Infec'ons of the respiratory system in childhood

Theprinciplesofdiagnosisandtreatment

• Variedagents–Bacteriaandviruses• Clinicalpicturemayvarywithe;ologicalagent• Maybepresentinnormalpeoplebutmaycausediseaseinonlyfew.

Epidemiology

INTRODUCTION

•  Upperandlowerrespiratorytractseparatedatbaseofepiglo@s•  Upperrespiratorytractconsistsofairwaysfromthenostrilstothevocalcordsinthelarynx,includingtheparanasalsinusesandthemiddleear•  Thelowerrespiratorytractcoversthecon;nua;onoftheairwaysfromthetracheaandbronchitothebronchiolesandthealveoli•  Thechildren<5yrsofagegetanaverageofthreetosixepisodesofARIsannuallyregardlessofwheretheyliveorwhattheireconomicsitua;on•  TheseverityofLRIsinchildrenunderfiveisworseindevelopingcountries

Acute respiratory infec'ons

Ø ARIRESPONSIBLEFOR20%OFCHILDHOOD(<5YEARS)DEATHS(INWHICH90%FROMPNEUMONIA)

Ø ARImortalityhighestinchildren§  HIV-infected§  Under2yearofage§  Malnourished§ Weanedearly§  Poorlyeducatedparents§  Difficultaccesstohealthcare

Ø Out-pa;entsvisits§  20-60%

Ø Admissions§  12-45%

• Maycausetheinflamma;onofrespiratorytractanywherefromnosetoalveoli.• Maybeclassifiedas–AURI–AcuteUpperRespiratoryInfec;on(commoncold,pharyngi1s,epiglo41s,&o11smediaetc.)

orALRI–AcuteLowerRespiratoryInfec;on(laryngi1s,layngotrachei1s,bronchi1s,bronchioli1s&pneumonia)

Acute respiratory infec'ons

UPPER RESPIRATORY TRACT INFECTIONS

•  Diseasesofthenoseandsinuses:•  RHINITIS(COMMONCOLDORCORYZA)-RHINOVIRUSES,ENTEROVIRUSES,CORONAVIRUSES•  SINUSITIS-VIRAL/BACTERIAL

•  ACUTEPHARYNGITIS•  ADENOVIRUS,ENTEROVIRUS,RHINOVIRUS,GROUPABETAHEMOOLYTICSTREPTOCOCCUS(olderchildren)

•  LARYNGITIS:•  ACUTEINFECTIOUSLARYNGITIS-VIRAL/DIPTHERIA•  CROUP•  Inflamma;onofthelarynxtracheaandbronchi•  ACUTEEPIGLOTTITIS(SUPRGLOTTITIS)

•  EARINFECTIONS(ACUTEOTITISMEDIA)-VIRUSES,PNEUMOCOCCUS,HEMOPHILUSINFLUENZA,MORAXELLACATARRHALIS

•  TONSILLITIS•  GROUPABETAHEMOLYTICSTREPTOCOCCI,EBV

•  Childrenaverage8episodesperyear,adults3episodesperyear•  E;ologies:

•  Rhinoviruses30to35%•  Coronavirusesabout10%•  Miscellaneousknownvirusesabout20%•  Influenzaandadenovirus-30%•  Undiscoveredvirusesupto35%•  GroupAstreptococci5%to10%

•  Parainfluenzawasthefirstrespiratoryvirusisolated(1955)•  Seasonalvaria;on

•  Rhinovirusearlyfall•  Coronavirus-winter

Common Cold- RHINITIS

• Commonsymptomsaresorethroat,runningnose,nasalmucosaconges;on,sneezing,some;mesaccompaniedbyconjunc;vi;s,myalgias,fa;gue•  Incuba;onperiod12-72hours• Nasalobstruc;on,sneezing,scratchythroat• Mediandura;on1weekbut25%canlast2weeks• Pharyngealerythemaiscommonerwithadenovirusthanwithrhinoorcoronavirus

