Pneumonia

Important points in history

• Cough
  • Duration(days)
  • Associated whooping/vomiting/cyanosis?
• Fever
• Breathlessness – what can they no longer do?
• Eating/ drinking/ feeding
• HIV status
• Immunisation history
• TB contacts
• Prematurity/low birth weight
• Cerebral palsy, other neuromuscular disease

Important points on examination

• ABCs
• Blantyre coma score
• Hydration status
• Head bobbing (in smaller children)
• Grunting
• Nasal flaring
• Tracheal tug
• Lymphadenopathy
• Subcostal and intercostal recessions
• Crackles
• Bronchial breath sounds
• Increased breath sounds (over consolidation)
• Decreased breath sounds (over effusion)
• Reduced air entry/ reduced expansion
• Cyanosis and oxygen saturation
• Finger clubbing
• Tachypnoea (varies by age)

Severity

• Tachypnoea (by age as above)
• Chest indrawing

• Cough or difficulty breathing +
• Central cyanosis / oxygen saturations <90%
• Severe respiratory distress (e.g. grunting, severe indrawing, head bobbing, nasal flaring)
• Convulsions/ LOC/ feeding/ lethargy



• If only cough (+/- fever) and no tachypnoea or indrawing, consider viral URI or differential diagnosis (as listed below)
• It is difficult to tell bacterial / viral pneumonia apart either clinically or radiologically
• Any child who looks toxic should receive antibiotics as this is more likely to be bacterial

Special points if under 2 months old

• Always admit these babies!
• Often Group B Streptococcus
• Is this definitely pneumonia – could it be neonatal septicaemia?

Does this baby need an LP?

Investigations

• MPS and PCV
• CXR if not improving or deteriorating
• Gastric aspirate or sputum if suspicion for TB
• Blood culture isn’t usually necessary. Consider if severely unwell, immunocompromised or other signs (eg neck stiffness)

Differential diagnosis of pneumonia

• Foreign body – sudden onset, choking, stridor, focal wheeze
• Pertussis – no or incomplete DPT, “whoops”, well between bouts of cough, no fever
• Tuberculosis – cough ≥2 weeks, weight loss, TB contact, night sweats
• PCP – 2-6 months old, HIV exposed, clear chest, profoundly hypoxic, hyper- expanded chest
• Other HIV related lung diseases – Kaposi’s sarcoma, lymphocytic interstitial pneumonitis, chronic lung disease, CMV pneumonitis
• Staphylococcal pneumonia – septic skin pustules. Cavitation on CXR. Consider flucloxacillin, but ceftriaxone will normally cover
• Severe anaemia – pallor and tachypnoea with a clear chest
• Acidotic breathing - from severe dehydration or local mankhwala
• Cardiac disease – oedema, gallop rhythm, hepatomegaly, clubbed, murmur, displaced apex
• Paraffin inhalation
• Malaria
• Aspiration – patients with neuromuscular disease/CP, history of vomiting/choking, R lower lung findings. Consider adding metronidazole or using amoxicillin-clavulanate for po treatment
• Bronchiolitis

Treatment

See algorithm below

Supportive Care

• Fever (>39 C) causing distress, give paracetamol
• If wheeze is also present, trial of salbutamol nebuliser
  • < 4 years - 2.5 mg
  • > 4 years 5 mg
• Daily maintenance fluids: oral fluids + feeds (will need more fluids if febrile)
• NGT if child cannot drink/ breast feed
• Viral infections won’t respond to antibiotics. Treat the child, not just the temperature! If the child looks well, hold your nerve and don’t change the antibiotics. Monitor closely.
• Oxygen if saturations <90% on room air
• If no pulse oximeter available, give oxygen to patients with increased work of breathing, any cyanosis, or increased respiratory rate.

Complications of pneumonia

• Effusion/ empyema – stony dull, no air entry. Persistent fever with empyema (consider TB if you see these on X-ray)
• Pneumothorax – tracheal deviation, hyper-resonance one side

When to discharge

• Eating and drinking
• Not in respiratory distress
• No follow up needed for simple pneumonia