Case discussion
August 16, 2019

  • Qusay is an 8y old boy, was never diagnosed to have any medical illness before, presented to ER with cough, shortness of breath and fever…
  • What do you want to ask ??
  • History ??
  • Physical examination


What is pneumonia?

pneumonia is an infection of the lower respiratory tract that involves the airways and parenchyma with consolidation of the alveolar spaces.

How common is pneumonia ??
And is it a fatal disease ??

  • Incidence— The World Health Organization (WHO) estimates there are 156 million cases of pneumonia each year in children younger than five years, with as many as 20 million cases severe enough to require hospital admission.
  • Mortality— The mortality rate in developed countries is low (<1 per 1000 per year). In developing countries, respiratory tract infections are not only more prevalent but more severe. Worldwide, lower respiratory tract infections accounted for nearly 800,000 deaths among children ≤19 years in 2015


Are there any specific pediatric population, who are at higher risk of developing pneumonia ??

Risk Factors:

  • Lower socioeconomic class.
  • School-age children.
  • Underlying cardiopulmonary disorders and other medical conditions predispose to pneumonia and contribute to increasing severity. These include:
  • Congenital heart disease
  • Bronchopulmonary dysplasia
  • Cystic fibrosis
  • Asthma
  • Sickle cell disease
  • Neuromuscular disorders, especially those associated with a depressed consciousness
  • Some gastrointestinal disorders (eg, gastroesophageal reflux, tracheoesophageal fistula)
  • Congenital and acquired immunodeficiency disorders
  • Cigarette smoke


Are there any specific patterns to pneumonia that specify them under different categories ??

  • Patterns of pneumonia— There are five patterns of bacterial pneumonia:
  • Lobar pneumonia – Involvement of a single lobe or segment of a lobe. This is the classic pattern of S. pneumoniaepneumonia.
  • Bronchopneumonia – Primary involvement of airways and surrounding interstitium. This pattern is sometimes seen in Streptococcus pyogenesand Staphylococcus aureuspneumonia.
  • Necrotizing pneumonia (associated with aspiration pneumonia and pneumonia resulting from S. pneumoniaeS. pyogenes, and S. aureus).
  • Caseating granuloma (as in tuberculous pneumonia).
  • Interstitial and peribronchiolar with secondary parenchymal infiltration – This pattern typically occurs when a severe viral pneumonia is complicated by bacterial pneumonia.

There are two major patterns of viral pneumonia:

  • Interstitial pneumonitis
  • Parenchymal infection with viral inclusions

What will you find on examination that would make you think of pneumonia ??

Examination findings vary depending on the site of infection as follows:

  • Inspiratory crackles, also called rales and crepitations, are more common in lobar pneumonia and bronchiolitis/pneumonia
  • Decreased breath sounds may be noted in areas of consolidation
  • Coarse, low-pitched continuous breath sounds (rhonchi) are more common in bronchopneumonia
  • Expiratory wheezes, high-pitched breath sounds, are caused by oscillation of air through a narrowed airway; they are more common in bronchiolitis and interstitial pneumonitis

Discussion of IDSA guideline of  community acquired pneumonia in older than 3month children

  • Lets go back to our patient Qusay:
  • So now
  • He is on 7liters oxygen à 90%
  • RR 50
  • Signs of respiratory distress
  • Drowsy

Do you prefer to admit or manage as out patient !!!!!

  • Recommendations
  1. Children and infants who have moderate to severe CAP, as defined by several factors, including respiratory distress and hypoxemia (sustained saturation of peripheral oxygen [SpO2], ,90 % at sea level should be hospitalized for management, including skilled pediatric nursing care. (strong recommendation; high-quality evidence)
  2. Infants less than 3–6 months of age with suspected bacterial CAP are likely to benefit from hospitalization. (strong recommendation; low-quality evidence)
  3. Children and infants with suspected or documented CAP caused by a pathogen with increased virulence, such asmcommunity-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) should be hospitalized. (strong recommendation; lowquality evidence)
  4. Children and infants for whom there is concern about careful observation at home or who are unable to comply with therapy or unable to be followed up should be hospitalized. (strong recommendation; low-quality evidence)

When Should a Child With CAP Be Admitted to an Intensive Care Unit (ICU) or a Unit With Continuous Cardiorespiratory Monitoring?

