Pediatric Respiratory Physiology

TOPIC OUTLINE
I. Anatomy and physiology of the respiratory tract
II. Common respiratory problems in children
A. Infectious disorders
1. acute upper respiratory infections
» rhinitis
» sinusitis
» otitis externa/media
» acute tonsillopharyngitis
2. acute laryngitis
3. bronchitis
4. bronchiolitis
5. pneumonias
 Course Content: (cont.)
B. Non-infectious disorders
• foreign bodies
• atelectasis
• Asthma

C. Pulmonary tuberculosis
– primary infection
– progressive primary infection
– multidrug resistant pulmonary tuberculosis
– miliary tuberculosis
 Fetal Lung Development
• embryonic
• 7-16 weeks: formation
of the bronchial tree
• 17-24 weeks: primitive
gas exchange
surface forms
• 24-40 weeks: alveolar
development
continues
• 35 weeks: stable
surfactant production
 5 Stages of LUNG development
• EMBRYONIC: week 4 - 5
• PSEUDOGLANDULAR: week 5 – 16
• CANALICULAR: week 16 – 25
• SACCULAR: week 24 – 40
• ALVEOLAR: late fetal - 8 years
 STAGES OF LUNG DEVELOPMENT

Stage Human Features

lung buds originate as an

outgrowth from the ventral
Embryonic week 4 to 5 wall of the foregut where
lobar division occurs

conducting epithelial tubes

surrounded by thick
Pseudo
week 5 to 17 mesenchyme are formed,
glandular extensive airway branching
Terminal bronchioles
 Stage Human Features

Respiratory bronchioles are

produced, increasing number
of capillaries in close contact
Canalicular week 16 to 25 with cuboidal epithelium and
the beginning of alveolar
epithelium development (Type
I and II)

alveolar ducts and air sacs are

Saccular week 24 to 40 developed;
Surfactant synthesis

secondary septation occurs,

late fetal to 8 marked increase of the
Alveolar
years number and size of capillaries
and alveoli
 Postnatal Lung Development
• Newborn
– Airway branching complete
– Alveolar formation is not complete
Age 1-10 years: number of alveoli increase
Age 10 to young adult: lung grows larger with
little alveolar growth
Anatomical and physiological differences
between adults and children
• As children grow, the airway enlarges and
moves more caudally as the cervical spine
elongates.
• The pediatric airway overall has poorly
developed cartilaginous integrity allowing
for more laxity throughout the airway.
• narrowest point in the airway is below the
cords for children.
Anatomical and physiological differences
between adults and children

• The magnitude of these differences relate

to age
• largest variation: in neonates and infants
• The older child increasingly approximates
to adult parameters
 ANATOMICAL differences in the airway
• Compared to the adult, in the child:
– obligate nasal breathers
– ribs are oriented much more horizontally
and rib cage is much softer
– large tongue
– Narrower at all levels
– larynx is smaller and is in a higher
position and more anterior
 LARYNX
• High position
• Infant : C 1
• 6 months: C 3
• Adult: C 5-6
 ANATOMICAL differences in the airway
• Compared to the adult, in the child:
– epiglottis is longer, floppy and U-shaped ;
– in the younger child, the narrowest part of
the upper airway is the cricoid ring
– Tracheal cartilage is softer and smaller in
both length and diameter
 ANATOMICAL differences in the
airway
• diaphragm is flatter and less domed;
moves less efficiently and contains fewer
fatigue-resistant muscle fibers
• Infants and young children rely on
diaphragm to breathe more than adults do
 MUSCLE FIBERS
• Type I fibers
– slow-twitch and high-oxidative in nature
– Low contractility but are fatigue resistant

