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Pneumonia in children: Management and complications. Pierre Goussard , Robert Gie Tygerberg Children`s Hospital and Stellenbosch University. 6 month old girl presents with cough and respiratory distress. Pneumonia is the single greatest cause of death in children worldwide .

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Pneumonia in children management and complications

Pneumonia in children: Management and complications

Pierre Goussard , Robert Gie

Tygerberg Children`s Hospital and Stellenbosch University



  • Pneumonia is the single greatest cause of death in distresschildren worldwide .

  • Each year, 2 million children younger than 5 years die of pneumonia, representing 20% of all deaths in children within this age group .

  • 155 million cases of pneumonia occur in children every year worldwide

  • In many children with LRTI, diagnostic testing may identify 2 or 3 pathogens, including combinations of both viruses and bacteria, making it difficult to determine the significance of any single pathogen


CAP distress

  • CAP can be defined as acute infection (of less than 14 days’ duration), acquired in the community, of the lower respiratory tract leading to cough or difficult breathing, tachypnoea or chest-wall indrawing

  • CAP accounts for between 30% and 40% of hospital admissions, with associated case fatality rates of between 15% and 28%.

  • Mixed bacterial and viral infections may occur in 30 - 40% of cases of childhood CAP.


  • S. pneumoniae as the most common distressdocumented bacterial pathogen, occurring in 4%–44% of all children

  • Viral etiologies of CAP have been documented in up to 80%of children younger than 2 years; in contrast, older children, 10–16 years, who had both clinical and radiographic evidence of pneumonia, documented a much lower percentage of viral pathogens

  • RSV is consistently the most frequently detected, representing up to 40%of identified pathogens in those younger than 2 years, but rarely identified in older children with CAP.

  • Epidemiologic investigations of hospitalized children with CAP document that 2%–33% are simultaneously infected by 2 or more viruses


Terminology
Terminology distress

  • Community acquired pneumonia

  • Hospital acquired pneumonia

  • Ventilator associated pneumonia


Terminology1
Terminology distress

  • ‘‘Simple pneumonia’’ as either bronchopneumonia (primary involvement of airways and surrounding interstitium), or lobar pneumonia involving a single lobe.

  • ‘‘Complicated pneumonia’’ is defined as a pulmonary parenchymal infection complicated by parapneumonic effusions, multilobar disease, abscesses or cavities, necrotizing pneumonia, empyema, pneumothorax or bronchopleural fistula


Causes of cap
Causes of CAP distress


Etiology of cap
Etiology of CAP distress

  • < 3 months

    • Gram negative organisms

    • Group B streptococcus

    • Staphylococcus aureus

    • Haemophilus influenzae

    • Other atypical

      • chlamydia, ureoplasma


  • 3 distressmonths - 5 years

    • Streptococcus pneumoniae

    • Haemophilus influenzae

    • Staphylococcus aureus

  • > 5 years

    • Streptococcus pneumoniae

    • Mycoplasma pneumoniae

    • Staphylococcus aureus


Mycoplasma
Mycoplasma distress

  • Atypical pneumonia caused by Mycoplasma is characteristically slowly progressing, with malaise, sore throat,low-grade fever, and cough developing over 3–5 days



Diagnosis of cap
Diagnosis of CAP distress

  • Diagnosis includes:

    • clinical evaluation

    • radiographic evaluation

    • aetiological investigations

  • To establish :

    • whether pneumonia is present

    • assess the severity of pneumonia

    • determine the causative organism


  • WHO distressdefines pneumonia primarily as cough or difficult breathing and age-adjusted tachypnea: (age 2–11 months, RR > 50/min; 1–5 years, RR > 40/min; >5 years, >20 breaths/min)

  • Furthermore, severe pneumonia is defined as ‘‘cough or difficulty breathing plus one of the following:

    • lower chest indrawing

    • nasal flaring

    • grunting.

