Hey guys. I'm a final year med student...just made this presentation recently for my peads class. Hope u guys find it useful.

1. PNEUMONIA
Saadia Sajjad.
Roll no. 460

2. Learning Objectives
 To describe the presentation of pediatric
pneumonia
 To outline the management of pediatric
pneumonia
 To summarize the complications of pediatric
pneumonia
 To highlight interventions to prevent and
protect against pediatric pneumonia

3. What is Pneumonia?
Pneumonia: an inflammation of the lung parenchyma
and is associated with consolidation of alveloar spaces.
The term “Lower Respiratory Tract Infection”
(LRTI) may include pneumonia, bronchiolitis and/or
Bronchitis.
Types:
Broncho-Pneumonia
Lobar Pneumonia.

5. Epidemiology
Pneumonia kills more children under the age of five
than any other illness in every region of the world.
It is estimated that of the 9 million child deaths in 2007,
20% (1.8 million) were due to pneumonia
Approximately 98% of children who die of pneumonia
are in developing countries.

7. Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
Newborn E.Coli
Group B Streptococci
Staph. Aureus
Klebsiella
Pseudomonas
1-3 months Chlamydia trachomatis
Respiratory Syncytial virus
Other respiratory viruses
3-12 months Respiratory Syncytial virus
Staph Aureus
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae

8. Age Group Common Pathogens (in Order of Frequency)
2-5 years Respiratory Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae
5-18 years Mycoplasma pneumoniae
Streptococcus pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Influenza viruses A and B
Adenoviruses
Other respiratory viruses

9. Age
Presence of cough,
difficulty breathing,
shortness of breath, chest pain
Fever
Recent upper respiratory tract infections
Associated symptoms
Duration of symptoms Immunizations status
TB exposure
Maternal Chlamydia,
Group B Strep status during
pregnancy
Choking episodes
Previous episodes
Pneumonia History

10. Pneumonia History
Travel history
Day care attendance
Animal exposure
Ill contacts
Past Medications
Birth History
Medications
Allergies
Immunization Status
Home Environment
Social History
Family History

11. Recognition of Signs of Pneumonia
Tachypnea is the most sensitive and specific sign of
pneumonia
Age Respiratory
Rate
(breaths/min)
Indication of
severe
infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5
years
> 40 >50
Greater than 5
years
> 20

12. Other signs of pneumonia -
Indrawing
out---breathing---in
Lower chest wall indrawing: with
inspiration,
the lower chest wall moves in

13. Other signs of pneumonia -
Nasal Flare
Nasal flaring: with inspiration, the
side of the
nostrils flares outwards

14. Diagnosis in Community
Setting
SIGNS Classify AS Treatment
•Tachypnea
•Lower chest wall
indrawing
•Stridor in a calm child
Severe Pneumonia •Refer urgently to hospital for injectable
antibiotics and oxygen if needed
•Give first dose of appropriate antibiotic
•Tachypnea Non-Severe
Pneumonia
•Prescribe appropriate antibiotic
•Advise caregiver of other supportive measure
and when to return for a follow-up visit
•Normal respiratory rate Other respiratory
illness
•Advise caregiver on other supportive
measures and when to return if symptoms
persist or worsen

15. Does this infant child have
pneumonia?
 The Rational Clinical Exam, Journal of the
American Medical Association
 Observation of the infant is the most important part
of the examination – does the child look sick?
 Respiratory rate should be calculated over two
thirty second intervals, or one minute due to
moment to moment variability.
 Auscultation is unreliable when examining
infants.
 In older children, examination will show diminished
movements on affected side, dullness on percusion,
bronchial breathing. Moist rales on resolution.

