Bronchopneumonia

CHAPTER II

LITERATURE REVIEW

2.1. Definition

            Bronchopneumonia is a condition that child with respiratory distress; any of: rapid, noisy, or difficult breathing; respiratory rate >60/min; chest retractions; cough; grunting; who has a positive blood culture or predisposing factors. Bronchopneumonia which is a febrile illness with cough, respiratory distress with evidence of localised or generalised patchy infiltrates on chest x-ray.¹

In bronchopneumonia, the focus of infection and the inflammatory response is in the bronchi and surrounding parenchyma. Consolidation is segmental in distribution, and involvement is patchy; segmental involvement may become confluent to produce a more homogeneous pattern. Bronchopneumonic patterns are commonly observed in pulmonary infections due to S. aureus or nonencapsulated H. influenzae. With S. aureus infections, macro- and microabscess formation may occur rapidly. Also, pneumatoceles occur during the first week of lung involvement in about half the children with S. aureus pneumonia. These cystic spaces are believed to be the consequence of a check valve opening between a peribronchial abscess and an adjacent bronchus.

A bronchopneumonic pattern of consolidation is commonly observed when pneumonia is engrafted on underlying bronchiectasis or chronic bronchitis. In such predisposing circumstances, S. pneumoniae infection may produce a bronchopneumonic pattern rather than its usual lobar consolidation. In the presence of underlying emphysema, the radiographic pattern of pneumococcal pneumonia may also be altered from its usual homogeneous pattern to one that contains multiple radiolucencies (representing unconsolidated emphysematous areas) that may be misinterpreted as abscesses.

Segmental bronchopneumonia is the radiographic picture in pneumonia due to C. pneumoniae or M. pneumoniae, and in many viral pneumonias. Any of the bacterial species that cause nosocomial pneumonia can produce a radiographic pattern of bronchopneumonic consolidation.

Like lobar pneumonia, centrilobular and peribronchiolar opacity pneumonia (bronchopneumonia), a characteristic imaging category of pneumonia that is commonly encountered in all patient groups. It is an especially common imaging category in CAP that follows viral infection. It is also called bronchopneumonia because it is associated with acute infection of the walls of bronchioles that spreads into the peribronchiolar alveoli, and often involves the lung in a patchy multifocal distribution.

       I.            Predisposing factors of bronchopneumonia;

a.       Maternal fever (≥ 38˚C)

b.      Foul smelling liquor

c.        Prolonged rupture of membranes (>24 hours)

    II.            Clinical picture of sepsis

a.       Poor feeding

b.      Lethargy

c.       Poor reflexes

d.      Hypothermia or hyperthermia

e.       Abdominal distension

 III.            Radiograph suggestive of pneumonia

a.       nodular or coarse patchy infiltrate

b.      diffuse haziness or granularity

c.       air bronchogram

d.      lobar or segmental consolidation

e.       radiological changes not resolved within 48 hours

 IV.            Positive sepsis screen (any of the following):

a.        Bands ≥ 20% of leucocytes

b.      Leucocyte count out of reference range

c.       Raised C reactive protein

d.      Raised erythrocyte sedimentation rate

2.2. Etiology  

Many patients with bronchopneumonia have mild and self-limited disease attributable to respiratory viruses, including epidemic influenza, adenovirus, rhinovirus, and respiratory syncytial viruses (RSV). Some of these viruses can produce more serious primary pneumonia, as well as set the stage for bacterial or other etiology superinfection pneumonia, especially when there are co-morbid conditions. Severe acute respiratory syndrome, a newly identified coronavirus infection, can produce severe viral pneumonia with a broad spectrum of imaging findings, including bronchopneumonia.

Other organisms that commonly cause bronchopneumonia include Mycoplasma pneumoniae, Chlamydia pneumon;iae, Haemophilus influenzae, and Neisseria catarrhalis (Moraxella catarrhalis).Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa are also common causes of nosocomial (and ventilator-associated) bronchopneumonia, and of community-acquired bronchopneumonia in patients with co-morbid conditions. These latter pneumonias are associated with necrosis, abscess formation and pleural effusion.

