protocols in pulmonology

7/31/2019 Protocols in Pulmonology

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PHARYNGO -TONSILLITIS

ETIOLOGY

Viral cau se:

Rhin o viru s( com m on cold)( 60 %)

Enterovirus,Influenza virus,Para-influenza virus.

Adenovirus,

Special: HIV, Cytomegalovirus, Coxsackievirus, Herpes simplex,

Ebs tein -barr viru s, Bird flu?).

Bact e r ia l caus e :

Group A B-hemolytic streptococci (GABHS), 15-30% > 3yr

C, diptheriae, Hemophilus influenzae, N. meningitides.

Special; Gonococcus , A. h emolyticu m, an d Mycoplasm a pn eum oniae

Diagnosis of viral is mainly clinical

Blood cou n t, E SR a n d CRP- low predictive valu e

T h r o a t c u l t u r e

Gold standard for diagnosing streptococcal pharyngit is cannot

differentiate between car riers an d ca se

Negative throat culture result has a very high negative predictive

valu e for GABHS p h ar yngitis

Major drawba ck - lag time of 18 -48 h ou rs

Not curren tly pra cticed in m ost centers in Ind ia !


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In ch i ld ren wit h n o pen ic i ll in a l l e rgy

An tibiotic (rou te) da ys Ch ildr en

(30kg

Pen icillin V (ora l) (10 d) 25 0 m g BID 50 0 m g TID

Am oxycillin (ora l) (10 d) 40 m g/ kg/ da y 250 m g TID

Benzat h ine pen icillin G (IM) (single dose) 6 lakh u n its 1.2 m illion

un i t s

In ch ildren with pen icillin allergy (n on type 1)

An tibiotic (rou te) (da ys) Ch ildr en (


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Management protoclol

Examine eye/ ear / nose / body

Conjunctivitis / coryza,

diarrhea, hoarseness/ cough

Purulent/ patches/ toxic /

tender L. nodes

- Viral > -

Symptomatics (3-4 d)

Bacterial antibiotics

before / after culture

Responds No response

Culture / RADT Response Follow

up-ve

+ve


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SINUSITIS

Two types of settings

Prolonged, u pper respiratory signs / sympt oms > 10-14 days.

Severe u pper r espiratory signs/ symp toms ( fever >102 d egree F,

Facial swelling and pain)

Class i f ica t ion o f S inu s i t i s

Acu te infection 14/ 102degree F, pu ru lent discha rge , s ick ch ild

Su bacu te : 30 -90 days

Recu rren t: < 30 d ays; relap se after 10 da ys

Chron ic: > 90 da ys.

De v e lo p m e n t o f s in u s e s

Development begins complete

development

Maxillar y an d eth m oid

s i n u s e s

10 th week POG At birth

Sph enoid sinu s 3Yrs 8 yrs

Fronta l s inus 7- 8 yrs Ear ly teens

Pred ispos ing fac t o rs

Viral URI

Allergic rh initis an d n as al polyps

Nas al foreign body


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Adenoidal hypertrophy

Nas ogas tric tu be

Cleft palate

GERD

Mucociliar y d isord ers

PC D

CF

Karta geners s ynd rome

Imm u n odeficiency stat u s

Dental infections

Co m m o n Pa t h o ge n s

Acute an d Su bacu te s inu si t is

s t rept . Pneu moniae

Non typeable H. influ enzae

Moraxella catarrhalis

Strept p yogens ( beta h em)

Chronic Sinusit is

Bacterial pathogens not well defined

Polymicrobial infection common

Alph a h emolytic strept, s tap h au reu s, CONS, Non t ypeable H

in fluen zae, Mora xella cat ar rh alis & An aer obic Bacter ia

Guidelines for Radiological Diagnosis

X- rays th erefore not n eeded in m ost.


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Clinical correlation is good.

X- rays recommended if:

Recur ren t

Complications Unclear diagnosis

M a na ge m e n t M e d i c a l

An tibiotics Main s ta y :

Am oxycillin (40 m g/ kg/ da y)

Cefuroxime

Co - am oxy- clavu lan ic a cid can be s econd lin e if initial ch oice

was a m oxicillin

Macrolides e.g. Azith rom ycin

Select an y of th ese bas ed on cost an d sa fety

If severe disea se or failu re to firs t lin e dr u gs

Paren tera l ceftriaxone/ cefotaxim e then m ay switch to oral

cefpodoxime

Treat for 10 to 14 days or 1 week beyond symptom resolution,

whichever is lat er.

In case of persistent non response ( already used 1st and 2nd l ine

drugs)

Ima ging an d s inu s a spira t ion could be done.

