1. ©2012 MFMER | slide-1 Pneumonia: An Update fischer.phil@mayo.edu GMHC, Louisville November 2014

2. ©2012 MFMER | slide-2 Objectives Describe how to appropriately diagnosis pneumonia in a febrile coughing child; be able to articulate the limitations of various diagnostic modalities Implement appropriate evidence-based treatment for children with severe lower respiratory infections of both bacterial and viral etiology

3. ©2012 MFMER | slide-3 A Child A 10 month old child presents with two days of fever and cough. What is needed to appropriately make a diagnosis? What treatment is most likely to help?

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6. Pneumonia 1,200,000 deaths per year Many cases vaccine-preventable ~30% of children provided antibiotics World Health Organization, 2012 ©2012 MFMER | slide-6

7. Pneumonia 1,200,000 deaths per year>>ACT ! 18% of under 5 deaths ~3200 deaths per day Vaccine-Preventable >> PREVENT !! Inadequate Care>>Dx & Rx !!! World Health Organization, 2012 www.who.int/mediacentre/factsheets/fs331/en J Trop Pediatr 60:91-92, 2014 ©2012 MFMER | slide-7

9. A 10 month old is febrile and coughing. What equipment is most useful in establishing a diagnosis? A.A blood count machine B.An x-ray machine C.A stethoscope D.None of the above

11. Tachypnea as a means of diagnosing “pneumonia” 2 - 12 months> 50 breaths / minute 12 - 60 months> 40 breaths / minute IF tachypnea (or severe retractions), give antibiotic. IF very sick, hospitalize for parenteral therapy.

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13. What Causes Fever and Tachypnea? ©2012 MFMER | slide-13

14. What Causes Fever and Tachypnea? Bacterial Pneumonia Malaria Viral Respiratory Infection Fever Plus: Metabolic Acidosis - diabetes - dehydration Anxiety ©2012 MFMER | slide-14

15. Diagnosis of Pneumonia (Identification of Need for Antibiotics) ©2012 MFMER | slide-15

16. Pediatr Infect Dis J 29:406, 2010 ©2012 MFMER | slide-16

17. 1622 children < 5 yo with “possible pneumonia” emergency department, Boston 20% of tachypneic children >> x-ray pneumonia 12% non-tachypneic >> radiographic pneumonia So, RR is not discriminating, but RR is somewhat predictive Pediatr Infect Dis J 29:406, 2010 ©2012 MFMER | slide-17

18. Boston emergency department, 2574 pts < 21yrs If O2 sat < 92%, 37% - radiographic pneumonia If also no wheeze, 51% pneumonia If also focal rales, 70% pneumonia Tachypnea and retractions NOT linked to dx Pediatrics 128:246, 2011 ©2012 MFMER | slide-18

19. Boston again, emergency department, 2008 kids Tachypnea vs Radiographic Pneumonia AgeSensSpec Pos Pred Value 2-12 mo25%76%11% 1-5 yrs37%72%24% Pediatr Infect Dis J31:561, 2012 ©2012 MFMER | slide-19

20. Diagnosis of Pneumonia (Maybe x-ray is not definitive?) < 6 mo old, admitted, lower respiratory infection 40 chest x-rays reviewed by pediatric radiologists Kappa FINDINGWithin Between “consolidation”.91.79 “normal”.80.66 “airway disease”.68.48 Pediatr Infect Dis J 15:600-604, 1996 ©2012 MFMER | slide-20

21. Diagnosis of Pneumonia (Identification of Need for Antibiotics) Maybe x-ray is not definitive? PLOS One 5:e11989, 2010 ©2012 MFMER | slide-21

22. Pneumonia Dx – Better than X-Ray? ©2012 MFMER | slide-22

23. Ultrasound to Diagnose Pneumonia? New York emergency department, 20 children H1N1 epidemic, 2009 Intra-Observer Reliability to Differentiate Bacterial vs Viral vs Both vs Neither (K = 0.82) Critical Ultrasound Journal 4:16, 2012 ©2012 MFMER | slide-23

24. Ultrasound to Diagnose Pneumonia? New York emergency department 200 children, 1-8 years of age, 18% “pneumonia” Ultrasound with x-ray as “gold standard” 86% sensitivity 89% specificity JAMA Pediatr 167:119, 2013 ©2012 MFMER | slide-24

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26. Ultrasound vs X-Ray 163 children in Taiwan, 2010-2012 Clinical diagnosis of “pneumonia” Chest x-ray + in 152 and ultrasound in 159 Ultrasound finding of air bronchograms most helpful Ultrasound a “complementary tool” Ho MC et al. Pediatrics and Neonatology 2014 ©2012 MFMER | slide-26

