Pediatric Community Acquired

Pneumonia
• Mark Nicholas B. Reyes
• Medical Intern
 Sample Case

• A.S.
• Male
• 5 y.o.
• Chief complaint: cough
 Sample Case
History of Present Illness

• Productive cough and colds

• Fever (Tmax 38.2C)
• 1x vomiting of previously ingested
2 days prior to food
• Poor appetite and activity
admission • No diarrhea
• No difficulty of breathing
 Sample Case
History of Present Illness

• Persistence of distressing cough and

colds
• Intermittent fever
1 day prior to • 5x vomiting of previously ingested
milk
admission • Mottling of the skin on upper and
lower extremities
 Sample Case
History of Present Illness

• Still febile at 38C

• Perioral cyanosis during coughing
Few hours prior to episodes
• Irritable with poor suck, activity, and
admission appetite
 Sample Case
Past Medical History

• Pneumonia (2019)
• Complete immunization at par with age
 Sample Case
Family History

• Hypertension - Maternal and paternal side

• No heredofamilial diseases like:
• Diabetes mellitus
• Cancer
• Stroke
• Asthma
• Seizure
• Heart Disease
 Sample Case
Developmental History

• Emotional/Social Milestones
• 12 months: has favorite things and people
• Language/Communication
• 12 months: Responds to simple spoken requests
 Sample Case
Developmental History

• Cognitive (learning, thinking, and problem-solving)

• 12 months: Copies gestures
• Movement/ Physical development
• 18 months: drinks from cup
 Sample Case
Review of Systems

Head and Neck No headache, no head injury

Ears and nose No ear pain, no ringing, no nose bleeds
Throat No bleeding gums, no sore tongue

Eyes No change in vision

 Sample Case
Review of Systems

CVS No chest pain

Renal No difficulty in urinating
Urogenital No discharge

Neurologic No loss of consciousness

Muscular No muscle and joint pains
 Sample Case
Physical Examination

General Survey Awake, irritable, in mild

cardiorespiratory distress
Vital Signs HR: 132 bpm RR: 32 cpm
Temp: 37.6C 02 saturation: 96%
Wt: 8.5kg Ht. 69cms
Eyes Anicteric sclerae, pink palpebral
conjunctiva, no matting, sunken
eyeballs
 Sample Case
Physical Examination

Ears Normoset ears, no ear deformity, no

tragal tenderness, no aural discharge
Mouth/throat Moist oral mucosa, moist lips, non
hyperemic pharyngeal wall
Chest Symmetric chest expansion, bibasal
crackles, shallow subcostal retractions,
no wheezes
 Sample Case
Physical Examination
Cardiovascular Adynamic precordium, tachycardic,
regular rhythm, no murmurs
Gastrointestinal Globular, soft abdomen, nondistended,
hyperactive bowel sounds
Extremities Grossly normal extremities, warm
extremities, full equal pulses, CRT <2
secs, no cyanosis with good skin turgor
Musculoskeletal No limitations of movement
 Sample Case
Neurologic Examination

Sensorium and Awake with good eye contact

affect
Orientation Oriented to the three spheres
Glasgow coma 15/15
scale
 Sample Case
Neurologic Examination

Cranial Nerves I: n/a

II: 2-3mm equally reactive to light
III,IV, and VI: EOMs with full ROM
V: n/a
VII: No fascial asymmetry
VIII: Intact gross hearing
IX, X: Can swallow with intact gag reflex
XII: can moe, shrug shoulders
 Sample Case
Admitting Impression and Plan
Admitting Pediatric Community Acquired
Impression Pneumonia - B
Plan DAT with SAP
D5 0.3NaCl 500cc x 50 cc/hr(30ck6)
Monitor vital signs q4h and record
Diagnostic Examinations
- CBC PC
- CXR (AP-L)
- UA
 Sample Case
Admitting Impression and Plan

