Sorasasak Lochindarat, M.D. Queen Sirikit National Institute of Child Health

Transcription

1 Management of Severe Pneumonia in Children Sorasasak Lochindarat, M.D. Queen Sirikit National Institute of Child Health

2 Epidemiology i

3 Figure1: Distribution of 10.5 million deaths among children less than 5 years old in all developing countries, (WHO)

4 Bull World Health Organ 2008;86:

5 Bull World Health Organ 2008;86:

6 Bull World Health Organ 2008;86:

7 Etiology

8 Figure : Etiology of severe pneumonia in children in developing countries J Clin Invest 2008;118(4):

9 Progressive Primary Pulmonary Tuberculosis : ARDS

10 Aetiology of pneumonia in children with severe malnutrition (Trop Med Int Health 2009;14: )

11 VIRUSES ASSOCIATED WITH PNEUMONIA IN CHILDREN Age Group Viruses Infants Preschool School Age Respiratory syncytial Parainfluenza type 1, Influenza A Influenza B Parainfluenza type Adenovirus Measles +* +* + Cytomegalovirus Metapneumovirus *Important cause in developing countries.

12 Aetiology and epidemiology Strep pneumoniae is the most common bacterial cause of pneumoniae in children, followed by mycoplasma and chlamydophila pneumoniae Viruses are most commonly found in younger 8 40 % of CAP is mixed infection % of CAP, a pathogen is not identified % of CAP is caused by virus in children

13 Severity Assessment

14 (Pediatr Respir Rew 2011;12:52 59.)

15 > WHO/ARI/91.20

16 (Thorax 2002;57 suppl 1 : i1 24.)

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18 Indication for transfer to intensive care Failing to maintain SaO 2 > 92 % in FiO2 > 0.6 Shock Rising RR and PR with severe respiratory distress and exhaustion, + raised PaCO 2 Recurrent apnea or slow irregular breathing (Thorax 2002;57 suppl 1 : i1 24.)

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20 Investigation i

21 Defining Bacterial Pneumonia Clinical diagnosis Sens Any X-ray abnormality Lobar consolidation Culture proven bacterial pneumonia Spec

22 Chest radiography CXR (PA, lateral) in all hospitalized patients with CAP Repeat CXR in children that not improve or deteriorate after hrs. of ATB (Clinical Infectious Diseases, Aug 2011)

23 Blood culture Should be obtained in presumed bacterial CAP that is moderate to severe Repeated blood cultures in bacteremic CAP

24 Lab Rapid test for flu and RSV Acute phase reactants, (ESR, CRP, serum procalcitonin), can not distinguish between viral and bacterial CAP Pulse oximetry should be performed in all severe CAP

25 Atypical pathogens Serologic test for IgM of chlamydiphila pneomonia and Mycoplasma pneumonia Quadrupling of serum IgG between acute and convalescent phase, but limited clinical value Cold agglutinin for M. pneumoniae is low specificity and positive predictive value PCR for C. pneumoniae and M. pneumoniae is helpful for rapid diagnosis i (Curr Opin Pulm Med 2005;11: )

26 Additionaltests tests for severe/ Life threatening CAP Tracheal aspirations/bronchoscopic or blind bronchoalveolar larvage for Gram stain, culture Rapid test for flu and RSV PCR for virus (flu, parainflu, RSV, adeno, rhino, humanmpv) AFB, PCR for TB, culture for TB Modified AFB (Nocardia) Fresh smearfor fungus, culture for fungus Galacfomannan (Aspergillus)

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28 Use of bacterial urine antigen detection in the diagnosis of pediatric LRTI Urine antigen was present in 4 % of asymptomatic children 16 % of children with AOM 24 % of children with CAP The specificity is too poor for diagnosis of CAP (Pediatrics i 1996;78:1 9.) 1 9

29 Treatment

30 Empiric i Therapy for Severe CAP in Pediatrics i To cover bacterial CAP To cover atypical CAP To cover flu CAP Ceftriaxone/cefotaxime f plus Azithromycin Oseltamivir i vancomycin/clindamycin for Zanamivir suspected MRSA alternative for cephalosporins: Levofloxacin alternative Other macrolide Levofloxacin

31 Anti infective treatment of severe CAP Ceftriaxone or cefotaxime for Not tfully immunized i children In region of high level pen resistance of invasive pneumococcus Left threatening empyema

32 Anti infective treatment of severe CAP Vancomycin not more effective than third gen cephalosporins in pneumococcal pneumonia Empiric combination with a macrolide, in addition to a β lactam ATB for whom atypical pathogens can t be rule out Vancomycin/clindamycin cin/clindam cin in addition to β lactam ATB if consistent with MRSA

