Community Acquired Pneumoniarevisedii

8/14/2019 Community Acquired Pneumoniarevisedii

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COMMUNITY-COMMUNITY-ACQUIREDACQUIRED

PNEUMONIAPNEUMONIA


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COMMUNITY-ACQUIREDCOMMUNITY-ACQUIRED

PNEUMONIAPNEUMONIA

DefinitionDefinition

Pneumonia acquired within thePneumonia acquired within the

communitycommunity


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Standardizing pneumonia definitionStandardizing pneumonia definition


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Pneumonia Or Malaria?Pneumonia Or Malaria?

Raised respiratory rate

Plasmodiumfalciparum

parasitemia>100,000/l


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ACUTE PNEUMONIAACUTE PNEUMONIA

Acute inflammation of the lungAcute inflammation of the lung

parenchyma caused by micro-parenchyma caused by micro-

organismsorganisms


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DEFINITIONS OF SOMEDEFINITIONS OF SOME

TERMSTERMS

GruntingGruntingAn expiratory sound, usually low pitched and withAn expiratory sound, usually low pitched and with

musical qualities.musical qualities.

In older children, it is frequently a sign of:In older children, it is frequently a sign of: chest pain in pneumonia with pleuritis;chest pain in pneumonia with pleuritis; pneumonia when many alveoli are affected;pneumonia when many alveoli are affected;

Also frequently seen in:Also frequently seen in: neonatal respiratory distress syndrome andneonatal respiratory distress syndrome and pulmonary oedemapulmonary oedema


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Flaring Alae NasiFlaring Alae Nasi

Widening of nostrils.Widening of nostrils.

Occurs in pneumonia complicated byOccurs in pneumonia complicated by

pleuritis.pleuritis.

Intercostal IndrawingIntercostal Indrawing

Retraction of the soft tissue betweenRetraction of the soft tissue between

the ribs during inspiration.the ribs during inspiration. It is a sign of hyperinflation and aIt is a sign of hyperinflation and a

flattened diaphragm due to smallflattened diaphragm due to small

airway obstruction.airway obstruction.


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Lower Chest Wall IndrawingLower Chest Wall Indrawing

Inward movement of the lower chest wall duringInward movement of the lower chest wall during

inspiration (sometimes the xiphisternum is alsoinspiration (sometimes the xiphisternum is alsopulled in).pulled in).

Occurs when the intrathoracic pressure isOccurs when the intrathoracic pressure is

lowered:lowered:a) Bronchial asthma;a) Bronchial asthma;

b) Bronchiolitis; andb) Bronchiolitis; and

c) Laryngotracheobronchitis.c) Laryngotracheobronchitis.

These cause airway obstruction and also reduceThese cause airway obstruction and also reduce

the intrathoracic pressure and therefore canthe intrathoracic pressure and therefore can

cause lower chest wall indrawing.cause lower chest wall indrawing.


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CLASSIFICATION OF SEVERITY OFCLASSIFICATION OF SEVERITY OF

PNEUMONIAPNEUMONIA

Non-Severe PneumoniaNon-Severe Pneumonia

Cough or difficult breathing andCough or difficult breathing and fastfast

breathing:breathing:

age < 2 monthsage < 2 months :: >> 60 breaths/min60 breaths/min

age 2 up to 12 months :age 2 up to 12 months : >> 50 breaths/min50 breaths/min

age 1 up to 5 yearsage 1 up to 5 years :: >> 4040

breaths minbreaths min


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Severe PneumoniaSevere Pneumonia

Cough or difficult breathing plusCough or difficult breathing plus atat

least oneleast one of the following signs:of the following signs:

Lower chest wall indrawing;Lower chest wall indrawing;

Nasal flaring;Nasal flaring;

Grunting (in young infants).Grunting (in young infants).


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Very Severe PneumoniaVery Severe Pneumonia

Cough or difficult breathing plusCough or difficult breathing plus atatleast oneleast one of the following:of the following:

Central cyanosis;Central cyanosis;

Inability to breast feed or drink, orInability to breast feed or drink, or

vomiting everything;vomiting everything;

((convulsions, lethargy orconvulsions, lethargy or

unconsciousnessunconsciousness););

Severe respiratory distress.Severe respiratory distress.


