PneumoniaPneumonia

DefinitionDefinition

Inflammation Inflammation

of the parenchyma of the lungsof the parenchyma of the lungs

(terminal and respiratory (terminal and respiratory bronchioles, alveoli, and bronchioles, alveoli, and

interstitium)interstitium)

EpidemiologyEpidemiology

Worldwide, more than 3 million children Worldwide, more than 3 million children die of pneumonia annually;die of pneumonia annually;

97% decline in annual mortality from 97% decline in annual mortality from pneumonia in US between the years of pneumonia in US between the years of 1939 and 1996;1939 and 1996;

0,1—0,4% 0,1—0,4% of mortality in total;of mortality in total; Mortality in nosocomial pneumonias is Mortality in nosocomial pneumonias is 1515

—50%. —50%.

Normal defense Normal defense mechanismsmechanisms

Nasopharyngeal air filtration; Nasopharyngeal air filtration; Laryngeal protection of the airway from Laryngeal protection of the airway from

oral and gastric fluid; oral and gastric fluid; Mucociliary clearance; Mucociliary clearance; Normal cough reflexes; Normal cough reflexes; Secretory IgASecretory IgA Macrophages of alveoli and bronchiolesMacrophages of alveoli and bronchioles

Predisposition factors in Predisposition factors in childrenchildren

Incomplete tissue differentiation Incomplete tissue differentiation → → generalized inflammationgeneralized inflammation

Narrower airway space Narrower airway space → obstruction→ obstruction Abundant vascularization of mucosa → Abundant vascularization of mucosa →

rapid edemarapid edema Laryngeal cartilage softening → croupLaryngeal cartilage softening → croup Incomplete defense mechanismsIncomplete defense mechanisms

ClassificationClassification

Groups of pneumonias:

Primary

Secondary (complication

of other diseases)

ClassificationClassification

Variety of

pneumonias

Out-of-hospital ("home")

Hospital (nosocomial)

Aspirative In patients

with immune deficiency

gram-positive cocci

Obligate Anaerobes,

Gram-negative bacilli

Pneumocystas, Fungi, Viruses(CMV)

Staphylococci, Gram-negative

microflora

Perinatal infection

Chlamidias, Pneumocystas,

Ureaplasmas

ClassificationClassification

Forms of pneumonias:

Focal Segmental ( mono- or

poly-)Croupous

Interstitial

ClassificationClassification

Course of pneumonia

AcuteLingering

(6 weeks – 8 months)

Recurrent

ClassificationClassification

Presence of complications

Complicated Not complicated

ClassificationClassification

Localization of process:Localization of process: lung, lobe, lung, lobe, segment, one-sided, double (two sided).segment, one-sided, double (two sided).

Risk factorsRisk factors

Lung disease (asthma or cystic fibrosis);Lung disease (asthma or cystic fibrosis); Anatomic problems (tracheoesophageal Anatomic problems (tracheoesophageal

fistula);fistula); Gastroesophageal reflux disease Gastroesophageal reflux disease

(aspiration);(aspiration); Neurologic disorders (which compromise Neurologic disorders (which compromise

clearing of the airway); clearing of the airway); Immunodeficiency diseasesImmunodeficiency diseases

EtiologyEtiology

Complication of ARD inComplication of ARD in 20% 20% of infants and of infants and 10% 10% of preschool age childrenof preschool age children

Bacterial and viral causes are found in 44-85% of Bacterial and viral causes are found in 44-85% of children with community-acquired pneumonia, children with community-acquired pneumonia, with more than one pathogen in 25-40%. with more than one pathogen in 25-40%.

The most common combination of pathogens is The most common combination of pathogens is Streptococcus pneumoniae Streptococcus pneumoniae (pneumococcus) with (pneumococcus) with either either respiratory syncytial virus (RSV)respiratory syncytial virus (RSV) or or Mycoplasma pniumoniae.Mycoplasma pniumoniae.

