Upper & Lower

Respiratory Tract
Infection
Presented By:
Thanushri Shruti Pillai A/P V.Ravindran
(67930)
Lew Wang Ting (66466)
Chong Zhane Yane (65664)
Nur Nabil Nandhira Binti Mohamad
1 Ibrahim (65090)
Siti Nurshamila Binti Shaffaee (67785)

Lecturer: Prof. Dr. Mohd Ameenudeen B.A. Sultan Abdul Kader

 Content
Introduction:
1. Anatomy of Respiratory Tract
Upper Respiratory Tract Infection
1. Acute Epiglottitis
2. Tonsilitis
3. Acute Otitis Media
4. Retropharyngeal Abscess
Lower Respiratory Tract Infection
a) Bronchiolitis
2 - Bronchiolitis Obliterans
b) Viral Croup
c) Pneumonia
d) Pertussis
 Anatomy of Respiratory
Tract
3
 Anatomy of Respiratory Tract
➢Upper respiratory tract :
✓Nasal cavity and
paranasal sinuses,
pharynx and larynx
➢Lower respiratory tract :
✓Trachea, bronchi,
bronchioles and lungs
➢Upper and lower
respiratory tract are
separated by the vocal
4
cord
 Acute Epiglottitis
Epidemiology
Introduction
Pathophysiology
Clinical Feature
5 Investigation
Management
Complication
 EPIDEMIOLOGY
• 99% reduction in incidence-
-> from introduction of HiB
immunization
• Affects all age group BUT
most common in children
1-6 years of age

6
 Introduction
• Acute inflammation of the
epiglottis and surrounding
structures (aryepiglottic
fold and arytenoid soft
tissues)
• Marked edema of
supraglottic structures -->
airways obstruction
• Etiology: Haemophilus
influenza type b, Group
A,B and C Streptococci,
Streptococcus
7
pneumoniae, Klebsiella
pneumoniae,
Staphylococcus aureus
 Pathophysiology
• Infective agents invade the epiglottis --> cause
inflammation
• Bacteria invade directly into loosely attached
submucosa membrane --> bacteremia
• Resulting in oedema of epiglottis and surrounding
tissues--> leading to airway obstruction

8
 Clinical Feature
Symptoms
- high grade fever
- difficult to speak and
swallow
- drooling of saliva
- noisy breathing
- cough (rare)
Signs
- ill looking/ toxic
appearance
9 - tripod position
- stridor (late sign)
 Differential Diagnosis

Infectious Diseases
• Viral laryngotracheobronchitis (Croup)
• Bacterial tracheitis
• Diphtheria
• Tonsilitis
• Pertussis
• Subglottic laryngitis

Non-Infectious Diseases
10 • Allergic reactions
• Foreign body aspiration
• SLE
• Tumours
 Investigation
Laryngoscopy
- requires visualization: cherry red,
intense swelling of epiglottitis and
surrounding
- performed in ICU/OT
- intubate child before obstruction
occurs

Blood investigations
- blood test and blood C & S

11
Lateral X-ray film
- swollen epiglottis (thumbprint sign)
 Investigation

12
 Principle of Management
• Admit to hospital urgently (ICU or anesthetist room)
• Tracheostomy/endotracheal intubation in GA
• Administered high flow humidified oxygen saturation--> achieve
maximal alveoli O2 saturation
• Monitor respiratory and cardiac problem
• Medical treatment
- IV antibiotic (after diagnosis and patent airway) : Ceftriaxone,
Cefotaxime
13 - 2- 5 days
 Complication
• Otitis media
• Meningitis
• Pericarditis
• Pneumonia
• Cervical adenitits
• Septic shock
14
 Prognosis & Prevention

Prognosis Prevention
• Usually resolve after 2-3 days of • Prophylactic rifampicin for close
treatment household contacts
• HiB vaccination in all children

15
 Tonsilitis
Anatomy
Definition
Etiology & Pathogenesis
Clinical Presentation
16
Complication
Investigation
Management
Prognosis & Prevention
 Anatomy
Walderyer’s ring
Lymphoid tissue that surrounds the
opening of the oral and nasal cavities
into the pharynx.
Composed of:
➢Lingual tonsil
➢Palatine tonsil
➢Tubal tonsil
17 ➢Pharyngeal tonsil “adenoid”

Nelson Textbook of Pediatrics, 2-Volume Set

 Definition
• A form of pharyngitis where there is intense inflammation of the
tonsils, often with a purulent exudate.
• Common pathogens: group A β-haemolytic streptococci and
Epstein–Barr virus (infectious mononucleosis).
• Viral origin: Adenoviruses, Enteroviruses, Rhinoviruses
• Other terminologies : Recurrent Tonsilitis
Chronic Tonsilitis
18