           

The role of Staphylococcus aureus in the etiology of bronchopneumonia in the ventilator-associated milieu pneumonia (VAP) is controversial because airway recovery of the organism is not usually associated with the characteristic imaging signs of CAP caused by that organism in patients without co-morbid conditions, i.e., rapid development and necrosis. The organisms that cause peripheral airspace consolidation pneumonia are not restricted from also causing bronchopneumonia when bronchioles are already inflamed by recent infection.

Non-infectious simulators and etiologies of centrilobular and peri-bronchial opacities include aspiration pneumonia, itself a frequent non-infectious cause of bronchopneumonia, as

well as a facilitator of superinfection. Other causes include bronchiolo-alveolar cell carcinoma, non-infectious granulomasdue to pneumoconiosis, sarcoidosis, respiratory bronchiolitis, hypersensitivity pneumonitis, bronchiolitis obliterans organizing pneumonia, asthma, autoimmune disease, and bronchiolitis obliterans. They can also be found in patients with small mucous airway plugs and other endobronchial disease.    

Etiology of Bronchopneumonia for neonates; infant; and child;

Age	Common Etiology	Less Etiology
Birth-20days	Bacteria	Anaerob Bacteria
	E. colli	Streptococcus group D
	Streptococcus group B	Haemophillus influenza
	Listeria monocytogenes	Streptococcus pneumonia
		Ureaplasma urealyticum
		Virus
		Citomegalovirus
		Herpes Simplex Virus
3weeks-3months	Bacteria	Bacteria
	Chlamydia trechomatis	Bordetella pertusis
	Streptococcus pneumonia	Haemophillus influenza type B
	Virus	Moraxella catharalis
	Adenovirus	Staphylococcus aureus
	Influenza Virus	Ureaplasma urealyticum
	Parainfluenza Virus 1,2,3	Virus
	Respiratory syncytial virus	Cytomegalo Virus
4 months - 5 years	Bacteria	Bacteria
	Chlamydia pneumonia	Haemophillus influenza type B
	Mycoplasma pneumonia	Moraxella catharalis
	Streptococcus pneumonia	Staphylococcus aureus
	Virus	Neisseria meningitidia
	Adenovirus	Virus
	Influenza virus	Varicella-Zoster Virus
	Parainfluenza virus
	Rhinovirus
	Respiratory Syncytial Virus
>5 years	Bacteria	Bacteria
	Chlamydia pneumonia	Haemophillus influenza
	Mycoplasma pneumonia	Legionella sp
	Streptococcus pneumonia	Staphylococcus aureus
		Virus
		Adenovirus
		Influenza virus
		Parainfluenza virus
		Rhinovirus
		Respiratory Syncytial Virus
		Epstein-bar virus
		Varicella-zoster virus

2.3. Epidemiology     

Bronchopneumonia is estimated that 3.9 million of the 10.8 million deaths in children annually world wide occur in the first 28 days of life. More than 96% of all child deaths occur in developing countries, and pneumonia accounts for a substantial proportion of these. Intrauterine and early onset pneumonia was found at autopsy in 10–38% of stillborn and 20–63% of liveborn babies who subsequently died (with all but one of six studies in the range of 20–32%). In a separate series of 1044 autopsies on neonatal deaths in the first 48 hours of life, 20–38% had pneumonia, with the highest incidence in poorer socioeconomic groups. There are therefore likely to be between 750 000 and 1.2 million neonatal deaths annually where pneumonia is involved, and neonatal pneumonia accounts for 10% of global child mortality.

Throughout childhood, the greatest risk of death from pneumonia is in the neonatal period. In a field trial of community based management of childhood pneumonia in India, more than half of all child deaths from pneumonia occurred among neonates. Pneumonia mortality risk is strongly dependent on birth weight and age of onset. Case fatality rates are much higher for intrauterine or early onset pneumonia than for late onset neonatal pneumonia, and higher among low birthweight newborns. The proportion of neonatal respiratory distress that is caused by pneumonia will depend on where the source population is from (tertiary hospital, district hospital, or community), the stage in the perinatal period, the gestational age of the babies and the availability of intensive care, and the definition of pneumonia. Of 150 neonates with respiratory distress presenting to a referral hospital in India, 103 (68.7%) were diagnosed to have pneumonia. Using a different case definition in a teaching hospital in Brazil, of 318 infants presenting with respiratory distress within the first 4 days of life, bacterial infection was proven on culture in 31 (9.7%), and another 62 (19.5%) had radiographic signs of pneumonia.

