A mother came to hospital with her baby 2 yrs old, she says

that her baby is not feeding well, have fast breathing and is
coughing since 4 days. What might be the diagnosis for
baby?
• Respiratory examination in pediatrics.mp4
 Inspection of chest
• Nearly circular or cylindrical in infants
• The shape may be normal, barrel shaped(asthma )
or pigeon shaped.(rickets)
• Barrel shaped chest is seen when lungs are
chronically overinflated with air, so the rib cage stays
partially expanded all the time this makes breathing
difficult as well
• Symmetry
• Movement of chest: breathing is mostly abdominal in
infants
 Palpation
• Look for any tender areas, crepitus and assess any
differences of movements on two sides of chest
• Feel any abnormal vibrations e.g ronchi, friction rub,
crackles.
• Vocal or tactile fermitus is looked for by comparing
tactile transmission of spoken words or cry in infants
• Assess the expansion of chest on two sides.
 Lung sounds
• Pleural rubs are discontinuous or continuous, creaking or
grating sounds. The sound has been described as similar to
walking on fresh snow type of sound.
• Coughing will not alter the sound. They are produced because
two inflamed surfaces are sliding by one another, such as in
pleurisy.
• Crackles, crepitations, or rales are the clicking, rattling, or
crackling noises that may be made by one or both lungs of a
human with a respiratory disease during inhalation.
• Rhonchi are coarse rattling respiratory sounds, usually
caused by secretions in bronchial airways.
 percussion
• Tympanitic, drum-like sounds heard over air filled structures
during the abdominal examination.
• Hyperresonant (pneumothorax) said to sound similar to
percussion of puffed up cheeks.
• Normal resonance/ Resonant the sound produced by
percussing a normal chest.
• Impaired resonance (mass, consolidation) lower than normal
percussion sounds.
• Dull (consolidation) similar to percussion of a mass such as
a liver.
ARI/Pneumonia
 Acute Respiratory Tract Infection
• Acute respiratory infection is an acute infection of any
part of respiratory tract and related structures
including paranasal sinuses, middle ear and pleural
cavity.
• It may cause inflammation of respiratory tract
anywhere from nose to alveoli with a wide range of
combinations of symptoms and signs.
 ARI
• It includes all infections of less than 30 days
duration, except the infection of ear lasting less than
14 days.
• The incidence of ARI is highest in young children,
especially below 5 years of age and decreases with
the increasing age.
 ARI includes

• Pneumonia
• Diptheria
• Pertussis (Whooping cough)
 Pneumonia
Definition

Pneumonia is defined as acute inflammation and

consolidation of lung parenchyma.

25
Classification

Pneumonia can be classified

• on anatomic basis

• on severity basis

• on etiologic basis.

26
Classification on Anatomic Basis
a. Bronchonpeumonia

Patchy consolidation of lungs is known as

bronchopneumonia.

b. Lobar or Lobular Pneumonia

One or more lobes of lungs are involved.

c. Interstitial Pneumonia

Alveoli or interstitial tissues of lungs are affected.

27
Classification on Severity Basis

WHO classification of Pneumonia

depending upon the severity is categorized
in accordance to age of the child.

• For the children within 2 months to 5 years

of age

• For the infant less than 2 months of age

28
 Classification on Severity Basis
For the children within 2 months to 5 years of age

• No Pneumonia

• Pneumonia

• Severe Pneumonia

• Very Severe Pneumonia

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Classification on Severity Basis

For the infant less than 2 months of age

• No Pneumonia

• Severe Pneumonia

• Very Severe Pneumonia

30
Classification on Etiologic Basis
a. Bacterial Pneumonia

It may be caused by Pneumococcus,

Streptococcus, Staphylococcus, Hemophilus
influenza and H. pertusis.
b. Viral Pneumonia

It is caused by virus like Influenza, Measles,

Adenovirus and Respiratory Syncytial Virus
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Miscellaneous Types
a. Aspiration Pneumonia
It is caused by aspiration of food, nasal drops,
amniotic fluid by newborn, water (drowning).

b. Loffler’s Pneumonia
It is a disease in which eosinophils accumulate
in lungs in response to parasitic infection.
It may be caused by parasites like Ascaris,
lumbricoides, Strongyloides, stercoralis and
Ancylostoma duodenale.
32
 Miscellaneous Types
c. Chemical Pneumonia
It results from aspiration of Kerosene oil
poisoning.
d. Hypostatic Pneumonia
It results from collection of fluid in dorsal region
of lungs and occurs especially in those confined
to bed for long time (like bed ridden patients.)

