Community acquired

Pneumonia

An initiative of ETAT+ Trainers

Outline
• Facilitators: Prof. Grace Irimu and Dr. Diana Marangu

• Causative organisms and effect of the vaccines - Mariana

Mutinda

• Clinical presentation and syndromic classification – Tauhida

Abubakar and Wangui Mavumba

• Diagnosis - Duncan Tumwa

• Specific Treatment - Fareen Musa

• Supportive management - Rachael Kanguha

• Oxygen therapy - Edith Gicheha

• Outcomes - Sylvia Mwathi

Etiology and effects
of vaccines
Etiology

Bacterial causes of CAP

• Global Burden of Disease data 2015 ,64% of pneumonia deaths
in the under 5 years were due to bacterial etiology, specifically
S. pneumoniae or H. influenzae.

• In the PERCH study (2011-2014) :

• Bacterial pneumonia accounted for 27% of all admissions

with S. pneumoniae isolated in 19/56(33%) of all
positive cultures.
• Kilifi site, H. influenzae was as common as S. pneumoniae.

• M. tuberculosis was 6% of all the isolated pathogens.

Estimates of the global, regional, and national morbidity, mortality, and etiologies of lrti in 195 countries: a systematic analysis for the
GBD Study 2015
Causes of severe pneumonia requiring hospital admission in children without HIV infection from Africa and Asia: the PERCH multi-
country case-control study
Etiology

Bacterial causes of CAP

• Other bacterial pathogens in LMIC settings:
• Bordetella Pertussis,
• Klebsiella pneumoniae and
• Escherichia coli .

• In South Africa, 2% of clinical pneumonia cases among infants

enrolled in a birth cohort, were caused by pertussis and 4% of
under 5 children presenting to a tertiary academic hospital had
evidence of pertussis infection.(2016).

• In PERCH study, B. pertussis positive cases (2.3%) were from

the African sites only and in children between 1-5 months old.
Aetiology of childhood pneumonia in a well vaccinated South African birth cohort: a nested case-control study of the Drakenstein Child Health
Study. Prof Zar et al
Pertussis-Associated Pneumonia in Infants and Children From Low- and Middle-Income Countries Participating in the PERCH Study
Etiology

Viral causes of CAP

• Global data 2015, RSV accounted 20% and Influenza for 10%
of the pneumonia deaths in LMIC for under 5 years.

• In the PERCH study

• Viral causes accounted for 61% of all cases of pneumonia

• RSV as the major cause at 31%.

• Kilifi site, RSV was commonest followed by rhinovirus, hMPV,

parainfluenza then lastly influenza virus.

Estimates of the global, regional, and national morbidity, mortality, and etiologies of lrti in 195 countries: a systematic analysis for the
GBD Study 2015
Causes of severe pneumonia requiring hospital admission in children without HIV infection from Africa and Asia: the PERCH multi-
country case-control study
Etiology

Fungal causes of CAP

• PERCH study:

• HIV infected , Pneumocystis pneumonia (PCP) was

the most common cause of fungal pneumonia.

• Isolation of P. jirovecci in the Kilifi site accounted for

2.3% of all the causes of pneumonia in the HIV
uninfected population.

Causes of severe pneumonia requiring hospital admission in children without HIV infection from Africa
and Asia: the PERCH multi-country case-control study
Etiology

Top ten causes of pneumonia in

Kenya 1.3%
2.3% 1.9%
2.4%
RSV
Rhinovirus
5.1
% hMPV
Parainfluenza
5.7%
H. influenzae
8% 36% Pneumococcus
Influenza
10% PJP
13% M. TB
S.aureus
Causes of severe pneumonia requiring hospital admission in children without HIV infection from Africa and Asia: the PERCH multi-country case-control study
Etiology

