Pneumonia

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff with the assessment and management of pneumonia in children who present to the Emergency Department.

Definition

Pneumonia is a lower respiratory tract infection caused by viruses or bacteria. It may involve a lobe (lobar pneumonia) or be more diffuse (bronchopneumonia).

Background

  • Pneumonia can be caused by viruses (such as RSV, influenza, parainfluenza and adenovirus), bacteria (most commonly Streptococcus pneumoniae) or atypical bacteria (Mycoplasma pneumoniae and Chlamydia trachomatis)
  • Viral pneumonia is more common than bacterial pneumonia
  • The most common cause of bacterial pneumonia in the < 5 year olds is Streptococcus
  • The most common cause of bacterial pneumonia in the > 5 year olds is Mycoplasma

Assessment

  • Differentiation between viral and bacterial pneumonia is best done by clinical acumen
  • Neither X-ray appearance, WCC, neutophil count or CRP is reliable in trying to distinguish between viral and bacterial pneumonia

Examination

  • Pneumonia will usually present with fever, cough, tachypnoea and possibly grunting
  • It can also present as fever without a source (especially in neonates), and occasionally as abdominal pain or meningism
  • Clinically, tachypnoea is a consistently useful sign, but auscultatory signs can be unreliable
  • Most children seen in our community with fever and respiratory symptoms will not have pneumonia.

Other clinical features to note:

  • In the preschool child, if wheeze is present, primary bacterial pneumonia is unlikely
  • Presence of bilateral signs with wheeze and/or crackles is more suggestive of a viral pneumonia
  • Mycoplasma is the most common cause of community acquired pneumonia in school age children. It generally has a more indolent course and may have quite variable signs. It is often associated with malaise, headache and sore throat.

Investigations

Chest X-ray

  • A chest X-ray may be useful in children with either isolated focal signs or a clear chest
  • The presence of lobar or segmental consolidation suggests bacterial pneumonia (usually Streptococcus)
  • Cavitation and significant pleural effusions are rare and suggest a bacterial cause.

Blood culture

  • Should only be performed in children thought to have bacterial pneumonia who are septic or sick enough to require respiratory support.

Blood tests

  • WCC, CRP and ESR are unreliable in distinguishing between bacterial and viral pneumonia
  • Bacterial serological tests are unhelpful, with the possible exception of paired Mycoplasma titres

Nasopharyngeal aspirate (NPA)

  • Viruses 
  • May be useful to identify Mycoplasma in school age children
  • Bacterial culture is meaningless and should not be done.

Management

  • Most children with bacterial pneumonia can be treated at home with oral antibiotics and General Practitioner follow up in 24 hours.
  • Children presenting with mild symptoms of lower respiratory tract infection are likely to be viral and should not be treated with antibiotics.

Medication

Antibiotic management for community acquired pneumonia (CAP), aspirate pneumonia and empyema is guided by the Children's Antimicrobial Management Program (ChAMP) - acute respiratory tract infection.

Admission criteria

  • Toxic/septic appearance
  • Clinical evidence of significant respiratory distress
  • Hypoxia - reduced oxygen saturation < 93%
  • Extensive consolidation, large effusion or cavitation on chest X-ray
  • Not tolerating oral antibiotics
  • History of chronic respiratory disease, congenital cardiac disease, immunodeficiency, trisomy 21 or ex-preterm (< 32 weeks)
  • Geographic location and access to travel of parents, or other adverse social circumstance

Some children who need only 24 hours of IV Antibiotics can be admitted to ESSU.

Referrals and follow-up

If discharged, ensure that child is reviewed within 24 hours, preferably by the child's GP.

Follow up CXR is usually not necessary.

Bibliography

  1. AMH Children’s Dosing Companion (2015) Australian Medicines Handbook Pty Ltd
  2. Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2010.
  3. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
  4. Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Scho. Nelson Textbook of Pediatrics: 20th Edition. Publisher: Elsevier

Endorsed by:  Director, Emergency Department  Date:  May 2018


 Review date:   May 2021


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