Pneumonias

ASSIST. PROF. DR. MOHAMMED A. YOUNIS

Tikrit university college of medicine
 Objectives:
■ Function of the respiratory system
■ Definitions in pneumonia
■ Epidemiology
■ Etiology
■ Pathophsiology
■ Clinical picture
■ Investigations
■ Treatment
■ complications
■ prevention
 Function of the respiratory system

■ The main function of the respiratory system is to provide

oxygen, the most important energy source for the body's
cells.
■ Inspired air (the air you breath in) contains the oxygen,
and travels down the respiratory tree to the alveoli.
■ The oxygen moves out of the alveoli and is sent into
circulation throughout the body as part of the red blood
cells.
■ The oxygen in the inspired air is exchanged within the
alveoli for the waste product of human metabolism,
carbon dioxide.
■ The air you breathe out contains the gas called carbon
dioxide. This gas leaves the alveoli during expiration.
■ To restate this exchange of gases simply, you breathe in
oxygen, you breathe out carbon dioxide
Definitions in pneumonia

■ Pneumonia refers to the inflammation of

pulmonary tissue.
– It is associated with consolidation of the alveolar
spaces.
■ Pneumonitis is a general term for lung
inflammation that may or may not be
associated with consolidation.
■ Lobar pneumonia describes pneumonia
localized to one or more lobes of the lung in
which the affected lobe or lobes are com
pletely consolidated.
Definitions in pneumonia

■ Bronchopneumonia refers to inflammation of

the lung that is:
– Centered in the bronchioles. and
– Leads to the production of a
mucopurulent exudate that obstructs
some of these small airways and causes
patchy consolidation of the adjacent
lobules.
– Bronchopneumonia is usually a
generalized process involving multiple
lobes of the lung
Definitions in pneumonia

■ Interstitial pneumonitis refers to

inflammation of the interstitium, which
is composed of the walls of the
alveoli, the alveolar sacs and
ducts, and the bronchioles.
– Interstitial pneumonitis may be seen
acutely with viral infections but also
may be a chronic process.
Epidemiology

Every year,

Pneumonia
causes 1.2 million deaths in
children under 5

Source: UNICEF, 2006

 Under 5 Child Mortality
Global Distribution of Cause Specific Child Deaths

Under-nutrit
ion
(underlying Leading infectious
cause) cause of death in
children < 5

Source: 2005 World Health Report

 Epidemiology Of Pneumonia In
Developing Countries

■ 146 million pneumonia episodes annually

■ Globally, ≈11-20 million
hospitalizations/year in children <5 years
■ ≈1.2 million pneumonia deaths annually
■ ≈15-34% of WHO pneumonia cases have
evidence of consolidation on chest x-ray
Etiology
■ The cause of pneumonia depends on:
– Age.
– Immune status.
– Presence of CF or chronic lung disease.
– Exposure history.
– Nosocomial versus community acquisition.
Age pathogen

Group B streptococci, E.coli,

Haemophilus influenzae, Streptococcus
Neonate less 3wks
pneumoniae

RSV, other respiratory viruses

(parainfluenza virses, influenza viruses,
3wk-3mo
adenovirus),Haemophilus
influenzae,Streptococcus pneumoniae
above viruses,S. pneumoniae, S. aureus, H.
4mo-4year influenzae, mycoplasma pneumonia
group A streptococcus

Over 5 yr above with Legionella pneumophila

Pneumonia risk factors

■ Environmental factors (e.g, indoor air

pollution)
■ Crowded living conditions
■ Malnutrition
■ Presence of other illnesses (eg. HIV)
Predisposing Factors to infectious
pneumonia:

■ Anatomic respiratory system

malformations.

■ Altered systemic or local

immunity.

■ Exposure to cigarette smoke.

In high mortality areas, most
fatal pneumonia is likely caused
by two bacteria:
Streptococcus pneumoniae
and
Haemophilus influenzae type b
(Hib)
Defense Mechanisms
■ 80% of cells lining central airways are
ciliated, pseudostratified,
columnar epithelial cells
■ Each ciliated cell contains
about 200 cilia that beat in
coordinated waves about
1000/minute
■ So the lower respiratory tract
is normally sterile
Pathophysiology
The invading organism
causes symptoms, in part,
by provoking an overly
exuberant immune
.response in the lungs
The small blood vessels in
the lungs (capillaries)
become leaky
protein-rich fluid difuses
into the alveoli results
in a less functional area for
oxygen-carbon dioxide
.exchange
Pathophysiology