Cold

•  Mainchallengeistodis;nguishbetweenuncomplicatedcoldandstreptococcalpharyngi;sorbacterialsinusi;s•  Goodexamina;on

•  Markedexudateorpharyngealerythemasuggests•  Streptococcalinfec;on•  Adenovirus•  Diphtheria

•  Rapidan;gentestsforgroupAstreptococcus•  Rapidtechniquesforinfluenza,RSV,parainfluenza

Diagnosis and treatment

Cold- treatment

• Reduc;onofmucosaledemaandexcessivesecre;onofmucus:•  properhydra;onchild•  airhydra;on•  nasallavagewithsalinesolu;on,seawater•  suc;onofsecre;onsininfants•  decongestants(nasalsympathomime;cseg.xylometazoline,oxymetazoline)inolderchildren

• Communityacquiredbacterialsinusi;s•  S.pneumoniae•  H.influenzae•  S.pyogenes

• Nosocomialsinusi;s•  Seenincri;callyill,mechanicallyven;lated

•  S.aureus•  Pseudomonasaeruginosa•  Serra1amarcescens

•  fungal

Sinusi's

Sinusi's

• Acute-dura;onto12weeks• Clinicaldiagnosisonly

•  conserva;vetreatment•  Sinusx-rayifthesuspectedpresenceoffluid

• Chronic-dura;on>12weeksdiagnosis:interview+imagingtest•  anatomicalchangesinthesinuses•  CT,X-raybays•  invasivetreatment

• Clinicalfeatures•  Sneezing•  Nasaldischarge•  Facialpressure•  Fever•  Purulentdrainage•  Headache

•  Sinusimagingnotrou;nelyrecommended

Acute sinusi's

• Maxillary:usuallyuncomplicated•  Ethmoid:cavernoussinusthrombosis-serious•  Frontal:osteomyeli;soffrontalbone;cavernoussinusthrombosis;epidural,subdural,orintracerebralabscess;orbitalextension•  Sphenoid:Rare,riskoftoextensiontointernalcaro;dartery,cavernoussinuses,pituitary,op;cnerves;commonmisdiagnosesincludeophthalmicmigraine,asep;cmeningi;s,trigeminalneuralgia,cavernoussinusthrombosis

Acute sinusi's: complica'ons

Acute ethmoid sinusi's

•  theearliestdevelopingsinusinflamma;on• possibleinyoungerchildren,infants•  theseveresymptomsprogressesrapidly•  theinflammatoryprocessintheorbital;ssue(especiallyininfants)• highriskofintracranialcomplica;ons-CT•  absolutelynecessaryhospitaliza;on,consulta;onophthalmology

Acute maxillary sinusi's

•  -Complica;onofacuteinfec;onsupperrespiratorytract,childhoodinfec;ousdiseases,odontogenic•  -Over5-6yearsofage•  -Bilateralorunilateral•  -Headache,dila;on,painaggravatedby;l;ngthehead,cough,nasalpurifica;on

Acute frontal sinusi's

•  -Usuallycoexistswithinflamma;onofthemaxillaryandethmoidsinuses,upperrespiratorytractinfec;on•  -Olderchildren•  -Severeheadache,painintheprojec;onofthesinuses,during;l;nghead

Symptoma'c treatment:

• NSAIDs• mucoly;cs•  Inhala;ons• Drugsdecongestants• nasallavagewithsalinesolu;on•  Ensuringthecomfortofthechild(lyingdownwithheadheldhigh,non-smokingenvironment),•  adequatehydra;on

Treatment

•  Inpa;entswithmildormoderatecourseofacutesinusi;s,las;nglessthan7-10daysappliesvigilantobserva;on•  Theuseofan;bio;csisrecommendedwhen:

•  Orofacialpain,feverabove39stC•  Noimprovementaoer7-10days•  Signsofdeteriora;onaoerini;alclinicalimprovement

•  An;bio;c10-14days•  Ilinetherapy:amoxicillin•  IIlinetherapy:amoxicillinwithclavulanicacid•  inhypersensi;vityreac;onstopenicillins-cefuroxime•  Inthecaseofimmediatehypersensi;vitytobeta–lactams-macrolides:clarithromycin,azithromycin

