1. Morning Report July 23, 2013 Good Morning

2. Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/Vague Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problemSystemic problem AcquiredCongenital New problem Recurrence of old problem Semantic Qualifiers

4. Illness Script Predisposing Conditions  Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult  What is physically happening in the body, organisms involved, etc. Clinical Manifestations  Signs and symptoms  Labs and imaging

5. Predisposing Conditions Incidence: 35-40/1000 in <5yo, 7/1000 in older children and adolescents Boys > girls List 2 environmental risk factors for PNA  Lower socioeconomic status  Smoke exposure-cigarette smoke or wood smoke  Cold weather  Alcohol Question  B….aspiration

6. Predisposing Conditions Name 4 medical conditions that increase PNA risk  Medical history  Sickle cell  BPD  GERD  Cystic Fibrosis  Heart disease  Immunodeficiency  Increased aspiration  Neuromuscular disorder  Seizure disorder Question  E. Viral agents are the most common cause of PNA in  infants and young children

7. Pathophysiology What method of transmission is reponsible for the spread of PNA?  Spread by droplets Typically follows URI Mechanism  Colonization of nasopharynx with further inhalation of  microorganisms, leading to a pulmonary focus of  infection  Less commonly…bacteremia results from the initial upper  airway colonization with subsequent seeding of lungs

8. Pathophysiology What is the most common organism causing bacterial PNA?  Streptococcus pneumonia What are 3 additional pathogens that cause bacterial PNA?  S. aureus, Group A Strep, GNR (<3mo), anaerobes 6 week old, afebrile infant with tachypnea, cough, and CXR showing interstitial changes?  Chlamydia pneumoniae What are 2 viral causes of PNA?  RSV, Parainfluenza, Influenza, Metapneumovirus, etc.

9. Pathophysiology Question  C. Mycoplasma pneumoniae Microbiology of PNA changes based on the age of the patient, and this should be kept in mind when making management decisions!

10. Clinical Manifestations Bacterial PNA Abrupt onset High fever Cough  Sometimes productive Toxic appearance Respiratory distress  Tachypnea (most sensitive/specific)  Retractions  Nasal Flaring  Grunting  Hypoxia Chest pain Emesis and abdominal pain Focal findings on lung exam  Crackles  Diminished breath sounds  Bronchial breath sounds  Egophany

11. Clinical Manifestations Atypical PNA School age or older Constitutional symptoms  Fever  Malaise  Myalgias  Headache Gradual development of dry cough later in the illness as other symptoms improve

12. Clinical Manifestations Bacterial Atypical Tuberculosis

13. Clinical Manifestations Question  C. Development of an empyema Name 3 possible complications of pneumonia  Lung abscess  Pleural effusion  Empyema  Necrotizing pneumonia  Pneumothorax  Sepsis  Bronchopulmonary fistula  Pneumatoceles

14. Complications Lung abscess  Often develop following aspiration  Thick-walled cavity with  air/fluid level  TB should be considered  Needle aspiration for culture Necrotizing pneumonia  Rare complication of bact PNA  Liquefaction/necrosis caused by  toxins of virulent organisms  VERY ill  IV abx for at least 4 weeks

15. Complications Sterile para-pneumonic effusion Purulent effusions with resultant empyema  Persistent fever, ill-appearing, tachypnea, increased WOB,  chest pain and splinting  Dullness to percussion/decreased air entry CXR with decubitus, US, CT

16. Treatment Question  C. Outpatient treatment with high dose Amoxicillin Outpatient therapy (7-10days total)  First line: High dose Amoxicillin at 80-100mg/kg/day  Penicillin allergy?  Cephalosporin (non-type 1)  Clindamycin/Azithromycin (type 1 allergy)  Atypical organisms: Azithromycin x 5 days  Aspiration PNA: Augmentin or Clindamycin Inpatient therapy (duration varies)  Ceftriaxone or Ampicillin  More extensive disease/failed treatment  Vancomycin, Clindamycin  Azithromycin (adjunctive coverage sometime given)

17. Treatment

18. Admission Criteria for admission  <3 months  Respiratory distress  Hypoxemia  Dehydrated  Highly febrile/toxic Underlying disease Testing (once admitted)  CBC  Blood culture  CXR  +/- Sputum culture

19. Treatment Tests to consider for patient who is not improving clinically?  Bronchoscopy, lung aspiration, open lung biopsy MORE CONTENT SPECS  Recurrent PNA: >1 episode/year, >3 episodes in lifetime  Anatomic lesions: vascular rings, cysts, pulmonary sequestration  Respiratory tract disorders: CF, GERD, aspiration  Immunodeficiency: HIV, CGD, hypogammaglobulinemia  **REFER if documented  Congenital lesions of the lung (CCAM, sequestration, etc) can  mimic PNA  Prevention of PNA  Good handwashing, personal respiratory hygeine, proper  immunization, breastfeeding, limiting sick contacts, decrease  smoke exposure

20. Thanks!! Almost every content spec  “Pneumonia.” Pediatrics in Review. 2008, volume 29, p147 Class Housestaff Today! 1 st years – Board Room B 2 nd years – Board Room A 3 rd years – 2 center

21. Bon Voyage Rocky! He’s headed to Indonesia on a medical service trip!!!