Illustrated Textbook of Paediatrics, 6th

edition.
 Etiology & Pathogenesis

Viruses: Bacteria:
1. Respiratory syncytial virus 1. GAS: Streptococcus
2. Influenza A and B pyogenes β - Hemolytic GAS
(most common cause)
3. Epstein-Barr virus
4. Adenovirus 2. Neisseria gonorrhoeae
5. Herpes simplex
19 6. Rhinovirus 3. Fusobacterium necrophorum

Nelson Textbook of Pediatrics, 2-Volume Set

20
 Clinical Presentation
Predominant Symptoms: Signs:
• Fever • Dry tongue
• Sore throat • Erythematous enlarged
• Otalgia (reffered pain) tonsils
• Painful swallowing • Tonsillar or pharyngeal
(odynophagia) - refuse to eat exudate
• Tender cervical LN • Enlargement and
21 tenderness of the
• Constitutional symptoms
jugulodigastric LN
 Others:
• Airway obstruction
• Foul breath

22
23

Zitelli BJ, Davis HW; Atlas pediatric physical diagnosis, ed 4, Philadelphia, 2002
 Complication
• Suppurative Complication • Non-Suppurative Complication
• Peritonsillar abscess/Quinsy • Rheumatic fever
(most common) • Scarlet fever
• Retropharyngeal abscess • Poststreptococcal glomerulonephritis
• Otitis media
• Sinusitis
• Cervical lymphadenitis
24

Walijee, Hussein & Patel, Chirag & Brahmabhatt, Pranter. (2017).

Tonsillitis.
 Investigation
• Throat swab for culture & sensitivity
• Rapid antigen detection test (detection of GAS infection).
• FBC (leukocytosis, neutrophilia in GBHAS)
• ESR, CRP
• Urea & electrolytes
• CT scan with contrast
• Histology (to rule out cancer)
25

Reference: Head & Neck ENT surgery 4th ed

 Differential Diagnosis

Infectious
Epiglottitis Agranulocytosis
mononucleosis

Retropharyngeal
Traumatic ulcer Aphthous ulcer
abscess

26 Malignancy/
Leukemia
 Principle of Management
• Symptom relief: rest, sufficient fluid intake, analgesics, salt-water
gargles
• Antibiotic (Penicillin / Erythromycin - if penicillin allergy) often
prescribed for severe pharyngitis and tonsillitis even though only a
third are caused by bacteria, usually 10 days.
• Amoxicillin is best avoided as it may cause a widespread
maculopapular rash if the tonsillitis is due to infectious
mononucleosis.
• Surgical: tonsillectomy
27

Zitelli BJ, Davis HW; Atlas pediatric physical diagnosis, ed 4, Philadelphia, 2002
 Tonsillectomy
INDICATIONS COMPLICATIONS
1. Sore throats caused by tonsillitis 1. Hemorrhage
2. Five or more episodes of sore 2. Pain
throat per year 3. Post-operative airway
3. Symptoms for at least a year obstruction
4. Episodes of sore throat that are 4. Local trauma to oral tissues
disabling and prevent normal
functioning
5. peritonsilar abscess
28
6. obstructive symptoms
 Epidemiology
• 1.3% of outpatient visits to health care providers in the U.S. and is
diagnosed in 2 million persons in the outpatient setting each year in
the U.S.
• Peak Incidence: Late winter/early spring (GAS infections)
• Predominant Sex: Females = males
• Predominant Age: All ages affected
• common in children age 3 to 7 (exploring phase) *
• Streptococcal pharyngitis most common among school-age children
(5 to 15 years of age). GAS are responsible for 5% to 15% of cases of
29 pharyngitis in adults and 20% to 30% of cases in children (5 to 15
years of age).
 Prognosis

• Usually resolves within 3-4 days without

treatment.
• Because of improvements in medical and
surgical treatments, complications associated
with tonsillitis, including death, are rare.

30
 Prevention

31
 Acute Otitis Media
Anatomy
Definition
Epidemiology
Etiology & Pathogenesis
Clinical Presentation
Investigation
32
Management
Complication
Prognosis & Prevention
 Anatomy

33
 Definition
A suppurative
infection of the
middle ear cavity
due to the
dysfunction of
eustachian tube

34

American Academy Of Pediatrics Subcommitee On Management Of Acute Otitis Media

 Epidemiology
• Peak incidence is between 6 and 15 months of life.
• By 2 years old, 90% of children will have at lest one episode of
symptomatic or asymptomatic otitis media.
• Infants and young children prone to have AOM because their
Eustachian tubes are short, horizontal and function poorly.

35

Nelson Essentials of Paediatrics. 7th Ed, 2015.

 Etiology

Bacterial pathogen
• Streptococcus pneumoniae
• Nontypable Haemophilus influenza
• Moraxella catarrhalis
• Goup A streptococcus (less common)

36

Nelson Essentials of Paediatrics. 7th Ed, 2015.

