Pneumonia is defined as the inflammation of lung tissue caused by an infectious agent that results in acute respiratory signs and symptoms. It can either be acquired outside (community-acquired) or within the hospital (hospital-acquired) ? Who shall be considered as having community-acquired Pneumonia? ? For ages 3 months to 5 years are tachypnea and/or chest indrawing For ages 5 to 12 years are fever, tachypnea, and crackles ? Who shall be considered as having community-acquired Pneumonia? Beyond 12 years of ages are the presence of the following features: y Fever, tachypnea, and tachycardia y At least one abnormal chest findings of diminished breathing sounds, ronchi, crackles or wheezes ? Tachypnea is still the best predictor of pneumonia Who will require admission? ? A patient who is at moderate to high risk to develop pneumonia-related mortality should be admitted A patient who is minimal to low risk can be managed on an outpatient basis ? Risk Classification of Pneumonia
Variables PCAP A Minimal risk None Yes Possible None Able >11 mos PCAP B Low risk Present Yes Possible Mild Able >11 mos PCAP C Moderate risk Present No Not possible Moderate Unable 50/min >40/min >30/min >60/min >50/min >35/min >70/min >50/min >35/min Risk Classification of Pneumonia Variables PCAP A Minimal risk PCAP B Low risk PCAP C Moderate risk PCAP D High risk Signs of respiratory failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f.
Sensorium None None None None None Awake None None None None None Awake Intercostal/Subcostal Present Present None None Irritable Supraclavicular/Interco stal/Subcostal Present Present Present Present Lethargic/Stuporous/ Comatose Complication (effusion, pneumothorax) Action Plan None None Present Present OPD follow up at end of treatment OPD follow up after 3 days Admit to regular ward Admit to ICU Refer to specialist ? The presence of retraction on admission was the best single predictor of death ? Inability to cry, head nodding and a respiratory rate of >60/min were the best predictors of hypoxemia
Diagnostic Tools Chest X-Ray PA-lateral ? White cell count ? Acute Phase Reactants ? y ESR and CRP have not been demonstrated to differentiate viral from bacterial infection Diagnostic Tools ? Microbiology y Blood C/S y Plueral fluid C/S y Tracheal aspiration C/S y Sputum C/S ? Oxygen saturation and/or Blood Gas y To help the clinician in deciding the appropriate intervention What diagnostic aids are requested for a patient classified as PCAP A or PCAP B? ? No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting
What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D? ? The following should be routinely requested: y Chest x-ray PA-lateral y White blood cell count y Culture and sensitivity of Blood for PCAP D Pleural fluid Tracheal aspirate upon initial intubation Blood gas and/or pulse oximetry What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D? ? The following may be requested: y Culture and sensitivity of sputum for older children ? The following should not be routinely requested: Erythrocyte sedimentation rate y C-reactive protein When is antibiotic recommended? ? For a patient classified as either PCAP A or B and is: y Beyond 2 years of age y Having high grade fever without wheeze ? For a patient classified as PCAP C and is: y Beyond 2 years of age y Having high grade fever without wheeze y Having alveolar consolidation in the CXR y Having WBC > 15,000 ? For a patient classified as PCAP D Etiology ? First 2 years: viruses As age increases bacterial pathogens become more prevalent ? ? PCAP managed as an outpatient: Bacterial pathogen is more common y Streptococcus pneumoniae is the pathogen in more than half (Others: M. pneumoniae, C. pneumoniae) ? PCAP managed as an inpatient: y Bacterial pathogen is more common y Streptococcus pneumoniae is the pathogen in little more than half (Others: H. influenzae b, M. pneumoniae, C. pneumoniae) ? Haemophilus influenzae type b should be given in patient below 5 years of age who has not completed the primary series of Hib immunization Bacterial vs Viral Features Fever Wheeze Bacterial T>38. 5°C Absent Viral T