Lower Respiratory tract infections

For learners of the lesson (BSc

Nursing/Midwiefry)
Werku Etafa (MSc, Assist.Prof)
 Common childhood LRTIs
• Bronchiolitis
• Pertussis
• Pneumonia
 1. Bronchiolitis
• Caused by obstruction and collapse of the small airways during expiration.
• Obstruction due to acute infectious inflammatory disease of the URT and
LRT
• Occur in all age group
• 90% are aged 1-9 months (rare after 1 year of age),
• Boys affected more than girls
• Major concern not only the acute effects of bronchiolitis but the possible
development of chronic airway hyperreactivity (asthma)
• Infants affected most often because of their small airways, high closing
volumes, and insufficient collateral ventilation
 Etiological agents
• Isolated agent in 75% of children younger than 2 years and highly
contagious
• Two RSV subtypes A (severe) and B (structural variations in the G protein)
• Viral shedding in nasal secretions for 6-21 days after symptoms develop.
• IP=2-5 days
• Complex immunologic mechanisms play a role in RSV bronchiolitis.
• Type I allergic reactions mediated by the IgE antibody account for
significant bronchiolitis thus breastfed babies (colostrum-IgA) relatively
protected
• Human metapneumovirus, parainfleunze, influenza, rhinovirus, adenovirus
• Accounts for 5-15% particularly among older children and adults
Risk factors
Pathophysiology
Clinical presentation
Bronchiolitis
 Severe bronchiolitis
• Signs of severe, life-threatening illness are central
cyanosis, tachypnea of >70 breaths/min, listlessness,
and apneic spells.
• At this stage, the chest may be significantly
hyperexpanded and almost silent to auscultation
because of poor air movement
Differential diagnosis
 Investigation
 Bronchiolitis is a clinical diagnosis
Management
 2. PERTUSSIS

 Pertussis is an acute respiratory disorder characterized by

paroxysmal cough (whooping cough) and copious secretions.
 Also called Bronchitis

 Case definition:
 Cough more than 2 weeks plus one of the following (paroxysmal
cough, whoop or post tussive vomiting)
ETIOLOGY
 Pertussis means intense cough
 Caused mainly by Bordetella pertussis
 Gram negative rods affecting only humans
EPIDEMIOLOGY
 Affect adolescents and adults in vaccinated population
 Transmission is via aerosol droplets and secretions
 Contagious to 100% of susceptible population
 Vaccination and infection has no complete protection
 Peak incidence in children 1-5 years
 Immunity wanes 3-5 years after vaccination
 PERTUSSIS
Pathogenesis
 Incubation period of 1-2 weeks

 Transmitted via aerosol route

 Affect mainly ciliated epithelia with mucosal sloughing

 Prodcue pertussis toxin which has several effects

 Protect organism, mucosal damage, insulin secretion,

lymphocytosis, histamine sensitivity
 Tracheal cytotoxin is also elaborated to protect the bacteria
and further mucosal damage
CLINICAL MANIFESTATIONS
 Incubation period of 3-12 days
 Three stages, each lasting two weeks:
 Catarrhal, Paroxysmal and Convalescence stages
 Catarrhal stage
 Runny nose, sneezing, low grade fever

 Mild occasional cough similar to common cold

CLINICAL…
 Paroxysmal stage
 Sudden bursts of repetitive coughing, chin and

chest held forward, tongue protruding, eyes bulging

and watering, face purple and ending with a long
inspiratory effort
 Post-tussive vomiting and exhaustion common

 Child appears normal between episodes

 Attacks occur more frequently at night (15-24

attacks/24 hours)
CLINICAL…
 Convalescence stage (Recovery)
 Number, severity and duration of paroxysmal

attacks decrease
 Paradoxically in infants, with increase in strength,

coughs and whoops become louder and more

classic
 Immunized children have shortening of all clinical

stages
 PERTUSSIS
Clinical manifestation
Physical examination
 Normal appearing child who bursts in to paroxysmal
cough, whooping and vomiting
 No marked fever