  1. A child should be admitted to an ICU if the child requires invasive ventilation via a nonpermanent artificial airway (eg, endotracheal tube). (strong recommendation; high-quality evidence)
  2. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child acutely requires use of noninvasive positive pressure ventilation (eg, continuous positive airway pressure or bilevel positive airway pressure). (strong recommendation; very lowquality evidence)
  3. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has impending respiratory failure. (strong recommendation; moderate-quality evidence)
  4. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion. (strong recommendation; moderate-quality evidence)
  5. A child should be admitted to an ICU if the pulse oximetry measurement is ,92% on inspired oxygen of $0.50. (strong recommendation; low-quality evidence)
  6. A child should be admitted to an ICU or a unit with continuous cardiorespiratory monitoring capabilities if the child has altered mental status, whether due to hypercarbia or hypoxemia as a result of pneumonia. (strong recommendation; low-quality evidence)
  7. Severity of illness scores should not be used as the sole criteria for ICU admission but should be used in the context of other clinical, laboratory, and radiologic findings. (strong recommendation; low-quality evidence)
  • The PICU team is informed about an expected admission, they are preparing the picu room, do you want to proceed to do any labs?
  • Recommendations
  • Microbiologic Testing
  • Blood Cultures: Outpatient
  1. Blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting. (strong recommendation; moderate-quality evidence)
  2. Blood cultures should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy (strong recommendation; moderate-quality evidence).

Blood Cultures: Inpatient

  1. Blood cultures should be obtained in children requiring hospitalization for presumed bacterial CAP that is moderate to severe, particularly those with complicated pneumonia. (strong recommendation; low-quality evidence)
  2. In improving patients who otherwise meet criteria for discharge, a positive blood culture with identification or susceptibility results pending should not routinely preclude discharge of that patient with appropriate oral or intravenous antimicrobial therapy. The patient can be discharged if close follow-up is assured. (weak recommendation; low-quality evidence)

Follow-up Blood Cultures

  1. Repeated blood cultures in children with clear clinical improvement are not necessary to document resolution of pneumococcal bacteremia. (weak recommendation; low-quality evidence)
  2. Repeated blood cultures to document resolution of bacteremia should be obtained in children with bacteremia caused by S. aureus, regardless of clinical status. (strong recommendation; low-quality evidence) Sputum Gram Stain and Culture
  3. Sputum samples for culture and Gram stain should be obtained in hospitalized children who can produce sputum. (weak recommendation; low-quality evidence)


Testing For Viral Pathogens

  1. Sensitive and specific tests for the rapid diagnosis of influenza virus and other respiratory viruses should be used in the evaluation of children with CAP. A positive influenza test may decrease both the need for additional diagnostic studies and antibiotic use, while guiding appropriate use of antiviral agents in both outpatient and inpatient settings. (strong recommendation; high-quality evidence)
  2. Antibacterial therapy is not necessary for children, either outpatients or inpatients, with a positive test for influenza virus in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection. (strong recommendation; high-quality evidence).
  3. Testing for respiratory viruses other than influenza virus can modify clinical decision making in children with suspected pneumonia, because antibacterial therapy will not routinely be required for these children in the absence of clinical, laboratory, or radiographic findings that suggest bacterial coinfection. (weak recommendation; low-quality evidence)

Testing for Atypical Bacteria:

  1. Children with signs and symptoms suspicious for Mycoplasma pneumoniae should be tested to help guide antibiotic selection. (weak recommendation; moderate-quality evidence)
  2. Diagnostic testing for Chlamydophila pneumoniae is not recommended as reliable and readily available diagnostic tests do not currently exist. (strong recommendation; high-quality evidence)

Complete Blood Cell Count

  1. Routine measurement of the complete blood cell count is not necessary in all children with suspected CAP managed in the outpatient setting, but in those with more serious disease it may provide useful information for clinical management in the context of the clinical examination and other laboratory and imaging studies. (weak recommendation; low-quality evidence)
  2. A complete blood cell count should be obtained for patients with severe pneumonia, to be interpreted in the context of the clinical examination and other laboratory and imaging studies. (weak recommendation; low-quality evidence)

Acute-Phase Reactants:

  1. Acute-phase reactants, such as the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration, or seru procalcitonin concentration, cannot be used as the sole determinant to distinguish between viral and bacterial causes of CAP. (strong recommendation; high-quality evidence)
  2. Acute-phase reactants need not be routinely measured in fully immunized children with CAP who are managed as outpatients, although for more serious disease, acute-phase reactants may provide useful information for clinical management. (strong recommendation; low-quality evidence)
  3. In patients with more serious disease, such as those requiring hospitalization or those with pneumonia-associated complications, acute-phase reactants may be used in conjunction with clinical findings to assess response to therapy. (weak recommendation; low-quality evidence)

Pulse Oximetry

  1. Pulse oximetry should be performed in all children with pneumonia and suspected hypoxemia. The presence of hypoxemia should guide decisions regarding site of care and further diagnostic testing. (strong recommendation; moderatequality evidence)