Consideration in etiology of childhood

pneumonia in special populations
Other causes of Neutropenic patients Sickle cell anemia — M.
Pneumonia in and WBC defects- pneumoniae, C.
Gram-negative bacilli pneumoniae) commonly
immunocomprom and S. aureus are associated with the acute
ised include: common, Opportunistic chest syndrome.
fungi, such Other bacterial causes
as Aspergillus spp include S pneumoniae, S.
Viral causes of aureus, and H.
pneumonia, which HIV positive patients- influenzae( dysfunctional
may be life- Pneumocystis jirovecii complement system and
threatening in the Mycobacterium functional asplenia)
immunocompromised tuberculosis
host- RSV, SARs-Cov
2, CMV, EBV Cystic fibrosis — S.
Malnutrition aureus, Pseudomonas
S.Pneumoniae aeruginosa, and H.
RSV influenzae (mostly non
Influenza typeable strains)
Life threatening infectious complications of sickle cell disease; A concise narrative review Dominik O et al
Risk Factors for severe acute LRTI In children Rudan et al
Risk factors

Changing risk factors for

childhood pneumonia
Low • 3.2 times increased odds- severe pneumonia in LMIC
birthweight • 1.8 times increased odds in high-income countries.

Lack of
breastfeeding • Increases odds of severe pneumonia by 2.7 times in
in the first 4 LMIC and 1.3 times in high-income countries.
months

Undernutrition increases the frequency and

Malnutrition
severity of pneumonia episodes

Risk factors for severe acute lower respiratory infections in children: a systematic review and meta-analysis. Jackson S et al
Risk factors

Changing risk factors for

childhood pneumonia
▪ has uniform risk, with odds ratios between 1.9 and 2.3 in
Household
both low- and middle-income countries and high-income
crowding
countries.

▪ HIV-infected children have 6 times increased odds of

HIV infection
developing severe pneumonia or of death compared to HIV-
uninfected children

Lack of
▪ lack of measles vaccination by the end of the first year of
measles
age increases odds of pneumonia by 1.8 times
vaccination

Indoor air
pollution (use
increases odds of pneumonia by 1.6 times
of solid or
biomass fuels)
Risk factors for severe acute lower respiratory infections in children: a systematic review and meta-analysis. Jackson S et al
Effect of vaccines

Effects of Pneumococcal conjugate

vaccine
The Pneumococcal Conjugate Vaccine Impact Study (PCVIS) Kilifi
• For invasive pneumococcal disease involving any S. pneumoniae strain,
the average incidence dropped by 68% and there was an 85%
reduction in pneumococcal pneumonia among children younger than 5
years.
• A decline in incidence was observed for all PCV10 serotypes, and this
was significant for serotypes 1 and 14, the most common serotypes in
the pre-vaccine era.

In the South African vaccine efficacy trial, children vaccinated with

nine-valent PCV were 31% (95% CI: 15–43) less likely to be
hospitalized for pneumonia in which a respiratory virus was
identified, and 45% (95% CI: 14–64) less likely to be hospitalized
with pneumonia associated with influenza type A/B viruses.

Effect of ten-valent pneumococcal conjugate vaccine on invasive pneumococcal disease and nasopharyngeal carriage in Kenya: a longitudinal
surveillance study
https://www.who.int/bulletin/volumes/86/5/07-044503/en/
Clinical presentation
and Classification
Clinical presentation

Basis of clinical signs of pneumonia

• Immunization status
• immunocompromised state Exposure to pathogens
• Environmental pollution

Infection and proliferation of Susceptible host

pathogen in lower tract epithelium

Systemic inflammatory
Accumulation of plasma exudates,
response(IL 1,TNF-α)
fibrin,bacteria and cellular debris

Disruption of
Irritation of airways and failure Decreased Increased resp Refusal to
hypothalamic
of ciliary clearance gas diffusion drive breastfeed
thermoregulation

Hypoxemia
cough Tachypnea Tachypnea Fever /chills
Lower chest wall
in drawing
Classification

• A multi-hospital retrospective cohort study- 16,162 Children aged 2–

59 months admitted with pneumonia in Kenya

• 321 (3%) of patients with non-severe pneumonia died compared

with 488 (14%) patients with severe pneumonia.

• Severe undernutrition (WAZ) was associated with mortality among

children having non-severe pneumonia:
Classification

Classification of pneumonia

Revised WHO classification and treatment of childhood pneumonia at health facilities

Classification

2016 Pediatric Pneumonia Guidelines

Cyanosed or oxygen Saturation<90%?
Yes Severe pneumonia-
Unable to drink? admit, injectable
penicillin and
Reduced level of consciousness?
gentamicin
Grunting ?

