Transcript Pediatric Pneumonia - Lock Haven University of Pennsylvania

PEDIATRIC PNEUMONIA
Emily Shultz
July 30, 2009
PRESENTATION: DAY 1
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The patient is a 27 month, African American male
who presented to the office with a history of cough
and fever for two days. He also had nasal congestion,
decreased oral intake and was vomiting phlegm. Mom
denied diarrhea or him pulling at his ears.
His vitals: pulse ox 87%, respirations 30 breaths/min,
pulse 168 beats/min, temperature 101.3°F.
Major findings on exam: yellow nasal discharge, TM’s
gray bilaterally no bulging or erythema, posterior
pharynx without erythema, exudates or tonsillar
hypertrophy. No lymphadenopathy of his neck and
his lungs were clear to auscultation without wheezes,
rhonchi, or rales bilaterally in all lung fields.
PMH
Prematurity- born 25 weeks gestation and spent
16 weeks in the NICU
 Retinopathy of prematurity for which he received
laser therapy
 Patent ductus arteriosus (PDA) for which he
received ductus ligation
 Bronchopulmonary dysplasia (BPD) for which he
was on oxygen for the first year of his life
 Asthma for which he was taking nebulized
solutions of Xopenex and Pulmicort
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PRESENTATION: DAY 1 CON’T
Precepting physician ordered CBC with
differential and chest x-ray and for him to return
in the afternoon.
 Chest x-ray was read as “normal” by the
radiologist and the laboratory technicians
claimed they could not get a sample due to
dehydration.
 Physician sent him home to continue nebulized
solution of Xopenex, Pulmicort, Tylenol and
Singulair. Started on Amoxicillin 250 mg, 1 tsp
BID.
 Return the next day or call if worsens.
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PRESENTATION DAY 2
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Overnight mom had been giving him breathing
treatments q 4-5 h because he was struggling to
breathe.
Spit out the Amoxicillin.
He had only had 2 wet diapers in the past 17 hours
and it had been 2 days since his last bowel movement.
Nothing else about his history had changed overnight.
Vitals: pulse ox 83%, respirations 92, heart rate 202,
temperature 103.8°F.
On exam: nasal flaring, retractions, accessory muscle
use. Decreased breath sounds bilaterally and slight
rales in both upper lobes.
PRESENTATION: DAY 2 CON’T
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Patient sent to the hospital on diagnosis of fever, with
admission orders for oxygen by nasal cannula, IV
fluids, Tylenol, oxygen tent, mist tent, vitals to be
taken every 15 minutes, a repeat CBC, rapid antigen
test, throat culture and sensitivity.
At the hospital his O2 sats were 93 on high flow
oxygen by nasal cannula and his temperature was
104.4°F.
Started on methylprednisolone and cefotaxine (3rd
gen. cephalosporin)
Repeat chest x-ray showed consolidations in both
upper lobes as well as some infiltrate on the right
middle lobe.
Patient was taken by life flight to nearby PICU where
his therapies were continued and he stayed for 4
days.
ETIOLOGY
Age
Birth-3 weeks
 3 weeks-3 months
 3 months-preschool
age (4-5)
 5 years-16 years
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Most common causative
agent
Group B streptococcus
 Streptococcus pneumonia
 Viruses (RSV most
common)
 Mycoplasma pneumonia
and Chlamydia
pneumonia
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SIGNS/SYMPTOMS
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Clinical picture varies with causative agent and age
Cardinal signs cough, fever, tachypnea
Other s/s:
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Cyanosis
Breathing difficulty*
Chest pain
Lethargy*
Poor feeding/loss of appetite*
Vomiting*
Abdominal pain
Nasal flaring*
Retractions*
Reduced oxygen saturation*
Dullness to percussion and tactile fremitus
Rales*, wheezing, bronchial breathing, pleural rub
SIGNS/SYMPTOMS CON’T
Bacterial
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Abrupt onset
Temp > 39 C
Wet, productive cough
Family not ill
Affect any age, esp. infants
Respiratory
distress/toxicity
Unilateral, anatomically
confined dullness,
diminished or tublar
breath sounds heard
CXR- consolidation in lobe,
segment, or subsegment
Viral
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Gradual onset
Temp < 39 C
Nonproductive cough
Family usually ill with
URI
Affect any age
Respiratory distress
Diffuse bilateral
crackles or wheezes
CXR- interstitial
infiltrate in diffuse or
perihilar distribution
STUDIES
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Chest x-ray is gold standard
Can be used to help determine the causative
organism (ie fluffy or patchy infiltrate Chlamydia or
Mycoplasm)
 In some patients with a normal appearing chest xray, but clinical symptoms, the infiltrates can be seen
on a CXR 24-48 hours later
 “Although severe dehydration theoretically could
result in a diminished exudative response by
decreasing blood volume and hydrostatic pressure,
this has not been shown experimentally” (Marx,
2006).
