PNEUMONIA

Supervision :
Dr:hassan algefry
Prepared by:
Khalid saleh
Salmeen awad
 Objectives:
 FUNCTION OF THE RESPIRATORY
SYSTEM
2
 DEFINITIONS IN PNEUMONIA
 EPIDEMIOLOGY
 ETIOLOGY
 PATHOPHSIOLOGY
 CLINICAL PICTURE
 INVESTIGATIONS
 TREATMENT
 COMPLICATIONS
 PREVENTION
 Function of the 3respiratory system

 The main function of the respiratory system is to provide

oxygen, the most important energy source for the body's
cells.
 Inspired air (the air you breath in) contains the oxygen,
and travels down the respiratory tree to the alveoli.
 The oxygen moves out of the alveoli and is sent into
circulation throughout the body as part of the red blood
cells.
 The oxygen in the inspired air is exchanged within the
alveoli for the waste product of human metabolism, carbon
dioxide.
 The air you breathe out contains the gas called carbon
dioxide. This gas leaves the alveoli during expiration.
 To restate this exchange of gases simply, you breathe in
oxygen, you breathe out carbon dioxide
 Definitions in pneumonia
4

Pneumonia refers to the inflammation of

pulmonary tissue.
 It is associated with consolidation of the alve­olar spaces.
Pneumonitis is a general term for lung
inflammation that may or may not be
associated with consolidation.
Lobar pneumonia describes pneumonia
localized to one or more lobes of the lung in
which the affected lobe or lobes are com­
pletely consolidated.
 Definitions in pneumonia
5

Bronchopneumonia refers to
inflammation of the lung that is:
 Centered in the bronchioles. and
 Leads to the production of a mucopurulent exudate
that ob­structs some of these small airways and causes
patchy consolidation of the adjacent lobules.
 Bron­chopneumonia is usually a generalized process in­
volving multiple lobes of the lung
 Definitions in pneumonia
6

Interstitial pneumonitis refers to

inflammation of the interstitium, which is
composed of the walls of the alveoli, the
alveolar sacs and ducts, and the bron­
chioles.
 Interstitial
pneumonitis may be seen
acutely with viral infections but
also may be a chronic process.
Epidemiology

Every year,

Pneumonia
causes over two million deaths
in children under 5

Source: UNICEF, 2006

7
 Under 5 Child Mortality
8
Global Distribution of Cause Specific Child Deaths

Other, 10%
Injuries, 3%
HIV/AIDs, 3%
Measles, 4% Neonatal, 37%
Under-nutrition
(underlying cause) Leading infectious
Malaria, 8% cause of death in
children < 5

Diarrhea, 17%

Pneumonia, 19%

Source: 2005 World Health Report

Epidemiology Of Pneumonia In Developing
Countries
9

146 million pneumonia episodes annually

Globally, 11-20 million hospitalizations/year in

children <5 years
1.8 million pneumonia deaths annually
15-34% of WHO pneumonia cases have evidence
of consolidation on chest x-ray
Childhood pneumonia mortality
(2005)
10

Map Source: PneumoADIP based on WHO estimates in Williams BG et al.

Lancet ID 2003
 Etiology
11

The cause of pneumonia depends on:

 Age.
 Immune status.
 Presence of CF or chronic lung disease.
 Exposure history.
 Nosocomial versus community acquisition.
Age Bacterial

Group12B streptococci, coliform

Neonate Bacteria
Staphylococcus attreus,

Haemophilus in­
4-16 wk fluenzae,t Streptococcus
pneumoniae
S. pneumoniae, S. aureus, H.
Up to 5 yr influenzae,
group A streptococcus
Over 5 yr H. influenza
Age Viral

CMV herpesvirus,
Neonate
enterovirus
CMV, RSV, influenza virus,
4-16 wk parain-
fluenza virus
RSV, adenovirus, influenza
Up to 5 yr
virus
Influenza virus, varicella,
Over 5 yr
adenovirus
13
Age Others
Mycoplasma hominis,
Neonate
Ureaplasma urealyticutn
Chlantydia trachornatis,
4-16 wk
U. urealyticum
-------------------------------------
Up to 5 yr
--------
Mycoplasma pneumoniae,
Over 5 yr Chlamydia pneumoniae,
Legionella
14
pneumophiln
 Pneumonia risk factors
15

Environmental factors (e.g, indoor air pollution)

Crowded living conditions
Malnutrition
Presence of other illnesses (eg. HIV)
 Predisposing Factors to infectious pneumonia:
16

Anatomic respiratory system

malformations.