  • Very severe pneumonia is defined as ‘‘cough or difficulty breathing plus one of the following:

    • Cyanosis

    • severe respiratory distress

    • inability to drink or vomiting everything

    • lethargy/unconsciousness/convulsions.’’

  • Infants and young children tend to have more severe pneumonia with a greater need for hospitalization and a higher risk of respiratory failure.


Diagnosis
Diagnosis distress

  • Blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting

  • Blood cultures should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy

  • C-reactive protein or serum procalcitonin concentration, cannot be used as the sole determinant to distinguish between viral and bacterial causes of CAP

  • Pulse oximetry should be performed in all children with pneumonia and suspected hypoxemia


Chest x ray
Chest X-ray distress

  • Routine chest radiographs are not necessary for the confirmation of suspected CAP in patients well enough to be treated in the outpatient setting

  • Chest radiographs, posteroanterior and lateral, should be obtained in patient :

    • with suspected or documented hypoxemia

    • significant respiratory distress

    • Suspected PTB

    • Foreign body aspiration

    • those with failed initial antibiotic therapy to verify the presence or absence of complications of pneumonia, including parapneumonic effusions, necrotizing pneumonia, and pneumothorax.



Impact of hiv infection on clinical diagnosis of cap
Impact of HIV infection on clinical diagnosis of CAP distress

  • Clinical signs of CAP are similar in HIV-infected and HIV uninfected children.

  • However, pneumonia resulting from opportunistic pathogens should also be considered in HIV infected children.

  • Of these, PCP is the most common and serious infection among infants, occurring commonly at 6 weeks - 6 months of age.

  • PCP is frequently (20 - 40%) the initial presenting feature of AIDS in HIV-infected children not taking co-trimoxazole prophylaxis.

  • Although PCP may present with a tetrad of features comprising tachypnoea, dyspnoea, fever and cough, these are not specific for pneumonia caused by P. jiroveci.

  • Hypoxia may be prominent and rapidly progressive.

  • Other stigmata of AIDS such as hepatosplenomegaly and generalised lymphadenopathy are not always present and adventitious sounds in the chest may be absent despite clinical signs of severe respiratory distress.


Which organism
Which organism distress

  • PJP

  • CMV

  • Fungal

  • Gram negative

  • Other opportunistic virus infection

  • MTB


Hospitalization
Hospitalization distress

  • Children and infants who have moderate to severe CAP, as defined by several factors, including respiratory distress and hypoxemia (sustained saturation of peripheral oxygen [SpO2],,90 % at sea level)

  • Infants less than 3–6 months of age with suspected bacterial CAP

  • Children and infants with suspected or documented CAP caused by a pathogen with increased virulence, such as community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) should be hospitalized


Antibiotic use in the treatment of cap
Antibiotic use in the treatment of CAP distress

  • Difficult to distinguish between pneumonia caused by bacteria and viral infections

  • 30-40% have mixed bacterial-viral infections

  • Children with pneumonia require an antibiotic

  • Most bacterial pneumonia respons to amoxicillin


Choice of antibiotic
Choice of antibiotic distress

  • CAP VS HAP

  • Age of child

  • Immunestatus of child

  • IV VS oral


Age distress

  • < 2 months risk of gram negative infection

    • Add aminoglycoside

  • > 5 years have more infection with Mycoplasma pneumoniae

    • Add macrolide


Immunestatus
Immunestatus distress

  • Congenital immundefiency

    • T-cell defiency

    • B-cell defiency

  • Acquired immundefiency

    • HIV

    • Malnutrition

    • Cancer patient


Treatment with oral antibiotics
Treatment with oral antibiotics distress

  • Amoxicillin should be used as first-line therapy for previously healthy, appropriately immunized infants and preschool children with mild to moderate CAP suspected to be of bacterial origin. Amoxicillin provides appropriate coverage for Streptococcus pneumoniae, the most prominent invasive bacterial pathogen

  • Amoxicillin should be used as first-line therapy for previously healthy appropriately immunized school-aged children and adolescents with mild to moderate CAP for S. pneumoniae,