• Type II fibers
– fast-twitch and low-oxidative
– have high contractility but are more prone to
fatigue.
– The proportion of type I fibers in the
diaphragm and intercostals of premature
infants is only around 10%.
– This increases to around 25% in full-
term newborns and around 50% in
children >2 years.
– Respiratory muscles of premature
babies and young infants are therefore
more susceptible to fatigue, resulting in
earlier decompensation.
• Overall, the pediatric airway being smaller,
has poorly developed cartilaginous
integrity allowing for more laxity
throughout the airway.
 ANATOMY PEDIATRIC ADULT

Tongue Large Normal

Epiglottis shape Floppy, omega Firm, flatter

shaped
Epiglottis level Level C3 - C4 Level of C5 – C6

Larynx shape Funnel shaped Column

Larynx position Angles posteriorly Straight up and

away from the down
glottis
Narrowest point Subglottic region At level of vocal
cords
Lung volume 250 ml at birth 6000 ml as adult
 PHYSIOLOGICAL differences in
breathing between adults and children

• Compliant chest wall → creates a greater

negative inspiratory pressure ; “sucks in”
the floppy airway → decreases airway
diameter → increases the work of
breathing
• The work of breathing is higher in children,
consuming relatively more oxygen.
? Remember: Lung volumes and
capacities
• Tidal volume (VT) is the amount of air moved in
and out of the lungs during each breath; at rest,
tidal volume is normally 6-7 mL/kg body weight.

• Inspiratory capacity (IC) is the amount of air

inspired by maximum inspiratory effort after tidal
expiration.

• Expiratory reserve volume (ERV) is the amount

of air exhaled by maximum expiratory effort after
tidal expiration
• Residual volume (RV) - The volume of gas
remaining in the lungs after maximum
expiration
• Vital capacity (VC) - defined as the amount of
air moved in and out of the lungs with
maximum inspiration and expiration.
• Total lung capacity (TLC) - is the volume of
gas occupying the lungs after maximum
inhalation.
 Dynamic volumes
• Maximum forced expiratory flow (FEF
max) is generated in the early part of
exhalation
– commonly used indicator of airway
obstruction in asthma and other obstructive
lesions
– a decrease in flow is a reflection of increased
airway resistance
• Forced vital capacity (FVC) - the total
volume exhaled during this maneuver
• FEV1 - volume exhaled in one second
• FEV1/FVC is expressed as a percentage
of FVC
• Chest wall compliance is a major
determinant of FRC.
• The increased chest wall compliance in
infants allows greater chest wall retraction
because of less opposition to the lung
recoil, thereby decreasing FRC
 Infants and children…
• Tidal volume is proportionally smaller to that
of adolescents and adults
• Metabolic oxygen requirements of infants and
children are about double those of
adolescents and adults
• Children have proportionally smaller
functional residual capacity, and therefore
proportionally smaller oxygen reserves
 PULMONARY
SIGNS & SYMPTOMS
 A child who appears in respiratory
distress might not have a respiratory
illness
• abnormalities of central nervous system
(encephalitis)
• neuromuscular disease such as Guillain-
Barre syndrome or myasthenia gravis and
those with an abnormal respiratory drive
• metabolic acidosis (diabetic ketoacidosis)
 Respiratory Distress: S/S
• diagnosed from
signs such as:
– cyanosis
– nasal flaring
– grunting
– tachypnea
– wheezing
– chest wall retractions
– stridor
 Tachypnea
• Less than 3 months: > 60 breaths per
minute
• 3 months - 12 months: > 50 breaths per
minute
• 1 year – 4 years: > 40 breaths per minute
 AIRWAY : 3 anatomic parts

• extrathoracic airway
– from the nose to the thoracic inlet

• intrathoracic-extrapulmonary airway
– from the thoracic inlet to the main stem bronchi

• intrapulmonary airway
– within the lung parenchyma
 valuable signs in localizing the site of
respiratory pathology