Lower chest wall indrawing Pneumonia- Oral

Yes
OR Fast breathing? amoxicillin. Counsel
on when to return
• RR ≥ 50 aged 2 –11 months
• RR ≥ 40 aged 12 – 59months
Yes

None of the above? No pneumonia- no

antibiotics

REVISED WHO CLASSIFICATION AND TREATMENT OF CHILDHOOD PNEUMONIA AT HEALTH FACILITIES: EVIDENCE SUMMARIES
Diagnosis
Diagnosis

Use of CXR in diagnosing pneumonia

WHO
Standard criteria for the radiologic diagnosis of pneumonia:
1. Endpoint consolidation or pleural effusion ±air bronchogram
2. Other infiltrates
3. No consolidation/infiltrate/effusion

British Thoracic society

• Children with signs/symptoms of pneumonia but not admitted should not have
a CXR
• CXR is too insensitive to differentiate viral or bacterial aetiology

Pediatric Infectious Diseases Society of America

• Not necessary for the confirmation of pneumonia in outpatient settings
• Done if there is hypoxaemia or marked respiratory distress or failed initial
antibiotic therapy and to verify the presence/absence of complications of
pneumonia

Andronikou S, Lambert E, Halton J, et al. Guidelines for the use of chest radiographs in community-acquired pneumonia in children and
adolescents. Pediatr Radiol. 2017;47(11):1405–1411. doi:10.1007/s00247-017-3944-4
D. Marangu, H.J. Zar / Paediatric Respiratory Reviews 32 (2019) 3–9
Diagnosis

Relevant CXR thoracic anatomy

Imaging Studies | Clinicians Pocket Reference, 11th Edition.Labelled chest X-ray

Diagnosis

CXR interpretation
1 3 aspects of quality and patient details

3 structures that are white

2

Rule of ‘3’s in
CXR 3 structures that are black
3
interpretation
3 steps in assessing the lungs
4

3 aspects of the diaphragm and pleura

5

Robert Gie, 2003; Diagnostic atlas of intrathoracic tuberculosis in children; A guide For Low Income Countries
Diagnosis

CXR interpretation
3 aspects of quality and patient
details 1. Patient details: name, gender, DOB
Clavicle ends(medial)
(also date and time the film was taken)
2. Rotation
• Medial aspect of each clavicle

Spinous equidistant from the spinous processes

processes • Spinous processes vertically orientated
against the vertebral bodies
3. Penetration
• Intervertebral spaces can just be
distinguished through the heart shadow.
4. Inspiration
• See 8-9 posterior ribs or the 6-7 anterior
8th ribs
6th anterior rib posterior
rib
Robert Gie, 2003; Diagnostic atlas of intrathoracic tuberculosis in children; A guide For Low Income Countries
Diagnosis

CXR interpretation
3 structures that are white

1. Soft tissue
• Examine the soft tissue of the
chest for swelling or lumps
2. Bony structures
• Fractures, signs of rickets or
1 areas infiltration

2 3 3. Heart shadow
• Cardiac shadow for position,
size and shape

https://radiopaedia.org/articles/chest-radiograph-paediatric?lang=us
Diagnosis

CXR interpretation
3 structures that are black

1. The trachea and the bronchi

1 • Follow the trachea and bronchi
carefully, looking for
1 1
displacement or narrowing
2. The right and left lung
2
3. Gastric bubble
2 • Look to ensure that the gas
shadow in the stomach does
3
not extend into the chest
(hernia)

Robert Gie, 2003; Diagnostic atlas of intrathoracic tuberculosis in children; A guide For Low Income Countries
Diagnosis

CXR interpretation
3 steps in assessing the lungs

1. Compare the sizes of the two

lungs
2. Compare the vascularity of the
two lungs
3. Compare the two hilar
shadows for:
• Position
• Size
• Shape

Robert Gie, 2003; Diagnostic atlas of intrathoracic tuberculosis in children; A guide For Low Income Countries
Diagnosis

CXR interpretation
3 aspects of the diaphragm and pleura

1. The position of the left

and right diaphragms
3
2. The two costophrenic
angles
3. The pleura on both sides