Neonatal pneumoniaNeonatal pneumonia - - bacterialbacterial

Group B streptococci (GBS)Group B streptococci (GBS) Staphylococcus aureusStaphylococcus aureus Escherichia coli Escherichia coli Streptococcus epidermalisStreptococcus epidermalis Chlamidia trachomatis Chlamidia trachomatis Listeria monocytogenesListeria monocytogenes Ureaplasma urealiticumUreaplasma urealiticum AnaerobesAnaerobes

Neonatal pneumonia - Neonatal pneumonia - viralviral

CMVCMV RubellaRubella HSVHSV

Infants - bacterialInfants - bacterial

Gram-negative bacteriaGram-negative bacteria Chlamidia trachomatisChlamidia trachomatis Moraxella catarrhalis Moraxella catarrhalis Str. pneumoniae (seldom) Str. pneumoniae (seldom) Haemophilus influenzae type b (Hib) Haemophilus influenzae type b (Hib)

Infants - viralInfants - viral

RSVRSV Parainfluenza virus 3Parainfluenza virus 3

5 months – 5 years, viral5 months – 5 years, viral

Viral pneumoniasViral pneumonias are predominant: are predominant: RSV (esp. RSV (esp. << 3 yr of age) 3 yr of age) Parainfluenza viruses Parainfluenza viruses Influenza virusesInfluenza viruses AdenovirusesAdenoviruses

Peak attack rate - 2 and 3 yr Peak attack rate - 2 and 3 yr (unlike bronchiolitis – 1-st yr of life)(unlike bronchiolitis – 1-st yr of life)

5 months – 5 years, 5 months – 5 years, bacterialbacterial

Str. pneumoniae (pneumococcus), Str. pneumoniae (pneumococcus), Haemophilus influenzae type b (Hib) Haemophilus influenzae type b (Hib) Micoplasma pneumoniae Micoplasma pneumoniae Chlamydia pneumoniae Chlamydia pneumoniae S aureus S aureus Moraxella catarrhalis Moraxella catarrhalis Bordetella pertussis (different clinics) Bordetella pertussis (different clinics)

Haemophilus influenzae type b and Str. Haemophilus influenzae type b and Str. pneumoniae will become rare after vaccination! pneumoniae will become rare after vaccination!

5 years – 15 years, 5 years – 15 years, outpatientoutpatient

Micoplasma pneumoniae Micoplasma pneumoniae Chlamydia pneumoniae Chlamydia pneumoniae Str. pneumoniae (pneumococcus), Str. pneumoniae (pneumococcus), Respiratory viruses (influenza…) Respiratory viruses (influenza…)

Immunodeficiency statesImmunodeficiency states

Humoral immune insufficiency:Humoral immune insufficiency: Str. pneumoniaeStr. pneumoniae Staph. aureusStaph. aureus CMVCMVCellular immune insufficiency (AIDS, etc.):Cellular immune insufficiency (AIDS, etc.): Pneumocystis cariniiPneumocystis carinii Micobacterium aviumMicobacterium avium CandidaCandida AspergillusAspergillus

Nosocomial pneumoniasNosocomial pneumonias

Klebsiella pneumoniaeKlebsiella pneumoniae Staphulococcus aureusStaphulococcus aureus Proteus vulgarisProteus vulgaris Pseudomonas aeruginosaPseudomonas aeruginosa EnterobacterEnterobacter AcinetobacterAcinetobacter Candida albicansCandida albicans

Other etiology Other etiology

Pseudomonas and Staphulococcus Pseudomonas and Staphulococcus aureus are aureus are common causes of common causes of pneumoniapneumonia in patients with cystic fibrosis.in patients with cystic fibrosis.

Other etiologyOther etiology

Aspiration of food or gastric acid, foreign Aspiration of food or gastric acid, foreign bodies, hydrocarbons and lipoid bodies, hydrocarbons and lipoid substances; substances;

Hypersensitivity reactions; Hypersensitivity reactions; Drug – or radiation induced pneumonitis. Drug – or radiation induced pneumonitis.

