PNEUMONIA.

MANINGU JR
MD3 STUDENT KIUT, APRIL 2024.
 OUTLINE

1. Anatomy of upper and lower respiratory tract

2. Definition of pneumonia
3. Etiology
4. Clinical features
5. Diagnosis and classification of pneumonia
6. Treatment
7. Prognosis
UPPER AND LOWER RESPIRATORY TRACT
DEFINITION

• Pneumonia is defined as an infection of the lower respiratory tract that involves the airways and
parenchyma with consolidation of the alveolar spaces.
Etiology
Pneumonia in children is commonly caused by viruses, bacteria and fungi.
. Viruses
a)
 Measles virus
 Respiratory syncytial virus (RSV)
 Influenza virus
 Parainfluenza virus
 Respiratory adenovirus, etc.
 HIV-1
ETIOLOGY CONT…

b). Bacteria
Bacteria that cause pneumonia in children differ depending on
the age of the child.
Bacterial causes in children from birth to 2 months old
o Streptococcus group B
o Esch. coli (in neonates).
o Klebsiella species
ETIOLOGY CONT…

Bacterial causes in children above 2 months old

o Streptococcus pneumoniae
o Hemophilus influenzae type b
o Staphylococcus aureus
o Mycobacterium tuberculosis
ETIOLOGY CONT…

c). Fungi
Histoplasmosis
Coccidiomycosis

d). Atypical organisms

Chlamydia trachomatis in infants between 4-18 weeks
Chlamydophilus pneumoniae – is rare
Mycoplasma pneumoniae in children older than 5 years
Pneumocystis jiroveci (carinii) in children with HIV/AID
ETIOLOGY CONT…

e). Additional agents

 (New corona virus (Novo-corona) which cause COVID-19
 SARS-associated coronavirus (SARS CoV) which cause severe
acute respiratory syndrome (SARS)
 Influenza virus A (H5N1) which cause avian influenza or bird flue, a
highly contagious disease of poultry and other birds. Outbreaks in
humans have been reported in S.E Asia.
ETIOLOGY CONT…

 Swine influenza virus (SIV or H1N1) causes swine or pig

influenza. Outbreaks in humans have been reported
 Legionella pneumophila causes Legionnaires’ disease, a rare
cause of pneumonia in children
ETIOLOGY CONT…

f). Other causes of pneumonia

 Kerosene poisoning – causes kerosene pneumonitis
 Aspiration of food, oily nose drops and liquid paraffin-cause
aspiration pneumonia
 Strongyloides stercoralis and Ascaris lumbricoides larvae migrating
through the lungs (Loeffler's syndrome)
 Hypersensitivity
CLINICAL FEATURES

Clinical features in Older children (6 years and above)

Classic presentation as seen in adults. The clinical features include:
Upper respiratory tract infection with running nose and cough followed by:
Fever of sudden onset with or without

o Headache
o Shaking chills
o Anorexia
CLINICAL FEATURES CONT…

Cough
Fast breathing (tachypnoea)
Difficulty in breathing (dyspnea)
Chest pain
Acute abdominal pain (acute abdomen) due to referred pain from
pleuritic inflammation
CLINICAL FEATURES CONT…

In severe pneumonia,
Central cyanosis
Grunting
Severe respiratory distress
Inability to feed
Prostration
 Anxiety
Convulsions, lethargy or unconsciousness.
PHYSICAL SIGNS

On examination, depending on severity, the signs will be:

Nasal flaring (flaring of the alae nasi)
 Lower chest wall in-drawing (subcostal recession), intercostal and
supraclavicular retraction (recession).
Impaired (dull) percussion note,
 increased tactile vocal fremitus
Reduced air entry, bronchial breath sounds, fine crackles, increased
whispering pectoriloquy
DIAGNOSIS

 Diagnosis is based on history taking, physical examination and

laboratory findings, Bacteriological confirmation is difficult, Blood
culture may be positive in 5-10% of cases.
 The following laboratory investigation can be done:
(a) Full blood picture (FBP) - leukocytosis with neutrophilia and
elevated band cell count
(b) BS and MRDT to exclude malaria
DIAGNOSIS CONT…

(c) Chest X-Ray – will show one or more of the following:

