PEDIATRIC RESPIRATORY EMERGENCIES : DISEASE OF LUNGBy Duangruethai Tunprom, MD. 3rd years emergency medical resident, PMK hospital

outline

Upper airway obstruction & infection Lower airway obstruction Disease of the lung

Pneumonia

Diagnosis by Clinical sign & symptom CXR

Limit diagnostic test

WHO Published guidelines for clinical diagnosis

pneumonia Tachypnea & retraction as indicator of lower

respiratory disease Tachypnea

> 50 /min in pt < 1year > 40 /min in pt > 1year

Manifestration Cough , wheezing, nasal flaring, retraction,

grunting, use accessory muscle

Pneumonia(cont.)

40/1000 in preschool ages 7/1000 in 12 -15 years Male > female = 2 : 1 Viral pneumonia 60 -90 % of all

pneumonia Except neonate bacterial pneumonia

predominate Immunocompromised host mixed &

opportunistic infection

Pneumonia (cont.)

Passively acquired maternal antibodies Protection against S. pneumoniae & H.

influenzae During 1st few months of life

Altered protective mechanisms increase risk developing pneumonia Congenital anatomic abnormality Immune deficiencies Neurologic alteration predispose to aspiration Alteration in quality of secreted mucus (cystic

fibrosis)

Cough may aid diagnosis Staccato & paroxysmal cough in infant Caused Chlamydia trachomatis

Hacking quality Caused from Mycoplasma infection

Pneumonia syndromes

Bacterial viral Chlamydia Mycoplasma

Historical Age Fever Onset

AnyHigh(>39 c)Abrupt, often after URI

AnyLow grade Gradual

4-16 wksUsually noneGradual

5-18 yrsLow gradual

CoughAssociated symptoms

ProductiveChest painFocal infarct

NonproductiveMyalgia, rash, sore throat, coryza

StaccatoConjunctivitis

Hacking, headache, rash, sore throat

Physical Lung

Toxic appearanceConfined rales

Diffuse ralesWheezingStridor

Diffuse ralesRare wheez

Unilateral rales

Pneumonia syndromes

Bacterial viral Chlamydia Mycoplasma

Chest radiograph Infiltration Pleural effusion Other

Lobar or segmentalOccasionalPneumatocelleAbscess

Interstitial

RareHyperinflationAtelectasis

Diffuse interstitialNoneHyperinflation

Lobar or diffuse

Rare

Lab Increased WBC granulocytosis

Normal or increase WBC countLymphocytosis

Normal WBC countEosisnophilia

Normal WBC count

Pathogens(common)

Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus

RSV, Parainfluenzae, Influenza, Adenovirus, Enterovirus

Chlamydia trachomatis

Mycoplasma pneumoniae

Bacteria pneumonia

Streptococcus pneumoniae M/C of bacterial pneumonia

Previous M/C H. influenzae incidence decrease 90 % since onset

effective immunization Now occur in older children

S. pneumoniae & H. influenzae Associate pleural effusion 25 -75 % Bacteremia 75 – 95 %

Group A streptococcal pneumonia Occur as a complication of varicella Typical severe illness Abrupt onset Rapid progression to toxicity High fatality rate 30 – 60 %

standard CXR for diagnosis of pneumonia : 2-view plain chest radiograph

may not differentiate between viral disease and bacterial disease.

left lower lobe infiltrate

Bacterial pneumonia Round pneumonia on

chest radiographs should raise suspicion for a bacterial etiology, particularly Streptococcus pneumoniae and Staphylococcus aureus

Mark I Neuman, MD, MPH, Assistant Professor of Pediatrics:Pediatrics, Pneumonia: Differential Diagnoses & Workup.Harvard Medical School; Attending Physician, Division of Emergency Medicine, Children's Hospital Boston;Oct 21, 2010.

Viral pneumonia

viral pneumonias, 4 common radiographic findings were detected:

1. parahilar peribronchial infiltrates2. Hyperexpansion3. segmental or lobar atelectasis4. hilar adenopathy

Mycoplasma pneumonia

M pneumoniae, 3 radiographic patterns 1. peribronchial and perivascular interstitial

infiltrates2. patchy consolidations3. homogeneous acinar consolidations like

ground-glass

consolidation in the lingula and small left pleural effusion

Chlamydial pneumonia

Chlamydia pneumoniae pneumonia.

