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BROCHIOLITIS and Pneumonia in children.ppt
- 1.
- 2. Introduction Pneumonia isan infection of the lower respiratory tract and lung parenchyma which leads to consolidation. Can be caused by viruses, bacteria or fungi. Non infectious causes include aspiration, hypersensitivity reactions and drug or radiation induced pneumonitis Most serious cases are bacterial in origin
- 3. Etiology of pneumonia AgeOrganism Neonates Group B Streptococcus, staphylococcus aureus. Gram-negative organisms (E. Coli, Klebsiella) Less common: CMV, HSV, Chlamydia, Listeria, Bordetella pertussis < 5 years Streptococcus pneumoniae Haemophilus influenzae Group A Streptococcus Staphyloccus aureus (severe), especially post-measles Bordetella pertussis Viral: RSV, measles, influenza, adenovirus, parainfluenza School age Streptococcus pneumoniae Mycoplasma, Chlamydia Viral pneumonias as above Adults Streptoccus pneumoniae ‘Atypical’ organisms (Mycoplasma, Chlamydia, Legionella) H. Influenzae Viral pneumonias: influenza, adenovirus, Varicella Zoster
- 4. Transmission of Pneumoniain children. Pneumonia Inhalation of infected droplets from cough or sneeze. Aspiration of Pathogens found on nasopharynx. Through blood (haematogenous)
- 5. Risk factors Bypassedupper airway-tracheostomy Aspiration(food or gastric acids, foreign bodies) Disruption of mucociliary blanket Cellular or humoral immunodeficiency/immunosuppression Altered lung parenchyma
- 6. Cont… Environmental factors : Indoor air pollution(cooking and heating with biomass fuels e.g. wood or dung). Living in crowded homes Parental smoking
- 7. Physiological defence mechanism Anatomicaland mechanical barriers: (Mucociliary, epiglottic reflexes, cough reflex.) Humoral immunity: (IgA and other IgG and IgM)
- 8. Pathogenesis. The lowerrespiratory tract is normally kept sterile by physiologic defense mechanisms. The mucociliary clearance, secretory IgA and clearing of the airway by coughing as well as macrophages present in alveoli and bronchioles. Resulting in airway obstruction from swelling, abnormal secretions, and cellular debris.
- 9. Cont… Usually inhaledinfectious pathogens direct damage the respiratory epithelium, which leads to swelling or oedema. And hence airway obstruction. During resolution, intra-alveolar debris is ingested and removed by the alveolar macrophages. This consolidation leads to decreased air entry and dullness to percussion. The small caliber of airways in young infants makes them particularly susceptible to severe infection.
- 10.
- 11. Classification of Pneumonia Pathoge n Anatomy Acquring •Bacteria, • fungi, • Viral, • Atypical • Lobar • Bronchial • Community acquired Pneumonia(CAP). • Hospital acquired pneumonia • Immuno -compromised acquired pneumonia.(ICAP)
- 12. WHO Classification Severepneumonia (needs admission) Pneumonia No signs of Pneumonia or Severe Pneumonia (cough or cold)
- 13. Signs and Symptoms Severepneumonia Cough or difficult in breathing plus at least one of the following: Sop <90% on pulse oximetry or central cyanosis Severe respiratory distress(grunting, very severe chest indrawing.) Signs of Pneumonia with a general danger signs: ( inability to breast feed, lethargy or unconscious ,convulsisons).
- 14. Cont… Pneumonia Cough or difficultin breathing plus one of the following signs: Fast breathing : age <2 months > 60 br/ min 2-11 months >50 br/min 1-5 years > 40br/min Lower chest wall indrawing
- 15.
- 16. Cont… Chest auscultation Decreasedbreath sounds Bronchial breath sounds Crackles
- 17. Investigations • Full bloodpicture Increased WBC with neutrophilia suggests bacterial process • Blood cultures • Induced sputums or gastric aspirates for AFB smear and culture if not responding to treatment • Chest x-ray, especially in: ◦ Severe pneumonia not responding to treatment or with complications ◦ HIV infection
- 18. Diagnosis By history,clinical presentation CXR; which may show: hyperinflation with bilateral interstitial infiltrates if viral pneumonia, consolidation if pneumococcal pneumonia, NOTE: CXR alone is not diagnostic feature.
