Pneumonia and

Bronchiolitis
Pneumonia
 Pneumonia: an inflammation of the lung
parenchyma and is associated with
consolidation of alveolar spaces.
The term Lower Respiratory Tract
Infection (LRTI) may include
pneumonia, bronchiolitis and/or
Bronchitis..
Inflammation of parenchyma leads to alveoli filled with exudate,
inflammatory cells and fibrin
Bronchopneumonia vs Lobar
pneumonia
 Pulmonary host defense
Location Host defense mechanism
Upper airways
Nasopharynx Nasal hair, mucocilliary apparatus,
IgA secretion
oropharynx Saliva, sloughing of epithelial, local
complement, normal flora
Conducting airways
Trachea, bronchi Cough, epiglottic reflexes,
mucocilliary apparatus, IgG, IgM, IgA

Lower respiratory tract

Terminal airways, alveoli Surfactant, Immunoglobulin,
complement, cytokines, alveolar
macrophages, leukocytes.
 Pathophysiology

LRT inoculated by
Nasopharyngeal
microaspiration,
colonization by
bacteremia,viremi
microorganism
a
Organism express
specific virulence
factor- enhance
propagation and
survival
Pulmonary host
defenses
determine whether Cause damage to
infection is lung
established and
illness occurs
 Risk factors

Congenital or
Malnutrition
acquired Intubation and
and metabolic
immunodeficie tracheostomy
derangement
ncy
CNS
Viral infection
depression
predispose
( inhibit cough
bacterial
and gag
infection
reflex)
 Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
Newborn E.Coli
Group B Streptococci
Staph. Aureus
Klebsiella
Pseudomonas

1-3 months Chlamydia trachomatis

Respiratory Syncytial virus
Other respiratory viruses

3-12 months Respiratory Syncytial virus

Staph Aureus
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae
Age Group Common Pathogens (in Order of
Frequency)
2-5 years Respiratory Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae

5-18 years Mycoplasma pneumoniae

Streptococcus pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Influenza viruses A and B
Adenoviruses
Other respiratory viruses
Clinical features (History)
Newborn

rarely cough
Commonly with poor feeding, irritability, tachypnea,
retractions, grunting and hypoxemia

Infants

Cough (persistent) most common

Antecedent upper respiratory symptoms
Congestion, fever, irritability, wheezing (noisy breathing) and
decreased feeding

Toddlers and preschoolers

Fever, cough , tachypnea, congestion, posttussive emesis

Antecedent upper respiratory tract illness

Older children and adolescents

Fever, cough (productive or nonproductive), congestion, chest

pain,dehydration and lethargy

Constitutional symptoms

Headache, pleuritic chest pain, abdominal pain, V, D,

pharyngitis and otalgia/otitis (younger children, adolescents)
Clinical features (Physical)
Inspection
Degree of respiratory effort and accessory muscle
use, RR, during feeding
Grunting, flaring and retractions
Central cyanosis implies a deoxyhemoglobin
concentration of approximately 5 g/dL or more may
due to severe derangement of gas exchange
Chest pain observed with inflammation of or near
the pleura
Abdominal pain or tenderness seen in children with
lower lobe pneumonia
High temp + pleural effusion
Percussion
Identify an area of consolidation (dullness)

Auscultation
Presence of crackles or rales
Asymmetry of breath sounds in infants, such as
focal wheezing or decreased breath sounds in one
lung field
Lobar pneumonia (pleural space) and pericardial
effusion (H influenzae) causing friction rub
Recognition of Signs of Pneumonia
Tachypnea is the most sensitive and specific sign of
pneumonia

Age Respiratory Indication of

Rate severe
(breaths/min) infection
(breaths/min)

< 2 months > 60 >70

2 to 12 months > 50
12 months to 5 > 40 >50
years
Greater than 5 > 20
years
 Pneumonia Severity Assessment

Mild Severe
Temperature <38.5 C Temperature >38.5 C
Infants RR < 50 breaths/min RR > 70 breaths/min
Mild recession Moderate to severe recession
Taking full feeds Nasal Flaring
Cyanosis
Intermittent Apnea
Grunting Respirations
Not feeding

Temperature <38.5 C Temperature >38.5 C

Older RR < 50 breaths/min RR > 50 breaths/min
Children Mild breathlessness
No vomiting
Severe difficulty in breathing
Nasal Flaring
Cyanosis
Grunting Respirations
Signs of dehydration
 Indications for Admission
Age Group Indications for Admission to Hospital