1
1
2 2

Robert Gie, 2003; Diagnostic atlas of intrathoracic tuberculosis in children; A guide For Low Income Countries
Diagnosis

CXR features suggestive of pneumonia

1
Lobar Pneumonia

1. Air space opacification

affecting one lobe
2. Opacification sharply
defined at the fissures
3. Non-opacified bronchus
within a consolidated
results in air
bronchograms

Right upper lobe pneumonia

Fradiopaedia.org%2Fcases%2Fright-upper-lobe-pneumonia-paediatric&psig
Diagnosis

CXR features suggestive of pneumonia

2
Bronchopneumonia

1. Patchy opacifications in

more than one lobe

2. More commonly in lung

bases

Fradiopaedia.org%2Fcases%2Fright-upper-lobe-pneumonia-paediatric&psig
Diagnosis

CXR features suggestive of pneumonia

3
Pleural effusion

1. Abnormal collection of
fluid in the pleural space
2. In children meniscus sign
is uncommon
3. Most CXR are taken
supine
4. Identified by following
the pleural edge
5. Blunting of costophrenic &
Left sided pleural effusion
cardiophrenic angles
Source: Image provided by Diana Marangu
Diagnosis

CXR features suggestive of pneumonia

4
Viral pneumonia

CXR patterns can be

variable
Commonly-
• diffuse opacities
• Less commonly:
Pleural effusion,
• hilar
lymphadenopathy

Fradiopaedia.org%2Fcases%2Fright-upper-lobe-pneumonia-paediatric&psig
Diagnosis

Look out for features of tuberculosis on CXR

• Tuberculosis is endemic in our setting
• Oliwa et al systematic review: tuberculosis can be a cause of acute severe
pneumonia in children1
• On a CXR look out for hilar lymphadenopathy on an AP and lateral film

Hilar
lymphadenopath
y on Lat CXR
(doughnut sign)

Suspected hilar and paratracheal lymph gland enlargement. The diagnosis

can be made with more certainty when a lateral chest radiograph is examined
as well2
1Oliwa et al;Tuberculosis as a cause or comorbidity of childhood pneumonia in tuberculosis-endemic areas: a systematic review; Lancet Respir
Med. 2015 Mar;3(3):235-43
2Robert Gie, 2003; Diagnostic atlas of intrathoracic tuberculosis in children; A guide For Low Income Countries
Diagnosis

Chest ultrasound in diagnosis of pneumonia

Diagnosis

Features suggestive of pneumonia on chest

ultrasound
Compact B lines

Loss of pleural line echogenicity over and area of

consolidation

Air bronchograms

Pleural effusion-hypoechoiec fluid

Absent pleural sliding- suggests pneumothorax

Stadler JAM, Andronikou S, Zar HJ. Lung ultrasound for the diagnosis of community-acquired pneumonia in children. Pediatr Radiol.
2017;47(11):1412–1419. doi:10.1007/s00247-017-3910-1
Diagnosis

Laboratory investigations in pneumonia

Full haemogram
• Raised white blood cell count, CRP and ESR
• Leukocytosis with a left shift
• Leukopenia - ominous clinical sign of impending sepsis

Bekdas et al study on paediatric differentiating bacterial vs viral pneumonia

Results
When the neutrophil/lymphocyte and CRP/MPV (mean platelet volume) ratios identify
bacterial pneumonia could be correctly in 90.3% cases and pneumonia related
complications in 88.9% cases

• Nasopharyngeal swabs – use molecular techniques to detect viral e.g. RSV,

influenza & SARS-CoV-2 or bacterial causes e.g. B. pertussis
• Induced sputum – use molecular techniques detect aetiology e.g M.tuberculosis, P.
jirovecii
• Blood culture- positivity rate of 6–14% in severe pneumonia
• Pleural fluid analysis- microscopy, culture, gram staining, molecular tests

Bekdas et al Neutrophil/lymphocyte and C-reactive protein/mean platelet volume ratios in differentiating between viral and bacterial
pneumonias and diagnosing early complications in children
Pediatric Pneumonia Workup;https://emedicine.medscape.com/article/967822-workup
D. Marangu, H.J. Zar / Paediatric Respiratory Reviews 32 (2019) 3–9
www.https://youtu.be/osl9W-O0O5g
Treatment
Treatment

2016 Pediatric Pneumonia Guidelines

Cyanosed or oxygen Saturation<90%?
Yes Severe pneumonia-
Unable to drink? admit, injectable
penicillin and
Reduced level of consciousness?
gentamicin
Grunting ?