Adjuvant th erapies :

lim ited da ta

not recomm ended


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ACUTE OTITIS MEDIA

Sign s of acu te otitis m edia

Erythema

Fluid

Impaired mobility

Acut e symptom s

Man agem en t of AOM- Und er 2 yrs

An algesia pa ra cetam ol in good doses a s good a s ibu pr ofen

Decon gesta n ts n o role

An tibiotics in d ivided d oses for 10 da ys

ch oices, first line Am oxycillin / co-am oxycla v

second line * second generation cephalosporins e.g.

cefaclor, cefu roxime

co-am oxyclav- if n ot u sed ear lier.

Man agemen t of AOM in > 2 vr old ch ildr en

An algesics --> ma in sta y of trea tm ent

Decongesta n ts h ave qu estiona ble role

Antibiotics

No ur gen cy to sta rt a nt ibiotics u nlike a


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P r o t o c o l fo r m a n a g in g Ac . Ot i t i s m e d i a


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CROUP

? CHARACTERISTICS :

Acu te on set

Fever, ru n n ing nos e an d cou gh - in fective etiology - likely to be

upper airway

ch an ged cough ch ar act er- likely to be involving lar ynx.

Hence a n acu te u pper airway in fectionlaryn git is +.

GRADING SEVERITY OF CROUP

Mild Moderate Severe

General

appearance

Happy, feeds

well, interestedin su r rou ndings

Fussay bu t

interactive,comforted by

paren t s

Restless,

agitated, alteredsensor ium

Str idor Stridor oncoughing &

crying, No

stridor at rest

Stridor at rest ,worsening with

agitation

Stridor at rest ,worsening with

agitation

Respiratory

distress

No distress Tach ypnoea,

tachycardia &chest re t rac t ions

Marked

tachycardia withchest re t rac t ions

Oxygena tion >92% in room

a ir

>92% in room

a ir

92%

An tibiot ics No ro le No role No role


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Managem en t o f mi ld c roup

Requires no t rea tm ent

Symp tomat ic t rea tmen t :

Fever - u se a nt ipyretics to d ecrease oxygen requ iremen t.

If bothersome coryza- 1st generation anti-histaminics may be

u s e d

Norma l saline n as al drops - if na sa l blockad e.

Grey areas :

Cold a i r inh ala t ion / ba th room s teaming may help

A single oral dose of prednisolone/ dexameth as one p referred by

few to decrease the parental stress as well as the r isk of return

to the m edical care.

PARENTAL ADVICE :

Parents to be informed that croup generally gets more severe at

nights .

To look ou t for increa sing s everity man ifested by

increa sing str idor,

increasing breathing difficulty , and

child gettin g in creas ingly agita ted with refu sa l of feeds

To come back to medical assistance if severity increases


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INVESTIGATING CROUP:

S Crou p is a clin ical diagnosis. In vestigations n ot requ ired in a typical

croup.

In a child with airway obstruction, neck radiographs or blood tests

cause anxiety which may precipitate further distress and obstruction.

X -ra y AP view of th e s oft t iss u e of n eck

if don e - reveals a ta pered n ar rowin g ( st eeple sign ) of th e

su bglot t ic t rachea ins tead of norma l shou ldered appeara nce .

sh ould be d one if:

- poor respons e to t rea tm ent

- poss ibility of Retroph ar yngeal abs cess

o toxic with h igh fever

o difficu lty in s wallowin g, dr oolin g of sa liva

o

ma lnou rished child / s ta ph ylococcal skin st igma ta

MODERATE CROUP

Increase in severity is not considered by mere increase in the

intensity of the sound , but by increasing degree of obstruction. Croup

can be called as modera te when child develops str idor at res t .

M a n a g e m e n t :

Observation for up to 4 h ours

st eroid -> if n ot given before , u se a dose of oral / n ebu lized/

IM


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Repeat dose of nebulized steroid - if previous dose > 12 hours

back.

Nebu lized Adren alin e :

Used if symp toms are in creasing . -> Repeated if

clinically indicated

Routinely available adrenaline as effective as racemic

form.

If symp toma tic at th e end of 4 h rs, h e can be discha rged.

STEROID AND ADRENALINE DOSE

Ste ro ids

Repeated doses of 2 m g neb u lized bu deson ide 12 h r X 48 h rs

Ora l an d IM dexam eih as one is equ ally efficacious

Oral corticosteroids are preferred for their ease

Doses-> dexam ethas one 0 .15- 0 .30 m g/ kg, prednisolone 1 - 2 mg /

k g

Adrenal ine

Adrenaline is used in severe cases and those poorly responsive to

steroids

0.5 m l/ kg of 1:1000 dilu tion t o maximu m of 5 m l.