16. Pneumonia Severity Assessment
Mild Severe
Infants Temperature <38.5 C
RR < 50 breaths/min
Mild recession
Taking full feeds
Temperature >38.5 C
RR > 70 breaths/min
Moderate to severe recession
Nasal Flaring
Cyanosis
Intermittent Apnea
Grunting Respirations
Not feeding
Older Children Temperature <38.5 C
RR < 50 breaths/min
Mild breathlessness
No vomiting
Temperature >38.5 C
RR > 50 breaths/min
Severe difficulty in breathing
Nasal Flaring
Cyanosis
Grunting Respirations
Signs of dehydration

17. Indications for Admission -
IMCI
 All Children with Very Severe Pneumonia need
admission
 Very Severe Pneumonia includes any of:
 Cough or difficult breathing plus at least one of the
following:
 Central cyanosis
 Inability to breastfeed or drink, or vomiting everything
 Convulsions, lethargy or unconsciousness
 Severe respiratory distress (e.g. head nodding)
 Some or all of the other signs of pneumonia (tachypnea,
grunting, nasal flare, indrawing, changes in auscultation)

18. Age Group Indications for Admission to Hospital
Infants Oxygen Saturation <= 92%, cyanosis
RR > 70 breaths /min
Difficulty in breathing
Intermittent apnea, grunting
Not feeding
Family not able to provide appropriate observation or supervision
Older Children Oxygen Saturation <= 92%, cyanosis
RR > 50 breaths /min
Difficulty in breathing
Grunting
Signs of Dehydration
Family not able to provide appropriate observation or supervision
Indications for Admission

19. Investigations
Chest X-ray
WBC Count
Blood Culture
Gram Staining of expectorated sputum
Pleural fluid examination
ASO titre
Tuberculin skin test

20. Chest X-ray
Consider if available and:
 Infection is severe
 Diagnosis is otherwise inconclusive
 To exclude other causes of shortness of
breath (e.g.. foreign body, heart failure)
 To look for complications of pneumonia
unresponsive to treatment (e.g.. empyema,
pleural effusion)
 To exclude pneumonia in an infant less than
three months with fever

25. Complications of Pneumonia
Pleural effusion
Empyema
Parapneumonic effusions
Lung abscess
Pneumothorax
Pneumatocele
Delayed Resolution
Respiratory Failure
Metastatic Septic lesions
Activation of latent TB

29. Treatment – IMCI Guidelines
Antibiotic therapy
Chloramphenicol (25 mg/kg IM or IV every 8 hours) until the child
has improved. Then continue orally 3 x/ day for a total course of 10
days.
If chloramphenicol is not available, give benzylpenicillin (50 000
units/kg IM or IV every 6 hours) and gentamicin (7.5 mg/kg IM once
a day) for 10 days.
If the child does not improve within 48 hours,
Switch to gentamicin (7.5 mg/kg IM once a day) and cloxacillin
(50 mg/kg IM or IV every 6 hours), for staphylococcal
pneumonia.
When the child improves, continue cloxacillin (or dicloxacillin)
orally 4 times a day for a total course of 3 weeks.

30. Supportive Treatment – IMCI
Guidelines
Oxygen therapy
If fever (=>39oC) causing distress, give paracetamol
If wheeze is present, give a rapid-acting broncho-dilator
Gentle suction any thick secretions in the throat, which the
child cannot clear.

31. Ensure that the child receives daily maintenance fluids for
the child's
age - avoid overhydration.
Encourage breastfeeding and oral
fluids.
If the child cannot drink, insert a
NG tube and give maintenance fluids in frequent small
amounts.
If the child is taking fluids adequately by mouth, do not use
a NG tube as it increases the risk of aspiration pneumonia.
If oxygen is given by nasopharyngeal catheter at the same
time as NG fluids, pass both tubes through the same
nostril.
Encourage the child to eat as soon as food can be taken.

32. Prevention Strategies
Vaccination against measles, Streptococcus
pneumoniae, and Haemophilus influenzae type b
Public awareness
Interventions to protect against pneumonia
Zinc supplementation
Prevention of HIV in Children
Co-trimoxazole prophylaxis for
HIV-infected children

33. Prevention - Vaccination
Haemophilus Influenzae type B (Hib)
vaccine
Pneumococcal conjugate vaccine
Pneumonia is a possible complication of Measles, thus
prevention of measles would decrease the incidence of
pneumonia.

35. A Complicated Case from
Gambia
Based on a true
story

36. Case – Chief Complaints
A 1 year old child is brought in for fever,
cough,
lethargy, and mild respiratory distress
increasing over 2 weeks.
You take a focused medical history from the
child’s mother.
What are the patient’s vital signs?

