1. Topics
Respiratory disorders
Respiratory infections
Pneumonia

2. Respiratory Disorders
50% of consultation with general practitioners or acute
illness in young children and a third of consultations in older
children
20-35% of acute pediatric admissions to hospital, some of
which are life-threatening
Asthma is the most common chronic illness of childhood
Cystic fibrosis is the most common inherited disorder in
Caucasians causing chronic disease

3. Respiratory Infections
The most frequent infections of childhood: 6-
8/year
Pathogens:viruses,bacterial, other pathogens
Host and environmental factors
Classification of respiratory infections

4. Classification of Respiratory Infections
According to the level of the respiratory tree most involved:
Upper respiratory tract infection
Lower respiratory tract infection

5. Pneumonia
Enmei Liu
Children’s Hospital, CMU

6. Case -1
Jack, age four months, is sent at home by his general practitioner because of two days of rapid, laboured breathing and poor feeding. He was born at 27 weeks’ gestation, birth weight 979g and was discharged home at three months of age. On examination he was a fever of 37.4C and a respiratory rate of 60 breaths/min. His chest is hyperinflated with marked intercoatal recession. On auscultation there are generalized fine crackles and wheezes.

7. Question
Do you have any comments or what do you conclude anything from this case?

8. Case -1
Jack, age four months, is sent at home by his general practitioner because of two days of rapid, laboured breathing and poor feeding. He was born at 27 weeks’ gestation, birth weight 979g and was discharged home at three months of age. On examination he was a fever of 37.4C and a respiratory rate of 60 breaths/min. His chest is hyperinflated with marked intercoatal recession. On auscultation there are generalized fine crackles and wheezes.

9. Question
What is pneumonia?

10. Definition
Pneumonia is an inflammation of the parenchyma of the lungs.

11. Question
How about the prevalence of pneumonia?

12. Incidence Pneumonia accounts for approximately 15%
of all respiratory tract infections.
Worldwide, about 3 million children die each
year from pneumonia, with the majority of
these deaths occurring in developing countries.
Pneumonia remains the most common cause of
morbidity in China.

13. Question
How to classify pneumonia in clinic?

14. Classification
Anatomy
Pathogens
Severity
Duration
Onset site

15. Based on anatomy or X-ray manifestation
Bronchopneumonia
Lobar or Lobular Pneumonia
Interstitial Pneumonia

16. Based on etiology Bacterial pneumonia Viral Pneumonia
Mycoplasma Pneumonia
Chlamydia Pneumonia

17. Based on the process of pneumonia
Acute Pneumonia
Prolonged Pneumonia
Chronic Pneumonia

18. Based on the severity of pneumonia
Mild Pneumonia
Severe Pneumonia

19. Based on the onset site of pneumonia
Community Acquired Pneumonia (CAP)
Hospital Acquired Pneumonia (HAP)

20. Bronchopneumonia

21. Question
Why are children likely have bronchopneumonia?

22. Characters of childhood airway anatomic
structure and their respiratory physiology
Immune function of childhood
High risk factors: premature baby, underlying
disorders

23. What cause bronchopneumonia?
Question
What cause bronchopneumonia?

24. Causes of Bronchopneumonia
• Bacteria: Streptococcus pneumoniae,
Haemophilus influenzae
• Viruses
• Mycoplasma

25. Pathology of Pneumonia

26. Pathology of Pneumonia
Inflammaory exudate
Inflammaory exudate

27. Question
What are the pathophysiology of
pneumonia?

28. URTI Pathogens Bronchitis cough Pneumonia rales fever tachypnea
Inflammatory exudate
Obstruction of airway
Gas exchange abnormal
Ventilation abnormal
fever
tachypnea
cyanosis
hypoxemia
hypercapnia
toxinemia

29. Question
What are the signs and symptoms of pneumonia?

30. The clinical signs and symptoms of pneumonia depend primarily on the age of the patient, the causative organism, and the severity of the disease.