Chronic sinusi's

•  1)An;bio;csmin.3weeks.•  2)Drugsdecongestants(eg.Oxymetazolinenasal,oralpseudoephedrine)•  3)Mucoly;c•  4)steroides(nasal,oral)•  5)salinetonose

•  2)surgicaltreatment-correc;onofanatomicalabnormali;es:adenoidectomy,adenotonsilectomy,correc;onofnasalseptum

•  Inflammatorysyndromeofthepharynx•  Mostcasesareviral•  MostimportantbacterialcauseisStreptococcuspyogenes(15-20%)

• Presentswithsoreorscratchythroat•  Inseverebacterialcasestheremaybeodynophagia,fever,headache

Acute pharyngi's

Acute pharyngitis- diagnosis

Congestion of the throat mucosa Vesicles Enlarged lumps of the throat back Pharyngitis usually coexists acute rhinitis Symptomatic treatment: - Antipyretics, analgesics - cough suppressants - Decongestant

Acute pharyngi's: physical examina'on

• Viral:edemaandhyperemiaoftonsilsandpharyngealmucosa-Rhinovirus,Coronavirus-coldsymptoms•  Streptococcal:exudateandhemorrhageinvolvingtonsilsandpharyngealwalls•  Epstein-Barrvirus(infec;ousmono):mayalsocauseexudate,withnasopharyngeallymphoidhyperplasia

•  Inflammatorysyndromeofthepharynx•  Mostcasesareviral•  MostimportantbacterialcauseisStreptococcuspyogenes(15-20%)

• Presentswithsoreorscratchythroat•  Inseverebacterialcasestheremaybeodynophagia,fever,headache

Acute pharyngi's

Cause Symptoms

Rhinovirus,Coronavirus Coldsymptoms

Adenovirus Pharyngealerythemaandexudatemaymimicstreptococcalpharyngi;sConjunc;vi;s(follicular)presentin30-50%ofcases;commonlyunilateralbutbilateralin25%ofcases

Ebstein-Barrinfec;on Fever,swollenlymphnodes,swollentonsilswithexudation

Enterovirus-e.g.Coxsackievirus(Herpangina) Small,1-2mmvesiclesonthesoopalate,uvula,andanteriortonsillarpillarswhichrupturetoformsmallwhiteulcersVomi;ngOccursmainlyinchildren

HSV-1 Severe,blisters,ulcera;onofthemucousmembranes,pain,profusesaliva;on,lackofappe;te

q  Tonsilli;siscausedbyavarietyofcontagiousviralandbacterialinfec;ons.

q  Itisspreadbyclosecontactwithotherindividualsandoccursmoreduringwinterperiods.

q  Themostcommonbacteriumcausingtonsilli;sisstreptococcus.

Tonsili's

Streptococcal pharyngi's (tonsili's)- symptoms •  suddenonset•  fever>38.5°C,headache,malaise•  sorethroataggravatedbyswallowing•  ooenabdominalpain,nausea,vomi;ng•  thepeakincidence:5-15yearsofage•  especiallyinwinter,spring•  e;ology:β-hemoly;cstreptococcusgroupA(Streptococcuspyogenes)•  includesthethroatandtonsils(tonsilli;s)•  some;mes-rush-Scarletfever

•  Enlarged,redtonsilswithexudatefoci•  loosenessandrednessofthethroat• hypertrophyoffolliclesbackofthethroat• painandswollenlymphglandsintheneckfrontandsubmandibular• petechiaeonthepalate

Physical examina'on

Streptococcal pharyngi's - diagnosis

•  Symptomsandsigns• Physicalexamina;on• Rapidtest-Streptest• ASO,throatswabculture