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EPIDEMIOLOGYEPIDEMIOLOGY

Incidence & MortalityIncidence & Mortality Burden on the under 5 years oldsBurden on the under 5 years olds

Mortality: 1 in 5 deaths amongMortality: 1 in 5 deaths among

under5under5

Risk FactorsRisk Factors

Low birth weightLow birth weight

InfancyInfancy

Outdoor Air PollutionOutdoor Air Pollution

Indoor Air PollutionIndoor Air Pollution


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Risk Factors (contd.)Risk Factors (contd.)

CrowdingCrowding-Poor Housing-Poor Housing

-Large Family Size (> 6)-Large Family Size (> 6)

NutritionNutrition

-Non breast feeding-Non breast feeding

-Vitamin A-Vitamin A

-Protein Energy Malnutrition-Protein Energy Malnutrition

HIV/AIDSHIV/AIDS

-Pneumonia unchanged in children with-Pneumonia unchanged in children with

HIVHIVinfectioninfection

-In symptomatic HIVinfected children:-In symptomatic HIVinfected children:

Incidence bacterial pneumoniaIncidence bacterial pneumonia

Severity bacterial pneumoniaSeverity bacterial pneumonia


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AETIOLOGYAETIOLOGY

A. BacteriaStreptococcus pneumoniae

Haemophilus influenzae

Staphylococcus aureus

Haemolytic streptococcus

Escherichia coli

Klebsiella Sp.

Proteus mirabilisPseudomonas aeruginosa

Mycobacterium tuberculosis

Non-typhoidal salmonella


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Aetiology (contd.)Aetiology (contd.)

B. VIRUSESB. VIRUSES

MeaslesMeasles

Respiratory Syncytial Virus (RSV)Respiratory Syncytial Virus (RSV) AdenovirusAdenovirus

ParainfluenzaeParainfluenzae

Influenzae A& BInfluenzae A& B Herpes simplex Type 1Herpes simplex Type 1


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Aetiology (contd.)Aetiology (contd.)

C. NON-VIRAL, NON-BACTERIALC. NON-VIRAL, NON-BACTERIAL Mycoplasma pneumoniaeMycoplasma pneumoniae Ureaplasma urealyticumUreaplasma urealyticum ChlamydiaChlamydia

D. PROTOZOAD. PROTOZOA

Pneumocystis carinii (jiroveci)Pneumocystis carinii (jiroveci)

E. FUNGIE. FUNGI CandidaCandida AspergillusAspergillus HistoplasmaHistoplasma


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CLINICAL FEATURES OFCLINICAL FEATURES OF

PNEUMONIAPNEUMONIA

Depend on:Depend on: Age of the patientAge of the patient

Immune and nutritional status of theImmune and nutritional status of the

patientpatient Peculiarities of the infectingPeculiarities of the infecting

organismsorganisms

Severity of the infectionSeverity of the infection


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PNEUMONIAPNEUMONIA

TheThe classical presentationclassical presentation found infound in

older children and adolescentsolder children and adolescents isis

that ofthat of

a brief mild upper respiratory tracta brief mild upper respiratory tract

infection followed by :infection followed by :

a) sudden onset of chills and rigors,a) sudden onset of chills and rigors,

b) high fever,b) high fever,

c) cough, andc) cough, and

d) chest pain.d) chest pain.


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PNEUMONIA (contd.)PNEUMONIA (contd.)

Immunocompetent older childrenImmunocompetent older childrenmay not be extremely ill.may not be extremely ill.


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Infants can present with:Infants can present with:

Mild upper respiratory tract infectionMild upper respiratory tract infection

characterized by stuffy nose,characterized by stuffy nose,

Fretfulness andFretfulness and

Diminished appetite leading toDiminished appetite leading to

Abrupt onset of fever, restlessness,Abrupt onset of fever, restlessness,apprehension and respiratoryapprehension and respiratory

distress.distress.


