BRONCHOPNEUMONIA

INTRODUCTION

Pneumonia is the leading infectious cause of death in children worldwide, accounting for 15% of
all deaths of children under five years old.

DEFINITION

 It is a inflammatory process involving lung parenchyma “Indian Academy of Pediatrics”

 It is a inflammation with consolidation (it is a state of being solid with exudate) of
parenchymal cells of the lung. “Marlow – Redding”
INCIDENCE
Occurs most commonly in infants and young children 30% children are admitted
because of pneumonia 90% of deaths in respiratory illnesses are due to pneumonia The condition
kills an estimated 1.8 million children every year, according to World Health Organization. In
India, the casualty is as high as 3 to 4 lakh children.
CLASSIFICATION
Classification based on anatomy
 Lobar pneumonia: Replacement of alveolar air with cellular exudates.
 Interstitial pneumonia: Proliferation and desquamation of alveolar cells.
 Bronchopneumonia: Inflammation of terminal bronchioles.

Classification based on etiology

 Infective: Bacterial, atypical, and viral pneumonia

 Noninfective: Chemical, aspiration pneumonia

Classification based on source of infection:

 Community acqiured pneumonia (CAP): Caused by an infectious agent contracted

outside the hospital.
 Hospital acquired pneumonia (HAP): Pneumonia that occurs 48 hrs or more after
admission in a patient who had no signs of disease at the time he or she was presenting in
the hospital.
 Opportunistic pneumonia: In immune compromised child
Classification according to WHO:

 No pneumonia: Cough or cold, no fast breathing, chest indrawing or indicators of severe

illness.
 Pneumonia: Increased respiratory rate - <2 mo old: > 60 per minute, 2-12 mo old > 50,
per minute 12-60 months old> 40 per minute
 Severe pneumonia: Chest indrawing
 Very severe pneumonia: cyanosis, severe chest indrawing, inability to feed

ETIOLOGY
 Bacterial: Streptococcal pneumonia, H. Influenza, Staphylococcus aureas,
Mycobacterium tuberculosis, pneumococcus, etc.
 Viral: Respiratory syncytial virus, parainfluenza virus, influenza virus, adenovirus, etc.
 Atypical: Chlamydia and Mycoplasma.
 Others: Aspiration of food, oily nasal drops, kerosene poisoning

PATHOPHYSIOLOGY

Pneumonia is characterized by inflammation of the alveoli and terminal airspaces in response to

invasion by an infectious agent introduced into the lungs through hematogenous spread or
inhalation. The inflammatory cascade triggers the leakage of plasma and the loss of surfactant,
resulting in air loss and consolidation. The breach in pulmonary defence mechanism leads to
reactive edema with more proliferation of organism. This is followed by two consecutive stages
of consolidation in the involved lobe. In early consolidation, red hepatisation occurs due to
collection of polymorphoneuclear leukocytes, fibrin, RBC, etc. In second phase of consolidation,
grey hepatisation takes place with deposition of fibrin and active phagocytosis. During
resolution, intra-alveolar debris is ingested and removed by the alveolar macrophages. These
stages occur mainly in lobar pneumonia. In bronchopneumonia, a patchy consolidation involving
one or more lobes occurs and the neutrophilic exudate it centered in bronchi and bronchioles,
with centrifugal spread to the adjacent alveoli
 Viral pneumonias are characterized by the accumulation of mononuclear cells in the
submucosa and perivascular space, resulting in partial obstruction of the airway. In
staphylococcal pneumonia, abscess erodes the walls of the bronchi and cavities of the abscess are
filled with trapped air and thus pneumatoceles are formed,

CLINICAL FEATURES

 Cough
 Fever
 Signs of respiratory distress: Tachypnea, history of breathlessness or difficulty in
breathing with chest retractions, nasal flaring, grunting, use of accessory muscles of
respiration. Tachypnca is significant if respiratory rate is more than 50 breaths per minute
in 2-12 months of age and more than 40 breaths per minute in 12 months to 5 years of
age. Chest indrawing is a sign of severe pneumonia.
 Chest pain
 Abdominal pain (referred pain from the diaphragmatic pleura might be the first sign of
pneumonia in little children) and/or vomiting.
 Headache
 Signs of severe pneumonia differ with age comprise of temperature 38.5°C, respiratory
rate > 70 breaths/ min in infants and > 50 breaths/min in older children, moderate-to-
severe recessions in infants and severe difficulty in breathing in older children, chest
indrawing, nasal faring, cyanosis, intermittent apnoea, grunting, not feeding in infants
and signs of dehydration in older children, tachycardia, capillary refilltime >2S. Impaired
consciousness or convulsions may also be seen.
 On auscultation, crackles, bronchial breath sounds and diminished breath sounds.

