©2012 mfmer | slide-1 pneumonia: an update [email protected] gmhc, louisville november 2014
TRANSCRIPT
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Objectives
• Describe how to appropriately diagnosis pneumonia in a febrile coughing child; be able to articulate the limitations of various diagnostic modalities
• Implement appropriate evidence-based treatment for children with severe lower respiratory infections of both bacterial and viral etiology
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A Child
A 10 month old child presents with two days of fever and cough.
What is needed to appropriately make a diagnosis?
What treatment is most likely to help?
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Pneumonia
1,200,000 deaths per year
Many cases vaccine-preventable
~30% of children provided antibiotics
World Health Organization, 2012
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Pneumonia
1,200,000 deaths per year >> ACT !
18% of under 5 deaths
~3200 deaths per day
Vaccine-Preventable >> PREVENT !!
Inadequate Care >> Dx & Rx !!!World Health Organization, 2012
www.who.int/mediacentre/factsheets/fs331/en
J Trop Pediatr 60:91-92, 2014©2012 MFMER | slide-7
A 10 month old is febrile and coughing. A 10 month old is febrile and coughing. What equipment is most useful in What equipment is most useful in establishing a diagnosis?establishing a diagnosis?
A. A blood count machine
B. An x-ray machine
C. A stethoscope
D. None of the above
Tachypneaas a means of diagnosing “pneumonia”
2 - 12 months > 50 breaths / minute
12 - 60 months > 40 breaths / minute
IF tachypnea (or severe retractions), give antibiotic.
IF very sick, hospitalize for parenteral therapy.
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What Causes Fever and Tachypnea?
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What Causes Fever and Tachypnea?
Bacterial Pneumonia
Malaria
Viral Respiratory Infection
Fever Plus:
Metabolic Acidosis
- diabetes
- dehydration
Anxiety
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Diagnosis of Pneumonia(Identification of Need for Antibiotics)
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Pediatr Infect Dis J 29:406, 2010
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1622 children < 5 yo with “possible pneumonia”
emergency department, Boston
20% of tachypneic children >> x-ray pneumonia
12% non-tachypneic >> radiographic pneumonia
So, RR is not discriminating,
but RR is somewhat predictivePediatr Infect Dis J 29:406, 2010
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Boston emergency department, 2574 pts < 21yrs
If O2 sat < 92%, 37% - radiographic pneumonia
If also no wheeze, 51% pneumonia
If also focal rales, 70% pneumonia
Tachypnea and retractions NOT linked to dxPediatrics 128:246, 2011
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Boston again, emergency department, 2008 kids
Tachypnea vs Radiographic Pneumonia
Age Sens Spec Pos Pred Value
2-12 mo 25% 76% 11%
1-5 yrs 37% 72% 24%
Pediatr Infect Dis J31:561, 2012
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Diagnosis of Pneumonia(Maybe x-ray is not definitive?)
< 6 mo old, admitted, lower respiratory infection
40 chest x-rays reviewed by pediatric radiologists
Kappa
FINDING Within Between
“consolidation” .91 .79
“normal” .80 .66
“airway disease” .68 .48
Pediatr Infect Dis J 15:600-604, 1996
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Diagnosis of Pneumonia(Identification of Need for Antibiotics)
Maybe x-ray is not definitive?
PLOS One 5:e11989, 2010
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Pneumonia Dx – Better than X-Ray?
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Ultrasound to Diagnose Pneumonia?
New York emergency department, 20 children
H1N1 epidemic, 2009
Intra-Observer Reliability to Differentiate
Bacterial vs Viral vs Both vs Neither
(K = 0.82)
Critical Ultrasound Journal 4:16, 2012
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Ultrasound to Diagnose Pneumonia?
