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Good Morning!. Morning Report July 3, 2012. Semantic Qualifiers. Illness Script. Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult

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  1. Good Morning! Morning Report July 3, 2012

  2. Semantic Qualifiers

  3. 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

  4. CXR #1

  5. Predisposing Conditions • Medical history • Sickle cell • BPD • GERD • Cystic Fibrosis • Heart disease • Immunodeficiency • Increased aspiration • Neuromuscular d/o • Seizure d/o • 35-40/1000 incidence in <5yo • 7/1000 incidence in adolescents • colder months • lower socioeconomic status • smoke exposure • boys> girls

  6. Pathophysiology • Spread by droplets • Typically follows URI • Mechanism • Colonization of nasopharynxwith 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 • Organisms • Streptococcus pneumonia = MOST COMMON • Others: S. aureus, Group A Strep, GNR (<3mo), anaerobes

  7. Clinical Manifestations • Abrupt onset • High fever • Cough • Sometimes productive • Toxic appearance • Respiratory distress • Tachypnea (most sensitive/specific) • Retractions • Nasal Flaring • Grunting • Hypoxia • Chest pain

  8. Clinical Manifestations • Focal findings on lung exam • Crackles • Diminished breath sounds • Bronchial breath sounds • Egophany • Unilateral focal infiltrate on CXR

  9. Organisms**

  10. Treatment** • Outpatient therapy (7-10days total) • First line: High dose Amoxicillin at 80-100mg/kg/day • Penicillin allergy: Cephalosporin (non-type 1); • Clinda/Azithro (type 1 allergy) • Atypical organisms: Azithromycin x 5 days • Inpatient therapy (duration varies) • Ceftriaxone or Ampicillin • More extensive disease/failed treatment • Vancomycin • Clindamycin • Azithromycin (adjunctive coverage sometime given)

  11. Admission** • Criteria for admission • <3 months • Respiratory distress • Hypoxemia • Dehydrated • Highly febrile/toxicUnderlying disease • Testing • CBC • Blood culture • CXR • +/- Sputum culture

  12. Complications** • Lung abscess • 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

  13. 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

  14. CXR #2

  15. Thanks!! • Almost every content spec  • “Pneumonia.” Pediatrics in Review. 2008, volume 29, 147 • Noon conference = YOGA (12:15)

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