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Pneumonia, Pediatric, Emergency Medicine

Basics

Description

- <2 wk: - Group B Streptococcus species - Enteric gram-negative organisms - Respiratory syncytial virus (RSV) - Herpes simplex virus - S. aureus

- 3 mo " “8 yr: - Viral (predominate): - RSV - Parainfluenza virus - Influenza virus - Adenovirus

- General (in all ages): - Cough - Rales - Fever - Hypoxia - Tachycardia - Tachypnea, retractions, grunting - Rash (up to 10% of cases); usually maculopapular - Nonspecific symptoms of toxicity - Pulmonary exam: - Decreased breath sounds, ventilation - Dullness to percussion - Wheezing, ronchi, rales

- Infants <6 mo: - Altered behavior: Listless, irritable - Apnea (esp. RSV in premature infants) - Conjunctivitis (Chlamydia <1 mo old) - Cyanosis - Grunting - Poor feeding - Temperature instability (hypothermia/hyperthermia) - Vomiting, often with coughing - Cough - Nasal congestion - Nasal flaring - Wheezing - Staccato cough (Chlamydia)

- Children >5 yr: - Pleuritic chest pain - Productive cough - Rigors, chills

  • Mechanism is often unknown.
  • Source is oropharyngeal aspiration (most common) or hematogenous.
  • Distribution depends on the organism: Interstitial (Mycoplasma pneumoniae, virus), lobar (Streptococcus pneumoniae), abscesses (Staphylococcus aureus), or diffuse (Pneumocystis carinii)

Etiology

  • <2 wk:Group B Streptococcus speciesEnteric gram-negative organismsRespiratory syncytial virus (RSV)Herpes simplex virusS. aureus
  • 2 wk " “3 mo:Chlamydia trachomatisParainfluenza virusRSVS. pneumoniaeS. aureusH. influenzaBordetella pertussis
  • 3 mo " “8 yr:Viral (predominate):RSVParainfluenza virusInfluenza virusAdenovirusS. pneumoniaeH. influenza in unimmunized childrenGroup A streptococcusS. aureusB. pertussis
  • >8 yr:M. pneumoniae most commonViralS. pneumoniae
  • Recent immigrants from developing countries:Mycoplasma tuberculosisH. influenzaB. pertussis
  • Immunocompromised (e.g., HIV, cancer):P. cariniiMycoplasma avium complexM. tuberculosisKlebsiella pneumoniaePseudomonas aeruginosa
  • Less common:Fungal (coccidioidomycosis, histoplasmosis)Rickettsia (Q fever)

Diagnosis

Signs and Symptoms

  • General (in all ages):CoughRalesFeverHypoxiaTachycardiaTachypnea, retractions, gruntingRash (up to 10% of cases); usually maculopapularNonspecific symptoms of toxicityPulmonary exam:Decreased breath sounds, ventilationDullness to percussionWheezing, ronchi, rales
  • Infants <6 mo:Altered behavior: Listless, irritableApnea (esp. RSV in premature infants)Conjunctivitis (Chlamydia <1 mo old)CyanosisGruntingPoor feedingTemperature instability (hypothermia/hyperthermia)Vomiting, often with coughingCoughNasal congestionNasal flaringWheezingStaccato cough (Chlamydia)
  • Children >5 yr:Pleuritic chest painProductive coughRigors, chills

History

  • Immunization history
  • Past medical history include immune status
  • Exposures
  • Progression of signs and symptoms

Physical Exam

  • Pulmonary exam may be helpful, particularly in children >5 yr.
  • Peripheral and central cyanosis should be assessed.
  • Evidence of respiratory compromise, distress, failure

Essential Workup

  • Pulse oximetry
  • Chest radiograph:Gold standard for diagnosisShould be ordered for patients with signs of lower respiratory tract infection and patients <36 mo old with marked leukocytosis or neutrophilia (WBC >15,000 or absolute neutrophil count [ANC] >9,000).Much overlap between viral and bacterial findingsViral and M. pneumoniae tend to show interstitial infiltrates, often perihilar and peribronchial.Bacterial pneumonias may show focal lobar consolidation, focal alveolar infiltrates, and possibly effusion or pneumatocele.Round pneumonia pathognomonic of S. pneumoniaLateral decubitus films may aid in demonstrating effusion.

