Pneumonia (pediatrics)

Pneumonia is the acute or chronic inflammation of the lung parenchyma due to infectious, allergic, physical, or chemical noxious agents. It usually represents an acute inflammation at the level of the respiratory bronchioles, alveolar spaces, and interstitium. Pneumonia is the third leading cause of death worldwide. The causative agent is usually recognized in up to 50% of cases.

Pneumonias occur particularly often in the first year of life, after which their incidence decreases. In the Czech Republic, 80,000 to 150,000 pneumonia cases with a lethality of 10–20% are reported every year. The rise in cases is due to increasing age of the population and related polymorbidities, new agents (SARS), population migration, AIDS, drug addiction, air conditioning,…

Pneumonia cases are most often of infectious origin and are transmitted by respiratory droplets. They usually begin with an infection of the upper respiratory tract. Then, the infection spreads to the bronchi and alveoli. Hematogenous spread is rare.

Pneumonia is a febrile illness whose most common manifestation is cough. Other signs (which may not manifest at first) are tachypnea, respiratory insufficiency, and crackling sounds during lung auscultation. Infiltrates in lung tissue are a typical finding on a skiagram.

There are no specific symptoms that would allow pneumonia to be diagnosed. The probability of diagnosis is increased by the presence of the above symptoms. We must take into account that younger children in particular are more likely to have non-specific symptoms such as lethargy, vomiting, and reluctance to eat or exercise.

Pathophysiology
The pathophysiological basis is inflammatory infiltration of lung tissue and alveolar exudation. Risk factors for pneumonia are hypoventilation due to pulmonary causes (chronic respiratory insufficiency, foreign body aspiration, bronchiectasis, stenoses, ciliary epithelial dysfunction, interstitial pulmonary fibrosis, cystic fibrosis), hypoventilation due to extrapulmonary diseases (postoperative conditions, conditions with impaired consciousness, neuromuscular diseases), and immune disorders (congenital immunodeficiency in children).

According to the course

 * Acute
 * Chronic - inflammation lasting more than 3 months
 * Recurrent - recurrent inflammation in the same location;
 * Migrating - pulmonary infiltrates migrate, appearing at different times in different parts of the lungs.

According to etiology

 * Infectious: bacterial, atypical (viral, etc...), fungal, parasitic
 * Non-infectious (so-called "pneumonitis"): aspiration, inhalation, post-radiation, post-drug administration, hypersensitivity (allergic)

By location of acquisition and epidemiology

 * Community pneumonia
 * This is the most common type of pneumonia, up to 90%, obtained in a normal environment outside a hospital facility
 * Occurs outside the hospital or was diagnosed within 48 hours of admission (the child was hospitalized during the incubation period). The child had not been hospitalized or stayed in a medical facility in the previous two weeks.
 * They are usually treated on an outpatient basis and usually bacterial causative agents are sensitive to common ATB.
 * originators: G +: Str. pneumoniae, Str. pyogenes, Staph. aureus; G-: H. influenzae, Klebsiella pneumoniae


 * Lobar Pneumonia and bronchopneumonia illustrated.jpgNosocomial pneumonia
 * Infection occurs aerogenically (contamination of the respiratory airways), hematogenously (translocation of microbes in the blood), or via microaspiration of oropharyngeal secretions that contain the original airway flora, colonizing microbes from the environment, or GIT flora.
 * Therapy must be initiated empirically (each workplace knows at least approximately its epidemiological situation), then adjusted based on cultivation


 * 1) Early nosocomial pneumonia - develops after 48 hours after admission to hospital, agents: G-: Pseudomonas aeruginosa, Klebsiella pn., E. coli, Proteus vulg .; G+: Staph. aureus; anaerobes
 * 2) Late nosocomial pneumonia - develops after 4 days, more G-causes appear
 * 3) Ventilator-associated pneumonia
 * it is nosocomial pneumonia caused by microaspiration of microorganisms from the oropharynx and stomach in patients connected to the ventilator


 * Pneumonia in immunocompromised patients
 * patients treated with cytostatics, radiation, after transplantation, HIV positive
 * in addition to classic pathogens (klebsiel, enterobacteria), opportunistic pathogens (RS virus, CMV, herpes zoster, pneumocystis, mycobacteria) also appear
 * Pneumonia in social care institutions
 * Elderly polymorbid patients, who often visit medical facilities, are more likely to have resistant strains