Treatment •  Fenoxymetylopenicilinpo100000–200000j.m./kg/24h2xfor10days(bw<40kg)2-3mlnj.m./24h2xfor10dni(childrenbw>40kg)•  Benzylpenicylinbenzathineim1x•  600000j.m.(children<40kg),1,2mlnj.m.(children>40kg)•  Cefadroxil30mg/kg1xfor10days(children<40kg)1g1xdzfor10dni(children>40kg)•  macrolides:clarithromycin,azithromycinIncasesoffrequentrecurrence:clindamycinoramoxicillinclavulanate

Complica'on aJer tonisili's

•  Systemic:•  Acuterheuma;cfever(heart,joints,skin,CNS)•  Acutepost-streptococcalglomerulonephri;s•  Myocardi;s

•  Local:•  Peritonsillarabscess(afewdaysaoerthere-anginafever,sorethroatononeside)•  Recurrentpharyngi;s,o;;smedia,sinusi;s

• Vincent’sangina:anaerobicpharyngi;s(exudate;foulodortobreath)•  Ludwig’sangina-poten;allylife-threatening,rapidlyexpanding,diffuseinflamma;onofthesubmandibularandsublingualspaces,dentalorigin• Quinsy:peritonsilli;s/peritonsillarabscess.Medialdisplacementofthetonsil;ooenspreadofinfec;ontocaro;dsheath

Vincent’s angina and Quinsy

•  S.pneumoniaeandH.influenzaetheleadingcausesinallagegroups)• Moraxellacatarrhalis:10%ofcases•  Somecasesmaybeviral(RSV,influenza,enteroviruses)• Mycoplasmapneumoniae:inflamma;onofthetympanicmembrane

Acute o''s media

Acute o''s media

§ Themostcommonconsequenceofaprolongedinfec;onofthenasopharynxunderfavorableanatomicalcondi;ons:§  Dysfunc;onoftheEustachiantube§  Hypertrophytonsils§  Adenoidhypertrophy

§ Cri;calroleofEustachiantubeasconduitbetweennasopharynx,middleear,andmastoidaircells

§ Childrenhaveshorter,widerEustachiantubesthanadults

•  earpain(throbbing)• hearingproblems•  coexis;ngsymptomsofcatarrhalinfec;ons•  aversiontofood(infants)•  irritability•  inchildren<3yearsofagenonspecificsymptoms:anxiety,vomi;ng,slightfever/fever,cryingatnight,conjunc;vi;s,poorappe;te,rubbingtheear

Symptoms

Otoscopic examina'on

Acuteo;;smedia-signstheeardrumis:§ bulging§ cloudiness§ redness

O''s media with effusion

O;;smediawitheffusion(OME)-serouso;;smedia(SOM)orsecretoryo;;smedia(SOM)§ Presenceoffluidinthemiddleear§ Thefluidmaytakeweekstoresolve

Differen'al diagnosis- AOM

•  inflamma;onofthecervicallymphnodes• pharyngi;sandtonsilli;s• mumps• diseasesoftheteeth,temporomandibularjoint• boilintheexternalauditorymeatus•  foreignbodyintheearcanal

AOM- complica'ons

• mastoidi;s• meningi;s•  venoussinusesthrombosis• brainabscess• VIInervepalsy•  labyrinthi;s•  recurrento;;smedia•  lossofhearing!!!

Treatment

• Acuteo;;smediawithpainintheini;alperiodshouldbetreatedwithibuprofenoracetaminophen.

•  Immediatean;bio;ctreatmentisrecommended:1.  Inchildrenunder6monthsofage2.  Inchildrenwithahighfeverandvomi;ng3.  Inchildrenunder2yearsofagewithbilateralo;;smedia4.  Inpa;entswithleakagefromtheear

Treatment

• Amoxicillin75-90mg/kg/dayin2doses(<40kg),1500-2000mgevery12hours(>40kg),treatment;me10daysinchildren<2r.ż5daysinchildren>2r.ż.•  Second-linean;bio;cs:amoxicillinwithclavulanicacid,cefuroximeaxe;l,cefaclor,ceoriaxone•  Inthecaseofallergytopenicillin:macrolides