Need for repeated doses sh ould alert the n eed for int u bation / PICU

carep


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STE ROIDS IN CROUP

Th e us e of steroids h as been a ss ociated with ,

Redu ced average length of sta y in th e emergency

Decreas e in th e nu m ber of adr ena lin e nebu lization n eeded.

Redu ced need for en dotrach eal int u bat ion.

If requ ired, th e du rat ion of in tu ba tion is d ecreased.

Current evidence more strong for its efficacy in moderate to severe

croup.

MANAGEMENT OF SEVERE CROUP

Continu e oxygen a s requ ired.

Admit.

Continu e nebu lized adr ena lin e as frequen tly as n eeded,

if requ ired > 2 h rly, cons ider s h ifting to PICU.

Steroids to be continu ed.

INTUBATION

if airway obstru ction/ work of breath in g is worsening, then one h as to

consider intubation and venti lat ion.

Experienced hands only , as intubation is difficult and if fails the

pat ient m ay be worse , ? Rapid sequ ence in tu bat ion.

u se a tu be ha lf s ize sm al ler tha n opt ima l.

Trach eostomy is t h e las t option


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Typical paroxysm :

A series of rapid, forced expirations (usually 5-10), followed by

gasp ing in h alat ion , lead in g to th e typical wh oop

Cyanosis, bulging eyes, protrusion of the tongue, salivation,

lacrimation an d distens ion of th e neck veins occur s.

post-tussive vomiting is common.

Several t imes per hou r- dur ing both da y and night .

Triggered by yawn ing, s n eezin g or ph ysical exertion. In between

th e paroxysm s, th e patient is u su ally well.

DIGNOSIS CONFIRMATION

CBC

Abs olu te lymph ocyte cou n t > 10,000/ micro It

ALC a bove a ge specific m ean h as 70 % sen sitivity.

Norma l coun t does not exclu de pertu ss is

Neona tes ma y have mu ch h igher coun ts

CXR not sensitive or specific

Role of cu ltu res - not of pra ctical im porta n ce

Serology an d PCR not recom men ded routinely

Diagn osis u su ally clinical aided b y CBC.


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TREATMENT

Antibiotics

reduce transmissibil i ty

ma y redu ce sympt oms if given in 1st week.

lim ited r ole as u su ally diagn osed later .

Avoidance of cough provoking factors.

Humidified oxygen and assisted ventilation in seriously ill, usually

infants.

Dose an d du ra t ion S ta tus

Eryth romycin 40-59 mg/ kg/ day q 6

hr ly x 14 da ys

Side effects

dura t ion / adherence,

not > 1 month

Cla r ith romycin 15mg/ kg/ day

Q 12 h r ly x 7 da ys

Expensive. Drug

interaction, not > 1

month

Azith rom ycin (DOC) 6 m o n t h s : 1 0 m g/ k g

on d a y 1 a n d 5 m g / k gday 2-5

Cheap, no drug

interaction can be

given >1 m ont h

Cotrimoxazole 8 m g/ kg of TMP Q 12

h rly x 14 da ys

Intolerant / CI of

macrolides

TRE ATMENT- S UPPOR TIVE

One m ay try bron chodialators/ cough seda tives an d individu alise as

per response

Routinely none of the following are of any benefit

Antihistaminics

Steroids Salbutamol

Pertussis immunoglobulin


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DIPHTHERIA

CRITERIA TO pfcNOSE DIPHTHERIA

Sore throat with m emb ran e in ton sillopha ryngeal area

Fever, hoarsen ess, bar king cough, str idor, mem bra ne over pha rynx

an d la rynx

Sero- sanguinous nasal d ischarge , crus ts and a whi te membrane

on s e p tu m .

Late pres enta tion s : us u ally n o visible mem bra n e

Palata l or bu lbar palsy

myocardit is with prior s ore thr oat

Acu te polyneu ropath y with or with out prior s ore throat .

May occu r even in previous ly im m u n ized

CONFIR MING DIPHTHE RIA

Smear and culture of the membrane or scrapping below the

m e m b r a n e

Sta in with Neiss er or Albert st ain

MANAGEMENT OF DIPHTH ER IA

Hospitalization in in fectiou s diseas e facility

Droplet isolation till thr ee cons ecu tive da ily cultu res a re n egative

Start treatment without waiting for microbiologic culture confirmation


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Comp onents of therap y

Diph th eria a n titoxin (DAT), m ost cru cial

Antibiotics

Supportive care

Man agemen t of complication s

Trea tm en t - DAT

Always ad minister tes t d ose

If allergic des en sitize

Fu ll dos e given IV at one tim e, dilu ted in NS (1;20 ), ra te of m l/ m inu te

Limited a vaila bility at ID hos pita ls

Serum s ickn ess in 1 0% pat ients

Type Tota l dose in

u n i t sNasa l 10,00 0 20,00 0

Laryngeal / ph aryngeal 20,000 40,000

Tons illar 15 ,00 0 25 ,00 0

Combined types / delayed diagn osis 40,00 0 60,00 0

Severe diseas e* 80,00 0 100 ,000

Carr ier / conta ct Not required

* Extens ive disease/ more than 3 days dura t ion / neck

edema/ t achycard ia / collapse / b rea th lessness .