2.4. Pathophysiology

Commonly some microorganism has inhaled to peripheral lung by respiratory track. Swelling caused by tissue reaction that may easily proliferating and diffusing microorganism to the other tissues. Infected lung area may there consolidation; there were PMN cell, fibrin, eritrosit, swelling fluid, and microorganism founded at alveoli. This stage called red hepatisation stage. And then increasingly fibrin deposite, there is fibrin and PMN cell founded at alveoli, then degeration cell, thining fibrin, microorganism and loss debrisment. This is called resolution. Broncopulmonary system for uninfected lung area will be normal.

Antibiotics should given as soon as possible for cutting previous illness, so those stage that explained were not founded. Some bacteria could more pathological than others bacteria. Streptococcus pneumonia would manifestate as diffuse consolidation entire all lung area (bronchopneumonia); and for children would manifestate localized consolidation at one lobus (pneumonia lobaris). Pneumococcell and little absesses commonly caused by staphylococcus aureus for neonates and infants. As staphylococcus aureus could release some toxin and enzyme like hemolysin, lekosydine, staphylokinase, and Coagulase. Coagulase could interacted with plasma factor and release active agent that converting fibrinogen to fibrin; so there is fibrinopurulent eksudate. There is correlation between coagulase product and microorganism virulence. Some staphylococcus couldn’t  release coagulase less made seriously disease. Penumotoccell would stay at infected lung for many months; but not needed the next management.

2.5. Diagnostic

Etiologic diagnostic according to microbiologic test and/or serologic is the base of optimal theraphy. But, etiologic finding of bacteria is not easy because adequate laboratorium is required. Because of that, bronchopneumonia in infant commonly diagnosed according to symptoms which can be seen from respiratory system, and radiologic findings. The most predictor of pneumonia is fever, cyanotic, and more than one respiratory symptoms consist of : tachypnea, cough, nostril breathing, retraction, ronchi, and decreased breath sound.²

Because the high rate of morbidity and mortality of infant pneumonia, in case for the treatment, WHO develops diagnosis guidelines and simple treatment. The guidelines is mostly given to primary heath care service, and as health education to community in developing countries. The goal is to simplify diagnostic criteria according to clinical manifestations that can be detected directly; to determine disease classification, and determining antibotic used. Simple clinical manifestation include tachypnea, dyspnoe, and some emergency sign so infant can be referred quickly to health care service. Tachypnea can be assessed from counting breath frequency along one minute when the infant at calm condition. Dyspnoe can be assessed by looking chest retraction at the lower chest region when the infant inhaled (epigastrium retraction). Emergency sign in infant at 2 months – 5 years old is cannot be able to drink, seizures, decreased consciousness, stridor, and malnutrition, emergency sign for infant at age under 2 months years old is poor feeding, seizures, decreased alertness, stridor, wheezing, and fever.²

How to diagnose bronchopneumonia; once caregivers have recognized the danger (signs of brochopneumonia (cough and fast or difficult breathing) and taken their children to appropriate medical care, health personnel – including trained community health workers – should then diagnose and treat bronchopneumonia in children according to the following Integrated Management of Childhood Illness (IMCI) guidelines.⁵

Children aged 2 months to 5 years are diagnosed with bronchopneumonia if they exhibit a cough and fast or difficult breathing. Thresholds for fast breathing depend on the child’s age. Severe bronchopneumonia in children is diagnosed if they exhibit lower chest wall indrawing  when the child’s chest moves in or retracts during inhalation or stridor (a harsh noise made during inhalation). Respiratory rate timers should be available to help health personnel count breathing rates.⁵