33
 Other classification
• Community acquired pneumonia: occurs with in first
48hrs of hospitalization. Common organism are
Pneumonia are streptococci, hemophilus influenza,
mycoplasma, viral, pneumococcal
• Hospital acquired: pneumonia occurred greater than
48 hrs after hospital admission. About 0.5 to 1% of
all hospitalization
• Pneumonia in immune compromised host: child
using immuno-suppressive agent, chemotherapy,
nutritional depleted, broad spectrum antibiotics,
genetic acquired pneumonia
Causative Organisms
Bacterial: Pneumococcus, Staphylococcus,

Streptococcus, H. influenzea, Klebsiella, M

tuberculosis, E. coli, H. pertusis

Viral: Influenza, measles, chickenpox,

respiratory syncytial virus (RSV)

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 Causative Organisms

Fungal: Candidiasis, Histoplasmosis,

Blastomycosis, Coccidiomycosis

Protozoal: Pneumocystis carnii, Toxoplasma

gondii and E. histolytica.

36
 Risk Factors

• Malnutrition
• Vitamin A deficiency
• LBW
• Lack of breast feeding
• History of previous respiratory tract infection
• Passive smoking
• Young age, advanced birth order
• Indoor and outdoor pollution
• Family history
• Overcrowding damp residence
• immobility
Vit A deficiency and pneumonia
• Vitamin A/retinol is involved in the production,
growth and differentiation of red cells, lymph cells
and antibodies , and epithelial integrity.
• Because of its proven effectiveness in protecting
against measles-associated pneumonia , vitamin A
supplementation has been investigated as a
possible intervention to speed recovery, reduce the
severity and prevent against subsequent episodes
of acute lower respiratory tract infections
 Pathogenesis
Bacteria or virus reach the lungs through
respiratory passage and multiply in the alveoli.

They disturb the defense mechanism of the

lungs.

There will be gross alteration in properties of

normal lung secretions
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 The first stage is attack is called ‘engorgement’.

During this period, the lungs become dark bluish red and
heavy.

During the next stage i.e. ‘red hepatization’ , the affected

lobe becomes solid with red cells and finrin and air is
displaced.
40
In the last stage i.e. ‘grey hepatization’,
the pleural surface becomes dull in
colour and alveoli are filled with
leucocytes and fibrin.

The invading organism produces

inflammation in mucosa with exudation
in alveoli due to which it becomes
consolidated.
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Clinical Features
• Sudden onset.
• High fever with chills
• Cough with thick sputum
• Increased respiratory rate.
• Grunting respiration
• Nasal flaring
• Running nose
• Irritability
• Malaise
• Sore throat
• anorexia 42
 Clinical Features
• Late Symptoms Include
• Convulsions
• Drowsiness
• Inability to drink from mouth
• Chest in drawing
• Wheezing
• Hoarseness of voice
• Cyanosis
• Pleural pain which may be increased by deep
breathing and is referred to shoulder or
abdomen. 43
 WHO classification of signs and symptoms of
Pneumonia

No • Cough or cold, No fast breathing

Pneumonia
• Increased respiratory rate
• <2 months > 60 per min
Pneumonia • 2-12 months >50 per min
• 12- 60 months (5 yrs) > 40 per min
Severe • Chest in drawing with or without fast
Pneumonia breathing

Very severe • Cyanosis, severe chest in drawing, in

Pneumonia ability to feed 44
Diagnostic Evaluation
• History of the child reveals presence of cough with
increased respiration.
• Chest X-ray:
X-ray finding suggesting bronchopneumonia
include diffuse patchy consolidation in lungs.
Consolidation is seen as homogenous opacity
occupying the anatomic area of a lobe, usually in
one lung
• Positive ASO Titer is diagnostic criteria of
streptococcal pneumonia

45
Diagnostic Evaluation

• Diagnosis is confirmed by isolating the organism in

blood or from pleural fluid or bronchoalveolar
lavage fluid.

