Pulmonary Case Conference

Pulmonary Case Conference

General Data

• DC • 1 year 6 months• Male • Phase 1 Lot 29 Block 2 St. Michael St.

Camacho Nangka, Marikina City• Roman Catholic

Chief Complaint

• Fever

HPI4DaysPTC

•fever (max temp 38.90C, axillary) •(+)clear watery nasal discharge•(+)decrease in appetite,

• Paracetamol 25mg/kg/dose

3DaysPTC(+) persistence of symptoms

Phenylpropanolamine HCl drops (Disudrin) 1.6mg/kg/dose

HPI

2DaysPTC•Persistence of symptoms •(+) productive cough•3 episode of post tussive vomiting of previously ingested fluids with sputum amt 5-15ml/ episode•Prefer drinking than eating

HPI1Day PTC

•one episode of vomiting, with fever, colds, cough, decreased level of activity and decreased fluid and food intake

• consult at a local hospital • CBC (Hb 103g/L, Hct 0.32, WBC 4.8 x

109/L, platelet 270 x 109/L, Neutrophil 0.49, Lymphocytes 0.51

• Diagnosis: Lower Respiratory Tract infection

• Med: Cefixime 6mg/kg/day ; Salbutamol nebulization q8

HPIFew hours PTC

•bloody nasal discharge •blood-tinged sputum•Persistence of fever, decreased level of activity, and poor oral intake•sought consult at USTH Pedia-SBC,

Review of SystemsGeneral: (-) weight loss Skin: (-) rashes, (-) jaundice, (-) cyanosisHead: (-) injuries/lacerations, (-) eye redness, (-) eye discharge/exudates,

(-) tearing, (-) aural discharge, (-) cleft lip or palatePulmonary: HPICardiac: (-) edema, (-) cyanosisGastrointestinal: (-) diarrhea, (-) constipation, (-) melena, (-) hematocheziaGenitourinary: (-) hematuria, (-) anuria/oliguriaNeurologic/Psychiatric: (-) convulsionsHematopoietic: (-) easy bruisability, (-) bleeding manifestationsExtremities: (-) joint deformities, (-) joint swelling

Gestational History

• 28 year old, G3P2 (2002).• Frequent prenatal check-up at a local clinic • No hepatitis B screening and gestational diabetes

screening done• Denied:

• use of illicit drugs, smoking, and drinking alcohol during pregnancy. She also denied exposure to radiation or other chemicals

• Medications:– multivitamins– anti-Koch’s medication for a month

Birth History • Term at 39-40 weeks AOG delivered via NSD. • Lying-in clinic.• Attended by a midwife • labor for 2 hours • Birth weight was 6.5kg.

Neonatal History• spontaneous cry; no resuscitation was needed.• poor suck at birth• No congenital abnormalities were noted.

Feeding History

• Patient was not breastfed due to inability of mother to excrete milk.

• Milk (0-6months) - Bona (2:1 dilution) 2oz – 10-12x/day

• (6 months – 1year) – Bonamil (2:1 dilution) 4oz – 10-12x/day

• Current: Bear Brand Jr (1:1 dilution) 6oz – 4-6x/day• Complementary Feeding started at 9 months

(gruel, chicken, bread)

Feeding History

Past Medical History• Pneumonia (2009) Immunization History• Completed EPI at a local

health center• BCG 1 dose• Hepatitis B 3 doses• OPV 3 doses• DPT 3 doses• Measles 1 dose

Developmental/ Behavioral history

• Patient’s development is at par with age. – Motor: walks and runs well,

ascends stairs one foot at a time,

– Language: knows more than 10 words including mama and papa,

– Fine: drinks from a cup and uses spoon.

– Social: Understands simple directions, Shows affection by kissing parents

Socioeconomic and Environmental History• Lives with his parents and 2 older brothers

– 2-storey house• made of wood and concrete• well lit and well ventilated.

• Main water: NAWASA and water used for drinking is boiled for 30 minutes.

• Garbage is collected 3x/week and segregates and recycles.

• Father often smokes inside the house. • They have no pets and no nearby factories.

Family History

• (+) Hypertension – maternal grandmother• (+) PTB – mother – took medications for only a

month, stopped since pregnant with child • (-) DM, cancer, asthma, allergies, kidney and

thyroid disorders

Family Profile

Physical Examination

Awake, irritable, ill looking, not in cardiorespiratory distress, well nourished, moderately dehydrated

Vital signs: CR: 145bpm,regular RR: 33cpm, regular Temp:

37.00C Anthropometric measurement: Weight: 10kg (z score 0 normal) Length: 80cm (z score 0

normal) Weight for length (z score 0 normal) BMI: 15.63 (z score

0 normal)


Warm, moist skin, no active dermatoses, good skin turgor, CRT <2sec

No scalp lesions, tauma, deformities, sutres and fontanels closed

Pink palpebral conjunctiva, anicteric sclera, pupils 2-3mm ERTL, (+) sunken eyes

Midline nasal septum, (+) turbinates congested, (+) clear nasal discharge

Nonhyperemic external auditory canal, intact tympanic membrane, (+) retained cerumen, AU