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Tr ea t m e n t c on t i n u e d

An tibiotics (pen icillin G/ Procaine pen icillin / Eryth rom ycin for 14

days)

Strict bed res t for 2 - 3 weeks

Adequate nutri t ion and hydration

Steroids not recommen ded

Carni t ine 10 0 m g/ kg/ day BD for 4 doses ma y help prevent ing

myocarditis.

# u se fu lness if given lat e in the disea se???

Airway ma in taina nce in th ose ha ving obstr u ction

# Intu bat ion/ t racheotomy, oxygen therapy

Complete immunization on recovery.

BRONCHIOLITIS

FEATURES:

You n g, well lookin g in fa n t

Tach ypnea ++

Tachycardia++

Saturating well

Bilateral scattered wheeze


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GRADING BR ONCHIOLITIS

MILD MODERATE SEVERE

F e e d i n gabi l i ty

NormalAbility to

feed

Appea r sh ort ofBrea th dur ing

feeding

May be relu ctan t oru n ab le to feed

Respira tory

d is t ress

Little or n o

resp

distress

Moderat e d istress

with

some chest

Wall retra ction s

an d n as al flaring.

Severe distr ess with

marked chest wallre t rac t ions , na sal

flaring an d grun tin g

Can ha ve frequent

an d p rolonged

a p n e a s .

Saturation Saturation>92%

Satu ration 9 2%

IV flu ids

Cardiorespiratory

monitoring

ABG/ CXR

Assess need for

ventilatory

su pport/ ICU care


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DIFF ER ENTIAL DIAGNOSIS :

Pneumonia

GERD with a sp iration

Foreign b ody

Congen ital heart d iseas e

Broncho-pulmonary dysplasia

Congenital an oma lies like vascu lar r ing

BRONCHIOLITIS

- R is k f a c t o r s f o r in c r e a s e d s e v e r i t y a n d h o s p i t a l i za t i o n .

Infants in day care

Exposure to pa ssive sm oke

Crowding in t h e hou seh old

Infants you nger tha n 2-3 mont hs

Prema tu re birth s < 3437 weeks

Con genital heart diseas e

Chronic lung disease l ike CF, Recurrent aspiration, BPD,

congenital malformations etc.

Immunodeficiency

Hypoxia


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INDICATIONS FOR HOSPITALIZATION

In fan t s you nger than 3 m onths

Oxygen s atu rat ion < 92%

Resp Rate > 70/ min

ILL appearing child

In fan ts with one or m ore risk factors m entioned b efore are likely to

ha ve a s evere cou rse an d m erit ad miss ion.

INVESTIGATIONS :

Bron ch iolitis is a clin ical diagn osis

In vestigations cont ribu te very little

CXR ma y be in dicat ed in

severe respiratory distress or

in a case of diagnostic u n certainty

Atypical course

Chest X-ray

often reveals bilateral hyperinflation findings like segmental

atelectas is m ay be seen some times.

Blood tests do not contribut e


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MANAGEMENT:

Non con t rovers ia l Cont rovers ia l

Oxygen

IV flu ids

Fever man agement

Adren alin e n ebu lization

Bronchodilators

Steroids

Antibiotics

Lim i ted u se- n o t be ing d iscu ssed

Palavizumab and Ribavarin

FEEDING AND FLUIDS:

Oral feedin g

May be cont inu ed in infan ts with n o more than moderate

respiratory difficulty. (respiratory rate < 80 breaths per minute,

some ch est wall retraction, Sp02 . 92% +/ - oxygen)

Nas ogas tric tu be feedin g

Generally reserved for th e recovery pha se b ecau se;

# NG tubes blocks one nostril- increased airway

resistan ce, in creased work of breat hing.

# Feed in th e stoma ch - in creased th e r isk of reflu x an d

asp ira t ion a s compresses th e diaph ragm.


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INTRAVENOUS FLUIDS:

Administered when there is moderate to severe or severe

respiratory difficulty.