31. Tachypenea
Fever
Rales
Cough
Cyanosis

32. Nasal Flaring
out breathing in
With inspiration, the side of the nostrils flares outwards

33. Lower Chest Wall Indrawing
out breathing in
With inspiration, the lower chest wall moves in

34. Tachypenea
Fever
Rales
Cough
Cyanosis

35. Important Points Classic findings of pneumonia that occur in
adults and older children, such as fever,cough
and rales, are often absent in infants and
toddlers.
Generally present with nonspecific signs and
symptoms including lethargy, irritability, poor
feeding, vomiting.
If it appear respiratory failure or other
abnormality of other system-severe pneumonia.

36. Complications Empyema Pyopneumothorax Pneumatocele Lung abscesses
Atelectasis

37. Laboratory Examination
White blood cell count and C-reaction protein
Pathogens examination:
1)Sputum cultures
2)Blood cultures
3)Rapid screening tests for virus or bacterial
Bronchoscopy
Blood gas analysis: hypoxia and/or hypercapnia

38. Radiograph Evaluation
Typical X-ray manifestation of
bronchopneumonia is patchy infiltrates
bilaterally
Complication: lung abscesses, empyema,
pyopneumothorax, pneumatocele, atelectasis CT

39. Normal chest X-ray

40. Patchy infiltrates

41. Lobar pneumonia of the right lower zone consolidation

42. lung abscesses

43. pyopneumothorax

44. Question
How to diagnosis pneumonia clinically?

45. According to the typical clinical manifestation
of bronchopneumonia.
According to X-ray manifestation
Pay attention to the atypical manifestation of
infants
Evaluate the severity of pneumonia
Find the etiology of pneumonia

46. Differential Diagnosis
Bronchitis
Foreign Body Inspiration
Tuberculosis

47. How is pneumonia treated?
Question
How is pneumonia treated?

48. Management Supportive care Antimicrobials therapy
Hospitalization in selected cases

49. Supportive Care Adolescents.
Respiratory care may range from oxygenation,
bronchodilators for wheezing, humidification or
mist, suctioning, and postural drainage, intubation
and mechanical ventilation.
Hydration (sometimes intravenous)
Control of fever
Management of complications

50. Antimicrobial Therapy Adolescents.
Organism
Antimicrobial
Bacteria
Atypical
S. pneumoniae 
Penicillin (if not resistant). third-generation cephalosporin e.g. cefotaxime\ceftriaxone (if resistant to penicillin)
Chlamydia 
Azithromycin (other macrolides e.g erythromycin); alternative, sulfa drugs 
Azithromycin (other macrolides); alternative, tetracycline (if older than 8 years) 
Mycoplasma
H. influenzae 
Azithromycin or Amoxicillin (if not resistant)
Beta lactamase 
Cefuroxime or third-generation cephalosporin (if beta lactamase and resistant)
Viruses
RSV 
Ribavirin (optional)
S. aureus
Methicillin (if not resistant) Vancomycin (if MRSA-methicillin resistant S. aureus) if penicillin allergy: vancomycin, clindamycin 
Influenza
Amantadine (if severe)

51. Organisms Causing Pneumonia and Empiric Therapy in Pediatric
Age Group 
Bacterial 
Viral 
Empiric Therapy
Neonate (0-28 days)
Group B streptococcus, gram-negative enteric E. coli, Klebsiella, Listeria monocytogenes, S. aureus, other gram-positive)
Cytomegalovirus Herpes simplex
Ampicillin and aminoglycoside (gentamicin or tobramycin or amikacin, or third- generation cephalosporin). Note: Avoid ceftriaxone 2° to bilirubin
Infants 3-16 weeks; afebrile pneumonia infancy
Chlamydia trachomatis Ureaplasma urealyticum CytomegalovirusPneumocystis carinii
Erythromycin Sulfonamide
Infants febrile or ill appearing age 1-3 months
Same organisms as for neonate plus S. pneumoniae, H. influenzae, S. aureus
Not applicable
Antibiotic (nafcillin, oxacillin, or methacillin) Broad-spectrum cephalosporin (e.g., cefotaxime)
Toddler or preschool age
S. pneumoniae, H. influenzae M. pneumoniae, Chlamydia
RSV Parainfluenza Adenovirus Influenza
Azithromycin Amoxacillin-clavulanate: not active against atypical organisms (Mycoplasma, Chlamydia)

