Ch 19 PEDS Community Acquired Pneumonia (B/V), Parapneumonic effusion and empyema, Bronchiolitis, Mycoplasma pneumonia, Aspiration pneumonia

Question 1

Children less than 2 years old with community-acquired pneumonia is often _______

Answer 1

Viral

Question 2

What are viral pathogen causes of community-acquired pneumonia?

(PHIR)

Answer 2

Parainfluenza
Human metapneumonvirus
Influenza A/B
RSV

Question 3

What is the MOST common bacterial cause of Community-acquired pneumonia in children?

What are some less common causes? (newborn, atypical)

Answer 3

S. pneumoniae (bacterial usually follows viral lower respiratory tract infection)

Other bacteria less common:
Chlamydia trachomatis (newborns to 12 weeks)
C. pneumoniae,
C. pittaci
B. pertussis
M. pneumonia (often referred to as “atypical pneumonia”, more common in children > 5yr)
Legionella

Question 4

What kinds of children are at high risk for bacterial community-acquired pneumonia?

(I AM A)

Answer 4

Compromised pulmonary defense system:

Immunocompromised
Aspirates own secretions or while eating
Malnourished children
Abnormal mucociliary clearance

Question 5

What are NOT reliable findings or diagnostic tools that may distinguish viral from bacterial pneumonia?

Answer 5

Findings:
Fever
Severity of illness
Character of cough

Diagnostic:
CBC
Chest XRAY (some differences, cannot determine severity, may show improvements overtime)

Question 6

What may the CBC show for bacterial community-acquired pneumonia in a child? What about overwhelming infection?

Answer 6

WBC elevated with left shift

Overwhelming infection - WBC < 5000

Question 7

What treatment should the NP institute for Community-acquired pneumonia?

Answer 7

General supportive measures:
   Antipyretics
   Increased fluids (hydrate/electrolytes)
   Nutrition
   O2 if hypoxic

Viral or Bacterial:
PO Amoxicillin 5 - 10 days (unless you know the cause ie viral influenza = O,Z / bacterial M. Pneum = macrolide (azirthryomycin)

Question 8

List the patients that should be hospitalized for Community-acquired pneumonia (viral or bacterial, does not make a difference):

(_____ and ____ with M-CHEAP)

Answer 8

all infants < 3 months for abx (IV or PO)
(note: consider hospitalization for 3 - 6 months old, greater than 6 months with no RDS can be treated PO amoxcillin)

any child with: 
   Moderate or Severe respiratory distress
   Clinical deterioration on treatment
   Hypoxemia
   Effusion of CXR
   Apnea
   Poor feeding

Question 9

If patient is managed outpatient, what is the treatment for Bacterial Community-acquired pneumonia with the S. Pneumoniae pathogen? Follow-up?

(know drug, dose, frequency, duration)

Answer 9

Empiric antibiotic -
Treat S. Pneumoniae
AMOXICILLIN 80 - 90 mg/kg/day BID for 5-10 days

Close follow-up within 12 hours to 5 days

Question 10

If the patient is managed outpatient, what is the treatment for Bacterial Community-acquired pneumonia with the M. Pneumoniae pathogen? (drug, dose, frequency, duration)

What class of medications should be considered?

Follow-up?

Answer 10

Children > 5 years old higher incidence of M.Pneumoniae
AMOXICILLIN 80 - 90 mg/kd/day BID for 5 - 10 days

Consider Macrolide antibiotics for M. Pneumonia

Close follow up within 12 hours to 5 days

Question 11

What is the best treatment option for a child with viral RSV pneumonia? A Child with a history of congenital heart disease with RSV pneumonia, what should be considered for this child?

Answer 11

General supportive care

Any child with BPD or any severe pulmonary/heart conditions or immunocompromised =
hospitalized
possible Ribavirin
rapid viral diagnostic tests

Question 12

What medications can be given to a child with Influenzae A/B pneumonia?

OZ

Answer 12

Start within 48 hours of symptoms, give for 5 days

Oseltamvir (Tamiflu)
Zanamivir (Relenza) must be > 5 years old

Question 13

What two medications are not recommended for influenzae A/B community-acquired pneumonia

Answer 13

Amantadine
Rimantadine

Both are ANTIVIRALS
High resistance

Question 14

What class of medications is best for bacterial community-acquired pneumonia with S. Pneumoniae for children allergic to penicillins?