The patient becomes relatively oxygen*

deprived, while retaining potentially
.damaging carbon dioxide
The patient breathes faster and faster, in*
an effort to bring in more oxygen and
.blow off more carbon dioxide
Mucus production is increased, and the*
leaky capillaries may tinge the mucus
.with blood
Mucus plugs actually further decrease*
the efficiency of gas exchange in the
.lung
Pathophsiology

The alveoli fill further with fluid and debris from

the large number of white blood cells being
.produced to fight the infection
Consolidation, a feature of bacterial
pneumonias, occurs when the alveoli, which are
normally hollow air spaces within the lung,
instead become solid, due to quantities of fluid
.and debris

Viral pneumonias, and mycoplasma**

pneumonias, resulting in patchy
consolidation(bronchio pneumonia) . These
types of pneumonia primarily infect the walls of
.the alveoli and the parenchyma of the lung
In Pnemoccocal pneumonia: the
involved lobe under goes the following
changes:
1- congestion: alveoli become edematous
and filled with microorgansims.
2- Red hepatization: alveoli contain
PMN,RBC,fibrin & organisms.
3- gray hepatization: deposition of fibrin
on the pleural surface & phagocytosis
start.
4- resolution: neutrophile is degenerated
, fibrin threads & the remaining bacteria
digested & removed
pathophysiology
So, the major pulmonary abnormalities
occur in the pneumonia are:
1_ reduction in the total available surface
area of the respiratory membrane.
2_ decrease ventilation- perfusion ratio.
Both these effects cause hypoxemia &
hypercapnia.
3-Hyperinflation of the patent alveoli
Infectious Pneumonia

■ Viral Pneumonia:
– ETIOLOGY: The most common viruses
causing pneumonia include respiratory
syncytial virus (RSV), parainfluenza,
influenza, and adenoviruses.
– CLINICAL MANIFESTATIONS:
preceded by URTI.
Low temperature.
 Signs of respiratory distress.
Auscultation:
widespread rales.
wheezing
■ Investigations:
– Chest X-Ray: Diffuse infiltration with
hyperinflation.
– CBC: Lymphocytosis with normal or slite
elevation of APR.
– Definitive Dx by PCR.
Treatment

■ Supportive measures.
■ Admition needed for :
– IV fluid.
– O2.
– Ventilatory support.
■ Antibiotic if secondary bacterial
infection.
 Bacterial
pneumococcal pneumonia
■ Most common bacterial pathogen
causing pneumonia (90% of childhood
bacterial pneumonia).
■ Common in winter & early spring.
■ Highest 3-8 y of age.
■ More common through asymptomatic
carrier.
pneumococcal pneumonia
■ In untreated cases, a clincal crisis occurs
about the 7th day of illness & complete
resolusion needs 1-3 weeks.
■ The stages interrupted if antibiotics were
used early.
– CLINICAL MANIFESTATIONS:
Mild URTI of few days followed by:
1. Sudden rise of temperature ≥ 40 C & febrile convulsion
may occur in susceptible person.
2. Dyspnea , grunting & cyanosis may occur.
3. Chet pain of pleuritic nature.
4. Cough start later is dry then purulent sputum.
pneumococcal pneumonia
■ Chest signs:
1. Early →diminished air entry over the affected
area.
2. Later on signs of consolidation (dullness
,bronchial breathing & increased vocal
resonance).
3. When resolution start→ crepitations become
prominent while other signs gradually fade.
pneumococcal pneumonia

■ Investigations:
1. WBCs leukocytosis.
2. Culture for organism.
3. Counter immunoelectrophresis & latex
agglutination.
4. X-ray →lobar pneumonia more common in
older children than infants.
→may signs of complications as collapse.
pneumococcal pneumonia
treatment
■ Supportive care.
■ Antipyretic analgesics: paracetamol (15 mg/kg/dose) for
fever & pleuritic pain.
■ Antibiotics : penicillin the drug of choice for 7-10 days:
1. In infants & young children penicillin-G 50,000 iu/kg/day
parenterally in 4 doses.
2. In older children singl IM injection of procaine penicillin
600,000 iu followed by oral penicillin-V 50,000
IU/kg/day.
3. If patient allergic to penicillin erythromycin or
cephalosporin's (crfazolin 50mg/kg/day or cefuroxime
100mg/kg/day).
■ Treatment of complications.
■ Pneumococcal vaccine.
Staphylococcal Infection