  • The PICU team called you, and the patient transferred,
  • You already took cbc, crp, renal profile, venous blood gas, blood culture
  • In the picu, the nurse is asking the picu team if they prefer to do any imaging,
  • What do you think is the proper action ??
  • Initial Chest Radiographs: Outpatient
  • Routine chest radiographs are not necessary for the confirmation of suspected CAP in patients well enough to be treated in the outpatient setting (after evaluation in the office, clinic, or emergency department setting). (strong recommendation; high-quality evidence)
  1. Chest radiographs, posteroanterior and lateral, should be obtained in patients with suspected or documented hypoxemia or significant respiratory distress and in those with failed initial antibiotic therapy to verify the presence or absence of complications of pneumonia, including parapneumonic effusions, necrotizing pneumonia, and pneumothorax. (strong recommendation; moderate-quality evidence)
  • Initial Chest Radiographs: Inpatient
  1. Chest radiographs (posteroanterior and lateral) should be obtained in all patients hospitalized for management of CAP to document the presence, size, and character of parenchymal infiltrates and identify complications of pneumonia that may lead to interventions beyond antimicrobial agents and supportive medical therapy. (strong recommendation; moderate-quality evidence)
  • Follow-up Chest Radiograph
  1. Repeated chest radiographs are not routinely required in children who recover uneventfully from an episode of CAP. (strong recommendation; moderate-quality evidence)
  2. Repeated chest radiographs should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration within 48–72 hours after initiation of antibiotic therapy. (strong recommendation; moderate-quality evidence)
  3. Routine daily chest radiography is not recommended in children with pneumonia complicated by parapneumonic effusion after chest tube placement or after video – assisted thoracoscopic surgery (VATS), if they remain clinically stable. (strong recommendation; low-quality evidence)
  4. Follow-up chest radiographs should be obtained in patients with complicated pneumonia with worsening respiratory distress or clinical instability, or in those with persistent fever that is not responding to therapy over 48-72 hours. (strong recommendation; low-quality evidence)
  5. Repeated chest radiographs 4–6 weeks after the diagnosis of CAP should be obtained in patients with recurrent pneumonia involving the same lobe and in patients with lobar collapse at initial chest radiography with suspicion of an anatomic anomaly, chest mass, or foreign body aspiration. (strong recommendation; moderatequality evidence)
  • Qusay is contected to the cardiorespiratory monitor
  • HR 170, BP 60/30 and not responding to you !!!
  • What wil you do ???!!!!!
  1. What Additional Diagnostic Tests Should Be Used in a Child With Severe or Life-Threatening CAP?
  • Recommendations
  1. The clinician should obtain tracheal aspirates for Gram stain and culture, as well as clinically and epidemiologically guided testing for viral pathogens, including influenza virus, at the time of initial endotracheal tube placement in children requiring mechanical ventilation. (strong recommendation; lowquality evidence)
  2. Bronchoscopic or blind protected specimen brush sampling, bronchoalveolar lavage (BAL), percutaneous lung aspiration, or open lung biopsy should be reserved for the immunocompetent child with severe CAP if initial diagnostic tests are not positive. (weak recommendation; low-quality evidence)
  • Do you to give any antibiotics ???

Anti- Infective Treatment

VII. What Is the Appropriate Duration of Antimicrobial Therapy for CAP?

  • Recommendations
  1. Treatment courses of 10 days have been best studied, although shorter courses may be just as effective, particularly for more mild disease managed on an outpatient basis. (strong recommendation; moderate-quality evidence)
  2. Infections caused by certain pathogens, notably CAMRSA, may require longer treatment than those caused by S. pneumoniae. (strong recommendation; moderate-quality evidence)


  1. How Should a Parapneumonic Effusion Be Identified?
  • Recommendation
  1. History and physical examination may be suggestive of parapneumonic effusion in children suspected of having CAP but chest radiography should be used to confirm the presence of pleural fluid. If the chest radiograph is not conclusive, then further imaging with chest ultrasound or computed tomography (CT) is recommended. (strong recommendation; high-quality evidence)
  • Now lets go back to our patient Qusay
  • What will you do to the effusion ???
  • Is it only medical treatment ??? !!!
  • Or will you drain it ??? !!!

What Factors Are Important in Determining Whether Drainage of the Parapneumonic Effusion Is Required?


  1. The size of the effusion is an important factor that determines management .(strong recommendation; moderate-quality evidence)
  2. The child’s degree of respiratory compromise is an important factor that determines management of parapneumonic effusions (strong recommendation; moderatequality evidence)
  • 120ml of perulant discharge was drained by the chest you inserted, will you send the fluid for any specific tests ????

