Lower respiratory tract infections

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Lower respiratory tract infections in children

• Mostafavi SN. MD
• Pediatric infectious disease departement
• Isfahan University of Medical Science

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Lower respiratory tract infections

• Pneumonia
• Viral
• Bacterial
• Afebrile
• Atypical
• Aspiration
• Nosocomial
• Bronchiolitis
• Empyema

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Case 1

• A 6 months old boy brought with high fever and
  cough. On physical exam tachypnea and bilateral
  coarse rales were found. Whats your diagnosis?

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Diagnosis of pneumonia

• What's suggestive symptoms and signs of
  pneumonia?
• Which patient has definite diagnosis of pneumonia?

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Symptoms/signs of pneumonia

• All respiratory infections fever, cough,
• Lower respiratory involvement respiratory
  distress, tachypnea, cyanosis
• Pneumonia fine rales, decreasing breath sounds,
  bronchophonia,
• Definite new pulmonary infiltration in CXR

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Case 1-1

• A 6 months old boy brought with high fever and
  cough. On physical exam tachypnea and bilateral
  coarse rales were found. Whats your diagnosis?

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Case 1-2

• A 6 months old boy brought with high fever and
  cough. On physical exam tachypnea and bilateral
  coarse rales were found. Whats your diagnosis?

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Case 1-2

• Has the infant need admission?

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Admission criteria in pneumonia

• Inability to intake fluid or medications
• Cyanosis( o2 satlt 92)
• Severe respiratory distress( apnea, )
• Toxic appearance
• Pleural effusion
• Sometimes lt 1 year

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Case 1-2

• Has the patient need antibiotic?

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Type of pneumonia Viral bacterial
History Agelt 5, gradual onset, mild fever, cough, respiratory distress Abrupt onset, high fever, severe cough, significant respiratory distress
Physical exam Bilateral rales, high pitched breath sounds, Focal rales
X ray infiltrates Bilateral interstitial , peribronchiolar, parenchymal, hyperinflation Lobar, lobular consolidation , dense parenchymal
ESR, CRP, WBC, PMN NL to mild increase Significant increase
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Case 1-3

• A 6 months old boy brought with high fever and
  cough. On physical exam tachypnea and bilateral
  coarse rales were found. If he need any
  antibiotic?

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Case 1-2

• A 6 months old boy brought with high fever and
  cough. On physical exam tachypnea and bilateral
  coarse rales were found. If he need any
  antibiotic?

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• Which antibiotic should be prescribed for the
  infant?

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Microorganism Outpatient Inpatient
S. pneumonia High dose amoxicillin( 85), macrolides(60-80) High dose penicilline(85), high dose ampicilline( 85), Ceftriaxone( gt 95), ceftriaxon vancomycine( 100)
H. Inluenza ( lt 5 yr) Low dose amoxicillin( 50), low dose co Amoxiclav (gt95), macrolids(gt 90) Low dose ampicillin(50), ceftriaxone( 100)
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Case 1-2

• What's the clinical course of the patient?

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Clinical course of bacterial pneumonia

• Improve in fever and respiratory signs in 48-72
  hours
• Clearing CXR in 4-8 weeks

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Case 2

• A 7 years old girl brought with high fever,
  malaise, protracted cough, mild diarrhea since 5
  days ago. On PE she had bilateral fine rales
  without significant respiratory distress. She
  received coamoxiclave since 72 hour ago. Whats
  your diagnosis?

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Atypical pneumonia

• What's the suggestive symptoms and signs of
  atypical pneumonia?

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Atypical pneumonia

• Age 5-15 yr
• Severe constitutional signs high fever,
  prolonged fever, anorexia, malaise
• Mild respiratory signs coryza, protracted
  prolonged cough, no/mild distress, bilateral mild
  rales
• Prominent extrapulmonary signs rash, diarrhea,
  abdominal pain, CNS,
• Prominent x ray abnormalities bilateral
  interstitial, lobar infiltrates specially in
  lower lobes
• No response to beta-lactams and dramatic response
  to azithromycine, clarithromycine, erythromycine

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Case 3

• A 2 month old boy brought with severe cogh since
  two days ago and coryza and mild cough since five
  days ago. His mother has signs of URTI since 7
  days ago. On PE RR70/min, mild cyanosis and
  diffuse wheezing were found. What's your
  diagnosis?

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Main clues in bronchiolitis

• Agelt1 yr ( 2-6 mo), peak admission 1-3 mo
• Epidemic in Day to Farvardin months
• Initially coryza, cough then severe cough,
  wheezing, dyspnea
• Sometimes fever
• Hyperinflation, perihilar infiltration in x ray

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Case 3- x ray
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Case 3

• A 2 month old boy brought with severe cogh since
  two days ago and coryza and mild cough since five
  days ago. His mother has signs of URTI since 7
  days ago. On PE RR70/min, mild cyanosis and
  diffuse wheezing were found. Has the patient need
  admission?

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Admission in bronchiolitis

• O2 saturationlt 90-92
• Agelt 6 wk
• Reduced intake
• Underlying heart, lung, immunological disease
• Severe respiratory distress including apnea

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• What's the outpatient management of bronchiolitis?

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Out patient management of bronchiolitis

• No effect of salbutamol, theophylline G,
  corticosteroids, cough suppressants
• Supine position with the head elevated
• Small frequent feeding
• Nose drops and clearing
• Warning signs
• Mist therapy

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