52. Question
How about the clinical course of pneumonia ?

53. Clinical Course Adolescents.
With treatment, pneumonia caused by
bacteria can usually be cured in 1 or 2 weeks
Pneumonia caused by a virus often lasts longer

54. Specific Pneumonias

55. Brochiolitis Brochiolitis is the most common serious
respiratory infection of infancy
Two to three per cent of all infants are admitted to
hospital with the disease each year during annual
winter epidemics.
Ninety per cent are aged 1-9 months bronchiolitis is rare
after one year old.
Respiratory syncytial virus (RSV) is the pathogen in 75-
80% cases

56. Clinical Features Coryzal symptoms precede a dry cough and increasing
breathlessness.
Wheezing is often but not always present.
Feeding difficulties associated with increasing dyspnoea
are often the reason for admission to hospital.
Recurrent apnoea is a serious complication in infants in
the first few months of life.
Infants born prematurely who develop
bronchopulmonary dysplasia and infants with congenital
heart disease are more severely affected.
The finding on examination are characteristic:
Sharp, dry cough
Tachypnoea
Subcostal and intercostals recession
Hyperinflation of the chest

57. Investigations
RSV can be identified rapidly using a fluorescent antibody
test on nasopharyngeal secretions.
The chest X-ray shows hyperinflation of the lungs due to
small airways obstruction and air trapping.
Blood gas analysis, which is required in only the most
severe cases, shows lowered arterial oxygen and raised
CO2 tension

58. Hyperinflation of the lungs with flattening of diaphragm

59. Management Is supportive. Humidified oxygen is delivered into a head-
box
Mist, antibiotics and steroids are not helpful
Nebulised bronchodialators do not reduce the severity or
duration of the illness
The antiviral drug ribavirin only marginally shortens viral
excretion and clinical symptoms, and should be considered
only for infants with underlying cardiopulmonary
disorders or immunodeficiency
Fluids may need to be given by nasogastric tube or
intravenously
Mechanical ventilation is required in about 2% of infants
admitted to hospital

60. Bronchiolitis
Etiology： Respiratory syncytial virus (RSV) is the pathogen in 75-80% cases
Clinical features:
Age:3-6 month
Season
Wheezing
X-ray
Duration:7-10 days
Management:

61. Staphylococcus aureus .
S. aureus is an uncommon but important cause of
pneumonia that can occur in any age group.
S. aureus is a rapidly progressive fulminant illness
S. aureus pneumonia easily occurs complications.
Blood cultures are positive in 20-30% of patients .
The pleural effusions should be drained by
thoracentesis or, if large, by a chest tube.
Pneumatoceles are also common and are found in 45-
60% of patients with S. aureus pneumonia.
Methicillin or vancomycin should be
administered for 3-4weeks.

62. Mycoplasma Pneumonia M pneumoniae is a common cause of symptomatic
pneumonia in older children.
Endemic and epidemic infection can occur.
The incubation period is long (2-3weeks), and the onset
of symptoms is slow.
Although the lung is the primary infection site,
extrapulmonary complications sometimes occur.

63. Clinical Features Fever, cough, headache, and malaise are common
symptoms as the illness evolves.
Rales are frequently present on chest examination,
decreased breath sounds or dullness to percussion
over the involved area may be present.

64. Laboratory findings counts are usually normal.
The total and differential white blood cell
counts are usually normal.
The cold hemagglutinin titier should be
determined, because it may be elevated
during the acute presentation. A titer of 1:64
or higher supports the diagnosis.

65. Imaging
Chest x-rays usually demonstrate intersititial or bronchopneumonic infiltrates, frequently in the middle or lower lobes. Pleural effusions are extremely uncommon.