 Chest finding is normal unless complicated

 Young infants and neonates develop cough followed by

apnea, gagging and cyanosis
 Immunized children and adults feel sudden onset
suffocation, coughing but no prominent whoop
 PERTUSSIS

Differential Diagnosis
 Tuberculosis

 Bronchial asthma

 Congestive heart failure

 Viral bronchitis (adeno, infleunza, parainfleunza)

 Atypical pneumonia (mycoplasma, chlamydia)

 PERTUSSIS
Complications
 Most hospitalizations and deaths occur <6 months
 Apnea for young infants, hypoxia
 Seizure, coma and death
 Superimposed bacterial pneumonia
 Pulmonary hypertension
 Weight loss due to vomiting and failure to take
 Conjunctiva hemorrhage, epistaxis, petechiae
 Pneumothorax
 Abdominal hernias
 Rectal prolapse
 Intracranial bleeding
 PERTUSSIS

Diagnosis
 CBC often show Leucocytosis due to lymphocytosis

 Thromobocytosis

 Chest X-ray: may show infiltrates or patchy atelectasis

 Serology test four fold rise in antibody against pertussis

 Naso-pharyngeal swab or aspiration to culture Bordetella is the

gold standard test
 Direct immunofluorescent antibody, PCR test
 PERTUSSIS

Treatment
 Hospitalization, patient isolation, Aerosol precaution

 Start antibiotics (Either of the following Macrolides)

 Erythromycin 50mg/kg/day in 4 divided doses for 2 wks

 Clarithromycin 15mg/kg/day in 2 divided doses for 1wk

 Azithromycin 10mg/kg/day daily doses for 5 days

 Nursing management
 Suctioning of secretions
 Humidity environment

 Treat complications

 Frequent Feeding (NGT may be required)

 Watch for paroxysms

 Should be seen BID & Stat by nurses and physician, respectively.

 PERTUSSIS PREVENTION

Prevention
 Patient isolation, Aerosol protection

 Chemoprophylaxis similar dosage to treatment

 Vaccination of both patients and contacts

 DTaP 2, 4, 6, 15-18 months then 4-6 years

 70-90% protection but wanes with in few years

4. PNEUMONIA
Definition
 Pathological: An inflammation of lung parenchyma
 IMNCI: A child having cough and fast breathing

 Community Acquired Pneumonia (CAP)

 Pneumonia acquired in the community
 Hospital Acquired Pneumonia /HAP/ (HCAP or VAP)
 Acquired in hospitals after 48 hours of admission or until 2
weeks after discharged from hospital
 Health care acquired pneumonia (HCAP)
 Ventilation acquired pneumonia (VAP)
 Viruses are the commonest causes of pneumonia
 Bacterial pneumonia is the leading cause of mortality
 PNEUMONIA

The World Health Organization (WHO)

Fast breathing means:
 Below 2 months: 60 breaths/min and above
 2 to 12 months: 50 breaths/min and above
 1 to 5 years: 40 breaths/min and above
 5-10 years: 30 breaths/min and above
 >10 years: 20 breaths and above
 PNEUMONIA IN CHILDREN

Severe pneumonia (indication for admission)

