Lower respiratory tract infection (LRTI) in

1. L ower respiratory tract infection (LRTI) in Children Dr.Osama Felemban MBBS DCH CABP AFSA CPPF Consultant Pediatric Pulmonology Clinical Assistant Professor Pediatric Department King Abdulaziz University Hospital Faculty of Medicine KAU

2. Over view Epidemiology Pathophysiology Clinical Presentation Clinical Approach Differential diagnosis Investigations Management Complication & prognosis Prevention Take Home massages References

3. 1- Over view LRTI : infection below the level of larynx Larynogotracheobronchitis Bronchitis Bronchiolitis Pneumonia

4. 2- Epidemiology The estimated incidence of LRTI is 30 per 1,000 children per year in the UK . Boys affected > than girls, (children born between 24-28 weeks compared to born at term .) Haemophilus influenzae  infection is uncomon because of immunization.

5. 3 - Pathophysiology Essentially, it is inflammation of the airways/pulmonary tissue, due to viral or bacterial infection, below the level of the larynx . Gastro- oesophageal reflux may cause a chemical pneumonitis. Smoke and chemical inhalation may cause pulmonary inflammation

6. Etiology Viral infections : e.g Influenza A Respiratory syncytial virus (RSV) Human metapneumovirus ( hMPV ) Varicella -zoster virus (VZV ) Chickenpox

7. Bacterial infection : Streptococcus pneumoniae  (the majority of bacterial pneumonias) H. influenzae Staphylococcus aureus Klebsiella pneumoniae Enterobacteria - eg,  Escherichia coli Anaerobes

8. Atypical organisms Mycoplasma pneumoniae     Legionella pneumophila ,   Chlamydophila pneumoniae     Secondary bacterial infection relatively common following viral upper respiratory tract infection (URTI) or LRTI.

9. 4 - Clinical Presentation typical viral URTI Fever Bacterial pneumonia :++ in children (persistent or repetitive fever > 38.5°C) with chest recession and a raised resp.rate Audible wheezing is not seen very often in LRTI (common with more diffuse infections ;   M. pneumoniae   and bronchiolitis). Stridor or croup suggests URTI, epiglottitis or foreign body inhalation.

10. 5 – Clinical Approach History : symptoms of LRTI is variable with age Newborn and neonates  present with: Grunting Poor feeding Irritability or lethargy Tachypnoea ± Fever (±Hypothermia) Cyanosis (in severe infection) Cough (±) In this age group beware: Particularly of streptococcal sepsis and pneumonia in the first 24 hours of life Chlamydial pneumonia, which may be accompanied by chlamydial conjunctivitis (presents in the second or third week)

11. History Infants  present with: Cough (the most common symptom after the first four weeks) Tachypneic (according to severity) Grunting Chest indrawing Feeding difficulties Irritability and poor sleep Breathing, which may be described as 'wheezy' (but usually upper airway noise) History of preceding URTI (very common ) Atypical and viral infections (especially pneumonia) may have only low-grade fever or no fever

12. Toddlers/pre-school children : P receding URTI is common Cough is the most common symptom Fever occurs most noticeably with bacterial organisms Pain (chest and abdominal) Vomiting with coughing is common (post- tussive vomiting ) Lower lobe pneumonias can cause abdominal pain

13. Older children : There will be additional symptoms to those above More expressive and articulate children will report a wider range of symptoms Constitutional symptoms may be variable described Atypical organisms are more likely in older children

14. Physical Examination General points: Examination can be difficult in young children (particularly auscultation) A careful routine of observation is essential to identify respiratory distress Pulse oximetry can be very useful in evaluation. High fever over 38.5°C may occur often

15. signs of respiratory distress: Cyanosis in severe cases Grunting Nasal flaring. In children aged under 12 months this can be a useful indicator of pneumonia Marked tachypnoea Chest indrawing ( intercostal and suprasternal recession) Other signs ; subcostal recession, abdominal 'see-saw' breathing and tripod positioning Reduced oxygen saturation (less than 95%)

16. Observation: I n good light, with the chest and abdomen uncovered, is essential Count respirations and note the respiratory rate (RR) Newborn 30-60/minute Infant 20-30/minute Toddler 20-30/minute Child 15- 20/ minute Observe the infant's feeding (to uncover decompensation during feeding) Observe the chest movements (for example, looking for splinting of the diaphragm )