Moist buccal mucosa, hyperemic posterior pharyngeal wall, tonsils grade II, bilateral

Supple neck, no palpable cervical lymph nodesSymmetrical chest expansion, (-) retractions, clear breath

soundsAdynamic precordium, apex beat at 4th LICS MCL, no murmursGlobular abdomen, normoactive bowel sounds, soft, no

palpable massesRedundant prepuce, bilateral descended testesPulses full and equal, no edema, no cyanosis

Neurologic Examination

• Awake, irritable, with spontaneous eye movement, pupils isocoric 2-3mm ERTL, no facial asymmetry, uvula midline, gross movements on all extremities, no muscle atrophy

Course in the Wards

VS on PE

• Carl Justine Decallos 316D

CR:152 RR:52 T:36.6 BW:10 kg BL:80cm BSA: 0.47

1st Hospital DayAdmitted on 1-26-11• Ill looking, poor oral intake, sunken eyeballs• Diet for age• Precaution given to progression of dehydration and signs of

respiratory distress• IVF: D5 0.3 Nacl 500cc 20-21 drops for 8 hrs• Losses were replaced via oral rehydration• Labs done: CBC with platelet• Medications started:

– Paracetamol 250mg/5ml 0.25ml q4– 0.65% NaCl nasal drops, 2-3gtts/nostril every 6 hours, then suction– Kamilosan oral spray for irritated throat 2 sprays TID

Admitting Impression

• Acute nasopharyngitis with moderate signs of dehydration

2nd Hospital Day

Jan 27 • IVF rate was decreased to 10-11gtts/min

and shifted to IVF D5IMB• Fair oral intake• No signs of dehydration• Clear and equal breath sounds

3rd Hospital DayJan 28• Chest X-Ray (PA, LAT) was requested• Salbutamol challenge• RR: 50, CBS, febrile 38-39

7:00pm• Ampicillin 250mg/SIVP q6h after negative skin test• PE: febrile 38-39, RR: 40-50, (+) rhonchi, tachypnea, retractions• Suction nasal secretions q4-6hrs• Strict aspiration precautions

4th Hospital Day

Jan 29• Day 1 of Ampicillin• PE: (-) fever, retractions

(+) crackles, RR: 30-40• Chest xray: pneumonia bilateral• IVF increased to D5IMB 41-42ml/hr

5th Hospital DayJan 30• Salbutamol Nebulization, 1 neb q3• IVF decreased to 31-32ml/hr• PE: (+) fair fluid intake and appetite

3:40pm• (+) nocturnal cough, (+) crackles, good air entry• Ampicillin is increased to 375mg/SIVP every 6 hrs• Increased Salbutamol neb 1 neb q2

7:50pm• Ampicillin is once more increased to 500mg/SIVP

Same IVF regimen

6th Hospital Day

Jan 31• Salbutamol frequency was tapered to Q3

7th Hospital Day

Feb 1• Salbutamol frequency was further lowered to

Q4• Patient advised to consume Ampicillin and

start Amoxicillin 250mg/5ml 3ml q8 (45mkd)• The remaining HD’s were unremarkable and

patient was subsequently discharged.

Subjective data• 1 year 6 months• Male• Fever• Nasal discharge• Decrease in appetite• Productive cough• Post-tussive vomiting• Eager to drink• Decreased level of activity• Blood tinged sputum

• No weight loss• Tears while crying (?)• No diarrhea• PMH: pneumonia• Exposure to cigarette

smoke• FH: mother - PTB

Objective data• CBC: anemia, leukopenia, neutropenia, lymphocytosis• Awake, irritable, ill looking, not in cardiorespiratory

distress?, well nourished, moderately dehydrated• VS: tachycardia, tachypneic • Warm, moist skin, good skin turgor, CRT <2sec• (+) sunken eyes, pulses full and equal• (+) turbinates congested, (+) clear nasal discharge• Moist buccal mucosa, hyperemic posterior pharyngeal

wall, tonsils grade II, bilateral, oral lesions?• Symmetrical chest expansion, (-) retractions, clear breath

sounds

Approach to DiagnosisSign or symptom pointing to an organ or part

of an organ system

signs symptom Organ system

Subjective findings

Moderate Dehydration

Vomiting, multiple episodes

Eager to drink

Decreased level of activity

Decrease in

appetite

Objective findings

Moderate Dehydratoin

(+) sunken eyeballs

Warm, moist skin

Good skin turgor

CRT < 2 secs.

