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TRIASTA, MAMC, 2012

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

7/2/12

A child with cough or difficult breathing ASSESS

Ask:
How old is the child? Is the child coughing? For how long? Ages 2mos. 5y.o: Is the child able to

drink? Age less than 2mos: Has the young infant stopped feeding well?
Does the child has fever?
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LOOK, LISTEN
Count the breaths in one minute Look for chest indrawing Look and listen for stridor Look and listen for wheeze

Is it recurrent
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FAST BREATHING
Young infant age less than 2 months:

60 breaths per minute or more

Child age 2 months up to 12months:

50 breaths per minute or more

Child age 1 to 5 years:

40 breaths per minute or more

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A child has INDRAWING if:

The lower chest wall goes in when the

child breathes in
CHEST INDRAWING is a sign of severe

pneumonia in children aged 2 months up to 5 years

Only SEVERE CHEST INDRAWING is a

sign of severe pneumonia in young infants 7/2/12

CLASSIFY THE ILLNESS

2 months up to 5 years SIGNS:
Not able to drink Convulsions Abnormally sleepy or difficult to wake Stridor in calm child Severe malnutrition

Classify

VERY SEVERE DISEASE

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Age less than 2months

SIGNS:
Stopped feeding well Convulsions Abnormally sleepy Stridor in calm child Wheezing Fever or low body temperature

CLASSIFY:
VERY SEVERE DISEASE
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< 2 months old

No Pneumonia

Severe Pneumonia

Very Pneumonia

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2 months - 5 years
No pneumonia

Pneumonia

Severe Pneumonia

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2 months - 5 years
Very severe Pneumonia Central cyanosis Inability to feed/drink Stridor Convulsions Sleepy

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Most common pathogens:

Streptococcus pneumoniae Chlamydia pneumoniae Mycoplasma pneumoniae

Major causes of hospitalizations:

Streptococcus pneumoniae Haemophilus influenzae Staphycoccus aureus
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Neonates:
Group B, E.coli,Strep pneumonia, H.influenzae

<3
Respiratory syncytial virus, Strep pneumonial,

Influenzae virus

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Introduction
Pneumonia - is defined as the

inflammation of lung tissue caused by an infectious agent that results in Acute respiratory signs and symptoms
It can be either Acquired (Community

Acquired) or within the hospital (Hospital acquired)

It is ranked to be the 3rd in ten

leading cause of morbidity

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Etiologic causes of Pneumonia

AGE GROUP 1. Neonates ETIOLOGY Group B Strepcoccus E. Coli L. Monocytogenes 2. Infants younger than 3 Group B Strepcoccus mos. Chlamydia Trachomatis 3. Older infants, pre Strep.pneumoniae schoolers, younger than 5 H.Influenzae years old 4.Older than 5 years old S.Pneumoniae Mycoplasma Pneumoniae 5. 5-10 years old C. Pneumoniae 7/2/12 M. Pneumonaie

SIGNS AND SYMPTOMS

FEVER COUGH

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SIGNS AND SYMPTOMS

DIFFICULTY OF BREATHING CHEST PAIN

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SIGNS AND SYMPTOMS

ABDOMINAL PAIN VOMITING

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Who shall be considered as having Community Acquired Pneumonia?

Predictors of Community Acquired

Pneumonia in patient with cough

1. For ages 3 months-5 years are tachypnea and or

chest indrawing
2. For ages 5-12 years are fever, tachypnea, and

crackles
3. Beyond 12 years old are the presence of the

following features:
A. Fever, tachypnea and tachycardia B. At least one abnormal chest findings of diminished

breath sounds, rhonchi, crackles and wheezes

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2. Who will require admission?

1. A patient who is at moderate risk

to develop pneumonia-related mortality should be admitted.

2. A patient who is at minimal to low

risk can be managed on out patient basis

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Risk Classification for Pneumonia Based Mortality

VARIABLE PCAP A Min risk
Yes Possible None Able >11 mo.

PCAP B Low risk

Present Yes Possible Mild Able >11 mo.

PCAP C Mod risk

Present No Not possible Moderate Unable <11 mo.

PCAP D High risk

Present No Not possible Severe Unable <11 mo.

