PNEUMONIA

Dr. Anamika Mahato

Lecturer
Dept of Pediatrics, Dhulikhel Hospital
Dr. Sameera t
Pneumonia – Inflammation of the parenchyma of the lungs.

Epidemiology

▪ Leading cause of death globally among children < 5 year, accounting for 920,000
deaths each year.

▪ Incidence is more than 10 – fold higher, and the number of childhood related deaths
from pneumonia ≈ 2,000 fold higher, in developing than in developed countries.

▪ Improved access to healthcare in rural areas of developing countries and introduction

of vaccines are important factors in reducing pneumonia related deaths.
 Etiologic Agents Grouped by Age of the Patient

• Neonates:
• Group B streptococcus,
• Escherichia coli,
• Streptococcus pneumoniae,
• Haemophilus influenzae
• 3 wk-3 mo:
• Respiratory syncytial virus,
• Other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza viruses,
human metapneumovirus, adenovirus),
• S. pneumoniae,
• H. influenzae
• If patient is afebrile, consider Chlamydia trachomatis
• 4 mo-4 yr :
• Respiratory syncytial virus,
• other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza viruses,
human metapneumovirus, adenovirus),
• S. pneumoniae,
• H. influenzae,
• Mycoplasma pneumoniae,
• group A streptococcus

• > 5 yr:
• M. pneumoniae,
• S. pneumoniae,
• Chlamydophila pneumoniae,
• H. influenzae,
• influenza viruses, adenovirus, other respiratory viruses,
• Legionella pneumophila
 Causes of Infectious Pneumonia

Bacterial
• Streptococcus pneumoniae: Consolidation, empyema
• Group B streptococci : Neonates
• Group A streptococci : Empyema
• Staphylococcus aureus : Pneumatoceles, empyema; nosocomial pneumonia
• Mycoplasma pneumoniae : Adolescents; summer–fall epidemics
• Chlamydophila pneumoniae : Adolescents
• Chlamydia trachomatis Infants
• Mixed anaerobes: Aspiration pneumonia
• Gram-negative enterics : Nosocomial pneumonia
Viral Pneumonia

 RSV, influenza, parainfluenza and adenovirus may be responsible for about 40 %

of the cases.
Others
▪ Although most cases of pneumonia are caused by microorganisms.

▪ Non-infectious causes:

oAspiration (of food or gastric acid, foreign bodies, hydrocarbons, and

lipoid substances).

oHypersensitivity reactions, and

oDrug- or radiation-induced pneumonitis.

 Risk factors
• Low birth weight
• Malnutrition
• Vitamin A deficiency
• Lack of breast feeding
• Passive smoking
• Large family size
• Family history of bronchitis
• Advanced birth order
• Crowding
• Young age
• Air pollution
 ANATOMICAL CLASSIFICATION

Pathologically, there is a consolidation of alveoli or infiltration of the interstitial

tissue with inflammatory cells or both.
 Clinical features
• Viral and bacterial pneumonias are often preceded by several days of symptoms of an URTI,
typically rhinitis and cough.

• In viral pneumonia, fever is usually present; temperatures are generally lower than in
bacterial pneumonia.

• Tachypnea is the most consistent clinical manifestation of pneumonia.

• Increased work of breathing accompanied by 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

• Rapid progression of symptoms is characteristic in the most severe cases of bacterial

pneumonia.
• Bacterial pneumonia in adults and older children typically begins suddenly with a shaking chill
followed by a high fever, cough, and chest pain.

• Other symptoms that may be seen include drowsiness with intermittent periods of restlessness;
rapid respirations; anxiety; and, occasionally, delirium.

• Circumoral cyanosis may be observed.

• Physical findings depend on the stage of pneumonia.

• Early in the course of illness

• Diminished breath sounds,

• scattered crackles, and

• rhonchi

• commonly heard over the affected lung field.

• With the development of increasing consolidation or complications of pneumonia
such as effusion, empyema, and pyopneumothorax, dullness on percussion is noted
and breath sounds may be diminished.

• Abdominal pain is common in lower lobe pneumonia.

• The liver may seem enlarged because of downward displacement of the diaphragm
secondary to hyperinflation of the lungs or superimposed congestive heart failure.
 Pneumococcal Pneumonia
• Transmitted by droplets and more common in winter months.

• Overcrowding and diminished host response predisposes children to pneumococcal infection.

Pathogenesis:

• Bacteria multiply in the alveoli and an inflammatory exudate is formed.

• Scattered areas of consolidation occur, which coalesce around the bronchi and become lobar
or lobular in distribution.

• No tissue necrosis.
Clinical features:
• Incubation period: 1-3 days.

• Onset is abrupt with headache, high fever, chills, cough (Initially dry- thick rusty sputum).