Qusay is now connected to the under water seal

  1. What Laboratory Testing Should Be Performed on Pleural Fluid?
  • Recommendation
  1. Gram stain and bacterial culture of pleural fluid should be performed whenever a pleural fluid specimen is obtained. (strong recommendation; high-quality evidence)
  2. Antigen testing or nucleic acid amplification through polymerase chain reaction (PCR) increase the detection of pathogens in pleural fluid and may be useful for management. (strong recommendation; moderate-quality evidence)
  3. Analysis of pleural fluid parameters, such as pH and levels of glucose, protein, and lactate dehydrogenase, rarely change patient management and are not recommended. (weak recommendation; very low-quality evidence)
  4. Analysis of the pleural fluid white blood cell (WBC) count, with cell differential analysis, is recommended primarily to help differentiate bacterial from mycobacterial etiologies and from malignancy. (weak recommendation; moderate-quality evidence)
  • After 24hours, Qusay was extubated, he is complaining of pain at the site of the tube, but he is conversing properly with you, awake and alert,
  • What wil you do ??
  • For how long you will keep the tube
  • Now its draining 3ml/kg/24hours

XIV. When Should a Chest Tube Be Removed Either After Primary Drainage or VATS?

  1. A chest tube can be removed in the absence of an intrathoracic air leak and when pleural fluid drainage is ,1 mL/kg/24 h, usually calculated over the last 12 hours. (strong recommendation; very low-quality evidence)
  2. What Antibiotic Therapy and Duration Is Indicated for the Treatment of Parapneumonic Effusion/Empyema?
  • Recommendations
  1. When the blood or pleural fluid bacterial culture identifies a pathogenic isolate, antibiotic susceptibility should be used to determine the antibiotic regimen. (strong recommendation; highquality evidence)
  2. In the case of culture-negative parapneumonic effusions, antibiotic selection should be based on the treatment recommendations for patients hospitalized with CAP. (strong recommendation; moderate-quality evidence)
  3. The duration of antibiotic treatment depends on the adequacy of drainage and on the clinical response demonstrated for each patient. In most children, antibiotic treatment for 2–4 weeks is adequate. (strong recommendation; low-quality evidence)

How Should Nonresponders With Pulmonary Abscess or Necrotizing Pneumonia Be Managed?

  • Recommendation
  1. A pulmonary abscess or necrotizing pneumonia identified in a nonresponding patient can be initially treated with intravenous antibiotics. Well-defined peripheral abscesses without connection to the bronchial tree may be drained under imaging-guided procedures either by aspiration or with a drainage catheter that remains in place, but most abscesses will drain through the bronchial tree and heal without surgical or invasive intervention. (weak recommendation; very low-quality evidence)

Quash is now transferred to the floor, he received 12 days IV ceftriaxone, he is afebrile for the past week, active, tube is removed, he is on room air, and not in distress, what will you do ???


  • When Can a Hospitalized Child With CAP Be Safely Discharged?
  • Recommendations
  1. Patients are eligible for discharge when they have documented overall clinical improvement, including level of activity, appetite, and decreased fever for at least 12–24 hours. (strong recommendation; very low-quality evidence)
  2. Patients are eligible for discharge when they demonstrate consistent pulse oximetry measurements .90% in room air for at least 12–24 hours. (strong recommendation; moderatequality evidence)
  3. Patients are eligible for discharge only if they demonstrate stable and/or baseline mental status. (strong recommendation; very low-quality evidence)
  4. Patients are not eligible for discharge if they have substantially increased work of breathing or sustained tachypnea or tachycardia (strong recommendation; high-quality evidence)
  5. Patients should have documentation that they can tolerate their home anti-infective regimen, whether oral or intravenous, and home oxygen regimen, if applicable, before hospital discharge. (strong recommendation; low-quality evidence)
  6. For infants or young children requiring outpatient oral antibiotic therapy, clinicians should demonstrate that parents are able to administer and children are able to comply adequately with taking those antibiotics before discharge. (weak recommendation; very low-quality evidence)
  7. For children who have had a chest tube and meet the requirements listed above, hospital discharge is appropriate after the chest tube has been removed for 12–24 hours, either if there is no clinical evidence of deterioration since removal or if a chest radiograph, obtained for clinical concerns, shows no significant reaccumulation of a parapneumonic effusion or pneumothorax. (strong recommendation; very low-quality evidence)
  8. In infants and children with barriers to care, including concern about careful observation at home, inability to comply with therapy, or lack of availability for follow-up, these issues should be identified and addressed before discharge. (weak recommendation; very low-quality evidence)