37
 Clinical Presentation

38

Illustrated Textbook of Paediatrics, 6th ed, 2021

 Clinical Presentation
In infants:
• Most frequent symptoms are non-specific , include fever, irritability
and poor feeding

In older children and adolescents:

• Usually presented with fever and otalgia (acute ear pain)

Other clinical presentation:

39 • Otorrhea (ear drainage) after spontaneous perforation of tympanic
membrane.
• Signs of common cold which predispose to AOM
Nelson Essentials of Paediatrics. 7th Ed, 2015.
 Differential Diagnosis
OM with effusion (OME)
• OME is the presence of effusion
without any of the other signs and
symptoms
• OME may occur either as the sequel of
AOM or eustachian tube dysfunction
secondary to an upper respiratory
tract infection
• It may also predispose to the
development of AOM
40
 Differential Diagnosis

41
 Acute Otitis Media with Bulbous Myringitis

42

Zitelli and Davis' Atlas of Pediatric Physical Diagnosis, 7th edition, 2018
 Images of Acute Otitis Media

43

Zitelli and Davis' Atlas of Pediatric Physical Diagnosis, 7th edition, 2018
 Investigation
1. Tympanometry
Provides objective acoustic
measurements of the tympanic
membrane–middle ear system
by reflection or absorption of
sound energy from the
external ear duct as pressure in
the duct is varied.

44

Nelson Essentials of Paediatrics. 7th Ed, 2015.

 Investigation
2. Pneumatic otoscopy - standard for clinical diagnosis
• Allows evaluation of ventilation of the middle ear.

45
 Principles of Management
• Antibiotics
• 1st line therapy : Amoxicillin (80-90 mg/kg/day in two divided doses)
• If failed at 3 days of amoxicillin, recommended treatment:
• High-dose amoxicillin-clavulanate

• Ceftriaxone ( 50mg/kg IM in daily doses for 3 days) : for children with

vomiting that precludes oral treatment
• Tympanocentesis - for patients who are difficult to treat or who do not
respond to therapy.
• Acetaminophen and ibuprofen are recommended for fever.
46

Nelson Essentials of Paediatrics. 7th Ed, 2015.

 Complication
• Tympanic membrane perforation
• Chronic effusion
• Chronic otorrhea
• Hearing loss
• Cholesteatoma (mass-like keratinized epithelial growth)
• Petrositis
• Intracranial extension (brain abscess, subdural empyema, or venous
thrombosis)
• Mastoiditis
47

Nelson Essentials of Paediatrics. 7th Ed, 2015.

 Complication

48

Zitelli and Davis' Atlas of Pediatric Physical Diagnosis, 7th edition, 2018
 Prognosis & Prevention

Prognosis Prevention
Persistent middle ear effusion may • Conjugate S. pneumoniae
last for many weeks or months in vaccine reduces pneumococcal
some children but usually resolves OM
by 3 months following infection • Annual immunization against
influenza virus may be helpful in
high-risk children.
49
 Retropharyngeal Abscess
Definition & Epidemiology
Etiology & Pathogenesis
Clinical Manifestation
Investigation
Management
50 Complication
Prevention
 Definition
• A soft tissue infection of the throat
that involves retropharyngeal space
• Anatomic Boundaries of
retropharyngeal space:
✓Anterior: Buccopharyngeal fascia
(middle layer of the deep cervical
fascia)
✓Posterior: Alar Fascia (deep layer of the
deep cervical fascia)
✓Superior: Skull base
51 ✓Inferior: Fusion of the two fascia at the
level between the first and second
thoracic vertebrae
Ferri’s Clinical Advisor 2022
 Retropharyngeal Abscess VS Peritonsillar Abscess

52
 Epidemiology
• Occur most commonly in child aged between 2 – 4 years old
• 70% of cases are in patients < 6 years old
• 50% of cases occur in patients < 3 years old
• This represent the peak age group for numerous viral upper
respiratory tract infections and their attendant complications
(Acute otitis media and sinusitis)
• Less common in older children and adults

53

Ferri’s Clinical Advisor 2022

 Etiology & Pathogenesis
• Retropharyngeal space comprises two chains of lymph nodes
that drain the nasopharynx, adenoids, posterior paranasal
sinuses, middle ear, and Eustachian tube
• Suppurative infections in these areas provide seeding for
infection for retropharyngeal abscess
• Prominent bacterial species:
❑Streptococcus pyogenes (GAS)
❑Staphylococcus aureus
❑Respiratory Anaerobes (including Fusobacteria, Prevotella, and
Veillonella sp.)
❑Haemophilus sp.
54
• Young children: Lymphatic spread from septic focus in pharynx
or sinuses to the retropharyngeal space

Ferri’s Clinical Advisor 2022

 Clinical Manifestations
Symptoms Signs
• Fever, insidious onset • Moderately toxic
• Sore throat • Tachypnoea
• Irritability • Neck Stiffness
• Drooling of saliva
• Drooling of saliva
• Muffled voice (dysphonia)
• Midline or unilateral swelling
• Nuchal rigidity (possibly) of posterior pharyngeal wall
• Odynophagia (Fluctuant)
55 • Inspiratory stridor • Inspiratory stridor
• Respiratory distress