Pulses full and equal

SYMPTOMMINIMAL OR NO

DEHYDRATION(<3% loss of BW)

MILD TO MODERATE DEHYDRATION

(3-9% loss of BW)SEVERE DEHYDRATION

(>9% loss of BW)

Mental Status Well; alert Normal, fatigued or restless, irritable

Apathetic, lethargic, unconscious

Thirst Drinks normally; might refuse liquids

Thristy; eager to drink Drinks poorly; unable to drink

Heart rate Normal Normal to increased Tachycardia with bradycardia in most severe cases

Quality of pulses Normal Normal to decreased Weak, thready, or impalpable

Breathing Normal Normal; fast deep

Eyes Normal Slightly sunken Deeply sunkenTears Present Decreased absent

Mouth and tongue Moist Dry parched

Skinfold Instant recoil Recoil in <2 sec Recoil in >2 secCapillary refill time Normal Prolonged Prolonged; minimal

Extremities Warm Cool Cold; mottled; cyanotic

Urine Output Normal to decreased Decreased MinimalFrom: Department of Health and Human Services, Centers for disease Control and Prevention: Diagnosis and management of foodbourne illnesses. MMWR2004:52;5

Respiratory System

URTI

Acute Nasopharyngitis

Acute tonsillopharyngitis

LRTI

Pneumonia

Management

Assess airway patency, breathing and circulatory status of the patient

Goals

• Imminent concerns– Stabilize the patient– Address the disease– Monitor the status

• Educational concerns– Provide general prevention and measures regarding

specific disease entities– Provide alternatives to what was used on the patient– Provide a broad view regarding handling the patient’s

concerns even after the imminent disease has resolved

Initial survey

• Awake, irritable, ill looking, in cardiorespiratory distress, well nourished, moderately hydrated

• Poor oral intake, sunken eyeballs• (+) turbinates congested, (+) clear nasal discharge• tonsils grade II, bilateral, hyperemic PPW• Pulses? Buccal mucosa? Tears? Skin turgor?• Vital signs:

– CR: 145bpm, irregular– RR: 33cpm, irregular – Temp: 37.00C

Dehydration

• General Prevention– Early institution of adequate oral maintenance

fluid therapy in children with gastroenteritis, with particular attention to replacement of ongoing stool losses and slow administration of fluids to children with vomiting.

– Use of appropriate solutions is essential to prevent electrolyte disturbance and worsening of diarrhea.

Dehydration• General Measures

– ORS 2.0-2.5% glucose and 75mmol/L Na (WHO solution) or 45-50mmol/L Na (Pedialyte, Infalyte)

– Replace entire deficit in 4 to 6 hours.• Mild – 50mL/kg• Moderate to severe – 80-100mL/kg• Ongoing losses – approximately 5mL/kg

– Slow administration -> increased volume and rate (after1 hour) with strict limits when vomiting is present

• 5mL q1-2 min– Participation of the caregiver– Monitor weight, intake and output and clinical signs

• Intractable vomiting, clinical deterioration, lack of improvement after 4 hours

Dehydration• Pharmacologic

– Curative• Treat underlying cause

– Therapeutic• Vomiting – ondansetron 0.15mg/kg

• Non Pharmacologic/Supportive– IV fluids

• Severe dehydration, shock, poor gag/suck, depressed mental status, preterm infant, severe hypernatremia (>160 mmol/L), suspected surgical abdomen

• Monitor weight, intake and output, and clinical signs.• For mild to moderate isonatremic dehydration• Rapid replacement over 2 to 6 hours (25-50 cc/kg/hr)

Dehydration

• Patient – 10 kg; moderately dehydrated• Maintenance (Holiday-Segar) = 10x100 =

1000mL• Deficit (Ludan) = 10x100 = 1000 mL• Total = 2000 mL / 24 hours = 83.33 mL/hr

• D5 LRS IMB NaCl 20-21 drops/ minute to run for 24 hours

Dehydration

Dehydration

Dehydration

• Follow up recommendations– Admission criteria

• Failure of oral or IV hydration within 4 hours• Severe hypernatremia• Substansial ongoing losses suggesting high likelihood of

recurrence of dehydration– Discharge criteria

• After initiating ORT – tolerate oral fluids at an acceptable rate to replace their deficit over 4-6 hours may be discharged with a willing and reliable caregiver and complete ORT at home

Dehydration• Expected course/prognosis

– Excellent• Possible complications

– Severe -> hypovolemic shock and ARF– Hyponatremia -> hypotonia, hypothermia, seizures– Overly rapid correction of hypernatremia -> cerebral edema

• Patient monitoring– On going losses -> maintenance solution– 5-10mL/kg for each diarrheal stool– Avoid clear liquids with excessive glucose (juices, punches, cola)– <6 months -> do not give large amount of water -> hyponatremia

Pneumonia• General Prevention

– Vaccination: influenza and pneumococcal• Lowers rate of all-cause mortality during hospitalization, respiratory

failure, and shortens median length of hospital stay

• General Measures– Outpatient: empiric treatment

• Unlike adults, there is no validated tool to identify those patients at low risk who can be treated as outpatients. In general, children, especially neonates should be managed as in patients.

