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Clinical Manifestations of
Pneumonia
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VIRAL PNEUMONIA
preceded by several days of symptoms of an upper
respiratory tract infection, typically rhinitis and cough
Low Grade Fever: usually present; temperatures are
generally lower than in bacterial pneumonia.
Tachypnea: most consistent clinical manifestation of
pneumonia
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VIRAL PNEUMONIA
Increased work of breathing: accompanied by intercostal,
subcostal, and suprasternal retractions, nasal flaring, and use
of accessory muscles
Cyanosis and respiratory fatigue: for severe infection
especially in infants
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VIRAL PNEUMONIA
Crackles and wheezing: often difficult to localize the source
of these adventitious sounds in very young children with
hyperresonant chests
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BACTERIAL PNEUMONIA
Sudden onset of chills in adults or older children
followed by a high fever, cough, and chest pain
In older children and adolescents: brief URTI
followed by the abrupt chills and high fever
accompanied by:
drowsiness with intermittent periods of
restlessness
rapid respirations
dry, hacking, unproductive cough
anxiety
occasionally, delirium
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BACTERIAL PNEUMONIA
Circumoral cyanosis may be
observed
Splinting: noted on the affected side
to minimize pleuritic pain and
improve ventilation. They may lie on
their side with their knees drawn up
to their chest.
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PNEUMOCOCCAL PNEUMONIA IN
INFANTS
Prodrome of URTI and decreased appetite
Sudden onset of fever
Restlessness, apprehension
Respiratory distress
GI manifestations: Vomiting, anorexia, diarrhea and
abdominal distention
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PHYSICAL EXAMINATION
Depends on the stage of pneumonia
Early stage:
diminished breath sounds
scattered crackles
rhonchi
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PHYSICAL EXAMINATION
Dullness on percussion and decreased breath sounds due
to consolidation or complications of pneumonia such as
effusion, empyema, or pyopneumothorax
Lag in respiratory excursion: occurs on the affected side
Abdominal distention: due to gastric dilation from
swallowed air or ileus
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PHYSICAL EXAMINATION
Abdominal pain: common in lower lobe pneumonia
Enlarged liver: due to downward displacement of the
diaphragm secondary to hyperinflation of the lungs or
superimposed congestive heart failure
Nuchal rigidity: especially with involvement of the right
upper lobe or if with meningitis or hematogenous spread of
disease
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PCAP CLASSIFICATION
CLASSIFICATIO
N PROVIDED
BY
Philippine Academy
of Pediatric
Pulmonologists
Philippine Health
Insurance Corp
World Health
Organization
pCAP A or B
---
Nonsevere
pCAP C
Pneumonia I
Severe
pCAP D
Pneumonia II
Very severe
Variable
CLINICAL
1. Dehydration None Mild Moderate Severe
2. Malnutrition None Moderate Severe
3. Pallor None Present Present
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PCAP CLASSIFICATION
4. Respiratory Rate
3-12months
1-5 years
>5years
50/min to
60/min
40/min to
50/min
30/min to
40/min
>60/min to
70
>50/min
>35/min
>70/min
>50/min
>35/min
5. Signs of
respiratory failure
a. Retraction
b. Head
bobbing
c. Cyanosis
d. Grunting
e. Apnea
f. Sensorium
None
None
None
None
None
None
IC/Subcostal
Present
Present
None
None
Irritable
Supraclaviclular/
SC
Present
Present
Present
Present
Lethargic/Stupor
ous/ Comatose
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PCAP CLASSIFICATION
DIAGNOSTIC AID
AT SITE-OF-CARE
pCAP A or B
---
Nonsevere
pCAP C
Pneumonia
I
Severe
pCAP D
Pneumonia II
Very severe
1. Chest xray
findings of any of
the following:
effusion; abscess;
air leak; lobar
consolidation
None Present Present
2. Oxygen
saturation at room
air using pulse
oximetry
95% <95% <95%
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ATYPICAL PNEUMONIA
MANIFESTATIONS
Cough and copious purulent sputum production
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ATYPICAL PNEUMONIA
PHYSICAL EXAM
Crackles localized in the affected area
Wheezing and digital clubbing
In severe cases: dyspnea and hypoxemia
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DIAGNOSTIC TESTS
*Recommendations from PAPP*
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DIAGNOSTIC TESTS
for pCAP A or B
Chest Radiograph
May be requested to rule out
pneumonia-related complications
or pulmonary conditions
simulating pneumonia
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DIAGNOSTIC TESTS
for pCAP A or B
Chest Radiograph
Should not be routinely requested
to predict end-of-treatment clinical
outcome
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To determine appropriateness of
antibiotic usage (but not routinely
requested):