Altered systemic or local

immunity.

Exposure to cigarette smoke.

In high mortality 17areas, most
fatal pneumonia is likely caused
by two bacteria:

Streptococcus pneumoniae
and
Haemophilus influenzae type b (Hib)
 Pneumococcus and Hib account for
more than half of all pneumonia deaths
in children
18 <5
2.0 Deaths attributed to
2.5
1.8
Pneumococcal and Hib
2 pneumonia
Deaths (m illions)

1.5
0.9
1 0.4
1.4 0.3
0.5

0
Pneumonia Diarrhea Malaria Measles AIDs

Source: 2005 World Health Report and WHO

Disease Burden estimates
 Defense Mechanisms
19

80% of cells lining central airways are ciliated,

pseudostratified,
columnar epithelial cells
Each ciliated cell contains
about 200 cilia that beat in
coordinated waves about
1000/minute
So the lower respiratory tract
is normally sterile
 20

Pathophysiology
The invading organism
causes symptoms, in part,
by provoking an overly
exuberant immune
.response in the lungs
The small blood vessels in
the lungs (capillaries)
become leaky protein-
rich fluid difuses into the
alveoli results in a less
functional area for oxygen-
.carbon dioxide exchange
 21
Pathophsiology

The patient becomes relatively oxygen*

deprived, while retaining potentially
.damaging carbon dioxide
The patient breathes faster and faster, in*
an effort to bring in more oxygen and
.blow off more carbon dioxide
Mucus production is increased, and the*
leaky capillaries may tinge the mucus
.with blood
Mucus plugs actually further decrease*
the efficiency of gas exchange in the
.lung
Pathophsiology 22

The alveoli fill further with fluid and debris from

the large number of white blood cells being
.produced to fight the infection
Consolidation, a feature of bacterial
pneumonias, occurs when the alveoli, which are
normally hollow air spaces within the lung,
instead become solid, due to quantities of fluid
.and debris

Viral pneumonias, and mycoplasma**

pneumonias, resulting in patchy
consolidation(bronchio pneumonia) . These
types of pneumonia primarily infect the walls of
.the alveoli and the parenchyma of the lung
In Pnemoccocal pneumonia: the involved lobe
under goes the following changes:
1- congestion: alveoli become edematous and
23
filled with microorgansims.
2- Red hepatization: alveoli contain
PMN,RBC,fibrin & organisms.
3- gray hepatization: deposition of fibrin on the
pleural surface & phagocytosis start.
4- resolution: neutrophile is degenerated , fibrin
threads & the remaining bacteria digested &
removed
 24

pathophsiology
So, the major pulmonary abnormalities occur in
the pneumonia are:
1_ reduction in the total available surface area
of the respiratory membrane.
2_ decrease ventilation- perfusion ratio.
Both these effects cause hypoxemia &
hypercapnia.
3-Hyperinflation of the patent alveoli
 Infectious Pneumonia
25

Viral Pneumonia:
 ETIOLOGY: The most common viruses causing pneumonia
include respiratory syncytial virus (RSV), parainfluenza,
influenza, and adenoviruses.
 CLINICAL MANIFESTATIONS:
preceded by URTI.
Low temperature.
 26

Signs of respiratory distress.

