COMMUNITY-

ACQUIRED
PNEUMONIA
 COMMUNITY-ACQUIRED
PNEUMONIA
Definition

 Pneumonia acquired within the

community
 Standardizing pneumonia definition
Pneumonia Or Malaria?
Raised respiratory rate
Plasmodium
falciparum
parasitemia
>100,000/µl
 ACUTE PNEUMONIA
 Acuteinflammation of the lung
parenchyma caused by micro-
organisms
 DEFINITIONS OF SOME
TERMS
Grunting
An expiratory sound, usually low pitched and with
musical qualities.

In older children, it is frequently a sign of:

 chest pain in pneumonia with pleuritis;
 pneumonia when many alveoli are affected;

Also frequently seen in:

 neonatal respiratory distress syndrome and
 pulmonary oedema
Flaring Alae Nasi
Widening of nostrils.
 Occurs in pneumonia complicated by
pleuritis.

Intercostal Indrawing
Retraction of the soft tissue between
the ribs during inspiration.
 It is a sign of hyperinflation and a
flattened diaphragm due to small
airway obstruction.
Lower Chest Wall Indrawing
Inward movement of the lower chest wall during
inspiration (sometimes the xiphisternum is also
pulled in).

 Occurs when the intrathoracic pressure is

lowered:
a) Bronchial asthma;
b) Bronchiolitis; and
c) Laryngotracheobronchitis.

These cause airway obstruction and also reduce

the intrathoracic pressure and therefore can
cause lower chest wall indrawing.
 CLASSIFICATION OF SEVERITY OF

PNEUMONIA
Non-Severe Pneumonia

 Cough or difficult breathing and fast

breathing:
– age < 2 months : > 60 breaths/min

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

– age 1 up to 5 years : > 40

breaths/min
Severe Pneumonia

Cough or difficult breathing plus at

least one of the following signs:

 Lower chest wall indrawing;

 Nasal flaring;

 Grunting (in young infants).

Very Severe Pneumonia
Cough or difficult breathing plus at
least one of the following:
 Central cyanosis;
 Inability
to breast feed or drink, or
vomiting everything;
 (convulsions,
lethargy or
unconsciousness);
 Severe respiratory distress.
 EPIDEMIOLOGY
Incidence & Mortality
 Burden on the under –5 years olds
 Mortality: 1 in 5 deaths among
under–5

Risk Factors
• Low birth weight
• Infancy
• Outdoor Air Pollution
• Indoor Air Pollution
Risk Factors (contd.)
• Crowding
-Poor Housing
-Large Family Size (> 6)
• Nutrition
-Non breast feeding
-Vitamin A
-Protein Energy Malnutrition
• HIV/AIDS
-Pneumonia unchanged in children with
HIV
infection
-In symptomatic HIV–infected children:
↑Incidence bacterial pneumonia
↑Severity bacterial pneumonia
 AETIOLOGY
A. Bacteria
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Haemolytic streptococcus
Escherichia coli
Klebsiella Sp.
Proteus mirabilis
Pseudomonas aeruginosa
Mycobacterium tuberculosis
Non-typhoidal salmonella
 Aetiology (contd.)
B. VIRUSES
 Measles
 Respiratory Syncytial Virus (RSV)
 Adenovirus
 Parainfluenzae
 Influenzae A& B
 Herpes simplex Type 1
 Aetiology (contd.)
C. NON-VIRAL, NON-BACTERIAL
 Mycoplasma pneumoniae
 Ureaplasma urealyticum
 Chlamydia

D. PROTOZOA
Pneumocystis carinii (jiroveci)

E. FUNGI
 Candida
 Aspergillus
 Histoplasma
 CLINICAL FEATURES OF
PNEUMONIA
Depend on:
 Age of the patient
 Immune and nutritional status of the
patient
 Peculiarities of the infecting
organisms
 Severity of the infection
 CLINICAL FEATURES OF
PNEUMONIA
The classical presentation found in
older children and adolescents is
that of
a brief mild upper respiratory tract
infection followed by :
a) sudden onset of chills and rigors,
b) high fever,
c) cough, and
d) chest pain.
 CLINICAL FEATURES OF
PNEUMONIA (contd.)
 Immunocompetent older children
may not be extremely ill.
 CLINICAL FEATURES OF
PNEUMONIA (contd.)
Infants can present with:
 Mild upper respiratory tract infection
characterized by stuffy nose,
 Fretfulness and
 Diminished appetite leading to
 Abrupt onset of fever, restlessness,
apprehension and respiratory
distress.
 CLINICAL FEATURES OF
PNEUMONIA (contd.)
Some infants may have
*few or non-specific findings on
history and physical examination.
 CLINICAL FEATURES OF
PNEUMONIA
(contd.)
Others may have
*fever only or signs of generalized
toxicity.
SUMMARY OF CLINICAL FEATURES
OF PNEUMONIA
Symptoms
 Cough