 Lobar pneumonia- consolidation localized to one or more lobes of
the lung,
 Bronchopneumonia – patchy consolidation of the lobules ,
 Interstitial pneumonia - inflammation of the interstitial spaces
 Complications of pneumonia if present, such as empyema, pleural
effusion, lung abscess or atelectasis, pneumatoceles, and
pneumothorax.
RIGHT LOWER LOBE CONSOLIDATION IN A PATIENT WITH
BACTERIAL PNEUMONIA.
DIAGNOSIS CONT…

(d) Pulse oximetry in severe pneumonia to guide when to start and

when to stop oxygen therapy.
(e) Other investigations, if indicted include;
 Sputum for Gene-Xpert
 Sputum for AFB
 Sputum staining for fungus
PNEUMONIA IN INFANTS AND YOUNG CHILDREN (UNDER 5
YEARS OLD)

 Children younger than 5 years old are also called infants and
young children
 The clinical features in this age group usually differ from those in
older children and adults. The younger the child, the less the
typical signs of pneumonia. For example, neonates may have
fever and subtle or no sign of pneumonia.
CONT…

The clinical features in this age group include:

1. Symptoms
a) Non-specific symptoms, and include:
 Fever
 Shaking chills
 Vomiting everything
 Restlessness
 Inability to breastfeed or drink
CONT…

b) Specific symptoms which include:

 Cough
 Fast breathing
 Difficulty in breathing
SIGNS

Minimal signs, and include:

 Tachypnoea
 Nasal flaring (flaring of alae nasi)
 Lower chest wall in-drawing
 Grunting respiration in severe pneumonia
 Crackles but are rarely heard in young infants
CONT…

 Signs of CNS hypoxia, such as:

o Agitation
o Convulsions,
o Lethargy or unconsciousness
ASSOCIATED SYMPTOMS AND SIGNS

Meningism - seen in lobar pneumonia

Paralytic ileus – often seen in gram negative bacterial pneumonia
Osteomyelitis or sepsis – often seen in staphylococcus aureus
pneumonia
Malnutrition – seen in PTB and HIV
Hepatomegaly – seen in severe pneumonia and cardiac failure
DIAGNOSIS AND CLASSIFICATION OF PNEUMONIA

 Diagnosis of pneumonia in infants and young children is based on criteria

recommended by the WHO.
 The criteria are recommended for diagnosis of all Acute respiratory tract infection
(ARI) in this age group where auscultatory lung findings for pneumonia are minimal.
 In accordance with the WHO recommendations, the ARI is classified into 3
categories, namely:

I. Severe Pneumonia,
II. Pneumonia,
III. no pneumonia: cough or cold.
1. NO PNEUMONIA COUGH OR COLD

 cough or cold is common, self-limiting viral infection that require only supportive care.

Diagnosis: Common features are:

• Cough
• Nasal discharge
• Mouth breathing
• Fever
The following are absent:
General danger signs
Signs of severe pneumonia or pneumonia
Stridor when the child is calm
Wheezing
TREATMENT

Treat the child as an outpatient.

Soothe the throat and relieve the cough with a safe remedy, such as
a warm, sweet drink.
Relieve high fever (≥ 39 °C) with paracetamol 10-15 mg/kg per dose
8 hourly if the fever is causing distress to the child.
Clear secretions from the child’s nose before feeds with a cloth
soaked in water that has been twisted to form a pointed wick.
CONT…

Prognosis
Good. Most episodes end within 7-14 days.

Complications
Triggering of asthma attacks (asthma exacerbation)
Otitis media
Pneumonia
Bronchitis
Bronchiolitis
Sinusitis
2. PNEUMONIA

Diagnosis
Cough or difficulty in breathing with:
 Fast breathing
• ≥60 breaths/min in a child aged below 2 months
• 50 breaths/min in a child aged 2-11 months
• 40 breaths/min in a child aged 1-5 years
 Lower chest wall indrawing
 PNEUMONIA CONT…

 Other findings which may or may not be present on chest auscultation include:
 Crackles
 Pleural friction rub.
There will be no signs of severe pneumonia, such as:
 Oxygen saturation < 90% on pulse oximetry or central cyanosis
 Severe respiratory distress (e.g. grunting, very severe chest wall
indrawing)
 Inability to breastfeed or drink or vomiting everything
 Convulsions, lethargy or reduced level of consciousness.
Auscultatory findings of decreased or bronchial breath sounds,
crackles or signs of pleural effusion or empyema.
TREATMENT

Treat child as an outpatient.

