. NON-VIRAL, NON-BACTERIAL  Mycoplasma pneumoniae  Ureaplasma urealyticum  Chlamydia D. PROTOZOA Pneumocystis carinii (jiroveci) E. FUNGI  Candida  Aspergillus  Histoplasma

CLINICAL FEATURES OF PNEUMONIA Depend on:  Age of the patient  Immune and nutritional status of the patient  Peculiarities of the infecting organisms  Severity of the infection

CLINICAL FEATURES OF PNEUMONIA The classical presentation found in older children and adolescents is that of a brief mild upper respiratory tract infection followed by : a) sudden onset of chills and rigors, b) high fever, c) cough, and d) chest pain.

CLINICAL FEATURES OF PNEUMONIA (contd.)  Immunocompetent older children may not be extremely ill.

CLINICAL FEATURES OF PNEUMONIA (contd.) Infants can present with:  Mild upper respiratory tract infection characterized by stuffy nose,  Fretfulness and  Diminished appetite leading to  Abrupt onset of fever, restlessness, apprehension and respiratory distress.

CLINICAL FEATURES OF PNEUMONIA (contd.) Some infants may have *few or non-specific findings on history and physical examination.

CLINICAL FEATURES OF PNEUMONIA (contd.) Others may have *fever only or signs of generalized toxicity.

SUMMARY OF CLINICAL FEATURES OF PNEUMONIA Symptoms  Cough  Breathlessness

breathing

 Fever

/ Difficulty in

SUMMARY OF CLINICAL FEATURES OF PNEUMONIA (contd.) Simple Clinical Signs •Tachypnoea •Flaring alae nasi •Chest wall indrawing



CLINICAL FEATURES OF PNEUMONIA (contd.)

In addition, the following signs may be elicited:

Palpation  Chest movement  Mediastinal shift  Vocal fremitus :

: diminished or absent : none increased or normal

Percussion  Dull or resonant Auscultation  Breath sounds : bronchial  Added sounds : (crackles)  Vocal resonance

normal ( vesicular ) or none or crepitations :

normal or increased

PHYSICAL SIGNS OF COMMON RESPIRATORY LESIONS Signs

Lobar consolidation

Pleural effusion

Pneumothorax

Generalized emphysema

Collapse

Fibrosis

Chest deformity

None

None

None

Barrel-shaped (i.e. increased AP diameter)

Indrawing of intercostal spaces

Flat over the affected area

Chest Movement

Diminished or absent

Diminished or absent

Diminished or absent

Diminished but there is symmetrical expansion

Absent

Diminished

Mediastinal shift

None

Displaced to the opposite side if large

Displaced to the opposite side if tension

None

Displaced to the affected side

Displaced to the affected side

Vocal fremitus

Increased

Absent

Decreased

Decreased

Decreased

Variable

Percussion note

Dull

Stony dull

Hyperresonant or tympanitic

Hyperrsonant,absent cardiac and liver dullness

Dull

Variable. Dull over affected areas, normal over areas of compensatory emphysema

PHYSICAL SIGNS OF COMMON RESPIRATORY LESIONS Signs

Lobar consolidati -on

Pleural effusion

Pneumothorax

Generalized emphysema

Collapse

Fibrosis

Breath sound

Bronchial

Diminished vesicular,someti mes it is bronchial at the upper level of the field

Diminished vesicular or absent

Diminished vesicular

Absent

Variable diminished vesicular or absent, vesicular with prolonged expiration or low pitched bronchial

Added sound

Crepitations (crackles)

Pleural rub may initially be present

None

Rhonchi None (Wheezes) or coarse crepitations (crackles) if chronic bronchitis or asthma is present

Variable. May be none or fine crepitations (crackle)

Vocal resonan -ce

Increased often with whispering pectoriloquay and aegophony

Diminished or Diminished absent, sometimes aegophony at the upper level of the fluid

Diminished or absent

Decreased or normal

Diminished or absent

CLINICAL FEATURES OF PNEUMONIA (contd.) 

In hydro-, pyo-, or haemopneumothora x, there are signs of pneumothorax over the air and signs of pleural fluid over the liquid. Splashing sounds may be heard if the chest is shaken.



In cavitation which very often is associated with consolidation or fibrosis, the breath sound is amphoric and there is whispering pectriloquay. There are also crackles (coarse crepitations).