Larynx diseases

• Acutediffuseinflamma;onofthelarynx(laryngi;sacutadiffusa)• Acuteinflamma;onoftheepiglo@s(epiglo@;sacuta)• Acutecroup(laryngi;sacutasubglo@ca)• Acuteinflamma;onofthelarynx,tracheaandbronchi(laryngotracheobronchi;s)• Acutemalignantinflamma;onofthelarynx,tracheaandbronchi(laryngotracheobronchi;smaligna)

Larynx disease signs

• Withoutstenosisofthelarynx:•  hoarseness•  aphonia•  barkingcough

• Withnarrowingofthelarynx•  hoarseness•  aphonia•  Inspiratorystridor•  Laryngealdyspnea(inspiratory,inspiratory-expiratory)•  workofaccessorymuscles

•  Life-threa;nginfec;on• Occursmostlyinwinters• Peakincidence:-1–6years• Maleaffectedmore• Bacterialinfec;on(Hemophilusinfluenzatypeb)• Concomitantbacteremia,pneumonia,o;;smedia,arthri;sandotherinvasiveinfec;onscausedbyH.influenzatypebmaybepresent

ACUTE EPIGLOTTITIS

• Clinicalfeatures•  Highfever,sorethroat,dyspnea,rapidlyprogressingrespiratoryobstruc;on•  Pa;entmaybecometoxic,difficultswallowing,labouredbreathing,drooling,hyperextendedneck•  Cyanosis,coma,death•  Stridorisalatefinding

ACUTE EPIGLOTTITIS

• Donotexaminethethroat• Assessmentofseverity

•  Degreeofstridor•  Respiratoryrate•  Heartrate•  Levelofconsciousness•  Pulseoximetry

EXAMINATION

• DIAGNOSIS:•  “CHERRYRED”APPEARANCEOFEPIGLOTTISONLARYNGOSCOPY•  THUMBSIGNONLATERALNECKRADIOGRAPH

ACUTE EPIGLOTTITIS

• NEEDTOBEMANAGEDWITHENDOTRACHEALINTUBATION• HELPFROMANAESTHETIST• BLOODCULTURES•  FLUIDANDELECTROLYTESUPPORT•  INTRAVENOUSAMPLICILLIN100mg/kg/dayORCEFTRIAXONE100mg/kg/day.• OTHEROPTIONS

•  (CEFUROXIMEORCEFOTAXIME)TOTALTREATMENT:-7-10DAYS

• RIFAMPICINPROPHYLAXISTOCLOSECONTACTS

TREATMENT - ACUTE EPIGLOTTITIS

• VIRALINFECTIONLEADINGTOMUCOSALINFLAMMATIONOFTHEGLOTTICANDSUBGLOTTICREGIONS• COMMONLYDUETOINFLUENZA(TYPEA),PARAINFLUENZA(1,2,3)ANDRSV• AGE:-6MONTHS–6YEARS

Laryngi's acuta subgloUca (VIRAL CROUP)

•  INITIAL:-RUNNINGNOSE,MILDCOUGH,FEVER(LOWGRADE)•  LATER(24-48HOURS):-

•  BARKINGCOUGH•  HOARSENESSOFVOICE•  NOISYBREATHING(MAINLYONINSPIRATION)

•  SYMPTOMSWORSENATNIGHTANDONLYINGDOWN•  CHILDRENPREFERTOBEHELDUPRIGHTORSITINBED•  SYMPTOMSRESOLVEWITHINAWEEK

CLINICAL FEATURES

• HOARSEVOICE• NORMALTOMODERATELYINFLAMMEDPHARYNX•  SLIGHTLYINCREASEDRESPRATEWITHPROLONGEDINSPIRATIONANDINSPIRATORYSTRIDOR• DIAGNOSIS

•  MAINLYACLINICALDIAGNOSIS

EXAMINATION

•  TREATMENT•  MOISTORHUMIDIFIEDAIR•  COLDNEBULISATION–0,9NaCl•  LOWTEMPERATURE18-20stC•  Treatmentoffever•  Fluids•  STEROIDS

•  REDUCETHESEVERITYANDDURATION/NEEDFORENDOTRACHEALINTUBATION•  dexametazon 0,15 - 0,6 mg/kg mc im. lub iv.)