The clinical diagnosis of bronchopneumonia has traditionally been made using auscultatory findings such as bronchial breath sounds and crepitations in children with cough. However, the sensitivity of auscultation has been shown to be poor and varies between 33 %- 60% with an average of 50 % in children. Tachypnea is the best single predictor in children of all ages. Measurement of tachypnea is better compared with observations of retractions or auscultatory findings. It is nonetheless important to measure respiratory rate accurately. Respiratory rate should be counted by inspection for 60 seconds. However in the young infants, bronchopneumonia may present with irregular breathing and hypopnea.¹

Bronchopneumonia is an infection in the lungs; a germ such as bacteria, virus, fungus or parasite can cause it. When a child gets bronchopneumonia, tiny air sacs in the lungs can fill with fluid. This fluid blocks the air sacs and oxygen cannot get to the body from the lungs. Signs of bronchopneumonia; Chills, Fever, Chest Pain, Cough with yellow or green mucus, Feeling very tired, Trouble breathing or fast breathing, Poor appetite or poor breast or bottle feeding.⁴

Hospitalization indication for child with bronchopneumonia is; chest pain when he or she breathes; long coughing spells; trouble breathing or fast breathing; nausea and vomiting; a high fever that comes on quickly or a fever that lasts more than 1 to 2 days; confusion.⁴

Chest X-rays and laboratory tests are used to confirm the presence of bronchopneumonia, including the extent and location of the infection and its cause. But in resource-poor settings without access to these technologies, suspected cases of bronchopneumonia are diagnosed by their clinical symptoms. Children and infants are presumed to have bronchopneumonia if they exhibit a cough and fast or difficult breathing. Caregivers, therefore, have an important role to play in recognizing the symptoms of bronchopneumonia in children and seeking appropriate medical care as necessary.⁵

Children with bacterial bronchopneumonia cannot be reliably distinguished from those with viral disease on the basis of any single parameter; clinical, laboratory or chest radiograph findings.¹

1.      Chest radiograph

Chest radiograph is indicated when clinical criteria suggests bronchopneumonia. It will not identify the aetiological agent. However the chest radiograph is not always necessary if facilities are not available or the bronchopneumonia is mild.

2.      Complete white blood cell and differential count

This test may be helpful as an increased white blood count with predominance of polymorphonuclear cells may suggest bacterial cause. However, leucopenia can either suggest a viral cause or severe overwhelming infection.

3.      Blood culture

 Blood culture remains the non-invasive gold standard for determining the precise aetiology of bronchopneumonia. However the sensitivity of this test is very low. Positive blood cultures are found only in 10% to 30% of patients with bronchopneumonia. Even in 44% of patients with radiographic findings consistent with bronchopneumonia, only 2.7% were positive for pathogenic bacteria. Blood culture should be performed in severe bronchopneumonia or when there is poor response to the first line antibiotics.

4.      Culture from respiratory secretions

It should be noted that bacteria isolates from throat swabs and upper respiratory tract secretions are not representative of pathogens present in the lower respiratory tract. Samples from the nasopharynx and throat have no predictive values. This investigation should not be routinely done.

5.      Other tests

Bronchoalveolar lavage is usually necessary for the diagnosis of pneumocystis carini infections primarily in immunosuppressed children. It is only to be done when facilities and expertise are available. If there is significant pleural effusion diagnostic, pleural tap will be helpful. Mycoplasma pneumoniae, Chlamydia, Legio nella and Moxarella catarrhalis are difficult organisms to culture, and thus serological studies should be performed in children with suspected atypical pneumonia. An acute phase serum titre of more than 1:160 or paired samples taken 2-4 weeks apart showing four fold rise is a good indicator of Mycoplasma pneumoniae infection. This test should be considered for children aged five years or older with pneumonia.¹