Auscultation:
widespread rales.
wheezing
Investigations:
 Chest X-Ray: Diffuse infiltration with hyperinflation.
 CBC: Lymphocytosis with normal or slite elevation of APR.
 Definitive Dx by PCR.
27
 Treatment
28

Supportive measures.
Admition needed for :
 IV fluid.
 O2.
 Ventilatory support.
Antibiotic if secondary bacterial infection.
 Bacterial
pneumococcal pneumonia
29

Most common bacterial pathogen causing

pneumonia (90% of childhood bacterial pneumonia).
Common in winter & early spring.
Highest 3-8 y of age.
More common through asymptomatic carrier.
 pneumococcal pneumonia
30

 In untreated cases, a clincal crisis occurs

about the 7th day of illness & complete
resolusion needs 1-3 weeks.
 The stages interrupted if antibiotics were
used early.
 CLINICAL MANIFESTATIONS:
Mild URTI of few days followed by:
1. Sudden rise of temperature ≥ 40 C & febrile convulsion
may occur in susceptible person.
2. Dyspnea , grunting & cyanosis may occur.
3. Chet pain of pleuritic nature.
4. Cough start later is dry then purulent sputum.
 pneumococcal pneumonia
31

 Chest signs:
1. Early →diminished air entry over the affected
area.
2. Later on signs of consolidation (dullness
,bronchial breathing & increased vocal
resonance).
3. When resolution start→ crepitations become
prominent while other signs gradually fade.
 pneumococcal pneumonia
32

 Investigations:
1. WBCs leukocytosis.
2. Culture for organism.
3. Counter immunoelectrophresis & latex
agglutination.
4. X-ray →lobar pneumonia more common in
older children than infants.
→may signs of complications as collapse.
 pneumococcal pneumonia
33
treatment
 Supportive care.
 Antipyretic analgesics: paracetamol (15 mg/kg/dose) for
fever & pleuritic pain.
 Antibiotics : penicillin the drug of choice for 7-10 days:
1. In infants & young children penicillin-G 50,000
iu/kg/day parenterally in 4 doses.
2. In older children singl IM injection of procaine
penicillin 600,000 iu followed by oral penicillin-V
50,000 IU/kg/day.
3. If patient allergic to penicillin erythromycin or
cephalosporin's (crfazolin 50mg/kg/day or cefuroxime
100mg/kg/day).
 Treatment of complications.
 Pneumococcal vaccine.
 Bacterial
34

Streptococcal Pneumonia:
 Group A beta-hemlytic streptococci most common.
 Mainly tracheobronchitis & interstetial pneumonia.
 Pleural effusion is common & is serosanguinous.
 CLINICAL MANIFESTATIONS:
 Usually follows exanthems &viral influenza.
 high fever.
 chills.
 signs of respiratory distress.
 It may occasionally be more insidious, and the child will
appear only mildly ill, with cough and low-grade fever.
 Bacterial
35

What testing would you do?

 Bacterial
36

Investigations:
 Leukocytosis with predominance of polymorphs.
 A rise in serum antistreptolysin titer is supportive
diagnostic evidence.
 Bacteremia occurs in about 10% of patients.
 Definitive diagnosis rests on recovery of the organism
from pleural fluid, blood, or lung aspirate.
 Bacterial
37

Chest roentgenograms usually show diffuse

bronchopneumonia, often with a large pleural
effusion. Final roentgenographic resolution may not
be complete for up to 10 wk.
 TREATMENT
38

The drug of choice is penicillin G (100,000

units/kg/24 hr) intially by parentral dose &
completed orally for2-3 weeks.
If empyema develops, a thoraco centesis should be
performed for diagnostic purposes and for removal
of fluid.
 Staphylococcal Infection
39

Staphylococci are common cause of pyogenic

infections in infants and children. These organisms
are gram positive cocci & classified to strains (S.
aureus, S. epidermidis, and S. sapropyticus).
Staph. is a part of the normal flora & is present in
anterior nares & moist areas of the body in about
30% of asymptomatic people.
 Staphylococcal Infection
40

Transmission occurs via hands, nasal discharge,

person to person & rarely air. The newborn infants
are extremely susceptible to staph. ; The
nasopharynx, skin, & umbilical stump are most
common sites of colonization. S. aureus colonizes
skin & MM through its affinity for host
glycoconjugates &intracellular matrix components.
 Staphylococcal Pneumonia
41

