X-ray examination of a patient with pneumonia with inflammatory infiltrates visible.
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.[1][2][3]
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,…[2]
Pneumonia cases are most often of infectious origin and are transmitted by respiratorydroplets. They usually begin with an infection of the upper respiratory tract. Then, the infection spreads to the bronchi and alveoli. Hematogenous spread is rare.[1]
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.[4]
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.[4]
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).[4]
Classification of pneumonia
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.
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
Scheme of lobar pneumonia and bronchopneumonia.Nosocomial 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
Early nosocomial pneumonia - develops after 48 hours after admission to hospital, agents: G-: Pseudomonas aeruginosa, Klebsiella pneumoniae., E. coli, Proteus vulgaris .; G+: Staph. aureus; anaerobes
Late nosocomial pneumonia - develops after 4 days, associated with G- bacteria more often.
Ventilator-associated pneumonia
it is a nosocomial pneumonia caused by microaspiration of microorganisms from the oropharynx and stomach in patients connected to a mechanical ventilator
Pneumonia in immunocompromised patients
Immunocompromised patients include patients treated with cytostatics or radiation therapy, and patients after a transplantation, and HIV positive patients.
in addition to classical pathogens resposnible for pneumonia (klebsiella, enterobacteria), opportunistic pathogens (RSV, CMV, herpes zoster virus, pneumocystis jirovecii, mycobacteria) become important pneumonia causative agents.
Pneumonia in social care institutions
Elderly polymorbid patients, who often visit medical facilities, are more likely to experience infections with resistant strains[5][4]
have atypical symptoms (nonspecific "flulike" symptoms - headaches, muscles, joints, also nausea, vomiting)
radiological findings correspond to a disseminated pulmonary process
characterized by intracellular parasitism
interstitial inflammation, at the level of the alveolar wall and the interstitium itself
leukopenia with relative lymphocytosis
According to the mechanism of origin
primary (isolated lung disease)
secondary (complication of other systemic diseases)
Acute pneumonia: mostly a primary disease because it arises in previously healthy 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.[4]
According to the pathological-anatomical picture
Lobar
There is limited inflammatory involvement of the pulmonary alveoli. Gradually, a productive cough with expectoration of purulent sputum (more likely in older children who can cough more readily). Sometimes, there is also pleural pain on top of the rapidly increasing temperature.
Lobular (bronchopneumonia)
There is inflammation of the lung parenchyma, which occurs secondary to an infection of the bronchial tree whereby inflammation spreads to adjacent lung tissue.
Viruses (respiratory syncytial virus, parainfluenza, influenza, adenoviruses, rhinoviruses), less often bacteria (pneumococci, staphylococci, streptococci, Hemophilus influenzae).
Pneumonia in children older than 6 years
Most often Mycoplasma pneumoniae, viruses (parainfluenza, influenza), bacteria (pneumococci, Hemophilus influenzae, streptococci).[4]
Epidemiology
The incidence of pneumonia in EU countries is 1000 children/year. This is 2-3 million cases of childhood community-acquired pneumonia in absolute numbers 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 certain risk factors, this figure rises to 30%.[4]
Risk factors
Factors that increase the likelihood of pneumonia and increase complications and mortality during treatment include:
Personal history: perinatal condition, age, risk factors, vaccination, stay in a facility where they could have been exposed with infected individuals
Epidemiological anamnesis: contact with infection, contact with animals
Travel anamnesis: stays abroad, contact with persons at risk (migrants).[4]
Clinical picture
In the case of typical pneumonia, the following symptoms develop rapidly:
Cough
fever
tachypnea
dyspnea
involvement of auxiliary respiratory muscles
Auscultation findings
initially auscultation of breathing sounds can be negative for any abnormality, but as the pneumonia progresses, one can hear weakened breathing and even bronchial breathing (in the case of consolidation of lung tissue), wheezing, and crepitation.
Other symptoms
abdominal pain (should be distinguished from appendicitis in right-sided pneumonia)
A typical X-ray of pneumonia shows opacities, 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 the pneumonia. In an uncomplicated course, the infiltrate is perihilar and peribronchial. An infiltrate that has spread into the interstitium is a sign of the spread of inflammation into the lung tissue. If alveolar effusion is present, pneumonia is often of viral etiology. Atelectasis develops in severe inflammatory disease, pneumonia due to a foreign body obstruction, or lung tissue compression (e.g., due to pleural effusion).[4]
Imaging methods
posterior (possibly lateral) chest X-ray
when pleural effusion is suspected, US imaging can be used[4]
The X-ray finding may be false negative in some cases, such as:
at the onset of the disease
in significant dehydration
in patients experiencing leukopenia, agranulocytosis, or immune disorders
in infiltration of an area that is not visible in the anterior image (effusion retrocardially or retrodiaphragmatically).[4]
Indications for performing a chest X-ray
pneumonia not responding to standard outpatient treatment
complicated pneumonia
high inflammatory parameters (CRP, procalcitonin, FW, leukocytosis)
The possible causative agents can be narrowed by taking into account the age of the child, the epidemiological situation, and the course of the disease. This is complemented with the use of specific diagnostic methods:
blood culture (before ATB administration)
cultivation of biological material (sputum, upper respiratory tract swab, thoracocentesis)
antigen in urine - Streptococcus pneumoniae, Legionella pneumophila (in patients over 14 years of age)
direct detection in nasopharyngeal secretion - viruses (immunofluorescence, agglutination, PCR)
in severe condition with suspected sepsis: platelets and coagulation examinations.[4]
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 aminoglycosides for example.
sepsis with dissemination of infection to other sites (arthritis, otitis, nephritis, endocarditis, meningitis, peritonitis), possibly leading to septic shock[3]
Comparison table for typical and atypical pneumonia
↑ abcdefghijklmnopqrstHRODEK, Otto a Jan VAVŘINEC. PEDIATRIE. 1. vydání. Praha : Galén, 2002. s. 207. ISBN 80-7262-178-5.
↑ČEŠKA, Richard, et al. Interna. 1. vydání. Praha : Triton, 2010. 855 s. s. 473-474. ISBN 978-80-7387-423-0.
↑KRÁKOROVÁ, G, J FERDA a B KREUZBERG. Atypické pneumonie. Postgraduální medicína [online]. 2001, roč. -, vol. 9, s. -, dostupné také z <http://www.zdn.cz/clanek/postgradualni-medicina/atypicke-pneumonie-140497>. ISSN 1214-7664.