 Moderate to severe retractions

 Nasal flaring

 Grunting

 Cyanosis

 Failure to suck or take oral fluids

 Dehydration

 Convulsion

 Shock

 Lethargy or coma
ETIOLOGY
 Most cases of pneumonia are caused by microorganisms
 Noninfectious causes include
 aspiration of food or gastric acid, foreign bodies,
 hydrocarbons, and lipoid substances, hypersensitivity reactions, and
 drug- or radiation-induced pneumonitis.
 The cause of pneumonia in an individual patient is often
difficult to determine
 direct culture of lung tissue is invasive and rarely performed.
 Cultures performed on specimens obtained from the upper
respiratory tract or “sputum” often do not accurately reflect the
cause of lower respiratory tract infection.
 ETIOLOGIES
Bacterial etiologies of pneumonia
Neonates
 Group B streptococcus, Gram negative rods
Infants
 S.aureus, Pneumococcus, C. trachomatis
One to five years
 Pneumococcus, S.pyogens, S.aureus
Above five years
 M. pneumoniae, C. pneumoniae, S. pneumoniae
Hospital acquired pneumona (Nosocomial)
 Gram negative rods , S.aureus, fungal
Aspiration pneumonia
 Oral anaerobes, mixed bacteria
Immunodeficiency (malnutrition, HIV etc)
 S.aureus, PCP, Gram negative rods, CMV, fungal
ETIOLOGY…
 Viral pathogens are a prominent cause of LRTIs in infants and
children <5 yr of age.
 Bronchiolitis peak incidence is high in the 1st yr of life
 The highest frequency of viral pneumonia occurs between the
ages of 2 and 3 yr, decreasing slowly thereafter.
 Of the respiratory viruses,
 Influenza virus , and RSV are the major pathogens
 Other common viruses causing pneumonia include parainfluenza
viruses, adenoviruses, rhinoviruses, and human metapneumovirus.

 The age of the patient may help identify possible pathogens

 PNEUMONIA
Risk factors
 Over crowding, Under vaccination

 Common cold, Smoking, Poverty

 Immunodeficiency (malnutrition, HIV)

 Congenital heart diseases

 Chronic lung diseases (asthma, BPD)

 Air way congenital malformations (TEF)

 Neuromuscular disorders (paralysis, coma etc.)

 Aspiration of secretions (seizure, coma, anesthesia,

foreign body etc)
PATHOGENESIS

 The LRT is normally kept sterile by physiologic defense

mechanisms,
 mucociliary clearance, the properties of normal
secretions IgA, and clearing airway by coughing.
 Viral pneumonia usually results from spread of
infection along the airways, accompanied by direct
injury of the respiratory epithelium
 Bacterial pneumonia most often occurs when
respiratory tract organisms colonize the trachea and
subsequently gain access to the lungs,
 But pneumonia may also result from direct seeding of lung
tissue after bacteremia
PATHOGENESIS…
 Recurrent pneumonia is defined as 2 or more episodes
in a single year or 3 or more episodes ever, with
radiographic clearing between occurrences.
 An underlying disorder should be considered if a child
experiences recurrent pneumonia
 Cystic fibrosis, Sickle cell disease, HIV/AIDS,
Pulmonary sequestration, Lobar emphysema

 GERD, Foreign body, TEF, Aspiration

CLINICAL MANIFESTATIONS

 Often preceded by several days of symptoms of an

URTIs, typically rhinitis and cough.
 In viral pneumonia, fever is usually present; but lower
 Tachypnea is the most consistent c/m of pneumonia.
 Increased work of breathing
 intercostal, subcostal, and suprasternal retractions,
 nasal flaring, and use of accessory muscles is common.
 Severe infection may be accompanied by cyanosis and
respiratory fatigue, especially in infants.
 Auscultation of the chest may reveal crackles and wheezing
 It is often not possible to distinguish viral pneumonia
clinically from disease caused by bacterial pathogens
C/MS…
 Bacterial pneumonia in adults and older children
 typically begins suddenly with a shaking chill followed by a
high fever, cough, and chest pain.
 Cyanosis may be observed.
 In many children, splinting on the affected side to minimize pleuritic
pain
 may lie on one side with the knees drawn up to the chest
 Physical findings depend on the stage of pneumonia.
 Early in the course of illness, diminished breath sounds, scattered
crackles, and rhonchi are commonly heard over the affected lung
field.
 Increasing consolidation or complications of pneumonia such as
 effusion, empyema, and pyopneumothorax, dullness on percussion
C/MS…
 In infants, there may be
 a prodrome of URTI and diminished appetite, leading to the
abrupt onset of fever, restlessness, apprehension, and respiratory
distress.
 Respiratory distress manifested as
 grunting; nasal flaring; retractions of the supraclavicular, intercostal, and
subcostal areas; tachypnea; tachycardia; air hunger; and often cyanosis.
 Results of physical examination may be misleading, particularly in
young infants, with meager findings disproportionate to the degree
of tachypnea.
 Some infants with bacterial pneumonia may have associated
gastrointestinal disturbances characterized by
 vomiting, anorexia, diarrhea, and abdominal distention secondary to a paralytic
ileus.
 Rapid progression of symptoms is characteristic in the most severe cases of bacterial
pneumonia.
DIAGNOSIS