 Breathlessness / Difficulty in
breathing

 Fever
SUMMARY OF CLINICAL FEATURES
OF PNEUMONIA (contd.)
Simple Clinical Signs

•Tachypnoea

•Flaring alae nasi

•Chest wall indrawing

 CLINICAL FEATURES OF
PNEUMONIA (contd.)
 In addition, the following signs may be elicited:

Palpation
 Chest movement : diminished or absent
 Mediastinal shift : none
 Vocal fremitus : increased or normal

Percussion
 Dull or resonant

Auscultation
 Breath sounds : normal ( vesicular ) or
bronchial
 Added sounds : none or crepitations
(crackles)
 Vocal resonance : normal or increased
PHYSICAL SIGNS OF COMMON RESPIRATORY LESIONS

Signs Lobar Pleural Pneumothorax Generalized Collapse Fibrosis

consolida- effusion emphysema
tion
Chest None None None Barrel-shaped Indrawing of Flat over the
deformity (i.e. increased A- intercostal affected area
P diameter) spaces

Chest Dimini- Diminished Diminished or Diminished but Absent Diminished

Movement shed or or absent absent there is
absent symmetrical
expansion

Mediasti- None Displaced to Displaced to the None Displaced to Displaced to

nal shift the opposite opposite side if the affected the affected
side if large tension side side

Vocal Increased Absent Decreased Decreased Decreased Variable

fremitus

Percussion Dull Stony dull Hyperresonant or Hyperrsonant,ab- Dull Variable. Dull

note tympanitic sent cardiac and over affected
liver dullness areas, normal
over areas of
compensatory
emphysema
 PHYSICAL SIGNS OF COMMON RESPIRATORY LESIONS
Signs Lobar Pleural effusion Pneumo- Generalized Collapse Fibrosis
consolidati thorax emphysema
-on
Breath Bronchial Diminished Diminished Diminished Absent Variable
sound vesicular,someti vesicular or vesicular diminished
mes it is absent vesicular or
bronchial at the absent,
upper level of vesicular with
the field prolonged
expiration or
low pitched
bronchial
Added Crepita- Pleural rub may None Rhonchi None Variable.
sound tions initially be (Wheezes) or May be none
(crackles) present coarse crepitations or fine
(crackles) if crepitations
chronic bronchitis (crackle)
or asthma is
present
Vocal Increased Diminished or Diminished Diminished or Dimini- Decreased or
resonan often with absent, absent shed or normal
-ce whispering sometimes absent
pectorilo- aegophony at the
quay and upper level of
aegophony the fluid
 CLINICAL FEATURES OF
PNEUMONIA (contd.)
 In hydro-, pyo-, or  In cavitation which
haemopneumothora very often is
x, there are signs of associated with
pneumothorax over consolidation or
the air and signs of fibrosis, the breath
pleural fluid over sound is amphoric
the liquid.
and there is
Splashing sounds
whispering
may be heard if the
chest is shaken. pectriloquay. There
are also crackles
(coarse crepitations).
 DIFFERENTIAL DIAGNOSES OF THE CHILD
PRESENTING WITH COUGH OR DIFFICULT
BREATHING

 Respiratory

 Cardiac

 Systemic
 DIFFERENTIAL DIAGNOSES OF THE CHILD
PRESENTING WITH COUGH OR DIFFICULT
BREATHING
 PNEUMONIA
 MALARIA
 SEVERE ANAEMIA
 CARDIAC FAILURE
 CONGENITAL HEART DISEASES
 TUBERCULOSIS
 PERTUSSIS
 FOREIGN BODY
 EMPYEMA
 PNEUMOTHORAX
 PNEUMOCYSTIS PNEUMONIA
 INVESTIGATIONS
AIMS
 To aid diagnosis
 To define the extent of disease
 To follow up response to treatment
INVESTIGATIONS (contd.)
 Chest X-ray

 Blood culture

 Full blood count

CHEST X-RAY
 PA view is sufficient for lobar or
bronchopneumonia except to
demonstrate additional features like
pleural effusion.
 Chest radiograph may show patchy
consolidation (bronchopneumonia),
lobar or segmental consolidation
(lobar pneumonia) or mixed picture.
INVESTIGATIONS (contd.)
“Others”
 Rapid antigen tests
 Lung aspiration?
 Immunofluorescence
 Cell culture
 Serology
INVESTIGATIONS (contd.)
Vaccine probe
 INVESTIGATIONS (contd.)
Chest X-ray picture
Lobar consolidation in older
Children common? with pneumonia
caused
by S. aureus.