DIAGNOSTIC TESTS
for pCAP A or B
Chest Xray
Complete
blood count
C-reactive
protein
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To determine appropriateness of
antibiotic usage (but not routinely
requested):
DIAGNOSTIC TESTS
for pCAP A or B
Erythrocyte
sedimentation
rate
Procalcitonin
Blood culture
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SHOULD BE DONE
To determine the etiology: Gram
stain and/or culture and sensitivity
of pleural fluid when available
DIAGNOSTIC TESTS
for pCAP C or D
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SHOULD BE DONE
To assess gas exchange: Oxygen
saturation using pulse oximetry,
Arterial blood gas
DIAGNOSTIC TESTS
for pCAP C or D
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MAY BE DONE
Chest x-ray PA-lateral: to confirm
clinical suspicion of multilobar
consolidation, lung abscess,
pleural effusion, pneumothorax or
pneumomediastinum
DIAGNOSTIC TESTS
for pCAP C or D
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MAY BE DONE
To determine appropriateness of
antibiotic usage: C-reactive
protein, Procalcitonin, Chest x-ray
PA-lateral, White Blood Cell count,
Gram stain of sputum or
nasopharyngeal aspirate
DIAGNOSTIC TESTS
for pCAP C or D
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MAY BE DONE
To determine etiology: Sputum
culture and sensitivity, Blood
culture and sensitivity
DIAGNOSTIC TESTS
for pCAP C or D
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MAY BE DONE
To predict clinical outcome: Chest
x-ray PA-lateral, Pulse oximetry
DIAGNOSTIC TESTS
for pCAP C or D
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MAY BE DONE
To determine the presence of
tuberculosis if clinically suspected:
Mantoux test (PPD 5-TU), Sputum
smear for aid fast bacilli
DIAGNOSTIC TESTS
for pCAP C or D
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MAY BE DONE
To determine metabolic
derangement: Serum electrolytes,
Serum glucose
DIAGNOSTIC TESTS
for pCAP C or D
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MANAGEMENT OF
PNEUMONIA
*Recommendations from PAPP*
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WHEN IS ANTIBIOTIC
RECOMMENDED?
For pCAP A or B,
>2 y/o
with high grade fever without wheeze
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WHEN IS ANTIBIOTIC
RECOMMENDED?
For pCAP C,
alveolar consolidation on chest x-ray
with any of the following:
Elevated serum CRP, PCT or WBC
High grade fever without wheeze
> 2 y/o
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WHEN IS ANTIBIOTIC
RECOMMENDED?
For pCAP D,
a specialist should be consulted.
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
For pCAP A or B without previous
antibiotic,
DOC: AMOXICILLIN
[40-50 mg/kg/day, maximum dose of 1500
mg/day in 3 divided doses for at most 7 days]
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
Alternative Drugs for pCAP A or B
without previous antibiotic,
AZITHROMYCIN
[10 mg/kg/day OD for 3 days or 10mg/kg/day at
day 1 then 5 mg/kg/day for days 2 to 5,
maximum dose of 500 mg/day]
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
Alternative Drugs for pCAP A or B
without previous antibiotic,
CLARITHROMYCIN
[15 mg/kg/day, maximum dose of 1000 mg/day
in 2 divided doses for 7 days]
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
For pCAP C, without previous
antibiotic,
Completely immunized against Hib
DOC: PENICILLIN G [100,000
units/kg/day in 4 divided doses]
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
For pCAP C, without previous
antibiotic,
Incomplete/unknown immunization status
DOC: AMPICILLIN [100 mg/kg/day in
4 divided doses]
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
For pCAP C, without previous
antibiotic (>15 y/o),
parenteral non-antipseudomonal -
lactam + extended macrolide
parenteral non-antipseudomonal -
lactam + respiratory fluoroquinolones
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
For pCAP C, without previous antibiotic,
and who can tolerate oral feeding and does
not require oxygen support,
AMOXICILLIN
[40-50 mg/kg/day, maximum dose of 1500 mg/day
in 3 divided doses for at most 7 days]
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
For a patient classified as pCAP C who
is severely malnourished or
suspected to have MRSA, or classified
as pCAP D,
referral to a specialist
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WHAT EMPIRIC TREATMENT SHOULD
BE ADMINISTERED IF A BACTERIAL
ETIOLOGY IS STRONGLY CONSIDERED?
For a patient who has been
established to have Mycobacterium
tuberculosis infection or disease,
antituberculous drugs
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WHAT TREATMENT SHOULD BE
INITIALLY GIVEN IF A VIRAL ETIOLOGY
IS STRONGLY CONSIDERED?
DOC: OSELTAMIVIR
30 mg BID for 15 kg body weight,
45 mg BID for >15-23 kg,
60 mg BID for >23-40 kg, and
75 mg BID for >40 kg
for laboratory confirmed, or clinically
suspected cases of influenza
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WHAT TREATMENT SHOULD BE
INITIALLY GIVEN IF A VIRAL ETIOLOGY
IS STRONGLY CONSIDERED?
