Pneumonia (Pathophysiology and management) by Sunil Kumar Daha

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1. Causative agents of pneumonia according to age group , Clinical features and management Sunil Kumar Daha

2. Pneumonia Inflammation of the lung parenchyma Classification: 1. Lobar or lobular, 2. Bronchopneumonia and 3. Interstitial pneumonia Pathologically, there is consolidation of alveoli , infiltration of interstitial tissue with inflammatory cells or both

3. Etiology Viral Pneumonia : RSV, Influenza, Parainfluenza and Adenovirus Bacterial Pneumonia: 1 st 2 months: Klibsella , E.coli and gram+ve organisms like pneumocci and staphylococci 3 months – 3 years: S. p neumonia , H. influenzae and staphylococci > 3 years: Pneumococci and Staphylococci Atypical pneumonia: Chlamydia and Mycoplasma spp . Pneumonia in immunocompromised Children : Pneumocystis Jeroveci , Histoplasmosis , Cocidiomycosis

4. Risk Factors Low birth weight Malnutrition Vitamin A deficiency Lack of breast-feeding Passive smoking Large family size Family history of bronchitis Advanced birth order Crowding Young age Air pollution

5. Pneumococcal pneumonia Causative organism : Streptococcous Pneumoniae Transmission : Infectious droplets Incubation period : 1 – 3 days Clinical features : Abrupt onset with headache, chills, cough and high fever Dry cough but rarely associated with thick rusty sputum Pleural pain may be present Respiration is rapid Grunting , chest in drawing ,difficulty feeding and cyanosis may be seen in severe cases

6. Pneumococcal pneumonia Treatment: Penicillin V 250 mg 8-12 hr orally for 7 days Penicillin-G 0.5 MU/kg/day IV Procaine Penicillin 0.6 MU IM daily, for 7 days Amoxycilin (30-40 mg/kg/day for 7 days) O 2 therapy for cyanosis, respiratory distress IV fluid if dehydrated

7. Staphylococcal Pneumonia Causative organism : Staphylococci Clinical features: Usually follows URTI, pyoderma or a purulent disease Patient is toxic and sick looking Cyanosis may be present Rapid progression of signs and symptoms Pulmonary infection complicated by disseminated disease pneumatoceles ( X-RAY)

8. Treatment: Antipyretics to control fever Hydration by intravenous fluid Oxygen to relieve dyspnea and cyanosis Empyema is aspirated and pus is sent for culture and sensitivity Antibiotic therapy with coamoxiclav , or a combination of cloxacilin and 3 rd generation cephalosporin If unresponsive, vancomycin , teicoplanin or linezolid is given Therapy to be continued till disappearance of evidence of disease clinically and radiographically . Staphylococcal Pneumonia

9. Haemophilus pneumonia Causative Organism: Haemophilus influenzae Clinical features: Gradual onset with nasopharyngeal infection Viral infections like influenza virus act synergistically with H. influenzae Moderate fever, dyspnoea , grunting, retraction of lower Intercostal spaces. Complications: Bacteremia, pericarditis, empyema, meningitis and polyarthritis

10. Treatment: Ampicilin at dose of 100mg/kg/day or, coamoxiclav Cefotaxime (100mg/kg/day) or ceftriaxone(50-75 mg/kg/day) in seriously ill patients. Haemophilus pneumonia

11. Streptococcal pneumonia Organism: Streptococcous pyogens Clinical features: Usually secondary to measles, chicken pox, whooping cough or influenza Abrupt onset with fever, chills, dyspnoea , rapid respiration, cough, blood streaked sputum Signs of bronchopneumonia are usually less pronounced

12. Primary Atypical Pneumonia Organism: M. pneumoniae Incubation period: 12-14 days Clinical features: Malaise, headache, fever, sore throat, myalgias and cough Cough initially dry, later mucoid with blood streak Mild pharyrngeal congestion, unusual dyspnea, cervical lymphadenopathy and few crepitations Hemolytic anemia may be seen Treatment: Macrolides or Tetracycline (for older children ) for 10 days

13. Pneumonia due to Gram- ve Organisms Organism: E.coli , Klebsella and Pseudomanas Clinical features: Gradual onset Minimal signs of consolidation Treatment: Cephalosporin 3 rd generation( cefotaxime or ceftriaxone, 75-100 mg/kg/day) with or without aminoglycosides for 10 to 14 days Ceftazidine or piperacilin-tazobactam for psedomonas infection

14. Viral pneumonia Organism: RSV ( <6 months of age), influenza, Para-influenza and adeno virus Clinical features: Fever and/or chills Cough , tachypnoea or dyspnoea Tachycardia or bradycardia Wheezing, rhonchi, rales Sternal or intercostal retraction Hypoxia, ARDS Supportive treatment

15. Pneumonia due to ingestion of aliphatic hydrocarbon Etiology: kerosene (hydrocarbons ) Clinical features: Cough, dysponea , high fever, vomitng , drowsiness and coma Treatment: Vomitting is not induced Gastric lavage not performed to prevent inadvertent aspiration Oxygen is given Use of Antibiotics and/or corticosteroids is not recomended

16. Loeffler’s syndrome Etiology : Larva of intestinal parasites Drugs: aspirin, penicillin, sulfonamide and imipramine Clinical features: Cough, low fever and scattered crepitation . Treatment: Symptomatic

17. Aspiration pneumonia Occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach. Symptoms Chest pain Coughing up foul-smelling, greenish or dark phlegm (sputum), or phlegm that contains pus or blood Fatigue ,fever, SOB,wheezing ,excessive sweating, breath odour ,difficulty swallowing Treatment is supportive.

18. Ref e rences : Nelson’s Textbook of Paediatrics 19 th edition. OP Ghai and Paul Bagga , E ssential Paediatrics 8 th edition Medscape

19. T hank you