• Pleural pain referred to the shoulder or abdomen.

• Rapid respiration, grunting, chest indrawing, difficulty in feeding, cyanosis.

• Percussion note impaired, air entry diminished, crepitations, bronchial breathing over areas
of consolidation.

• Meningismus may be present in apical pneumonia.

Diagnosis:
• X-ray findings: lobar consolidation.
• Leukocytosis.
• Sputum examination by gram staining and culture.
• Blood culture may be positive in 5-15% cases.

Treatment:
• Oxygen if cyanosis and respiratory distress.
• IV or IM Penicillin G- 50000 U/kg/day in divided doses for 5- 7 days.
• Procaine penicillin 600000 U IM per day or Penicillin V may be used orally instead.
• Alternative: Amoxycillin or ampicillin
• Alternative if allergic to penicillin: Chloramphenicol or cephalosporins.
 Staphylococcal Pneumonia
• Occurs in infancy and childhood.

• The pulmonary lesion may be primary infection of the parenchyma or secondary to

generalized staphylococcal septicemia.

• May be a complication of measles, influenza and cystic fibrosis of the lungs or may follow
minor staphylococcal pyoderma.

• Predisposing factors: Malnutrition, diabetes mellitus, macrophage dysfunction.

Pathogenesis:
• In infants, initially the pneumonic process is diffuse, then lesions suppurate,
resulting in bronchoalveolar destruction.

• Multiple microabscesses are formed, which erode the bronchial wall and discharge
their contents in the bronchi.

• Several pneumatoceles may form and may fluctuate in size over the time, ultimately
resolving and disappearing within few weeks to months.

• Epithelialization of the walls of air cyst may occur.

• Staphylococcal abscesses may erode into the pericardium causing purulent

pericarditis.
Clinical features:
• Follows URTI, pyoderma or other associated purulent disease.

• Features of pneumonia with fever and anorexia.

• Child is listless and irritable.

• Progression of the symptoms and sign is rapid.

• May be complicated by disseminated disease

• May manifest as metastaitc abscess into joints, bone, muscles, pericardium, liver, mastoid or
brain.
Diagnosis:

• With evidence of staphylococcal infection elsewhere in the body, characteristic

complication of pyopneumothorax or pericarditis are highly suggestive of the
diagnosis.

• X-ray:

• Pneumatoceles are present, characteristically in staphylococcal and klebsiella

pneumonia.

• Thin walled asymptomatic cysts for several weeks.

• Often staphylococci may be grown from the blood.

Treatment:
• Should be immediately hospitalized and isolated to prevent the spread of resistant
staphylococci.
• Fever is controlled by antipyretics and hydration is maintained.
• Oxygen is admintsered to relieve the dyspnea and cyanosis.

Specific:
• Empyema is aspirated and the pus sent for culture and sensitivity to antibiotics.
• Vigorous antibiotic therapy with penicillin G, erythromycin, cloxacillin or cephalosporins.
• Vancomycin or ticoplanin may be added if no response.
• Therapy should be continued for about 2- 6 wks, till all the evidence of disease disappear both
clinically and radiologically.
• Remaining course may be completed by oral antibiotics.
Complications:

• Intercostal decompression may be done for large pneumatoceles causing respiratory distress.

• Empyema and pyopneumothorax: Intercostal drainage under water seal or low pressure

aspiration may be done.

• Metastatic abscess: Surgical drainage.

• Significant pleural thickening: Decortication. Can be done by open thoracotomy or by

thoracoscopic surgery.

• Instillation of streptokinase or urokinase in pleural cavity when pleural fluid is thin may also help

in prevention of pleural thickening.

 Hemophilus Pneumonia
• Age group: 3 months- 3 years.
• Nearly always associated with bacteremia.
• Infection usually begins in the nasopharynx and spreads locally or through the blood
stream.
• Certain viral infections like influenza virus act synergistically with H. influenzae.

• Pathogenesis: similar to that with pneumococci. Extensive destruction of bronchial

epithelium and hemorrhagic edema extending into the interstitial area.
Clinical features:
• Gradual onset with nasopharyngeal infection.
• Moderate fever, dyspnea, grunting and retraction of the lower intercostal spaces.
• Course is subacute and prolonged.

Complications:
• Bacteremia, Pericarditis, Empyema, Meningitis and Polyarthritis.

Treatment:
• Ampicillin (100- 150 mg/kg/day) and Chloramphenicol (50 mg/kg/day) in 4 divided doses
• Alternative: Cefotaxim (100 mg/kg/day) or Ceftriaxone (50- 75 mg/kg/day).
 Streptococcal Pneumonia
• Infection of the lungs by group A beta hemolytic streptococci is usually secondary to measles,
chicken pox, influenza or whooping cough.