Therapeutics Salbutamol 1 neb q8

Cetirizine drops 1ml BID
Paracetamol drops (12mkdose)
s/b O2
 Pneumonia

• Inflammation of the parenchyma of the lungs

• Leading infectious cause of death among children <5 y/o
• Pneumonia mortality is closely linked to poverty
 Etiology

Age Group Frequent Pathogens (in order of frequency)

Neonates (< 3 weeks) GBS, E.coli, S. Pneumoniae, and Haemophilus influenza

3wk - 3 months RSV, S.pneumoniae, and H.influenzae

4months - 4 years RSV, S.pneumoniae, H. influenzae, M.pneumoniae, GAS

≥ 5 years M.pneumoniae, S.pneumoniae, C.pneumoniae

 Noninfectious Causes

• Aspiration
• Foreign bodies
• Hypersensitivity reactions
• Drug or radiation induced pneumonitis
 What are the defense mechanisms of the lower respiratory tract
against infections?

• Mucociliary clearance
• Macrophages
• Secretory IgA
• Coughing
 Pathogenesis
Viral Pneumonia

• Usually results from spread of infection along the airways, accompanied by direct
injury of the respiratory epithelium → airway obstruction, abnormal secretion, and
cellular debris
 Pathogenesis
Bacterial Pneumonia

• Most often occurs when respiratory tract organisms colonize the trachea and subsequently gain
access to the lungs
• May also result from direct seeding of lung tissue after bacteremia
 Pathogenesis
S. Pneumonia

• Local edema that aids in proliferation of organisms and spread to adjacent portion
leading to characteristic focal lobar involvement
 Pathogenesis
Group A streptococcus

• Results in more diffuse lung involvement

• Pathology includes:
• Necrosis of tracheobronchial mucosa
• Exudates, edema, and local hemorrhage
• Involves lymphatic vessels with pleural involvement
 Pathogenesis
S. Aureus

• Manifests as confluent bronchopneumonia

• Often unilateral
• Presence of extensive areas of hemorrhagic necrosis and irregular areas of
cavitation of the lung parenchyma
 Pathogenesis
Mycoplasma pneumonia

• Attaches to the respiratory epithelium

• Inhibits ciliary action
• Cellular destruction and inflammatory response in the submucosa
• Airway obstruction
• Spread of infection along the bronchial tree
 Clinical Manifestations

• Fever
• Tachypnea
• Cyanosis and fatigue in infants
• Diminished appetite
• Increased worked of breathing
• Crackles and wheezing
 Tachypnea

Age Normal Respiratory Rate Respiratory Rate Threshold

< 2months old 35-55 breaths/min ≥ 60 breaths/min

2 months - 11 months old 25-40 breaths/min ≥ 50 breaths/min

12 months - 59 months old 20-30breaths/min ≥ 40 breaths/min

≥ 5 years old 15-25 breaths/min ≥30 breaths/min

 Who shall be considered as having Community Acquired Pneumonia?

•A patient presenting initially with cough and/or respiratory difficulty may be

evaluated for possible presence of pneumonia
 Who shall be considered as having Community Acquired Pneumonia?

• Pneumonia may be considered if any of the following positive predictors of

radiographic pneumonia is present:

O2 saturation ≤94% Wheezing or crackles

Age-specific tachypnea Decreased breath sounds

Chest wall retraction Nasal Flaring

Fever
Consolidations as visualized
in lung ultrasound
Grunting
Who will require admission?
 Who will require admission?