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Some infants may haveSome infants may have

*few or non-specific findings on*few or non-specific findings on

history and physical examination.history and physical examination.


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PNEUMONIAPNEUMONIA

(contd.)(contd.)

Others may haveOthers may have

*fever only or signs of generalized*fever only or signs of generalized

toxicity.toxicity.


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SUMMARY OFSUMMARY OFCLINICAL FEATURESCLINICAL FEATURES

OF PNEUMONIAOF PNEUMONIA

SymptomsSymptoms

CoughCough

Breathlessness / Difficulty inBreathlessness / Difficulty in

breathingbreathing

FeverFever


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SUMMARY OFSUMMARY OFCLINICAL FEATURESCLINICAL FEATURESOF PNEUMONIA (contd.)OF PNEUMONIA (contd.)

Simple Clinical SignsSimple Clinical Signs

TachypnoeaTachypnoea

Flaring alae nasiFlaring alae nasi

Chest wall indrawingChest wall indrawing


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In addition, the following signs may be elicited:In addition, the following signs may be elicited:

PalpationPalpation Chest movementChest movement :: diminished or absentdiminished or absent Mediastinal shiftMediastinal shift :: nonenone

Vocal fremitusVocal fremitus :: increased or normalincreased or normal

PercussionPercussion Dull or resonantDull or resonant

AuscultationAuscultation Breath soundsBreath sounds :: normal ( vesicular ) ornormal ( vesicular ) or

bronchialbronchial Added soundsAdded sounds :: none or crepitationsnone or crepitations

(crackles)(crackles) Vocal resonanceVocal resonance :: normal or increasednormal or increased


PNEUMONIAPNEUMONIA (contd.)(contd.)


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SignsSigns LobarLobar

consolida-consolida-

tiontion

PleuralPleural

effusioneffusion

PneumothoraxPneumothorax GeneralizedGeneralized

emphysemaemphysema

CollapseCollapse FibrosisFibrosis

ChestChest

deformitydeformity

NoneNone NoneNone NoneNone Barrel-shapedBarrel-shaped

(i.e. increased A-(i.e. increased A-

P diameter)P diameter)

Indrawing ofIndrawing of

intercostalintercostal

spacesspaces

Flat over theFlat over the

affected areaaffected area

ChestChest

MovementMovement

Dimini-Dimini-

shed orshed or

absentabsent

DiminishedDiminished

or absentor absentDiminished orDiminished or

absentabsentDiminished butDiminished but

there isthere is

symmetricalsymmetrical

expansionexpansion

AbsentAbsent DiminishedDiminished

Mediasti-Mediasti-

nal shiftnal shift

NoneNone Displaced toDisplaced to

the oppositethe opposite

side if largeside if large

Displaced to theDisplaced to the

opposite side ifopposite side if

tensiontension

NoneNone Displaced toDisplaced to

the affectedthe affected

sideside

Displaced toDisplaced to

the affectedthe affected

sideside

VocalVocal

fremitusfremitus

IncreasedIncreased AbsentAbsent DecreasedDecreased DecreasedDecreased DecreasedDecreased VariableVariable

