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Pneumonia management and prevention

Pneumonia management and prevention. Dr. M. Akram Shaikh Paediatric Dept. LUMHS Jamshoro. Pneumonia leads causes of childhood deaths. Source: WHO estimates of the causes of death in children, 2000-03 Bryce, Lancet, 26 March 2005. Scope of the problem: all age groups.

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Pneumonia management and prevention

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  1. Pneumonia management and prevention • Dr. M. AkramShaikh • Paediatric Dept. LUMHS Jamshoro

  2. Pneumonia leads causes of childhood deaths Source: WHO estimates of the causes of death in children, 2000-03 Bryce, Lancet, 26 March 2005

  3. Scope of the problem: all age groups • Sixth leading Cause of Death • Number one cause of death from infectious disease • Up to 5.6 million cases per year • >10 million physician visits • Average Mortality rate for patients 12% Niederman MS, et al. Am J Am J Respir Crit Care Med 2001;163:1730 - 1754.

  4. COMMON CAUSES OF DEATH IN CHILDREN • GLOBAL:PNEUMONIA:3MILLION/YEAR • DIARRHOEA:2.8MILLION • MEASLES1.5MILLION • MALARIA 1-2 MILLION • PAKISTAN:PNEUMONIA AND DIARRHOEA KILLING ABOUT 3 LAC U5 CHILDREN/YEAR

  5. Etiology of pneumonia • Age-dependent • Neonatal period– GBS(group B strep.cocci) colonizes the genital area of 15-30% of pregnant women • 1% of infants born to untreated GBS- postive women will develop early onset disease • Other bacteria E. coli, K. pneumonia. L. monocytogenes

  6. Etiology-contd • Older children 1-10yr • Viruses play a large part as etiologic agent • Pneumococcus • H I flu • Group A streptococcus • Staph aureus • Mycoplasma and to a smaller extent chlamydia pneumoniae in school-children

  7. Respiratory Syncytial Virus Adenovirus Rhinovirus Parainfluenza/Influenza What causes Pneumonia: Viruses

  8. Streptococcus pneumoniae Haemophilus influenzae What causes Pneumonia: Bacteria Source: CF. Laine, T Sugishita, J Rabke-Verani , M Cavicchia

  9. Major pathogens in CAP S. pneumoniae the leading pathogen in CAP Only 7.5% patients had an atypical pathogen detected -Bartlett Jg & Mundy LM./new England Journal of Medicine (1995)333:1618-1624. *Average of prevalence figures from North American studies & British -Thoracic Society. Other bacteria include S. aureus, gram -ive bacilli and M. catarrhalis. -M.C. Mackean.Journal of infection (2002) 45:213-218 Evidence based Medicine: Review of BTS Guidel;ines for the Management of Community Acquired Pneumonia in Adults -Linda M.Mundy et al, Implications for macrolide treatment in CAP Chest (1998);113:1201-06

  10. Moderate – Severe Lower Respiratory Infection in children: • 1) Fever + • 2) Cough + • 3) Rapid breathing (more than 50 breaths/minute) • A child has tacypnoea if • Respiratory rate >60/min in children <2 months • Respiratory rate >50/min in children 2-11 months • Respiratory rate >40/min in children 12-59months Case Definition

  11. IMNCI : Assessment • INITIAL VISIT: Check for Any General Danger Signs • Ask: Is the child not able to drink or breast feed? • Does the child vomits everything? • Has the child had convulsions? • LOOK: • See if the child is lethargic or unconscious. • See if the child is convulsing now.

  12. Ask About Main Symptoms: does the child have cough or difficult breathing? • If yes, ask :for how long? • Look, Listen: • Count the breath in one minute. • Look for chest in drawing. • Look and listen for stridor. • Look and listen for wheeze.

  13. Classify cough and difficult breathing • SEVERE PNEUMONIA OR VERY SEVERE DISEASE IF: • Any general danger sign or • Stridor in calm child or • Chest in drawing • PNEUMONIA If :Fast breathing • NO PNEUMONIA (COUGH OR COLD) IF: No signs of pneumonia or very severe disease

  14. Clinical management of a sick child with cough or difficult breathing VERY SEVERE DISEASE Danger signs* YES Refer to hospital Give antibiotics NO SEVERE PNEUMONIA Assess for chest indrawing YES Refer to hospital Give antibiotics NO Assess for fast breathing (RR>50/40 breaths/minute) PNEUMONIA YES Give antibiotics NO=NO PNEUMONIA; COUGH OR COLD * Danger signs include cyanosis, convulsions, severe malnutrition, difficult to wake, not able to drink

  15. Right middle lobe pneumonia

  16. Pneumonia

  17. Control of Lower Respiratory Infections WHO focuses on the reduction of mortality requiring: Early/adequate diagnosis Correct case management Hospitalize for danger signs Access to health care Trained health staff Simple treatment protocols Immunization May increase transmission risk for meningitis MSF book, p. 178

  18. Recommended Antibiotics for Pneumonia Antibiotic Doses/day Relative cost Cotrimoxazole 2 PO Lowest Amoxicillin 3 PO Highest Procaine penicillin 1 IM Middle Antibiotic dose needs to be calculated by the weight of the child

  19. 7 Site Pakistan RCT Children 3-59 mo with WHO-defined severe pneumonia IV Ampicillin/hospitalization VS Home management/oral amoxicillin LANCET JAN 2008 • FINDING: • Home therapy with oral amoxicillin is equivalent to initial hospitalization and parenteral ampicillin for treatment of WHO-defined severe pneumonia in children 3-59 mo of age • Shorter course of high-dose amoxicillin (80-90 mg/kg/day administered twice a day for 5 days) is safe and efficacious

  20. Community based management of Severe Pneumoniacompletion by Fall 2009 • CHW manage severe pneumonia in children at the community level train Lady Health Workers in Pakistan in management of severe pneumonia under careful supervision and document the outcomes MORE CAREFUL APPROACH • Very young infants (3-5 mo old) • Very fast breathing • Underweight for age (WAZ < -2)

  21. Complications of CAP • Lung abscess • Pulmonary fibrosis • Pleural effusion • Empyema • Myocarditis • Meningitis • Arthritis 1. Davidson’ Principle of Medicine; 18th Edition 2000 Pg. 344

  22. Pneumonia: Prevention • Avoid overcrowding • Provide alternatives to open indoor fires • Provide adequate shelter and blankets/heating • Prevent malnutrition • Encourage breastfeeding • Vitamin A supplementation • Vaccinate • Reduce Pneumonia • Reduce secondary bacterial infections

  23. Existing vaccines to prevent pneumonia • Routinely used • Measles • Pertussis • Diphtheria • Haemophilusinfluenzaetype b (In some countries) • Pneumococcal • RSV

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