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October 23, 2019

Today’s lesson will be on pneumonia. Pneumonia is an infection in a lung parenchyma. When we look at children, the incidence of pneumonia decreases with age. However, be mindful that mortality in developed countries is estimated as one per 1,000 patients. Risk factors for pneumonia include the winter months with an increase in viral infections, an environment where smoke is present, lower socioeconomic homes, and being mindful greatly of underlying disease, specifically that affect the lung parenchyma. Adapted from Pediatrics in Review, you’ll see a listing of different pathogens that can cause pneumonia as it relates to age. This will help you tailor your therapies accordingly with the most likely cause of your patient’s illness. Clinical features that are seen in pneumonia are fever, cough, fatigue, retractions, and wheezing. The most sensitive of the features seen is tachypnea. You must have a good understanding of what a normal respiratory rate is for your patients, and therefore will give you a better understanding of what you may be treating. As you look to work up your patients, it is highly important to get a detailed history and present illness. Inquire about their travel history and concern for environmental exposures. Remember, your physical exam is not only what happens with your stethoscope, but also your vitals. Ill appearing children may need additional lab work, like a CBC or a BMP, but you also may need to pursue a chest x-ray, providing fluids and oxygen, tailoring your antibiotics, and obtaining a blood culture. With the use of antibiotic therapy, be mindful of the different pathogens that can affect your patient. Treatment of 10 to 14 days is the likely course of action. Children who are greater than three months of age and are nontoxic appearing may be managed in an outpatient status, with close follow up within 48 hours of being seen initially. Remember, children from three months to five years usually have a viral etiology as a cause of their pneumonia. As you think about different antimicrobials to use from an outpatient status, be mindful of your patient’s allergy profile. Think through the likely pathogen and choose your antibiotics appropriately. The complications that are seen with pneumonia are varied. As disease worsens, patients can have effusions, empyema, lung abscess, or even worse, necrotizing pneumonia. These complications can lengthen the antibiotic use, and transition the patient into needing a hospitalization for the continuation of their care. When we think about effusions and empyemas, it is important to asses the severity of the complication. Ultrasound, decubitus chest films, and chest CT can assist you in characterizing if you have an effusion, or an empyema with your patient. If you do collect fluid in your patient’s care, it is important to obtain a gram stain, culture, cell count and differential, pH, glucose, and LDH. With review of your history, be mindful that specific studies may be needed to help treat your patient. As we look at different x-rays to see how these microbes can affect the lung parenchyma, a viral infection is usually seen with hyperinflation, mild peribronchial cuffing, which is the inflammation that’s seen on the bronchials on end and within an x-ray, and patchy airspace disease. This, for the most part, represents atelectasis, but could be a developing infiltrate. Mycoplasma pneumonia, under the umbrella of atypical pneumonia, presents with bilateral reticular nodular interstitial infiltrates. Again, these patients can have patchy airspace disease, concerning for atelectasis. But be mindful of the history and the age of your patient, as an atypical pneumonia could be the etiology of their illness. Pneumococcal pneumonia presents with rounded pinpoint consolidation airspace disease, seen here in the right middle and lower lobe on this film. You may see air bronchograms medially going through the infiltrate as well. Empyema or effusion, as seen in this left lower lobe lingular consolidation, can be associated with also pericardial effusions. You must treat your patient accordingly to assist with their care. Volume loss on the left side also indicates a component of atelectasis in this radiograph. When we think about treating effusions and empyema, there are several avenues that we can take. Thoracentesis, removal of the fluid, is widely taken in patients for simple effusions. With concern of prolonged drainage, a test tube can be left in place to help facilitate care. VATS, video-assisted thorascopic surgery, can also be used to assist these patients with care, with the removal of infectious tissue or fluid done surgically. A meta analysis showed lower mortality and shorter length of stay, as well as shorter antibiotic duration, for those treated with VATS compared to a thoracentesis and chest tube drainage alone. Again, you would have to specifically tailor the therapy to your patient. As you think about admitting these patients, the concern comes in with several aspects of the patient’s history and their current state. Usually, a patient less than three months of age are admitted to the hospital for monitoring and their care. A patient with a history that would make you cautious of an immunocompromised state will also need to be admitted. The development of complications, respiratory distress, hypoxemia, a toxic appearing patient, warrant an admission to the hospital. If a patient has a history of lack of response to oral antibiotics necessitating IV antibiotics, along with an inability to take PO by mouth, and a concern about the caregivers ability to help the patient prompt admission to the hospital for IV therapy. As you think about the antimicrobials to use in your patient, again, the history is the key. Be mindful of the pathogens that could affect your patient, and then tailor your therapy accordingly. Usually, IV antibiotics are used until the patient is afebrile for several days, and then it’s followed by a 2 week course of high dose oral therapy.

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