• Isolation of organism from naso pharynx or thorat

by culture or PCR in viral pneumonia

• Blood test reveals increased blood count with

polymorphonuclear leucocytosis seen in bacterial
pneumonia
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 IMNCI Protocol for Management
of Pneumonia
Signs Classification Treatment

No signs of •If coughing more than 30

No Pneumonia days, refer for
pneumonia assessment
or Cough or Cold
•Soothe the throat and
no indications of relieve the cough with
safe home remedy if child
very severe is 6 months or older
disease •Follow up in 5 days if not
improving.

47
Signs Classification Treatment

•Give antibiotics for 5 days

Fast Breathing Pneumonia
•Soothe the throat and
relieve the cough with safe
remedy if child is 6 months
or older.
•Advise mother when to
return immediately.
•Follow –up in 2 days. 48
Signs Classification Treatment

•Any general danger signs Severe •Give antibiotics

•Chest in drawing
Pneumonia or •(refer to hospital
•Stridor in calm child
Very Severe urgently)
•Central cyanosis
•Inability to breast feed/drink or Disease
vomit everything
•Convulsions, lethargy or
unconsciousness
•Severe respiratory distress

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 Additional signs of severe pneumonia

• Fast breathing; age< 2 months;60/min, age 2 months to 12

months;50/min, age 1 yr to 5 yr: 40/min
• Nasal flaring
• Grunting
• Lower chest indrawing
• Chest auscultation: decreased breath sound, crackles,
abnormal vocal resonance
 Treatment of very severe pneumonia
• Admission
• Antibiotic
Chloramphenicol 25mg/kg, im/iv 8 hrly untill the child has
improved, then orally 3 times for total course 10 days
If chroamphenicol is not available give benzyal penicillin
50,000 U/kg im/iv 6hrly and gentamycin 7.5mg/kg IM once a
day for 10 days.
If child does not improve with in 48 hrs, switch gentamycin and
cloxacilline 150mg/kg im/iv 6 hrly when improves continue
cloxacilline 4 times for total course 3 weeks.
• Oxygen therapy
• Regular monitoring
Supportive Care

• If high fever: paracetamol

• If wheezes present: rapid acting bronchodilator
• Remove secretion by gentle suction
• Ensure fluid maintenance: breast feeding,
encourage oral feeding, if cant feed orally, NG tube
feeding
• Monitoring 3 hrly by nurses at at least twice a day
by doctor
Treatment of severe pneumonia
• Diagnosis: cough or difficult breathing plus
at least one of the following signs
 Lower chest wall indrawing
 Nasal flaring
 Grunting
In addition, some or all of the others signs of
pneumonia may also be present
Fast breathing
Chest auscultation: abnormal sound
 Treatment
• Admit in hospital
• Antibiotic: Benzyl penicillin (50,000)U/kg im/iv 4 times/day for
at least 3 days.
• When the child improves, switch to oral amoxicillin 15mg/kg 3
times a day with total course of 5 days. If does not improves
with in 48hrs or deterioration switch to chroramphenicol 125
mg/kg im/iv 8 hrly for 10 days.
• Supportive therapy as in very severe pneumonia(fever
management, secretion removal, wheezing management by
bronchodilator)
• Monitoring is done at least every 6 hrly by nurses and once a
day by doctor.
 pneumonia
• On examniation, the child has cough or difficult in
breathing and fast breathing
• Treatment:
Treat child as an out patient
Cotrimoxazole 4mg/kg, trimethoprium 20 mg/kg.
twice a day for 5 days or amoxicilline 15 mg/kg tds
for 5 days
 Pneumonia…
• First dose at clinic and teach the mother how to
give
• Follow up
• After 2 days or earlier if the child becomes more
sick or is not able to drink of breast milk
• If condition improving then continue antibiotics
• If not improved then 2nd line antibiotic and follow
up in 2 days
• If severe then admit to hospital
 No pneumonia (cough or cold)

Self limited viral infection characterized by cough,

nasal discharge, mouth breathing, fever etc requires
only supportive therapy.
 Nursing Diagnosis
• Ineffective airway clearance related to
inflammation, obstruction or secretions of
respiratory tract.