(Courtesy of Dr. Atsushi Nambu, Department of Radiology, University of Yamanashi, Yamanashi, Japan.)

PA CXR shows : poorly defined consolidation and ground-glass opacities in the left lower lobe.

Pertussis

Classic symptoms of pertussis paroxysmal cough, inspiratory whoop, and

vomiting after coughing. The cough from pertussis has been

documented to cause subconjunctival hemorrhages, rib fractures,

urinary incontinence, hernias, post-cough fainting, and vertebral artery dissection

Aspirate pneumonia

Aspiration Pneumonia ImagingAuthor: Jaw Lee, MD, Staff Physician, Department of Emergency Medicine, King-Drew Medical CenterContributor Information and DisclosuresUpdated: Dec 17, 2008

Aspirate pneumonia

Aspiration Pneumonia ImagingAuthor: Jaw Lee, MD, Staff Physician, Department of Emergency Medicine, King-Drew Medical CenterContributor Information and DisclosuresUpdated: Dec 17, 2008

location depends on the patient position often gravity dependent

Generally the right middle and lower lung lobes : M/C sites due to the larger caliber more vertical orientation of the right

mainstem bronchus

Pneumonia in immunocompromised host picture

Antibiotics for treatment of pediatric pneumonia

Age group Agent Outpatient treatment

Inpatient treatment

0 – 12 wks Group B streptococcusGram negative bacilli

(Listeria monocytogenes)

Bordetella pertussis or Chlamydia trachomatis

Erythromycin estolate

Ampi +Cefotaxime or CeftriaxoneErythromycin

estolate

12 wks – preschool age

Streptococcus pneumoniae

(Haemophilus influenzae,Staphylocooccus

aureus,Group A streptococcus, Neisseria meningitidis)

Mycoplasma pneumoniae or

Chlamydia pneumoniae

MRSA or clinically ill

Amoxicillin-clavulanic acidOr Cefuroxime Or Azithromycin

Or Clarithromycin

Add ErythromycinOr Azithromycin

Or Clarithromycin

CefuroximeOr CefotaximeOr CeftriazoneOr Clindamycin

Add ErythromycinOr Azithromycin

Or Clarithromycin

Add Vancomycin

School age to adolescent

Mycoplasma pneumoniae or

Chlamydia pneumoniae

MRSA or clinically ill

ErythromycinOr Azithromycin

Or ClarithromycinOr Tetracycline(>8

yrs)Or Fluoroquinolone

(>16yrs)

CefuroximeOr CefotaximeOr CeftriazoneOr ClindamycinAnd Macrolide

Add Vancomycin

Antibiotics for treatment of pediatric pneumonia

Age group Agent Outpatient treatment

Inpatient treatment

0 – 12 wks Group B streptococcusGram negative

bacilli (Listeria monocytogenes)

Bordetella pertussis or Chlamydia trachomatis

Erythromycin estolate

Ampi +Cefotaxime or CeftriaxoneErythromycin

estolate

Ceftriaxone is contraindication in infants age < 1 month old

Antibiotics for treatment of pediatric pneumonia

Age group Agent Outpatient treatment

Inpatient treatment

12 wks – preschool age

Streptococcus pneumoniae

(Haemophilus influenzae,Staphylocooccus

aureus,Group A streptococcus, Neisseria meningitidis)

Mycoplasma pneumoniae or

Chlamydia pneumoniae

MRSA or clinically ill

Amoxicillin-clavulanic acidOr Cefuroxime Or Azithromycin

Or Clarithromycin

Add Erythromycin

Or AzithromycinOr

Clarithromycin

CefuroximeOr CefotaximeOr CeftriazoneOr Clindamycin

Add Erythromycin

Or Azithromycin

Or Clarithromycin

Add Vancomycin

Antibiotics for treatment of pediatric pneumonia

Age group Agent Outpatient treatment

Inpatient treatment

School age to adolescent

Mycoplasma pneumoniae or

Chlamydia pneumoniae

MRSA or clinically ill

ErythromycinOr Azithromycin

Or Clarithromycin

Or Tetracycline(>8

yrs)Or Fluoroquinolone

(>16yrs)