The use of immunomodulators for
the treatment of viral pneumonia is
NOT recommended
Ancillary treatment
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WHEN CAN A PATIENT BE CONSIDERED
AS RESPONDING TO THE CURRENT
ANTIBIOTIC?
Decrease in respiratory signs and/or
defervescense within 72 hours after
initiation of antibiotic are predictors of
favorable response.
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WHEN CAN A PATIENT BE CONSIDERED
AS RESPONDING TO THE CURRENT
ANTIBIOTIC?
If clinically responding, further
diagnostic aids to assess response
such as CXR, CRP AND CBC should
not be routinely requested.
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WHAT SHOULD BE DONE IF A PATIENT
IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
If an outpatient classified as either
pCAP A or pCAP B, consider any of
the following:
Other diagnosis.
Coexisting illness.
Conditions simulating pneumonia.
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WHAT SHOULD BE DONE IF A PATIENT
IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
If an outpatient classified as either pCAP A
or pCAP B, consider any of the following:
May add an oral macrolide if atypical
organism is highly considered.
May change to another antibiotic if microbial
resistance is highly considered.
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WHAT SHOULD BE DONE IF A PATIENT
IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
If an outpatient classified as pCAP C,
consider any of the following:
Other diagnosis.
Coexisting illness.
Conditions simulating pneumonia.
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WHAT SHOULD BE DONE IF A PATIENT
IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
If an outpatient classified as pCAP C,
consider any of the following:
May add an oral macrolide if atypical
organism is highly considered.
May change to another antibiotic if microbial
resistance is highly considered.
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WHAT SHOULD BE DONE IF A PATIENT
IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
If an outpatient classified as either
pCAP C, consider any of the following:
May refer to a specialist.
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WHAT SHOULD BE DONE IF A PATIENT
IS NOT RESPONDING TO CURRENT
ANTIBIOTIC THERAPY?
If an inpatient classified as pCAP D,
immediate consultation with a specialist
should be done.
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WHEN CAN SWITCH THERAPY IN
BACTERIAL PNEUMONIA BE STARTED?
For pCAP C,
recommended in a patient who should
fulfill all of the following:
Responsive to current antibiotic therapy
Tolerance to feeding and without vomiting
or diarrhea
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WHEN CAN SWITCH THERAPY IN
BACTERIAL PNEUMONIA BE STARTED?
For pCAP C,
recommended in a patient who should
fulfill all of the following:
Without any current pulmonary
(effusion/empyema; abscess; air leak, lobar
consolidation, necrotizing pneumonia) or
extrapulmonary complications; and
Without oxygen support
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WHEN CAN SWITCH THERAPY IN
BACTERIAL PNEUMONIA BE STARTED?
For pCAP C,
switch therapy from three [3] days of
parenteral ampicillin to:
Amoxicillin [40-50 mg/kg/day for 4 days]
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WHEN CAN SWITCH THERAPY IN
BACTERIAL PNEUMONIA BE STARTED?
For pCAP D,
referral to a specialist should be considered
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WHAT ANCILLARY
TREATMENT CAN BE GIVEN?
For pCAP A or B,
cough preparation, elemental zinc, vitamin
A, vitamin D, probiotic and chest
physiotherapy should not be routinely
given during the course of illness
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WHAT ANCILLARY
TREATMENT CAN BE GIVEN?
For pCAP A or B,
a bronchodilator may be administered in
the presence of wheezing
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WHAT ANCILLARY
TREATMENT CAN BE GIVEN?
For pCAP C,
oxygen and hydration should be
administered whenever applicable.
Oxygen delivery through nasal catheter
is as effective as using nasal prong
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WHAT ANCILLARY
TREATMENT CAN BE GIVEN?
For pCAP C,
a bronchodilator may be administered
only in the presence of wheezing.
Steroid may be added to a
bronchodilator
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WHAT ANCILLARY
TREATMENT CAN BE GIVEN?
For pCAP C,
a probiotic may be administered
cough preparation, elemental zinc, vitamin
A, vitamin D and chest physiotherapy
should not be routinely given during the
course of illness.
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WHAT ANCILLARY
TREATMENT CAN BE GIVEN?
For pCAP D, referral to a specialist
should be considered
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HOW CAN PNEUMONIA BE PREVENTED?
The following should be given to
prevent pneumonia:
Vaccine against
Streptococcus pneumonia (conjugate
type) Influenza
Diphtheria, Pertussis, Rubella, Varicella,
Haemophilus Influenzae type b
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HOW CAN PNEUMONIA BE PREVENTED?
The following should be given to
prevent pneumonia:
Elemental zinc for ages 2 to 59 months to
be given for 4 to 6 months
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HOW CAN PNEUMONIA BE PREVENTED?
The following may be given to
prevent pneumonia:
Vitamin D3 supplementation
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HOW CAN PNEUMONIA BE PREVENTED?
The following should not be given to
prevent pneumonia:
Vitamin A
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THANK YOU!

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