  • Macrolide antibiotics should be prescribed for treatment of children (primarily school-aged children and adolescents) evaluated in an outpatient setting with findings compatible with CAP caused by atypical pathogens


Treatment of inpatients
Treatment of inpatients distress

  • Ampicillin or penicillin G should be administered to the fully immunized infant or school-aged child admitted to a hospital ward with CAP

  • Empiric combination therapy with a macrolide (oral or parenteral), in addition to a b-lactam antibiotic, should be prescribed for the hospitalized child for whom M. pneumoniae and C. pneumoniae are significant consideration


  • When distressS. aureus is suspected, cloxacillin is the drug of choice.

    • considered if there is radiological evidence of pneumatocele, empyema or abscess formation

    • child remains pyrexial 48 hours after starting amoxicillin.

  • HIV-infected children, approximately 60% of community acquired S. aureus may be resistant to cloxacillin and require treatment with vancomycin.


  • HIV-infected children requiring hospitalisation may distresshave pneumonia caused by Gram-negative bacteria.

  • Children with a high risk of being HIV-infected or who have symptomatic HIV disease or who are severely malnourished should have an aminoglycoside added to their empirical treatment regimen

  • PCP is suspected, co-trimoxazole should be added.


Iv treatment
IV treatment distress

  • < 3 months:

    • Ampicillin , gentamycin and cloxacillin

  • > 3 months :

    • Ampicillin IV

    • IF not improved after 24 – 48h

    • Ampicilin plus Cloxacillin IV

    • Or Cefuroxime IV


  • In children distresswith pneumonia, the increasing resistance of pneumococcus to penicillin can be overcome by giving a higher dose of amoxicillin.

  • Although standard doses of amoxicillin (15 mg/kg/dose three times a day) are likely to treat most cases of pneumococcal pneumonia in South Africa, the use of high-dose amoxicillin (30 mg/kg/dose 3 times a day) is advocated so as to overcome and limit the emergence of resistant pneumococci, and to successfully treat those additional few children with high-level pneumococcal resistance (minimal inhibitory concentrations (MICs) of ≥ 2.0 μg/ml).


Duration of treatment
Duration of treatment distress

  • Generally recommended that 5 days of therapy is sufficient for uncomplicated pneumonia.

  • A recent study of HIV-uninfected children with uncomplicated pneumonia reported that the clinical efficacy of 3 days of oral amoxicillin (15 mg/kg/dose) was similar to 5 days for outpatient therapy.

  • Children with S.aureus pneumonia should be treated for 14 - 21 days depending on clinical response.

  • Children infected with M. pneumoniae or C. pneumoniae require erythromycin for 10 days; alternatively the newer macrolides such as azithromycin may be used for 3 - 5 days.


Supportive treatment in the management of cap
Supportive treatment in the distressmanagement of CAP

  • Oxygen therapy

    • Nasal prongs are recommended for most children maximum fractional concentration of inspired oxygen (FIO2) of 28 - 35%

    • Facemask oxygen is designed to deliver 28% - 65% oxygen at a flow rate of 6 - 10 l/min

    • polymask whereby FIO22 concentrations of 60 - 80% may be achieved. The flow rate should be regulated to keep the bag of the mask inflated during inspiration and expiration.


Iv fluids
IV Fluids distress

  • In children with severe or complicated pneumonia, serum urea and electrolytes should be measured before instituting IV fluid as the syndrome of inappropriate antidiuretic hormone secretion (SIADH) is common.

  • In these children, intake should be restricted to 40 - 60% of normal


  • Vitamin A should not be given to children with distressacute pneumonia unless this is measles associated

  • In children with acute pneumonia, adjuvant treatment with 20 mg zinc per day until discharge was found to accelerate recovery from severe pneumonia, reducing the duration of hypoxia

  • Zinc should therefore be considered for use in children hospitalized with pneumonia, particularly if there is coexisting malnutrition.