 An infiltrate on CXR supports the DX of pneumonia;

 also indicate a complication such as a pleural effusion
or empyema.
 Viral pneumonia is usually characterized by
hyperinflation with bilateral interstitial infiltrates and
peribronchial cuffing
 Confluent lobar consolidation is typically seen with
pneumococcal pneumonia.
 The radiographic appearance alone is not diagnostic, and
other clinical features must be considered.
 Repeat chest radiographs are not required for proof of
cure for patients with uncomplicated pneumonia.
DX
 The peripheral white blood cell (WBC)
 In viral pneumonia, the WBC count can be normal or elevated
but is usually not higher than 20,000/mm3, with a lymphocyte
predominance.
 Bacterial pneumonia is often associated with an elevated WBC
count, in the range of 15,000-40,000/mm3, and a predominance
of granulocytes.
 Pneumococcal pneumonia is associated with a higher WBC count,
ESR, and CRP level, there is considerable overlap.
FACTORS SUGGESTING NEED FOR HOSPITALIZATION OF CHILDREN

 Age <6 mo
 Sickle cell anemia with acute chest syndrome
 Multiple lobe involvement
 Immunocompromised state
 Toxic appearance
 Moderate to severe respiratory distress
 Requirement for supplemental oxygen
 Dehydration
 Vomiting or inability to tolerate oral fluids or medications
 No response to appropriate oral antibiotic therapy
 Social factors (e.g., inability of caregivers to administer medications
at home or follow up appropriately)
TREATMENT
 For mildly ill children, amoxicillin is recommended.
 In communities with a high percentage of penicillin-resistant
pneumococci,
 high doses of amoxicillin should be prescribed.
 alternatives include clavulanate.
 For M. pneumoniae or C. pneumoniae a macrolide antibiotic
such as azithromycin is an appropriate choice.
 The empiric treatment of suspected bacterial pneumonia in a
hospitalized child requires an approach based on the clinical
manifestations at the time of presentation.
RX
 Parenteral cefotaxime or ceftriaxone is the mainstay of
therapy when bacterial pneumonia is suggested.
 If clinical features suggest staphylococcal pneumonia
(pneumatoceles, empyema), initial antimicrobial therapy
should also include vancomycin or clindamycin.
 Up to 30% of patients with known viral infection may
have coexisting bacterial pathogens.
 For pneumococcal pneumonia, antibiotics should
probably be continued
 until the patient has been afebrile for 72 hours, and
 the total duration should not be less than 10 to 14 days (or 5 days
if azithromycin is used).
 PROGNOSIS

 A number of factors must be considered when a

patient does not improve with appropriate antibiotic
therapy:
 (1) complications, such as empyema;
 (2) bacterial resistance;

 (3) nonbacterial etiologies

 (4) bronchial obstruction

 (5) pre-existing diseases

 (6) other noninfectious causes

 PNEUMONIA

Complications (local vs. distant)

Local
 Para pneumonic effusion
 Empyema
 Lung abscess
 Pneumothorax
Distant
 Meningitis
 Septic arthritis and
 Osteomyelitis etc
LEFT LOWER LOBE CONSOLIDATION

Lobar pneumonia---Pneumococcus
Bronchopneumonia--- staphylococcus
 PNEUMONIA

Right lower lobe pneumonia due to pneumococcus.

Nelson text book of pediatrics 18th ed.
 PNEUMONIA

Pneumonia complication. Right sided pleural effusion in AP

and right decubitus position. There is layering of pleural
fluid on the right side chest X-ray. Up to date 2010.
 PNEUMONIA

Prevention
 Vaccination
 (PCV, Hib, Influenza, pertussis, measles)
 Breast feeding
 Avoid over crowding

 Adequate nutrition

 Avoid indoor smoking and cigarette exposure

 Vitamin A supplementation
Thank you!