INVESTIGATIONS

 Chest X-ray - Lobar consolidation

 Total and differential blood counts and hemoglobin
 Sputum gram staining and culture
 Blood culture
  Serological tests for bacteria and viruses
 Urinary antigen tests
 Polymerase chain reaction

TREATMENT

 According to IMNCI guideline, treatment for children from 2 months to 5 years of age:
 Give appropriate antibiotic for 5 days.
 Non-severe pneumonia is treated with a 5-day course of either oral cotrimoxazole or
amoxicillin, which are usually effective for Streptococcus pneumoniae and Haemophilus
influenzae. Cotrimoxazole is used twice a day, whereas amoxicillin is given three times a
day.
 In severe pneumonia give first dose of IV or intramuscular chloramphenicol (40 mg/kg)
before referral to hospital. Other options for an intramuscular antibiotic for pre-referral
use include ampicillin plus gentamicin combination, or ceftriaxone.

Treatment according to specific organism:

 Pneumococcal pneumonia: Penicillin V 250 mg 8-12 hourly orally, penicillin G0.5

MU/kg/day IV or procaine penicillin 0.6 MUIM daily for 7 days. Amoxycilline may also
be given with or without clavulanic acid.
 Streptococcal pneumonia: It is also treated with penicillin as in case of pneumococcal
pneumonia.
 Staphylococcal pneumonia: Coamoxiclav, a combination of cloxacillin and a third-
generation cephalosporin such as ceftriaxone. In case of no response within 48 hrs
vancomycin may be needed. Therapy should be continued for 4-6 weeks if there is
empyema or pneumothorax. Initial IV therapy may be shifted with oral antibiotics later.
 Hemophilus pneumonia: It is treated with ampicillin 100 mg/kg/day or coamoxiclav.
Cefotaxime 100 mg/kg/day or ceftriaxone 50-75 mg/kg/day may be given in severe cases.
 Viral pneumonia: Ribavirin is advised.
Supportive measures:

 Hospitalized hypoxemic children should be given oxygen to maintain oxygen saturation

>92%.
 Dehydrated children should be provided adequate amount of oral fluids and if unable
administer IV fluids,
 Electrolytes and creatinine serum levels should be measured on daily basis.
 Fever management with paracetamol.
 Empyema is managed with closed drainage with indwelling intercostals tube.
 Good nutrition is ensured.

COMPLICATIONS

 Empyema
 Pleural effusion
 Lung abscess
 Necrotising pneumonia

NURSING MANAGEMENT

Assessment

 Respiratory status: Tachypnea, retractions, labored breathing, nasal flaring, crackles,

chest indrawing, diminished brenth sounds
 Cough with or without sputum
 Vital signs
 Pulse oximetry and ABG
 Signs of dehydration

NURSING DIAGNOSIS

 Ineffective airway clearance related to increased mucous production

 Impaired gas exchange related to ventilation perfusion mismatch
 Ineffective breathing pattern related to pulmonary congestion
  Imbalanced body temperature related to pulmonary infection
 Risk for fluid volume deficit related to effect of pulmonary inflammation,
 Acute pain related to coughing, secondary disease condition
 Deficient knowledge related to disease process and home care
 Anxiety (parental) related to child's problem and hospitalization

Goal

 Child will exhibit no signs of abnormal respiration.

 Child will have clear airways as evidenced by absence of abnormal breath sounds and
thick secretions.
 Child will maintain adequate gas exchange as evidenced by adequate oxygen saturation
and improved nail bed color.
 Child will maintain normal body temperature.
 Child will exhibit no signs of dehydration
 Child will have decreased pain as evidenced by less irritability and verbalization of
increased comfort.
 The parents will express confidence in home care of the child
 The parents will verbalize relief of anxiety.

Interventions

Facilitation of Respiration

 Assess respiratory rate, breathing pattern frequently

 Monitor oxygen saturation by pulse oximetry.
 Clear the airway by suctioning if indicated.
 Administer cough expectorant or mucolytics as prescribed
 Provide nebulisation with or without bronchodilator to clear the airway
 Provide propped up position or position of comfort to the child and change the position
every 2 hourly to promote pulmonary drainage.
 Encourage coughing and deep breathing if child is cooperative
  Administer humidified oxygen if needed.
 Infants can be avoided oral feeding to prevent aspiration.
 Administer antibiotics as prescribed to treat the infection.

Maintenance of body temperature and pam relief

 Administer antipyretics, analgesics as prescribed

 Promote adequate rest periods
 Use diversional therapies
 Provide comfortable position with extra pillows
 Maintain quiet and cool environment
 Restrict visitors to provide rest and prevent cross infection

Maintenance of fluid volume

 Provide oral or IV fluids as ordered

 Monitor intake output daily
 Observe for signs of dehydration and poor tissue perfusion
 Monitor weight daily
 Parental education and relief of anxiety:
 Provide all necessary information regarding disease process, treatment, and outcome to
parents.
 Encourage questions regarding child care.
 Involve in child care and encourage staying with the child.
 Inform about home management of the child.

Expected Outcome

 The child maintains normal respiration and adequate gas exchange

 The child exhibits no signs of fever
 The child maintains normal fluid volume and no dehydration
 The child verbalizes less pain.
 The parents exhibit confidence in child care and less anxiety.