•  NEBULIZEDADRENALINE(EPINEPHRINE)5mg

Treatment

Acute diffuse inflamma'on of the larynx

•  Inmostcases-adults,schoolchildrenandolderchildren•  E;ology–viral,misuseofvoice,otherirritantssubstances•  Symptoms:hoarseness,drycough,scratching,burninginthethroat,shortnessofbreathinyoungerchildren• Accompanyingsymptoms:runnynose,conjunc;vi;s•  Treatment-symptoma;c:Savingvoice,nebulisa;onwithsaline,mucoly;cs

• BRONCHITIS• BRONCHIOLITIS• PNEUMONIA

LOWER RESPIRATORY TRACT INFECTIONS

BRONCHITIS ACUTA

•  Cause•  Viral-Parainfluenzae,Adenovirus,RSV,Rhinovirus•  Bacteria

•  Primary:Bordetellapertusis,Mycoplasmapneumoniae•  Secondarytoviralinfec;on:H.influenzae,S.pneumoniae,S.aureus

•  Symptoms:•  drycoughprecededbyinflamma;onoftheURTI(2-3days)•  drycough,thenwetcough•  short-termfeverorfeverless•  vomi;ng•  expiratorydyspnea•  coughinguptoseveralweeks

BRONCHITIS ACUTA

Clinicalexamina4on•  Lungshyperinfla;on/disten;on• percussion-hyper-resonantsound,lungslimitsarelower,•  asculta;on:wheezing,rales,mediumandcoarsecracles,•  dyspneafeatures:tachypnea,respiratoryeffort,prolongedexpiratoryphase

Addi4onalexamina4on•  onlynecessaryinsevereorpersistentcases•  ChestX-ray-withoutpulomonaryconsolida;on,distensionperipheralpartsofthelungs•  gasanalysis• measurementofoxygensatura;on•  TestsforChlamydiapneumoniae,Mycoplasma,RSV

BRONCHITIS ACUTA -TREATMENT

• humidity,lowtemperature,properhydra;on•  an;pyre;cs•  symptomsofobstruc;on-nebulizedbronchodilators• bacterialsuperinfec;on-empirican;bio;c-amoxicillin;alterna;vely-cefuroxime,amoxicillinwithclavulanicacid,macrolide

•  Oneofthemostcommondiseasesininfantsandyoungchildren;typically<2yearsofage(mostinfants>6monthsofage)

•  Inflammatorydiseaseofthebronchioles•  Peakageofonset:6months

•  Some;messeverecourseoflife-threateningrespiratoryfailure

•  Mostcommonagent:RSV-respiratorysyncy;alvirus,•  Other-parainfluenzavirus,influenza,adenovirus,metapneumoviruses

•  Male:female:-2:1•  Occursmostlyinautumn/spring

•  transmissionbydropletsandbydirectcontact

BRONCHIOLITIS

•  Twophases:1.  2-3daysofinflamma;onURTI2.  Rapiddeteriora;onofgeneralcondi;on:

•  Dyspnea-insipratory-expiratory,respiratorycyanosis,•  Dry,paroxysmalcough,some;mescausingvomi;ng•  Loud,wheezingbreath•  Irritability,feedingdifficulty•  Episodesofapnoea

CLINICAL FEATURES

•  Rapidshallowbreathing(60-80/min)•  Centralcyanosis/pallor•  Useofaccessorymusclesofrespira;on

Subcostal/intercostalrecessions,Flaringofalaenasi

•  Expiratorywheeze/grun;ng•  Prolongedexpira;on,tachypnoe•  Hyper-resonantpercussionnotes•  Chesthyperinfla;on•  Ausculta;on:finecracklesatthetopoftheinhala;onandexhala;onbeginning,wheezing,silenceoverthelungs!!!(extremehyperinfla;on)