- 19. Differential diagnosis Diagnosis Infavor Severe Malaria •Fast breathing in febrile child •Blood smear or rapid test positive(parasitaemia). •Anaemia or palmar pallor •Lives in or travelled to malarious area •Deep (acidotic) breathing or Lower chest indrawing in severe malaria •Chest clear on ascultation Severe anemia •Shortness of breath on exertion •Severe palmar pallor •Hemoglobin <6 g/dl. Cardiac failure •Raised JVP in older children •Apex beat displaced to the left •Gallop rhythm •Heart murmur(in some cases) •Basal fine crackles •Enlarged palpable liver Effusion/ empyema •Reduced movement on affected side of the chest •Stony dullness to percussion(over the effusion) •Air entry absent(over the effusion)
- 20. cont… Diagnosis In Favor Congenitalheart disease(cyanotic) •Cyanosis •Finger clubbing •Heart murmur •Signs of cardiac failure Congenital heart disease(acyanotic) •Difficulty in feeding or breastfeeding with failure to thrive •Sweating of the forehead •Heaving of precordium •Heart murmur(in some cases) •Signs of cardiac failure. Asthma or wheeze •Reccurent episodes of shortness of breath or wheeze •Night cough or cough and wheeze with exercise •Response to bronchiodilators •Known or family history of allergy or asthma Bronchiolitis • Cough •Wheeze and crackles •Age usually <2 years.
- 21. Cont… Diagnosis In favor Tuberculosis•Chronic cough (>14 days) •History of contact with TB patient •Poor growth/ wasting or weight loss •Positive Mantoux •Chest x-ray may show primary complex or miliary TB •Sputum positive in older child Pertussis •Paroxysms of cough followed by whoop, vomiting, cyanosis or apnea •Well between paroxysms(No symptoms between bouts of cough) •No fever •No history of DPT vaccination Foreign body •History of sudden choking •Sudden onset of stridor or respiratory distress •Focal areas of wheeze or reduced breath sounds Pneumothorax •Sudden onset ,usually after major trauma •Unilateral hyper-resonance on percussion •Shift in mediastinum to opposite side Pneumocystis •2-6 month old child with central cyanosis •Hyper-expanded chest •Tachypnea •Finger clubbing •Chest x-ray changes, but chest clear on auscultation •Hepatosplenomegaly, lymphadenopathy •HIV test positive in mother or child
- 22. Management of SeverePneumonia Supportive Oxygen therapy 1-2 litres/min (0.5 litre/min for young infants) ◦ All children with signs of hypoxia if a pulse oximetry not available ◦ Saturation <90% if a pulse oximetry available Nasal prongs best method of delivery Paracetamol for fever > 39 degree centigrade. Bronchodilator for wheeze or start steroids Suction for secretions which the child cannot clear
- 23. Cont… Antibiotic therapy Ampicillin100-200mg/kg IV in 4 doses for at least 7 days. Gentamycin 5mg/kg IV once a day for at least 7 days. When improving, change to oral amoxicillin (40 mg/kg BD) for 5- 7 days total If not improving after 48 hours,and staphylococcal pneumonia is suspected switch to Cloxacillin 50 - 100mg/kg/day in 3 doses IM or IV for 7 - 10 days and gentamicin 5mg/kg IM or IV once a day for 7 days. Use ceftriaxone 50-75mg/kg /day IM or IV once daily for 7 days for bacterial infection in cases of failure of first line treatment.
- 24. Management of Pneumonia Treat the child as outpatient Give first dose at clinic and teach mother/caregiver how to give other doses at home. Amoxicillin (40 mg/kg BD for at least 5 days) Amoxicillin preferred if pneumonia develops in an HIV-positive child using CTX for PCP prophylaxis
- 25. ‘Atypical Pneumonia Mycoplasmapneumoniae and Chlamydia pneumoniae Generally more common in older children >5 years Often not severely ill Consider especially in older children treated as outpatients who have not responded to amoxicillin Treat with macrolide antibiotics ◦ Erythromycin 12.5 mg/kg QDS OR ◦ Azithromycin 10 mg/kg OD day 1 then 5 mg/kg OD days 2-5
- 26. Aspiration pneumonia Predisposing conditions: Altered consciousness Dysphagia Neurologic disorder Mechanical disruption of usual defenses ◦ NG tube Other ◦ Protracted vomiting ◦ Gastric outlet obstruction ◦ Large volume NG tube feedings ◦ Recumbent positioning
- 27. Cont… Treatment: Coverage oforal anaerobes important (if there are teeth) ◦ (Ampicillin OR benzylpenicillin) AND metronidazole 7.5 mg/kg IV/PO TDS ◦ Alternatives if available Clindamycin 10 mg/kg IV/PO TDS Amoxicillin/ clavulanate (Augmentin) 10 mg/kg PO TDS
- 28. Staphylococcal pneumonia Suggestedby ◦ Rapid clinical deterioration ◦ Pneumatocele or pneumothorax with effusion on CXR ◦ Gram-positive cocci in sputum smear ◦ Growth of S. aureus in sputum or empyema fluid ◦ Septic skin pustules
- 29. Cont… Treatment: ◦ Cloxacillin(50-100mg/kg/day in 3 doses IM or IV ) + gentamicin 5mg/kg IM or IV once a day). ◦ When child improves after 7days Continue orally cloxacillin three times a day for 10 days total .