33 General management O 2 therapy (nasal cannulae, head box, face mask) for SpO 2 < 92 % in room air Agitation may be a symptom of hypoxia NG tube may compromise breathing IV fluid should be given at 80% maintenance and serum electrolytes monitored for SIADH Chest PT no benefit, should not be performed in children with pneumonia In ill child, minimal handling may reduce metabolic and O 2 requirement

34 Parapneumonic Effusion

35 Management of parapneumonic effusions Size of effusion Bacteriology Chest tube drainage Small : < 10 mm. of lat decubitus or opacified < ¼ of hemithorax Bacterial culture and Gram stain : neg/unknown No thoracentesis or chest tube Mod : > 10 mm. rim of Bacteria culture or Gram Thoracentesis fluid but opacified < ½ hemithorax stain : neg or pos (empyema) Chest drain in respiratory compromise or empyema Large : opacifies > ½ hemithorax Bacterial culture or Gram stain : pos (empyema) Chest drain

36 Lab testing for pleural fluid Gram stain & bacterial culture Ag testing or PCR Wbc with cell differential analysis, to differentiate bacterial from TB, Malignancy Pleural fluid parameters : ph, glucose, protein, LDH rarely change patient management & not recommended

37 A 2 YO.girl with pneumonia and pleural effusion. Hemo C/S: S.pneumoniae serotype 14, sensitive to penicillin and cefotaxime, but clinical not improved after ATB.

38 Chest CT scan: Loculated pleural effusion

39 Necrotizing Pneumonia

40 Necrotizing pneumoniaandand pneumatoceles As a result of localized bronchiolar and alveolar necrosis The main cause is S. aureus, followed by S. pneumoniae, H. influenzae, klebsiella pneumoniae and E. coli IV antibiotic until clinical improvement, followed by oral antibiotic for a total course of at least 3 weeks Most pneumotoceles disappear within 2 mo, although this may take as long as 6 mo. (Thorax 2011;66: )

41 Management of pulmonary abscess or necrotizing pneumonia can be treated with intravenous ATB most abscess will drain through the bronchial tree & heal well defined peripheral abscess without connection to bronchial tree may be drained under imaging guided procedures aspiration Drainage catheter in place

42 Staph Septicemia : septic emboli, necrotizing pneumonia, pneumothorax

43 Necrotizing pneumonia caused by Mycoplasma pneumoniae in pediatrics 14 year old girl : CXR showed consolidation RML with mod pleural effusion Pleural fluid : wbc 690 /mm 3 (N 14%, L 86%), rbc 840,000 /mm 3, protein 3.8 g/dl, LDH 2,320 IU/L) /) Complement fixation Ab titer =1/320 (Pediatr Infect Dis J 2004;23:564 7.)

44 Necrotizing pneumonia caused by Mycoplasma pneumoniae in pediatrics 4 year old boy: CXR showed total consolidation RL with pleural effusion Pleural fluid : wbc 990 /mm 3 (N 80%, L 20%), rbc 720 /mm 3, protein 4.1 g/dl, LDH 3,216 IU/L) Complement fixation Ab titer =1/1280 (Pediatr Infect Dis J 2004;23:564 7.)

45 Macrolide for Very Severe Pneumonia

46 Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bateremia Prospective, multicenter, international observational study of 844 patients C bacteremic pneumococcal pneumonia Not critically ill Critically ill (Am J Respir Crit Care Med 2004;170:440-4.)

47 Combination antibiotic therapy with macrolides improves survival in intubated t patients t with community acquired i pneumonia Prospective, observational cohort, multicenter study in 27 ICU of 9 European countries (Intensive Care Med 2010;36: )

48 Combination antibiotic therapy with macrolides improves survival in intubated t patients t with community acquired i pneumonia Survival graph for severe CAP c ventilator Survival graph for sepsis/septic shock (Intensive Care Med 2010;36: )

49 Macrolide and Anti-inflammatory Effect Macrolides and anti-inflammatory effect have been studied over the past several years In general, short-term (7.28 days) administration of macrolides resulted in an enhance immune response, whereas long-term treatment was associated with a decreased d response Most immunomodulatory effect are shared by the 14- and 15-member ring macrolides, but not 16 member ring Labro MT. J Antimicrob Chemother 1998;41(suppl B):37-46