• If specific pathogen is known or suspected, use appropriate antibiotic therapy

• For patients with more severe disease, beta lactam antibiotic may be combined with a macrolide

Pneumonia• Pharmacologic

– Curative• Amoxicillin (80-100mkd TID)

– H. influenzae non-type B• Amoxicillin/clavulanate (25-45 mkd BID/TID)• Cefuroxime or cefprozil (30mkd BID), cefdinir (14mkd BID), cefpodoxime (10mkd BID)• Ceftriaxone 50 mg/kg IM to initiate therapy• Macrolide or cephalosporin

– Therapeutic• Paracetamol (10mkd)

• Non-pharmacologic– Avoid strenous activities and exposure to smoke– Adequate nutrition and hydration– Watchful monitoring of deterioration of patient’s status

Pneumonia

• General Measures– Inpatient

• Failure of outpatient therapy• Hypoxemia• Inability to maintain oral hydration• Respiratory distress/apnea• Toxic appearance• Complications (effusion/empyema)• Risk to infection ( <2 months/immunocompromised)

Pneumonia• Pharmacologic

– Curative• Erythromycin (10 mg/kg IV q6h), azithromycin (2.5 mg/kg IV q12h)• If febrile – cefotaxime (200mkd q8h)• Atypical pathogen not suspected – ceftriaxone (50-75mkd q12-24h),

cefotaxime (200mkd q8h)– Therapeutic

• Paracetamol (10mkd)

• Non-pharmacologic/supportive– Oxygen as needed to keep saturation >95%– Intubation and positive pressure ventilation if clinically

indicated

Pneumonia

• Follow up recommendations– Expected course/prognosis

• Uncomplicated pneumonia -> 3-5 days– Possible complications

• Pleural effusion• Empyema• Lung abscess• Pneumatoceles• Pneumothorax• Bacteremia/sepsis

Pneumonia

• Patient monitoring– Outpatient – follow up after 3 days– Worsening or not improving – repeat or additional diagnostic

studies• Persistent fever – loculated pleural fluid or empyema

– CXR – abnormal up to 10 weeks after successful treatment• Follow up CXR – indicated for severe disease or complications

(effusion/empyema)– Recurrent bacterial pneumonia – underlying anatomical or

immunologic disorder• Abnormal antibody production, cystic fibrosis, tracheoesophangeal

fistula, pulmonary sequestration


• General Prevention– Can return to school or day care 24 hours after

starting antimicrobial therapy• General Measures

– Usually no therapy indicated, except for streptococcal origin (rare: fungal/bacterial)

– May withhold treatment for GAS pharyngitis until throat culture is available

– Steroids – not recommended


• Pharmacologic– Curative

• Oral penicillin V, IM benzathine penicillin G• Amoxicillin, Clindamycin, 1st generation oral cephalosporin• Azithromycin, Clarithromycin

– Therapeutic• Paracetamol

• Non-pharmacologic/supportive– Oral hygiene– Surgical (?)

• Tonsillectomy


• Follow up recommendations– Duration of therapy

• 10d = 3-5d -> similar cure rates– Streptococcal pharyngitis

• Clinical improvement is rapid

• Expected course/prognosis– Streptococcal -> associated with ARF and APGN– Viral -> self limited


• Possible complication– Streptoccal pharyngitis

• Suppurations• ARF• APGN

– Lemierre Syndrome• Pharyngitis -> sepsis + suppurative thrombophebitis of IJV• Seeding of septic thromboemboli

– Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS)

Herpangina

• General Prevention– Avoid contact with infected individual– MOT: feco-oral-> general hygeine

• General Measures– Self limited– Palliative and supportive– Hydration

Herpangina• Pharmacologic

– Curative • None

– Therapeutic• Analgesics

– Paracetamol• Topical anesthetics• Mouth wash

• Non pharmacologic/supportive– Hydration– Clear liquids, non irritating foods– Proper hygeine

Herpangina

• Follow up recommendations– Complete recovery

• Possible complications– Exanthem– Aseptic meningitis– Myocarditis– Encephalitis

Growth and development

• Weight: 10kg (z score 0 normal) • Length: 80cm (z score 0 normal)• Weight for length (z score 0 normal) • BMI: 15.63 (z score 0 normal) • HC: 47cm• Teeth (deciduous): all except second molars

Age Weight gain (oz/mon) Growth in length (cm/mon)

HC (cm/month)

1-3 8 oz 1.0 0.25

Growth and development

• Monitor progression of developmental milestones– Gross motor: runs well; walks up, down stairs one

step at a time– Fine motor: builds tower of 7 cubes, imitates a

circular stroke– Language: combines two to three words in

sentences; 2 step commands– Social: removes garment; toilet trained by day; turns

pages one at a time

Nutrition

• Multivitamins 10 mL QD• RENI – 1070 kcal (CHO – 161g - 642 kcal;

CHON 28 g - 112kcal; fats 30g – 268kcal)

Immunization

• Completed EPI at a local health center– BCG 1 dose– Hepatitis B 3 doses– OPV 3 doses– DPT 3 doses– Measles 1 dose

• Update vaccinations– DPT, OPV booster – 1 year after primary– MMR, varicella, Hib vaccines, pneumococcal

Preventive Pediatrics• Injury prevention

– Car restraints, protect from falls, supervise play near street, never leave unattended in car or house, water safety

• Good parenting practices– Read simple stories regularly, play games, praise/show affection;

short ritual before bedtime, night fears, night awakening, toilet training readiness

• Discipline– Need for autonomy and independence, self-comforting behavior,

thumb-sucking, masturbation, favorite toy or possession• Nutrition

– Wean from bottle, fluoride when needed

Sources• American Academy of Pediatrics. Group A streptococcal infections. Report of

the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:610-620

• Bisno, A.L. et al., Diagnosis and Management of Group A Streptococcal Pharyngitis: A practice guideline. Clin Infect Dis. 1998; 26:1020-1021.