Lower chest wall indrawing? Pneumonia- Oral

Yes amoxicillin. Counsel
OR Fast breathing? on when to return
(RR ≥ 50 aged 2 –11 months
RR ≥ 40 aged 12 – 59months)
Yes

None of the above? No pneumonia- no

antibiotics

REVISED WHO CLASSIFICATION AND TREATMENT OF CHILDHOOD PNEUMONIA AT HEALTH FACILITIES: EVIDENCE SUMMARIES 2014
Treatment

Antibiotics for community-acquired pneumonia in children (Review) Lodha R, Kabra SK, Pandey RM 2013
Treatment

Antibiotics for community-acquired pneumonia in children (Review) Lodha R, Kabra SK, Pandey RM 2013
Treatment

Amoxicillin equivalent to parenteral antibiotics in the treatment of resource-deficient infants with tachypnea by Ambrose Agweyu, 2015
Treatment

A randomized controlled trial of hospitalversus home based therapy with oralamoxicillin for severe pneumonia inchildren aged 3–59 months:
TheIndiaCLEN Severe Pneumonia Oral Therapy(ISPOT) StudyArchana B. Patel1, Akash Bang2*, Meenu Singh 2015
Treatment

Why use amoxicillin DT

• More stable than liquids; longer shelf life

• Does not need refrigeration- ideal for low income settings

• Less bulky- transport and store

• Breast-milk/ water

• Ideal for 0-6months,

• Cheaper than the oral equivalent- cost effective method

Treatment

Oral amoxicillin versus benzyl penicillin for severe pneumonia among kenyan children: a pragmatic randomized controlled noninferiority trial.2015
Agweyu A1, Gathara D1, Oliwa J1
Treatment

Benefits of the new recommendation

• Access to antibiotic treatment closer home.

• Less need for referral.

• Reduced hospitalizations- reduction in nosocomial

infections.

• Better adherence due to the simplified treatment.

• Reduces antibiotic resistance

• Simplified training of health care workers.

Revised WHO classification and treatment of childhood pneumonia at health facilities

Treatment

Special considerations
• Cautious application of the national guideline to the
following groups of patients- Applies to 6-59months
Assessment Possible action/ cause
Cough or fever more Consider TB
than 14 days
Exposure to TB or Possibility of TB
chronic cough
SAM Use guidelines for severe acute
malnutrition
HIV infection Use guidelines for HIV infected children

Readmission Hospital acquired infection/TB/missed

diagnosis
Treatment

HIV infected/exposed
HIV infected or exposed with either
• Severe pneumonia or
• Pneumonia with in-drawing

• Admit
< 12months of age give empiric
• Treat with crystalline
treatment for PCP – high dose
Penicillin & Gentamicin
cotrimoxazole
• Oxygen if required

Empiric treatment- not recommended for above one year

Supportive treatment
Supportive treatment

Principles of supportive care

Fluid management :
• Oral feeds most preferred
• NGT- severely ill / unable to feed
• Intravenous fluids- Vomiting everything, unarousable .

Analgesics/ antipyretics:
Paracetamol 10-15mg/kg 4-6 hourly

Respiratory support.

• Regular monitoring of vitals and clinical status

• Steroids and chest physiotherapy not recommended
Supportive treatment

Paludo C., Zhang L., Lincho C.S., Lemos D.V., Real G.G. & Bergamin J.A., 2008, ‘Chest physical therapy for children hospitalised with acute pneumonia: A randomised controlled trial’, Thorax 63(9), 791–794.
10.1136/thx.2007.088195 –Available from: https://pubmed.ncbi.nlm.nih.gov/18276723/
Supportive treatment

Chaves GSS, Freitas DA, Santino TA, Nogueira PAMS, Fregonezi GAF, Mendonça KMPP. Chest physiotherapy for pneumonia in children. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD010277. DOI:
10.1002/14651858.CD010277.pub3.
Supportive treatment

Detection of hypoxemia-Pulse oximeter

Non invasive method for measuring
arterial oxygen saturation across a
translucent part of the body
Normal range- above 90%

Measures O2 saturation of hemoglobin

by comparing the absorbance of light of
different wavelengths and the readings
shown on a display

• Do not reflect on CO2 - cannot be used to detect hypercarbia

• Cannot indicate the adequacy of ventilation in children receiving
oxygen, clinical monitoring of work of breathing is a guide to
adequacy of ventilation.