New York emergency department
200 children, 1-8 years of age, 18% “pneumonia”
Ultrasound with x-ray as “gold standard”
86% sensitivity
89% specificity
JAMA Pediatr 167:119, 2013
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Ultrasound vs X-Ray
163 children in Taiwan, 2010-2012
Clinical diagnosis of “pneumonia”
Chest x-ray + in 152 and ultrasound in 159
Ultrasound finding of air bronchograms most helpful
Ultrasound a “complementary tool”
Ho MC et al. Pediatrics and Neonatology 2014©2012 MFMER | slide-26
Causes of Pneumonia
Pediatr Infect Dis J 31:e78, 2012
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Causes of Pneumonia
Viral PCR
RSV, Metapneumovirus, or Parainfluenza positive
Likely Causative
Coronavirus and Enterovirus positive
Cases ~ Controls
Pediatrics 133:e538, 2014
Pediatr Infect Dis J 31:e78, 2012
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Antibiotics for Pneumonia
< 2 months: Hospitalize amp/gent
2+ mo, outpt High HIV area amox x 5 days
Low HIV area amox x 3 days
2+ mo, severe amp or benzylpen PLUS gent ≥ 5 d
2+ mo, 2nd line ceftriaxone (80 mg/kg IM or IV daily) ≥ 5 d
Amox 40 mg/kg/dose orally twice daily
Amp 50 mg/kg/dose IM or IV every 6 h
Benzylpenicillin 50,000 u/kg/dose IM or IV every 6 h
Gent 7.5 mg/kg/dose IM or IV daily
WHO Hospital Care for Children 2013
Lassi ZS Arch Dis Child 2014
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Complicated Pneumonia (Effusion)
Antibiotics (likely 3 weeks, parenteral for at least first week, then cloxacillin orally)
Tap if > 1 cm fluid
Drainage tube if persists
Fibrinolytics if organized
Video-Assisted Thoracoscopic Surgery if needed
Thorax 66:815, 2011
WHO Hospital Care for Children 2013©2012 MFMER | slide-30
Supportive Care for Child With Pneumonia
Oxygen (for sat < 90%, excessive effort)
Fear of Oxygen? Deal with It! Stevenson (Tanzania). Arch Dis Child 2014
Fluids and nutrition (IV vs NG vs oral)
Analgesics (to decrease distress, for T> 39o C)
It matters less what disease the patient has
and more what patient has the disease.
Hippocrates
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Zinc for Pneumonia?
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Zinc for Pneumonia?
meta analysis
7 randomized controlled studies
1066 children < 5 yrs
developing countries
NO DIFFERENCE
in severity or duration of illnessPediatr Resp Rev 13:184, 2012
94 children in Tanzania – NO EFFECTJ Trop Pediatr 60:104-111, 2014
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Why Do Kids Die of Pneumonia?Why Do Kids Die of Pneumonia?
Days of Illness Before Death 7
Hours of Illness Before Home Rx 4
Days of Illness Until Health Care 2
Days from First Treatment to Death 7
(2/3 of Deaths in Hospital)
Problems:
1. Mistreatment with Anti-Malarials
2. Delays in Seeking Care
3. Low-Quality CareUganda Bull World Health Organ 86:332, 2008
Tachypneaas a means of diagnosing “pneumonia”
2 - 12 months > 50 breaths / minute
12 - 60 months > 40 breaths / minute
IF tachypnea (or severe retractions), give antibiotic.
IF very sick, hospitalize for parenteral therapy.
A Common SituationA Common Situation
A previously healthy ten week old presents with:2 days of nasal congestion1 day of cough and noisy breathingperhaps mild fever
The exam shows: interactive child with rapid breathing and retractions
coarse, wheezy breath sounds
RSV Bronchiolitis in Africa?RSV Bronchiolitis in Africa?
Kilifi, Kenya
RSV Bronchiolitis in Kenya?RSV Bronchiolitis in Kenya?
Of 25,149 “under 5s” admitted ’02-’07 in Kilifi
> 7359 (29%) had severe pneumonia
> 15% with RSV (20% of those < 6 months)
O.3% of under 5s hospitalized for RSV per year
Of those admitted, 2% die Nokes DJ. Clinical Infectious Diseases 49:1341, 2009
Bronchiolitis in Thailand?
354 children 1-12 months old, Bangkok
Lower Respiratory Tract Infection
Influenza 7%
RSV 29% especially July – October
J Med Assoc Thai 94:S164, 2011
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WHAT Causes Bronchiolitis?WHAT Causes Bronchiolitis?Respiratory Syncytial Virus (RSV) – esp 2-6 mo
Human Metapneumovirus - identified 2001
similar illness to RSV but severe if co-infected
Human Bocavirus – identified 2005
similar illness to RSV but severe if co-infected
Rhinovirus – typically older than RSV kids
Adenovirus, Coronavirus, Enterovirus
Influenza Virus, Parainfluenza VirusArch Dis Child 93:793, 2008
Arch Dis Child 95:35, 2010
The 10 Week Old Has Bronchiolitis.The 10 Week Old Has Bronchiolitis.
What Treatments Might Help?What Treatments Might Help?
The 10 Week Old Has Bronchiolitis.The 10 Week Old Has Bronchiolitis.
What Treatments Might Help?What Treatments Might Help?
Supportive Care
Fluids – possibly IV if tachypnea, poor feeding
Nutrition
Suction – temporary relief, deeper not helpful
Oxygen– maybe keep O2 saturation > 89%
Chest Physiotherapy – distress >> benefitPediatrics 118:1774, 2006
Treatment of Child With BronchiolitisTreatment of Child With Bronchiolitis
Cough Suppression and/or Decongestants
Not effective
Some risk of toxicity
NOT recommended JAMA 299:887, 2008, Pediatr Nurs 33:515,
2007
Treatment of Child With BronchiolitisTreatment of Child With BronchiolitisAlbuterol/Salbutamol
Several Studies
Transient mild improvement in up to 25%
Improvement not sustained
No change in overall clinical course
Maybe helpful if previous recurrent wheezing Pediatrics 118:1774, 2006; Arch Dis Child 93:793, 2008
Possible therapeutic trial??