• Ineffective breathing pattern related to

inflammatory process.

• Fluid volume deficit related to fever, anorexia

and vomiting.
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 Nursing Diagnosis

• Anxiety related to respiratory distress and

hospitalization.

• Parental role conflict related to illness of the

child.

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 Nursing Management
Nursing management is focused on

1. Make continuing assessment

2. Facilitate respiratory efforts

3. Control fever

4. Maintain fluid and electrolyte balance along with

nutritional status of the child

5. Promote rest and sleep

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 Nursing Management
Nursing management is focused on

1. Make continuing assessment

2. Facilitate respiratory efforts

3. Control fever

4. Maintain fluid and electrolyte balance along with

nutritional status of the child

5. Promote rest and sleep

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 Nursing Management
Make continuing assessment
• Monitor the child’s respiratory rate and
pattern.
• Monitor breath sounds to note presence
of rales, ronchi and wheezing.
• Observe for signs of respiratory distress.

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 Nursing Management:
Facilitate respiratory efforts
• Maintain patent airway and provide high
humidity atmosphere.
• Administer oxygen to maintain the oxygen
saturation in blood.
• Place the child in semi-fowlers position to
help in breathing.

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 Nursing Management:
Facilitate respiratory efforts
Position of the child should be changed frequently

to prevent pooling of secretion in lungs.

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 Nursing Management:
Facilitate respiratory efforts

• Keep the child warm and comfortable.

• Administer cough suppressants and

bronchodilators, as prescribed.

• Provide steam inhalation and chest

physiotherapy to help drainage of secretions.

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Nursing Management: Facilitate respiratory
efforts
• If the child is old enough, teach them effective
coughing and deep breathing.

• Give increased amount of fluids as this will help

in liquefying the thick tenacious secretions.

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Nursing Management:
Control fever
• Provide bed rest to the child.

• Administer the prescribed antibiotics.

• Tepid sponging is done to reduce fever.

• Increase the fluid intake to prevent dehydration

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Nursing Management
Maintain fluid & electrolyte balance
• Provide adequate fluid to meet increased fluid
demand of the child.

• If the child is having breathing difficulty, do not

give anything orally as there is greater risk of
aspiration.

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Nursing Management
Maintain fluid & electrolyte balance
• When oral feedings are started, after the child’s
condition permits, feed the child slowly and
carefully to prevent aspiration and aggravation of
cough.

• Give high calorie liquid to the child.

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Nursing Management:
Promote rest and sleep
• Handle the child as little as possible to provide
rest.
• Provide diversion therapy to the child to avoid
boredom.
• Administer mild sedatives (if prescribed) when
the child is restless or irritable.

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Complications
• Pleural effusion
• Emphysema: is a long-term, progressive disease of
the lungs that primarily causes shortness of breath
due to over-inflation of the alveoli (air sacs in the
lung).
• Pneumatocele: is a cavity in the lung parenchyma
filled with air that may result from pulmonary trauma
during mechanical ventilation.
• Bronchiectasis: is a disease in which there is
permanent enlargement of parts of the airways of the
lung.

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Prevention

The Pneumococcal Conjugate Vaccine (PCV 13)

• The Pneumococcal Conjugate Vaccine is

recommended for all children <2 years of age.

• This vaccination should be repeated every five to

seven years, where as the flu vaccine given
annually.

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73
 Research Article

Risk Factors for Pneumonia in Children under 5 Years in a

Teaching Hospital in Nepal
• The objective of the study was to identify the risk factors for
pneumonia among children under-5 years of age.
• A case control study was carried out among the mothers
having under-5 years children who were admitted in the
paediatric ward of Dhulikhel Hospital in 2012/13.
 Methodology
• A convenience sampling technique was used to select 50
children with pneumonia and 150 children with non-
pneumonia diseases matched on age, sex and setting.
• A semi-structured interview consisting of questions related
to risk factors for pneumonia was used to collect data from
mothers of both cases and controls.
 Result
• The present study suggests that two factors related to
smoke, presence of a smoky chulo in a household and both
parents smoking, are modifiable risk factors related to
pneumonia in young children.