Nonsense supportive therapy
Nonsense supportive therapy distress

  • Chest physiotherapy.

  • Cocktails of nebulized drugs including mucolytics

  • Bronchoscopy is not indicated since Pneomonia is not an endobronchial disease.


Measures of no value in the treatment of cap
Measures of distressno value in the treatment of CAP

  • Chest physiotherapy

  • Mucolytic agents

  • Nebulized bronchodilators or saline do not improve the outcome of CAP.

  • No evidence to support the use of oral or inhaled corticosteroids


Complications of pneumonia
Complications of pneumonia distress

  • Empyema

  • Lung abscess

  • Necrotising pneumonia


Empyema
Empyema distress

  • Pus in the thoracic cage

  • Byington et al. found, among 540 children admitted to hospital with community-acquired bacterial pneumonia, 153 (28%) had parapneumonic effusions

  • Rise in hospital admissions

    • 40/100000 to 120/100000 in Leuven

  • Streptococcus pneumonia remains the most important pathogen.


Imaging
Imaging distress

  • Ultrasound imaging gives some idea on staging but does not provide a high level of accuracy.

  • Role:

    • estimate the size of the effusion

    • presence of loculi

    • And presents of pleural thickening


Criteria of rw light
Criteria of RW Light distress

  • Parapneumonic effusions are exudates

  • Least one of the following criteria is fulfilled:

    (1) pleural fluid LDH/plasma LDH>0.6 of

    pleural >200 IU/l,

    (2) pleural fluid protein/plasma protein

    >0.5,

    (3) glucose levels <60 mg/d


Staging empyema
Staging empyema distress

  • High level of intervention

    • High numbers of polymorphonuclear leukocytes,

    • LDH> 1,000 IU/l,

    • glucose <30 mg/dl

    • pH<7.2

  • Care has to be taken when measuring pleural pH s


Size of tube bigger better
Size of tube: Bigger better ? distress

  • While a large bore surgical drain is often believed to be more efficient, a post hoc analysis of a study comparing (VATS) and urokinase was in favor of small percutaneous drains by the Seldinger technique

  • Drain of choice

    • Expensive

    • Less damage


Necrotising pneumonia
Necrotising pneumonia distress

  • Also termed cavitary pneumonia or cavitatory necrosis

  • Diagnosis of NP can be suspected on CXR

    • dense lobar consolidation and pleural effusion

  • Chest CT is needed for a more definitive diagnosis.


  • Loss of normal pulmonary parenchymal architecture and the presence of areas of decreased parenchymal enhancement, representing liquefaction, that are progressively replaced by multiple small air or fluid filled cavities

  • The pathophysiology of NP is thought to be one of massive pulmonary gangrene, tissue liquefaction and necrosis


Causes
Causes presence of areas of decreased parenchymal enhancement, representing liquefaction, that are progressively replaced by multiple small air or fluid filled cavities

  • Streptococcus pneumoniae

  • Staphylococcus aureus

  • Mycoplasma pneumoniae,


  • Children with NP have increased risk for developing a BPF. presence of areas of decreased parenchymal enhancement, representing liquefaction, that are progressively replaced by multiple small air or fluid filled cavities

  • Likely due to the friability of the inflamed pleura

    abutting the necrotised lung

  • All patients who developed BPF in the present series had a chest drain in place for 7 days,

  • Length of chest tube drainage is a risk factor for development of BPF.

Sawicki GS. Eur Respir J 2008:31:1285-1291


  • Necrotising pneumonia should be recognised as an increasingly detected complication of paediatric CAP

  • It is distinct from pleural effusion and empyema.

  • Conservative management of necrotising pneumonia with antibiotics and ICD for pleural effusions results in good outcomes

  • There is no indication that surgical resection is necessary


Management of the child not responding to treatment
MANAGEMENT OF THE CHILD NOT increasingly detected complication of paediatric CAPRESPONDING TO TREATMENT

  • Children who are not responding to initial therapy after 48–72 hours should be managed by one or more of the following:

    • Clinical and laboratory assessment

    • Severity of illness : Imaging evaluation to assess the extent and progression of the pneumonic or parapneumonic process.