■ Staphylococci are common cause of

pyogenic infections in infants and
children. These organisms are gram
positive cocci & classified to strains (S.
aureus, S. epidermidis, and S.
sapropyticus).
■ Staph. is a part of the normal flora & is
present in anterior nares & moist areas
of the body in about 30% of
Staphylococcal Infection

■ Transmission occurs via hands, nasal

discharge, person to person & rarely
air. The newborn infants are extremely
susceptible to staph. ; The
nasopharynx, skin, & umbilical stump
are most common sites of colonization.
S. aureus colonizes skin & MM through
its affinity for host glycoconjugates
&intracellular matrix components.
Staphylococcal
Pneumonia
■ It is a rapidly progressive infection more
common in infants than in children.
■ 70% occur in infants < 1 year of age &
characterized by:
– Frequently preceded by viral URTI.
– More severity & more complication (mortality up
to 30%).
– Causes bronchopneumonia more on one side.
– Lead to pyo-pneumothorax.
– Radio logically shows area of Hgic necrosis &
irregular cavitations.
Staphylococcal Infection
■ The clinical manifestations:
– Patient commonly < 1 year.
– History of staph. skin infection in the patient or
family member.
– Symptoms of viral URTI.
– Sudden onset of high fever, cough, & respiratory
distress & bad general condition.
– The infant is pale ,toxic, irritable with severe
distress.
– Severe dyspnea & shock like state may be
present; GIT manifestations may be secondery
to paralytic ileus.
Staphylococcal Infection
■ On chest examination: decrease breath
sounds, crepitations, wheezes & if
complications develop lead to dullness to
percussion with decease breath sounds &
vocal fremitus.
■ Investigations: as Streptococcal.
■ CXR: picture of bronchopneumonia, picture
of later complication & high incidence of
pneumatoceles (which may persist for
months after cure).
Staphylococcal Infection

■ What treatment would you prescribe?

Staphylococcal Infection

■ Treatment:
– Supportive care.
– Antibiotic for 3-4 weeks:
■ Methicillin 200mg\kg\d IV * TDS.
■ Cloxacillin 100mg\kg\d IV * TDS.
■ If allergy to penicillin present give
cephalosporin 50mg\kg\d.
– Treatment of complications.
Mycoplasma Pneumonia

■ Mycoplasmas are the smallest

free-living organisms, lack cell wall &
are distinct from bacteria.
■ M. pneumonia is a major cause of
illness in school-aged children & young
adults.
■ Clinical illness is unusual < 4 year &
peak attack occurs at 6-15 year.
Mycoplasma Pneumonia

■ M. pneumonia is estimated to cause

1\2 million of pneumonia cases & 11
million of tracheobronchitis in US.
■ The illness occurs at irregular intervals
& transmission is by droplet spread
with incubation period 2-3weeks.
Mycoplasma Pneumonia

■ The clinical manifestations are of atypical

pneumonia:
– Gradual onset with headache, malaise, fever,
sore throat, & cough.
– Sputum production, rales, & pleural effusions are
frequent.
– Severe disease associated in children with SCA.
– Other manifestations include skin eruptions &
less commonly meningoencephalitis, Guillian
Barre syndrome,heamolytic anemia,
thrombocytopenia, myocarditis and pericarditis.
Mycoplasma Pneumonia

■ The diagnosis is by positive cold

agglutinins titers & confirmed by
increase in specific antibodies IgM or
IgG.
■ Treatment:
– Erythromycin or doxycyclin (in children >
10 year) is drug of choice.
 Lobar pneumonia Bronchopneumonia
etiology 90% pneumococcal may H. Staph.aureus
influenza Strept.pyogenes
H-influnza & Gram -v
age 3-8 years Usually <2 years.

pathology Consolidation of a lobe Inflammed bronchi & scattered

Bronchial tree is free patches of Consolidation
bilaterally.
Local signs Signs of consolidation on the Bilateral MSCC+wheeze.
lobe

TVF Increased over the affected Differ from area to area.

lobe.
Type of breathing Bronchial on affected lobe. Vesicular .

Vocal resonance increased Variable from area to area.

