18/10/13901

Mostafavi SN. MD Pediatric infectious disease departement Isfahan University of Medical Science 18/10/13902

Lower respiratory tract infections Pneumonia: – Viral – Bacterial – Afebrile – Atypical – Aspiration – Nosocomial Bronchiolitis Empyema 18/10/13903

Case 1 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis? 18/10/13904

Diagnosis of pneumonia What's suggestive symptoms and signs of pneumonia? Which patient has definite diagnosis of pneumonia? 18/10/13905

Symptoms/signs of pneumonia All respiratory infections: fever, cough, Lower respiratory involvement: respiratory distress, tachypnea, cyanosis Pneumonia: fine rales, decreasing breath sounds, bronchophonia, … Definite: new pulmonary infiltration in CXR 18/10/13906

Case 1-1 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis? 18/10/13907

Case 1-2 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis? 18/10/13908

Case 1-2 Has the infant need admission? 18/10/13909

Admission criteria in pneumonia Inability to intake fluid or medications Cyanosis( o2 sat< 92%) Severe respiratory distress( apnea, …) Toxic appearance Pleural effusion Sometimes < 1 year 18/10/139010

Case 1-2 Has the patient need antibiotic? 18/10/139011

Type of pneumonia Viralbacterial HistoryAge< 5, gradual onset, mild fever, cough, respiratory distress Abrupt onset, high fever, severe cough, significant respiratory distress Physical exam Bilateral rales, high pitched breath sounds, Focal rales X ray infiltrates Bilateral interstitial, peribronchiolar, parenchymal, hyperinflation Lobar, lobular consolidation, dense parenchymal ESR, CRP, WBC, PMN NL to mild increaseSignificant increase 18/10/139012

Case 1-3 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. If he need any antibiotic? 18/10/139013

Case 1-2 A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. If he need any antibiotic? 18/10/139014

Which antibiotic should be prescribed for the infant? 18/10/139015

MicroorganismOutpatientInpatient S. pneumoniaHigh dose amoxicillin( 85%), macrolides(60- 80%) High dose penicilline(85%), high dose ampicilline( 85%), Ceftriaxone( > 95%), ceftriaxon+ vancomycine( 100%) H. Inluenza ( < 5 yr) Low dose amoxicillin( 50%), low dose co Amoxiclav (>95%), macrolids(> 90%) Low dose ampicillin(50%), ceftriaxone( 100%) 18/10/139016

Case 1-2 What's the clinical course of the patient? 18/10/139017

Clinical course of bacterial pneumonia Improve in fever and respiratory signs in hours Clearing CXR in 4-8 weeks 18/10/139018

Case 2 A 7 years old girl brought with high fever, malaise, protracted cough, mild diarrhea since 5 days ago. On PE she had bilateral fine rales without significant respiratory distress. She received coamoxiclave since 72 hour ago. Whats your diagnosis? 18/10/139019

Atypical pneumonia What's the suggestive symptoms and signs of atypical pneumonia? 18/10/139020

Atypical pneumonia Age 5-15 yr Severe constitutional signs: high fever, prolonged fever, anorexia, malaise Mild respiratory signs: coryza, protracted prolonged cough, no/mild distress, bilateral mild rales Prominent extrapulmonary signs: rash, diarrhea, abdominal pain, CNS, … Prominent x ray abnormalities: bilateral interstitial, lobar infiltrates specially in lower lobes No response to beta-lactams and dramatic response to azithromycine, clarithromycine, erythromycine 18/10/139021

Case 3 A 2 month old boy brought with severe cogh since two days ago and coryza and mild cough since five days ago. His mother has signs of URTI since 7 days ago. On PE RR=70/min, mild cyanosis and diffuse wheezing were found. What's your diagnosis? 18/10/139022

Main clues in bronchiolitis Age:<1 yr ( 2-6 mo), peak admission: 1-3 mo Epidemic in Day to Farvardin months Initially coryza, cough then severe cough, wheezing, dyspnea Sometimes fever Hyperinflation, perihilar infiltration in x ray 18/10/139023

Case 3- x ray 18/10/139024

Case 3 A 2 month old boy brought with severe cogh since two days ago and coryza and mild cough since five days ago. His mother has signs of URTI since 7 days ago. On PE RR=70/min, mild cyanosis and diffuse wheezing were found. Has the patient need admission? 18/10/139025

Admission in bronchiolitis O2 saturation< Age< 6 wk Reduced intake Underlying heart, lung, immunological disease Severe respiratory distress including apnea 18/10/139026

What's the outpatient management of bronchiolitis? 18/10/139027

Out patient management of bronchiolitis No effect of salbutamol, theophylline G, corticosteroids, cough suppressants Supine position with the head elevated Small frequent feeding Nose drops and clearing Warning signs Mist therapy 18/10/139028

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