Ferri’s Clinical Advisor 2022

 Differentiating Features for Deep Neck Infection
Space Clinical Features ∗
Woody submental induration, protruding
Submandibular space (Ludwig angina) swollen/necrotic tongue, no trismus, rotted lower
molars commonly present
Lateral pharyngeal space (anterior) Fever, toxicity, trismus, neck swelling
No trismus, no swelling (unless ipsilateral parotid is
Lateral pharyngeal space (posterior) involved), cranial nerve IX-XII palsies, Horner
syndrome, carotid artery erosion
Neck stiffness, decreased neck range of motion,
Retropharyngeal space (retropharynx) soft-tissue bulging of posterior pharyngeal wall,
sore throat, dysphagia, dyspnea
Retropharyngeal space (“danger space”) Mediastinal or pleural involvement
56 Neck stiffness, decreased neck range of motion,
Retropharyngeal space (prevertebral) cervical instability, possible spread along length of
vertebral column
Jugular vein septic thrombophlebitis (Lemierre Sore throat, swollen tender neck, dyspnea, chest
syndrome) pain, septic arthritis
Ferri’s Clinical Advisor 2022
 Investigation
Laboratory Tests
Complete Blood Count: WBC (leukocytosis)
Imaging Studies
1. X Ray of the neck
• Delineating the presence of retropharyngeal abscess
• Lateral Neck Film: Widened retropharyngeal space ( >7mm at C2 / >14mm at C6)
2. CT scan of the neck
• To identify abscesses in the retropharyngeal spaces
• Can demonstrate extension of retropharyngeal abscess to contiguous spaces in neck
• Finding: Low density core, soft tissue swelling, obliterated fat planes and mass effect
57 impinging on the posterior pharyngeal wall with complete rim enhancement and
scalloping of the abscess borders.
 Imaging Findings of Retropharyngeal Abscess

58 Lateral radiographs of the neck show normal lateral Computed tomography scan of a
cervical view (A, arrows) and expansion of the retropharyngeal abscess (A and B) demonstrates
prevertebral soft tissues by a retropharyngeal a low-density core, soft tissue swelling,
abscess (B, arrows). obliterated fat planes, mass effect, and rim
enhancement.

Ferri’s Clinical Advisor 2022

 Management
1. Antibiotic (Ampicillin-sulbactam 300mg/kg/day IV divided q6h or
clindamycin 25-40mg/kg/day IV divided q8h) are effective anti-
microbial selection – adjusted as culture data become available.
2. Child is monitored as inpatient for 48 hours.
3. If the child is clinically improved, consider discharge home with a
course of oral antibiotic.
4. If no clinically improvement, repeat CT scan and surgical drainage
or prolonged IV antibiotic therapy maybe warranted.

✓Surgical Intervention historically played a prominent role in the management of

59
retropharyngeal abscess in conjunction with antibiotic therapy.
✓Prompt surgical drainage is indicated when there is a large hypodense area
suggestive of an abscess or when patient are not responded to parenteral alone.
 Complications
• Airway Obstruction
• Septicemia
• Thrombosis of the internal jugular vein
• Carotid Artery Rupture
• Acute Necrotizing Mediastinitis
• If the abscess rupture, the infection can spread to other part
• Jugular Vein Suppurative Thrombophlebitis (Lemnierre
syndrome)
60
 Prognosis & Prevention

Prognosis Prevention
The complication of deep neck • Early diagnosis
infection in any space are • Prompt and appropriate
numerous and potentially fatal. management

61
 Bronchiolitis
Definition & Epidemiology
Etiology & Pathogenesis
Clinical Feature
Investigation
Management
62
Complication
Prognosis & Prevention
 Definition &
Epidemiology
• Disease of small bronchioles with
increased mucus production &
bronchospasm
• Common in aged 1-6 months old.
• Most severe cases occur among
young infants.

63
 Etiology
Common Causative Agent:
• Respiratory Syncytivial virus (RSV) – more than 50% of cases
• Human metapneumovirus
• Parainfluenza viruses
• Influenza viruses
• Adenoviruses
• Rhinoviruses
• Coronaviruses
• Mycoplasma pneumoniae, infrequently
64

Mode of transmission: in contact with infected respiratory secretions. Eg: hand carriage of
contaminated secretions
 Pathogenesis

65
 Clinical feature
- Upper respiratory tract infection
- Diminished appetite
- Fever
- Progress to respiratory distress with
paroxysmal cough, dyspnea and
irritability
- Tachypneic
- Apnea (very young infants)
66
 Physical Examination
• Vital signs: respiratory rate, oxygen saturation, Heart rate
• Nasal flaring
• Suprasternal and intercostal retractions
• Hyperinflation of the chest
• Percussion: Hyperresonance on percussion
• Auscultation: diffuse wheeze and crackles