Differential Diagnosis of
Recurrent Pneumonia
■ In a few children pneumonia may persist
longer than 1 month or may be recurrent. In
such cases the possibility of underlying
disease must be investigated further.
■ The differential diagnosis:
– Hereditary disorders
– Disorders of immunity
– Disorders of leukocytes
– Disorders of cilia
– Anatomic disorders
Differential Diagnosis of
Recurrent Pneumonia
■ The Evaluation includes:
– Tuberculin skin test
– Sweat chloride determination
– Serum immunoglobulin & IgG
subclass determinations
– Bronchoscopy
– Barium swallow
Would you hospitalize him?
Indications for hospitalization
include the following
– Age less than 6 months
– Moderate to severe RD
– Failure to respond to oral antibiotics
– Inability to take oral antibiotics at home
– Lobar consolidation in more than one lobe
– Immunosuppression
– SCA with acute chest syndrome.
– Need O2 ,vomiting and dehydration.
– Underlying cardiopulmonary disease (BPD
or Pulmonary HTN)
 Complications of Pneumonia
Abscess. It typically occurs as a result of aspiration
pneumonia, when a mixture of organisms is carried into
the lung. Untreated abscesses can cause hemorrhage
(bleeding) in the lung, but targeted antibiotic therapy
significantly reduces their danger.

Respiratory Failure. Respiratory failure is one of the top

causes of death in patients with pneumococcal
pneumonia. Acute respiratory distress syndrome (ARDS)
is the specific condition that occurs when the lungs are
unable to function and oxygen is so severely reduced
that the patient's life is at risk. Failure can occur if
pneumonia leads to mechanical changes in the lungs
(ventilatory failure) or oxygen loss in the arteries
.(hypoxemic respiratory failure)
Bacteremia. Bacteremia, bacteria in the blood,
is the most common complication of
pneumococcus infection, although it rarely
spreads to others sites.
Pleural Effusions and Empyema In some cases
of pneumonia the pleura become inflamed,
which can result in breathlessness and acute
chest pain when breathing.
Collapsed Lung. In some cases, air may fill up
the area between the pleural membranes,
causing the lungs to collapse.
Prevention of pneumonia
mortality
■ Case Management
■ Risk Modification
– Hand washing, indoor pollution control
■ Improved Nutrition
– Exclusive breast feeding, supplements
■ Vaccines
– Pertussis, measles, Hib, pneumococcal
Case Management
Integrated Management of Childhood Illness (IMCI)

■ Educates family and community

– Care seeking, prevention and nutrition, proper
implementation of prescribed care

■ Promotes comprehensive care at health care

provider level
– accurate diagnosis
– appropriate combined treatment
– referral of severely ill children
– Improved counseling of families
– emphasizes nutrition and vaccination
Vaccines
■ Measles and Pertussis
vaccines have already
reduced cases of child
pneumonia
■ Hib and pneumococcal
vaccines should be an
integral part of a
pneumonia prevention
program
Epiglottitis and Croup
■ STRIDOR
■ It is a harsh, high-pitched &
mainly inspiratory sound that result
from obstruction of the upper airway.
Generally, it can be differentiated from
obstruction of the middle airway
which produce monophonic wheeze
and is inspiratory & expiratory,
whereas obstruction of the lower
airway produce polyphonic wheeze
which is mainly expiratory.
■
■ The most common causes of strider include:-
1. Infection of upper airway e.g. Croup (acute or
spasmodic), Acute epiglottitis, Bacterial tracheitis,
Diphtheria.
2. Congenital malformation of Larynx e.g.
Laryngomalacia, Subglottic stenosis,
3. Acquired condition of larynx e.g. Laryngeal
papillomatosis & other laryngeal tumors, Foreign
bodies, GERD, Anaphylaxis, Angioedema,
Hypocalcemia, Hysterical strider.
4. Congenital malformation of Trachea e.g.
Tracheomalacia, Subglottic tracheal web or stenosis,
5. Tracheal compression by external mass e.g.
Vascular ring or sling, Thyroid enlargement,
Esophageal FB, Mediastinal masses.
■
‘cruop: a clinical condition
characterized by a combination of
stridor, hoarseness and barking cough is
the commonest cause of acute airway
obstruction in children,
(90 percent).
Croup
■ Caused by :parainfluenza virus type I.
other viruses including:
-parainfluenza virus type II,
-respiratory syncytial virus (RSV) and
-influenza virus types A and B, and
-can complicate measles.
■ Children between six months and three years of
age
a peak incidence in two year olds.
■ Boys > girls.
■ The annual incidence: 1.5-6% in children younger
than six years.
■ Usually self-limiting; 50 percent
improve within 24 hours of the onset ,
and most recover within four days
without treatment.