Pathology of lobar Pathology of lobar pneumoniapneumonia

4 stages: 4 stages: CongestionCongestion - 24 hours (vascular engorgement - 24 hours (vascular engorgement

with fluid and neutrophils in the alveoli). with fluid and neutrophils in the alveoli). Red hepatizationRed hepatization (fibrin deposition and (fibrin deposition and

extravasation of red blood cells). extravasation of red blood cells). Gray hepatizationGray hepatization (fibrinous plugs and (fibrinous plugs and

degraded cells in the alveolar spaces). degraded cells in the alveolar spaces). ResolutionResolution - after approximately 1 week - after approximately 1 week

(macrophage-mediated phagocytosis). (macrophage-mediated phagocytosis).

Pathology of interstitial Pathology of interstitial pneumoniapneumonia

Walls of the alveoli and interstitial septae are Walls of the alveoli and interstitial septae are involved, and the alveolar space is spared. involved, and the alveolar space is spared.

Interstitial cellular infiltrate (lymphocytes, Interstitial cellular infiltrate (lymphocytes, macrophages, and plasma cells). macrophages, and plasma cells).

Lobar pneumonia, interstitial pneumonia, Lobar pneumonia, interstitial pneumonia, bronchial inflammation, and bronchiolar bronchial inflammation, and bronchiolar inflammation often coexist in the same child. inflammation often coexist in the same child.

Ways of disseminationWays of dissemination

BronchogenicBronchogenic LymphogenicLymphogenic HematogenicHematogenic Aspiration (newborns)Aspiration (newborns) Contact (rare) Contact (rare)

Clinical presentationClinical presentation

Main syndromes:Main syndromes: Syndrome of intoxicationSyndrome of intoxication Syndrome of respiratory insufficiencySyndrome of respiratory insufficiency Syndrome of focal changesSyndrome of focal changes

Syndrome of respiratory Syndrome of respiratory insufficiencyinsufficiency

DyspneaDyspnea Participation of axillary muscles in Participation of axillary muscles in

breathing act breathing act Retraction of flexible parts of thorax Retraction of flexible parts of thorax Pallor of skin, Pallor of skin, Cyanosis of nasolabial triangle or Cyanosis of nasolabial triangle or

spread cyanosisspread cyanosis

Degrees of respiratory Degrees of respiratory insufficiencyinsufficiency

SignsSigns

DegreesDegrees

II IIII IIIIII

TachipnoeTachipnoe At stressAt stress At restAt rest > 70 / min> 70 / min

Intercostal Intercostal retractionretraction

MildMild ModerateModerate SevereSevere

Auxiliary Auxiliary musclesmuscles

NoNo ModerateModerate SevereSevere

CNSCNS IrritabilityIrritability WeaknessWeakness →→→→ComaComa

CyanosisCyanosis PerioralPerioral NasolabialNasolabial SpreadSpread

Syndrome of intoxicationSyndrome of intoxication

Fever Fever Worsening of feelingWorsening of feeling Sleep disturbancesSleep disturbances Decreasing of appetiteDecreasing of appetite FlaccidityFlaccidity Adynamia or hyperexcitability, motor Adynamia or hyperexcitability, motor

anxietyanxiety Muffled heart sounds, tachycardia. Muffled heart sounds, tachycardia.

Syndrome of intoxicationSyndrome of intoxicationInfants of the first two months of life:Infants of the first two months of life: Flaccidity Flaccidity Refusing of breast feedingRefusing of breast feeding Weight loss Weight loss Decreasing of physiological reflexes Decreasing of physiological reflexes Appearance of gastrointestinal disordersAppearance of gastrointestinal disorders DehydrationDehydration

Syndrome of focal Syndrome of focal changeschanges

Percussion Percussion - shortening of - shortening of resonance on the place of lesion;resonance on the place of lesion;

AuscultationAuscultation - harsh, bronchial or - harsh, bronchial or weakened bronchial breathing on weakened bronchial breathing on the place of lesion; fine bubbling the place of lesion; fine bubbling rales or crepitation rales above the rales or crepitation rales above the infiltrative foci.infiltrative foci.

