PNEUMONIA

Dr M Liyungu Sichimba

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Respiratory System Divisions
 Upper tract
◦ Nose, pharynx
and associated
structures
 Lower tract
◦ Larynx, trachea,
bronchi, lungs

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PNEUMONIA
 Pneumonia is an inflammation of the
parenchyma of the lung
 it is an important cause of morbidity and

mortality in developing countries

 4 million deaths annually in developing

countries
 20 % of all deaths in children are due to LRTI,

90% of these are due to pneumonia

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Classification
 Community acquired pneumonia (Pneumonia
acquired outside hospital settings) or
Hospital acquired Pneumonia
 Pneumonia or Severe pneumonia
 Lobar, broncho or interstitial Pneumonia
 Congenital Pneumonia
 Aspiration Pneumonia

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Risk factors
 Low birth weight babies
 Malnourished children
 Non breastfeeding children
 Children not fully Immunized
 Children living in crowded communities

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ETIOLOGY
 Viruses: influenza A and B, RSV, adenovirus, parainfluenza

 Gram + bacteria: Str.pneumoniae, Str.pyogenes, Staph.aureus

 Gram- bacteria: H.influenzae, Kl.pneumoniae, Ps.aeruginosa,

N. meningitides, E.coli, Proteus, Enterobacter.

 Atypical nonbacterial bacilli: Mycoplasma or Chlamydia

pneumoniae,Legionella (acquired by breathing droplets or
contaminated water)
 HIV infected children may have TB Pneumonia, PCP, CMV
Pathophysiology of Pneumonia
 The development of pneumonia requires that a pathogen reaches the
alveoli and that the host defenses are overwhelmed by microorganism
virulence or by the inoculum size.

 The sources of microorganisms are nasal carriers, sinusitis,

oropharynx, gastric, or tracheal colonization, and hematogenous
spread

 Invading organisms cause symptoms by provoking an immune

response in the lung, specifically the alveoli

 The capillaries become leaky and protein rich fluid seeps into the
alveoli. Gas exchange function of the lungs is impaired
 This lead to hypoxia while retaining Carbon dioxide
 Hypoxia triggers fast breathing hence the respiratory rate increases
 Mucus production is increased

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Immune response in Pneumonia
 Numerous types of inflammatory cells are
activated
 Triggers release of cytokine and mediators to

modify activities of inflammatory cells

 These promotes neutrophil accumulation and

local inflammation
 Causing fever, chills, fatigue
Stages of consolidation
Stage 1
 Congestion stage, the lung is hyperaemic.

Fluid moves from the intravascular spaces to

the lung tissue, Alveoli
Stage 2
 Red hepatisation
 The Lung appears red and firm like the liver.

Massive exudate of RBCs, Neutrophils and

fibrin. Occurs in the first 2 or 3 days
 Bronchial breath sounds
Stages of consolidation ….
Stage 3
 Grey Hepatisation
 Hypereamia subsides but lung remains hard

due to progressive disintegration of the RBCs

and persistent fibrin
 Suppurative exudate giving the lung the

greyish appearance
Stages of consolidation…..
Stage 4
 Resolution stage
 Consolidation exudates within the lung

undergoes progressive digestion

 Most debris is ingested by macrophages
 If complete resolution takes place, the lung

returns to normal state with normal gas

exchange
Complications of Pneumonia
 Septicemia
 Acute respiratory distress
 Respiratory failure
 Multi organ failure
 Death
SYMPTOMS OF PNEUMONIA
 Cough
 Difficulties or fast breathing
Raised respiratory rate
- 60 per minute or more if child less than 2mths
- 50 per minute or more if child 2 month to 12 months
- 40 per minute or more if child 12 months up to 5 yrs
- 30 per minute or more if child above 5 yrs
 Fever >37.5 degrees Celsius
 Child may not be able to drink or feed
 Child may have Diarrhea or Vomiting

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SIGNS OF PNEUMONIA
 Infants
◦ Cyanosis
◦ Increased respiratory rate
◦ Nasal flaring
◦ Subcostal recession
◦ Crepitations, Rhonchi, bronchial breath sounds
◦ Intermittent apnea
◦ Grunting

• Older children
◦ Cyanosis
◦ Increased respiratory rate
◦ Nasal flaring
◦ Subcostal recession
◦ Crepitations, Rhonchi, bronchial breath sounds
◦ Restlessness of agitation
◦ Signs of dehydration

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Investigations
 Full blood count
 CXR
 U, Creatinine and electrolytes
 Blood culture
 Arterial blood gases

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Management of pneumonia
 General measures
1. Oxygen by nasal cannula or mask. If oxygen
saturation is less than 92%
2. IV fluids of required. Give two thirds of
requirements .
3. Anti pyretics and analgesics
4. Close monitoring of vital signs

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Management cont…
Antibiotic therapy
0 -3mths.
Benzyl Pen. 50,000iu /kg/dose QID
and Gentamycin 7.5mg od

Above 3 mths.
Benzyl Pen. 50,000iu /kg/dose QID
Gentamycin 2.5 to 5mg/kg BD

 Ceftriaxone 50 mg /kg /dose OD or Cefotaxime 50mg

/kg/dose QID should be considered if no improvement in 48hrs

 Community acquired Pneumonia that needs no admission.

Amoxycillin oral 3 to 5 days can be given/

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Management cont…..
 In infants with HIV infection or exposure PCP
therapy with high dose IV or PO
Cotrimoxazole, 20mg /kg/day of
trimethoprim should be included

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ACUTE VIRAL BRONCHIOLITIS

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 Acute Viral Bronchiolitis
 Viral bronchiolitis is the commonest lower
respiratory tract infection in children less than
12 months of age and is the most frequent
cause of hospitalization in infants under
6 months of age.

 It is caused by viral infections of the lower

respiratory tract, principally by Respiratory
Syncytial Virus (RSV).
 It is seasonal, characterized by fever, nasal

discharge, dry, wheezy cough

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Diagnosis

 Diagnosis is clinical
 Affects infants with worsening respiratory

symptoms after 2 or 3 days of coryzal

symptoms
 Tachypnea with subcostal and intercostal

recession
 Fine crepitations and rhonchi are present
 Infants are rarely toxic
 High temperature is not common

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 Pathophysiology:
 Histopathology descriptions from infant autopsy
specimens document infection of the bronchiolar
epithelium, with subsequent epithelial cell necrosis.

 In addition, there is peri bronchiolar mononuclear

infiltration and submucosal edema.

 As a result of these changes, plugs of mucus laden with

cellular debris are formed, leading to areas of partial or
complete airway obstruction.

 Hyperinflation occurs following trapping of air peripheral

to the sites of partial occlusion. Subsequently, with
complete obstruction, multiple areas of atelectasis
develop.

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Treatment
 No specific therapy, TX is largely supportive
 Give Oxygen via nasal cannula
 Tube feeding if child is unable to feed
 IV fluids if child is dehydrated
 Antibiotics are of no benefit.
 Bronchodilators may produce short term

relief via spacer of inhaler

 Use of systemic steroid has no benefit

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References
 General Peadiatrics protocols adopted from
ADH, First edition
 Coovadias Peadiatrics and child health, 7th

edition
 Revised WHO guideline on management of

Pneumonia. 2014

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