EXAMINATION FINDINGS IN BRONCHIOLITIS

•  ChestX-ray•  Hyperinfla;on,increasedlucencyandincreasedbronchovascularmarkingsandmildinfiltrates

•  arterialbloodgas(hypercapnia,hypoxemia,acidosis)•  completebloodcount,CRP•  Pulseoximetry•  Nasopharyngealswabs(viralculture)•  Viralan;bodytests

BRONCHIOLITIS

AchestX-raydemonstra;nglunghyperinfla;onwithaflazeneddiaphragmandbilateralatelectasisintherightapicalandleobasalregionsina16-day-oldinfantwithseverebronchioli;s

• COMPLICATIONS•  Pneumonia•  Pneumothorax•  Dehydra;on•  Respiratoryacidosis•  Respiratoryfailure•  Heartfailure•  Prolongedapneicspellsàdeath

BRONCHIOLITIS

•  Mainlysuppor;ve-humidifytheair,appropriateplacementofthechild,assistedevacua;onofsecre;onsfromthenose•  Nebulisa;onshypertonic3%sodiumchloridesolu;on•  nebulizedadrenaline•  Oxygeninhala;on(achieveO2>92%)•  Iftachypneic,limittheoralfeedsanduseangtubeforfeeding•  Parenteralfluidstolimitdehydra;on•  Correctrespacidosisandelectrolyteimbalance•  Mechanicalven;la;on(severerespdistressorapnoea)

•  Notrou;nelyrecomended:β-agonists,an;cholinergics,Ribavirin,steroids•  Notusedrou;nely:Immunoglobulinan;-RSV

BRONCHIOLITIS - treatment

Inflamma;onofthelungparenchymaandisassociatedwiththeconsolida;onofthealveolarspacesDevelopedworld

Viralinfec;onsLowmorbidityandmortality

Developingworld-commoncauseofdeathBacteriaandPCPin65%

PNEUMONIA

• Varyaccordingto•  Age,immunestatus,wherecontracted

• Developedcountries•  Viruses:RSV,Adenovirus,Parainfluenza,Influenza•  MycoplasmapneumoniaeandChlamydiapneumoniae•  Bacteria:5-10%

• Developingcountries•  S.pneumoniae,H.influenzae,Saureus•  Viruses40%•  Other:Mycoplasma,Chlamydia,Moraxella

E'ology

ETIOLOGY ACCORDING TO AGE

AGEGROUP CAUSATIVEORGANISM

NEONATES GROUPBSTREPTOCOCCUSE.COLIKLEBSIELLASTAPHAUREUS

INFANTS RSV,parainflenza,adenovirus,infleunzavirusgrypy,enterovirus,rhinovirus,HSVPNEUMOCOCCUSCHLAMYDIAH.INFLUENZATYPEb

CHILDREN1TO5YRS RESPIRATORYVIRUSESPNEUMOCOCCUSH.INFLUENZATYPEbC.TRACHOMATISM.PNEUMONIAES.AUREUSGPASTREPTOCOCCUS

CHILDREN5TO18YRS M.PNEUMONIAEPNEUMOCOCCUSC.PNEUMONIAEH.INFLUENZATYPEb

Pneumonia

Pneumonia

Community-AcquiredPneumonia

Atypicalpneumonia

(mycoplasma;c,chlamydia,viral)

Typicalpneumonia(bacterial)

Nosocomialpneumonia

Aspira;onpneumonia

Pneumonia- diagnosis

ü Fever ü Cough ü Dyspnea expiratory- inspiratory, ü Tachypnoe And … +Typical sounds during auscultation + typical changes in X-ray •  ThebasisofdiagnosisisachestX-ray•  Lungconsolida;onoftheonesegmentallobe•  Inters;;alchangesNOTE:intheearlystagesofthediseasex-raymaybenormal