CefuroximeOr CefotaximeOr CeftriazoneOr ClindamycinAnd Macrolide

Add Vancomycin

Management

Infant < 2 mo Infant 2 -3 mo Infant & children > 3 mo

Management : Infant < 2 mo

3 factors in directing management Patient’s age Likely pathogen Degree of illness Age < 2 mo with pneumonia Admit

Immunological immature Sign of sepsis may be subtle Blood urine CSF C/S

Ampicillin + Aminoglycoside

Management : Infant 2 -3 mo

Blood & urine C/S Ampicillin + 3rd gen Cephalosporin(Ceftriaxone is contraindication in infants age < 1 month old)

If C.trachomatis & B.pertussis Erythromycin Other macrolide, sulfonamide

Management : Infant & children > 3 mo

1st line : Amoxicillin & Amoxicillin-clavulonic acid

If resistant S.pneumoniae Cefuroxime High dose Amoxicillin( 80-100 mg/kg/day)

Management : School age to adolescent

1st line : Macrolide M/C pathogen :

Mycoplasma pneumoniae Chlamydia pneumoniae

Outpatient reevaluate

F/U 24 – 48 hrs If have sign of bacteremia

Single dose IM ceftriaxone Follow by oral therapy

Indication for hospitalization

Toxic appearance Vomiting or

dehydration Respiratory

compromise Distress Hypoxia Inadequate

ventilation

Multilobar disease Pleural effusions Impaired immune

function Unstable social

environment Age < 6 months

F/U •Clinical 2-3 wks after diagnosis•CXR 6-8 wks

Complication of pneumonia

Pleural effusion, emphysema

Hypoxia, progressive respiratory failure with multiorgan failure

Apnea without other symptom in infants < 3 months Viral Chlamydial pertussis

M/C dehydration Additional infection

foci result from bacteremia : Meningitis Epiglottitis Pericarditis septic arthritis soft tissue infection

Local Systemic

Noninfectious causes that may present as pneumonia

Noninfectious causes that may present as pneumonia

Noninfectious causes that may present as pneumonia

Other respiratory emergencies Cystic fibrosis Chronic lung disease

Cystic fibrosis

Autosomal recessive Mutation in CF

transmembrane conductance regulator (CTFR)

Incidence 1 /2500 Present :

Hispanic Native americans African American Asians

Progressive lung disease & infection

Most morbidities & Nearly all mortality

Defects in Chloride transport across airway epitheliam Reduced ciliary clearance of thickened

mucus Decrease antimicrobial effect of the

airway surface Increase bacterial adherence Innate secretion of inflammatory

cytokines

Cystic fibrosis

CXR Emphysema Peribronchial

thickening Bronchiectasis Focal infiltration

Treatment Acute exacerbation

Oral or IV penicillin () Or Ceftazidime

+Aminoglycoside Clearance thick mucoid

secretion May response

bronchodilator, mucolytics (inhaled N-acetyl cysteine)

Short term inhaled corticosteroid•Duration 10-14 days•Careful antibiotic : cover MRSA,•If previous antistaph prophylaxis : cover Pseudomonas•If Burkholderia cepacia significant increase mortality in CF

Chronic lung disease

Chronic lung disease (CLD) of infantcy = bronchopulmonary dysplasia Common in premature infants Affects 40% of children with a birth weight < 1000

g Severity related to

Degree of prematurity Use peripartum steroids Damage incurred by ventilation in the neonatal period Nutritional status

Chronic lung disease

Treatment Prevention

Influenza vaccine : All of infants 6-23 month during appropriate season

Heptavalent pneumococcal vaccine & H.influenzae vaccine type B

Monoclonal immunoglobulin palivizumab : Monthly prophylaxis against RSV

Inhaled bronchodilator Becareful : hypoxia & hypercabia

Thank you

From 7th ed Rosen’s emergency medicine ,2010 Mark I Neuman, MD, MPH, Assistant Professor of Pediatrics :

Pediatrics, Pneumonia: Differential Diagnoses & Work up. Harvard Medical School; Attending Physician, Division of Emergency Medicine, Children's Hospital Boston;Oct 21, 2010.