LOWER RESPIRATORY

TRACT INFECTIONS
(LRTI)

Dr. Goytiom Y
LRTI
 Includes
 Bronchitis*
 Bronchiolitis*
 Pneumonia*
UNDER FIVE MORTALITY IN ETHIOPIA….2010

Nearly 60% of deaths were

having underlying malnutrition
 PNEUMONIA
Introduction
 Viruses are the commonest causes of pneumonia

 Major causes of viral pneumonia include RSV, adenovirus,

Influenza and Parainfluenza viruses
 Bacterial pneumonia is the leading cause of mortality

 Classified as community or nosocomial pneumonia

Definition
 Pathological: An inflammation of lung parenchyma

 IMNCI: A child having cough and fast breathing

IMNCI CLASSIFICATION
CONT…
 Pneumonia
 Classification
 Based on etiologic agent
 Infectious (Viral, Bacterial, Mycobacterium, Fungal, Parasitic)
 None infectious (FBS)
 Based on area affected
 Lobar Interstitial pneumonia
 Broncho Necrotizing pneumonia
 Place accusation
 Community acquired
 Hospital acquired
 Severity
No pneumonia
 Simple pneumonia
 Sever pneumonia
 duration of symptom
 Typical
 atypical
 PNEUMONIA
PATHOGENESIS
 Transmitted via aerosol droplets form a carrier

 Droplets are aspirated or inhaled in to the lungs

 Bacteria proliferate in the alveoli and bronchioles

 Macrophages ingest and produce cytokines

 Neutrophils migrate to the site of inflammation

Pathologic findings of pneumonia

1. Congestion---edematous lung due to inflammation

2. Red hepatization--- liver like lung due to RBCs

3. Gray hepatization--- RBC hemolysis

4. Resolution---- Normalization of lung parenchyma

 CONT…
Bacterial etiologies of pneumonia
Neonates
 Group B streptococcus, Gram negative rods

Infants
 S.aureus, Pneumococcus, C. trachomatis

One to five years

 Pneumococcus, S.pyogens, S.aureus

Above five years

 M. pneumoniae, C. pneumoniae, S. pneumoniae

Hospital acquired pneumona (Nosocomial)

 Gram negative rods , S.aureus, fungal

Aspiration pneumonia
 Oral anaerobes, mixed bacteria

Immunodeficiency (malnutrition, HIV etc)

 S.aureus, PCP, Gram negative rods, CMV, fungal
 CONT…
Risk factors
 Over crowding, Under vaccination

 Common cold, Smoking, Poverty

 Immunodeficiency (malnutrition, HIV)

 Congenital heart diseases

 Chronic lung diseases (asthma, BPD)

 Air way congenital malformations (TEF)

 Neuromuscular disorders (paralysis, coma etc.)

 Aspiration of secretions (seizure, coma, anesthesia,

foreign body etc)
 CONT…

Clinically
 Fever , runny nose, cough and irritability may precede
respiratory distress
 High grade fever, dry cough, fast breathing and nasal flaring are
frequent signs in infants
 Sub costal and intercostal retraction, grunting and cyanosis
develop as the disease get worse
 Older children could complain chest pain and difficulty of
breathing
 Neonates could have apnea or septis like illness
 CONT…

Physical examination
 Fast breathing, nasal flaring and grunting

 Subcostal, substernal and intercostal retractions

 Lethargy and cyanosis are late signs of hypoxia

 Dullness to percussion of the affected chest

 Bronchial breath sounds or decreased air entry on the site of

consolidation
 Coarse crepitations on auscultation of the chest

 Abdominal distention due to aerophagia

 CONT…
The World Health Organization (WHO) to define
fast breathing (tachypnea)
 Below 2 months: 60 breaths/min and above
 2 to 12 months: 50 breaths/min and above

 1 to 5 years: 40 breaths/min and above

 ≥5 years: 20 breaths/min and above

Severe pneumonia (indication for admission)

 Moderate to severe retractions

 Nasal flaring, Apnea, hypoxia

 Grunting, Cyanosis

 Lethargy or coma, Dehydration

 Failure to suck or take oral fluids

 CONT…
Diagnosis
 Cough and fast breathing is pneumonia (IMNCI)

