PNEUMONIA

Inflammation of the parenchyma

of the lungs (Nelson Text book of
Pediatrics 17th ed.)
Inflammation of lung tissue caused
by an infectious agent that results in
acute respiratory signs and
symptoms
(Philippine Pediatric Society, Inc. Clinical Practice Guidelines In The Evaluation and
Management of Pediatric Community Acquired Pneumonia 2004)

EPIDEMIOLOGY
MORBIDITY
3rd leading cause in the Philippines
(2000)
Steady increase from 380.3/100,
000(1990) to 829.0/100, 000 (2000) in
all age groups
MORTALITY
3rd leading cause in the Philippines
(1997)
Age: < 1y
: 235.4/ 100, 000
(1997)
1 - 4 y : 50/ 100, 000 (1997)

Risk Factors
LUNG DISEASES: Asthma and Cystic Fibrosis
ANATOMIC PROBLEMS: tracheoesophageal fistula
GERD with Aspiration
NEUROLOGIC DISORDERS: interfere with protection
of the airway or compromise clearing

DISEASES that ALTER the IMMUNE SYSTEM:

immunodeficiency disease

SEASON of the YEAR

IMMUNIZATION STATUS
HEALTH STATUS

ETIOLOGY
VIRAL AGENTS

BACTERIAL AGENTS

common
Influenza virus
Respiratory Syncytial
Virus
Adenoviruses

Gram (+)
Strep pneumoniae
Staph aureus

rare
Rubeola
Herpes Zoster Virus
Varicella virus
Cytomegalovirus

Gram (-)
H. Influenzae
Klebsiella pneumoniae
Moraxella catarrhalis
P. Auroginosa
Atypicals
Mycoplasma pneumoniae
Chlamydia pneumoniae
Legionella pneumophilq

ETIOLOGY
FUNGAL AGENTS

PARASITIC AGENTS

Histoplasmosis
Coccidiomycosis
Sporotrichosis
Cryptococcosis
Aspergillosis
Candidiasis

Toxoplasma gondii
Strongyloides stercoralis
Ascariasis
Other Hookworms

EPIDEMIOLOGY
age

0 48 hrs
1 14
days
2wk2mon
2mon 5y
5 18 y

agent by

Group B Streptococcus
E. coli. Klebsiella, Enterobacter,
Listeria
S. aureus, Anaerobes, Group B
Strep
Enterobacter, Group B Strep, S
aureus,
C. albicans, H. influenzae, S.
pneumoniae
H. influenzae, S. pneumoniae
S. pneumonia, M. pneumoniae

PATHOPHYSIOLOGY viral
1. By droplet or aerosol, virus enters to respiratory
system through smallest airways infecting upper
respiratory tract and extend downwards.
2. Destruction od ciliary epithelium with sloughing of
cellular debris, accompanied by infiltration of lymphocytes
Into submucosa and perivascular area
3. Progression leads to inflammatory edema of airway
walls and alveoli, and secretion of mucous, producing
Varying degrees of obstruction.
This produce crackles or wheezes
4. Denudation of epithelium and hemorrhagic exudation.

CLINICAL PRESENTATION
Influenza Virus
viral

high-grade fever, myalgia, headache sore throat,

dry hacking cough, dec WBC, pulmonary infiltrates
in chest x-ray
RSV
fever for 3 days, followed by coughing and wheeze
in severe cases: chest retractions, labored breathing,
dyspnea and hypoxemia, in 5 7 day period
Adenoviruses
Upper respiratory symptoms may precede pneumonia
by 4- 7 days, fever, tachypnea, ronchi, wheez

PATHOPHYSIOLOGY
bacterial

1. Infection is by aspiration or hematogenous route

2. Infection reaches alveoli which becomes filled with
edema fluid and large numbers of RBC and neutrophils
(red hepatization) followed by deposition of fibrin and the
degradation of inflammatory cells (gray hepatization)
3. Consolidation as intra-alveolar debris is ingested and removed
by macrophages leads to decreased air entry and dullness to
percussion. Inflammation in the small airways leads to crackles.
4. Inflammation and pulmonary edema causes the lungs to
become stiff and less distensible, decreasing tidal volume.
5. Poorly ventilated areas of the lung may remain well perfused,
resulting in ventilation/perfusion (V/Q) mismatch and hypoxemia.
Tachypnea and hypoxia are common.