• rate and depth of respiration

• retractions
• stridor
• Wheezing
• grunting
 AIRWAY : 3 anatomic parts
• extrathoracic airway
– Hallmark: Inspiratory stridor
– retractions (chest wall, intercostal,suprasternal)
– With increased negative intrathoracic pressure
during inspiration
 Stridor
• is a harsh, high-pitched respiratory sound
• usually inspiratory but can be biphasic and
is produced by turbulent airflow
• it is not a diagnosis but a sign of upper
airway obstruction
• Intrathoracic-extrapulmonary airway
– Hallmark: Expiratory wheezing

• Intrapulmonary airway
– Rapid and shallow respirations (tachypnea)
– Grunting
 GRUNT
• is produced by expiration against a partially
closed glottis
• is an attempt to maintain positive airway
pressure during expiration
• most beneficial in alveolar diseases that
produce widespread loss of FRC, such as in
pulmonary edema, hyaline membrane
disease, and pneumonia
INTERPRETING THE CLINICAL SIGNS OF
RESPIRATORY DISEASE

EXTRA-THORACIC INTRATHORACIC- INTRA-PULMONARY

EXTRA
SIGN AIRWAY PULMONARY AIRWAY
AIRWAY
OBSTRUCTION OBSTRUCTION OBSTRUCTION

Tachypnea + + +++
Retractions ++++ ++ ++

Stridor ++++ ++ −

Wheezing ? +++ ++

Grunting ? ? +++
 DIAGNOSTIC PROCEDURES
• CBC – not very reliable
• Cultures – if (+) exudates
• Chest radiographs
– In infants and young children ( AP-Lateral
views)
• Why? Lesions in the hilar areas maybe
obscured by the cardiac silhouette
• ABG
RESPIRATORY DISORDERS
 RHINITIS
• is a viral illness
• prominent symptoms:
– rhinorrhea (nasal discharge)
– nasal obstruction
 Common cold
• P.E. limited to the upper respiratory tract

• A change in color or consistency of the

secretions is common during the course of
illness and is NOT indicative of sinusitis or
bacterial superinfection
• A green or yellow nasal discharge should
not be construed as evidence of
secondary bacterial infection (neutrophils
cause yellow-green discoloration because
of their natural myeloperoxidase activity).
 FORMS OF RHINITIS
allergic rhinitis nonallergic
(hay fever) rhinitis
(common cold)
• pollen
• dust mites • RHINOVIRUSES
• mold • Adenoviruses
• animal • RSV
dander
• Coxsackie’s viruses
 RHINITIS

• common in children under 5 years of age.

• Most children will develop three to eight colds

or respiratory illnesses a year. This number
may even be higher in children who attend
day care or are exposed to tobacco smoke.
Epidemiology

• Mode of transmission:
– by aerosols
• Small particle (Influenza virus)
• Large particle
– direct contact (Rhinoviruses and RSV)

• Rhinoviruses remain viable on skin and also on

objects (fomites) for at least 2 hours.
Clinical manifestations:
• Fever +/-
• rhinorrhea
• sore throat 50%
– 1ST symptom to appear
– cough
– similar cases in the family
 RHINORRHEA
CONDITION DIFFERENTIATING FEATURES

Prominent itching and sneezing

Allergic rhinitis Nasal eosinophils
Unilateral, foul-smelling secretions
Foreign body Bloody nasal secretions

Presence of fever, headache or facial pain,

Sinusitis or periorbital edema or persistence of
rhinorrhea or cough for >14 days

Mucopurulent nasal discharge that

Streptococcosis excoriates the nares
Pertussis Onset of persistent or severe cough
Persistent rhinorrhea with onset in the 1st
Congenital syphilis 3 months of life
 Treatment (Symptomatic) :
fever antipyretics

nasal obstruction saline nasal

drops/solution

rhinorrhea antihistamines
 Complications:
• Otitis media – most common
• Bacterial sinusitis
– should be considered if rhinorrhea or daytime
cough persists without improvement for at
least 10-14 days or if signs of more-severe
sinus involvement such as fever, facial pain,
or facial swelling develop.
• Exacerbation of asthma
 PREVENTION
• Chemoprophylaxis or immunoprophylaxis is
generally not available for the common cold.
• Vitamin C and echinacea DO NOT prevent the
common cold.