WHO oxygen therapy for children 2016 : https://www.who.int/maternal_child_adolescent/documents/child-oxygen-therapy/en/

Supportive treatment

Oxygen delivery administration

• Preferred method for spontaneously breathing patients.
• Safe, simple, easily tolerable
• Humidification for high flow
• Titrate the flow against the SP02

• Used to deliver high dose oxygen to spontaneously

breathing patients.
• Post resuscitation care.
• Titrated every 15mins depending on need

• Mechanical ventilation recommended in severe ARDS and

those hypoxemic on non invasive modes.
• Avoid hypoxemia while on MV

• Face masks and headboxes not recommended.

• Oxygen wastage
• Potential risk of carbon dioxide toxicity.

WHO Oxygen therapy for children 2016

Supportive treatment

Rojas‐Reyes MX, Granados Rugeles C, Charry‐Anzola LP. Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age. Cochrane Database of Systematic Reviews
2014, Issue 12. Art. No.: CD005975. DOI: 10.1002/14651858.CD005975.pub3.
Supportive treatment

Rojas‐Reyes MX, Granados Rugeles C, Charry‐Anzola LP. Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age. Cochrane Database of Systematic Reviews 2014,
Issue 12. Art. No.: CD005975. DOI: 10.1002/14651858.CD005975.pub3.
Oxygen therapy

Complications of oxygen therapy-

a) O2 toxicity (overdose->96%)
Peripheral vessels CNS Respiratory system

Induces vasoconstriction- • ROS-neuronal • Absorptive atelectasis,

impaired organ perfusion- damage – • Reactive oxygen species-
esp cerebral and coronary • Tracheobronchitis,
convulsions,
region • Pleuritic pain,
• Retinal damage, • Bronchial irritation,
neonates- ROP • Diffuse alveolar damage -
eventual pulmonary fibrosis

Helmerhorst, H.J.F., Schultz, M.J., van der Voort, P.H.J. et al. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care 19, 284 (2015). https://doi.org/10.1186/s13054-015-0996-4
 Oxygen therapy

Complications of oxygen therapy

b) Hypoxia (underdose- <90%)
All body organs Respiratory system

Failure of oxygen dependent Na/K ATPase • Pulmonary arteries-

pumps-energy failure- membrane vasoconstriction.
depolarization- uncontrolled Ca2+ influx- • Sustained hypoxic constriction-
activation of calcium dependent caspases, pulmonary hypertension
proteases- cell death

Michiels C. (2004). Physiological and pathological responses to hypoxia. The American journal of pathology, 164(6), 1875–1882. https://doi.org/10.1016/S0002-9440(10)63747-9
 Oxygen therapy

Oxygen Therapy
• Indication - Hypoxia

o Neonates; Respiratory Distress Syndrome, Neonatal pneumonia, TTN, birth

asphyxia

o Children; Severe pneumonia, ARDS, sepsis, meningitis

Kenyan Pediatric protocol 2016; WHO oxygen therapy for children 2016 : https://www.who.int/maternal_child_adolescent/documents/child-oxygen-therapy/en/
Oxygen therapy

Oxygen sources
Oxygen
cylinders
Oxygen splitters Allows independent
control of O2 flow
rates for more than
one patient needing
O2 by sharing one O2
Oxygen
tank.
concentrators

Central Used for patients receiving oxygen via nasal

piped cannula
oxygen Helps in conservation of oxygen especially
in low resource settings

WHO oxygen therapy for children 2016 : https://www.who.int/maternal_child_adolescent/documents/child-oxygen-therapy/en/

Oxygen therapy

Humidification
• Reduce dryness of O2 from a source by bubbling it through water.