Differential Diagnosis

Condition	Differentiating signs/symptoms	Differentiating tests
Bronchitis	Patient with bronchitis often have a lower grade fever than in patient with pneumonia, and may appear less ill, and no rales on lung examination	The chest radiograph may interpretated by normal
Bronchiolitis	Infants with pneumonia generally have higher fever (≥40°C) than with bronchiolitis. Wheezing is not a common finding in pneumonia. While in bronchiolitis is more common.	An FBC may demonstrate leukocytosis and neutrophilia in pneumonia than in patient with bronchiolitis The presence of a focal infiltrate on chest x-ray would increase the suspicion of pneumonia.
Bronchiectasis	Patients with pneumonia describe symptoms of short duration (7 to 10 days), as opposed to years in bronchiectasis. Auscultation findings (rhonchi, wheezing, crackles) may be similar in bronchiectasis and pneumonia, especially multi-lobar pneumonia. Bronchial breath sounds, which are characteristic of pneumonia, are not present in bronchiectasis.	CXR and chest CT results in pneumonia are quite variable and often depend on aetiology. In bronchiectasis, there is characteristic dilation of bronchi with or without airway thickening. Consolidation, which is seen in pneumonia, is not seen in bronchiectasis.
Asthma	Patients with asthma have bilateral wheezing; In asthma, bronchospasm is recurrent and progressive.	PFT may be useful to diagnose asthma in patients who have residual obstructive findings.
ARDS	Dyspnoea and tachypnoea are common before intubation. If ARDS is secondary to an infection, a fever will be present. Furthermore, fever is a feature of fibroproliferative ARDS.	The ratio of FiO2 to PaO2 <200 supports ARDS in the context of a diffuse opacity. Patients are typically intubated and sedated and therefore a common method of diagnosis is generalised pulmonary opacity seen on CXR.
Laryngotracheobronchitis (croup)	A viral infection of the upper airways, often caused by parainfluenza viruses. Characterised by fever, inspiratory stridor, and a barking cough. Symptoms often worsen at night.	Diagnosis is usually clinical. Sub-glottic narrowing may be seen on an AP neck radiograph; however, this investigation is rarely indicated.
Tuberculosis	A history of immunosuppression or prolonged course that is not responding to antibacterial therapy suggests tuberculosis.	Sputum cultures and acid fast bacilli stains positive. A cavity on the CXR may be observed.
Atelectasis	Usually not hypoxic or febrile, although a low-grade fever may be present.	Leukocytosis and sputum production may or may not be present. Opacities on a CXR tend to be more linear than lobar shaped.

2.6. Management

Assessment of severity of pneumonia

The predictive value of respiratory rate fo r the diagnosis of pneumonia is age specific (Table 7)

Age                                                                 Respiratory Rate Less than 2 months                                         > 60 /min 2- 12 months                                                   > 50 /min 12 months – 5 years                                        > 40/ min

Table 7: Definition of Tachypnoea

Assessment of severity is essential for optimal management of pneumonia. Pneumonia may be categorized according to mild, severe, very severe based on the respiratory signs and symptoms (Table 8 and Table 9)⁵

Table 8: Assessment of severity of pneumonia in infants below two months old.

Severe pneumonia                               Severe chest indrawing or fast breathing Very severe pneumonia                       Not feeding Convulsions Abnormally sleepy or difficult to wake Fever/ low body temperature Hypopnea with slow irregular breathing

 

Table 9: Assessment of severity of pneumonia in children age 2 months to 5 years old

Mild Pneumonia                                  Fast breathing Severe pneumonia                               Chest indrawing Very severe pneumonia                       Not able to drink Convulsions Drowsiness Malnutrition

 

II Assessment of oxygenation

The best objective measurement of hypoxia is by pulse oximetry which avoids the need for arterial blood gases. It is a good indicator of the severity of pneumonia.

III Criteria for hospitalization

Community acquired pneumonia can be treated at home. It is crucial to identify indicators of severity in children who may need admission as failure to do so may result in death. The following indicators can be used as a guide for admission.

1. Children aged <3 months whatever the severity of pneumonia.

2. Fever (>38.50 C), refusal to feed and vomiting

3. Rapid breathing with or without cyanosis

4. Systemic manifestation

5. Failure of previous antibiotic therapy

6. Recurrent pneumonia

7. Severe underlying disorders ( i.e. immunodeficiency, chronic lung disease )

IV Antibiotic therapy

When treating pneumonia clinical, laboratory and radiographic findings should be considered. The age of the child, local epidemiology of respiratory pathogens and sensitivity of these pathogens to particular microbial agents and the emergence of antimicrobial resistance also determine the choice of antibiotic therapy (Table 10 and Table 11) The severity of the pneumonia and drug costs have also a great impact on the selection of therapy.¹

The majority of childhood infections are caused by viruses and do not require any antibiotic. However, it is also very important to remember that we should be vigilant to choose appropriate antibiotics especially in the initial treatment to reduce further mortality and morbidity.¹

Table 10: Susceptibility (%) pattern of Streptococcus pneumoniae found in Malaysia.