(marked chest wall retractions, nasal flaring, expiratory

gru nt ing, ma rked ta chypnoea (.80/ min), apn oeic episodes, or

visible tiring during feeding.

Considerable variation in the intravenous hydration strategies

recommended.

Norma l genera l ma in tena n ce IV flu ids to be u sed.

OXYGEN:

Common sen se dictates i ts u se to overcome h ypoxemia

In genera l, aim to ma in tain Sp0 2 > 92%

Can accept 90% to 92% Sp02, if the child is not distressed and is

feeding well

BRONCHODILATORS :

There is no role for routine bronchodilators in bronchiolitis as they

do not;

imp rove oxygen s atu rat ion.

affect rate or duration of hospitalization.


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A trial of n ebu lised bron ch odilat or can be given in :

Older in fan t ( > 6 m ont h s) with wheeze.

Those with a stron g history of atopy, fu rth er thera py continu ed

if th ere is a objective impr ovemen t.

STEROIDS:

Multiple studies have failed to demonstrate any clear efficacy of

corticost eroids in viral br onch iolitis

NEBULISED ADRENALINE

Little support from randomized clinical trials for its use in all

children with m oderate/ severe diseas e

Improvement in respiratory symptoms across studies

incons isten t an d sh ort lived.

May u se n ebu lised Adren aline as a potential rescue m edication for

th ose wh o are to be ad mitted.

Dose varies between 0.01 ml/ kg to 0.3 ml/ kg per dose of 1: 1000

solut ion.

ANTIBIOTICS:

RCTs failed to demonstrate any benefit in hospitalized infants with

bronchiolitis.


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Th e on ly role of a n tibiotics is

complicated bronchiolitis where a secondary bacterial infection

is s u spected.

Th is is rar e, bu t n ot eas ily exclu ded in a sick infan t with fever,

toxicity an d s ign ifican t opa cities on th e ches t X-ray

SEDATION

No sa fe seda tion ; seda tives s h ould b e avoided

Irr itab ility ma y be a s ign of Hypoxia

Sedatives can decrea se th e oxygen ation a s well as give false sen se

of relief.

Attemp ts to comfort th e child a s far a s p ossible

Fever con trol

Nasal clearing

Feeding

Non th reaten in g m an ner of oxygena tion/ neb u lisa tion


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VIRAL BRONCHIOLITIS

Mild bronchiolitis

Normal ability to

feed

Little/no resp.

distress

Not hypoxemic

Moderatebronchiolitis

Moderate resp.distress

Mild hypoxemia brief apnea

short of breath

Severe bronchiolitis

Severe resp.

distress apnoeic episodes

hypoxemic

Looking tired

Cant feed

Does not needinvestigations

Home treatment

Admit

Humidified O2

to maintain Sa2above 92%

IV fluids

Adrenaline trial

Observe for

deterioration

Admit ICU care

O2 to maintain

Sa2 above 92%

IV fluids

Adrenaline trialcardio

respiratorymonitoring

A BG, CXR Assess need for

ventilatorysupport/ ICU

care

Improvement

Decrease O2

(guided by SaO2)

Re-establishfeeding

Discharge whendistressdecreased and

feeding well

Deterioration


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PNEUMONIA

TACHYPNEA

Most Consistent Clinical sign of pneumonia

Ag e R e s p i r a t o r y r a t e (b r e a t h s / m i n )


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Chi ld wi th cough , rap id an d d i fficu lt b rea t h ing

Tachypnoea

A sensitive and specific tool - 66% approx.

as good or bet ter then au scu lta t ion for pneu monia

Any clinician therefore must use this merely as a beginning step

(Tria ge s ign )

An d t h en u se a ll th eir clin ical sk ills for th e fina l con clus ion

Remember several other cl inical si tuations that cause radia breathing

e,g,

Respiratory cau ses: Asth m a / Bronchiolites / WALRI

Non respiratory causes: metabolic acidosis, CHF, rasied ICT

Pneumonia any cause

WALRI, Asthma,LTB,

Nonrespiratory


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Differe n t ia l d iagnosis

First ru le ou t non - resp iratory cau ses for tachypnoea,

Th en, t h e No- pu lmon ary cau ses a re ru led out cl inically.

