Pneumonia Name Dr J Mackintosh & Dr J Thurlow Date 18/11/2014 CME Teaching Kiambu District Hospital

Objectives Differential diagnoses for a child with respiratory distress How to recognise a child with pneumonia How to assess a child with pneumonia How to categorise and appropriately treat pneumonia

Pneumonia Top 5 killer in Sub-Saharan Africa

Differential diagnoses for a child with respiratory distress Lung / Airway Disease • Pneumonia Systemic Disease • Asthma • Malaria • PTB • Severe anaemia • HIV-PCP • Severe dehydration • Croup (LTB)-Bacterial or viral • Cardiac disease • Renal disease • Bronchiolitis Foreign Body

HOW TO RECOGNISE A CHILD WITH PNEUMONIA Vaccination history: HiB/pneum

Detailed History Fever ? Length (acute <2 weeks) Cough Associated with rapid breathing? History choking (?foreign body) Contacts with TB Known or possible HIV infection (think PCP) Vaccination history BCG, DTP, HiB, pneumococcus (bacterial tracheitis/croup) FH asthma

Detailed Examination Coarse crackles, bronchial breathing or dull to percussion Signs of respiratory distress Tachypnoea Lower chest wall indrawing Grunting (can also be found in systemic illness) NB deep acidotic breathing is a sign of systemic illness not respiratory

Pneumonia A few signs in a child with cough and difficulty breathing can classify severity Kenya is not using the classification in the WHO pocketbook 2013 where pneumonia is classified into 2 groups - pneumonia and severe pneumonia However, in 2015 this classification is going to be revised by the KPA.

History of cough or difficult breathing, age >60 days

How to assess and provide acute management for a child with pneumonia Airway Breathing Circulation Disability

A Airway SSSS Safe Stimulate – if not alert Shout for help – if not alert Setting Patent Added noises eg stridor (indicating obstruction)-if so suck out what you can see!

B Breathing Are they Breathing? If not 5 inflation breaths and follow resuscitation for a collapsed child If they are breathing what is the adequacy? Cyanosis (Peripheral/central) Grunting Head-nodding Rapid or slow breathing: count respiratory rate Chest wall indrawing Deep acidotic breathing Auscultate: wheeze or crackles or bronchial breathing Oxygen saturations ? Oxygen

Deep acidotic breathing vs Lower chest wall indrawing

C Circulation (for a non-collapsed child) Large pulse: HR Peripheral pulse: ?weak Capillary refill time Temperature gradient Severe pallor ? Fluid bolus/urgent transfusion

D Disability ? 10% dextrose bolus AVPU scale Alert Voice Pain (appropriately) Unresponsive Check blood glucose if convulsing/AVPU<A ? 10% dextrose bolus

Very Severe Pneumonia Cough & difficulty breathing >60 days PLUS Cyanosis Or inability to drink/breast feed Or grunting Or AVPU <A Very severe pneumonia Oxygen, IV penicillin and gentamycin

Severe Pneumonia Cough & difficulty breathing >60 days + lower chest wall indrawing AVPU = A Severe pneumonia IV benzylpenicillin No cyanosis No inability to feed No grunting No AVPU <A

Pneumonia Cough & difficulty breathing >60 days Pneumonia + RR ≥ 50 (2-11 months) + RR ≥ 40 (≥12 months) Pneumonia PO Cotrimoxazole or PO Amoxicillin (if patient has had cotrimazole previously for this illness) No cyanosis No inability to feed No grunting No AVPU <A No indrawing

Treatment failure At any point If severe pneumonia becomes very severe Add gentamycin At 48 hours Very severe pneumonia getting worse Change to Ceftriaxone Unless Staph suspected: add cloxacillin Severe pneumonia without improvement in RR, indrawing, fever, drinking

Treatment failure At Day 5 Ensure HIV test done BUT GOOD PRACTICE TO TEST ALL CHILDREN PRESENTING TO HEALTHCARE FACILITIES At Day 7 Investigate for TB

Any Questions?

Summary Name 10 differential diagnoses ABCD approach Know how to recognise & treat a child with pneumonia Use Kenyan Guidelines 2013 to help diagnose & manage a child with pneumonia (they will be updated in 2015!)

References Kenyan Guidelines 2013 WHO Hospital Care for Children 2013 ETAT+ Modules for participants 2013