1. Co-morbid illnessNone 2.Compliant caregiver 3.Ability to follow up 4. Presence of dehydration 5.Abilty to feed 6. Age 7. RR 2-12 mo. 1-5 yrs >5 yrs

>50/min >40/min >30/min

>50/min >40/min >30/min

>60/min >50/min >35/min

>70/min >50/min 7/2/12 35/min >

8. Signs of resp. Failure a. Retraction b. Head bobbing c. Cyanosis d.Grunting e. Apnea f. Sensorium

Risk Classification for Pneumonia Based Mortality

None None None None None None Awake None None None None None None Awake Intercostal/S Present Present Present None None Irritable

Supra/Inter/Su bcostal rets Present Present Present Present Present Lethargic/Stu Purous/comat ose Present

9. Complications

None

None

Present

ACTION PLAN

OPD follow up OPD follow up Admit to at the end of after 3 days regular ward the treatment

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Admit to crtitical care unit Refer to specialist

3.What diagnostic aids are initially requested for a patient classified as either PCAP A or B being managed in the ambulatory setting?

No diagnostic aids are initially

requested for a patient classified as either PCAP A or PCAP B who is being managed in the ambulatory setting

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4. What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D being managed in a hospital setting?
1. The following should be routinely requested: A. Chest Xray PA-lateral B. White blood cell count C. Culture and sensitivity of Blood for PCAP D Pleural fluid Tracheal aspirate upon initial intubation Blood gas and Pulse oximetry 2. The following maybe requested: Culture and sensitivity of sputum for older children 3. The following should not be routinely requested: 7/2/12

5 When is antibiotic recommended?

An antibiotic is recommended 1. For a patient classified as either PCAP A

or B and is
A. Beyond 2 years of age B. Having high grade fever without wheeze 2. For a patient classified as PCAP C and is A. Beyond 2 years of age B. Having high grade fever without any

wheeze

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6.What empiric treatment should be administered if a bacterial etiology is strongly considered? 1. For a patient classified as PCAP A or B

without previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided doses) is the drug of choice.
2. For a patient classified as PCAP C

without previous antibiotic and who has completed the primary immunization against Haemophilus influenzae type B, Penicillin G(100, 000 units/kg/day in 4 divided doses) is the drug of choice
7/2/12 If a primary immunization against Hib has

7.What treatment should initially be given if a Viral etiology is strongly considered?

1. Ancillary treatment should be given 2. Olsetamivir (2mg/kg/dose BID for 5

days) or Amantadine (4-8 mg/kg/day for 3-5 days) may be given for Influenza that is either confirmed by laboratory or occuring as an outbreak

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When can be a patient be considered as responding to the current antibiotic?

1. Decrease in respiratory signs

(particularly tachypnea) and deferverescene within 72 hours after initiation of antibiotic are predictors of a favorable therapeutic response
2. Persistence of symptoms beyond

72 hours after initiation of antibiotic requires reevaluation

3. End of treatment Chest

Xrat,WBC,ESR,CRP should not be 7/2/12

9.What should be done if a patient is not responding to a current antibiotic therapy

1. If an outpatient classified as either

PCAP A or PCAP B is not responding to the current antibiotic within 72 hours, consider any of the following

a. Change the initial antibiotic b. Start on an oral macrolide c. Reevaluate diagnosis

2. If an inpatient classified as PCAP C 7/2/12

What should be done if a patient is not responding to a current antibiotic therapy

Continuation:

b. Presence of complications (pulmonary or extrapulmonary) c. Other diagnosis

3. If an inpatient classified as PCAP D is

not responding to the current antibiotic within 72 hours, consider immediate reconsultation with a specialist
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10. When can switch therapy in bacterial pneumonia could be started?

Switch from intravenous antibiotic

administration to oral form 2-3 days after initiation of antibiotics is recommended in a patient who
A. Is responding to the initial

antibiotic therapy
B. Is able to feed with intact

gastrointestinal absorption
C. Does not have any pulmonary or
7/2/12 extrapulmonary complications

11. What ancillary treatment can be given?

1. Among inpatients, oxygen and

hydration should be given if needed

2. Cough preparations, chest

physiotherapy, bronchial hygiene, nebulization using normal saline solution, steam inhalation, topical solution, bronchodilators and herbal medicines are not routinely given in Community acquired pneumonia.
3. In the presence of wheezing, a 7/2/12

12. How can Pneumonia be prevented?

1. Vaccines recommended by the

Philippine Pediatric Society should be routine administered to prevent Pneumonia

2. Zinc supplementation (10 mg for

infants and 20 mg for children)beyond 2 years of age given for a total of 4-6 months maybe administered to prevent Pneumonia
3. Vitamin A, immunomodulators and 7/2/12