According to the clinical and X-ray image

 * typical (bacterial)
 * have classic symptoms of pneumonia (fever, cough and shortness of breath)
 * are caused by bacterial pathogens
 * lobe, lobular pneumonia or bronchopneumonia, with exudate formation in the alveoli
 * there is usually leukocytosis in the blood count


 * atypical
 * have atypical symptoms (general "flu" symptoms - headaches, muscles, joints, also nausea, vomiting)
 * radiological findings corresponding to the disseminated pulmonary process
 * characterized by intracellular parasitism
 * interstitial inflammation, at the level of the alveolar wall and the interstitium itself
 * in the blood picture leukopenia with relative lymphocytosis

According to the mechanism of origin

 * primary (isolated lung disease)
 * secondary (complications of other systemic diseases)

Acute pneumonia: mostly a primary disease because it arises from full health in the lung tissue that was previously normally ventilated. Secondary pneumonia: occurs in children with altered health status or in children predisposed to the development of a respiratory infection.

According to the pathological-anatomical picture

 * 1) Lobar
 * 2) *Limited inflammatory involvement of the pulmonary alveoli. Gradually, a productive cough with expectoration of purulent sputum (in older children, able to cough up), sometimes also pleural pain, is added to the rapid rise in temperature.
 * 3) Lobular (bronchopneumonia)
 * 4) *Inflammation of the lung parenchyma, which occurred secondary to infection of the bronchial tree by spreading the inflammation to the adjacent lung tissue.
 * 5) Interstitial

According to the X-ray finding

 * Allar - the entire pulmonary wing is affected;
 * lobar - one lobe is affected;
 * segmental - segment impairment;
 * bronchopneumonia - the infiltrate does not respect the anatomical arrangement of the lungs (boundaries of lobes and segments).

According to severity

 * 1) Lightweight.
 * 2) *Only cough is present, without tachypnoea or dyspnoea, with colds or pharyngitis.
 * 3) Moderate.
 * 4) *Cough and tachypnoea without dyspnoea.
 * 5) Heavy.
 * 6) *Cough, tachypnoea and dyspnoea with involvement of auxiliary respiratory muscles. Inability to drink in infants.

According to age
This division takes into account the frequent use of certain pathogens depending on the age of the child.


 * 1) Neonatal pneumonia;
 * 2) * Gram-negative bacteria (Escherichia coli, Klebsiella pneumoniae), group B streptococci.
 * 3) Infant pneumonia (2-11 weeks of age);
 * 4) * Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, cytomegalovirus, Pneumocystis carinii.
 * 5) Pneumonia in children aged 3 months to 5 years;
 * 6) * viruses (respiratory syncytial virus, parainfluenza, influenza, adenoviruses, rhinoviruses), less often bacteria (pneumococci, staphylococci, streptococci, Hemophilus influenzae).
 * 7) Pneumonia in children older than 6 years;
 * 8) * most often Mycoplasma pneumoniae, viruses (parainfluenza, influenza), bacteria (pneumococci, Hemophilus influenzae, streptococci).

Epidemiology
The incidence of pneumonia in EU countries is 1000 children / year, in absolute numbers 2-3 million cases of childhood community-acquired pneumonia per year. Pneumonia is the most common fatal infectious disease in children in developed countries. In uncomplicated pneumonia without other risk factors, mortality is less than 0.5%, in the presence of risk factors up to 30%.

Risk factors
Factors that increase the likelihood of pneumonia and increase complications and mortality during treatment include:


 * Low age;
 * prematurity;
 * comorbidities (other lung diseases, heart disease, kidney or liver diseases, malignancies);
 * severe general condition;
 * extrapulmonary manifestations coexisting with pneumonia;
 * severe X-ray findings (multilobar infiltrates, bilateral infiltrates, cavitation, pleural effusion);
 * hyposaturation;
 * severe leukopenia or leukocytosis;
 * signs of renal failure;
 * non-compliance family.

Anamnesis

 * OA: perinatal course, age, risk factors, vaccination, stay in a collective facility;
 * epidemiological anamnesis: contact with infection, contact with animals;
 * travel anamnesis: stay abroad, contact with persons at risk (migrants).

Clinical picture
In the case of typically ongoing pneumonia, the following symptoms develop rapidly


 * Cough;
 * fever;
 * tachypnoea;
 * dyspnoea;
 * involvement of auxiliary respiratory muscles.

Listening finding


 * initially it can be negative, in developed pneumonia weakened breathing, tubular breathing (in case of condensation of lung tissue), wheezing, crepitation.