17. Auscultation: Examine with warm hands and a stethoscope Take the opportunity to examine a quiet sleeping child Upper respiratory noises can be identified by listening at the nose and chest Crepitations in the chest may indicate pneumonia, + when accompanied by fever

18. Percussion: Identifies consolidation Consolidation is a later and less common finding than the crepitation of a pneumonia Later in older children there may be dullness to percussion over zones of pneumonic consolidation Bronchial breathing and signs of effusion occur late in children and localization of consolidation can be difficult to diagnose

19. 6 - Differential diagnosis Asthma Inhaled foreign body Pneumothorax Cardiac dyspnoea Pneumonitis from other causes: Extrinsic allergic alveolitis Smoke inhalation Gastro- oesophageal reflux

20. 7 - Investigations CBC: White cell count is often elevated . Microbiological studies : Blood cultures are seldom positive in pneumonia (fewer than 10% are bacteraemic in pneumococcal disease ). S putum culture Imaging: Chest radiography (CXR) is not routinely indicated in outpatient management. CXR cannot differentiate reliably between bacterial and viral infections.

21. Other tests: Tuberculin skin testing if tuberculosis is suspected. Cold agglutinins when mycoplasmal infection is suspected (50% sensitive and specific). ESR , CRP Diagnostic procedures: Drainage and culture of pleural effusions may relieve symptoms and identify the infection.

22. 8 - Management Most children with lower respiratory tract infection (LRTI) and pneumonia can be treated as outpatients, with oral antibiotics. Older children can be managed with close observation at home if they are not distressed or significantly dyspnoeic and parents can cope with the illness. Viral bronchitis and croup do not require antibiotics and mild cases can be treated at home

23. Admission of severe LRTI : Oxygen saturation <92% Respiratory rate >70 breaths/minute (≥50 breaths/minute in an older child) Significant tachycardia for level of fever Prolonged central capillary refill time >2 seconds Difficulty in breathing as shown by intermittent apnea, grunting and not feeding

24. Presence of comorbidity : congenital heart disease, chronic lung disease of prematurity, chronic respiratory conditions such as - cystic fibrosis, - bronchiectasis or - immune deficiency

25. Admission should also be considered for: All children under the age of 6 months Children in whom treatment with antibiotics has failed (most children improve after 48 hours of oral, outpatient antibiotics) Patients with troublesome pleuritic pain

26. Be sure to offer the patient and parents general support, explanation and reassurance. Respiratory support as required, including oxygen Pulse oximetry to guide management Severe respiratory distress with ↓level of consciousness and failure to maintain oxygenation indicates a need for intubation

27. Medications Antipyretics (avoid aspirin due to the danger of   Reye's syndrome ). Antibiotic treatment

28. 9 - Complication & prognosis Complete resolution after treatment should be expected in the vast majority of cases. Bacterial invasion of the lung tissue can cause pneumonic consolidation, septicemia, empyema, lung abscess (especially  S. aureus ) and pleural effusion. Respiratory failure, hypoxia and death are rare unless there is previous lung disease or the patient is immunocompromised.

29. 10 - Prevention Prevention of pneumococcal pneumonia and influenza by vaccination, for high-risk individuals with pre-existing heart or lung disease. Smoking in the home is a major risk factor for all childhood respiratory infection.

30. 11 - Take Home massages Understanding the pathophysiology of LRTI Conducting proper History Performing careful physical Examination Comprehension the Impact of the disease on the family Close follow up after discharge Avoidance of bad Habit : Smoking

31. 12 - References Guidelines for the management of community acquired pneumonia in children ; British Thoracic Society (2011 ) Pediatric Essntial Nelsom 2011 van Woensel JB, van Aalderen WM, Kimpen JL ; Viral lower respiratory tract infection in infants and young children. BMJ. 2003 Jul 5;327(7405):36-40. Michelow IC, Olsen K, Lozano J, et al ; Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004 Apr;113(4):701-7. Krilov LR ; Respiratory syncytial virus disease: update on treatment and prevention. Expert Rev Anti Infect Ther . 2011 Jan;9(1):27-32. Feverish illness in children - Assessment and initial management in children younger than 5 years ; NICE Guideline (May 2013) Mahabee-Gittens EM, Grupp -Phelan J, Brody AS, et al ; Identifying children with pneumonia in the emergency department. Clin Pediatr ( Phila ). 2005 Jun;44(5):427-35. Haider BA, Saeed MA, Bhutta ZA ; Short-course versus long-course antibiotic therapy for non-severe Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005976.