67
 Investigation
• Chest x-ray
• Evidence of hyperinflation
• Segmental collapse/consolidation
• Lobar collapse/consolidation
• Blood gas analysis
• Viral testing ( PCR or rapid immunofluorescence)

68
Guideline for Hospital Admission in Viral Bronchiolitis

69
 Management

1) Important to assess respiratory status and oxygenation (SpO2 >93%)

- Administer supplemental oxygen to hypoxemic children.
2) Monitor sign of impending respiratory failure
- Unsatisfactory SpO2 (unable to maintain inspired oxygen >40%) or Rising pCO2.
3) Intravenous fluid
- Isotonic solutions (0.9% saline ± glucose) with careful monitoring to avoid
risk of hyponatremia.
4) Feeding
5) Pharmacotherapy
- 3% saline solution via nebulizer
- Inhaled β2-agonists
- Inhaled steroids
70 - Antibiotics
- Chest physiotherapy
 Complications
- Respiratory failure
- Apnea is major concern for very young infants
- Bronchiolitis obliterans

Prognosis Prevention
▪ Most hospitalized children show
marked improvement in 2 to 5 • Monoclonal antibody of
days with supportive treatment RSV (Palivizumab)
alone • IM injection monthly
▪ 1-2% mortality rate among • Reduces the number of
71 infants with pre-existing
cardiopulmonary or hospital admission in high-
immunologic impairment risk infants (mainly preterm)
72
 Bronchiolitis Obliterans
Introduction
Clinical Manifestation
Investigation
Management
73
 Introduction
• Chronic Obstructive Lung disease
• In non transplant patient, BO
commonly occur in paediatric
population after respiratory infections
• Bronchiolitis Obliterans Syndrome
• Related to post transplant patient
(lung and bone marrow)

• Bronchiolitis Obliterans Organizing

Pneumonia
74 • Cryptogenic Organizing Pneumonia
• Extension of inflammatory process
from distal alveolar ducts into alveoli
with proliferation of fibroblast.
 Clinical Manifestations
- Dyspnea and cough (persistent & progressive)
- Sputum production
- Wheezing
- Fever
- cyanosis

Physical Examination
Non-specific : Decrease breath sounds, prolonged expiratory phase, wheezing,
75 crackles

Nelson Textbook of Pediatric

 Investigation
• Biopsy: Open lung biopsy / transbronchial
biopsy
• Chest x-ray: relatively normal but can
demonstrate hyperlucency and patchy
infiltrates.
• Pulmonary function test: sign of airway
obstruction
• Ventilation-perfusion scans: typical moth-
eaten appearance of multiple V/Q mismatch.
• HRCT: mosaic pattern of hyperlucency, air
trapping and bronchiectasis
76
 Treatment
• Immunosuppression are given to post-lung transplantation
• Corticosteroids
• First line therapy for symptomatic and progressive disease in BOOP
• Azithromycin effective in BOS
• Supportive measures:
• Oxygen, Antibiotic for secondary infection, bronchodilators

77
 Viral croup
Definition & Epidemiology
Pathogenesis & Etiology
Clinical Feature
Differential Diagnosis
78
Investigation
Management
Complication
 Definition

79
A clinical syndrome characterized by barking cough,
inspiratory stridor, hoarseness and respiratory
distress of varying severity
 Epidemiology
▪ Most patients with croup are between the ages of 6 months to
3 years old, peak in the second year of life.
▪ Boys > girls
▪ Occurs most commonly in the late fall and winter
▪ Approximately 15% of patients have strong family history of
croup
▪ Recurrent (2 or more croup-like episodes) are frequent from 3
to 6 years of age
80

Nelson Textbook of Pediatrics 21st Edition

 Etiology
• Parainfluenza virus (74%), (Types 1, 2 and 3)
• Respiratory Syncytial Virus (RSV)
• Influenza virus Types A and B
• Adenovirus
• Enterovirus
• Measles
• Mumps
• Rhinoviruses
• Mycoplasma pneumoniae and Corynebacterium Diphtheriae
81 (rare)

Paediatric Protocol 4th edition

 Clinical Feature
Early (12-72 hours)
- Low grade fever
- Coryzal symptoms (runny nose, sore throat)
- Mild cough
Late
- Increasingly bark-like cough
- Inspiratory, harsh stridor (occur when excited, at rest or both)
- Hoarseness of voice
82 - Respiratory distress (varying degree)
 Clinical Feature

83
 Differential diagnosis
• Epiglottitis, bacterial tracheitis, and
parapharyngeal abscess. *
• Non-infectious causes of stridor
• Mechanical and anatomical causes
(foreign body aspiration, laryngomalacia,
subglottic stenosis, haemangioma,
vascular ring, vocal cord paralysis).