• Casey, J.R. et al, Meta-analysis of cephalosporin vs penicillin treatment of group A sstreptococcal tonsillopharyngitis in children. Pediatrics. 2004; q113:866-882.

• Swedo, S.E. et al., Pediatric Autoimmune neuropsychiatric disorders associated with streptococcal infections: Clinical description of the first 50 cases. Am J Psychiatry. 1998; 155:264-271.

• Armon, K. et al. An Evidence and Consensus based on Guideline for Acute Diarrhea Management. Arch Dis Child. 2001; 85:132-142.

• Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: Oral rehydration, maintenance, and nutritional therapy. MMWR.

• Chang, L.Y. et al. Transmission and clinical features of enterovirus 71 infections in household contacts in Taiwan. JAMA 2004; 291: 222-227. and Philippine

Sources• Behrman, R. E. et al. Nelson’s Textbook of Pediatrics, 16th ed. • Committee on Immunization, Infectious disease society, and Philippine

Foundation for Vaccination. Childhood Immunization Schedule. 2002.• DOH & Health Services for Disease Control and Prevention.

Recommended Childhood and Adolescent Immunization Schedule. 2005.

• Bradley, J. S. Management of community acquired pediatric pneumonia in an era of increasing antibiotic resistance and conjugate vaccines. Pediatr Infect Dis J. 2002; 21:592-598.

• Kabra, S.K. Antibiotics for community acquired pneumonia in children. Cochrane Database Syst Rev. 2006.

• Winters R.W.: Principles of Pediatric Fluid Therapy. Little, Brown, 1982.• Hay, W.W. et al. Current Diagnosis and treatment in Pediatrics. 19th ed.

DISCUSSIONClk. Alexander L. Gonzales II

NASOPHARYNGITIS DEHYDRATION

PNEUMONIA

NASOPHARYNGITISDISCUSSION

NASOPHARYNGITIS

• Principal involvement is in the throat• Uncommon below 1 year• Peak at 4-7 years & continues throughout childhood• Prominent in cases of Diphtheria, herpangina,

adenovirus & Infectious mononucleosis

ETIOLOGY

• Viral: Adenovirus, enterovirus, EB virus, Herpes simplex virus.

• Bacterial: Group A hemolytic streptococcus.• Mycoplasma

CLINICAL MANIFESTATIONS

• Fever, variable depending on etiology.• Throat: erythema, exudates, ulceration, enlarged

tonsils & peticheal mottling of the soft palate• Conjunctivitis, rhinitis, hoarseness , cough• Cervical lymphadenopathy• Headache, abdominal pain

ASSESSMENT CRITERIA

• Younger child:

• Older child:

•Diarrhea.•Restlessness

•Irritability. •Vomiting.

• Fever.•Sneezing.

•Chilly.•Cough.

•Dryness & irritation of nose& throat.•Sneezing.•Muscular aches.

DIAGNOSIS

• Clinical• Throat culture• Rapid streptococcal detection kits

DIFFERENTIAL DIAGNOSIS• Infectious mononucleosis, when a

membranous exudate is present• Diphtheria, especially in the underimmunized• Herpangina, with many vesiculoulcerative

lesions in the anterior pillars & soft palate• Agranulocytosis, yellowish dirty white

exudates covering the tonsils & post ph wall• Kawasaki disease

COMPLICATIONSLow rate with viral infectionSpectrum of illness extend from pharyngitis to

tonsillitis, retropharyngeal abscess or peritonsillar abscess

In debilitated children, large chronic ulcers in the pharynx (viral or bacterial)

Mesenteric adenitis ( viral or bacterial) abdominal pain with or without vomiting

Acute glomerulonephritis & Rheumatic fever, may follow streptococcal infections

TREATMENT• Penicillin for 10 days in proven streptococcal

pharyngitis (125-250mg every 8 hrs) Or erythromycin if allergic to penicillin

• Symptomatic Rx, warm saline gargle, steam inhalation, cool bland liquids as ginger ale. Acetaminophen for throat pain.

DEHYDRATIONDISCUSSION

DEHYDRATION• Fluid and electrolytes requirements• Water: Constitutes about 70% of infant's body weight

as compared to 60% in adults• Total body water = intracellular space + intravascular

space + interstitial space• Average daily requirement of water (ml/kg):

– First year: 130 – 150 – 2 to 4 years: 100 – 130– 4 to 10 years: 70 – 100– 10 to 18 years: 50- 70

DEHYDRATION• Dehydration occurs when the amount of

water leaving the body is greater than the amount being taken in.

• We lose water routinely when:– We breathe and humidified air leaves the body;– We sweat to cool the body; and, – We urinate or have a bowel movement to get rid

the body waste products.

DEHYDRATION• Diarrhea: is the most common reason for loss of excess water. Worldwide, more

than four million children die each year because of dehydration from diarrhea.• Vomiting: can also be a cause of fluid loss .• Sweat: The body can lose significant amounts of water when it tries to cool itself

by sweating whatever the cause of hotness of the body such as intense exercising in a hot environment, or presence of fever .