PercussionPercussion

notenote

DullDull Stony dullStony dull Hyperresonant orHyperresonant or

tympanitictympanitic

Hyperrsonant,ab-Hyperrsonant,ab-

sent cardiac andsent cardiac and

liver dullnessliver dullness

DullDull Variable. DullVariable. Dull

over affectedover affected

areas, normalareas, normal

over areas ofover areas of

compensatorycompensatory

emphysemaemphysema

PHYSICAL SIGNS OF COMMON RESPIRATORY LESIONS


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SignsSigns LobarLobar

consolidaticonsolidati

-on-on

Pleural effusionPleural effusion Pneumo-Pneumo-

thoraxthorax

GeneralizedGeneralized

emphysemaemphysema

CollapseCollapse FibrosisFibrosis

BreathBreathsoundsound

BronchialBronchial DiminishedDiminishedvesicular,sometivesicular,someti

mes it ismes it is

bronchial at thebronchial at the

upper level ofupper level of

the fieldthe field

DiminishedDiminishedvesicular orvesicular or

absentabsent

DiminishedDiminishedvesicularvesicular

AbsentAbsent VariableVariablediminisheddiminished

vesicular orvesicular or

absent,absent,

vesicular withvesicular with

prolongedprolonged

expiration orexpiration or

low pitchedlow pitchedbronchialbronchial

AddedAdded

soundsound

Crepita-Crepita-

tionstions

(crackles)(crackles)

Pleural rub mayPleural rub may

initially beinitially be

presentpresent

NoneNone RhonchiRhonchi

(Wheezes) or(Wheezes) or

coarse crepitationscoarse crepitations

(crackles) if(crackles) if

chronic bronchitischronic bronchitis

or asthma isor asthma is

presentpresent

NoneNone Variable.Variable.

May be noneMay be none

or fineor fine

crepitationscrepitations

(crackle)(crackle)

VocalVocal

resonanresonan

-ce-ce

IncreasedIncreased

often withoften with

whisperingwhispering

pectorilo-pectorilo-

quay andquay andaegophonyaegophony

Diminished orDiminished or

absent,absent,

sometimessometimes

aegophony at theaegophony at the

upper level ofupper level ofthe fluidthe fluid

DiminishedDiminished Diminished orDiminished or

absentabsent

Dimini-Dimini-

shed orshed or

absentabsent

Decreased orDecreased or

normalnormal

PHYSICAL SIGNS OF COMMON RESPIRATORY LESIONS


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In hydro-, pyo-, orIn hydro-, pyo-, or

haemopneumothorahaemopneumothora

x, there are signs ofx, there are signs of

pneumothorax overpneumothorax over

the air and signs ofthe air and signs of

pleural fluid overpleural fluid over

the liquid.the liquid.

Splashing soundsSplashing sounds

may be heard if themay be heard if the

chest is shaken.chest is shaken.

In cavitation whichIn cavitation which

very often isvery often is

associated withassociated with

consolidation orconsolidation orfibrosis, the breathfibrosis, the breath

sound is amphoricsound is amphoric

and there isand there is

whisperingwhisperingpectriloquay. Therepectriloquay. There

are also cracklesare also crackles

(coarse crepitations).(coarse crepitations).


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DIFFERENTIAL DIAGNOSES OF THE CHILDDIFFERENTIAL DIAGNOSES OF THE CHILD

PRESENTING WITH COUGH OR DIFFICULTPRESENTING WITH COUGH OR DIFFICULT

BREATHINGBREATHING

RespiratoryRespiratory

CardiacCardiac

SystemicSystemic


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DIFFERENTIAL DIAGNOSES OF THE CHILDDIFFERENTIAL DIAGNOSES OF THE CHILD

PRESENTING WITH COUGH OR DIFFICULTPRESENTING WITH COUGH OR DIFFICULT

BREATHINGBREATHING

PNEUMONIAPNEUMONIA MALARIAMALARIA SEVERE ANAEMIASEVERE ANAEMIA

CARDIAC FAILURECARDIAC FAILURE CONGENITAL HEART DISEASESCONGENITAL HEART DISEASESTUBERCULOSISTUBERCULOSIS PERTUSSISPERTUSSIS

FOREIGN BODYFOREIGN BODY EMPYEMAEMPYEMA PNEUMOTHORAXPNEUMOTHORAX PNEUMOCYSTIS PNEUMONIAPNEUMOCYSTIS PNEUMONIA


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INVESTIGATIONSINVESTIGATIONSAIMSAIMS

To aid diagnosisTo aid diagnosis

To define the extent of diseaseTo define the extent of disease

To follow up response to treatmentTo follow up response to treatment


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INVESTIGATIONS (contd.)INVESTIGATIONS (contd.)

