Good Morning 

1. Good Morning  Morning Report July 23, 2013

2. 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 • Focal findings on lung exam • Crackles • Diminished breath sounds • Bronchial breath sounds • Egophany 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

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 Tuberculosis Atypical

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/toxicUnderlying 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! 1st years – Board Room B 2nd years – Board Room A 3rd years – 2 center

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