• Diabetes: In people with diabetes, elevated blood sugar levels cause sugar to spill into the urine and water then follows. For this reason, frequent urination and excessive thirst are among the symptoms of diabetes.

• Chronic renal failure: dehydration occurs due to polyuria.• Burns: dehydration occur because water moves into the damaged skin. Other

inflammatory diseases of the skin are also associated with fluid loss.• Inability to drink fluids: The inability to drink adequately is the other potential

cause of dehydration.

MORTALITY/MORBIDITY

• Morbidity varies with the degree of volume depletion and the underlying cause.

• The severely volume-depleted infant or child is at risk for death from cardiovascular collapse.

• Hyponatremia resulting from replacement of free water alone may cause seizures.

• Improper management of volume repletion may cause iatrogenic morbidity or mortality.

Symptom Mild (<3% body weight lost)

Moderate (3-9% body weight lost)

Severe (>9% body weight lost)

Mental status Normal, alert Restless or fatigued,

irritableApathetic, lethargic, unconscious

Heart rate Normal Normal to increased Tachycardia or bradycardia

Quality of pulse Normal Normal to decreased Weak, thready,

impalpable

Breathing Normal Normal to increased Tachypnea and hyperpnea

Eyes Normal Slightly sunken Deeply sunken

Fontanelles Normal Slightly sunken Deeply sunken

Tears Normal Normal to decreased Absent

PHYSICAL FINDINGS SEEN WITH DIFFERENT LEVELS OF PEDIATRIC DEHYDRATION

Mucous membranes Moist Dry Parched

Skin turgor Instant recoil Recoil <2 seconds Recoil >2 seconds

Capillary refill <2 seconds Prolonged Minimal

Extremities Warm Cool Mottled, cyanotic

Mental status Normal, alert Restless or fatigued, irritable

Apathetic, lethargic, unconscious

Heart rate Normal Normal to increased Tachycardia or bradycardia


Quality of pulse Normal Normal to decreased

Weak, thready, impalpable

Breathing Normal Normal to increased

Tachypnea and hyperpnea

Eyes Normal Slightly sunken Deeply sunken

Fontanelles Normal Slightly sunken Deeply sunken

Tears Normal Normal to decreased Absent

Mucous membranes Moist Dry Parched

Skin turgor Instant recoil Recoil <2 seconds Recoil >2 seconds

Capillary refill <2 seconds Prolonged Minimal

Extremities Warm Cool Mottled, cyanotic


IMCI MANAGEMENT: Integrated management of childhood illness ( WHO)

• Plan A: – Give fluid and food to treat diarrhea at home – If child is 2 years or older and there is Cholera in your area, give antibiotic for

cholera.– Advise mother when to return immediately– Follow-up in 5 days if not improving

• Plan B: – Give fluid and food for some dehydration– If child has also a severe classification:

• Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way• Advise the mother to continue breast-feeding

– If child is 2 years or older and there is Cholera in your area, give antibiotic for cholera.

– Advise mother when to return immediately– Follow-up in 5 days if not improving

IMCI MANAGEMENT: Integrated management of childhood illness ( WHO)

• Plan C: – Give fluids for severe dehydration or If child has also

another severe classification:• Refer URGENTLY to hospital with mother giving

frequent sips of ORS on the way• Advise the mother to continue breast-feeding• If child is 2 years or older and there is Cholera in your

area, give antibiotic for cholera

PNEUMONIADISCUSSION

PNEUMONIA

• Inflammation of the parenchyma of the lungs• May be caused by:

– Microorganisms– Aspiration– Hypersensitivity reactions– Drug or Radiation induced pneumonitis

EPIDEMIOLOGY

EPIDEMIOLOGY

• Each year it cause approximately 2-3 million deaths among children <5 years old and are the leading cause of death in this age group

• About 1% of pneumonia cases result in sequelae (e.g., bronchiectasis)

• In the Philippines, it ranks 3rd in the ten leading causes of mortality in all age groups (CPG on Pneumonia, PPS)

Leading Etiologic Agents of Pneumonia Infants and Children

Age Bacterial pathogens

Viral Pathogens

Other

Neonate Group B StreptocaccusGram-negative bacilli( E.coli,K.pneumoniae,Proteus spp.,others)S.aureus

RSVHerpes simplex virusCMVAdenovirus

1-3 mo. S.pneumoniaeH.Infuenzae type b

RSV C.trachomatis

4 mo.-5 yrs S.pneumoniaeH.Influenzae type b

Parainflenza virus1 and 3,AdenovirusInfluenza viruses A and B

5 yrs and older S.pneumoniae M.pneumoniaeC.pneumoniae

Clues to The Etiology of Pneumonia Obtained Through History - Taking

Type of Contact or Prodrome Disease or Organism

- Contact with an individual with a lung infection

TuberculosisM.pneumoniaeRSVS.pneumoniae

- Infant/young child in day care H.Influenzae type BN.meningitisRespiratory viruses

Clues to The Etiology of Pneumonia Obtained Through History – TakingType of Contact or