    • Further investigation to identify whether the original pathogen persists, the original pathogen has developed resistance to the agent used, or there is a new secondary infecting agent.


Reasons for poor response too treatment the bug the drug the host
Reasons for poor response too treatment increasingly detected complication of paediatric CAPThe bug, the drug, the host

BUG

  • Other organismsas what was expected

  • Unusual organisme: egTB, Mycoplasma pneumoniae, chlamydia trachomatis

  • Organism resistant too antibiotics


Reasons for poor response too treatment the bug the drug the host1
Reasons for poor response too treatment increasingly detected complication of paediatric CAPThe bug, the drug, the host

DRUG

  • wrong antibiotic

  • Wrong dose of antibiotics


Reasons for poor response too treatment the bug the drug the host2
Reasons for poor response too treatment increasingly detected complication of paediatric CAPThe bug, the drug, the host

HOST

  • Immunodefiecny

  • Complication of pneumonia(empyema longabcesses, septisemie, meningitis)

  • Underlying cause for pneumonia (foreign body aspiration, bronchiectasis)


Repeat chest x ray
Repeat Chest X-ray increasingly detected complication of paediatric CAP

  • Repeated chest radiographs are not routinely required in children who recover uneventfully from an episode of CAP

  • Repeated chest radiographs should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration within 48–72 hours after initiation of antibiotic therapy.

  • Repeated chest radiographs 4–6 weeks after the diagnosis of CAP should be obtained in patients with recurrent pneumonia involving the same lobe and in patients with lobar collapse at initial chest radiography with suspicion of an anatomic anomaly, chest mass, or foreign body aspiration


Indications for transfer and admission to a picu
Indications for transfer and admission to a PICU increasingly detected complication of paediatric CAP

  • Failure to maintain a saturation of > 90% on an FIO2 of > 70%

  • If the partial pressure of arterial oxygen (PaO2):FIO2 ratio is < 100

  • Apnoea

  • Hypercarbiawith resulting acidaemia(Ph < 7.25)

  • Exhaustion


Prevention of pneumonia
Prevention of Pneumonia increasingly detected complication of paediatric CAP

  • Pneumococcal conjugate vaccines are extremely effective in preventing radiographicallyconfirmed pneumonia (20 - 37% reduction) in HIV-uninfected children.

  • The vaccine also prevents 13% of all clinically diagnosed severe pneumonia in HIV-infected children.

  • Furthermore, the vaccine is effective in preventing 85% of invasive pneumococcal disease in HIV-uninfected children and 65% in HIV-infected children

  • Influenza vaccine.

    • Children with chronic pulmonary, cardiovascular or immunosuppressive disease or those on aspirin should be vaccinated annually at the start of the influenza season.


When do you refer
When do you refer increasingly detected complication of paediatric CAP


Conclusions
CONCLUSIONS increasingly detected complication of paediatric CAP

  • Pneumonia common in children less than 5years

  • Strep Pneumonia remains commonest cause

  • Non- response is more often related too local complication than drug resistance

  • High dose of ampicillin covers intermediate resistant Strep Pneumonia

  • Pulse oximetry is important to monitor children` saturations


PNEUMONIA increasingly detected complication of paediatric CAPIN CHILDREN

NORMALE IMMUNITY

IMMUUNSUPRESSION

  • Common organism

  • Gram nag organism

  • Uncommon organism

COMMUNITY AQURRIED

HOSPITAL AQUIRRED

Resistant gram neg orgs

Resistant staph aureus

3m-5y

<3m

>5y

Group B strep

Gram nag orgs

H influenzae

Staph aureus

Strep pneumo

H influenzae

Staph aureus

Strep pneumo

Mycoplasma


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