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

2. 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

3. Pneumonia
Top 5 killer in Sub-Saharan Africa

4. 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

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

6. 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

7. 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

8. 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.

9. History of cough or difficult breathing, age >60 days

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

11. 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!

12. 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

13. Deep acidotic breathing vs Lower chest wall indrawing

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Any Questions?

23. 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!)

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