PNEUMONIA

DR MRS ODOCHI EWURUM

 INTRODUCTION
• Pneumonia is an inflammation of the
parenchyma of the lung caused by
microorganismns.
• The lung parenchyma consists of respiratory
bronchioles, alveolar ducts, alveolar sacs,
alveoli and interstitial tissue.
• Pneumonia results in a response that leads to
damage to the lung parenchyma in which
resolution may be partial or complete.
 INTRODUCTION
• Pneumonitis or alveolitis is appropriately
reserved for the inflammation of the lungs
caused by chemical or physical injury(e.g
burns)
 CLASSIFICATION
Pneumonia may be classified in various ways as
follows.
• Based on probable origin
- Community acquired
- Hospital acquired (nosocomial or health care
associated infection)
- Aspiration
- Pneumonia in the immunocompromised
patients
 CLASSIFICATION
• Based on anatomical involvement or pattern
of distribution
-Bronchopneumonia
-Lobar or segmental Pneumonia
• Based on the type of infecting organism
-Viral
-Bacterial
-Fungal
 CLASSIFICATION
-Atypical
-Parasitic
• Based on actual infecting organismn
-Pneumococcal, Streptococcal, Staphylococcal
- Hemophilus Influenza
- Tuberculous
 EPIDEMIOLOGY
• Pneumonia ranks high amongst the causes of
childhood morbidity and mortality.
• Infants and toddlers are more frequently affected
than older children.
• It occurs throughout the year however it is more
common during the rainy and harmattan season in
Nigeria.
• Unlike in developed countries the disease is usually
more severe in less priviledged communities.
 EPIDEMIOLOGY OF PNEUMONIA
• Pneumonia killed more than 80800 children
under the age of 5 years in 2017 or around
2,200 every day.
• I t accounts for 15% of all deaths of children
under 5 years.
• Globally there are over 1400 cases of
pneumonia per 100000 children, or I case per
71 children every year.
 EPIDEMIOLOGY
RISK FACTORS
• Lack of breast feeding especially exclusive
breast feeding
• Malnutrition including Vitamin A deficiency
• Poor Socio-economic status
• Large family size
• Young age in the <5 years especially within
the first 2 years
 EPIDEMIOLOGY
• Low birth weight
• Overcrowding
• Previous illness- HIV, SCA, congenital lung or
airway disorders
• Indoor and outdoor pollution including
smoking
 AETIOLOGY
• Viruses- most common cause of pneumonia in
children. Accounts for ≈50% in all ages but up
to 80% in < 2yrs
• Bacteria- organisms are age-dependent
• Atypical organisms- mycoplasma, chlamydia,
pneumocystis jiroveci, moxerella
• Fungal –Coccidiodes, Aspergillus,
Cryptococcus, Histoplasma.
• Parasitic- ascaris, toxoplasma, schistoma
• In 20-60% of pneumonias, no pathogen may
be identified.
 VIRAL PATHOGENS
• Viruses (common) • Viruses (uncommon)
– Respiratory syncytial – Varicella–zoster virus
virus- commonest – Coronaviruses
virus – Enteroviruses
(Coxsackievirus and
– Influenza A or B echovirus)
– Parainfluenza viruses – Cytomegalovirus
1, 2, and 3 – Epstein–Barr virus
– Adenovirus – Mumps virus
– Measles virus – Herpes simplex virus (in
newborns)
– Coxiella burnetii
 BACTERIAL PATHOGENS
Neonates • >3 years
• Escherichia coli • Strep pneumoniae
• Klebsiella • Strep pyogenes
• Group B streptococcus • Bordetella pertussis
• Staphylococcus aureus • Staph aureus
3 months- 3 years
• Streptococcus
pneumoniae- accounts
for > 70% of bacterial
causes
• Haemophilus influenzae
 ATYPICAL PATHOGENS
• Chlamydia pneumoniae- implicated in 3mo- 3
years
• Mycoplasma pneumoniae- implicated in > 3 years
• Moraxella catarrhalis
• Legionella pneumophila
• Chlamydia trachomatis- implicated in neonates
• Pneumocytis jiroveci- implicated in HIV infection,
immunocompromised
 PATHOPHYSIOLOGY
• The lower respiratory tract is normally kept
sterile by physiologic defense mechanisms
including;
-The mucociliary clearance.
-Secretory immunoglobulin A (IgA).
-Clearing of the airway by coughing.
 PATHOPHYSIOLOGY
• Immunologic defense mechanisms of the lung
that limit invasion by pathogenic organisms
include;
-macrophages that are present in alveoli and
bronchioles.
-secretory IgA.
- other immunoglobulins.
 PATHOPHYSIOLOGY
• The lower respiratory tract which is usually
sterile is constantly exposed to infectious and
other agents.
• Except for its defensive mechanisms, the tract
would have been overwhelmed by these
agents.
• However, a number of organisms overcome
these defenses and cause pulmonary
infection.
 PATHOPHYSIOLOGY
• The pathogens enter into the lower respiratory
tract through the following;
-Inhalation of airborne droplets with pathogens
-Descending from URTI or from other LRTI
-Aspiration
-Haematogenous spread
• After gaining entry into the lungs, the
organismns establish themselves in small
bronchioles and alveoli from where they spread
to other parts of the lungs.
 PATHOPHYSIOLOGY
• When the pathogen invades the alveolar sacs
they multiply leading to trigger of the body’s
immune response.