Laboratory examLaboratory exam

CBC and urinalysisCBC and urinalysis Blood electrolytesBlood electrolytes Blood gases, pHBlood gases, pH Hepatic and renal biochemistryHepatic and renal biochemistry ProteinogrammaProteinogramma CoagulogrammaCoagulogramma

WBCWBC

Differentiation of viral and bacterial pneumonia:Differentiation of viral and bacterial pneumonia:

Viral - Viral - WBC normal or WBC normal or ↑ ↑ not higher than not higher than

20,000/mm3 20,000/mm3 Lymphocyte predominance. Lymphocyte predominance.

Bacterial – Bacterial – WBC 15,000-40,000/mm3 WBC 15,000-40,000/mm3 Granulocyte predominance.Granulocyte predominance.

Other examsOther exams

ECGECG Pulse, respiratory rate and blood Pulse, respiratory rate and blood

pressure monitoringpressure monitoring Weight monitoringWeight monitoring Fluid intake/loss monitoringFluid intake/loss monitoring Diuresis monitoringDiuresis monitoring

Etiologic diagnosisEtiologic diagnosis

Cultures:Cultures: blood (positive in only 10-30% blood (positive in only 10-30% with pneumococcal pneumonia) sputum with pneumococcal pneumonia) sputum (no value in children) and pleural fluids(no value in children) and pleural fluids

Serologic methodsSerologic methods (Ab titers rise) – for (Ab titers rise) – for epidemiology; anti-streptolysin O (ASO) epidemiology; anti-streptolysin O (ASO) titer for group A streptococcal pneumonia.titer for group A streptococcal pneumonia.

Bacteriologic methodsBacteriologic methods (IFA, Blotts, (IFA, Blotts, hemagglutination)hemagglutination)

MolecularMolecular (PCR) (PCR)

X-ray - pneumococcal X-ray - pneumococcal pneumonia pneumonia

Confluent lobar consolidation Confluent lobar consolidation

X-ray – bacterial X-ray – bacterial pneumoniapneumonia

Focal or segmental infiltrative changesFocal or segmental infiltrative changes Reaction of lung's hylus (perivascular Reaction of lung's hylus (perivascular

and peribronchial shadowings) on the and peribronchial shadowings) on the side of lesionside of lesion

X-ray - viral pneumoniaX-ray - viral pneumonia

Hyperinflation with bilateral interstitial Hyperinflation with bilateral interstitial infiltrates and peri bronchial cuffinginfiltrates and peri bronchial cuffing

Diffuse interstitial infiltrates on Diffuse interstitial infiltrates on chest radiographchest radiograph

Differential diagnosisDifferential diagnosis

Acute respiratory viral infectionsAcute respiratory viral infections BronchiolitisBronchiolitis In lingering course of pneumonia -with In lingering course of pneumonia -with

primary tuberculosis, cystic fibrosisprimary tuberculosis, cystic fibrosis Respiratory allergosesRespiratory allergoses Foreign body, aspirationForeign body, aspiration Lagyngeal malformations, lagyngospasmLagyngeal malformations, lagyngospasm Croupous pneumonia – appendicitis, Croupous pneumonia – appendicitis,

meningitis, peritonitismeningitis, peritonitis

ManagementManagement

Indications for hospitalization:Indications for hospitalization: Age before 3 yearsAge before 3 years Severe formsSevere forms ComplicationsComplications Respiratory insufficiencyRespiratory insufficiency Chronic diseasesChronic diseases ImmunodeficienciesImmunodeficiencies Low social and economic level of familiesLow social and economic level of families

ManagementManagement

Antibiotics (empiric and targeted)Antibiotics (empiric and targeted) Respiratory insufficiency Tx, oxigenRespiratory insufficiency Tx, oxigen Symptomatic Tx (NSAIDs, mucolytics)Symptomatic Tx (NSAIDs, mucolytics) Desintoxication and rehydrationDesintoxication and rehydration Surgery (if required)Surgery (if required)