ProdromeDisease or Organism

-Animal contact PsittacosisTularemiaPlaque, Q fever

Geographic regions HistoplasmosisCoccidioidomycosisRickettsial infections

Building construction Aspergillus spp.Air conditioning cooling towers Legionaires’ disease



-Outbreak/epidemic Group A StreptococcusInfluenzaRSV

- Smoker,smoking in household,wood-burning stove

Increase in all lower respiratory infections

- Short prodrome Bacterial agents such as S.pneumoniae,H.influenzae type b, Group A Streptococcus



- Long prodrome M.pneumoniaeC.pneumoniae or C.trachomitisRSV

- Preceding rash MeaslesN.meningitidisM.pneumoniaeS.aureus

Preceding focal abscess;intra-or extrapulmonary

S.aureus

PATHOGENESIS

• Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the patient inhales aerobic microorganisms that colonize the upper respiratory tract or respiratory support equipment

• Aspiration: occurs when the patient aspirates colonized upper respiratory tract secretions

• Hematogenous: originate from a distant source and reach the lungs via the blood stream.

COMMUNITY ACQUIRED PNEUMONIA

• Infection of the lung parenchyma in a person who is not hospitalized or living in a long-term care facility for ≥ 2 weeks

• Most common pathogen = S. pneumoniae (60-70% of CAP cases)

NOSOCOMIAL PNEUMONIA

• Hospital-acquired pneumonia (HAP)– Occurs 48 hours or more after admission, which

was not incubating at the time of admission• Ventilator-associated pneumonia (VAP)

– Arises more than 48-72 hours after endotracheal intubation

NOSOCOMIAL PNEUMONIA

• Healthcare-associated pneumonia (HCAP)– Patients who were hospitalized in an acute care hospital

for two or more days within 90 days of the infection; resided in a nursing home or LTC facility; received recent IV abx, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic

CLINICAL MANIFESTATIONS

EXTRAPULMONARYDisseminated disease Skin and soft tissue involvement arising from

bacteremia, meningitis

PLEURITIC

Referred pain to neck and back Abdominal pain if diaphragmatic involvement

PLEURAL EFFUSION/EMPYEMA

LOWER RESPIRATORY

Tachypnea/Dyspnea Shallow or grunting respiration Cough Nasal flaring intercostal

retraction

NON-SPECIFIC

Fever Malaise Headache GI complaints Apprehension Restlessness

DIAGNOSIS• Diagnostic evaluation of lower respiratory

infections:– WBC count Blood cultures– C-reactive protein– Chest radiograph– Bacterial antigen assays– Nasopharyngeal cultures

Epidemiology,Clinical,and Laboratory Features of Acute Pneumonia in Normal Infants and Children According to Etiologic Agents

Bacteria Virus MycoplasmaHistorical clues - Age Any,esp.infant Any School

age,adolescent

- Temp. Majority ≥ 39° C < 39° C Majority < 39° C

- Onset Abrupt Gradually worsening URI

Gradually worsening cough

- Others in home ill Infrequent Frequent Frequent,wk.apart

- Ass. Signs,symptom

Meningitis,otitis,arthritis

Myalgia,rash,conjunctivitis

Headache,sorethroat,myalgia

- Cough Productive Nonproductive Hacking

- Pleuritic chest pain Frequent Infrequent Infrequent


Bacteria Virus Mycoplasma

Physical Findings - Auscultatory

Confined rales,no rales.Occasional dullness to percussion,diminished tubular sounds

Diffuse,bilat. Rales.Wheezes in young infant

Unilateral rales in most

-Toxicity Degree illness > findings

Degree illness ≤ findings

Degree illness < findings

Epidemiology,Clinical,and Laboratory features of Acute Pneumonia in Normal Infants and Children According to Etiologic Agents


Radiographic Findings - Initial examination

Hyperaeration ± alveolar infiltrate

Hyperaeration± interstitial infiltrate

Alveolar-interstitial patchy infiltration

-Progression Frequent, rapid

Infrequent May be migratory

-Pleural fuild May be large, rapidly progressive

Infrequent, small, not progressive

Infrequent, small, not progressive



Laboratory Findings - Peripheral WBC/cu.mm

Majority> 15,000.Granulocytes predominate

Majority<15,000.Lymphocytes predominate

Majority normal or less than 15,000

- C-reactive protein

Majority Infrequent Infrequent

- Sed rate ≥ 30 mm/hr

Majority Majority Majority

Considerations for Inpatient Management of Children with Pneumonia

• Toxic appearance• Respiratory distress• Pleural effusion• Age considerations:

– <3 months– <3 years, with lobar pneumonia– <5 years, with lobar pneumonia (more than 1

lobe)

Considerations for Inpatient Management of Children with Pneumonia

• Existing chronic disease– Pulmonary (including asthma)– Cardiac– Renal– Diabetes mellitus– Metabolic disorders– Anemia (including sickle cell disease)– Malignancies

• Immunocompromised host• Progression of pneumonia during outpatient therapy

Initial Therapy of Pneumonia

Age

Treatment Principal pathogensOutpatient Hospitalized

0-4 wks. - Ampicillin and Gentamicin (+/-cefotaxime)

Group B Streptococcus(++)Enteric gram negativea bacilli(+)