However, airway symptoms can

become
serious and even life-threatening.
■ In the absence of medical therapy, 20
percent of patients may be admitted to
hospital and 10 percent of these may
require intervention for acute airway
obstruction, either intubation or
tracheostomy.
Diagnosis:
- Clinical.
- Is a diagnostic dilemma.
- X-Ray of the thoracic inlet:
characteristic narrowing of the
subglottis on an anteroposterior view
(‘steeple’ or ‘pencil tip’ sign)
The Westley Croup Score

Severity of symptoms to be classified

■total score correlating with the diameter
of the tracheal lumen.
The Westley Croup Score
■ A maximum score is 17,
■ a score of 2–3 equates to mild croup,
■ 4–7 to moderate croup and
■ 8 or more to severe croup.
Treatment:
■ For mild croup, treatment can be supportive
■ reassurance of both parents and child, and
observation and monitoring of the child's
symptoms,..
■ humidified environment;
■ Nebulized epinephrine (1 mL of 1 in 1000
epinephrine diluted in 3 mL of 0.9 percent saline)
reducing mucosal oedema by an alpha-agonist
effect causing vasoconstriction and bronchodilation;
it may postpone or eliminate the need for an
artificial airway, or give symptomatic relief until
effective treatment can be given.
■ Corticosteroids have a systemic
antiinflammatory effect.
-There is a reduction in capillary endothelial
permeability and therefore in mucosal
oedema,
- stabilization of lysosomal membranes,
decreasing the inflammatory reaction.
Recent evidence suggests that
glucocorticoid use should be not be
confined to moderate or severe cases but
Clinical benefit can be measured by
■ improvement in croup score,

■ reduced hospital admission rates,

■ shorter length of stay,

■ lower intubation rates or

■ a reduced need for cointerventions
such as the administration of
epinephrine nebulizers.
■ It is difficult to make definitive
recommendations regarding the
superiority of any glucocorticoid, dose,
or route of administration.
■ An oral dose of dexamethasone
(0.6 mg/kg) is preferred because of its
safety and efficacy.
■ In a child who is vomiting, nebulized
budesonide (2 mg) may be considered.
Acute epiglottitis
■ The classical presentation is:
■ a toxic child with a short history of sore
throat,
■ inspiratory stridor, muffled voice and
■ drooling due to odynophagia and
dysphagia.
■ progressive respiratory distress.
■ The child is febrile, tachypnoeic and is
sitting upright, with the neck extended
to optimize the airway, and using the
■ When acute epiglottitis is suspected,
pharyngeal examination should not be
attempted, as simple manipulation
with a tongue depressor may
precipitate acute airway obstruction,
■ the use of a fibreoptic or small rigid
endoscope can assist the diagnosis in
patients with an atypical presentation.
endoscopic evaluation will confirm
gross erythema and oedema of the
supraglottic structures.
■ When the diagnosis is confirmed, the
airway should be secured by
endotracheal intubation.
■ If this is unsuccessful, a rigid
bronchoscope may be passed to allow
tracheostomy. .
■ Despite this, mortality remains as high
as 2 percent.
■ Investigations prior to securing the airway
are contraindicated but a soft tissue lateral
radiograph of the neck will typically show a
thickened oedematous epiglottis – the
‘thumb sign’
Acute epiglottitis. Radiological appearance of
the oedematous epiglottis (arrowed).
■ The causative organism can be
identified from nasopharyngeal swabs,
laryngeal swabs, sputum samples or
blood cultures taken after intubation.
■ Traditionally, acute epiglottitis has
been a manifestation of invasive Hib
infection.
■ Other organisms are less common ;
they include: meningococcus,
Haemophilus parainfluenzae and
Staphylococcus aureus.
■
Treatment

■ Treatment is with intravenous

antibiotics; ampicillin resistance due to
beta-lactamase production is now over
50 percent in Haemophilus influenzae,
■ so empirical treatment with
third-generation cephalosporins for
five to seven days is advised.
■ Chloramphenicol is an alternative in
the event of allergy to cephalosporins.
■ Penicillin-sensitive Streptococci are the
usual cause of acute epiglottitis in
children who have been immunized
against Hib and they should be treated
accordingly.
■ Recovery is characterized by resolution
of systemic symptoms and the
supraglottic inflammation.
■ The child can then be extubated and
discharged from hospital.
■ Rifampicin prophylaxis has been
recommended to eradicate the carrier
state for unimmunized members of the
household who are four years old and
younger
■ THANK YOU