Pneumonia
Pneumonia is an infection of the
lower respiratory tract and lung paren-chyma that leads to consolidation.
Viruses alone account for 14–35% of all community acquired pneumonia in
childhood. In 20–60% of children a pathogen is not found. Common infecting
bacterial agents by age are:
·
Neonates: group B streptococcus, Escherichia coli, Klebsiella, Staphylococcus
aureus.
·
Infants: Streptoccus pneumoniae, Chlamydia.
·
School age: Streptococcus pneumoniae,
Staphylococcus aureus, group A streptococcus,
Bordetella pertussis, Mycoplasma pneumoniae.
Certain groups of children are at
risk of pneumonia, e.g. those with:
·
congenital
lung cysts;
·
chronic
lung disease;
·
immunodeficiency;
·
cystic
fibrosis;
·
sickle
cell disease;
·
tracheostomy
in situ.
The patient may have had a recent
URTI and may also be complaining of pleuritic chest pain or abdominal pain. The
typical history will have:
·
temperature 38.5*C;
·
shortness
of breath;
·
cough;
with sputum production in older children (>7yrs).
Check for the following:
·
Signs of respiratory distress: tachypnoea; grunting; intercostal
recession; use of accessory muscles
for breathing. A resting respiratory rate of
70breaths/min in infants or >50breaths/min in children indicates severe
illness.
·
Desaturation and cyanosis: pulse oximetry should be performed
in every child admitted to hospital
with pneumonia. SpO2 ≤92% in room air indicates severe illness.
·
General health and lethargy.
·
Auscultation signs of lobar
pneumonia: dullness
to percussion; crackles; decreased
breath sounds; tactile vocal fremitus; bronchial breathing.
The investigations that help in
diagnosis include:
·
Sputum: culture may be of limited value.
·
Nasopharyngeal aspirate: viral immunofluorescence in
infants.
·
Blood: culture should be done in all
children with severe bacterial pneumonia
(not necessary in community-acquired pneumonia).
·
CXR: not as routine.
·
Pleural fluid: when there is a significant
pleural effusion, an aspirated sample
should be sent for culture and antigen testing once a drain is inserted.
·Viral
titres: save a sample of
blood for acute titre testing, which can be
assayed the same time as the convalescent sample if a microbiological
diagnosis is not made.
There are a variety of changes
ranging from lobar consolidation to the mere presence of patchy bilateral
infiltrates. In general, routine CXR is not needed in children with mild
uncomplicated LRTI. In other cases, look for pleural effusions, fluid levels,
apparent round pneumonia, cavitation, hilar adenopathy, and any calcification.
At follow-up, patients with history of significant acute X-ray change (e.g.
lobar collapse, apparent round pneu-monia, empyema) or continuing symptoms will
require repeat X-ray.
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