Antibiotic                   Susceptible                 Intermediate                          Resistance Azithromycin              98.1                                                                             1.9 Cefuroxime                 99.6                                                                             0.4 Chloramphenicol         95.1                             1.5                                           3.4 Chlindamycin              9.2                               0.4                                           0.4 Cotrimoxazole             86.4                             3.9                                           9.7 Erythromycin              98.4                             0.4                                           1.1 Penicillin                     93.0                                                                             7.0 Tetracycline                 78.2                             0.8                                           21.0

 

Pathogens                                                                   Antimicrobial agent Beta- lactam susceptible Streptococcus pneumonia                                           Penicillin, Cephalosporins Haemophilus influenzae type b                                   Ampicillin,Chloramphenicol, Cephalosporins Staphylococcus aureus                                                Cloxacillin Group A Sreptococcus                                                Penicillin,Cephalosporin Mycoplasma pneumoniae                                           Macrolides such as erythromycin and Azithromycin Chlamydia pneumoniae                                              Macrolides such as erythromycin and Azithromycin Bordetella pertussis                                                     Macrolides such as erythromycin and Azithromycin

Table 11: Predominant bacterial pathogens of children and the recommended antimicrobial agents to be used.¹

Table 12: Commonly used antibiotics and their dosages

Intravenous Antibiotics                                            Dosages Amoxycillin-Clavulanate Acid                                   10-25mg/kg/dose 8 hrly Ampicillin -sulbactam                                                 10-25 mg/kg/dose 8 hrly Ampicillin                                                                   100mg/kg/day 6 hrly C. Penicillin                                                                 25,000-50,000U/kg/dose 6 hourly Cefuroxime                                                                 10-25 mg/kg/dose 8 hrly Cefotaxime                                                                 25-50mg/kg/dose 8 hrly Cloxacillin                                                                   25-50mg/kg/dose 6hrly Co-trimoxazole (trimethoprim )                                  4 mg/kg/dose 12 hrly Erythromycin                                                              7.5mg kg/dose 6 hrly

 

Oral Antibiotis Dosages Azithromycin                                                              10-15 mg/kg/day daily dose Augmentin                                                                  114 mg 12 hourly (less than 2 years) 228 mg 12 hourly (more than 2 years) Cefuroxime                                                                 125 mg 12 hourly (less than 2 years) 250 mg 12 hourly (more than 2 years) Cotrimoxazole                                                             4 mg/kg/dose 12 hourly Cloxacillin                                                                   50mg/kg /dose 6 hourly Erythromycin Estolate                                                7.5 mg/kg/dose 12 hour ly Penicillin V                                                                 7.5 - 15 mg/kg/dose 6 hourly

INPATIENT MANAGEMENT

Antibiotic therapy

1st line                                     β lactams drugs: Benzlypenicillin, Amoxycillin, Ampicillin, Amoxycillin-Clavulanate 2nd line                                   Cephalosporins : Cefotaxime, Cefuroxime, Ceftazidime, 3rd line                                    Carbapenem: Imepenam Others                                     Aminoglycosides: Gentamicin, Amikacin

For inpatient management of children with severe pneumonia, the following antibiotic therapy is recommended.¹

If there are no signs of recovery; especially if the patient remains toxic and ill with spiking temperature for 48-72 hours, a 2nd of 3rd line antibiotic therapy need to be considered. If Mycoplasma or Chlamydia species are the causative agents, a macrolide is the appropriate choice.¹

A child admitted to hospital with severe community acquired pneumonia must receive parenteral antibiotics. As a rule, in severe cases of pneumonia, combination therapy using a second or third generation cephalasporins and macrolide should be given. Staphylococcal infections and infection caused by Gram negative organisms such as Klebsiella sp are more frequently reported in malnourished children.¹