 Pulse oxymetry (<90%)--- hypoxia

 CBC with differential

 ESR, PCR, Blood and sputum culture

 Chest X-ray
 Pneumonia based on site of lung involvement

 1. Lobar 3. Interstitial
 2. Bronchopneumonia 4. Necrotizing
 CONT…
Complications
Local complications
 Para pneumonic effusion

 Empyema(precence of pus in a bodily cavity)

 Lung abscess

 Pneumothorax(air or gas presence in the pleural cavity)

 Distant complications:

 Meningitis,

 septic arthritis

 osteomyelitis etc…
 MANAGEMENT OF PNEUMONIA
OPD: Oral penicillin or cephalosporin addition of macrolides or
tetracycline for atypical pneumonia

Inpatient management
 Oxygen and antipyretics

 Maintenance fluids (10% d/w plus 1/3rd N/S)

 Begin crystalline Penicillin parenterally

 3rd generation cephalosporin drugs are 2nd choices

 Macrolides added for atypical pneumonia

 Aspiration pneumonia need anaerobic coverage

 PCP should be addressed in immunosupressed

 CONT…

Prevention
 Vaccination

(PCV, Hib, Influenza, pertussis, measles)

 Breast feeding

 Avoid over crowding

 Adequate nutrition

 Avoid indoor smoking and cigarette exposure

 Vitamin A supplementation
NORMAL CHEST X-RAY
LEFT LOWER LOBE CONSOLIDATION

Lobar pneumonia---Pneumococcus
Bronchopneumonia--- staphylococcus
 CONT…

Right lower lobe pneumonia due to pneumococcus. Nelson text

book of pediatrics 18th ed.
 CONT…

Pneumonia complication. Right sided pleural effusion in

AP and right decubitus position. There is layering of
pleural fluid on the right side chest X-ray. Up to date 2010.
CONT…

Right sided empyema

due to complication
of pneumococcal
pneumonia. Nelson
text book of
pediatrics 18th ed.
 CONT…

Complication of pneumonia in a child. There is lung abscess

with air fluid level in the left panel and necrotizing
pneumonia on the right x-ray. Up to date 2010.
PNEUMONIA--- LEFT LOWER LOBE
CONSOLIDATION
Bilateral linear streaking due to viral interstitial pneumonia. 6 month
old infant having RSV bronchiolitis. Nelson text 19th ed.
Reticulonoduar
lesion on
perihilar area
due to atypical
pneumonia
Cavitary
pneumonia
involving the left
lower lobe due to
fungal , TB or
staph infection of
the lung. Look ring
like lesion with
central darker
area.
RIGHT LOBAR CONSOLIDATION---PNEUMONIA
BRONCHOPNEUMONIA---S. AUREUS
PNEUMONIA PREVENTION
ACUTE BRONCHITIS

 Isan infection which is not found as an isolate infection in

children but in adults
 Etiologies are

 Main causes are viruses

 S. pneumone

 H. influenza

 Staphylococcus
 C/F
 Cough which is dry, frequent and gradual onset
 Anterior chest pain
 Rhonchi and rales on auscultation

 Rx.
 Supportive ( sometimes we may use cough suppressants)
BRONCHIOLITIS

 Isan inflammation of bronchioles

 Commonly seen during the 1 st 2 years of age

 Etiologies
 RSV is responsible for >50 % of cases
 Influenza
 Adenoviruses
 Epidemiology
 Commonly seen in :
male and none breast fed infants


 Infants of smokers

 Pathophysiology
 The edema and mucus secretion results in bronchial
obstruction
 Hyper inflated lung – because of air trapping
 Athelectasis if there is complete obstruction, w/h results in
ventilation perfusion mismatch
 C/F
 History of URTI or contact with older children with URTI
 Fever, Wheezing, Feeding difficulty and all signs of
respiratory distress can be there
 Stay 1-3 days
 Dx.
 clinical
 Hyper inflation on chest x- ray

 Rx.
 Supportive
 No need to give antibiotics