It is a rapidly progressive infection more

common in infants than in children.
70% occur in infants < 1 year of age &
characterized by:
 Frequently preceded by viral URTI.
 More severity & more complication (mortality up
to 30%).
 Causes bronchopneumonia more on one side.
 Lead to pyo-pneumothorax.
 Radio logically shows area of Hgic necrosis &
irregular cavitations.
 Staphylococcal Infection
42

The clinical manifestations:

 Patient commonly < 1 year.
 History of staph. skin infection in the patient or
family member.
 Symptoms of viral URTI.
 Sudden onset of high fever, cough, & respiratory
distress & bad general condition.
 The infant is pale ,toxic, irritable with severe
distress.
 Severe dyspnea & shock like state may be present;
GIT manifestations may be secondery to paralytic
ileus.
 43
Staphylococcal Infection
On chest examination: decrease breath sounds,
crepitations, wheezes & if complications develop
lead to dullness to percussion with decease breath
sounds & vocal fremitus.
Investigations: as Streptococcal.
CXR: picture of bronchopneumonia, picture of
later complication & high incidence of
pneumatoceles (which may persist for months after
cure).
 Staphylococcal Infection
44

What treatment would you prescribe?

 Staphylococcal Infection
45

Treatment:
 Supportive care.
 Antibiotic for 3-4 weeks:
 Methicillin 200mg\kg\d IV * TDS.
 Cloxacillin 100mg\kg\d IV * TDS.
 If allergy to penicillin present give cephalosporin 50mg\kg\d.
 Treatment of complications.
 Mycoplasma Pneumonia
46

Mycoplasmas are the smallest free-living organisms,

lack cell wall & are distinct from bacteria.
M. pneumonia is a major cause of illness in school-
aged children & young adults.
 Clinical illness is unusual < 4 year & peak attack
occurs at 6-15 year.
 Mycoplasma Pneumonia
47

M. pneumonia is estimated to cause 1\2 million of

pneumonia cases & 11 million of tracheobronchitis in
US.
The illness occurs at irregular intervals &
transmission is by droplet spread with incubation
period 2-3weeks.
 Mycoplasma Pneumonia
48

The clinical manifestations are of atypical

pneumonia:
 Gradual onset with headache, malaise, fever, sore throat,
& cough.
 Sputum production, rales, & pleural effusions are
frequent.
 Severe disease associated in children with SCA.

 Other manifestations include skin eruptions & less

commonly meningoencephalitis, Guillian Barre
syndrome,heamolytic anemia, thrombocytopenia,
myocarditis and pericarditis.
 Mycoplasma Pneumonia
49

The diagnosis is by positive cold agglutinins titers &

confirmed by increase in specific antibodies IgM or
IgG.
Treatment:
 Erythromycin or doxycyclin (in children > 10 year) is drug of
choice.
 Chlamydia Pneumonia
50

It is an important cause of respiratory diseases in

children and adults.
The primary infection usually occurs in school age
children and reinfection during adulthood are
common.
Clinical picture as mycoplasma.
Pharyngitis, horsness and bronchitis are common.
The symptoms are mild but prolonged.
 Chlamydia Pneumonia
51

Treatment with erythromycin or tetracycline in older

children.
 Others
52

Slowly Resolving Pneumonia

 It refers to persistence of symptoms or radiographic
abnormalities beyond the expected time course.
 Considered factors:
 Inadequate treatment.
 Development of resistant organisms or impaired host defenses.
 Non – bacterial cause.
 Viral, fungal, parasite & mycobacterial infections.
 Obstructing endobronchial lesions (congenital or acquired).
 Others
53

 Foreign bodies, pulmonary sequestration, cystic adenomatoid

malformations, & post infectious bronchiectasis.
 Non infectious causes as bronchiolitis obliterans, hypersensitivity
pneumonitis, eosinophilic pneumonia, aspiration pneumonia &
Wegner granulomatosis.
 Sarcoidosis & pulmonary alveolar proteinosis but rare in children.
 Others
54