Pneumatocoele also common with

Staphylococcus, Klebsiella & Proteus
Chest X-ray picture
Patchy consolidations in
bronchopneumonia

Is it predictive of the aetiology of

pneumonia?
 INVESTIGATIONS (contd.)
Repeat chest x-ray may be needed for
follow up of complicated cases.
 INVESTIGATIONS (contd.)
FBC and DIFFERENTIAL WBC
 PCV may be low or normal.
 Blood film may show toxic granulations.
 Usually there is leucocytosis. Leucopenia
is an ominous sign.
 Differential WBC – Neutrophilia if
bacterial,
lymphocytosis if viral.

SPUTUM EXAMINATION (MCS)

 Very low yield because young children
rarely expectorate; when they expectorate
the sputum acquires contaminants from
INVESTIGATIONS (contd.)
BLOOD CULTURE
 Low yield 10-30% positive
Lung aspirate
 High yield but invasive

- MCS of aspirate for bacteria detection,

isolation and sensitivity test
- Immunofluorescence, cell culture of
aspirate for viruses
- Aspirate analyzed for other organisms
- Serologic tests are available to detect the
antigen but they are not routinely done
SERUM UREA and ELECTROLYTE
In very ill patient with suspected
electrolyte derangement due to
diarrhoea, vomiting and dehydration.
 COMPLICATIONS
Acute
 Heart failure
 Pleural effusion
 Empyema
 3 Ps
– Pneumatoceole
– Pneumothorax
– Pyopneumothorax
 Atelectasis
 Septicaemia
 Acute respiratory failure
 COMPLICATIONS (contd.)
Chronic
 Lung abscess
 Bronchiectasis
 TREATMENT
There is a need for:
 Antimicrobial Rx
 Oxygen and
 Supportive care
Antimicrobial treatment is guided by:
 Age of the patient
 Suspected or known immune status of the
patient as reflected by the nutritional
status
 Local epidemiological information
 Radiographic finding
 Microbiology results if available
 TREATMENT (contd.)

Neonate to 3 months
 Treat as sepsis with broad spectrum
antibiotics to cover for Gram +ve,
Gram -ve organisms & coliforms
 1st line antibiotic in this environment
cephalosporins e.g. cefuroxime plus
aminoglycosides e.g. gentamicin.
 Ceftazidime if Pseudomonas is
suspected.
3 months to 5years old
 Guide is simplified by this algorithm:
 Erythromycin, azithromycin etc
usually combined with
chloramphenicol to broaden the
spectrum.
• Erythromycin plus chloramphenicol :
Chlamydia or Mycoplasma
pneumonia is suspected.
 Ribavarin is the drug of choice for RSV
infection if:
Life threatening,
Bronchopulmonary dysplasia, or
Congenital heart diseases present.
• Rimantadine is the drug of choice for:
Influenza A & B pneumonia
 Oxygen therapy
Oxygen can be life-saving in hypoxic pneumonia
patients.

Absolute indications for oxygen therapy are:

 Central cyanosis
 Severe lower chest wall indrawing
 Oxygen saturation < 90%

Other indications are:

 tachypnoea of 20 breaths/min above the age-
specific cut -off point
 restlessness ( not due to meningitis)
 titubation
 tachycardia
 In a situation where medical oxygen
is not affordable, oxygen
concentrator is helpful. Pulse
oxymetry will help to ascertain
adequate oxygenation.
 Supportive Treatment

 Adequate calorie intake is ensured

by small frequent feeding with cup
and spoon or N/G tube feeding (in
those that feed poorly).
 Fluids – oral or iv to prevent or treat
dehydration
 Where pneumonia is not very severe, fluid
can be given at 100% maintenance. In
very severe pneumonia without
dehydration fluid is given at ¾
maintenance, to prevent SIADH. In very
severe pneumonia + dehydration –
administer deficit plus ¾ maintenance.
 Antipyretics/analgesics are restricted to
patients with temperature 390C and above
or very uncomfortable patients.
 Treat complications if and when they