27. Causes of Pneumonia Pediatr Infect Dis J 31:e78, 2012 ©2012 MFMER | slide-27

28. Causes of Pneumonia Viral PCR RSV, Metapneumovirus, or Parainfluenza positive Likely Causative Coronavirus and Enterovirus positive Cases ~ Controls Pediatrics 133:e538, 2014 Pediatr Infect Dis J 31:e78, 2012 ©2012 MFMER | slide-28

29. Antibiotics for Pneumonia < 2 months: Hospitalizeamp/gent 2+ mo, outptHigh HIV areaamox x 5 days Low HIV areaamox x 3 days 2+ mo, severeamp or benzylpen PLUS gent ≥ 5 d 2+ mo, 2 nd lineceftriaxone (80 mg/kg IM or IV daily) ≥ 5 d Amox 40 mg/kg/dose orally twice daily Amp 50 mg/kg/dose IM or IV every 6 h Benzylpenicillin 50,000 u/kg/dose IM or IV every 6 h Gent 7.5 mg/kg/dose IM or IV daily WHO Hospital Care for Children 2013 Lassi ZS Arch Dis Child 2014 ©2012 MFMER | slide-29

30. Complicated Pneumonia (Effusion) Antibiotics (likely 3 weeks, parenteral for at least first week, then cloxacillin orally) Tap if > 1 cm fluid Drainage tube if persists Fibrinolytics if organized Video-Assisted Thoracoscopic Surgery if needed Thorax 66:815, 2011 WHO Hospital Care for Children 2013 ©2012 MFMER | slide-30

31. Supportive Care for Child With Pneumonia Oxygen (for sat < 90%, excessive effort) Fear of Oxygen? Deal with It! Stevenson (Tanzania). Arch Dis Child 2014 Fluids and nutrition (IV vs NG vs oral) Analgesics (to decrease distress, for T> 39 o C) It matters less what disease the patient has and more what patient has the disease. Hippocrates ©2012 MFMER | slide-31

32. Zinc for Pneumonia? ©2012 MFMER | slide-32

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34. Zinc for Pneumonia? meta analysis 7 randomized controlled studies 1066 children < 5 yrs developing countries NO DIFFERENCE in severity or duration of illness Pediatr Resp Rev 13:184, 2012 94 children in Tanzania – NO EFFECT J Trop Pediatr 60:104-111, 2014 ©2012 MFMER | slide-34

35. Why Do Kids Die of Pneumonia? Days of Illness Before Death7 Hours of Illness Before Home Rx4 Days of Illness Until Health Care2 Days from First Treatment to Death7 (2/3 of Deaths in Hospital) Problems: 1. Mistreatment with Anti-Malarials 2. Delays in Seeking Care 3. Low-Quality Care Uganda Bull World Health Organ 86:332, 2008

36. Tachypnea as a means of diagnosing “pneumonia” 2 - 12 months> 50 breaths / minute 12 - 60 months> 40 breaths / minute IF tachypnea (or severe retractions), give antibiotic. IF very sick, hospitalize for parenteral therapy.

37. A Common Situation A previously healthy ten week old presents with: 2 days of nasal congestion 1 day of cough and noisy breathing perhaps mild fever The exam shows: interactive child with rapid breathing and retractions coarse, wheezy breath sounds

38. RSV Bronchiolitis in Africa? Kilifi, Kenya

39. RSV Bronchiolitis in Kenya? Of 25,149 “under 5s” admitted ’02-’07 in Kilifi > 7359 (29%) had severe pneumonia > 15% with RSV (20% of those < 6 months) O.3% of under 5s hospitalized for RSV per year Of those admitted, 2% die Nokes DJ. Clinical Infectious Diseases 49:1341, 2009

40. Bronchiolitis in Thailand? 354 children 1-12 months old, Bangkok Lower Respiratory Tract Infection Influenza7% RSV29%especially July – October J Med Assoc Thai 94:S164, 2011 ©2012 MFMER | slide-40

41. WHAT Causes Bronchiolitis? Respiratory Syncytial Virus (RSV) – esp 2-6 mo Human Metapneumovirus - identified 2001 similar illness to RSV but severe if co-infected Human Bocavirus – identified 2005 similar illness to RSV but severe if co-infected Rhinovirus – typically older than RSV kids Adenovirus, Coronavirus, Enterovirus Influenza Virus, Parainfluenza Virus Arch Dis Child 93:793, 2008 Arch Dis Child 95:35, 2010

42. The 10 Week Old Has Bronchiolitis. What Treatments Might Help?

43. Supportive Care Fluids – possibly IV if tachypnea, poor feeding Nutrition Suction – temporary relief, deeper not helpful Oxygen– maybe keep O 2 saturation > 89% Chest Physiotherapy – distress >> benefit Pediatrics 118:1774, 2006

44. Treatment of Child With Bronchiolitis Cough Suppression and/or Decongestants Not effective Some risk of toxicity NOT recommended JAMA 299:887, 2008, Pediatr Nurs 33:515, 2007

45. Treatment of Child With Bronchiolitis Albuterol/Salbutamol Several Studies Transient mild improvement in up to 25% Improvement not sustained No change in overall clinical course Maybe helpful if previous recurrent wheezing Pediatrics 118:1774, 2006; Arch Dis Child 93:793, 2008 Possible therapeutic trial??