Neonatal pneumoniaNeonatal pneumonia

Empiric treatment:Empiric treatment: Ampicillin 100 mg/kg per day, Ampicillin 100 mg/kg per day, and and Cefotaxime 100-150 mg/kg per dayCefotaxime 100-150 mg/kg per day Aminoglycozides in severe cases – Aminoglycozides in severe cases –

amikacin (15 mg/kg per day), netromicin amikacin (15 mg/kg per day), netromicin (7 mg/kg per day)(7 mg/kg per day)

At least 10 days, often 14 to 21 days At least 10 days, often 14 to 21 days

Neonatal pneumoniaNeonatal pneumonia

Other pathogens:Other pathogens: CMV pneumoniaCMV pneumonia – gancyclovir – gancyclovir HSV HSV - acyclovir 30 mg/kg per day - acyclovir 30 mg/kg per day Ureaplasma urealyticum and Chlamidia Ureaplasma urealyticum and Chlamidia

trachomatis trachomatis - erythromycin 50 mg/kg per - erythromycin 50 mg/kg per dayday

5 months – 5 years 5 months – 5 years

Amoxicillin alone in mild casesAmoxicillin alone in mild cases Amoxicillin/clavulanate or high doses of Amoxicillin/clavulanate or high doses of

amoxicillin (80-90 mg/kg/24 hr) or amoxicillin (80-90 mg/kg/24 hr) or cefuroxime - in communities with a high cefuroxime - in communities with a high % of penicillin-resistant pneumococci% of penicillin-resistant pneumococci

Ampicillin/sulbactam (200 mg/kg per day) Ampicillin/sulbactam (200 mg/kg per day) or cefuroxime (150 mg/kg per day) or or cefuroxime (150 mg/kg per day) or ceftriaxone (75 mg/kg per day) in severe ceftriaxone (75 mg/kg per day) in severe casescases

MacrolidesMacrolides

Clarithromycin (15 mg/kg per day divided Clarithromycin (15 mg/kg per day divided every 12 hours for 10 days) azithromycin every 12 hours for 10 days) azithromycin (10 mg/kg per dose 1 day, then 5 mg/kg (10 mg/kg per dose 1 day, then 5 mg/kg per dose daily for 4 days) for:per dose daily for 4 days) for:

Bordetella pertussisBordetella pertussis Chlamidia trachomatisChlamidia trachomatis Mycoplasma Mycoplasma pneumoniaepneumoniae Ureaplasma urealyticumUreaplasma urealyticum

Nosocomial pneumoniaNosocomial pneumonia

Parenteral cefuroxime (75-150 mg/kg/24 Parenteral cefuroxime (75-150 mg/kg/24 hr) or cephtriaxone (50-100 mg/kg/24 hr) hr) or cephtriaxone (50-100 mg/kg/24 hr)

Vancomycin or clindamycin, if Vancomycin or clindamycin, if staphylococcal pneumonia (e.g., staphylococcal pneumonia (e.g., pneumatoceles, empyema) is suspectedpneumatoceles, empyema) is suspected

Viral pneumoniaViral pneumonia

Withhold antibiotic therapy if:Withhold antibiotic therapy if: Mild diseaseMild disease Clinical evidence of viral infectionClinical evidence of viral infection No respiratory distress. No respiratory distress.

But: Up to 30% of patients with known viral But: Up to 30% of patients with known viral infection may have co-existing bacterial infection may have co-existing bacterial pathogenspathogens

Pneumonia in immune Pneumonia in immune deficiencydeficiency

Pneumocyscic pneumonia (PCP) – Pneumocyscic pneumonia (PCP) – kotrimoxazol, pentamidinkotrimoxazol, pentamidin

Candida – flukonazoleCandida – flukonazole CMV – foscarnet, gancyclovirCMV – foscarnet, gancyclovir HSV – acyclovirHSV – acyclovir M. avium complex - clarithromycinM. avium complex - clarithromycin

Resolution of pneumoniaResolution of pneumonia

Clinical improvement (e.g., fever, cough, Clinical improvement (e.g., fever, cough, dyspnea, chest pain) within 48-96 hr of dyspnea, chest pain) within 48-96 hr of initiation of antibiotics. initiation of antibiotics.