Clinical features:
• Abrupt onset of fever with chills, dyspnea, rapid respiration, blood streaked sputum, cough and
extreme prostration.
• Signs of bronchopneumonia are usually less, as the pathology is usually interstitial.
Complications:
• Serosanguineous or purulent empyema .
• Pulmonary suppuration is less common.
• 10 % of the patients have bacteremia.
• The condition mimics staphylococcal pneumonia when pneumatoceles are present.

Diagnosis:
• X-ray shows interstitial pneumonia, segmental involvement, diffuse peribronchial
densities or an effusion.
• Blood count shows increased neutrophils.
• Patient looks more ill in streptococcal pneumonia.
Treatment:

• Penicillin G (50000 – 100000 U/kg) daily in divided doses for 7 – 10 days.

• Response is gradual, but recovery generally complete.

• Empyema is treated by closed drainage with indwelling intercostal tube.

 Primary Atypical Pneumonia
• Etiological agent: Mycoplasma pneumoniae.
• Transmitted by droplet infection. Occurs in epidemics in the winter months.
• Children living in overcrowded environments are more prone.
• Uncommon in children below 4 yrs of age.

Clinical features:
• Incubation period: 12- 14 days. Onset may be insidious or abrupt.
• Initial symptoms: malaise, headache fever, sore throat, myalgia and cough (dry at first, later
mucoid, may be blood streaked).
• Dyspnea is unusual.
• Mild pharyngeal congestion, cervical lymphadenopathy, few crepitations.
• Extrapulmonary: hemolytic anemia.
Diagnosis:
• The leukocyte count is usually normal.
• Demonstration of IgM antibody by ELISA during the acute stage. IgG antibodies
are demonstrable by complement fixation after 1 week of illness and shows
increase in titers over 2-4 weeks.
• X-ray findings: poorly defined hazy or fluffy exudates radiate from the hilar
regions. Enlargement of the hilar lymph nodes and pleural effusion. Infiltrates
involve one lobe, usually lobar.

Treatment:
• Macrolide antibiotics (Erythromycin/ azithromycin/ N clarithromycin) or
tetracycline for older children for 7- 10 days.
 Pneumonia due to Gram- negative organisms

• Etiological agents: E.Coli, Klebsiella and pseudomonas.

• Affect small children (< 2 months of age) or children with malnutrition and poor
immunity.

• Pseudomonas may colonize airways of patient with cystic fibrosis and cause
recurrent pulmonary exacerbations.

• Pathology: Well demarcated areas of consolidation and necrosis occur due to

vasculitis. There is little inflammatory response.
Clinical features:
• Gradual onset and assumes life threatening proportions during its course.
• Signs of consolidation are minimal, particularly in infants.
• Constitutional symptoms are more prominent than respiratory distress.

Diagnosis:
• X-ray findings- massive consolidation. E.coli or Klebsiella pneumonia may have
pneumatoceles.

Treatment:
• IV third generation cephalosporins (Cefotaxime or Ceftriaxone) with or without
aminoglycoside for 10-14 days.
• Pseudomonas infection: ceftazidime is the drug of choice.
 Viral Pneumonia
• RSV is the most important cause in
infants under 2 years of age.
• At other ages: Influenza,
parainfluenza and adenovirus are
common.
• The bronchial tree or alveoli are
involved resulting in interstitial
pneumonia.
• There is no clinical evidence of
consolidation.
• Radiological signs: perihilar and
peribronchial infiltrates.
 PATHOGENESIS

• Viral pneumonia usually results from spread of infection along the airways,
accompanied by direct injury of the respiratory epithelium, which results in airway
obstruction from swelling, abnormal secretions, and cellular debris.

• Atelectasis, interstitial edema, and ventilation–perfusion mismatch causing significant

hypoxemia often accompany airway obstruction.

• Viral infection of the respiratory tract can also predispose to secondary bacterial
infection.
• WHO has recommended certain clinical criteria for diagnosis of pneumonia in children
at primary health care level for control of LRTI deaths.

• The clinical criteria for diagnosis of pneumonia:

- Rapid respiration with or without difficulty in breathing.

• Rapid respiration is defined as respiratory rate of

- > 60/ min: < 2 months of age.

- > 50/ min: 2 months – 1 year.

- > 40/ min: 1 – 5 years.

PNEUMONIA
• In children below 2 months of age, the presence of any of the following indicates Severe
disease:
- Fever (38*C or more).
- Convulsions.
- Abnormally sleepy or difficult to wake.
- Stridor in calm child.
- Wheezing.
- Not feeding.
- Tachypnea.
- Chest indrawing.
- Altered sensorium.
- Central cyanosis.
- Grunting.
- Apneic spells.
- Distended abdomen.
THANK YOU.