cari protocol
TRANSCRIPT
PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA
Dr. TRIASTA, MAMC, 2012
A child with cough or difficult breathing
ASSESS
Ask: How old is the child? Is the child coughing? For how long? Ages 2mos. – 5y.o: Is the child able to
drink? Age less than 2mos: Has the young
infant stopped feeding well? Does the child has fever? Has the child had convulsions?
LOOK, LISTEN
Count the breaths in one minute
Look for chest indrawing
Look and listen for stridor
Look and listen for wheeze
Is it recurrent
See if the child is abnormally sleepy or difficult to wake
Feel for fever or low body temperature
Look for severe malnutrtion
FAST BREATHING
Young infant age less than 2 months:
60 breaths per minute or more
Child age 2 months up to 12months:
50 breaths per minute or more
Child age 1 to 5 years:
40 breaths per minute or more
A child has INDRAWING if:
The lower chest wall goes in when the child breathes in
CHEST INDRAWING is a sign of severe pneumonia in children aged 2 months up to 5 years
Only SEVERE CHEST INDRAWING is a sign of severe pneumonia in young infants
CLASSIFY THE ILLNESS2 months up to 5 years
SIGNS: Not able to
drink Convulsions Abnormally
sleepy or difficult to wake
Stridor in calm child
Severe
malnutrition
Classify VERY SEVERE
DISEASE
Treatment: Refer Urgently
to hospital Give first dose
of antibiotics Treat fever if
present Treat
wheezing, if present
Age less than 2months
SIGNS: Stopped feeding
well Convulsions Abnormally sleepy Stridor in calm
child Wheezing Fever or low body
temperature
CLASSIFY: VERY SEVERE
DISEASE
TREATMENT Refer URGENTY
to hospital Keep infant warm Give first dose of
an antibiotic
< 2 months old
No Pneumonia
Severe Pneumonia
Very Pneumonia
RR < 60 bpm
No chest indrawing
RR > 60 bpm
Severe chest indrawing
Central cyanosis
Poor feeding
wheezing
Stridor, sleepy
Home care
Admit
Pen G + Genta
Pen G + Genta
2 months - 5 yearsNo pneumonia
Pneumonia
Severe Pneumonia
RR< 50 bpm <40 1-5y.o No chest
indrawing
RR >40 bpm No chest
indrawing
Chest indrawing No central
cyanosis
Able to drink
cough > 30days ASSESS
homecare
Homecare Cotri PO, Amox,
Ampi or Pen
Admit Pen IM/IV
2 months - 5 years
Very severe Pneumonia
Central cyanosis Inability to feed/drink Stridor Convulsions Sleepy
Admit Chloram IM/IV Worse Chloram--
Cloxa+ Genta (Staph pneumonia)
Most common pathogens: Streptococcus pneumoniae Chlamydia pneumoniae Mycoplasma pneumoniae
Major causes of hospitalizations: Streptococcus pneumoniae Haemophilus influenzae Staphycoccus aureus
Neonates: Group B, E.coli,Strep pneumonia, H.influenzae
< 3 Respiratory syncytial virus, Strep pneumonial,
Influenzae virus
Introduction
Pneumonia - is defined as the inflammation of lung tissue caused by an infectious agent that results in Acute respiratory signs and symptoms
It can be either Acquired (Community Acquired) or within the hospital (Hospital acquired)
It is ranked to be the 3rd in ten leading cause of morbidity
Etiologic causes of Pneumonia
AGE GROUP ETIOLOGY
1. Neonates Group B StrepcoccusE. ColiL. Monocytogenes
2. Infants younger than 3 mos. Group B StrepcoccusChlamydia Trachomatis
3. Older infants, pre schoolers, younger than 5 years old
Strep.pneumoniaeH.Influenzae
4.Older than 5 years old
5. 5-10 years old
S.PneumoniaeMycoplasma PneumoniaeC. PneumoniaeM. Pneumonaie
SIGNS AND SYMPTOMS
COUGH FEVER
SIGNS AND SYMPTOMS
DIFFICULTY OF BREATHING CHEST PAIN
SIGNS AND SYMPTOMS
VOMITING ABDOMINAL PAIN
Who shall be considered as having Community Acquired Pneumonia? Predictors of Community Acquired