• Patient classified as pCAP C may be managed initially as outpatient provided that

all of the following are not present:
• < 2 years old
• Convulsions
• CXR with effusion, lung abscess, air leaks, or multilobar pneumonia
• O2 sat ≤ 95% at room
 When is antibiotic recommended?
pCAP A or pCAP B

• Antibiotic may be administered if a patient is:

• Beyond 2 years of age or
• With high grade fever without wheeze
 When is antibiotic recommended?
pCAP C

• Empiric antibiotic may be started if any of the following is present:

• Elevated biomarkers:
• CRP
• Serum procalcitonin • Alveolar consolidation on CXR
• WBC count • Persistent high-grade fever
• Lipocalin-2 without wheeze
 What empiric treatment should be administered ?
Bacterial Etiology - pCAP A or B

• Amoxicillin
• 40-50 mg/kg/day TID
• 90mg/kg/day TID
• Azithromycin 10mg/kg/day OD
• Clarithromycin 15mg/kg/day BID
 What empiric treatment should be administered ?
Bacterial Etiology - pCAP C

• Pen G 100,000 units/kg/day in 4 divided doses

• Ampicillin 100 mg/kg/day in 4 divided doses
• Amoxicillin 40-50 mg/kg/day or 90 mg/kg/day
 What empiric treatment should be administered ?
Viral Etiology (pCAP C or D clinically suspected Influenza virus)

• Infants 3-8 months

• Oseltamivir 3mg/kg/dose BID x 5 days
• Infants 9-11 months
• Oseltamivir 3.5mg/kg/dose BID x 5 days
 What empiric treatment should be administered ?
Viral Etiology (pCAP C or D clinically suspected Influenza virus)

• ≥12 months, <15kg

• Oseltamivir 30mg BID x 5 days
• ≥ 12 months, > 15 kg but <23kg
• Oseltamivir 45mg BID x 5 days
• ≥ 12 months, > 23kg but < 40kg
• Oseltamivir 60mg BID x 5 days
• ≥ 12 months, > 40kg
• Oseltamivir 75mg BID x 5 days
 When can a patient be considered as responding to treatment?
pCAP A or B

• Clinical stability may be assessed within 24-48 hours after consultation if cough
has improved or body temperature has returned to normal
 When can a patient be considered as responding to treatment?
pCAP C

• Stabilitymay be assessed within 24-48 hours after admission if any of the

following parameters has significantly improved or returned to normal:
• Respiratory rate
• O2 sat at room air
• Body temp
• Work of breathing
 When can a patient be considered as responding to treatment?
pCAP D

• Clinicalstability may be assessed within 48-72 hours if ALL of the following

parameters have significantly improved:
• Respiratory rate
• O2 sat at room air
• Body temp
• Work of breathing
 What should be done if patient is not responding to current treatment?

pCAP A or B

• If not improving, or clinically worsening, within 72 hours, diagnostic evaluation to

determine if any of the following is present may be considered
• Coexisting illness
• Antibiotic resistance
• Other diagnosis:
• PTB
• Asthma
 What should be done if patient is not responding to current treatment?

pCAP C
• If not improving, or clinically worsening, within 48 hours, diagnostic evaluation to
determine if any of the following is present may be considered
• Coexisting illness or other etiologic agent
• Antibiotic resistance
 What should be done if patient is not responding to current treatment?

pCAP C
Other diagnosis:

• Asthma • PTB • Sepsis • Pleural effusion

• Pneumothorax • Lung abscess • Necrotizing • Acute respiratory

pneumonia failure
 When can switch therapy be started?
pCAP C

• Switch from intravenous antibiotic administration to oral form may be beneficial

to reduce length of hospital stay provided ALL of the following are present:
 When can switch therapy be started?
pCAP C

• Current parenteral antibiotic has been given for at least 24 hours

• Afebrile within the last 8 hours
• Responsive to current antibiotic therapy
• Able to feed, and without vomiting or diarrhea
• Without any current pulmonary or extrapulmonary complications
• O2 sat ≥ 95% at room air
 How can pneumonia be prevented?

• Vaccine against:
• S. pneumonia
• H. influenzae type B
• Breastfeeding
• Avoid cigarette smoke
 References

• Nelson Textbook of Pediatrics 21st Ed.

• 3rd PAPP Update [2016] in Evaluation and Management of Pediatric Community-Acquired
Pneumonia
THANK YOU!