IntroductionIntroduction Pneumonia is defined as the inflammation
of lung tissue caused by an infectious agent that results in acute respiratory signs and symptoms.
It can either be acquired outside (community-acquired) or within the hospital (hospital-acquired)
Who shall be considered as
having community-
acquired Pneumonia?
For ages 3 months to 5 years are tachypnea and/or chest indrawing
For ages 5 to 12 years are fever, tachypnea, and crackles
Who shall be considered as
having community-
acquired Pneumonia?
Beyond 12 years of ages are the presence of the following features:Fever, tachypnea, and tachycardiaAt least one abnormal chest findings of
diminished breathing sounds, ronchi, crackles or wheezes
Tachypnea is still the best predictor of pneumonia
Who will require
admission? A patient who is at moderate to high risk
to develop pneumonia-related mortality should be admitted
A patient who is minimal to low risk can be managed on an outpatient basis
Risk Classification of
PneumoniaVariables PCAP A Minimal risk
PCAP BLow risk
PCAP CModerate risk
PCAP DHigh risk
Co-morbid illness None Present Present Present
Compliant caregiver Yes Yes No No
Ability to follow up Possible Possible Not possible Not possible
Presence of dehydration None Mild Moderate Severe
Ability to feed Able Able Unable Unable
Age >11 mos >11 mos <11 mos <11 mos
Respiratory rate 2-12mos 1-5years >5 years
≥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 of
PneumoniaVariables PCAP A Minimal risk
PCAP BLow risk
PCAP CModerate risk
PCAP DHigh risk
Signs of respiratory failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f. Sensorium
NoneNoneNoneNoneNone
Awake
NoneNoneNoneNoneNone
Awake
Intercostal/SubcostalPresentPresentNoneNone
Irritable
Supraclavicular/Intercostal/Subcostal
PresentPresentPresentPresent
Lethargic/Stuporous/Comatose
Complication(effusion, pneumothorax)
None None Present Present
Action Plan OPD follow up at end of treatment
OPD follow up after 3 days
Admit to regular ward Admit to ICURefer to specialist
The presence of retraction on admission was the best single predictor of death
Inability to cry, head nodding and a respiratory rate of >60/min were the best predictors of hypoxemia
Diagnostic Tools
Chest X-Ray PA-lateral White cell count Acute Phase Reactants
ESR and CRP have not been demonstrated to differentiate viral from bacterial infection
Diagnostic Tools
MicrobiologyBlood C/SPlueral fluid C/STracheal aspiration C/SSputum C/S
Oxygen saturation and/or Blood GasTo help the clinician in deciding the
appropriate intervention
What diagnostic aids are requested
for a patient classified as PCAP
A or PCAP B? No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting
What diagnostic aids are initially requested for a
patient classified as either PCAP C or
PCAP D? The following should be routinely requested:
Chest x-ray PA-lateralWhite blood cell countCulture and sensitivity of
○ Blood for PCAP D○ Pleural fluid○ Tracheal aspirate upon initial intubation○ Blood gas and/or pulse oximetry
What diagnostic aids are initially requested for a
patient classified as either PCAP C or
PCAP D? The following may be requested:
Culture and sensitivity of sputum for older children
The following should not be routinely requested:Erythrocyte sedimentation rateC-reactive protein
When is antibiotic
recommended? For a patient classified as either PCAP A or B and is:Beyond 2 years of ageHaving high grade fever without wheeze
For a patient classified as PCAP C and is:Beyond 2 years of ageHaving high grade fever without wheezeHaving alveolar consolidation in the CXRHaving WBC > 15,000
For a patient classified as PCAP D
Etiology First 2 years: viruses
As age increases bacterial pathogens become more prevalent
PCAP managed as an outpatient:Bacterial pathogen is more commonStreptococcus pneumoniae is the pathogen in
more than half (Others: M. pneumoniae, C. pneumoniae)
PCAP managed as an inpatient:Bacterial pathogen is more commonStreptococcus pneumoniae is the pathogen in
little more than half (Others: H. influenzae b, M. pneumoniae, C. pneumoniae)
Haemophilus influenzae type b should be given in patient below 5 years of age who has not completed the primary series of Hib immunization
Bacterial vs Viral
Features Bacterial Viral
Fever T>38.5°C T<38.5°C
Wheeze Absent Present
Alveolar infiltrates in Chest Xray or an elevated white cell count favors bacterial pathogen
What empiric treatment should be
administered if a bacterial etiology is strongly considered? For a patient classified as PCAP A or B
without previous antibiotic, oral Amoxicillin (40-50mg/kg/day in 3 divided doses) is the DOC
For a patient classified as PCAP C without previous antibiotic who has completed primary immunization against H.Influenza type b, Penicillin G (100,000units/kg/day in 4 divided doses) is the DOC
What empiric treatment should be
administered if a bacterial etiology is
strongly considered?If a primary immunization againts Hib has not
been completed, intravenous Ampicillin (100mg/kg/day in 4 divided doses) should be given
For a patient classified as PCAP D, a specialist should be consulted
What treatment should be given if a viral etiology is
strongly considered? Ancillary treatment should be given
Oseltamivir (2mg/kg/dose BID for 5 days) or Amantadine (4.4-8.8mg/kg/day for 3-5days) may be given for influenza that is either confirmed by laboratory or occurring as an outbreak
When can a patient be
considered as responding to the current antibiotic? Decrease in respiratory signs (particularly
tachypnea) and defervescence within 72hours after initiation of antibiotic
Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation
End of treatment CXR, WBC, ESR or CRP should not be done to assess therapeutic response to antibiotic
What should be done if a patient is not responding
to current antibiotic therapy?
If an outpatient classified as either PCAP A or B is not responding within 72hours, consider any one of the following:Change the initial antibioticStart an oral macrolideReevaluate diagnosis
What should be done if a patient is not responding
to current antibiotic therapy?
If an inpatient classified as PCAP C is not responding within 72hours, consider consultation with a specialist because of the following possibilities:Penicillin resistant Streptococcus pneumoniaePresence of complication (pulmonary or
extrapulmonary)Other diagnosis
What should be done if a patient is not responding
to current antibiotic therapy? If an inpatient classified as PCAP D is
not responding within 72hours, consider immediate re-consultation with a specialist
When can switch therapy in bacterial
pneumonia be started?Switch from intravenous antibiotic
administration to oral from 2-3 days after initiation is recommended in a patient who:
Is responding to the initial antibiotic therapy Is able to feed with intact gastrointestinal
absorption Does not have any pulmonary or extra
pulmonary complication
What ancillary treatment can be
given? Among inpatient, oxygen and hydration
should be given if needed 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
What ancillary treatment can be
given? In the presence of wheezing, a
bronchodilator may be administered
How can Pneumonia be
prevented? Vaccines recommended by the Philippines Pediatric Society should be routinely administered
Zinc supplementation may be administered
Vitamin A, Immunomodulators, and Vitamin C should not be routinely administered as a preventive strategy
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