CLINICAL PRESENTATION

Nonspecific Signs and Symptoms:

bacterial
Fever
Chills
Irritability
Restlessness
Apprehension
Poor Feeding
Headache
Cough

Tachypnea
Use of Accessory muscles
Inequality of breath sounds
Crackles
Dullness to Percussion
Chest retractions
Abdominal breathing
Nasal flaring

CLINICAL PRESENTATION

bacterial

SPUTUM
Pneumococci
- bloody or rust-colored sputum.
Pseudomonas, Haemophilus, and pneumococcal species
-green sputum.
Anaerobic infections
- foul-smelling sputum.
Klebsiella and type 3 pneumococci
- sputum resembling currant jelly.

PATHOPHYSIOLOGY
This
is uncommon, but it is usually caused by endemic
fungal
and opportunistic fungi in individuals with severe immune
system problem due to AIDS, immunosuppressive drugs,
Or other medical problems.
The pathophysiology of pneumonia caused by fungi
is similar to that of bacterial pneumonia.

PATHOPHYSIOLOGY
1.parasitic
Parasites enters the body through skin
or being swallowed.
2. Parasite travels trhough the lungs, usually via blood.
3. A combination of cellular destruction and immune
response causes disruption of oxygen transport.
4. Eosinophils res[ond to the lungs and may also cause
eosinophilic pneumonia complicating the underlying
Parasitic pneumonia.

DIAGRAM
HISTOLOGY

CXR

CLASSIFICATION
ACUTE

by time

>3 weeks

Bacterial;
Bronchopneumonia
Atypical; Aspiration
CHRONIC

< 3 weeks
Non-infectious,
Mycobacterial,
Mixed bacterial infection,

CLASSIFICATION by
involvement
LOBAR
Single lobe or section of the
lung
MULTILOBAR

More than 1 lobe

INTERSTITIAL

Areas between alveoli

CLASSIFICATION

by origin

COMMUNIT
Y
ACQUIRED

Those who have not been

recently hospitalized and
those not qualified for
Hospital Acquired Pneumonia

HOSPITAL
ACQUIRED

Fever and Cough >48 Hours

after admission or <14 days
after discharge
New Pulmonary Infiltrates in
CXR

Clinical Practice Guideline

In the Evaluation and Management
of
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

(PCAP)

Predictors of CAP in a coughing

px
3 mos to 5 years:
Tachypnea and/or Chest indrawing
5 to 12 years:
Fever, Tachypnea and Crackles
> 12 years:
Fever, Tachypnea, Tachycardia w/ at least 1
abnormal chest findings::

Diminished breath sounds

Rhonchi
Rales
Wheezes

 Tachypnea is still the best predictor of

pneumonia
Respiratory Rate Criteria for Tachypnea:
WHO
2 to 12 mos old:
>50 cpm
1 to 5 yrs old: >40 cpm
>5 yrs old:

>30 cpm

PCAP A
Minimal
Risk

PCAP B
Low Risk

PCAP C
Moderate
Risk

PCAP D
High Risk

NONE

Present

Present

Present

Compliant
caregiver

Yes

Yes

No

No

Ability to
Follow-up

Possible

Possible

Not
possible

Not
possible

Presence of
DHN

NONE

Mild

Moderate

Severe

Able

Able

Unable

Unable

Comorbidities

Ability to Feed

Age
RR
2-12 mos
1-5 yrs
> 5 yrs
Signs of
Respiratory
Failure

Complications

PCAP A

PCAP B

PCAP C

PCAP D

Minimal Risk

Low Risk

Moderate
Risk

High Risk

>11 mos

>11 mos

<11 mos

<11 mos

>50
>40
>30

>50
>40
>30

>60
>50
>35

>70
>50
>35

No retraction,
head bobbing,
cyanosis,
grunting, apnea,
and awake

No retraction,
head bobbing,
cyanosis,
grunting,
apnea, and
awake

intercostal/
subcostal
retractions,
and irritable

Supraclavicular
/intercostal/sub
costal and signs
of RF

None

None

Present

Present

Diagnostics
For PCAP A or B:
Usually managed in an ambulatory setting
NO DIAGNOSTICS are initially requested for

either PCAP A or B

 For PCAP C or D:
Usually managed in a hospital setting
Routinely requested:
Chest X-Ray PAL
WBC count
Culture and sensitivity
Blood for PCAP D
Pleural fluid
Tracheal aspirate upon initial intubation