- 30. Complications Septicaemia. Pneumothorax. Pleural effusion. Empyema. Lung abscess.
- 31. Prevention Promoting breastfeeding, adequate nutrition intake.(it enhance natural immunity and reduce the length of illness) Immunization (pneumococcal-PCV, Measles, Hib and whooping cough) Addressing environmental factors e.g. indoor pollution by providing affordable indoor stoves. Encouraging good hygiene in crowded homes. Give prophylaxis(Cotrimoxazole) in HIV positive children.
- 32.
- 33. Definition: Bronchiolitis aninflammatory, obstructive small airway disease (lower respiratory tract - bronchioles.) It is caused primarily by viral infections with respiratory syncytial (RSV)
- 34. Pathogenesis Airway obstructionfrom fibrinous debris/mucus plugs plus abnormal mechanics of respiration - DIB Pneumonia, insterstitial infiltration and alveolar filling may develop, especially in the most severe cases.
- 35. Pathogenesis The sitesof inflammation are small bronchi and bronchioles The alveolar spaces are spares Viruses incubate and replicate 2 – 8 days in the nasopharynx then→ lower respiratory tract. Necrosis of the respiratory epithelium, excessive mucus production edema, dense plugs of debris causing obstruction.
- 36.
- 37. Causes of Bronchiolitis Respiratory Syncytial Virus is the major cause in > 90% of infants. Other causes include ◦ Parainfluenza virus ◦ Adenoviruses, and ◦ Measles virus. ◦ Mumps ◦ Mycoplasma pneumoniae
- 38. Risk children 2-12months Males Preterm Cardiac lesions Preexisting respiratory disease Congenital malformations
- 39. Clinical presentation ◦ URIsymptoms: fever, cough, coryza, SOB ◦ Wheezing ◦ Severe respiratory distress with marked chest wall retractions, nasal flaring and grunting ◦ Inability or reluctant to feed ◦ Frequent or prolonged apnoeic episodes ◦ Hypoxaemia which may not be corrected by extra oxygen
- 40. Differential diagnosis Pneumonia Anatomical abnormalities Congestive heart failure Allergic reactions Bronchial foreign body Pertussis
- 41. Complications Respiratory failure M. pneumoniae PCP Diffuse destruction of distal small airways. Bronchiectasis
- 42. Diagnosis History Physical examination Investigations: Bloodgases FBP (CBC) Chest X-Ray –peribrochial thickening and consolidation Blood culture Serum electrolytes CRP
- 43. Treatment - 1 1.Ensure ABCs 2. Oxygen therapy to maintain oxygen saturation at 95%. ◦ Give O2 2 L/min by nasal prongs, facemask, nasal catheter ◦ Use humidified O2 with nebulizer where possible. ◦ Continuous monitoring is recommended if supplemental oxygen is required.
- 44. Treatment - 2 3.Fluid therapy: ◦ Give IV fluids in the following conditions:- Moderate-to-severe or severe respiratory distress Marked tachypnoea (>60/min) Apnoeic episodes Tiring during feeds. ◦ Generally use normal maintenance volumes, N/S or N/5 dextrose saline. ◦ Increase fluid volumes (by up to 20%) if there is frequent fever (>38.5oC) and/or marked increased respiratory effort.
- 45. Treatment - 3 4.Drugs ◦ Generally don’t use bronchodilators in infants less than 6 months of age. ◦ If asthma is considered a possibility in infants aged 6 – 12 months, give a standard start dose of asthma and observe the response. If responds continue treatment as asthma.
- 46. Treatment - 4 ◦Generally don’t use antibiotics except in children with gross CXR changes, high persistent fever or child is severely sick and toxic.
- 47. Nursing monitoring and care Monitoring: Signs of deterioration requiring change in treatment: ◦ increasing fatigue, ◦ increasing effort of breathing, ◦ tiring, ◦ increasing difficulty with feeding. Continuity of O2 therapy O2 saturation (pulse oximeter) Vital signs: RR, PR, T
- 48. Care: Feeding byNGT Parent counseling and education General nursing care
- 49. Prevention Handwashing andcleaning of toys, furniture and clothing will reduce the risk of transmission. Early identification of family members during influenza season
Editor's Notes
- #23 Oxg