37. Vital signs are as follows: Temperature
38.7, Pulse 150, Respiratory Rate 54,
Oxygen Saturation 94% on room air.
What is observed on physical examination?
On observation the patient clearly appears septic.
Mild respiratory distress is present. Skin is mottled.
What is the likely diagnosis?

38. What other physical examination
information is immediately relevant to
forming an initial treatment plan for this
patient?

39. Weight and Hydration Status
The child is malnourished
The patient appears mildly dehydrated.
What interventions should be started?

40. Initial Treatment
A presumptive diagnosis of pneumonia is made. The
patient is admitted to the hospital and started on
broad spectrum IV antibiotics and appropriate
hydration and re-feeding.
The patient does not seem to improve initially.
What is your differential diagnosis?

41. Differential Diagnosis includes:
Pneumonia +/- complications (e.g.
Empyema)
Pneumonia in a patient with HIV
Tuberculosis
What is the first investigation you would
order? (assume first choice
investigation is available).

43. The chest x-ray reveals a right sided lobar
infiltrate.
What is the clinical correlation?

44. The patient begins to improve clinically.
Fever, cough and respiratory distress resolve.
However, over the next few weeks of
appropriate re-feeding, the patient fails to gain
weight despite remaining on broad spectrum
antibiotics.
What other investigations would you
Consider?

45. HIV test – negative
TB skin test – unreactive
Sputum culture – unable to induce sputum
*Important Note: The mother is no longer
with the patient. Another family member
reports that she is sick with a cough, fever,
and weight loss.*
What other courses of treatment should
be considered in this case?

46. The patient was started on treatment for
tuberculosis and began to improve and gain
weight.
This patient did well. The mother and other
close contacts were also treated for
tuberculosis.

47. This patient’s x-ray revealed a lobar
infiltrate.
Pneumonia commonly presents as a lobar
infiltrate.
Reactivation of TB tends to be apical, but
acute TB can present as a lobar infiltrate.
TB should remain as a differential diagnosis
and be reconsidered if there is a poor
response to treatment, or a possible
exposure history.
Summary

48. 1)What is the most sensitive and specific sign of
pneumonia in children?
A. Difficulty breathing
B. Fever
C. Tachypnea
D. Tachycardia
2)Which of the following immunization
effectively reduce pneumonia mortality in
children?
A. Haemophilus influenzae b Vaccine
B. Pneumococcal Conjugate Vaccine
C. Measles Vaccine
D. All of the above

49. 3)Which of the following bacterial pathogens most
commonly cause bacterial infections in neonates?
A. E. coli, S. pneumoniae, H. influenza
B. Group B Streptococci, E. coli, L. monocytogenes
C. Group B Streptococci, H. influenzae, E. coli
D. S. pneumoniae, H. influenzae, N. meningitides
E. S. pneumoniae, N. meningitides, L. monocytogenes
4)Which of the following pneumonia-causing pathogens is the
most common cause of pneumonia in immunized children?
A. Bordetella pertussis
B. Group A streptococcus
C. Haemophilus influenzae type B
D. Influenza
E. Streptococcus pneumoniae

50. 5) Which organism is NOT likely to cause pneumonia with
parapneumonic effusion or empyema?
A. Group A streptococcus
B. Mycoplasma pneumoniae
C. Staphylococcus aureus
D. Streptococcus pneumonia
6)Which organism is the most likely organism to cause
pneumonia in a 2 year old child?
A. Influenza
B. Metapneumovirus
C. Mycoplasma pneumoniae
D. Streptococcus pneumoniae
E. Respiratory syncytial virus

51. 7) Which combination of signs and symptoms is typical of
community acquired pneumonia?
A. Clear lung exam, fever, cough
B. Crackles, normal respiratory rate, cough
C. Tachypnea, cough, fever
D. Tachypnea, vomiting and rash
E. Wheezes, retractions, nasal flaring

52. 8)Which patient would be the most likely to have bacterial
Pneumonia?
A. 1 year old boy with 1 day history of low grade fever, barky cough,
RR of 30 in October
B. 3 year old male with 3 day history of fever, rhinorrhea, and faint
rash in May
C. 4 year old male with 5 day history of fever, cough, retractions and
fatigue in February
D. 5 year old female with asthma, and now 1-2 day history of fever
and wheezing in March
E. 8 year old female with 3 day history of fever, cough, sore throat
and myalgias in January