Evaluation:
 Identify the offending organism by gram stain &\or culture of
blood, sputum & bronchoalveolar lavage.
 Serological tests as ANCA for Wegner.
 Chest CT, flexible fiber optic bronchoscopy & lung biopsy.
 55
Lobar pneumonia Bronch pneumonia
etiology 90% pneumococcal may H. Staph.aureus
influenza Strept.pyogenes
H-influnza & Gram -v
age 3-8 years Usually <2 years.

pathology Consolidation of a lobe Inflammed bronchi & scatered

Bronchial tree is free patches of Consolidation
bilaterally.
Local signs Signs of consolidation on the Bilateral MSCC+wheeze.
lobe

TVF Increased over the affected Differe from area to area.

lobe.
Type of breathing Bronchial on affected lobe. Vesicular .

Vocal resonance increased Variable from area to area.

 56

Lobar pneumonia Bronch pneumonia

Type of Bronchial on affected lobe. Vesicular .
breathing

Vocal resonance increased Variable from area to area.

 Differential Diagnosis of Recurrent
Pneumonia
57

In a few children pneumonia may persist longer

than 1 month or may be recurrent. In such cases
the possibility of underlying disease must be
investigated further.
The differential diagnosis:
 Hereditary disorders
 Disorders of immunity
 Disorders of leukocytes
 Disorders of cilia
 Anatomic disorders
 Differential Diagnosis of Recurrent
Pneumonia
58

The Evaluation includes:

 Tuberculin skin test
 Sweat chloride determination
 Serum immunoglobulin & IgG subclass
determinations
 Bronchoscopy
 Barium swallow
Would you hospitalize
59 him?
 Indications for hospitalization
include the following
60

 Moderate to severe RD
 Failure to respond to oral antibiotics
 Inability to take oral antibiotics at home
 Lobar consolidation in more than one lobe
 Immunosuppresion
 Empyema
 Abscess or pneumatocele
 Underlying cardiopulmonary disease (BPD or Pulmonary
HTN)
 Complications of Pneumonia
Abscess. It typically occurs as61a result of aspiration
pneumonia, when a mixture of organisms is carried into
the lung. Untreated abscesses can cause hemorrhage
(bleeding) in the lung, but targeted antibiotic therapy
significantly reduces their danger.

Respiratory Failure. Respiratory failure is one of the top

causes of death in patients with pneumococcal
pneumonia. Acute respiratory distress syndrome (ARDS)
is the specific condition that occurs when the lungs are
unable to function and oxygen is so severely reduced
that the patient's life is at risk. Failure can occur if
pneumonia leads to mechanical changes in the lungs
(ventilatory failure) or oxygen loss in the arteries
.(hypoxemic respiratory failure)
Bacteremia. Bacteremia, bacteria in the blood,
is the most common complication
62 of
pneumococcus infection, although it rarely
spreads to others sites.
Pleural Effusions and Empyema In some cases
of pneumonia the pleura become inflamed,
which can result in breathlessness and acute
chest pain when breathing.
Collapsed Lung. In some cases, air may fill up
the area between the pleural membranes,
causing the lungs to collapse.
 Prevention of pneumonia mortality
63

Case Management
Risk Modification
 Hand washing, indoor pollution control
Improved Nutrition
 Exclusive breast feeding, supplements
Vaccines
 Pertussis, measles, Hib, pneumococcal
 Case Management
Integrated Management of Childhood Illness (IMCI)
64

Educates family and community

 Care seeking, prevention and nutrition, proper
implementation of prescribed care

Promotes comprehensive care at health care

provider level
 accurate diagnosis
 appropriate combined treatment
 referral of severely ill children
 Improved counseling of families
 emphasizes nutrition and vaccination
Vaccines
 Measles and Pertussis
vaccines have already
reduced cases of child
pneumonia
 Hib and pneumococcal
vaccines should be an
integral part of a
pneumonia prevention
program

65
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Thanks