Blood gases or pulse oximetry

 May be requested:
Sputum C/S for older children
Should NOT be routinely requested:
Erythrocyte Sedimentation Rate
C-Reactive Protein

Indications for hospitalization

All who appear toxic, dyspneic, or hypoxic
Suspected staphylococcal pneumonia (eg,

pneumatocele on CXR)
Significant pleural effusion
Suspected aspiration pneumonia (higher likelihood of
progression)
Those who cannot tolerate oral medications or who
are at significant risk for dehydration
Suspected bacterial pneumonia in very young infants,
especially with multilobar involvement
Poor response to outpatient therapy after 48 hours
Those whose family situation and chances for reliable
follow-up are suboptimal

Points to Consider
Etiology
Bacterial vs. Viral

Co-morbidities
Presence vs. Absence

Status of Host
Normal vs. Special

Antibiotic use is recommended in

PCAP A or B, if
> 2 yrs of age
(+) high grade fever, (-) wheeze

PCAP C, if
> 2 yrs of age, or
(+) high grade fever, (-) wheeze, or
(+) alveolar consolidation in CXR, or
WBC ct >15,000 cells/mm3

PCAP D

Bacterial etiology: Empiric

PCAP A or B without previous antibiotic
treatment
use

Drug of choice: Oral Amoxicillin (40-50

mg/kg/day TID)

 PCAP C without previous antibiotic use and

completed immunization against Hemophilus

influenzae type B
Drug of choice: Penicillin G (100,000 units/kg/day

QID)

PCAP C without previous antibiotic use with

incomplete immunization against Hemophilus

influenzae type B
Drug of choice: IV Ampicillin (100 mg/kg/day QID)

 PCAP D
A specialist should be consulted

Guidelines
Oral Amoxicillin should be given for average of

7 days
Switch therapy should be instituted on the 2nd
or 3rd hospital day among patients who have
responded initially to IV antibiotics
IV antibiotics may be continued for 7 days in
hospital only among patients who
cannot tolerate oral feeding, or
may be perceived to be poorly compliant with oral

antibiotic at home

Alternative drugs:
IV Chloramphenicol, Cefuroxime, and Ampicillin-

Sulbactam

Predictors of Response to
treatment
If within 72 hrs post therapy initiation, there

is

Decrease in respiratory signs (esp. tachypnea)

Defervescence

Persistence of symptoms beyond 72 hrs

requires REEVALUATION

Non-response to treatment within

72 hrs
If outpatient PCAP A/B, consider
Change the initial antibiotic
Start oral Macrolide
Reevaluate diagnosis

 If inpatient PCAP C, consult w/ specialist

for possibilities of:

Penicillin-resistant Streptococcus pneumoniae
(+) complications and other etiologic agents
Consider other diagnosis

 If PCAP D,
consult with specialist immediately

At the end of treatment

Chest X-ray, WBC ct, ESR or CRP should not

be done to assess therapeutic response

No advantage in requesting chest x-ray upon

completion of treatment

Radiologic findings of pneumonia

resolve
6-8 wks
Streptococcus pneumoniae

2-3 wks
Respiratory syncitial virus

1 yr
Adenovirus
Regelmann WE: Diagnosing the cause of recurrent and persistent pneumonia in children.
Pediatr Ann 22:561-568, 1993

Do children with pneumonia need

follow-up x-rays to verify
Generally, NO.
resolution?
EXCEPTIONS include those with
Pleural effusions
Persistent or recurrent S/Sx
Significant comorbid conditions
Immunodeficiency
Wacogne I, Negrine RJ: Are follow up chest x-ray examiantions helpful in the management of
children recovering from pneumonia? Arch Dis Child 88:457-458, 2003.