Staphyloccoccal infection

Staphylococcus aureus is responsible for a small proportion of acute respiratory infections in children. Nevertheless a high index of suspicion is required because of the potential for rapid deterioration. It is chiefly a disease of infants with a significant mortality rate. Radiological features suggestive of Staphylococcal pneumonia include the presence of multilobar consolidation, cavitation, pneumatocoeles, spontaneous pneumothorax, empyema and pleural effusion. Treatment with high dose intravenous cloxacillin (200mg/kg.day) for a longer duration and drainage of empyema will result in good outcome in the majority of cases.¹

II Supportive treatment

1. Fluid therapy

Oral intake should cease when a child is in severe respiratory distress. In severe pneumonia, inappropriate secretion of anti-diuretic hormone is increased, dehydration is therefore uncommon. It is important that the child should not be overhydrated.

2. Oxygen therapy

Oxygen reduces mortality associated with severe pneumonia. It should be given especially to children who are restless, tachypnoea with severe chest indrawing, cyanosed or not tolerating feeds. The SpO2 should be maintained above 95%.

3. Anti-tussive remedies

It is not recommended as it causes suppression of cough and may interfere with airway clearance. Adverse effects and overdosa ge have been reported.

4. Chest physiotherapy

The function of chest physiotherapy is to assist in the removal of tracheobronchial secretions resulting in an increase gas exchange and reduction in the work of breathing. However, trials have found no clinically discernible benefit or impact of chest physiotherapy on the course of illness in bronchiectasis, cystic fibrosis, pneumonia, bronchiolitis, asthma, acute atelectasis, inhaled foreign body and post extubation babies. There is no evidence to suggest that chest physiotherapy should be routinely performed in pneumonia¹

OUTPATIENT MANAGEMENT

In children with mild pneumonia, their breathing is fast but there is no chest indrawing. Oral antibiotics at an appropriate dose for an adequate duration is effective for treatment. The mother is advised to return in two days for reassessment or earlier if the child appears to deteriorate.

Children aged 2 months to 5 years with severe pneumonia should be referred to the nearest health facility immediately. Those diagnosed with pneumonia may be treated at home with a full course of effective antibiotics.

Cotrimoxazole and amoxicillin are effective drugs against bacterial pathogens and are often used to treat children with pneumonia in developing countries. Infants under two months with signs of pneumonia/sepsis are at risk of suffering severe illness and death more quickly than older children, and should be immediately referred to a hospital or clinic for treatment. Treatment regimens will need to be chosen based on their efficacy in local settings. Some areas may have high levels of resistance to certain antibiotics, rendering those drugs less effective for treating pneumonia.Other areas may have large numbers of high-risk groups, such as undernourished or HIV-positive children, and may need to adapt their treatment strategies accordingly.⁵

Infants less than 2 months old with signs of pneumonia should be referred promptly to the nearest health facility because they are at high risk of suffering severe illnessor death.⁵

           

Sign	Classify As	Treatment
·         Fast breathing (see below) ·         Lower chest wall indrawing ·         Stridor in calm child	Severe pneumonia	·         Refer urgently to hospital for injectable ·         antibiotics and oxygen if needed ·         Give first dose of appropriate antibiotic
Fast breathing The child has fast breathing if you count; ·         2 months to 12 months old 50 breaths or more per minute ·         12 months to 5 years old 40 breaths or more per minute	Non-severe pneumonia	·         Prescribe appropriate antibiotic ·         Advise mother on other supportive measures and when to return for a follow-up visit
No fast breathing	Other respiratory illness	Advise mother on other supportive measures and when to return; if symptoms persist or get worse

2.7. Prevention

There are several reasons why interventions that can only be delivered in hospitals will make little impact on deaths from bronchopneumonia. In many societies, infant are not taken outside the home, even if they are sick, so referral to a hospital is impossible. Often there is a preference for traditional village remedies. In addition, because the signs of severe illness can be very subtle in infants, parents may not recognise that their infant is sick until it is too late, and geographical and financial constraints make referral to hospital very difficult for much of the world’s population. On the other hand, interventions solely at community level will not fully address the often fatal complications of hypoxaemia and apnoea. Improving supportive care and the safety and accessibility of hospitals for seriously ill newborn babies is a high priority globally. A comprehensive approach to prevention and treatment of neonatal pneumonia would therefore involve interventions at community level, in primary health facilities, and in district and tertiary hospitals.