1-5 mo. Amoxicillin ( or amoxicillin-clavulanate)

Cefotaxime* Pneumococcus(++);virus(++);S.aureus(+)

6 mo.-6 yr. Amoxicillin ( or amoxicillin-clavulanate)

Cefotaxime* +/- macrolide†

Pneumococcus(++);virus(++);S.aureus(+);Group A Streptococcus(+);Mycoplasma(+)

6 yr. Macrolide † (+/-amoxicillin)

Cefotaxime* and macrolide †

Mycoplasma( ++);pneumococcus(+);S.aureus(+);Group A Streptococcus(+);Chlamydia(+)

Immunocompromised - Cefazidime‡ and Vancomycin +/-macrolide†

Many

+Occasional cause ++common cause *or ceftriazone or cefuroxime ,†Erythromycin azithromycin or clarithromycin ,‡cefepime

PREVENTION• HIB conjugate vaccine approved 1990 resulted in

virtual eliminated of disease in infants and children• Vaccine group 11% reduction in clinical episodes• 35% decrease in radiologically-diagnosed pneumonia• 63% decrease in radiologically-confirmed lobar

pneumonia

Pneumococcal Vaccine Linked To Less Hospitalizations, Costs For Children Under Age 2

Arch Pediatr Adolesc Med. 2007;161(12):1162-1168.

• Pneumonia is the leading cause of childhood illness and death worldwide, accounting for 2 million childhood deaths per year, mainly in developing countries.

• In 2000, American children began receiving the 7-valent pneumococcal conjugate vaccine (PCV7)--which protects against pneumococcal pneumonia, caused by the Streptococcus pneumoniae bacteria--as part of the routine immunization schedule.

• This vaccine is recommended for:– all children age 2 months to 23 months – children age 24 months to 59 months

Methodology

• health records were analyzed from a database of approximately 40 large employers each year from 1997 to 2004.

• The researchers used claims data and coding from hospitals and physician visits to determine the number and cost of health care visits due to all-cause and pneumococcal pneumonia. – More than 40,000 children younger than age 2 are

represented in the database each year.Fangjun Zhou, Ph.D., and colleagues at the Centers for Disease Control and Prevention, Atlanta

Results • Comparing the rates in 2004 with those in the baseline

period of 1997 to 1999 among children younger than 2 years:– Hospitalizations due to all-cause pneumonia:

• declined from 11.5 to 5.5 per 1,000 children (52.4 percent decline)– Outpatient visits due to all-cause pneumonia:

• declined from 99.3 to 58.5 per 1,000 children (41.1 percent decline)

• Rates of hospitalization due to pneumococcal pneumonia:– declined from 0.6 to 0.3 per 1,000 children (57.6 percent decline)

• rates of ambulatory visits:– declined from 1.7 to 0.9 per 1,000 children (46.9 percent decline)

Conclusion

• "These results add to the growing evidence base of benefits of PCV7 vaccination and suggest an important role for the vaccine in reducing the burden of pneumonia and associated medical costs."

Pneumococcal Vaccine Reduces Child Deaths In Developing Countries

Editorial adaptations by ScienceDaily from materials provided by Academy of Finland

• Infections caused by the pneumococcus (Streptococcus pneumoniae) bacterium are the major causes of child mortality worldwide.

• The World Health Organisation (WHO) estimates that more than a million children die from pneumococcal meningitis and pneumonia every year. Furthermore, pneumococci cause a far greater number of minor respiratory tract infections. Severe infections can cause children to be at high risk for permanent hearing impairment, which in turn may lead to delays in development and learning difficulties.

• In the Philippines, pneumonia is the leading cause of severe morbidity and mortality among children under five years of age.

Results• A total of 12 190 children aged between six weeks and six months

participated in the ARIVAC vaccine trial. The results showed that there was a 23 percent reduction in X-ray-confirmed pneumonia among children under two years of age who received the pneumococcal vaccine. However, the vaccine did not reduce clinically diagnosed pneumonia.

• The children were given three doses of either a pneumococcal conjugate vaccine or placebo. At the same time, they were also given vaccines included in the Filipino national vaccination programme as well as a Hib vaccine. A subset of approximately thousand children was studied separately to analyze the ability of the vaccine to induce antibodies and prevent nasopharyngeal carriage of pneumococcus.

• The pneumococcal vaccine was highly effective in producing antibodies and proved to be a safe vaccine overall.

Conclusion• The results of this ARIVAC trial can be put to good use in

pneumococcal vaccine development and in assessing the burden of disease of pneumococcal infections among children.

• The results can also provide robust support to decision-makers at a national level, especially in Asia. Despite the efficacy of the vaccine, price is still a big hurdle to overcome: for resource-poor countries that do not receive international financial aid, it may take several years if not decades before they can add the vaccine to the national vaccination program.

Conclusion

• One of the merits of the vaccine trial was the extent to which it fused together international research and development co-operation.

• “The pooling of funds from several different sources successfully ensured both the scientific quality of the research and the supply of local know-how and knowledge, in accordance with the principles of sustainable development.”

Academy Research Fellow Hanna Nohynek at THL

Documents

Pulmonary Case Conference