Radiographic improvement within 4-6 wk Radiographic improvement within 4-6 wk (time to complete resolution varies (time to complete resolution varies depending on the etiologic organism)depending on the etiologic organism)

Radiological resolutionRadiological resolution

Pneumococcal Pneumococcal pneumoniaspneumonias

1-3 mo1-3 mo

Chlamydial pneumoniaChlamydial pneumonia 1-3 mo1-3 mo

Mycoplasma pneumoniaeMycoplasma pneumoniae 2 wk to 2 mo2 wk to 2 mo

Staph., Legionella, and Staph., Legionella, and enteric G-negenteric G-neg

3-6 mo3-6 mo

Viral pneumoniaViral pneumonia many months.many months.

ComplicationsComplications

Complications

Pulmonary Extrapulmonary

Pulmonary complicationsPulmonary complications

Pleural effusionPleural effusion EmpyemaEmpyema Pericarditis Pericarditis Pulmonary destruction;Pulmonary destruction; Pneumothorax, etc.Pneumothorax, etc.

Extrapulmonary Extrapulmonary complicationscomplications

Hematologic spread (meningitis, Hematologic spread (meningitis, suppurative arthritis, and osteomyelitis)suppurative arthritis, and osteomyelitis)

Toxic shockToxic shock DIC - syndromeDIC - syndrome Cardiovascular insufficiencyCardiovascular insufficiency Respiratory distress syndrome of adult Respiratory distress syndrome of adult

typetype

EmpyemaEmpyema

The most common causes are The most common causes are S. aureus S. aureus and and S. pneumoniaeS. pneumoniae. .

Diagnosis - imaging studies (X-ray, Diagnosis - imaging studies (X-ray, ultrasonography and CT) ultrasonography and CT)

Empyema – treatmentEmpyema – treatment

Based on the stage (e.g., exudative, Based on the stage (e.g., exudative, fibrinopurulent, or organizing).fibrinopurulent, or organizing).

Antibiotic therapyAntibiotic therapy Drainage with tube thoracostomyDrainage with tube thoracostomy Newer approaches: fibrinolytic therapy Newer approaches: fibrinolytic therapy

and selected thoracoscopy to debride, and selected thoracoscopy to debride, lyse adhesions, and drain loculated areas lyse adhesions, and drain loculated areas of pus. of pus.

Slowly resolving Slowly resolving pneumoniapneumonia

Inadequate therapy (inappropriate antibiotic Inadequate therapy (inappropriate antibiotic choice, inappropriate dose, or poor choice, inappropriate dose, or poor compliance) compliance)

Development of resistant organisms Development of resistant organisms Impaired host defenses Impaired host defenses

(immunodeficiencies, ciliary dyskinesia, or (immunodeficiencies, ciliary dyskinesia, or other co-existing illnesses)other co-existing illnesses)

Nonbacterial cause for the pneumonia Nonbacterial cause for the pneumonia (viruses, fungi, parasites, and Mycobacteria)(viruses, fungi, parasites, and Mycobacteria)

Slowly resolving Slowly resolving pneumoniapneumonia

Obstructing endobronchial lesions (congenital Obstructing endobronchial lesions (congenital and acquired)and acquired)

Foreign bodiesForeign bodies Pulmonary sequestrationPulmonary sequestration Postinfectious bronchiectasis Postinfectious bronchiectasis Noninfectious causes (bronchiolitis obliterans, Noninfectious causes (bronchiolitis obliterans,

hypersensitivity pneumonitis, eosinophilic hypersensitivity pneumonitis, eosinophilic pneumonia, aspiration, Wegener granulomatosis, pneumonia, aspiration, Wegener granulomatosis, sarcoidosis and pulmonary alveolar proteinosis)sarcoidosis and pulmonary alveolar proteinosis)

Questions are welcome! Questions are welcome!