Other symptoms


 * abdominal pain (distinguished from appendicitis in right-sided pneumonia);
 * cough vomiting;
 * meningeal irritation in high fever;
 * signs of pleural irritation, chest pain.

Indications for hospitalization
The key indications for hospitalization are hypoxia (SaO2 <92%) and cyanosis. Other indications include:


 * The inability of the family to provide appropriate care for the child;
 * age under two months;
 * respiratory rate> 70 breaths per minute, dyspnoea, intermittent apnea, wheezing, rest stridor, exhaustion with labored breathing;
 * eating disorder, signs of malnutrition;
 * impaired consciousness;
 * non-compliance of the child's family;
 * outpatient treatment failure.

Indications for the transfer of a child to a pediatric intensive care unit (ICU)


 * The ability to keep the patient's SaO2 above 92% fails;
 * rival;
 * if resting respiratory and pulse rates increase with clinical signs of respiratory failure;
 * recurrent apnea or slow, irregular breathing.

Radiological diagnostics
A typical X-ray of pneumonia is shadowing, which is due to the presence of infiltrate in the lung parenchyma. According to the extent of the infiltrate, we can infer the severity of pneumonia. In an uncomplicated course, the infiltrate is perihilar and peribronchial. An infiltrate mixed with interstitial drawing is a sign of the spread of inflammation into the lung tissue. If alveolar effusion is present, pneumonia is often of viral etiology. Atelectasis (lung airtightness) develops in severe inflammatory disease, pneumonia due to foreign body obstruction, or lung tissue oppression (such as pleural effusion).

Imaging methods


 * posterior (possibly lateral) chest X-ray;
 * when pleural effusion USG is suspected to clear fluid.

The X-ray finding may be false negative in these cases


 * the onset of the disease;
 * significant dehydration;
 * leukopenia, agranulocytosis, immune disorders;
 * infiltration of an area that is not visible in the anterior image (effusion retrocardially or retrodiaphragmatically).

Indications for performing a chest X-ray


 * pneumonia not responding to standard outpatient treatment;
 * complicated pneumonia;
 * high inflammatory parameters (CRP, procalcitonin, FW, leukocytosis);
 * suspected aspiration;
 * suspected complications;
 * febrile unclear cause;
 * tachypnoea;
 * suspected TB.

Diagnosis of etiological agent
The choice of possible agents is narrowing taking into account the age of the child, the epidemiological situation and the course of the disease:


 * blood culture (before ATB administration);
 * cultivation of biological material (sputum, upper respiratory tract, pleural puncture);
 * antigen in urine - Streptococcus pneumoniae, Legionella pneumophilla (in patients over 14 years of age);
 * direct detection in nasopharyngeal secretion - viruses (immunofluorescence, agglutination, PCR);
 * serology.

Auxiliary examinations

 * Oxygen saturation of hemoglobin;
 * FW, CRP, blood count;
 * blood gases (PaO2, PaCO2);
 * iontograms, urea, aminotransferases;
 * in severe condition with suspected sepsis and platelets and hemocoagulation examination.

Therapy

 * penicillin, tetracycline and macrolide antibiotics (for typical pneumonias at least 10 days, for atypical 14 days to 3 weeks; intravenously 2 to 5 days); in nosocomial infections cephalosporins III., IV. generation (cefotaxime, ceftazidime, cefepime), higher generation penicillin antibiotics (ticarcillin, piperacillin / tazobactam, etc.), fluoroquinolones, carbapenems (imipenem, meropenem) or in combination with eg aminoglycosides.
 * symptomatic treatment:
 * expectorants, mucolytics, antitussives for irritating dry cough
 * antipyretics
 * analgesics for pleural pain
 * oxygen therapy for respiratory insufficiency
 * nebulization therapy
 * regime measures:
 * sufficient supply of fluids, calories, vitamins
 * respiratory rehabilitation
 * Functional lung examination is indicated 6 weeks after the pneumonia has subsided

Complication

 * respiratory insufficiency, pleural effusion, empyema, pulmonary abscess, pulmonary gangrene, atelectasis and subsequent bronchiectasis
 * sepsis with dissemination of infection to other sites (arthritis, otitis, nephritis, endocarditis, meningitis, peritonitis) to septic shock

Related articles

 * Pneumonia • Pneumonia in infants • Pneumonia in older children
 * Bacterial pneumonia • Atypical pneumonia • Abscessive pneumonia • Aspiration pneumonia
 * RDG examination in lower respiratory tract inflammation • Clinical evaluation of the severity of pneumonia