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STUDIES CON’T
Pulse oximetry
 CBC with differential
 Sputum culture and gram stain
 Rapid antigen test
 Mycoplasma IgM (children < 3 y/o not responsive
to amoxicillin)
 Rule out other diagnoses:
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PFT
Urinalysis
Urine culture and sensitivity
Arterial blood gas
Cerebrospinal fluid culture
Blood culture
DIFFERENTIAL DIAGNOSIS
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Acute bronchitis
Bronchiolitis
Asthma
Acute respiratory distress syndrome (ARDS)
Upper respiratory tract infection
Pulmonary embolism
Pulmonary tuberculosis
Sarcoidosis
Psittacosis
Congestive heart failure
Urinary tract infection
Gastroenteritis
Sepsis
GOAL OF TREATMENT
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First determine whether to manage inpatient or
outpatient
“Patients who meet admission criteria include those
who have a poor social situation for whom
appropriate follow-up is difficult, and patients who
have persistent hypoxia, inability to tolerate fluids,
or outpatient antibiotic failure”
 “Infants less than three months of age should be
admitted for intravenous antibiotics due to the high
risk for sepsis and meningitis”
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TREATMENT
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Antibiotics
Viral- supportive therapy if not acutely ill
 Bacterial
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Outpatient empiric therapy- Amoxicillin/ Ampicillin
 Inpatient 3rd generation cephalosporin ceftriaxone,
cefuroxime, or cefotaxime) instead of or in addition to
Amoxicillin/Ampicillin
 Adjust based on other clinical features, cost-effectiveness,
and tolerance.
 If Chlamydia sp. is suspected a macrolide (ie azithromycin
or erythromycin) can be used in an outpatient setting.
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Bronchodilator or steroid can be used in patients
with wheezing or a history of reactive airway
disease.
FOLLOW UP
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He was released on Monday (4 days later) with Omnicef,
methylprednisolone, Singulair, Xopenex and Pulmicort.
He returned to the office on Thursday, one week after his
admission to the PICU.
He was playful and talkative. His oxygen saturation was
100%. His mom said he was not coughing as much. He
was eating, drinking, sleeping, and urinating well.
His lungs sounded clear without wheezes, rhonchi, or
rales.
The doctor told him to finish the Omnicef,
methylprednisolone, take Singulair daily and decrease the
breathing treatments from four a day to two.
REFERENCES:
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Gunn, V., Opal, S.M., Kreindler, J. (2007). Communityacquired pneumonia in children. Retrieved July 12, 2009,
from www.mdconsult.com.
Lichenstein, R., Suggs, A.H., Campbell, J. (2003). Pediatric
Pneumonia. Emerg Med Clin North Am, 21(2): 437-451.
Long, S, Pickering, L.K., Prober, C.G. (Eds.). (2008).
Principles and Practice of Pediatric Infectious Diseases (3rd
ed.). Philadelphia: Churchill Livingston.
Marx, J.A. (Ed.). (2006) Rosen’s Emergency Medicine:
Concepts and Clinical Practice (6th ed.). Philadelphia:
Mosby Elsevier.
Shah, S., Sharieff, G.Q. (2007). Pediatric Respiratory
Infections. Emerg Med Clin North Am, 25(4): 961-979.