• The immune cells – alveolar macrophages,

neutrophils, lymphocytes and oesinophils
engulf the pathogens and release cytokines.
 PATHOPHYSIOLOGY
• The inflammatory response - apoptosis ,
vascular permeability with oedema, release of
cytokines- cause cell destruction and alveolar
congestion.
• This interrupts exchange of oxygen across the
alveolar membranes.
• The virulence and severity of the pneumonia
depends on the health of the individual, the
causative microrganismn and the size of the
innoculum.
 PATHOLOGY
Four Stages Of Inflammation occurs in
pneumonia. They are;
(1) Vascular Congestion: occurs within 24hrs.
-Characterized by marked capillary
engorgement/ congestion and alveolar
oedema.
-This protein-rich alveolar fluid contains
numerous bacteria and few neutrophils.
-This produces clear sputum.
 PATHOLOGY
(2) Red Hepatization:
-Occurs within the 2nd- 4th day. Many RBCs,
neutrophils, desquamated epithelial cells and
fibrin enter the alveoli.
-Lungs tissue appears red and has a similar
consistency as liver.
-This produces rusty sputum.
 PATHOLOGY
(3)Gray Hepatization: occurs within 4th -6th day.
-Alveoli filled with fibrinopurulent exudate made
up of haemolysed RBCs and de-granulated
neutrophils and macrophages.
-The haemosiderin from RBCs causes the lungs
to have gray-brown to yellow colour and firm
consistency but at this stage, the lungs are no
longer congested.
 PATHOLOGY
(4) Resolution:
-Occurs on the 8th -9th day.
-Characterized by resolution of the inflammatory
exudates and restoration of pulmonary
architecture by the breakdown of
inflammatory exudates by enzymes.
 LOBAR PNEUMONIA
• This is a type of pneumonia that involves one or
more lobes or part of a lobe of the lungs in which
the consolidation is virtually homogenous.
• AETIOLOGY
- Mostly caused by bacteria such as;
- Streptococcus Pneumonia
- Hemophius Influenzae
- Staphylococcus Pyogenes
- Streptococcus pyogenes
 LOBAR PNEUMONIA
• AETIOLOGY CONTD.
• Klebsiella Pneumoniae
• Pseudomonas
• Proteus specie
• Mycobacterium Tuberculosis
- Some cases of lobar pneumonia are caused by
viruses.
 LOBAR PNEUMONIA
• SYMPTOMS
- Fever, rigours
- Productive Cough
- Breathlessness
- Anorexia
- Pleuritic Chest pain
- Restlessness
- Cyanosis
 LOBAR PNEUMONIA
-Upper abdominal pain
-Vomitting and diahorrhea
-Occassionally haemoptysis
SIGNS
- Ill and anxious looking child
- Restless, toxic, cyanosed
- Tachycardia, dyspnea
- Tachypnea
 LOBAR PNEUMONIA
• SIGNS
- Central trachea and diminished chest expansion
over the affected segment or lobe.
- Dull percussion notes.
- Increase in tactile and vocal fremitus on the
affected side.
- Diminished breath sounds and bronchial breath
sounds sbsequently replaced by crepitations.
 BRONCHOPNEUMONIA
• There is patchy consolidation throughout a
lobe or the lungs.
AETIOLOGY
• Viral;
-Respiratory syncitial virus is probably the
commonest.
-Other viral causes include; Influenza,
parainfluenza, adenoviruses, rhinovirus and
measles.
 BRONCHOPNEUMONIA
AETIOLOGY
• Bacteria;
- Staphylococcus Pyogenes
- Streptococcus Pneumonia
- Haemophilus Influenza
- Mycobacterium Tuberculosis
 BRONCHOPNEUMONIA
• SYMPTOMS
- Fever
- Cough
- Breathlessness
- Anorexia
- Restlessness
- Cyanosis
 BRONCHOPNEUMONIA
SYMPTOMS
-Upper abdominal pain
-Vomitting and diahorrhea
-Chest pain is unusual
SIGNS
-Trachea is central
-Resonant percussion notes equal on both sides
-Crepitations( fine or coarse)
-Diminished breath sounds
INVESTIGATIONS FOR PNEUMONIA
The goals of investigation in Pneumonia are:
• To confirm the diagnosis.
• Determine the severity.
• Establish the presence of complications.
• To exclude the close differential diagnoses.
• To determine the causative organism.
• To monitor the response to the treatment
measures.
INVESTIGATIONS FOR PNEUMONIA
• The investigations of pneumonia include the
following;
(1) Radiology
(i) Chest X-ray
(ii) Chest Computed tomography
(iii) Magnetic resonance imaging
(2) Microbiological
(i) Nasal washings or nasopharyngeal swabs
(ii) Blood culture
INVESTIGATIONS FOR PNEUMONIA
(iii) Sputum culture
(iv) Pleural fluid culture