Chest X-rayChest X-ray

Blood cultureBlood culture

Full blood countFull blood count


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CHEST X-RAYCHEST X-RAY

PA view is sufficient for lobar orPA view is sufficient for lobar or

bronchopneumonia except tobronchopneumonia except to

demonstrate additional features likedemonstrate additional features like

pleural effusion.pleural effusion.

Chest radiograph may show patchyChest radiograph may show patchy

consolidation (bronchopneumonia),consolidation (bronchopneumonia),

lobar or segmental consolidationlobar or segmental consolidation

(lobar pneumonia) or mixed picture.(lobar pneumonia) or mixed picture.


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Vaccine probeVaccine probe


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Chest X-ray pictureChest X-ray pictureLobar consolidation in olderLobar consolidation in older

ChildrenChildren common?common? with pneumoniawith pneumonia

causedcausedbyby S. aureus.S. aureus.

Pneumatocoele also common withPneumatocoele also common with

Staphylococcus, Klebsiella & ProteusStaphylococcus, Klebsiella & Proteus


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Chest X-ray pictureChest X-ray picture

Patchy consolidations inPatchy consolidations in

bronchopneumoniabronchopneumonia

Is it predictive of the aetiology ofIs it predictive of the aetiology of

pneumonia?pneumonia?


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Repeat chest x-ray may be needed forRepeat chest x-ray may be needed for

follow up of complicated cases.follow up of complicated cases.


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FBC and DIFFERENTIAL WBCFBC and DIFFERENTIAL WBC PCV may be low or normal.PCV may be low or normal. Blood film may show toxic granulations.Blood film may show toxic granulations. Usually there is leucocytosis. LeucopeniaUsually there is leucocytosis. Leucopenia

is an ominous sign.is an ominous sign. Differential WBC Neutrophilia ifDifferential WBC Neutrophilia if

bacterial,bacterial,

lymphocytosis if viral.lymphocytosis if viral.

SPUTUM EXAMINATION (MCS)SPUTUM EXAMINATION (MCS) Very low yield because young childrenVery low yield because young children

rarely expectorate; when they expectoraterarely expectorate; when they expectoratethe s utum ac uires contaminants fromthe s utum ac uires contaminants from



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BLOOD CULTUREBLOOD CULTURE Low yield 10-30% positiveLow yield 10-30% positive



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Lung aspirateLung aspirate

High yield but invasiveHigh yield but invasive

- MCS of aspirate for bacteria detection,- MCS of aspirate for bacteria detection,

isolation and sensitivity testisolation and sensitivity test- Immunofluorescence, cell culture of- Immunofluorescence, cell culture of

aspirate for virusesaspirate for viruses

- Aspirate analyzed for other organisms- Aspirate analyzed for other organisms- Serologic tests are available to detect the- Serologic tests are available to detect the

antigen but they are not routinely doneantigen but they are not routinely done


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SERUM UREA and ELECTROLYTESERUM UREA and ELECTROLYTE

In very ill patient with suspectedIn very ill patient with suspected

electrolyte derangement due toelectrolyte derangement due to

diarrhoea, vomiting and dehydration.diarrhoea, vomiting and dehydration.


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COMPLICATIONSCOMPLICATIONS

AcuteAcute Heart failureHeart failure Pleural effusionPleural effusion EmpyemaEmpyema 3 Ps3 Ps

PneumatoceolePneumatoceole

PneumothoraxPneumothorax

PyopneumothoraxPyopneumothorax

AtelectasisAtelectasis SepticaemiaSepticaemia Acute respiratory failureAcute respiratory failure


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COMPLICATIONS (contd.)COMPLICATIONS (contd.)

ChronicChronic

Lung abscessLung abscess

BronchiectasisBronchiectasis


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TREATMENTTREATMENT

There is a need for:There is a need for: Antimicrobial RxAntimicrobial Rx Oxygen andOxygen and Supportive careSupportive care

Antimicrobial treatment is guided by:Antimicrobial treatment is guided by: Age of the patientAge of the patient Suspected or known immune status of theSuspected or known immune status of the

patient as reflected by the nutritionalpatient as reflected by the nutritionalstatusstatus Local epidemiological informationLocal epidemiological information Radiographic findingRadiographic finding

Microbiology results if availableMicrobiology results if available

( d )


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TREATMENT (contd.)TREATMENT (contd.)