46. Treatment of Child With Bronchiolitis Epinephrine/Adrenaline 194 infants hospitalized in Australia Nebulized epinephrine or saline three times Observed at admission, pre-dose, 30 & 60 min post-dose Increased HR after does of epinephrine No overall change in time to discharge readiness Longer stay required if epinephrine given to babies requiring oxygen and IV fluids N Engl J Med 349:27, 2003

47. Treatment of Child With Bronchiolitis Glucocorticoids (Steroids) 600 children 2-12 months old, US Dexamethasone (1mg/kg) vs placebo on arrival All improved over 4 hours No difference in need for admission, course No difference in condition after 4 hours New Engl J Med 357:331, 2007 Consistent with 13 other studies Cochrane Database Syst Rev 3:CD004878, 2004

48. Treatment of Child with Bronchiolitis Hypertonic Saline Nebulized 3% Saline versus 0.9% Saline Shorter Length of Stay by 0.94 days (p=0.0006) Lower Post-Inhalation Clinical Score for first three days of treatment (p<0.05) Cochrane Database Syst Rev 8;4:CD000458, 2008

49. Treatment of Child with Bronchiolitis Hypertonic Saline (with epinephrine) Nebulized 3% Saline versus 0.9% Saline Respiratory DistressNOT different Oxygen SaturationsNOT different Admission RequiredNOT different Return to EDNOT different Arch Pediatr Adolesc Med 163:1007, 2009

50. Treatment of Child with Bronchiolitis Hypertonic Saline Conflicting Evidence Likely not helpful in emergency department Perhaps try in inpatient setting Grewal S et al. JAMA Pediatrics 168:607, 2014 Wu S et al. JAMA Pediatrics 168:657, 2014 Florin TA et al. JAMA Pediatrics 168:664, 2014

51. Bronchiolitis and Evidence-Based Medicine No consistent evidence to support the use of: anti-viral drugs bronchodilators corticosteroids Use of these agents is NOT recommended 50-80% of hospitalized children receive this Rx Withholding therapy is much more difficult than giving it. N Engl J Med 357:403, 2007

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53. New Bronchiolitis Guidelines Just Say “No” To: Chest X-Rays Antibiotics Albuterol Chest Physiotherapy Ralston SL et al. Pediatrics 2014 ©2012 MFMER | slide-53

54. Bronchiolitis: What Should We Remember? Some treatments are helpful fluids, nutrition, oxygen Other treatments are not necessary cough suppressants steroids albuterol (unless concurrent reactivity) anti-viral agents Prevention can be effective help families quit smoking use good hand hygiene

55. Pause: What is IMCI? A.I have no clue B.Something for other people to do C.An active part of my daily practice

56. Integrated Management of Childhood Illness Holistic approach to child health and development Core: Acute Respiratory Infection Diarrhea and Dehydration Measles Malaria Malnutrition Link to home - Center in primary care – Refer prn Adapted into > 80 countries; Cost-effective Bull World Health Organ 77:582, 1999 Indian J Pediatr 69:41, 2002 Lancet 364:1583, 2004

57. IMCI Works! Pay attention to respiratory rate! - detect pneumonia (need for antibiotics) - identify severe malaria (need for hospital) Keep thinking! - risk under-diagnosis of bronchiolitis - risk over-diagnosis of pneumonia Indian J Pediatr 75:781, 2008 Auscultation does have value! Gowraiah V et al. Arch Dis Child 99:899, 2014 Duke T. Arch Dis Child 2014

59. Pneumonia 1,200,000 kids die each year>>ACT ! It’s partly preventable >> PREVENT !! immunize clean air clean hands Careis often inadequate>>Dx & Rx !!! ©2012 MFMER | slide-59

60. ©2012 MFMER | slide-60 A Child A 10 month old child presents with two days of fever and cough. What is needed to appropriately make a diagnosis? Count respiratory rate! Consider other evaluation. What treatment is most likely to help? Antibiotic if tachypneic. Anti-malarial if test-positive. Supportive care, especially if likely bronchiolitis.

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