Daniel Tawfik, MD PGY-3

Morning report
6 June 2014
icky breathing
HPI
Setting: ED
Patient: 7mo male
HPI:
Rhinorrhea, cough x 3 days
Increased cough with post-tussive emesis this AM
One episode of perioral cyanosis with retractions
No improvement noted with 2.5mg albuterol at
home
No fevers at home
PMH
Right congenital diaphragmatic hernia
V-V ECMO DOL 0-4
Repaired DOL 5
Revised at 3mo age
History of adrenal insufficiency
History of pulmonary hemorrhage
Chronic lung disease
Feeding problems, NG dependent with thickened
PO feeds
Recent hospitalization 1wk ago for RSV with
reactive component

PMH
Meds: MVI, Albuterol PRN (finished prednisolone
6 days ago)
Allergies: NKDA
Imms: UTD
FHx: No chronic or childhood illnesses
SHx: Lives with parents and 6 older siblings. One
brother with cough x 4 days.
Physical exam
VS: T 39.9, P 209, R 54, BP 105/63, SpO2 78% RA
GEN: awake, alert, crying
HEENT: NG in place, TMs clear, no oropharyngeal
lesions
RESP: Increased work of breathing, subcostal and
intercostal retractions, coarse breath sounds
throughout, scattered end-expiratory wheeze
CV: Tachycardic, perioral cyanosis, no murmurs or
gallops appreciated, heart sounds more prominent on
right.
GI: soft, nontender, nondistended, no HSM
EXT: warm, well-perfused, CRT 2 sec
SKIN: No rashes or lesions
DDx
RESPIRATORY
Asthma
Aspiration pneumonitis
Foreign body aspiration
CDH
Lung hypoplasia
CCAM/CPAM
Pneumothorax
Hemidiaphragm paralysis
CARDIOVASCULAR
VSD
ASD
TOF
TAPVR/PAPVR
HLHS
SVT
Vascular ring
PulmHTN

INFECTIOUS
bronchiolitis
CAP
HAP
Influenza
pertussis
ENT
TEF
Laryngeal cleft
tracheomalacia
HEME/ONC
Anemia
Leukemic lung infiltrate
NEURO
stroke
Seizure
OTHER
Pregnancy
Lupus
Studies
Pertinent labs:
WBC 46 (33% bands, 56% PMNs)
VRP: negative
Blood culture: negative
Pertinent imaging:
CXR: New focal LLL opacity. Unchanged
hypoplastic right lung and mediastinal shift to the
right.
Community-acquired pneumonia
>150 million cases per year
1.2 to 2 million deaths per year
18% of U5M
Leading cause of childhood mortality worldwide
40% hospitalization rate
Strep pneumo, H. flu, Mycoplasma most common
Moraxella, Chlamydia, Staph less common
Disposition
Inpatient
Hypoxemic
<6mo
Bad pathogen (MRSA, etc)
Compliance concerns

Diagnostic testing
Blood culture
If inpatient
If not improving or deteriorating
VRP
Mycoplasma
Test if suspicious
CBC
If inpatient
ESR/CRP
Response to therapy
CXR
If inpatient
If hypoxemic
Treatment
Oral
Immunized -> Amoxicillin +/- Azithromycin
Alternatives: clindamycin, cephalosporin, levofloxacin
Unimmunized -> Augmentin +/- Azithromycin
Alternatives: clindamycin, cephalosporin, levofloxacin
IV
Immunized -> Ampicillin +/- Azithromcyin
Alternatives: clindamycin, cephalosporin
Unimmunized -> Ceftriaxone +/- Azithromycin
Alternatives: clindamycin
Dosing
Amoxicillin 90 mg/kg/day divided TID x 10 days
Augmentin 90 mg/kg/day divided BID x 10 days
Ampicillin 200 mg/kg/day divided Q6h
Ceftriaxone 75 mg/kg Q24h
Clindamycin 40 mg/kg/day divided TID x 10 days
Azithromycin 10 mg/kg Q24h x 3 days
Resources
Intermountain CAP guidelines
https://intermountainhealthcare.org/ext/Dcmnt?ncid
=522578601
Intermountain CAP flashcard
https://intermountainhealthcare.org/ext/Dcmnt?ncid
=522833243

Empyema
1-2% of pneumonias (closer to 28% in Utah)
Treatment affected by size
< 25% of hemithorax
Antibiotics (Cefotax/Ceftriaxone/Ceftaroline + Clindamycin)
25-50% of hemithorax
CT + TPA or VATS
> 50% of hemithorax
CT + TPA or VATS
If drainage >2 days, may need open debridement

Ibuprofen and empyema?
OR 4 (2.5-6.5) if Ibuprofen used prior to
hospitalization (p <0.0001)
Ibuprofen caused empyema?
Pro-inflammatory at low doses (3 mg/kg)
Increased neutrophils and cytokines
Also associated wth increased necrotizing fasciitis with
Strep pyogenes
Ibuprofen result of empyema?
Increased pain with empyema -> more meds
Delay in hospitalization if more comfortable
References
Gereige RS, Laufer PM. Pneumonia. Peds in Rev. 2013; 34(10):438-56.
Bradley JS et al. The management of community-
acquired pneumonia in infants and children older than 3 months of age:
clinical practice guidelines by the Pediatric Infectious Diseases Society
and the Infectious Diseases Society of America. Clin Infect Dis. 2011;
53(7):e25-76.
Byington CL et al. An epidemiological investigation of a sustained high
rate of pediatric parapneumonic empyema: Risk factors and
microbiological associations. Clin Infect Dis. 2002; 34:434-40.
Rinaldo JE, Pennock B. Effects of ibuprofen on endotoxin-induced
alveolitis: biphasic dose response and dissociation between
inflammation and hypoxemia. Am J Med Sci 1986; 291:29-38.
Konstan MW et al. Effect of ibuprofen on neutrophil migration in vivo in
cystic fibrosis and healthy subjects. J Pharmacol Exp Ther 2003;
306(3):1086-91.
Peterson CL et al. Risk factors for invasive group A streptococcal
infections in children with varicella: a case-control study. Pediatr Infect
Dis J 1996; 15:151-6.