Answer 14

Cephlasporins or macrolides (S. Pneumoniae may be resistant to macrolides*)

Question 15

_______ is an atypical pneumonia that is the most serious acute respiratory illness in infants and young children.

Answer 15

Bronchiolitis - this is an atypical pneumonia (pg527Hays)

Question 16

A young child with a previous upper respiratory infection that has progressed to a cough, tachypnea, respiratory distress, and crackles or wheeze on physical exam is most likely:

Answer 16

Bronchiolitis

Question 17

What pathogens are commonly associated with Bronchiolitis?

HARP

Answer 17

Viral:
   Human Metapneumovirus
   Adenovirus
   RSV
   Parainfluenza / Influenza

(bacterial causes are less common)

Question 18

What are known risk factors that increases the likelihood of severe Bronchiolitis development? (who are high risk children)

What should you consider in terms of treatment for these children?

(P-CONS)

Answer 18

Infants < 6 months old
Premature < 35 weeks gestation history
Congential heart disease
Other severe pulmonary conditions (BPD, Pulm. HTN)
Neuromuscular disease
Significant immunocompromise

RSV prophylaxis therapy (Palivizumab vaccine - must qualify for treatment)

Question 19

What findings are typical for RSV Bronchiolitis?

Answer 19

1 - 2 days of fever
Rhinorrhea and Cough

then progresses to: Wheezing, Tachypnea, or Respiratory distress

breathing will be shallow with rapid respirations

Question 20

Current recommendations via AAP for Bronchiolitits instructs the NP to not utilize what diagnostic tools?

(include diagnostic tools and medication classes)

Answer 20

Diagnostic tool:
Viral Nasal Swab for routine RSV testing (only use this if an infant has been on prophylaxis with Palivizumab)
Chest XRAY (must have respiratory distress)

Medications:
Albuterol/salbutamol (no evidence for effectiveness)
Corticosteroids (no evidence for effectiveness)
Antibiotics (unless bacterial pathogen is strongly suspected)

Question 21

A child with suspected Bronchiolitis presents in your office. Respiratory distress is found on exam, the NP orders a chest XRAY.

What will the NP expect to see on XRAY for a child with Bronchiolitis?

Answer 21

Non-specific hyperinflation
Increased interstitial markings

(both are common viral caused findings on XRAY)

Question 22

Children that are severely ill from Bronchiolitis/severe RSV infections and have a cardiopulmonary or immune defect should be given what antiviral therapy?

Answer 22

Ribavirin (ANTIVIRAL) aerosol treatment

high-risk patients or severely ill patients should be hospitalized and given this antiviral

Question 23

Palivizumab injection is _____ and is only given to what types of individuals? When is this vaccine offered?

Answer 23

used to help prevent RSV - a RSV prophylaxis therapy

Give to: < 2 year olds who are at high risk for getting RSV
(prematurely born, CHD or lung diseases)

offered during RSV season, followed by a dose every 38 - 30 days throughout RSV season (Nov. - April)

Question 24

T/F Most children with RSV bronchiolitis are treated as outpatients

Answer 24

TRUE! - hospitalization is only necessary for severely ill or have high risk life-threatening risk factor

Question 25

A child with RSV bronchiolitis that needs to be hospitalized will present as: (HAMM)

Answer 25

Hypoxic on room air history of Apnea Moderate tachypnea with feeding difficulties/poor oral hydration Marked respiratory distress with retractions

Question 26

What three pathogens are found in Empyema? | Which one is the most common?

Answer 26

Streptococcus Pneumonia (most common) Haemophilus Influenzae Staphylococcus Aureus

Question 27

What kind of chest XRAY should you order on a child with suspected Empyema?

Answer 27

Lateral Decubitus (remember, this helps visualize pleural fluid - unless the fluid is loculated)

Question 28

What should the NP expect on exam in a child with empyema during the percussion assessment?

Answer 28

Dullness via percussion on the affected side The child will also prefer to lie on the affected side (easier to breathe)

Question 29

A large effusion may have what specific finding on exam?

Answer 29

Tracheal deviation to the contralateral side

Question 30

What are three expected findings in lab work and diagnostic tools for an empyema?

Answer 30

Elevated WBC with left shift Positive blood cultrure Thoracentesis - Neutrophils present in pleural fluid Bacterial thoracentesis results - pH < 7.2 and low glucose

Question 31

The thoracentesis for parapnuemonic effusion/empyema has identified your patient's causative organism, what should you order for treatment?

Answer 31

IV Antibiotics Drainage of fluid/effusion (large effusions may require chest tube drainage and/or video-assisted thoracoscopic surgery) Early use of Fibrinolytics - becoming standard of care in pediatrics

Question 32

A 5 year old child presents to your clinic bracing his chest with a fever, dry cough, that the mom reports it has been 3 weeks of this. Now her child has 'mucous when he coughs.' On auscultation, rales are present. What should you suspect?