• Interrupting the chain involved in the spread of

virus by direct contact may prevent colds.

• Prevention of the spread of viruses by direct contact

can be most readily accomplished by good hand
washing by the infected individual and/or the susceptible
contact.
 SINUSITIS
• Acute inflammation of the mucosa of one
or more of the paranasal sinuses
• Generally follows rhinitis
• 2 types: viral and bacterial
• Both the ethmoidal and
maxillary sinuses are
present at birth, but only the
ethmoidal sinuses are
pneumatized
• maxillary sinuses are not
pneumatized until 4 yr of age
• sphenoidal sinuses are
present by 5 yr of age
• frontal sinuses begin
development at age 7-8 yr
and are not completely
developed until adolescence.
 SINUSITIS
• Can occur at any age
• Predisposing conditions include viral upper
respiratory tract infections (associated with
out-of-home daycare or a school-aged
sibling), allergic rhinitis, and cigarette
smoke exposure
 SINUSITIS
• Etiology: Streptococcus pneumoniae
(∼30%)
• Pathogenesis: typically follows a viral
upper respiratory tract infection
 SINUSITIS: signs and symptoms
• nonspecific complaints, including nasal
congestion, purulent nasal discharge
(unilateral or bilateral), fever, and cough
• PE: erythema and swelling of the nasal
mucosa with purulent nasal discharge
 Diagnosis
• Based on history
• Persistent symptoms of upper respiratory
tract infection, including nasal discharge
and cough, for >10-14 days without
improvement, or severe respiratory
symptoms, including temperature of at
least 39°C and purulent nasal discharge
for 3-4 consecutive days
 TREATMENT
• although 50-60% of children with acute
bacterial sinusitis recover without
antimicrobial therapy
• For uncomplicated: Amoxicillin
 TREATMENT
• For penicillin-allergic patients: trimethoprim-
sulfamethoxazole, cefuroxime axetil, cefpodoxime,
clarithromycin, or azithromycin
• For children with risk factors
– antibiotic treatment in the preceding 1-3 mo, daycare
attendance, or age <2 yr for the presence of resistant
bacterial species
– for children who fail to respond to initial therapy with
amoxicillin within 72 hr
– Rx: high-dose amoxicillin-clavulanate (80-90 mg/kg/day
of amoxicillin)
 Sinusitis - Complications
• Eye complications:
– peri-orbital/ orbital cellulitis

• Intracranial complications:
– Meningitis
– cavernous sinus thrombosis
– Abscess
– Subdural empyema
 OTITIS EXTERNA
• Precipitating factors;
– Trauma
– Swimming
– Impacted cerumen
– Change from the normal acid to alkaline
pH of the external auditory canal
 OTITIS EXTERNA
• Etiology: Staph aureus (most common)
Others: gram negative bacilli
(Pseudomonas aeruginosa, Proteus
vulgaris, E. coli)
• s/s: ear pain aggravated by movement of
the tragus
hearing is normal
 TREATMENT
• Cleansing and drying of External Auditory
Canal
• If (+) infection: DO NOT irrigate
• If (+) cellulitis and chondritis: Rx antibiotic
– OXACILLIN or any penicillinase-resistant
penicillin
 OTITIS MEDIA
• Inflammation of the mucoperiosteal lining of the
eustachian tube, tympanic cavity, mastoid
antrum and mastoid air cell system
 OTITIS MEDIA
• Peak incidence: 1st 2 yrs
• Three pathogens predominate in OM:
Streptococcus pneumoniae (most common)
Haemophilus influenzae
Moraxella catarrhalis
 Predisposing factors of developing otitis
media in children:

