BRONCHOPNEUMONIA-POWER POINT PRESENTATION

Bronchopneumonia is a upper respiratory tract infection

1. MWANAMISI BAKARI BSCN PEDIATRIC PNEUMONIA

2. Pneumonia is defined as inflammation of the lung parenchyma . (Ref : Nelson Text Book of Pediatrics 20 th)

3. Epidemiology .. E ach year, about 156 million new episodes of pneumonia occur world wide . Am ong which 151 million episodes in developing countries . ( Ref : Epidemiology and Etiology of Childhood Pneumonia . Rudan I, Campbell, et al. Bull World Health Organ 2008 , May ; 86(5):408-16.)

4. I t i s the lea d ing cause o f U 5 m ortality , g l o bal l y accounting 1 6 % o f a l l U 5 deaths . Ref : WHO Fact sheet on Pneumonia . Epidemiology ..

5. Risk factors 1. Malnutrition ( Z <-2) 2. LBW-(< 2500gm) Non exclusive BF La c k of I mmuni z at i o n - ( Measles, Pentavalent Hib, Varicella) Indoor air Pollution Parental smoking Overcrowding Zinc deficiency Poor care giving practice Concomitant diseases (Diarrhoea, Heart Diseases, Asthma etc.)

6. Pneumonia : Classification Clinical classification Etiological classification Anatomical cl a ssi f icat ion Infectous Non- In f ec t o u s 1. Community acquired 2. Nosocomial pneumonia . 3. Pneumonia in immunocompromised Typical Atypical Pneumonia developed within 48 hours of hospital admission

7. Etiological Classification INFECTIOUS : Bacteria Virus Fungus(Histoplasma, Blastomyces,Aspergillus, C o c cidiode s , C r yp t o c o c cu s . P a r asi t es :A scar i s , Srongiloides . NON-INFECTIOUS : Aspiration of food, gastric acid, foreign body, hydrocarbons , lipoid substances . Hypersensitivity reactions, Drugs/radiation induced pneumonitis.

8. Etiology according to age Age group Frequent pathogens Neonates ( < 3 wk ) Group B streptococcus , E. coli & other Gram -ve bacilli, S. pneumoniae, H. influenziae type b. 3 wk – 3 mo RSV & other respiratory viruses, S. pneumoniae , H. influenziae type b, Chlamydia trachomatis. 4 mo – 4 yr RSV & other respiratory viruses, S. pneumoniae, H. influenziae type b , Mycoplasma pneumoniae, GAS. ≥ 5 yr M y c oplas m a , Chla m y d o phila pneumo n ia e, L eg ionella , S t r pneumoniae, H. influenzae type b, Respiratory viruses.

9. RECURRENT PNEUMONIA D efined as 2 or more episodes in a single year or 3 or more episodes ever, with radiographic clearing between occurrences. An underlying disorder should be considered if a child e x perien c e s recurrent pneumonia :

10. Recurrent pneumonia causes: A. Hereditary disorders: Cystic Fibrosis, Sickle Cell Disease. B. Disorders Selective of I mmu ni t y : HI V /AI D S, Bru t o n s a g a m ma g lobine m i a, I g de f ici e n c y , SCI D , Ch r onic G r an u lom a t o u s disease, Leucocyte adhesion defect. C. Disorders of cilia : Kartagener syndrome, Immotile cilia syndrome. Disorders: D. Ana t omi c Pulmona r y seques t r atio n , L obar emp h y s e ma, GER, TEF (H type), Bronchiectasis.

11. Mode of Transmission Droplet Nuclei Nosocomial Endogenous Blood Borne

12. P a th o g enesis Inhalation of droplet nuclei Hematogenous seeding Aspiration Colonization of organism in respiratory passage Inflammatory reaction in respiratory tract including lung parenchyma

13. Stages of pneumonia Stage of congestion : Lung parenchyma filled with inflammatory exudate. Stage of red hepatization : massive exudation with red cells, neutrophil & fibrin in alveoli . Stage of grey hepatization : progressive disintegration of RBC with greyish brown discoloration. Stage of resolution : Progressive removal of exudate from alveolar space.

14. In VI R AL PNEUMO N I A , l o w g r ade f e v e r i s usu a l l y p r esen t , al o n g with other features of respiratory distress : Tachypnea ( most consistent C/F), I nc r ease d w o r k o f b r ea t hin g evide n t b y i n t e r c o s t a l, s u b c o s ta l , a n d suprasternal retractions , nasal flaring , and use of accessory muscles, 4. hyper resonant chests 3. cyanosis and lethargy in case of severe infection , with crackles & wheezing . Clinical Manifestations

15. BACTERIAL pneumonia is characterized by : sudden high grade fever , cough, and chest pain . D rowsiness , occasionally with delirium A long with usual signs of respiratory distress, i . e . tac h y p nea , gru n tin g , nasa l f l a ri n g ; r et r actio n s o f the supraclavicular, intercostal, and subcostal areas & often cyanosis.

16. Investigations X-Ray Chest CBC ESR, C-Reactive Proteins. Blood culture. Mantoux Test

17. Chest X-Ray Viral pneumonia is usually characterized by: hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing . Confluent lobar consolidation &/or pleural effusion is typically seen with pneumococcal pneumonia .

18. CBC In viral pneumonia: WBC - normal or usually not higher than 20,000/mm 3 , with a lymphocyte predominance. In bacterial pneumonia: E levated WBC count, 15,000-40,000/mm 3 with predominance of granulocytes .