Advise caretaker to give normal fluid requirements plus extra breast milk or fluids if there is a fever.

Small frequent drinks are more likely to be taken and less likely to be vomited

Antibiotic therapy
Give oral amoxycillin at least 40 mg/kg per dose every 8 hours a day for 5 days.

Other medications
Avoid unnecessary harmful medications such as remedies containing atropine, codeine derivatives
or alcohol.
PNEUMONIA IN CHILDREN WITH HIV
INFECTION

1. Admit to hospital and manage as severe pneumonia

2. Give antibiotic as above – amoxycillin 40 mg/kg per dose every 8
hours for 5 days

3. Review progress daily

3. SEVERE PNEUMONIA

Diagnosis: Cough or difficulty in breathing with:

 Oxygen saturation <90% or central cyanosis
 Severe respiratory distress, such as:
 Grunting, or
 Very severe chest wall indrawing
Signs of pneumonia with general danger signs, such as:
 Inability to breastfeed or drink
 Lethargy or reduced level of consciousness,
 Convulsions
TREATMENT

Admit the child to hospital.

1. Oxygen therapy
 Ensure continuous oxygen supply, from either oxygen cylinder or
oxygen concentrator, at all times.
 Give oxygen to all children with oxygen saturation < 90%
 Use nasal prongs as the preferred method of oxygen delivery to
young infants; if not available, a nasal or nasopharyngeal catheter
may be used.
TREATMENT CONT…

2. Antibiotic therapy

 IV or IM ampicillin 50 mg/kg (or IV or IM benzylpenicillin G

50,000 Units/kg) every 6 hours for at least 5 days plus
 IV or IM gentamicin 7.5 mg/kg once a day for at least 5
days.
TREATMENT CONT…

3. Supportive care
 Remove by gentle suction any thick secretions at the entrance to the nasal
passages or throat, which the child cannot clear.
 If the child has fever (≥ 39 °C) which appears to be causing distress, give
paracetamol 10-15 mg/kg/dose every 6 hours.
 If wheezing is present, give a salbutamol nebulizer, and start steroids when
appropriate

Monitoring: The child should be checked:

 By a nurse at least every 3 hours, and
 By a doctor at least twice a day.
PREVENTION OF PNEUMONIA

Hand washing
Immunization by Pneumococcal conjugate vaccine
PCV.
In Tanzania we use PCV13 which contains thirteen
serotypes of pneumococcus (1, 3, 4, 5, 6A, 6B, 7F, 9V,
14, 18C, 19A, 19F and 23F) which are conjugated to
diphtheria carrier protein.
CONT…

 A child with persistent cough and fever for more than 2 weeks and
signs of pneumonia after adequate antibiotic treatment should be
evaluated for TB.
 Other indicators of tuberculosis include: prolonged fever without
other cause and acute malnutrition.
 Further investigations and treatment for TB, following national
guidelines, may be initiated and response to anti-TB treatment
evaluated.
COMPLICATIONS OF PNEUMONIA

1. Septicemia which may lead to:

 Septic shock
 Meningitis especially in infants
 Peritonitis (enterococcal species)
 Endocarditis especially in patients with valvular heart disease or
congenital heart diseases, and
 Septic arthritis (staphylococcus aureus)
 Osteomyelitis (staphylococcus aureus)
COMPLICATIONS OF PNEUMONIA

[Link] complications which include:

 Pleural effusion or Empyema

 Lung abscess.
 Pneumothorax (staphylococcal pneumonia)
 Subcutaneous emphysema (viral
pneumonias)
REFERENCE

1. WHO pocket book for hospital management (page no. 184)

2. Ghai essential pediatrics 8th edition (page no. 377)
3. Standard Tanzania Treatment Guideline and National Essential
Medicines List For Tanzania Mainland – 6th Edition 2021 (page no.
162)
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LISTENING.