84
 Investigation
1. Croup is a clinical diagnosis
2. Visualize the pharynx to exclude acute epiglottitis,
retropharyngeal abscess etc.
3. In severe croup, it is advisable to examine the pharynx under
controlled conditions, i.e., in the ICU or Operation Theatre
4. A neck Radiograph is not necessary. If done, show typical
subglottic narrowing/ steeple sign on posteroanterior view

85
 Assesment of severity
Clinical Assessment of Croup (Wagener);
⮚Severity
❑ Mild: Stridor with excitement or at rest, with no respiratory
distress.
❑ Moderate: Stridor at rest with intercostal, subcostal or sternal
recession.
❑ Severe: Stridor at rest with marked recession, decreased air entry
and altered level of consciousness.
⮚Pulse oximetry is helpful but not essential
86 ⮚Arterial blood gas is not helpful because the blood parameters may
remain normal to the late stage. The process of blood taking may
distress the child
87
 Management
INDICATIONS FOR HOSPITAL ADMISSION:

1. Moderate and severe viral croup

2. Age less than 6 months
3. Poor oral intake
4. Toxic, sick appearance
5. Family lives a long distance from hospital,
lack of transport

88
 Complication
• Viral pneumonia (1-2% of children)
• Parainfluenza virus pneumonia & Secondary bacterial
pneumonia (immunocompromised)
• Bacterial tracheitis

Prognosis
- Prognosis is excellent
- Usually lasts approximately 5 days
89
90
 Pneumonia
Clinical Definition
Epidemiology
Etiology & Classification
Clinical Presentation & Pathophysiology
Investigation
91 Management
Complication
Prevention
 Clinical Definition
• Bronchopneumonia: a febrile illness with cough, respiratory
distress with evidence of localised or generalised patchy infiltration
• Lobar pneumonia: similar to bronchopneumonia except that the
physical finding and radiographs indicate lobar consolidation

92
 Epidemiology
• Leading infectious cause of death globally among children
younger than 5 y/o.

93

Adapted from Nelson Essential Of Paediatrics 8th Edition 2019

 Epidemiology

Pneumonia is one of the top five causes of childhood death in Malaysia,

according to the Department of Statistics.
Adapted from The Star (2021)

Pneumonia claiming the lives of over 800,000 children under five every year, or
around 2,200 every day. This includes over 153,000 newborns.

Globally, there are over 1,400 cases of pneumonia per 100,000 children, or 1
94
case per 71 children every year.

Adapted from WHO Maternal Child Epidemiology Estimation (WHO-MCEE) 2018

 Aetiology
• Viruses, bacteria, and fungi can all cause pneumonia.
• Group B streptococci infections are most often transmitted to
the foetus in utero.
• Most commonly isolated virus is respiratory syncytial virus
(RSV).
• Often difficult to distinguish viral from bacterial disease

95
 Aetiology
• Age group is helpful in predicting aetiological agents.

96

Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition

 Route of Infection
Organism reach the lung by either of these routes:
• Pathogens that are commonly found in a child's nose or throat,
can infect the lungs if they are inhaled.
• Spread via air-borne droplets from a cough or sneeze.
• Spread through blood, especially during and shortly after birth.

97
 Classifications

Anatomy
Aetiology
Pathological agent

98
 Classifications (Anatomy)
Lobar pneumonia
• Affect entire lobe
• Primarily caused by pneumococci
• Characterized by inflammatory intra-alveolar exudate, resulting
in consolidation

99
 Classifications (Anatomy)
Bronchopneumonia
• Mostly common is descending infection that affects the bronchioles and
adjacent alveoli
• Primarily caused by pneumococci and/or other streptococci
• Characterized by acute inflammatory infiltrates that fill the bronchioles
and the adjacent alveoli (patchy distribution)
• Usually involves the lower lobes or right middle lobe and affects ≥ 1 lobe
• Manifests as typical pneumonia

100
 Classifications (Anatomy)
Interstitial pneumonia
• Interstitial inflammation, typically
caused by Mycoplasma and viral
infections
• Characterized by a diffuse patchy
inflammation that mainly involves the
alveolar interstitial cells
• Bilateral multifocal opacities are
classically found on chest X-ray
• Manifests as atypical pneumonia
101 • Often has an indolent course (walking
pneumonia)
 Classifications (Anatomy)

102
 Classifications (Aetiology)
Community acquired pneumonia
• acquired outside of a hospital
• main causes are bacteria, viruses and less commonly fungi
• most cases is not spread from person to person and quite often
is transmitted via droplets in the air, touching contaminated
objects, poor hygiene and sharing cups or utensil or from the
environment.