(v) Bronchoscopic fluid/ broncho-alveolar lavage
washings
(vi) Lung aspirate studies
(vii) Serology
(viii) Nucleic acid amplification test
(ix) Countercurrent immune-electrophoresis of
urine sample
INVESTIGATIONS FOR PNEUMONIA
(3) Arterial blood gas analysis.
(4) Serial pulse oximetry.
(5) Full blood count and differentials.
(5) Others:- Erythrocyte sedimentation rate
(ESR), C-reactive proteins.
INVESTIGATIONS FOR PNEUMONIA
RADIOLOGY
(i) CHEST XRAY;
- confirms the diagnosis of pneumonia and may
indicate a complication such as a pleural effusion or
empyema.
- Viral pneumonia is usually characterized by
hyperinflation with bilateral interstitial infiltrates
and peribronchial cuffing
- Confluent lobar consolidation is typically seen with
pneumococcal pneumonia
INVESTIGATIONS FOR PNEUMONIA
• RADIOLOGICAL FINDINGS IN PNEUMONIA;
-Peribronchial infilterates
-Lobar/segmental consolidation
-Air Bronchogramns
-Airspace obliteration
-Hilar lymphadenopathy
(ii) Chest CT and MRI is used under special
circumstances.
CHEST X-RAY IMAGE OF LOBAR
PNEUMONIA
CHEST X-RAY IMAGE OF LOBAR
PNEUMONIA
CHEST X-RAY IMAGE OF
BRONCHOPNEUMONIA
INVESTIGATIONS FOR PNEUMONIA
MICROBILOGY
(i) CULTURE OF SECIMENS;
- The definitive diagnosis of a bacterial infection
requires isolation of an organism from the
blood, pleural fluid, or lung.
- Blood culture correctly identifies the causative
oganismn in 20-30% of patients.
- Growth of respiratory viruses in tissue culture
usually requires 5–10 days.
INVESTIGATIONS FOR PNEUMONIA
-Sputum m/c/s is not reliable in children as sputum
will be contaminated by upper airway flora,
- Nasopharyngeal and throat swabs m/c/s may
identify the normal commensal organisms in the
nasopharynx and throat respectively and thus
not reliable in children.
-Pleural fluid culture, Bronchoscopic fluid/
broncho-alveolar lavage washings are used
when technically feasible.
INVESTIGATIONS FOR PNEUMONIA
• VIROLOGY;
- The definitive diagnosis of a viral infection
rests on the isolation of a virus or detection of
the viral genome or antigen in respiratory
tract secretions.
- Reliable DNA or RNA tests for the rapid
detection of RSV, parainfluenza, influenza, and
adenoviruses .
INVESTIGATIONS FOR PNEUMONIA
SEROLOGY;
-used to diagnose a recent respiratory viral infection but
generally require testing of acute and convalescent serum
samples for a rise in antibodies to a specific viral agent.
-Acute infection caused by M. pneumoniae can be
diagnosed on the basis of a positive PCR test or
seroconversion in an IgG assay.
-Serologic evidence such as the anti-streptolysin O (ASO)
titer may be useful in the diagnosis of group A
streptococcal pneumonia.
INVESTIGATIONS FOR PNEUMONIA
NUCLEIC ACID AMPLIFICATION TEST
-Used for a rapid detection of those pathogens
that are difficult to culture.
- An example is the polymerase chain
reaction(PCR) assay which may be applied to
specimens from respiratory secretions, lung
aspirate samples or blood.
INVESTIGATIONS FOR PNEUMONIA
COUNTERCURRENT IMMUNE-ELECTROPHORESIS
OF URINE SAMPLE;
-Involves identifying bacterial antigens of
capsulated bacteria like S. pneumoniae and H.
influenza even after initiating antimicrobial
treatment.
INVESTIGATIONS FOR PNEUMONIA
• PERIPHERAL WHITE BLOOD CELL COUNT (WBC);
-In viral pneumonia, the WBC count can be normal
or elevated but is usually not higher than
20,000/mm3, with a lymphocyte predominance.
-Bacterial pneumonia is often associated with an
elevated WBC count in the range of 15,000-
40,000/mm3 and a predominance of
granulocytes.
INVESTIGATIONS FOR PNEUMONIA
• BLOOD CHEMISTRY: Such as renal or hepatic
function are used to identify patients with co-
morbidities and dehydration.
• ARTERIAL BLOOD GAS ANALYSIS: Used to
assess the degree of hypoxia and the need for
oxygen administration.
• INVASIVE DIAGNOSTIC TECHNIQUES; Such as
thoracocentesis, bronchoscopy, transtracheal
INVESTIGATIONS FOR PNEUMONIA
- aspiration, transthoracic lung aspirate, open
lung biopsy are carried out to obtain suitable
materials for microscopic and cultural
evaluation.
DIFFERENTIAL DIAGNOSIS OF PNEUMONIA