In this setting of child with cough, rapid and difficult breathing, now

th e l ikelih oods are;

Pneu mon ia comp lication s

Bronchiolitis

Wh eeze as sociated with lower res pirat ory tract infection s

Asthma

Croup

Child wit h Cough, Rapid , Difficul t bre at h ing

Cons ider bron ch io li t i s i f :

Age 1 m onth 2 years

Presence of u pper res piratorycatar rh

Progress ive in creas e in r esp.distress (tach pn oea, retractions )

Wheeze crackles Clin ical an d ra diological evidence of

hyperinflation

Cons ide r a s th m a i f :

Recurrent episode,3 or more

Afebr ile epis odes

Wheeze

Good response to bronchodilator

Hyperinflation

Fam ily / person al history of atopyy

Cons ide r wheeze as soc . w ith LRTI(WLRI) if :

Recur rent episodes of distressu nd er 3 years of age

Progress ive in creas e in r esp.distress (tach ypnoea, retractions )

Wheeze crackles

Clinical an d ra diological evidence ofhyperinflation

No family or personal history ofatopy

Cons ider laryngo t rac h eo-bron ch ii t is Croup if :

Hoarseness of voice and barking/bra ssy of cough

Stridor

Mild t o ma rked respiratory distress

Sonorous rhonchi

Fever usually mild or spiking(tracheitis, rate)


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Can v i ra l LRTI o r bac t e r ia l pneu m on ia be c lin ica l ly d i s t in gu ished ?

May be d ifficu lt as th e investigat ion s do n ot con firm etiology

Advantage of using the suggested methodology - decreases the

confoun ders to viral pn eum onia alone ra ter th an broad ARI.

Com m un i ty acqu i r ed Pn eum on ia (CAP)

CAP is an acute infection of the pulmonary parenchyma in a

previously healthy child, outside of a hospital setting.

not have been hospital ized within 14 days prior to the onset of

symptoms, or

h as b een h ospitalized less th an 4 da ys prior to ons et of sympt oms.

I t exc ludes

Ch ild with im m u n e-deficien cy

Severe Malnutrition

Post m easles state

Ventilator as soc pneu mon ia / Nosocom ial sp read

Recurrent pneu monias

DIAGNOSIS RADIOLOGICAL

Do all pa tien ts reqiure a ch est ra diograph ?

NO

Not a ll CAP, pa rticu larly if on dom iciliary trea tm en t

Few-Yes,

If s ever ely ill

If comp licat ion su sp ected (for exam ple, pleura l effu sion)

Ambiguous Clinical features.


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MICROBIOGICAL

Not recom men ded rou tin ely

Takes long t im e an d h ence h as limited u ti lity

Spu tu m cultu res / cou gh swabs ha ve relatively poor reliability

Invas ive meth ods can n ot be ju stified for routine pn eu mon ias .

R ole o f pu l se oxym e t ry , a cu t e phase r eac t an t s

TLC,DLC,CRP are not diagnostic but may be useful to monitor the

response to t rea tmen t .

Pulse oxymetry is a good tool for assessing the severity and

m onitorin g respons e in th ose with severe disease.

AGE RELATED PATHOGENS INVOLVED IN COMMUNITY

ACQUIRE D P NEUMONIA

0 3 m ont h s Gram n egative, strept o. Pyogenes,

Chlamydia, viruses

3 mon th s 5 years Strept . Pneu mon iae, H.influ enze,

s tap aureus , v i ruses , mycoplasma

p n e u .

> 5 year s Mycoplas ma pn eum oniae, str .

pn eum oniae . Stap. Au reus , viru ses ,

str p. Pyogens .


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Reliabi l i ty of predic t ing a specia l e t io logical agent based

on c l in i ca l fea tu re s and / o r r ad iography

Gen era lly POOR.

ONE E XCEPTION STAPH

More like ly if

very ra pid pr ogress ion

skin lesions, infected scabies

PE / p n e u m ot h o ra x / e m p ye m a

? Post m eas les

SE VER ITY OF PNEUMONIA:

WHO classification is very simple and probably more useful from

management point of view.

Severe - tachypn oea with accessory mu scles in a ction - lower ches t

indrawing

Very severewith additional features like

Altered sen sorium

Cyanosis

severe gru nt

in termit tent apnea

difficu lty in feedin g


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INDICATIONS FOR ADMISSION TO HOSPITAL

Sa02 < 92%

Marked tach ypnea, sa y 20+ breaths / min a bove the cu t off for the

age.

Difficulty in breathing

Intermit tent apn ea, gru nt ing

Not feedin g/ deh ydrated

Family not able to provide appropriate observation or supervision.