103
 Classifications (Aetiology)
Nosocomial pneumonia
• nosocomial pneumonia, with onset > 48 hours after admission

Aspiration pneumonia
• commonly caused by inhaling a foreign object, vomit, mucous,
bodily fluids, or certain chemicals

104
 Atypical Pneumonia
• Some pneumonias had different characteristics compared to
“typical” pneumonias, such as
• Slightly different symptoms
• Appeared different on a chest X-ray
• Responded differently to antibiotics
• Bacteria is considered as being “atypical” if they are hard to
detect through standard bacterial methods.
• Chlamydia pneumoniae
• Chlamydia psittaci
105
• Legionella pneumophila
• Mycoplasma pneumoniae
• Even though they are called “atypical,” they are not uncommon.
 Atypical Pneumonia
• Mycoplasma pneumoniae
• under 40
• mild pneumonia symptoms (“walking pneumonia”)
• commonly causes earaches, headaches and a sore throat
• Chlamydia pneumoniae
• common in school-aged children and young adults.
• Chlamydia psittaci
• often infects birds
• infect people and cause psittacosis (less common) → mild pneumonia
• Legionella pneumophila
• most often in older adults, people who smoke and those with weakened immune
106 systems
• Legionnaires’ disease
• breathe in small droplets of water or swallow water containing Legionella into the
lungs
 Clinical Presentation
Symptoms:
• Fever
• Difficulty in breathing
• Cough
• Lethargy
• Poor feeding
• Grunting
• Localised chest, abdominal or neck pain(pleural irritation and
107
suggestive bacteria infection)
 Clinical Presentation
Signs:
• Tachypnoea
• Cyanosis
• Nasal flaring
• Head retraction
• Intercoastal, subcoastal and suprasternal retraction
• Dullness on percussion
• Decrease breath sound
• Presence of bronchial breath sound
108
• End inspiratory respiratory coarse crackles over the affected area
• Decrease vocal fremitus
109
 Assessment of Severity

110

Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition

 Investigations
1. Full blood count
• White blood cell count increase with predominance of
polymorphonuclear cell, suggestive bacteria cause
• Leukopenia suggestive either a viral cause or severe overwhelming
infection

2. Blood culture
• Non-invasive gold standard to determine aetiology
• Do in severe pneumonia or if poor response to first line antibiotics
111
3. Serology test
• Performed in patient with atypical pneumonia
Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition
 Investigations
4. Chest X-ray
• To confirm the diagnosis and the type of pneumonia
• To look for any consolidation, cavitation and effusion

112

Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition

 Differential Diagnosis
• Bronchiolitis
• Asthma
• Pulmonary oedema
• Allergic pneumonitis
• Pulmonary tuberculosis

113
 Principles of Management
Criteria for hospitalization:
• Children aged 3 months and below, whatever the severity of
pneumonia
• Fever (more than 38.5 ⁰C), refusal to feed and vomiting
• Fast breathing with or without cyanosis
• Associated systemic manifestation
• Failure of previous antibiotic therapy
• Recurrent pneumonia
114
• Severe underlying disorder, e.g. Immunodeficiency

Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition

 Principles of Management
Inpatient management
• Antibiotics
• For children with severe pneumonia:

• Second line antibiotic is considered when there is:

115 • No sign of recovery
• Remain toxic and ill with spiking temperature for 48-72 hours
• Macrolide antibiotic is used in pneumonia from Mycoplasma or Chlamydia

Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition

 Principles of Management
• Fluids
• withhold oral intake when child is in severe respiratory distress
• Oxygen
• restless, tachypnoeic, with severe chest indrawing, cyanosis or not tolerating
feeds
• maintain >95%
• Temperature control
• reduce discomfort from symptoms
• Chest physiotherapy
• removal of tracheobronchial secretions
• remove airway obstruction
116 • increase gas exchange and reduce the work of breathing
• Cough medication (not recommended)

Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition

 Principles of Management
Outpatient management
• In mild pneumonia, breathing is fast but there is no chest
indrawing
• Oral antibiotics can be prescribed
• Educate parents/caregivers about management of fever, prevent
dehydration and identify signs of deterioration
• Return in 2 days for reassessment or earlier if the condition is
getting worse
117

Adapted from Paediatric Protocol For Malaysian Hospital 4th Edition

 Complications
• Parapneumonic effusion
• Empyema
• Bronchiectasis
• Recurrent infection
• Lung abscess

118
 Prevention
• Vaccination
• Exclusive breastfeeding for 6 months
• Health education to parents to practice good hygiene
• Avoid overcrowding
• Limit contact with suspected infectious person