These include;
• Bronchiolitis
• Bronchial Asthma
• Bronchitis
• Bronchiectasis
• Lung Abscess
• Pulmonary edema
• Atelectasis due to foreign body or thick mucus
• Chemical pneumonitis
 COMPLICATIONS OF PNEUMONIA
• ACUTE (SHARE 4PS)
- Septicemia, Heart failure, Atelectasis, Respirat-
ory failure, Empyema, Pleural effusion, Pyo-
pneumothorax, Pneumothorax,Pneumatocele,
Subcutaneous emphysema(rare except in
measles infecton).
• CHRONIC
- Lung Abscess, Bronchiectasis
 TREATMENT OF PNEUMONIA
• PRINCIPLES OF TREATMENT:
- Eradicate the infection.
-Give supportive treatment.
- Manage the complications.
• SPECIFIC; Antibiotics, Antiviral, Antifungal drugs.
Antimicrobial treatment is guided by age of the
patient, immune status, local epidemiologic
information, radiologic findings and microbiology
results if available.
 TREATMENT OF PNEUMONIA
• SUPPORTIVE
- Hospital admission when necessary
-Oxygen therapy with monitoring of ABG
- Antipyretics
- Fluid therapy
- Trial of Bronchodilators
- Nursing care
 TREATMENT OF PNEUMONIA
-Appropriate feeding
-Chest physiotherapy(Percussion, postural
drainage, tracheal suction)
INDICATIONS FOR HOSPITALIZATION IN
PNEUMONIA
Age <6 months, Sickle cell anemia with acute
chest syndrome, Multiple lobe involvement,
Immunocompromised state,Toxic appearance,
 TREATMENT OF PNEUMONIA
Severe respiratory distress, Requirement for
supplemental oxygen, dehydration, vomiting,
no response to appropriate oral antibiotic
therapy, noncompliant parents.
FOR COMPLICATIONS
- Digitalize in CCF.
- Drain pleural fluid.
- Transfuse if patient is anaemic.
 PREVENTION OF PNEUMONIA
• IMMUNIZATION; Against respiratory
pathogens e.g measles, diptheria, pertussis, H.
influenza etc
• HEALTH EDUCATION; Parents and caregivers
should be given health education as follows:
- Reduction of overcrowding
- Adequate nutrition
- Advantages of breastfeeding
 PREVENTION OF PNEUMONIA
- Avoidance of practices such as kissing children
by those with respiratory tract infection.
- Reduction in air pollution caused by cigarette
and wood smoke.
• LEGISLATION; Government should enact laws
to reduce environmental pollution and
discourage cigarette smoking.
 .

THANKS FOR YOUR

ATTENTION
 SUGGESTED READING
(1) Sectish T.C, Prober C.G. Pneumonia. In: Kleigman MR,
Berham ER, Jenson BH, Stanton FB, editors. Nelson’s
Textbook of Paediatrics.19th ed. Elsevier; 2011.
(2) Aderele W.I,Johnson A.W.B.R. Pneumonia. In Azubuike JC,
Nkanginieme KEO. Paediatrics and Child Health in a Tropical
region.3rd ed. Owerri: African Educational services; 2007.
(3) Webb J.K.G. Pneumonia. In: Stanfield P, Brueton M, Chan
M, Parkin M, Waterston T, editors. Diseases of Children in
the Subtropics and Tropics. 4th ed. Educational Low priced
books.
(4) Internet.