19. TREATMENT T rea t ment o f suspected bacte r ial p neum o nia i s b a s ed o n the presumpt i ve cause,age and clinical appearance of the child. Fo r mi l d l y ill chil d r en who d o no t requ i re h o s p i t aliz a t i on , amo x ic i l l in is recommended. With the emerg e nce o f pe n ic i lli n-resist a nt pn e um o cocci, h igh dos e s of amoxicillin (80-90 mg/kg/24 hr) should be prescribed. Therapeutic alternatives include cefuroxime axetil and amoxicillin/clavulanate.

20. For school-aged children and in children with suggested infection of M. Pneumoniae or C. pneumoniae , a macrolide antibiotic such as azithromycin is an appropriate choice. I n ado l es c e n t s , a r espi r a t o r y f luo r o q ui n olone (l e v o f l o x a c i n, moxifloxacin) may be considered as an alternative.

21. The e m pir i c t r eatme n t o f suspe c t ed bac t er ia l pneumo n i a in a h ospi t al i z ed child start on the clinical manifestations at the time of presentation.

22. Indications for admission to hospital Young age - < 6 months of age; Toxic appearance Moderate to severe respiratory distress Inability of family to provide care at home; Failure of outpatient therapy; Complicated pneumonia Vomiting or inability to tolerate oral fluid or medications. Immunocompromised state

23. Treatment after hospital admission Supportive care for children Oxygen, if needed (SpO2-<92%) Fluids and ensure hydration Antipyretics, analgesics Antibiotics

24. 1 . In a r eas wi t h o u t s u bstantia l hi g h-le v el penicillin r e s i s t a n c e a mo n g S. pneumoniae, immuni z e d aga i ns t H . in f l u e nza e typ e b and S. 2. child r en w ho a r e ful l y pneumoniae and 3. are not severely ill should receive ampicillin or penicillin G. For children who do not meet these criteria, ceftriaxone or cefotaxime should be pneumonia initial antimicrobial used. If clinical features suggest staphylococcal therapy vancomycin or clindamycin .

25. to withhold I f v i r al pneumo n ia is s u spe c t ed, i t is r ea s ona b le antibiotic therapy, especially for those patients who are mildly ill, h a v e clini cal evid e n c e sug g esting vi r al in f e c tio n and are in no respiratory distress.

26. The optimal duration of antibiotic treatment for pneumonia has not been well- established in controlled studies. Antibiotics should generally be continued until the patient has been afebrile for 72 hr, and the total duration should not be < 10 days (or 5 days for azithromycin). Sho r t er c o ur ses (5-7 d a y s) m a y also b e e f f ect i v e, p ar t icula r l y f or child r en managed on an outpatient basis. In developing countries, oral zinc (10 mg/day for <12 mo, 20 mg/day for ≥12 mo) is advised to reduce mortality among children.

27. C om p li c a tions Pleural effusion Empyema Lung abscess Pneumothorax Pneumatocele Delayed Resolution Respiratory Failure Metastatic Septic lesions Activation of latent TB

28. Prognosis Typically, patients with uncomplicated community-acquired bacterial c ou g h, pneumonia show improvement in clinical symptoms (fever, tachypnea, chest pain), within 48-96 hours of initiation of antibiotics. R adio g r a p h ic evide n c e o f i m p r o v ement lags substant i al l y behin d clinic a l improvement. It may take 6 to 8 weeks to return to normal.

29. When a patient does not improve with appropriate antibiotic therapy complications, such as bacterial resistance nonbacterial etiologies such as viruses or fungi and aspiration of foreign bodies or food preexisting diseases such as immuno deficiencies, ciliary dyskinesia, cystic fibrosis, pulmonary sequestration or congenital pulmonary airway malformation and other noninfectious causes including bronchiolitis obliterans, hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration and granulomatosis with polyangitis are suspected .

30. is done to determine the reason for delay in response to A repeat chest X-ray treatment. Bronchoalveolar lavage may be indicated in children with respiratory failure. High-resolution CT scans may better to identify complications or an anatomic reason.

31. P r e v e n tion 1.Exclusive Breastfeeding up to 6 months of age . 2.Immunization against with-- Hib, PCV, Measles, Pertussis, Varicella. Adequete Nutrition---Under nutrition causes >1 millions death under 5 due to Pneumonia. Hand washing, safe water drinking & prevention of Diarrhoea. 5.Avoidance of parental or other sorts of secondary & tertiary smoking. 6.Free from indoor air pollution. 7.Zinc supplementation.

32. Q-1 Most dangerous sign in LRTI in Children is ? A-Abdominal Breathing B-Chest Retraction C-Grunting D- Tachypnoea

33. Q-2 WHO criteria for hospital Admission in Pneumonia ? A-High Fever B-Nasal Flaring C-Difficulty in breathing D-Chest Indrawing

34. Q-3 Which is the following is leading cause of mortality in Under 5 children in developing countries? A-Malaria B-Acute lower respiratory tract infections C- Hepatits D-Prematurity

35. Q-4 Pneumothorax Could be a complication of ? A- Staphyllococcal Pneumonia B -Pneumococcal P neumonia C - Klebsiella Pneumonia D-Viral Pneomonia

36. Q-5 A 4 year old malnourished child is brought to subcentre with breathing rate of 55/ min., Excessive crying, irritability, fever and not taking feeds. The ANM assesses the child and categorizes under the IMNCI guidelines for the management of ARI as ? A-No Pneumonia B-Very Severe Disease C-Pneumonia D-Upper Respiratory Tract infection

37. ANSWERS Q-1 (C)-Grunting Q-2 (C)- Difficulty in breathing Q-3 (B)-Acute lower respiratory tract infections Q-4 (A)- Staphyllococcal Pneumonia Q-5 (B)-Very Severe Disease

38. Viral vs Bacterial Pneumonia

39. Staphylococcal vs Streptococcal pneumonia