Treatment of Child With BronchiolitisTreatment of Child With BronchiolitisEpinephrine/Adrenaline
194 infants hospitalized in Australia
Nebulized epinephrine or saline three times
Observed at admission, pre-dose, 30 & 60 min post-dose
Increased HR after does of epinephrine
No overall change in time to discharge readiness
Longer stay required if epinephrine given to babies requiring oxygen and IV fluids
N Engl J Med 349:27, 2003
Treatment of Child With BronchiolitisTreatment of Child With BronchiolitisGlucocorticoids (Steroids)
600 children 2-12 months old, US
Dexamethasone (1mg/kg) vs placebo on arrival
All improved over 4 hours
No difference in need for admission, course
No difference in condition after 4 hoursNew Engl J Med 357:331, 2007
Consistent with 13 other studiesCochrane Database Syst Rev 3:CD004878, 2004
Treatment of Child with BronchiolitisTreatment of Child with Bronchiolitis
Hypertonic Saline
Nebulized 3% Saline versus 0.9% Saline
Shorter Length of Stay
by 0.94 days (p=0.0006)
Lower Post-Inhalation Clinical Score
for first three days of treatment (p<0.05) Cochrane Database Syst Rev 8;4:CD000458, 2008
Treatment of Child with BronchiolitisTreatment of Child with Bronchiolitis
Hypertonic Saline (with epinephrine)
Nebulized 3% Saline versus 0.9% Saline
Respiratory Distress NOT different
Oxygen Saturations NOT different
Admission Required NOT different
Return to ED NOT different
Arch Pediatr Adolesc Med 163:1007, 2009
Treatment of Child with BronchiolitisTreatment of Child with Bronchiolitis
Hypertonic Saline
Conflicting Evidence
Likely not helpful in emergency department
Perhaps try in inpatient setting
Grewal S et al. JAMA Pediatrics 168:607, 2014
Wu S et al. JAMA Pediatrics 168:657, 2014
Florin TA et al. JAMA Pediatrics 168:664, 2014
Bronchiolitis and Evidence-Based MedicineBronchiolitis and Evidence-Based Medicine
No consistent evidence to support the use of:
anti-viral drugs
bronchodilators
corticosteroids
Use of these agents is NOT recommended
50-80% of hospitalized children receive this Rx
Withholding therapy is much more difficult than giving it.
N Engl J Med 357:403, 2007
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New Bronchiolitis Guidelines
Just Say “No” To:
Chest X-Rays
Antibiotics
Albuterol
Chest Physiotherapy
Ralston SL et al. Pediatrics 2014
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Bronchiolitis: What Should We Remember?Bronchiolitis: What Should We Remember?
Some treatments are helpful
fluids, nutrition, oxygen
Other treatments are not necessary
cough suppressants
steroids
albuterol (unless concurrent reactivity)
anti-viral agents
Prevention can be effective
help families quit smoking
use good hand hygiene
Pause: What is IMCI?Pause: What is IMCI?
A. I have no clue
B. Something for other people to do
C. An active part of my daily practice
Integrated Management of Childhood IllnessIntegrated Management of Childhood IllnessHolistic approach to child health and development
Core:
Acute Respiratory Infection
Diarrhea and Dehydration
Measles
Malaria
Malnutrition
Link to home - Center in primary care – Refer prn
Adapted into > 80 countries; Cost-effectiveBull World Health Organ 77:582, 1999
Indian J Pediatr 69:41, 2002
Lancet 364:1583, 2004
IMCI Works!IMCI Works!
Pay attention to respiratory rate!
- detect pneumonia (need for antibiotics)
- identify severe malaria (need for hospital)
Keep thinking!
- risk under-diagnosis of bronchiolitis
- risk over-diagnosis of pneumoniaIndian J Pediatr 75:781, 2008
Auscultation does have value!Gowraiah V et al. Arch Dis Child 99:899, 2014
Duke T. Arch Dis Child 2014
Pneumonia
1,200,000 kids die each year>> ACT !
It’s partly preventable >> PREVENT !!
immunize
clean air
clean hands
Care is often inadequate >> Dx & Rx !!!
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A Child
A 10 month old child presents with two days of fever and cough.
What is needed to appropriately make a diagnosis? Count respiratory rate! Consider other evaluation.
What treatment is most likely to help? Antibiotic if tachypneic. Anti-malarial if test-positive. Supportive care, especially if likely bronchiolitis.
