childhood_Pneumonia-compressed final.pptx

Childhood pneumonia

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

2. EPIDEMIOLOGY .. pneumonia Each year, about 156 million new episodes of occur world wide. Among 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.)

3. It is the leading cause of U 5 mortality , globally accounting 16% of all U5 deaths. Ref : WHO Fact sheet on Pneumonia . EPIDEMIOLOGY ..

4. RISK FACTORS Malnutrition (Z <- 2) LBW- (<2500gm) Non exclusive BF Lack of Immunization-(Measles, Pentavalent Hib, Varicella) Indoor air Pollution Parental smoking Overcrowding Zinc deficiency Poor care giving practice Concomitant diseases (Diarrhoea, Heart Diseases, Asthma etc.)

5. PNEUMONIA : CLASSIFICATION Clinical classification Etiological classification Anatomical classification Infectous Non- Infectous 1. Community acquired 2. Nosocomial pneumonia . 3. Pneumonia in immunocompromised Typical Atypical Pneumonia developed within 48 hours of hospital admission

6. ETIOLOGICAL CLASSIFICATION INFECTIOUS : BACTERIA VIRUS FUNGUS(HISTOPLASMA, BLASTOMYCES, ASPERGILLUS, COCCIDIODES, CRYPTOCOCCUS . PARASITES:ASCARIS, SRONGILOIDES . NON- INFECTIOUS : ASPIRATION OF FOOD, GASTRIC ACID, FOREIGN BODY, HYDROCARBONS , LIPOID SUBSTANCES . HYPERSENSITIVITY REACTIONS, DRUGS/RADIATION INDUCED PNEUMONITIS.

7. ETIOLOGY ACCORDING TO AGE A g e g r o u p Frequent pathogens Neonate ( < 3 wk ) Group B streptococcus , E. coli & other Gram - vebacilli, S. pneumoniae, H. influenziae type b. 3 wk – 3 mo RSV & other respiratory viruses, S. pneumoniae , H. influenziae type b, Chlamydiatrachomatis. 4 mo – 4 yr RSV & other respiratory viruses, S. pneumoniae, H. influenziae type b , Mycoplasma pneumoniae, GAS. ≥ 5 yr Mycoplasma , Chlamydophila pneumoniae, Legionella, Str pneumoniae, H. influenzae type b, Respiratory viruses.

8. RECURRENT PNEUMONIA Defined 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 experiences recurrent pneumonia :

9. Recurrent pneumonia causes: A. HEREDITARY DISORDERS: CYSTIC FIBROSIS, SICKLE CELL DISEASE. . B . Disorders of Immunity : HIV/AIDS, Brutons agammaglobinemia, Selective Ig d e f i c ie n c y , SCID, Chronic Granulomatous disease , Leucocyte adhesion defect C. Disorders of cilia : Kartagener syndrome, Immotile cilia syndrome D. Anatomic Disorders: Pulmonar y s equestration, Lobar emphysema, GER, TEF (H type), Bronchiectasis.

10. MODE OF TRANSMISSION Droplet Nuclei Nosocomial Endogenous Blood Borne

11. PATHOGENESIS Inhalation of droplet nuclei Hematogenous seeding Aspiration Colonization of organism in respiratory passage Inflammatory reaction in respiratory tract including lung parenchyma

12. 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.

13. In VIRAL PNEUMONIA , low grade fever is usually present, along with other features of respiratory distress: Tachypnea ( mostconsistent C/F) Increasedwork of breathing evident by intercostal,subcostal, and suprasternal retractions , nasal flaring , and use of accessory muscles, C yanosis and lethargy in case of severe infection , with crackles & wheezing . H yper resonant chests Clinical Manifestations

14. BACTERIAL pneumonia is characterized by : S udden high grade fever , cough, and chest pain . Drowsiness , occasionally with delirium Along with usual signs of respiratory distress, i.e. tachypnea, grunting , nasal f laring; retractions of the supraclavicular, intercostal, and subcostal areas & often cyanosis

15. IMCI (2M – 5Y)

16. IMCI: DAY1 – 2M Fast breathing, Severe chest indrawing , G runting, hypo/ hyperthermia, not feeding well, convulsion . Any of these is classified as very severe disease .