Start Switch Therapy

from IV to Oral antibiotics
Within 2-3 days, if

(+) response to treatment

Px is able to feed with intact GIT absorption
(-) pulmonary or extra-pulmonary

complications

Oral Antibiotic

Dose

Duration

Amoxicillin

40-40 mg/kg/d max dose 750 mg-1.5

gm

TID

7 days

Azithromycin

10 mg/k/d max dose 600

OD

3 days

Cefodoxime proxetil

20 mg/k/d max dose 800

BID

7 days

Cefuroxime axetil

20-30 mg/k/d max 1-2 gm

BID

7 days

Chloramphenicol
palmitate

50-100 mg/k/d max 2 gm

QID

7 days

Co-amoxiclav

40-50 mg of amox /kg/d

BID

7 days

Clarithromycin

15 mg/k/d

BID

7 days

Cotrimoxazole

8-10 mg/k/d of trimethroprim adult

dose 320 gm; 40-60 gm of
sulfamethoxazole adult dose 1.6 gm

BID

7 days

Erythromycin

30-50 mg/k/d daily adult dose 1-2

gm

BID/TID

7 days

Sultamicillin

25-50 mg/k/d daily adult dose 750

mg-1.5 gm

BID

7 days

IV Antibiotic

Dose

Duration

Ampicillin

100- 200 mg/k/d daily adult dose 2-4

gm

Q6h

7d

Ampicillin-sulbactam

150-300 mg/k/d
(100-200 mg ampicillin)

Q6h

7d

Ceftriaxone

50-100 mg/k/d daily adult dose 2 gm

OD or q12h

7d

Cefuroxime

75-100 mg/k/d daily adult dose 2-4

gm

Q8h

7d

Penicillin G Na or K

100,000 to 200, 000 u/kg/d

Daily adult dose 8-12 M units max 24
units/24 hrs

Q6h

7d

Viral etiology: Management

Ancillary treatment should only be given
Antiviral agents may be given for influenza

that is either confirmed by laboratory or

occuring as an outbreak
Oseltamivir (2 mg/kg/dose BID for 5 days), or
Amantadine (4.4-8.8 mg/kg/day for 3-5 days)
Ribavirin

Ancillary treatment
Oxygen and Hydration if needed
Not routinely given in CAP:

Cough preparations
Chest physiotherapy
Bronchial hygiene (NSS nebulization)
Herbal medicines
Bronchodilators may be given if (+) wheezing

Cough Preparation

Adverse Effects

Codeine

Somnoloence, ataxia, miosis, nausea, vomiting, rash, facial

swelling, pruritus, addictive, if chronic respiratory
depression, obtundation

Dextromehorpan

Confusion, excitation, nervousness, irritability, addictive,

respiratory depression, behavioral disturbances

Guaifenesin

GIT disturbances, nausea, vomiting, dizziness, headache,

rash, diarrhea, drowsiness, abd. Pain

Bromhexine

GIT discomfort, rise of serum transaminases

Carbocisteine

Nausea, headache, GI discomfort, bleeding, diarrhea, rash

Diphenhydramine

Loss of appetite, nausea, vomiting, epigastric pain, diarrhea,

hallucinations, excitement, insomnia, drowsiness,
incoordination

Phenylpropanolamine

Headache, HPN crisis, seizures, arrhythmias, psychosis,

insomnia, stroke

Phenylephrine

HPN, pulmonary edema

Prevention
1.

Vaccines

Pneumococcal
HiB

2. Zinc supplementation

10 mg in infants
20 mg for children 2 yrs of age given for 4-6 mos

3. Vit A, Vit D, Vit C and immunomodulators

should NOT be routinely administered

KEY POINTS: PNEUMONIA

1.
2.
3.
4.

5.

Treatment is most commonly out-patient,

but follow-up is key.
Effusion or pneumatocele suggest a
bacterial cause
Radiologic findings in patients with
mycoplasmal infections are highly variable
In half of patients with chlamydial
pneumonia, conjunctivitis precedes
pneumonia
Hilar adenopathy suggests tuberculosis