Indications • Use distilled

• High flow rates above water ONLY
4L/min with nasal • Change the
catheters/nasal prongs water daily-
Reduces risk
• Use of Non Rebreather
of bacterial
Mask (10 – 15L/min) contamination

• O2 delivery at standard flow rate through a nasal catheter or nasal prongs

does not require humidification

WHO oxygen therapy for children 2016 : https://www.who.int/maternal_child_adolescent/documents/child-oxygen-therapy/en/

Oxygen therapy

Titrating & Stopping Oxygen

• When Oxygen is started, titrate every 10 -15mins until SpO2 is 90-95%

• Increase by 0.5L/min till maximum 8L/min with nasal prongs/catheters

and 15L/min in NRM then move to CPAP if necessary

• Stop titrating and begin close monitoring if clinically stable (no

emergency signs, SpO2 > 90% and no increase WoB)

• Discontinue oxygen 10 –15 min and carefully examined for changes in

WoB and SpO2, to assess whether supplemental oxygen is still required.
Recheck SpO2 after 1h, as late desaturation can sometimes occur

• Discharge only if child has been stable with SpO2 ≥ 90% and no
increased WoB on room air for at least 24hrs

WHO oxygen therapy for children 2016 : Sources and delivery of oxygen; page 32-33
Oxygen therapy

Complications of oxygen therapy

Oxygen toxicity
• Breathing molecular oxygen at increased fractional concentration of
oxygen in inspired gas (FiO2) and for longer duration is toxic.

• ROS production- overwhelm antioxidant mechanisms and damage

cells.

• In preterm infants, may led to: Retinopathy of prematurity –

Blindness and Chronic lung disease

Oxygen underdose
Hypoxic damage to tissues resulting in complications eg
neurodevelopmental delays.

Anastasiya V. Snezhkina et al. (2019) Oxidative Medicine and Cellular Longevity; Hindawi; Volume, Article ID 6175804, 17 pages
https://doi.org/10.1155/2019/6175804
Outcomes
Outcomes

Outcomes of pneumonia
Resolution of symptoms within 48-96hours of
1 antibiotic treatment.

No improvement/ persistence/ recurrence of

2
symptoms.

Prolonged hospital stay.

3 Mortality
Outcomes

Persistence of pneumonia
Aetiology Unusual course- persistent
symptoms
Bacterial lobar pneumonia, Moderate dyspnoea on exertion
mycoplasma, legionella, persists for 2-3 months.
TWAR(chlamydia pneumonia) Cough persists for several weeks.
Viral pneumonia or pertussis Cough persists for 3 to 4 months.

Remember to cover for atypical bacteria.

1 Gaston B. Pneumonia. Pediatr Rev. 2002;23(4):132–140. doi:10.1542/pir.23-4-132

Outcomes

Causes of no improvement/recurrence

1 Gaston B. Pneumonia. Pediatr Rev. 2002;23(4):132–140. doi:10.1542/pir.23-4-132

2 Alves dos Santos JW, Torres A, Michel GT, et al. Non-infectious and unusual infectious mimics of community-acquired pneumonia. Respir Med. 2004;98(6):488–494.
doi:10.1016/j.rmed.2003.12.006
Complications: Pleural effusion and empyema

Exudative Fibrino- Stage of

stage purulent organization
(effusion) stage (empyema)

https://pedsinreview.aappublications.org/content/23/12/417
Outcomes

Long term effects of pneumonia

❑ Several prospective studies have been done.

• Effects of childhood pneumonia on adult lung function are reduced

FEV1 and FVC , and increased odds of wheezing.
• These are independent of smoking the wheezing is found to be
partially or unresponsive to bronchodilators.
• Restrictive/obstructive lung disease, bronchiectasis and bronchiolitis
obliterans.
❑ Case control studies

• Shown that childhood pneumonia is an independent risk factor for

persistent cough and asthma in adulthood in cases with non atopic
parents.

1. Grimwood, K. and A.B. Chang, Long-term effects of pneumonia in young children. Pneumonia, 2015. 6(1): p. 101-114.
Summary
1. Correct assessment is key- (also assess for
COVID19 risk).
2. Correct classification- Severity and COVID
likely or unlikely.
3. Correct treatment- including specific and
supportive