Failu re of OPD trea tm ent

TREATMENT OF C A P

D i s e a s e P n e u m o n i a

S e t t i n g Domicilliary

Age First lin e Second lin e Su sp ected stp h .Disease

Up t o 3 m o n t h s Usu ally severe, treated a s inp atients

3 m o n t h s t o 5

years

Am oxycillin Co-a m oxy clav

OR

Chloremphenicol

Cefuroxime

OR

Co-am oxy clav

OR Amoxycillin +Clox

5 y e a r s p l u s Am oxycillin Macr olide OR

Co-am oxy clav

OR

Chloremphenicol

Cefuroxime

OR

Co-am oxy clav

OR Amoxycillin +

Clox


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S e ve r e v e r y s e v e r e p n e u m o n i a

Treat a s in-pat ient

Age Firs t l in e Secon d l in e

0 -3 m o n t h s Inj. 3 rd gen cepha losporin s

cefotaxim e/ ceftr iaxon e Am inoglycoside (Gen ta l/

Amikacin)

In j co-am ox clav

+

Aminoglycoside

(Genta / Am ika cin )

3 m o n t h s 5years

Inj. Am picillin OR

Inj. Chloremphenicol OR

Inj Am picillin +

Inj. Chloremphenicol (


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NOT Cefixime because it lacks action against strep.

Pneumoniae

Fluoroquinolones are not recommended

Total 5-7 d ays

If on s econ d l in e, then treat for 7-10 d ays

If sta ph ylococcal d isea se.;

2 weeks if n o comp licat ion :

Else 4-6 weeks

INDICATIONS FOR TRANSFER TO PICU

Failu re to m ainta in Sa 02 > 92% in Fi02 > 0.6

Cyanosis

Shock

Rising respiratory and pulse rates with clinical evidence of

severe respiratory distress and exhaustion with or without

ra ised p aC02

recur rent a pn ea or slow irregular breath in g.

Excessive diaphoresis

HAP- Hospi ta l Acqu ired pn eu m on ia

Ea rly -ons et HAP an d VAP,

occurring within the first 4 days of hospitalization,

More likely du e to a n tibiotic sen sitive ba cteria.

Usu ally carry a b etter prognosis,

Lat e -on se t HAP an d VAP (5 d ays o r m ore )

More likely du e to mu ltidru g-resist an t (MDR) pa th ogen s,

Associated with increa sed pa tient morta lity an d m orbidity.


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RE CURR ENT P NEUMONIA

'At least two episodes of pneumonia occurring in one year or three

epis odes over a n y period of time.'

Recurren t pn eum onia is a s ymptom of an u nder lying disease an d n ot

a d iagn osis in itself.

Ca u s e s i n c l u d e

Comm onest Asth m a (m is- diagnosis), Asp irat ion syndr omes

less comm on Congenital anom alies, FB, CVS sh u nts , TB, tum ors

Not infrequ en t CF, Im m u n odeficiency, ciliar y dyskines ia.

Key point s on history an d exam ina tion

Delayed cord fall - leu ko a dh esion d efects

History suggestive of aspiration (choking nasal regurgitation,

recurrent seizures)

Tem pora l relation of cough t o feeding or postu re

Fam ily or persona l h / o atopy noctu rn al cou gh, bronch odilator rel ief

Fam ily h/ o similar d isorder or consa ngu inity

Multiple m u ltifocal in fection s e.g. diarrh ea, pyoderm a, ea r infection s

Malab sorp tive stools

Contact history

Orophayrngeal examination

Clubbing


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Oth er feat u res of at opy e.g., flexu ra l derm at itis

Failu re to th rive, BCG scar , ton sil size

Pallor, gen a den opath y

Perforative otitis media

Cardiovas cular system

Respirat ory system .

KEY DIFF ER ENTIATION :

Upper an d lower resp i ra t o ry

s y m p t o m s

O n ly lo we r r e s p i r a t o r y s y m p t o m s

Asthma

Immunodeficiency

Ciliar y d yskines ia

CF

Aspiration syn drom es

Congenital a n oma lies

CVS sh un ts

FB

TB

Tumours

Sam e lobe Di ffe ren t lobes

Foreign b ody

Tuberculosis

Congenital anomaly

Aspiration

Asthma

C VS s h u n t

Mucociliar y d efects Immunodeficiencies


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Inves t iga t ions fo r t he cause o f b ronch iec ta s i s

The cau se rema ins u nkn own in 30-50% of pat ients .

Needed investigations are:

FO Bronch oscopy,

HRCT or bron chograph y

Seru m imm u n oglobu lin levels,

Gast ro esopha geal reflu x stu dies,

Test s for tu bercu losis a n d fun gal in fection s ABPA

Sweet chloride, an d

Ciliary's studies

In v e s t i ga t i o n s i n b r o n c h i e c t a s i s a r e 3 fo ld

A:- To as certain an d esta blish t h e diagnos is - HRCT or radiology.

B:- Pulmona ry Fu n ction Tests to access the fu n ctions capa city of

the lu ngs .

In vestigations in bron chiectas is

F i n d i n gs o n x -r a y o f c h e s t a r e n o n s p e c i fi c .