• developmental alterations of the Eustachian

tube (short, wide, & straight)
• an immature immune system
• frequent infections of the upper respiratory
mucosa
• the usual lying-down position of infants favors
the pooling of fluids, such as formula.
• Symptoms of AOM are variable, especially
in infants and young children.
• In young children, evidence of ear pain
may be manifested by irritability or a
change in sleeping or eating habits and
occasionally, holding or tugging at the ear
• Diagnosis: confirmed by otoscopy (TM)
– Findings: injection of TM
absent light reflex
decreased motility
retraction or bulging of TM
 Otitis media

• Acute Otitis media with

purulent effusion behind a
HEALTHY TYMPANIC MEMBRANE
bulging tympanic membrane.
 Treatment
AGE GROUP EMPIRIC THERAPY
Neonates Ampicillin , 200mg/kg/24hrs
parenteral in 4-6 hrly doses

Amikacin, 15mg/kg/24hrs

1-15 years Trimethoprim-

sulfamethoxazole , 10-
20mg/kg/24hrs in 2 12
hourly doses
 Otitis media
• Tympanostomy tube in place

Chronic OM
 ACUTE PHARYNGITIS
• Sore throat
 Pharyngitis: Etiology
A) Viral: Most common
Rhinovirus (most common).
Symptoms usually last for 3-5 days.
B) Bacterial: Group A beta hemolytic
streptococcus (GABHS)
Early detection can prevent complications
like acute rheumatic fever and post
streptococcal GN.
 Pathogenesis
• Colonization of the pharynx by GABHS
can result in either asymptomatic carriage
or acute infection.
• The M protein is the major virulence factor
of GABHS and facilitates resistance to
phagocytosis by polymorphonuclear
neutrophils
Pharyngitis: signs and symptoms

• Rapid onset
• absence of Cough
• Fever
• Sore throat
• Malaise
• Rhinorrhoea
• Classic triad of GABHS:
High fever
tonsillar exhudates
ant. cervical lymphadenopathy
 Streptococcal pharyngitis
• Physical examination:
– red pharynx
– enlarged tonsils with yellow blood-
tinged exudate
– petechiae on the soft palate and
posterior pharynx
– enlarged/tender anterior cervical lymph
nodes
Streptococcal pharyngitis
 Pharyngitis: Treatment
• early antibiotic therapy hastens clinical
recovery by 12-24 hr

• RX: penicillin
• amoxicillin
 Strep. pharyngitis

• Prevention of acute rheumatic fever is

successful if treatment started within 9
days of illness

• Clindamycin (20mg/k/day) -
recommended for carriers
 DIAGNOSIS
• PE: Tonsillar exudates, anterior cervical
lymphadenopathy
• Rapid strep: Throat swab. Sensitivity of 80%
and specificity of 95%.
Throat culture - Not required usually. Needed
only when suspicion is high and rapid strep is
negative
 Complications
• include :
– local suppurative complications, such as
parapharyngeal abscess, and later
nonsuppurative illnesses, such as acute
rheumatic fever and acute
postinfectious glomerulonephritis
 ACUTE TONSILLITIS
Etiology
 Tonsillitis often occurs with Pharyngitis.
 Viral or bacterial
 ACUTE TONSILLOPHARYNGITIS

• The pharynx is red

• tonsils are enlarged and classically
covered with a yellow, blood-tinged
exudate
• There may be petechiae or “doughnut”
lesions on the soft palate and posterior
pharynx, and the uvula may be red,
stippled, and swollen
 ATP : Treatment
A) Symptomatic: Saline gargles,
analgesics, cool-mist humidification and
throat lozenges
B) Antibiotics:
a) Benzathine Pn-G 1.2 million units
IM x 1OR Pn V orally for 10 days
b) For Pn allergic pts:
Erythromycin 500mg QID x 10 days
OR Azithro 500 mg OD x 3 days.
 Acute Inflammatory Upper
Airway Obstruction
(Croup, Epiglottitis, Laryngitis,
and Bacterial Tracheitis)
• The lumen of an infant's or child's airway is
narrow
• airway resistance is inversely proportional to
the 4th power of the radius