Diagnosis Tests & Interpretation

Lab

  • CBC with differential:Patients with bacteremia tend to have leukocytosis with left shift.Sensitivity and specificity are poor.Patients with WBC ≥20,000 or ANC >9,000 are at increased risk of pneumococcal bacteremia.B. pertussis usually has elevated WBC with lymphocytosis.
  • Blood culture:Low yield (<10 " “20%)Recommended in children <36 moProbably worthwhile in toxic patients requiring hospitalization
  • Arterial blood gas may be useful in determining degree of respiratory insufficiency in critically ill patients.
  • Electrolytes to exclude syndrome of inappropriate antidiuretic hormone secretion and in hypotensive children
  • Sputum for Gram stain and culture may be obtained in older children with suspected bacterial infection.
  • Mycoplasma IgM or cold agglutinin titers:Useful if suspecting this organismMore likely positive with severe illness
  • Nasopharyngeal washes for direct fluorescent antibody and culture:Identify RSV, C. trachomatis, and B. pertussis infections

Imaging

Chest radiographs are still the imaging modality of choice: ‚

  • Posteroanterior and lateral films should be obtained whenever possible.
  • CT provides additional detail and better identification of underlying lung pathology but adds little as an initial testing modality.

Diagnostic Procedures/Surgery

Pleural fluid (if present) for culture, Gram stain, protein, glucose, and cell counts ‚

Differential Diagnosis

  • Reactive airway disease (asthma, bronchiolitis [age <2 yr])
  • Aspiration:Gastroesophageal refluxVascular ringH-type tracheoesophageal fistulaForeign bodyHydrocarbon
  • Congestive heart failure
  • Congenital:Cystic fibrosisSequestered lobeCongenital lobe absenceHemangioma
  • Neoplasm

Treatment

Pre-Hospital

  • Pulse oximetry
  • Administer high-flow oxygen for respiratory distress.
  • IV fluids (0.9% normal saline [NS] 20 mL/kg initial bolus) for volume depletion, hypotension
  • Support and intubation for respiratory failure

Initial Stabilization/Therapy

  • If moderately or severely ill:Secure airway, as appropriate; intubate for clinical respiratory failure. Children with severe sepsis or septic shock benefit from aggressive airway management.High-flow oxygenIV hydration (0.9% NS 20 mL/kg initial bolus) and resuscitation if in shock or hypovolemia
  • Monitor
  • Ongoing pulse oximetry
  • Arterial blood gas if inadequate ventilation
  • Check bedside glucose in severely ill-appearing infants and toddlers:If hypoglycemic, administer glucose D25 at 2 mL/kg IV for toddlers or D10 at 5 mL/kg IV for neonates.

Ed Treatment/Procedures

  • Continue pre-hospital and initial stabilization therapy.
  • Early antibiotic therapy should be broad enough to address local resistance patterns in your area.
  • Often have concurrent reactive airway disease that needs specific treatment with bronchodilator (albuterol or levalbuterol)
  • Perform thoracentesis if pleural effusion is compromising respiratory function or for diagnostic tests.

Medication

  • Empiric therapy with oral antibiotics for most well-appearing children ≥6 mo:Infants <2 mo:Outpatient treatment generally not recommended unless child has no respiratory distress or associated conditions or issues.Children 3 mo " “5 yr:AmoxicillinAmoxicillin " ”clavulanateTrimethoprim " ”sulfamethoxazoleErythromycin " ”sulfisoxazoleMacrolide (azithromycin or clarithromycin)Children 5 " “18 yr:Macrolide (azithromycin or clarithromycin)
  • Initiate IV antibiotic therapy for moderate to severely ill children who require admission:Neonate:Ampicillin, and cefotaxime or gentamicinAzithromycin for suspected C. trachomatis or B. pertussis pneumoniaInfants 1 " “2 mo:Ampicillin and cefotaximeAzithromycin or erythromycin for suspected C. trachomatis or B. pertussisChildren ≥3 mo:Cefotaxime, cefuroxime, or ceftriaxoneVancomycin for suspected or confirmed penicillin-resistant S. pneumoniaeMacrolide (i.e., azithromycin) for suspected M. pneumoniaeClindamycin if group A strep suspected in patient with severe disease
  • Unusual organisms require specific therapy in coordination with infectious disease consultation.
  • Albuterol (0.5% solution or 5 mg/mL): Nebulizer 0.015 mg (0.03 mL)/kg per dose up to 5 mg per dose q10 " “20min as needed; metered dose inhaler (with spacer; 90 mg per puff) 2 puffs q10 " “20min up to total of 10 puffs
  • Amoxicillin: 80 mg/kg/24 h q12h PO
  • Amoxicillin " “clavulanate: 30 mg/kg/24 h q12h PO
  • Ampicillin: 100 " “150 mg/kg/24 h q6h IV
  • Azithromycin: 10 mg/kg/24 h daily for 1 day, then 5 mg/kg/24 h daily for 4 days
  • Cefotaxime: 50 " “75 mg/kg/24 h q8h IV, max. 2 g q8h
  • Ceftriaxone: 100 mg/kg/24 h q12 " “24 h IV, max. 2 g q12h
  • Cefuroxime: 100 mg/kg/24 h q8h IV, max. 2 g q8h
  • Clarithromycin: 15 mg/kg/24 h q12h PO, max. 500 g q12h
  • Clindamycin 30 " “40 mg/kg/24 h q6 " “8h IV
  • Erythromycin " “sulfisoxazole: 40 mg/kg/24 h as erythromycin q8h PO, max. 2 g/d
  • Gentamicin: 5 " “7.5 mg/kg/24 h q8 " “12h IV
  • Trimethoprim " “sulfamethoxazole: 8 " “10 mg/kg/24 h as TMP q12h PO
  • Vancomycin: 10 " “15 mg/kg/24 h q8 " “12h IV; max. 1,000 mg