Infants Oxygen Saturation <= 92%, cyanosis

RR > 70 breaths /min
Difficulty in breathing
Intermittent apnea, grunting
Not feeding
Family not able to provide appropriate observation or
supervision

Older Oxygen Saturation <= 92%, cyanosis

Children RR > 50 breaths /min
Difficulty in breathing
Grunting
Signs of Dehydration
Family not able to provide appropriate observation or
supervision
 Essential diagnosis and clinical
features
Bacterial Fever, cough, dypsnea
Abnormal chest xm- Crepts and reduced breath sound
pneumonia Abnormal cxr- infiltrates, hilar adenopathy, pleural
effusion
Preceding URTI (fever, coryza, cough, hoarseness)
Viral pneumonia Wheezing or crepts
Myalgia, malaise, headache (older)

Chlamydial Cough, pharyngitis, tachpnea, crepts, few wheeze,

fever
pneumonia Inclusion conjuctivitis, eosinophilia, elevated Ig

Mycoplasmal Fever, cough

Common older than 5 years
pneumonia

Hypersensitivity

History of exposure (birds, dust, molds, drugs)
Cxr- interstitial infiltrates
pneumonia Diffuse crepts, recurrent cough, fever, wheeze, weight
loss

Eosinophilic

Cxr- pulmonary infiltrates
Persistent cough, wheeze, crepts
pneumonia Increased eosinophils
Differential diagnosis

Asthma Aspiration Atelectasis

Bronchioliti Congenital
Congenital
s/ heart
anomalies
Obliterans disease

Congestive Malignancy
Cystic
heart - bronchial
fibrosis
failure tumor
 Investigation
May confirm diagnosis - consolidation
Classic lobar pneumonia Strep pneumonia
Cxr

Cannot differentiate between bacterial or viral
Cavities (air fluid level) Staph pnaumonia
Parapneumonic effusion / empyema
FBC , acute phase reactant (CRP) and ESR WBC (
Blood test viral/ bacterial), ESR (monitoring course of
pneumonia)
and Lymphocytosis suggest viral etiology
Leukocytosis bacterial cause, marked increase
culture pneumococcal pneumonia
Culture S. pneumonia
For M pneumonia, Chlamydia species and
Legionella
Serology Acute and convalescent serum samples were
collected and tested using enzyme immunoassay
forM pneumoniaeIgM and IgG antibodies
Nasopharyngeal Identify viral causes
aspirate
Distinguish between parapneumonic effusion or
Ultrasound of empyema
chest Thus fluid must be aspirated for diagnostic and
therapeutic purposes
 a

(A) Anteroposterior radiograph from a

child with presumptive viral pneumonia.
(B) Lateral radiograph of the same child
with presumptive viral pneumonia
 Right
lower lobe
consolidati
on in a
patient
with
bacterial
pneumoni
a.
Management General suppotive
Admission indication care
Analgesia for pain

O2 saturation (<93%)
O2 for hypoxia
Severe tachypnoea
Fluids
Dyspnoea

Grunting
Antibiotic
Determined
Newborn:
Apnoea by: age,
broad-
severity, cxr
spectrum IV
appearance
Not feeding >5:
amoxicillin/
Family unable to take Older
oral
good care infants: oral
macrolide
amoxicillin
(erythmycin
)
 Complication
Necrotizing pneumonia
Pleural effusion
Empyema
Lung abscess
ARDS
Pneumatocele
Bronchiectasis
Bronchiolitis
 DIAGNOSIS
Acute infectious inflammation of the
bronchioles resulting in wheezing and
airways obstruction in children less
than 2 years old
 MICROBIOLOGY
Typically caused by viruses
RSV-most common
Parainfluenza
Human Metapneumovirus
Influenza
Rhinovirus
Coronavirus
 EPIDEMIOLOGY
Typically less than 2 years with peak incidence 2
to 6 months

May still cause disease up to 5 years

Leading cause of hospitalizations in infants and

young children

Accounts for 60% of all lower respiratory tract

illness in the first year of life
RISK FACTORS OF SEVERITY
Prematurity
Low birth weight
Age less than 6-12 weeks
Chronic pulmonary disease
Hemodynamically significant cardiac disease
Immunodeficiency
Neurologic disease
Anatomical defects of the airways
ENVIRONMENTAL RISK FACTORS

Older siblings
Concurrent birth siblings
Passive smoke exposure
Household crowding
Child care attendance
High altitude
 PATHOGENESIS
Viruses penetrate terminal bronchiolar cells--
directly damaging and inflaming