R ~ 8l / r4
R – resistance, l – length, r – radius

• minor reductions in cross-sectional area due

to mucosal edema or other inflammatory
processes cause an exponential increase in
airway resistance and a significant increase
in the work of breathing.
 CROUP
(Laryngotracheobronchitis)
• Viral infection (parainfluenza)
• Affects larynx, trachea
• Subglottic edema; Air flow obstruction
• Incidence: 6 months to 4 years
Males > Females
 Croup: Signs/Symptoms
• Low grade fever
• “Cold” progressing to hoarseness
• “barking” cough
• Inspiratory stridor
 Croup: Management
• Mild Croup
– Reassurance
– Moist, cool air

• Severe Croup
– Humidified high concentration oxygen
– Nebulized racemic epinephrine
– Anticipate need to intubate, assist ventilations
 EPIGLOTTITIS

• Bacterial infection (Hemophilus influenza)

• Affects epiglottis, adjacent pharyngeal tissue
• Supraglottic edema

Complete Airway
Obstruction
 Epiglottitis: Incidence

• Incidence: Children > 4 years old

Common in ages 4 - 7
• Pedia incidence falling due to HiB vaccination
• Can occur in adults, particularly elderly
 Epiglottitis: Signs/Symptoms

• Rapid onset, severe distress in hours

• High fever
• Intense sore throat, difficulty swallowing
• Drooling
• Stridor
• Sits up, leans forward, extends neck slightly
• One-third present unconscious, in shock
 Epiglottitis

Respiratory distress+
Sore throat+Drooling =
Epiglottitis
 Epiglottitis: Management
• High concentration oxygen
• Do not attempt to visualize airway
 Epiglottitis

Immediate Life Threat

Possible Complete Airway
Obstruction
 Croup and Epiglottitis
CROUP EPIGLOTTITIS
Age 6 months to 4 years Age 3 to 7 years

Slow onset Rapid onset

Patient may lie or sit upright Patient prefers to sit upright

Barking cough No barking cough, possible

inspiratory stridor

Lack of drooling Drooling, pain during

swallowing

Low-grade fever High fever

 Acute Bronchitis
• Inflammation of the bronchial respiratory
mucosa leading to productive cough.
 Acute Bronchitis
• Etiology: A)Viral
B) Bacterial (Bordetella pertussis,
Mycoplasma pneumoniae,
and Chlamydia pneumoniae)
• Diagnosis: Clinical
• S/S: Productive cough, rarely fever or
tachypnea
 TREATMENT
A) Symptomatic

B) If cough persists for more than 10

days:
Azithromycin x 5 days
OR
Clarithromycin x 7 days
COMPLICATIONS

• chronic bronchitis,
• pneumonia,
• asthma,
• bronchiectasis
 BRONCHIOLITIS
• viral disease ( RSV >50% )
• more common in boys, in those who have
not been breast-fed, and in those who live
in crowded conditions.
• Incidence: Children < 2 years old
80% of patients < 1 year old
 Bronchiolitis: Pathophysiology
• bronchiolar obstruction with edema,
mucus, and cellular debris and air trapping
• ↑ Resistance in the small air passages
during both inspiration and exhalation
 Bronchiolitis: Pathophysiology
• BUT because the radius of an airway is
smaller during expiration……
the resultant respiratory obstruction
leads to early air trapping and
overinflation
• If obstruction becomes complete, trapped
distal air will be resorbed → develop
atelectasis.
 Bronchiolitis: Signs/Symptoms