DIFFERENTIAL DIAGNOSES OF THE CHILD PRESENTING WITH COUGH OR DIFFICULT BREATHING

 Respiratory  Cardiac  Systemic

DIFFERENTIAL DIAGNOSES OF THE CHILD PRESENTING WITH COUGH OR DIFFICULT BREATHING           

PNEUMONIA MALARIA SEVERE ANAEMIA CARDIAC FAILURE CONGENITAL HEART DISEASES TUBERCULOSIS PERTUSSIS FOREIGN BODY EMPYEMA PNEUMOTHORAX PNEUMOCYSTIS PNEUMONIA

INVESTIGATIONS

AIMS  To aid diagnosis  To define the extent of disease  To follow up response to treatment

INVESTIGATIONS (contd.)  Chest

X-ray

 Blood

culture

 Full

blood count

CHEST X-RAY  PA view is sufficient for lobar or bronchopneumonia except to demonstrate additional features like pleural effusion.  Chest radiograph may show patchy consolidation (bronchopneumonia), lobar or segmental consolidation (lobar pneumonia) or mixed picture.

INVESTIGATIONS (contd.) “Others”  Rapid antigen tests  Lung aspiration?  Immunofluorescence  Cell culture  Serology

INVESTIGATIONS (contd.) Vaccine probe

INVESTIGATIONS (contd.) Chest X-ray picture Lobar consolidation in older Children common? with pneumonia caused by S. aureus. Pneumatocoele also common with Staphylococcus, Klebsiella & Proteus

Chest X-ray picture Patchy consolidations in bronchopneumonia Is it predictive of the aetiology of pneumonia?

INVESTIGATIONS (contd.) Repeat chest x-ray may be needed for follow up of complicated cases.

INVESTIGATIONS (contd.) FBC and DIFFERENTIAL WBC  PCV may be low or normal.  Blood film may show toxic granulations.  Usually there is leucocytosis. Leucopenia is an ominous sign.  Differential WBC – Neutrophilia if bacterial, lymphocytosis if viral. SPUTUM EXAMINATION (MCS)  Very low yield because young children rarely expectorate; when they expectorate the sputum acquires contaminants from

INVESTIGATIONS (contd.) BLOOD CULTURE  Low yield 10-30% positive

Lung aspirate  High yield but invasive - MCS of aspirate for bacteria detection, isolation and sensitivity test - Immunofluorescence, cell culture of aspirate for viruses - Aspirate analyzed for other organisms - Serologic tests are available to detect the antigen but they are not routinely done

SERUM UREA and ELECTROLYTE In very ill patient with suspected electrolyte derangement due to diarrhoea, vomiting and dehydration.

COMPLICATIONS Acute  Heart failure  Pleural effusion  Empyema  3 Ps – – –   

Pneumatoceole Pneumothorax Pyopneumothorax

Atelectasis Septicaemia Acute respiratory failure

COMPLICATIONS (contd.) Chronic  Lung abscess  Bronchiectasis

TREATMENT There is a need for:  Antimicrobial Rx  Oxygen and  Supportive care Antimicrobial treatment is guided by:  Age of the patient  Suspected or known immune status of the patient as reflected by the nutritional status  Local epidemiological information  Radiographic finding  Microbiology results if available

TREATMENT (contd.) Neonate to 3 months  Treat as sepsis with broad spectrum antibiotics to cover for Gram +ve, Gram -ve organisms & coliforms  1st line antibiotic in this environment cephalosporins e.g. cefuroxime plus aminoglycosides e.g. gentamicin.  Ceftazidime if Pseudomonas is suspected.

3 months to 5years old  Guide is simplified by this algorithm:

 Erythromycin,

azithromycin etc

usually combined with chloramphenicol to broaden the spectrum. • Erythromycin plus chloramphenicol : Chlamydia or Mycoplasma pneumonia is suspected.



Ribavarin is the drug of choice for RSV infection if: Life threatening, Bronchopulmonary dysplasia, or Congenital heart diseases present.

• Rimantadine is the drug of choice for: Influenza A & B pneumonia

Oxygen therapy Oxygen can be life-saving in hypoxic pneumonia patients. Absolute indications for oxygen therapy are:  Central cyanosis  Severe lower chest wall indrawing  Oxygen saturation < 90% Other indications are:  tachypnoea of 20 breaths/min above the agespecific cut -off point  restlessness ( not due to meningitis)  titubation  tachycardia

 In

a situation where medical oxygen

is not affordable, oxygen concentrator is helpful. Pulse oxymetry will help to ascertain adequate oxygenation.

Supportive Treatment  Adequate

calorie intake is ensured

by small frequent feeding with cup and spoon or N/G tube feeding (in those that feed poorly).  Fluids

– oral or iv to prevent or treat

dehydration



Where pneumonia is not very severe, fluid can be given at 100% maintenance. In very severe pneumonia without dehydration fluid is given at ¾ maintenance, to prevent SIADH. In very severe pneumonia + dehydration – administer deficit plus ¾ maintenance.



Antipyretics/analgesics are restricted to patients with temperature 390C and above or very uncomfortable patients.



Treat complications if and when they