Pathologic changes begin 18-24 hours after

infection

Bronchiolar cell necrosis, ciliary disruption,

peribronchial lymphocytic infiltration

Edema, excessive mucus, sloughed

epithelium lead to airway obstruction and
atelectasis
 Clinical Features
Begin with upper respiratory tract symptoms:
Nasal congestion, rhinorrhea, mild cough, low-
grade fever

Progress in 3-6 days to rapid respirations, chest

retractions and wheezing.
 Examination
Tachypnea
80-100 in infants
30-60 in older children
Prolonged expiratory phase, rhonchi, wheezes
and crackles throughout

Possible dehydration
Possible conjunctivitis or otitis media
Possible cyanosis or apnea
 DIAGNOSIS
Clinical diagnosis based on history and physical
exam

Supported by CXR:
Hyperinflation, flattened diaphragms, air
bronchograms, peribronchial cuffing, patchy
infiltrates, atelectasis.
 VIRAL IDENTIFICATION
Generally not warranted in outpatients and rarely
alters treatment or outcomes
May decrease antibiotic use
May help guide antiviral therapy

Nasal wash or aspirate

Rapid antigen detection for RSV, parainfluenza,
influenza, adenovirus (sensitivity 80-90%)
Direct and indirect immunofluorescence tests
Culture and PCR
 DIFFERENTIAL DIAGNOSIS
Viral-triggered asthma
Bronchitis or pneumonia
Chronic lung disease
Foreign body aspiration
Gastroesophageal reflux
Congenital heart disease
Vascular rings, bronchomalacia, complete
tracheal rings or other anatomical abnormalities
 COURSE
Depends on co-morbidities
Usually self-limited
Symptoms may last for weeks but generally back
to baseline by 28 days

In infants > 6 months, average hospitalization

stays are 3-4 days, symptoms improve over 2-5
days but wheezing often persists for over a week

Disruption in feeding and sleeping patterns may

persist for 2-4 weeks
 SEVERITY ASSESSMENT
AAP defines severe disease as signs and
symptoms associated with poor feeding and
respiratory distress characterized by tachypnea,
nasal flaring, and hypoxemia

High likelihood of requiring IV hydration,

supplemental oxygen and/or mechanical
ventilation.
 HOSPITALIZATION
Children with severe disease
Toxic with poor feeding, lethargy, dehydration
Moderate to severe respiratory distress (RR > 70,
dyspnea, cyanosis)
Apnea
Hypoxemia
Parent unable to care for child at home
 SUPPORTIVE CARE
Respiratory support and maintenance of
adequate fluid intake

Saline nasal drops with nasal bulb suctioning

Antipyretics

Rest
 RESPIRATORY SUPPORT
Oxygen to maintain saturations above 90-92%
Keep saturations higher in the presence of fever,
acidosis, hemoglobinopathies
Wean carefully in children with heart disease,
chronic lung disease, prematurity
Mechanical ventilation for pCO2 > 55 or apnea
 FLUID ADMINISTRATION
IV fluid administration in face of dehydration due
to increased need (fever and tachypnea) and
decreased intake (tachypnea and respiratory
distress)

Monitor for fluid overload as ADH levels may be

elevated
 BRONCHODILATORS
Generally not recommended or helpful
Subset of children with significant wheezing or a
personal or family history of atopy or asthma may
respond
Trial with Albuterol or Epinephrine may be
appropriate
Therapy should be discontinued if not helpful or
when respiratory distress improves
 CORTICOSTERIODS
Not recommended in previously healthy children
with their first episode of mild to moderate
bronchiolitis
May be helpful in children with chronic lung
disease or a history of recurrent wheezing
Prednisolone, dexamethasone
 INHALED CORTICOSTEROIDS
Not helpful acutely to reduce symptoms, prevent
readmission or reduce hospitalization time

No data on chronic use in prevention of

subsequent wheezing
 RIBAVIRIN
May be useful in infants with confirmed RSV at
risk for more severe disease
Must be used early in the course of the illness
 ANTIBIOTICS
Not useful in routine bronchiolitis

Should be used if there is evidence of

concomitant bacterial infection
Positive urine culture
Acute otitis media
Consolidation on CXR
 COMPLICATIONS
Apnea
Most in youngest children or those with
previous apnea
Respiratory failure
Around 15% overall
Secondary bacterial infection
Uncommon, about 1%, most in children
requiring intubation
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