Follow-Up

Disposition

Admission Criteria

  • Toxic appearance
  • Respiratory distress or failure
  • Dehydration/vomiting
  • Apnea
  • Infants <2 mo
  • Infants <6 mo with lobar pneumonia
  • Hypoxia (O2 saturation <92% on room air [sea level])
  • Pleural effusion
  • Poor response to outpatient oral therapy
  • Immunocompromised children
  • Concern about noncompliant parents

Discharge Criteria

  • Most cases are mild and can be discharged home if no evidence of hypoxia, significant work-of-breathing, dehydration, vomiting, or noncompliance.
  • Ensured follow-up within 1 " “2 days

Issues for Referral

Respiratory failure, effusion, toxicity ‚

Followup Recommendations

Clinical resolution should be ensured through follow-up. ‚

Pearls and Pitfalls

  • Early, aggressive airway management for patients with severe sepsis and septic shock
  • Delays to antibiotic therapy should be avoided.
  • Discharged patients should have clear evidence of good support, follow-up, and lack of toxicity.
  • Local patterns of drug resistance should be known and empiric therapy should take these resistance patterns into consideration.

Additional Reading

  • Cevey-Macherel ‚ M, Galetto-Lacour ‚ A, Gervaix ‚ A, et al. Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines. Eur J Pediatr. 2009;168(12):1429 " “1436.
  • Kronman ‚ MP, Hersh ‚ AL, Feng ‚ R, et al: Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007. Pediatrics 2011;127:411 " “418.
  • Michelow ‚ IC, Olsen ‚ K, Loranzo ‚ J, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. 2004;113(4):701 " “707.
  • Murphy ‚ CG, van de Pol ‚ AC, Harper ‚ MB, et al. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med. 2007;14(3):243 " “249.
  • Shah ‚ SS, Dugan ‚ MH, Bell ‚ LM, et al. Blood cultures in the emergency department evaluation of childhood pneumonia. Pediatr Infect Dis J. 2011;30:475 " “479.

See Also (Topic, Algorithm, Electronic Media Element)

Asthma ‚

Codes

ICD9

  • 483.0 Pneumonia due to mycoplasma pneumoniae
  • 486 Pneumonia, organism unspecified
  • 507.0 Pneumonitis due to inhalation of food or vomitus
  • 481 Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]
  • 480.1 Pneumonia due to respiratory syncytial virus
  • 480.9 Viral pneumonia, unspecified
  • 482.40 Pneumonia due to Staphylococcus, unspecified
  • 483.1 Pneumonia due to chlamydia
  • 484.3 Pneumonia in whooping cough

ICD10

  • J15.7 Pneumonia due to Mycoplasma pneumoniae
  • J18.9 Pneumonia, unspecified organism
  • J69.0 Pneumonitis due to inhalation of food and vomit
  • J13 Pneumonia due to Streptococcus pneumoniae
  • J12.1 Respiratory syncytial virus pneumonia
  • J12.9 Viral pneumonia, unspecified
  • J15.211 Pneumonia due to methicillin suscep staph
  • J16.0 Chlamydial pneumonia
  • J17 Pneumonia in diseases classified elsewhere

SNOMED

  • 233604007 Pneumonia (disorder)
  • 422588002 aspiration pneumonia (disorder)
  • 46970008 Pneumonia due to Mycoplasma pneumoniae (disorder)
  • 34020007 pneumonia due to Streptococcus (disorder)
  • 195881003 Pneumonia due to respiratory syncytial virus
  • 233609002 Chlamydial pneumonia
  • 441658007 pneumonia due to Staphylococcus aureus (disorder)
  • 59475000 Pneumonia in pertussis (disorder)
  • 75570004 Viral pneumonia (disorder)