Pneumonia in patient with cough
1. For ages 3 months-5 years are tachypnea and or chest indrawing
2. For ages 5-12 years are fever, tachypnea, and crackles
3. Beyond 12 years old are the presence of the following features:
A. Fever, tachypnea and tachycardia B. At least one abnormal chest findings of diminished
breath sounds, rhonchi, crackles and wheezes
2. Who will require admission?
1. A patient who is at moderate risk to develop pneumonia-related mortality should be admitted.
2. A patient who is at minimal to low risk can be managed on out patient basis
Risk Classification for Pneumonia Based MortalityVARIABLE PCAP A
Min riskPCAP BLow risk
PCAP CMod risk
PCAP DHigh risk
1. Co-morbid illness
None Present Present Present
2.Compliant caregiver
Yes Yes No No
3.Ability to follow up
Possible Possible Not possible Not possible
4. Presence of dehydration
None Mild Moderate Severe
5.Abilty to feed Able Able Unable Unable
6. Age >11 mo. >11 mo. <11 mo. <11 mo.
7. RR2-12 mo.1-5 yrs>5 yrs
>50/min>40/min>30/min
>50/min>40/min>30/min
>60/min>50/min>35/min
>70/min>50/min> 35/min
Risk Classification for Pneumonia Based Mortality
8. Signs of resp. Failurea. Retractionb. Head bobbingc. Cyanosisd.Gruntinge. Apnea
f. Sensorium
NoneNoneNone
NoneNoneNoneAwake
NoneNoneNone
NoneNoneNoneAwake
Intercostal/SPresentPresent
PresentNoneNoneIrritable
Supra/Inter/Subcostal retsPresentPresent
PresentPresentPresentLethargic/StuPurous/comatose
9. Complications None None Present Present
ACTION PLAN OPD follow up at the end of the treatment
OPD follow up after 3 days
Admit to regular ward
Admit to crtitical care unitRefer to specialist
3.What diagnostic aids are initially requested for a patient classified as either PCAP A or B being managed in the ambulatory setting?
No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in the ambulatory setting
4. What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D being managed in a hospital setting?
1. The following should be routinely requested: A. Chest Xray PA-lateral B. White blood cell count C. Culture and sensitivity of Blood for PCAP D Pleural fluid Tracheal aspirate upon initial intubation Blood gas and Pulse oximetry 2. The following maybe requested: Culture and sensitivity of sputum for older children 3. The following should not be routinely requested: A. Erythrocyte sedimentation rate C reactive protein
5 When is antibiotic recommended? An antibiotic is recommended 1. For a patient classified as either PCAP A or B and is A. Beyond 2 years of age B. Having high grade fever without wheeze 2. For a patient classified as PCAP C and is A. Beyond 2 years of age B. Having high grade fever without any wheeze C, Having alveolar consolidation in the Chest Xray D. Having a WBC of >15000 3 . For a patient classified as PCAP D
6.What empiric treatment should be administered if a bacterial etiology is strongly considered? 1. For a patient classified as PCAP A or B without
previous antibiotic, oral Amoxicillin (40-50 mg/kg/day in 3 divided doses) is the drug of choice.
2. For a patient classified as PCAP C without previous antibiotic and who has completed the primary immunization against Haemophilus influenzae type B, Penicillin G(100, 000 units/kg/day in 4 divided doses) is the drug of choice
If a primary immunization against Hib has not been completed, IV Ampicillin (100 mg/kg/day in 4 divided doses) should be given.
3. For a patient classified as PCAP D, a specialist should be consulted
7.What treatment should initially be given if a Viral etiology is strongly considered?
1. Ancillary treatment should be given 2. Olsetamivir (2mg/kg/dose BID for 5
days) or Amantadine (4-8 mg/kg/day for 3-5 days) may be given for Influenza that is either confirmed by laboratory or occuring as an outbreak
When can be a patient be considered as responding to the current antibiotic?
1. Decrease in respiratory signs (particularly tachypnea) and deferverescene within 72 hours after initiation of antibiotic are predictors of a favorable therapeutic response
2. Persistence of symptoms beyond 72 hours after initiation of antibiotic requires reevaluation
3. End of treatment Chest Xrat,WBC,ESR,CRP should not be done to asses therapeutic response to antibiotic
9.What should be done if a patient is not responding to a current antibiotic therapy 1. If an outpatient classified as either PCAP A or
PCAP B is not responding to the current antibiotic within 72 hours, consider any of the following
a. Change the initial antibiotic b. Start on an oral macrolide c. Reevaluate diagnosis 2. If an inpatient classified as PCAP C is not
responding to the current antibiotic within 72 hours, consider consultation with a specialist because of trhe following possibilities:
a. Penicillin resistant Strepcoccous pneumoniae
What should be done if a patient is not responding to a current antibiotic therapy
Continuation: b. Presence of complications
(pulmonary or extrapulmonary) c. Other diagnosis
3. If an inpatient classified as PCAP D is not responding to the current antibiotic within 72 hours, consider immediate re-consultation with a specialist
10. When can switch therapy in bacterial pneumonia could be started?
Switch from intravenous antibiotic administration to oral form 2-3 days after initiation of antibiotics is recommended in a patient who
A. Is responding to the initial antibiotic therapy
B. Is able to feed with intact gastrointestinal absorption
C. Does not have any pulmonary or extrapulmonary complications
11. What ancillary treatment can be given? 1. Among inpatients, oxygen and
hydration should be given if needed 2. Cough preparations, chest
physiotherapy, bronchial hygiene, nebulization using normal saline solution, steam inhalation, topical solution, bronchodilators and herbal medicines are not routinely given in Community acquired pneumonia.
3. In the presence of wheezing, a bronchodilatory maybe administered.
12. How can Pneumonia be prevented? 1. Vaccines recommended by the Philippine
Pediatric Society should be routine administered to prevent Pneumonia
2. Zinc supplementation (10 mg for infants and 20 mg for children)beyond 2 years of age given for a total of 4-6 months maybe administered to prevent Pneumonia
3. Vitamin A, immunomodulators and Vitamin C should not be routinely administered as preventive strategy.