•  Signofrespiratorydistress;nasalflaring&chestindrawing

•  Youngerthan2months•  Decreasedlevelofconsciousness•  Stridorwhencalm

•  Severemalnutri;on•  Associatedsymptoma;cHIV/AIDS

Danger Signs

Bacterial pneumonia -symptoms

•  youngerchildrenooenatypicalsymptoms:•  fever>38.5stC,chills•  anxiety•  gastro–intes;nalproblems•  tachypnoe>50/min.•  withoutcoughingearlyinthedisease

•  inolderchildren(>6yearsofage)imageofatypical,similartothatobservedinadults:•  cough,tachypnea•  fever>38.5stC,chills•  paininthechest

Bacterial pneumonia

Clinicalexamina4on• Percussion:thedullsoundovertheareaofinflamma;on•  Tremorchestincreased• Ausculta;on:•  -finecracles•  -Tighteningofthefollicularmurmur•  -Murmurbronchial

Addi4onaltests•  X-rayCHEST:densityinflammatory:lobar,inters;;al

•  LABORATORYTESTS:•  -WBC(upto15-40thousand/mm3),thepredominanceofneutrophilsorWBC<5thousand/mm3(badprognosis)

•  -Shiototheleoinasmearofwhitebloodcells,anemiainsevereinfec;ons(eg.Staphylococcal)

•  -ArterialbloodgaspO2•  -ESR,CRP•  -Bacteriacultureofsputum,(chargeontopofthefever),pleuralfluid

Atypical pneumonia

•  Thee;ologyofMycoplasmapneumoniae,Chlamydophilapneumoniae•  schoolchildren•  insidiousonset• moderatefever•  jointpain,headache,cough,;ring,unproduc;ve,wheezing,•  respiratoryratenormalorincreased•  characteris;csofhyperinfla;on•  X-ray:inters;;alinfiltrates,pleuraleffusion,lymphadenopathyinthehilumlung•  Serologicaltests-an;bodies

Viral pneumonia

•  E;ology:RSvirus,influenza,parainfluenza,adenovirus,measles,CMV,• Pneumoniaprecededbyinflamma;onoftheupperairways•  Inolderchildrenmild,withoutcomplica;ons.Ininfantsandtoddlerscoursemaybesevereandlife-threatening.•  Inthecaseofthee;ologyofRSV->wheezing,shortnessofbreath•  Laboratorytests:leukocytosiswithlymphocytosis• X-ray:inters;;alchanges,hyperinfla;on

Treatment

•  Thecool,moistair• Respiratoryphysiotherapy• Adequatehydra;on• Proceedingsan;pyre;c(non-pharmacologicalmethod,drugs)andanalgesic• An;bio;c

• An;tussives,an;histamines-notrecommended!!

An'bio'cs

•  Children3week-thethirdmonthoflife-amoxicillinwithclavulanateorcefuroxime•  Inseverecases-cefotaximeorceoriaxoneincombina;onwithcloxacillin.•  Ifthee;ologyisatypical-macrolide•  Children3months-5yearsold–ampicilinoramoxicillin•  Children5-15yearsold-amoxicillinormacrolide,forsevereconcomitanttreatment->macrolideandamoxicillin

•  Thedura;onoftreatment7to10dayswhenazitromicin5days•  Inmilderformofdisease-5days

Preven'on

• VACCINATIONS:•  vaccina;onagainstH.influenzaetypeB(vaccina;onrequired)(2mo,3-4mo,5-6mo,16/18mo)•  vaccina;onagainstS.pneumoniae(vaccina;onrecommended)•  influenzavaccina;on(vaccina;onrecommendedonceayear)

Bacterial•  Poorlydemarcatedalveolaropaci;eswithairbronchograms•  Lobarorsegmental•  Opacifica;on

Viral•  Peripheralstreaking,inters;;alchanges,•  airtrapping

Radiology- chest X- ray

• Cluestootherspecificorganisms•  Staphylococcus–areasofbreak-down•  Klebsiella,anaerobes,H.influenzaorTB–cavita;ngorexpansilepneumonia•  TB,S.aureus,H.influenza

•  pleuraleffusionandempyema

Radiology