• Infant < 1 year old

• Recent upper respiratory infection exposure
• Gradual onset of respiratory distress
• Expiratory wheezing
• Extreme tachypnea (60 - 100+/min)
• Cyanosis
 Bronchiolitis: Management
• Humidified oxygen
• bronchodilators
• Anticipate need to intubate, assist
ventilations
 ASTHMA BRONCHIOLITIS
Age >2 years old <2 years old
Fever Normal temp positive
Family history positive Negative
Hx of Allergy Positive Negative
Response to positive negative
Epinephrine
 PNEUMONIA
• inflammation of the parenchyma of the
lungs
 Physiologic Pulmonary Defense
mechanisms
• mucociliary clearance
• the properties of normal secretions such
as secretory immunoglobulin A (IgA),
alveolar macrophages
 PNEUMONIA
• most cases of pneumonia are
INFECTIOUS caused by microorganisms
(viral and bacterial)
• NON-INFECTIOUS causes include
aspiration of food or gastric acid, foreign
bodies, hydrocarbons, and lipoid
substances, hypersensitivity reactions,
and drug- or radiation-induced
pneumonitis.
 PNEUMONIA
• 3 wks – 4yrs:
Streptococcus
pneumoniae
(pneumococcus)

• 5 yrs and older:

Mycoplasma
pneumoniae
and Chlamydia
• Recurrent pneumonia is defined as 2 or
more episodes in a single year or 3 or
more episodes ever, with radiographic
clearing between occurrences.
• An underlying disorder should be
considered if a child experiences recurrent
pneumonia.
 Clinical Symptoms of Pneumonia

• Triad of fever, cough

and tachypnea
• Tachypnea - most
consistent clinical
manifestation of
pneumonia
• PE: crackles, rhonchi,
decreased breath
sounds
 DIAGNOSIS
• An infiltrate on
chest radiograph
supports the
diagnosis of
pneumonia
 Viral pneumonia

• hyperinflation
• bilateral interstitial
infiltrates
• peri-bronchial
cuffing
Bacterial pneumonia - consolidation
 Diagnosis -Pneumonia
• Definitive diagnosis - isolation of
microorganism
• blood culture is positive only in 10-30% of
cases
• sputum culture - no clinical use
 TREATMENT
• For mildly ill children who do not require
hospitalization:
– amoxicillin is recommended
– In communities with a high percentage of
penicillin-resistant pneumococci, high doses
of amoxicillin (80-90 mg/kg/24 hr) should be
prescribed.
• Therapeutic alternatives : cefuroxime
axetil and amoxicillin/clavulanate.
 TREATMENT
• For school-aged children and in children in
whom infection with M. pneumoniae or C.
pneumoniae : a macrolide antibiotic such
as azithromycin
• In adolescents: a respiratory
fluoroquinolone (levofloxacin) may be
considered as an alternative
When to hospitalize?
 FACTORS SUGGESTING NEED FOR
HOSPITALIZATION OF CHILDREN WITH
PNEUMONIA
• Age <6 months
• Sickle cell anemia with acute chest syndrome
• Multiple lobe involvement
• Immunocompromised state
• Toxic appearance
• Moderate to severe respiratory distress
• Requirement for supplemental oxygen
• Dehydration
• Vomiting or inability to take oral fluids and medications
• No response to appropriate oral antibiotics
• Social factors
 Complication of Pneumonia
• Due to direct spread of bacterial infection
within the thoracic cavity
– Pleural effusion
– Empyema
– Lung abscess

• S. aureus , S. pneumonia, S. pyogenes -

most common causes of
parapneumonic effusions and of
empyema
Pleural effusion, right
 Complication of Pneumonia
• result of bacteremia and hematologic
spread
• Meningitis, suppurative arthritis, and
osteomyelitis are rare complications of
hematologic spread of pneumococcal or
H. influenzae type b infection.
 Parapneumonic Effusion
• Thoracentesis –diagnostic and
therapeutic
• Diagnostic: pleural fluid analysis
• Usually exudative
– Pleural fluid/serum protein >0.5
– Pleural fluid/serum LDH > 0.6
– Pleural fluid LDH > 2/3 upper normal
– pH < 7.2
QUESTIONS?