Neonate to 3 monthsNeonate to 3 months

Treat as sepsis with broad spectrumTreat as sepsis with broad spectrum

antibiotics to cover for Gram +ve,antibiotics to cover for Gram +ve,

Gram -ve organisms & coliformsGram -ve organisms & coliforms

1st line antibiotic in this environment1st line antibiotic in this environment

cephalosporins e.g. cefuroxime pluscephalosporins e.g. cefuroxime plus

aminoglycosides e.g. gentamicin.aminoglycosides e.g. gentamicin.

Ceftazidime if Pseudomonas isCeftazidime if Pseudomonas is

suspected.suspected.


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3 months to 5years old3 months to 5years old

Guide is simplified by this algorithm:Guide is simplified by this algorithm:


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Erythromycin, azithromycin etcErythromycin, azithromycin etc

usually combined withusually combined with

chloramphenicol to broaden thechloramphenicol to broaden the

spectrum.spectrum.

Erythromycin plus chloramphenicol :Erythromycin plus chloramphenicol :

Chlamydia or MycoplasmaChlamydia or Mycoplasmapneumonia is suspected.pneumonia is suspected.


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Ribavarin is the drug of choice for RSVRibavarin is the drug of choice for RSV

infection if:infection if:

Life threatening,Life threatening,

Bronchopulmonary dysplasia, orBronchopulmonary dysplasia, or

Congenital heart diseases present.Congenital heart diseases present.

Rimantadine is the drug of choice for:Rimantadine is the drug of choice for:

Influenza A & B pneumoniaInfluenza A & B pneumonia

Oxygen therapyOxygen therapy


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Oxygen therapyOxygen therapy

Oxygen can be life-saving in hypoxic pneumoniaOxygen can be life-saving in hypoxic pneumonia

patients.patients.

Absolute indications for oxygen therapy are:Absolute indications for oxygen therapy are: Central cyanosisCentral cyanosis

Severe lower chest wall indrawingSevere lower chest wall indrawing Oxygen saturation < 90%Oxygen saturation < 90%

Other indications are:Other indications are:

tachypnoea of 20 breaths/min above the age-tachypnoea of 20 breaths/min above the age-specific cut -off pointspecific cut -off point restlessness ( not due to meningitis)restlessness ( not due to meningitis) titubationtitubation

tachycardiatachycardia


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In a situation where medical oxygenIn a situation where medical oxygen

is not affordable, oxygenis not affordable, oxygenconcentrator is helpful. Pulseconcentrator is helpful. Pulse

oxymetry will help to ascertainoxymetry will help to ascertain

adequate oxygenation.adequate oxygenation.


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Supportive TreatmentSupportive Treatment

Adequate calorie intake is ensuredAdequate calorie intake is ensured

by small frequent feeding with cupby small frequent feeding with cup

and spoon or N/G tube feeding (inand spoon or N/G tube feeding (in

those that feed poorly).those that feed poorly).

Fluids oral or iv to prevent or treatFluids oral or iv to prevent or treat

dehydrationdehydration


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Where pneumonia is not very severe, fluidWhere pneumonia is not very severe, fluid

can be given at 100% maintenance. Incan be given at 100% maintenance. Invery severe pneumonia withoutvery severe pneumonia without

dehydration fluid is given at dehydration fluid is given at

maintenance, to prevent SIADH. In verymaintenance, to prevent SIADH. In verysevere pneumonia + dehydration severe pneumonia + dehydration

administer deficit plus maintenance.administer deficit plus maintenance.

Antipyretics/analgesics are restricted toAntipyretics/analgesics are restricted topatients with temperature 39patients with temperature 3900C and aboveC and above

or very uncomfortable patients.or very uncomfortable patients.

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Community Acquired Pneumoniarevisedii