66. Complications Extrapulmonary involvement of the blood,
CNS, skin, heart, or joints can occur
Direct Coombs-positive autoimmune hemolytic
anemia,Coagulation defects and
thrombocytopenia can also occur
A wide variety of skin rashes including
erythema multiforma and Stevens-Johnson
syndrome

67. Treatment Antibiotic therapy with erythromycin for 7-
10 days usually shortens the course of illness.
Supportive measures, including hydration,
antipyretics, and bed rest, are helpful.

68. Chlamydial Pneumonia
Pulmonary disease due to C trachomatis usually evolves
gradually as the infection descends the respiratory tract.
Infants may appear quite well despite the presence of
significant pulmonary illness.
Appropriate age: 2-12 weeks
Inclusion conjunctivitis, eosinophilia, and elevated
immunoglobulins can be seen.

69. Clinical Features About 50% of patients with chlamydial pneumonia
have active inclusion conjunctivitis or a history of it
Rhinopharyngitis with nasal discharge or otitis media
may have occurred or may by currently present
Cough is usually present. It can have a staccato character
and resemble the cough of pertussis
The infant is usually tachypenic. Scattered inspiraotrt
rales are commonly heard, but wheezes rarely
Significant fever suggests a different or additional
diagnosis

70. Laboratory findings Although patients may frequently be hypoxemic, CO2
retention is not common.
Peripheral blood eosinphilia has been observed in
about 75% of patients.
Serum immunloglobulins are usually abnormal. IgM
is virtually always elevated, IgG is high in many, and
IgA is less frequently abnormal.
C trachomatis can usually be identified in
nasopharyngeal washings using fluorescent antibody
or culture techniques.

71. Imaging
Chest x-rays usually reveal diffuse interstitial and patchy alveolar infiltrates, peribronchial thickening, or focal consolidation. A small pleural reaction can be present . Despite the usual absence of wheezes, hyperexpansion is commonly present.

72. Treatment Erythromycin or sulfisoxazole therapy should
be administered for 14 days.
Oxygen therapy may be required for
prolonged periods in some patients.

73. Summary Pneumonia in pediatric patients encompasses a wide
spectrum of etiologies and illness from mild to severe and
life threatening.
Therapy should include an antibiotic if a bacteria or
atypical bacteria (chlamydia or mycoplasma) is suspected.
No antibiotics are necessary for viral pneumonia.
Supportive therapy also includes fever control,
maintenance of hydration and respiratory care .
Close follow-up is necessary in order to detect any
secondary bacterial infection or the development of
complications.

74. Key Issues Etiology of pneumonia Pathophysiology of pneumonia
Clinical feature of pneumonia
Diagnosis and differential diagnosis of
pneumonia
Management of pneumonia
Several special pneumonias

75. Case -2
History:
A 9-week old female infant come to see doctor with a 3 week history of rhinorrhea and a 2 week history of cough. The cough is described as explosive and occurring in clusters and it persists as a major clinical symptom. On one occasion, the baby could not seem to catch her breath. She has not had any fever. No one else in this family is ill. At 6 weeks of age, the infant received on DPT.

76. Physical examination:
On physical examination the infant is alert and in moderate respiratory distress. Her temperature is 37.3C. Pulse 120beats/min, and respiratory rate is 65/min. There are intercostal and subcostal retractions. Ausculation reveals fine inspiratory rales throughout.

77. Laboratory data:
A complete blood count is normal showing a hemoglobin of 12.5g/dl, the white blood count was 6.2X103/mm3 with 21% polymorphonuclear leukocytes, 20% bands, 50% lymphocytes, and 9% eosinophils. The chest radiograph is shown bilaterally patchy infiltrates, more confluent in the upper lobes without penumothorax or pleural effusions.

78. Question Please discuss this case.
What is the most likely etiology diagnosis?

79. References Nelson Textbook of Paediatrics
Pneumonia(Sharon E. Mace, MD,
FACEP, FAA)
Current Pediatric Diagnosis and
Treatment
Mosby” s Crash Course
Pediatrics

80. Thank you very much!!! Please contact with me:
address:
Telephone:
Address: Children’s Hospital, CMU
Thank you very much!!!