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Pneumonia in children* - Coggle Diagram
Pneumonia in children*
definition: fever + respiratory syndromes + envolvement of the parenchyma (evidence by physical exam/xray)
prevention
Haemophilus influenzae vaccine
pneumococcal conjugate vaccine
etiology
Comminity-acquired
bacterial
<3mo: C. trachomatis, M. hominis, T. pallidum, Ureaplasma urealyticum
<5y: Sta. aureus, Str. pyogenes, C. pneumonae, M. pneumoniae
all: St. pneumoniae
CA-MRSA
viral: <5 y RSV, Influenza AB, Parainfluenza 1,2,3, Coronaviruses, Adenovirus. Rhinovirus, Human metapneumovirus
aspiration pneumonia: anaerobic Str., fusobacterius, bacteriodes
hospital acquired >48 after admission: Gram- bacilli, Sta. aureus
immunocompromised
WBC defect - Sta aureus, Gram- bacilli
Legionella pneumophilia
opportunistic fungi: Aspergillus spp, Mucoraceae spp, Fusarium spp
HIV: Pneumocystis jurovecii =carinii)
virus: RSV, adeno, influenza, parainfluenza, rhinovirus, human metapneumovirs, SARS-CoV-2, rubeola,VZV, CMV, EBV
CF: Sta. aureus, Pseudomonas aeruginosa, H. influenzae
pathologic patterns
bacterial pneumonia
bronchopneumonia - airways + surrounding interstitium -S. pyogenes, Sta. aureus
necrotizing pneumonia - aspiration, S. pneumoniae, S. pyogenes, Sta. aureus
caseating granuloma - tbc
lobar pneumonia - single lobe/segment - S. pneumoniae
interstitial and peribronchial with secondary infiltration - severe viral pneumponia complicated by bacterial pneumonia
viral pneumonia
interstitial
parenchymal
clinical features
key: fever + caugh + tachypnoe/dyspnoe
neonates/young infants: difficulty feeding, restlessness. fussiness, fever, leukocytosis
older children: pleuritic chest pain, abdominal pain, nuchal rigidity!, walking pneumonia - normal activity
evaluation
history and examination
general appearance
fever
tacypnea >40/perc, infant: 70/perc
respiratory dystress: tachypnoe, dyspnoe, hypoxaemia
lung examination
crackles
consolidated lung: decreased breath sounds, bronchiael breath sounds, bronchophony, whispered pectoriloguy, tactile fremitus, dullnes to percussion
wheezing
pleural effusion: chest pain with splinting, dullness to percussion, distant breath sounds, pleural friction rub
severity assessment
temperature >38.5°C
respiratory distress
cyanosis
altered mental state
hypoxaemia
dehydration
tachycardia
chest radiograph
routinely not indicatied
indications
severe disease
confirmation/exclusion when clinical findings inconclusive
hospitalization, to document presence, size, character, complications
history of recurrent pneumonia
exclusion of alternate explanations for respiratory distress: foreign body, heart failure
in 3-36 mo children with fever of >39°C + leukocytosis >20G/l and <10 y >38 °C + cough + leukocytosis >15 G/l
caveats
radiographic findings are poor indicators of etiologic diagnosis!
radiologic findings may lag behind symptoms, may be normal before hydration
interobserver/intraobserver variability - affected by clinical information
outpatient chest radiograph does not affect outcome
etiologic clues
segmental consolidation: bacterial pneumonia
clinical practice nut supported by literature: alveolar infiltrate- bacterial, insterstitial - viral, atypical bacterial
round pneumonia: >3cm, posterior, solitary - S. pneumoniae, streptococci, H. influenzae, S. aureus, M. pneumoniae
laboratory
WBC >15 G/l suggests pyogenic bacterial disease, but may be M. pneumoniae, influenza, adenocirus
eosinophylia: C. trachomatis
outpatent not needed: CRP, PCR, ESR
bacterial: CRP 40-60 mg/l, PCT
electrolites - dehydration
microbiological testing
indications: severe disease, complications, hospitalization, suspected unusual pathogen, fail to respond initial therapy
blood culture
sputum
pleural fluid
rapid diagnostic tests: RSV, influenza, parainfluenza, adenovirus, M. pneumoniae, Chlamydia, Human metapneumovirus
not indicated: nasopharyngeal cultures, serology
other: tuberculin skin test, urine antigen for legionellosis, histoplasmosis
clues to etiology
typical bacterial pneumonia
Str. pneumoniae, Sta. aureus, group A Streptococcus
upper respiratory tract symptoms, abrupt onset
febrile, ill-appeating patient, moderate-severe respiratory distress, chest pain, sepsis
auscultation: few/focal - limited to segment -decreased breath sound, crackles
atypical bacterial pneumonia
M. pneumoniae, C. pneumoniae
abrupt onset, fever, malaise, myalgia, headache, photophobia, sore throat, non-productive cough, wheezing
extrapulmonary manifestations: mild erythematous rash, urticaria, Stevens-Johnson, hemolytic anaemia, polyarthritis, pancreatisis, hepatitis, pericarditis, myocarditis, neurologic complications
afebrile pneumonia of infancy 2w-4mo
viral: gradual onset, upper respiratory symptomes, does not appear toxic, asucultation: diffuse, bilateral, wheezing