50 Acute Respiratory Failure (ARF)/ Acute Respiratory Distress Syndrome (ARDS)

51 Respiratory Failure ระบบหายใจไม สามารถแลกเปล ยน ระบบหายใจไมสามารถแลกเปลยน gas ให ม ใหม O 2 เพ ยงพอก บความต องการของร างกาย ง ง ง และ/หร อ ไม สามารถก าจ ด CO 2 ออกจากร างกาย 2

52 Clinical Classification Type I failure Type II failure : nonventilatory or normocapnic respiratory failure : low PO PaO 2, normal to low PaCO PCO 2 : ventilatory or hypercapnia failure : high PaCO 2, variable PaO 2 ARF criteria PaO 2 < 50 mm Hg PaCO 2 > 50 mm Hg absence of intracardiac shunt

53 Alveolar arterial O 2 tension difference P(A a)o 2 = [(PB PH 2 O) FiO 2 PaCO 2 /0.8] PaO 2 Normal < 30 mmhg in R/A < 50 mmhg in FiO Severe RF > 450 mmhg

54 Alveolar arterial l ilo 2 tension difference 1. ถ าม hypoxemia แต P(A-a)O 2 ปกต : alv. Hypoventilation 2. ถ า ถา P(A-a)O 2 สง ส ง : V/Q mismatch, diffusion defect, intrapulm shunt แก ไขได โดยให FiO จะท าให PaO 2 ส งข น ; ยกเว น shunt

55 Viral Pneumonia : interstitial perihilar infiltration,hyperaeration

56 Human flu A(H3N2) : ARDS

57 Adenoviral Pneumonia : intranuclear inclusion body

58 Invasive Pulmonary Aspergillosis

59 Signs of respiratory failure 1. Signs of resp. distress tachypnea nasal flaring chest indrawing accessory muscles orthopnea adventitious sounds 2. Signs of tissue hypoxia cerebral hypoxia : confusion, coma cyanosis

60 Signs of respiratory failure 3. Signs of sympathetic compensation early tachycardia hypertension sweating late bradycardia hypotension pulsus paradoxus 4. Signs of respiratory muscle fatigue paradoxical chest & abdominal motion bradypnea irregular breathing apnea

61 Management of ARF 1. Recognition ii & early interventionsi Respiratory distress Impending RF O2 therapy for Type I failure Mechanical ventilator for Type II failure Nonconventional methods of ventilatory support Nonventilatory methods of respiratory support

62 Methods of O 2 therapy FiO 2 O 2 Flow Rate (L/min) Nasal cannula Simple mask Partial rebreathing mask Non-rebreathing mask Head box 0.95 >10 The Harriet Lane Handbook: sixth edition

63 Nasal cannula Head box

64 A B (A) Partial rebreathing mask (B) Non-rebreathing mask (From Kacmarek)

65 Non-rebreathing mask

66 Management of ARF (con t) 2. Treat underlying causes Pneumonia : antimicrobial i Cardiogenic pulm edema : diuretic, inotropic Drug intox : antidote Massive effusion : thoracocentesis, ICD Pneumothroax : ICD

67 Management of ARF (con t) 3. Supportive care Fluid & electrolyte Rx ลด CHO Sedative / analgesic Inotropic drugs

68 Acute Respiratory Distress Syndrome (ARDS)

69 The American - European Consensus Conference on ARDS ARDS characteristics : 1. Acute onset of respiratory symptoms 2. Frontal chest radiograph with bilateral infiltrates 3. No clinical evidence of left atrial hypertension (PAWP < 18 mmhg) 4. PaO 2/FiO 2 < 200 mmhg g( (regardless of the PEEP level) (Am J Respir Crit Care Med 1994;149:818)

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71 ARDS / Acute hypoxemic respiratory failure ABG: PH 7.3 PaO2 60 PaCO2 45 HCO3 25 BE +2 (FiO2=0.6) PaO2/FiO2 = 60/0.6 = 100

72 (Semin Pediatr Infect Dis 2006;17:65 71.)

73 Prevention for CAP Immunization with PCV, Hib, Measles, pertussis, flu vaccines Parents/caretakers of infants < 6 mo., including pregnant adolescents, should be immunized with flu & pertussis vaccines to protect infants from exposure High risk infants should ldbe provided ddimmune prophylaxis with RSV specific monoclonal Ab.

74 Conclusion Pneumonia in children is the most serious illness and difficult to diagnose Associated with severe morbidity, enormous burden,, both economically and public health worldwide Future challenges include implementation of effective intervention strategies production of simple diagnostic tools development of effective vaccines

75 Thank You Very Much