a.       Teach children to wash their hands before eating and after using the toilet.

b.      Keep children away from people who are smoking.

c.       Make sure children get all of their vaccines or shots:

                    i.            All children 2 years and younger should get the PCV vaccine to protect against pneumonia. Children older than 2 years may need a different type of vaccine.

               ii.                To limit your children’s risk of pneumonia, have them get a flu shot every fall. You can get pneumonia from the flu.

d.      Make sure children are eating a healthy diet that includes fruits, vegetables and whole grain foods.

e.       Make sure children are getting plenty of sleep.⁴

2.8. Complication

Complication of bronchopneumonia in infant include thoracic empiema, purulent pericarditis, pneumothorax, or extrapulmonary infection such as purulent meningitis. Thoracic empiema is the most commonly complication in bacterial pneumonia.²

Ilten F et all, reported miocarditis complication (systolic pressure of right ventricel is increased, increased kinase creatinine, and heart failure) is enough high in pneumonia cases at 2-24 months years old. Because of that miocarditis is a fatal condition, and advises to do detection by noninvasive technique such as ECG, Echocardiography, and enzime test.²

2.9. Prognostic          

Overall, the prognosis is good. Most cases of viral pneumonia resolve without treatment; common bacterial pathogens and atypical organisms respond to antimicrobial therapy. Long-term alteration of pulmonary function is rare, even in children with pneumonia that has been complicated by empyema or lung abscess.

Patients placed on a protocol-driven pneumonia clinical pathway are more likely to have favorable outcomes. The prognosis for varicella pneumonia is somewhat more guarded. Staphylococcal pneumonia, although rare, can be very serious despite treatment.

Morbidity

Although viral pneumonias are common in school-aged children and adolescents and are usually mild and self-limited, these pneumonias are occasionally severe and can rapidly progress to respiratory failure, either as a primary manifestation of viral infection or as a consequence of subsequent bacterial infection.

Morbidity and mortality from RSV and other viral infections is higher among premature infants and infants with underlying lung disease. Significant sequelae occur with adenoviral disease, including bronchiolitis obliterans and necrotizing bronchiolitis. With neonatal pneumonia, even if the infection is eradicated, many hosts develop long-lasting or permanent pulmonary changes that affect lung function, the quality of life, and susceptibility to later infections.

Infants and postpubertal adolescents with TB pneumonia are at increased risk of disease progression. If TB is not treated during the early stages of infection, approximately 25% of children younger than 15 years develop extrapulmonary disease.

Bronchopneumonia occurs in 0.8-2% of all pertussis cases and 16-20% of hospitalized cases; the survival rate of these patients is much lower than in those with pneumonia that is attributed to other causes.

Immunocompromised children, those with underlying lung disease, and neonates are at high risk for severe sequelae, and they are also susceptible to various comorbidities. Cryptococcosis may occur in as many as 5-10% of patients with AIDS, and acute chest syndrome occurs in 15-43% of patients with sickle cell disease. Individuals with sickle cell disease not only have problems with their complement system, but they also have functional asplenia, which predisposes them to infection with encapsulated organisms such as S pneumoniae and H influenzae type B.

Mortality

The United Nations Children's Fund (UNICEF) estimates that 3 million children die worldwide from pneumonia each year; these deaths almost exclusively occur in children with underlying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression. Although most fatalities occur in developing countries, pneumonia remains a significant cause of morbidity in industrialized nations.

According to the WHO’s Global Burden of Disease 2000 Project, lower respiratory infections were the second leading cause of death in children younger than 5 years (about 2.1 million [19.6%]). Most children are treated as outpatients and fully recover. However, in young infants and immunocompromised individuals, mortality is much higher. In studies of adults with pneumonia, a higher mortality rate is associated with abnormal vital signs, immunodeficiency, and certain pathogens.