17. INVESTIGATIONS X- Ray Chest CBC ESR, C- Reactive Proteins. Blood culture. Mantoux Test

18. 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 .

19. VIRAL VS BACTERIAL PNEUMONIA

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

21. Acute phase reactants (ESR, CRP) : Higher in bacterial, normal or slightly raised in viral pneumonia. Blood culture : Blood culture results are positive in only 10%.

22. TREATMENT Treatment of suspected bacterial pneumonia is based on the presumptive cause,age and clinical appearance of the child. For mildly ill children who do not require hospitalization , amoxicillin is recommended. With the emergence of penicillin- resistant pneumococci, high doses of amoxicillin (80- 90 mg/kg/24 hr) should be prescribed. Therapeutic alternatives include cefuroxime axetil and amoxicillin/clavulanate.

23. 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 In adolescents , a respiratory f luoroquinolone (levof loxacin, moxifloxacin) may be considered as analternative.

24. The empiric treatment of suspected bacterial pneumonia in a hospitalized child start on the clinical manifestations at the time of presentation.

25. INDICATIONS FOR ADMISSION TO HOSPITAL Young age - < 6 months of age; Toxic appearance Moderate to severe respiratorydistress Inability of family to providecare at home; Failure of outpatienttherapy; Complicated pneumonia Vomiting or inability to tolerateoral fluid or medications. Immunocompromised state

26. TREATMENT AFTER HOSPITAL ADMISSION Supportive care for children Oxygen, if needed (SpO2- <92%) Fluids and ensurehydration Antipyretics, analgesics Antibiotics

27. 1. In areas without substantial high- level penicillin resistance among S. immunized against H. inf luenzae type b and S. fully pneumoniae, 2. children who are pneumoniae and 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 .

28. If viral pneumonia is suspected, it is reasonable to withhold antibiotic therapy, especially for those patients who are mildly ill, have clinical evidence suggesting viral infection and are in no respiratory distress.

29. 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). Shorter courses (5- 7 days) may also be effective, particularly for children managed on an outpatientbasis. In developing countries, oral zinc (10 mg/day for <12 mo, 20 mg/day for ≥12 mo) is advised to reduce mortality among children

30. COMPLICATIO NS Pleural effusion Empyema Lung abscess Pneumothorax Pneumatocele Delayed Resolution Respiratory Failure Metastatic Septic lesions Activation of latentTB

31. COMPLICATED PNEUMONIA

32. PROGNOSIS Typically, patients with uncomplicated community- acquired bacterial cough, pneumonia show improvement in clinical symptoms (fever, tachypnea, chest pain), within 48- 96 hours of initiation of antibiotics. Radiographic evidence of improvement lags substantially behind clinical improvement. It may take 6 to 8 weeks to return to normal.

33. When a patient does not improve with appropriate antibiotic therapy complications, such as empyema bacterial resistance nonbacterial etiologies such as viruses or fungi and aspiration of foreign bodies or food P reexisting 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, aspirationand granulomatosis with polyangitis are suspected .

34. IS DONE TO DETERMINE THE REASON FOR DELAY IN RESPONSE TO A repeat chest X- ray after treatment. BRONCHOALVEOLAR LAVAGE MAY BE INDICATED IN CHILDREN WITH RESPIRATORY FAILURE. HIGH- RESOLUTION CT SCANS MAY BETTER TO IDENTIFY COMPLICATIONS OR AN ANATOMIC REASON.

35. PREVENTI ON 1 . E x c lusive br eas t f ee d i n g up to 6 m ths age 2.Immunization against with- - Hib, PCV, Measles, Pertussis, Varicella. 3.Adequete Nutrition- -- Under nutrition causes >1 millions death under 5 due to Pneumonia. 4.Hand washing, safe water drinking & prevention of Diarrhoea. 5.Avoidance of parental or other sorts of secondary & tertiary smoking. 6.Free from indoor airpollution. 7.Zinc supplementation.