119
 Pertussis
Aetiology
Epidemiology
Pathogenesis
Clinical Features
Differential Diagnosis
Investigation
Principle of Management
120
Complication
Prognosis and Prevention
 Etiology
• Classic Pertussis (aka whooping
cough) is caused by Bordetella
pertussis
• Bordetella pertussis:
✓Gram –ve pleomorphic bacillus
✓Aerobic and encapsulated
✓Fastidious growth requirements
✓Infect only humans
✓Transmitted through air droplets
121
 Epidemiology
• Typical Incubation Period: 7-10 days (5-21 days)
• Infective period: First 2 weeks of cough
• Annual rate of pertussis was approximately 100-
200 cases per 100,000 population in pre-
vaccination era
• Incidence peaks among those <6 months old
• Infant that are not completely immunized have
more severe complications
122 • Rate of infection in late childhood and
adolescence have been rising due to combination
of waning immunity from previous vaccines,
under immunization, and improved diagnosis.
 Pathogenesis
1. Bordetella pertussis infection
is transmitted via aerosolized
respiratory droplets, which
are produced during
paroxysms of coughing.
2. Once infected, they cause
local tissue damage of the
ciliated epithelial cells of the
upper respiratory tract
leading to the symptoms of
cough.
3. The virulence factors of
Bordetella pertussis include
adhesins such as filamentous
123 haemagglutinin, fimbriae and
pertactin, which allow B.
pertussis to bind to ciliated
epithelial cells in the upper
respiratory tract.
 Clinical Manifestations
• Classic Pertussis is seen in children between 1-10 years old
• Progression of the disease is divided into:
• Catarrhal stage:
✓Marked by non-specific signs lasting 1-2 weeks
➢Increased nasal secretions
➢Low grade Fever
• Paroxysmal stage:
✓Most distinctive stage of pertussis and lasts 2-4 weeks
✓Coughing occurs in paroxysms during expiration → young children loses their
breath
✓This pattern of coughing is needed to dislodge plugs of necrotic bronchial
124 epithelial tissues and thick mucus
✓The forceful inhalation against a narrowed glottis that follows this paroxysm
of cough produces the characteristic whoop
✓Post tussive emesis is common
 Clinical Manifestation
• Convalescent Stage:
✓Gradual resolution of symptoms over 1-2 weeks
✓Less severe coughing
✓Paroxysms and whoops slowly disappear
• Although the disease typically lasts 6-8 weeks, residual cough may persist
for months, especially with physical stress or respiratory irritants
• The first sign in neonate: Apnoea
• Clinical features in young infants:
➢ unlikely to have classic whoop, more likely to have CNS damage due to
hypoxia
125 ➢Secondary bacterial pneumonia
• Adolescents and adults will present with prolonged bronchitic illness
with persistent, non-productive cough that often begins as a
nonspecific URTI.
Adapted from Nelson Essential Of Paediatrics 8th Edition 2019
 Clinical Manifestation

126
127
 Differential Diagnosis
• The diagnosis of classic pertussis for a young child is based on
the pattern of illness especially during the paroxysmal stage
• Other causes of pertussis-like prolonged cough illness:
✓Bordetella parapertussis - Cause similar but milder illness
✓Bordetella holmesii - Not prevented by vaccination
✓Mycoplasma pneumoniae
✓Chlamydophila pneumoniae
✓Adenoviruses
✓Respiratory Syncytial virus (RSV)
128

Adapted from Nelson Essential Of Paediatrics 8th Edition 2019

 Complication
• Major Complications: • The most frequent complication is pneumonia
caused by B. pertussis itself or from secondary
▪ Hypoxia bacterial infection (Streptococcus pneumoniae,
▪ Apnoea Haemophilus influenza, and Staphylococcus
▪ Pneumonia aureus)
▪ Seizures • Atelectasis
▪ Encephalopathy • Force of paroxysms lead to:
▪ Malnutrition • Pneumomediastinum
▪ Death • pneumothorax
• interstitial or subcutaneous emphysema
• Epistaxis
• Hernias
129
• Retinal and subconjunctival hemorrhages
• Otitis media
• Sinusitis
Adapted from Nelson Essential Of Paediatrics 8th Edition 2019
 Investigation

Laboratory Studies Imaging Studies

1. To isolate B. pertussis or detection of 1. Chest X Ray
its nucleic acid:
• Culture from nasopharyngeal swabs 1. Radiographic signs of
or aspirates segmental lung atelectasis
• Polymerase Chain Reaction (aware of (Paroxysmal stage)
false positive results) 2. Perihillar infiltrates
• Direct Fluorescent antibody staining –
not recommended
• Serology test – useful during
convalescent phase for confirmation
130
2. Full Blood Count: Lymphocytosis (75-
85% in infants and young children) – not
diagnostic!

Adapted from Nelson Essential Of Paediatrics 8th Edition 2019

 Principle of Management
• Recommended: Macrolide antibiotics
➢Azithromycin
➢Clarithromycin
➢Erythromycin
• Azithromycin is preferred in neonates due to the association
between erythromycin and development of pyloric stenosis.
• Treatment during catarrhal phase:
✓Eradicates nasopharyngeal carriage of organisms within 3-4 days
✓Lessen symptom severity
• Treatment in paroxysmal stage does not alter the course of illness
131
but decrease the potential to spread.
• Trimethoprim-sulfametoxazole – alternative therapy among children
older than 2 months.
 Prognosis & Prevention
Prognosis: Prevention
1. Most children recover normal ➢Pertussis vaccination
pulmonary function with complete ➢All household contact should get
healing of the respiratory epithelium prophylactic Azithromycin for 5 days
2. Most permanent disability is due to or Erythromycin for 7-14 days
encephalopathy (duration based on age)
➢Underimmunised close contact < 7
years old should get booster dose of
132 DTaP
 Prevention – Pertussis Vaccine

133
134