Answer 32

Mycoplasma Pneumonia - affects children > 5 years old, presents with fever and dry cough at onset. Develops into sputum production cough, headache, and malaise. Rales and chest pain are also present.

Question 33

What pathogen is commonly associated with Mycoplasma Pneumonia?

Answer 33

M. Pneumoniae incubation is 2 - 3 weeks long with slow onset of symptoms

Question 34

What are three expected findings in lab work and diagnostic tools for Mycoplasma Pneumonia?

Answer 34

Normal total WBC with differential Enzyme Immunoassay (EIA) and Complement fixation are sensitive and specific for M Pneumoniae (esp. asymptomatic children) Chest XRAY - infiltrates PCR - gold standard for diagnosis - however, the EIA and complement fixation are more specific for M. Pneumoniae bacteria.

Question 35

What life-threatening hematologic disorder may accompany M pneumoniae infection?

Answer 35

Direct Coombs-positive autoimmune hemolytic anemia

Question 36

What treatment is considered for the child with Mycoplasma pneumonia?

Answer 36

Supportive measures: hydration, antipyretics, bedrest Antibiotic class: MACROLIDES 7 - 10 days Azithromycin 10mg/kg (MAX 500mg) PO, then 5mg/kg/day (MAX 250mg) Alternate med: Ciprofloxacin

Question 37

What is the common cause of aspiration pneumonia?

Answer 37

Bacteria/gram-negative anaerobes in the mouth (chronic aspiration causes recurrent bouts of acute febrile pneumonia with “rattling” cough, wheezing, chronic chest infiltrates, failure to thrive)

Question 38

In aspiration pneumonia, what part of the lung is commonly affected?

Answer 38

right upper lobe in a supine patient

Question 39

T/F Children with underlying medical conditions are more at risk for developing aspiration pneumonia

Answer 39

TRUE! - table 19-6 pg. 529 Hays

Question 40

What underlying medical conditions place a child at a greater risk for aspiration pneumonia? (ASCENDING-M)

Answer 40

Anatomic Abnormalities (cleft, TE fistula, Vocal cord paralysis) Seizures CNS malformations/mass/TBI Encephalopathy Near-drowning Delayed maturation (down syndrome/prematurity) Iatrogenic (anesthesia, NG tube, tracheostomy tube) Neuromuscular disorders GI disease (reflux, achalasia, obstruction) Medications - depressed sensorium

Question 41

T/F Aspiration pneumonia is an acute illness

Answer 41

FALSE - aspiration pneumonia may be acute or chronic

Question 42

What findings may only present in chronic aspiration pneumonia versus acute aspiration pneumonia?

Answer 42

``` Chronic: *** "chest rattling" *** cough or wheezing chronic chest infiltrates bronchiectasis failure to thrive ``` Acute: typical pneumonia syndrome (acute onset of fever, cough, RD, hypoxemia, asymmetric auscultation findings, and asymmetric imaging findings)

Question 43

What are expected findings on a chest XRAY in a child with acute aspiration pneumonia?

Answer 43

Lobar CONSOLIDATION or Atelectasis | Focal or generalized alveolar or interstitial INFILTRATES

Question 44

What are expected findings on a chest XRAY in a child with chronic aspiration pneumonia?

Answer 44

PERIHILAR INFILTRATES with or without | Bilateral AIR TRAPPING

Question 45

_________ diagnostic can best delineate complications such as bronchiectasis in chronic aspiration or empyema in acute aspiration

Answer 45

Chest CT

Question 46

Patients with chronic aspiration pneumonitis, should be evaluated for ________

Answer 46

Dysphagia - impaired swallowing (see diagnostic tools related to the respiratory tract - rigid bronchoscopy*, FEES, VFSS*, UGI)

Question 47

What are some differential diagnosis related to aspiration pneumonia? (acute vs chronic) (chronic - FLICC)

Answer 47

Acute: Bacterial or viral pneumonias ``` Chronic: (common recurrent pneumonia disorders) Immunodeficiencies Ciliary dysfuncion Foreign body Chronic wheezing Interstitial lung disorders ```

Question 48

What is the treatment plan for an acutely ill aspiration pneumonia child?

Answer 48

Supportive: antipyretics, hydration, o2 if hypoxic | Antimicrobial therapy ***Clindamycin initial coverage***

Question 49

What is the treatment plan for chronic aspiration pneumonitis? (STOIC S)

Answer 49

Surgical correction of any anatomical abnormality Thickened liquids/Pacing systems or bottles Oral hygiene Inhaled Corticosteroids Chest PT Swallowing therapy Compromised CNS? = gastrostomy exclusively fed