Rin g like den sities with clear cent re

Irregu lar ill-defin ed vascu lar m ar king or

Unequa l aera tion du e to atelectasis an d h yperinflation

H ig h r e s o l u t i o n c o m p u t e r i z e d t o m o gr a p h i c s c a n (H R CT ) o f c h e s t :

Very sensitive and non invasive method

Fin dings inclu de

Lin ear n on ta pering a irway


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Co- Am oxyclav / ceftriaxon e with or with ou t flu roqu in olones if

pseu domon al colonization is su spected l ike in CF.

Airway cleaning, bronchial lavage and hygiene with chest

physiotherapy to br ing ou t spu tu m is very importan t an d pru dent s hou ld

be promoted.

Presented with fever, ches t pa in ,

Expectoration: 6 weeks

Did n ot respond to broad sp ectrum an tibiotics

He had mild clubbing, bronchial breathing right infrascapular region

an d crepita tion s a ll over righ t side of ches t

Wha t a re t he d iagnos t ic poss ibi li t i e s?

Cau ses of lu n g abs cess

Most frequently a complication of bacterial pneumonia

Epecially th ose du e to sta ph ylococcus a u reu s,

Klebsiella p neu mon ia a n d

Pseudomonas

May develop in sequestration of lung tissue or in association with

foreign bodies, bron chial cyst s or st enos is.

Staphylococci lungs abscess are often multiple, while those

complicating aspiration are solitary.

May ru ptu re in to th e pleu ra l space leading to pyopnu emothrax


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Lung abscesses are frequently a complication of higher bacterial

pneumonia or obstruction due to retained FB or bronchial cyst ,

congenital anomaly like sequestration of lung tissue may also lead to

lu ng abscess .

Take Hom e Messages

Viral infections and non infectious causes of cough do not need

antibiotic therapy

Few situa tion s for em piric u se of an tibiotics.

Unwana nted u se does not prevent a su bsequent s econdary infect ion

in most s itu a t ions .

First line a n tibiotics a re s till effective an d d ru gs of ch oice.

Newer 3rd -4th generation antibiotics should be reserved for few non

responders .

All non responders a re not du e to a res is tan t bu g. Other caus es are as

important .

Ta k e h o m e m a s s a ge s

Children p resen tin g with fever, cou gh with n as al / ear discha rge

[Includes: acute nasopharyngit is , tonsil l iopahryngit is , s inusit is and

otitis media]

Majority are du e to vira l in fection s

An tibiotics do not p revent s econda ry bacter ial infection s


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Do throat swab cu ltu re / RADT in acu te tons illopha ryngit is , if

Exudates on tonsil lar surface, cervical node enlargement, absence of

conjuctival congestion or symptoms persist for > 3 days

Cons ider s in u sitis: if URTI pers ist beyon d 7 -10 d ays

Do otoscopy in all URTIs to diagnosis otitis media

An tibiotics in : GABHS ph ar yngitis, s inu sitis, severe otitis m edia or red

an d bu lging tymp an ic mem bran e

Us e firs t lin e a n tib iotics firs t, AMOXYCILLIN IS STILLL EFFCTIVE.

Ta k e h o m e m e s s a ge s :

Ch i l d r e n p r e s e n t i n g w it h fe v e r , c o u gh w i t h n o i s y br e a t h i n g

Common conditions: adenoidal hypertrophy, croup, pertussis ,

d iphther ia

Croup: comm only du e to viru ses, n o an tibiotics

Croup : single dose of system ic st eroids with epin eph rine SOS

Diphtheria: Isolate, start penicillin and ADS, give immunization on

follow up.

Pertussis: Macrolides with supportive care.


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Ta k e h o m e :

Ch i l d r e n p r e s e n t i n g w it h b r e a t h i n g d i ffi c u lt y

[Com m on cond i t i on s : Br onch i o li t i s , pn eum oni a , Br onch i ec t as i s ,

e m p y e m a a n d lu n g a b s ce s s ]

Bronchiolitis: viral infection,

Oxygen inhalation, IV fluids

Adren alin e tr ial

P n e u m o n i a :

Ass ess clinically, n o n eed for C-X ra y in every ch ild.

Am oxicillin dr u g of ch oice for am bu latory trea tm en t

For h ospitalized ch ildren : In j Am picillin / Chloram ph enicol or Co-

Amoxyclavulanic acid.

Add macrolides if suspecting atypical organisms

Children< 3 months: Third generation cephalosporins +

Aminoglycosides

E m p y e m a

Cloxacillin + Ceftraixone or Co- Amoxyclav

protocols in pulmonology

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