Pediatric Respiratory Conditions/Diseases iii

• III. Pediatric AIDS Patients with Pneumonia

  Patients with AIDS has unusually frequent and severe occurrences of common childhood bacterial infections.

  • such as otitis media, sinusitis, and pneumonia.
• III. Pediatric AIDS Patients with Pneumonia

  Has recurrent fungal infections, such as candidiasis (thrush).

  • unresponsive to standard antifungal agents
  • suggestive of lymphocytic dysfunction.
• Pediatric AIDS Patients with Pneumonia

  Recurrent or unusually severe viral infections:

  • such as recurrent or disseminated herpes simplex or zoster infection or cytomegalovirus (CMV) retinitis
  • seen with moderate to severe cellular immune deficiency
• Pediatric Patients with AIDS – Signs and Symptoms

  1. Growth failure; failure to thrive; wasting
  2. Developmental delay particularly impairment in the development of expressive language, may indicate HIV encephalopathy
  3. Behavioral abnormalities (in older children), such as loss of concentration and memory, may also indicate HIV encephalopathy
• Pediatric Patients with AIDS

  • Efavirenz (Sustiva) can now be given to HIV infected children as young as 3 months and weighing at least 3.5 kg.
  • Capsules can be administered intact or as sprinkles, tablets must not be crushed
  • Efavirenz, a non-nucleoside reverse transcriptase inhibitor
  • Approved by the FDA in 1998 for the treatment of HIV-1 infected children 3 years of age or older and weighing at least 10 kg.
• Pediatric Patients with AIDS – Pneumocystis jirovecii Pneumonia (PCP)


  • A yeast-like fungus

  • Opportunistic which can cause lung infection on subjects with weak immune system

  • Airborne transmission

  
• Pediatric Patients with AIDS – Pneumocystis jirovecii Pneumonia (PCP)

  Signs and symptoms:

  • non-productive cough

  • dyspnea

  • tachypnea

  • fever

  • weight loss

  • night sweats

  • PTX (as complication)
• Pediatric Patients with AIDS – Pneumocystis jirovecii Pneumonia (PCP)

  
• Pediatric Patients with AIDS – Pneumocystis jirovecii Pneumonia (PCP)

  • Prophylaxis: co-trimoxazole, atovaquone, inhaled pentamidine

  • Therapeutic (21 days duration): simultaneous steroids; antipneumocystic agents:

  1. co-trimoxazole

  2. pentamidine

  3 trimetrexate

  4 dapsone

  5 atovaquone

  6 primaquine

  7 clindamycin
• III. Pulmonary Tuberculosis (PTB) in Children

  • PTB is caused by an aerobic bacteria (Mycobacterium tuberculosis); acid-fast bacilli
  • Mode of transmission: airborne; acquired through prolonged exposure from infectious patient; droplets inhaled in the air from cough, sneeze, speaking, singing or laughing in a poorly ventilated area.
  • A child can be infected with TB but may not show signs and symptoms (latent TB infection).
  • The bacteria may disseminate to other organs such as kidney, spine or brain (TB meningitis). More common in younger age <4 years old.
• III. Pulmonary Tuberculosis (PTB) in Children

  Stages of child TB infection:

  1. Exposure: the child has been in contact with a TB infection but have a negative TB skin test, normal CXR, and no symptoms.
  2. Latent TB infection: a child has the TB bacilli in his body, but has no symptoms. The child’s immune system is intact. Positive skin test but normal CXR. “Non-spreader”.
  3. Active TB infection: the child shows signs and symptoms. Positive both for skin test and CXR. If untreated, the child becomes a “spreader”.
• PTB Risk Factors in Children

  • Patient with HIV/AIDS

  • Diabetic

  • Weak immune system

  • Taking corticosteroid or undergoing chemotherapy

  • Lives someone with TB; lives in a crowded, poorly ventilated place

  • Comes from a country where TB is prevalent or with poor health care system
• PTB Common Signs/Symptoms

  Younger children:

  • Fever

  • Weight loss

  • Poor growth

  • Cough

  • Swollen lymph nodes

  • Chills
• PTB Common Signs/Symptoms

  Adolescents:

  ◼ Cough lasting >3 weeks

  ◼ Chest pain

  ◼ Hemoptysis

  ◼ Weakness

  ◼ Fatigue

  ◼ Swollen lymph nodes

  ◼ Weight loss

  ◼ Loss of appetite

  ◼ Fever

  ◼ Night sweats

  ◼ Chills
• PTB Diagnosis for Children

  • History taking and physical exam
  • Tuberculin skin test (Mantoux Test – PPD) – positive for induration (skin bump) after 2 – 3 days.
  • Chest x-ray – if (+) skin test
  • Direct sputum smear microscopy (DSSM) – acid-fast staining
  • Blood test – interferon gamma release assays (IGRA
• PTB Diagnosis for Children

  familiarize
• PTB Diagnosis for Children

  
• PTB Treatment for Children

  • A short-term hospital stay for initial treatment is done, and continue the rest of the period at home
  • For latent TB: a 6 – 12 months of isoniazid (INH)
  • For active TB: a 6 - 12 months therapy with isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E).
  • Example: Intensive phase (2RHZE), Continuous phase (4RH).
  • After 2 weeks of medication, a child is usually not contagious anymore.
  • Treatment must be completed and fully finished as prescribed by the physician.
• Pleural Effusion

  • Pleural effusions (liquid in the pleural space), which occur less frequently in children than in adults, can be caused by a variety of infectious and noninfectious diseases.
  • Causes of pleural effusions in children differ significantly from those in adults.
  • Pleural effusions in children most commonly are infectious (50% to 70% parapneumonic effusion); congestive heart failure is a less frequent cause (5% to 15%), and malignancy is a rare cause.
• Parapneumonic Effusion

  • PARAPNEUMONIC EFFUSION – excessive fluid in the pleural space in the presence of pneumonia, lung abscess, or bronchiectasis.
  • Non-tuberculous bacterial pneumonia constitutes the most frequent origin of pleural effusion in children.
  • Staphylococcus aureus - most common pathogen causing empyema (29% to 35% of cases), especially among infants younger than 2 years of age
• Parapneumonic Effusion

  • Streptococcus pneumoniae is up to 25% of cases of empyema.
  • Haemophilus influenzae is a less frequent pathogen but in children up to 5 years of age.
  • Group A streptococci have re-emerged as significant agents causing empyema in later childhood.
  • Anaerobic pulmonary infection is uncommon, and more than 90% of affected patients manifest periodontal infections, altered consciousness, and dysphagia.
  • Significant anaerobic bacteria are microaerophilic Streptococci, Fusobacterium nucleatum, and Bacteroides melaninogenicus
• Parapneumonic Effusion – Clinical Manifestations

  1. Cough, fever, chills, and dyspnea (in pneumonia).
  2. The child may be asymptomatic until the effusion becomes sufficiently large to cause dyspnea or orthopnea (in non-pneumonic cause).
  3. Children who have neurologic impairments are more likely to aspirate secretions or gastric content and develop anaerobic infections, which cause a more insidious onset of pneumonia and effusion.
• Parapneumonic Effusion – Clinical Manifestations

  • Complain of a sharp pleuritic pain with inspiration or cough, which is due to stretching of the parietal pleura.
  • As the effusion increases and separates the pleural membranes, pleuritic pain becomes a dull ache and disappears.
  • Specific signs indicating pleural effusion are much more difficult to elicit in the infant or the young child.
  • Dullness to percussion and decreased breath sounds over the affected area in large pleural effusion.
• Parapneumonic Effusion – Clinical Manifestations

  • In infants, breath sounds from one lung often are transmitted throughout the chest, making unilateral findings difficult to appreciate.
  • A pleural rub, due to roughened pleural surfaces; present in the early phase, but it disappears as fluid accumulates.
  • Decreased vocal fremitus and fullness of the intercostal spaces.
  • Expectoration of purulent sputum may herald the onset of bronchopleural fistula and ensuing pyopneumothorax (empyema).
• Parapneumonic Effusion – CXR Findings

  1. Findings of chest wall abscess and costal chondritis indicate extension of the process (i.e. empyema necessitatis).
  2. Decreased heart tones and pericardial rub indicate extension to the pericardium.
  3. Obliteration of the costophrenic sinus is the earliest diagnostic sign of the effusion.
  4. A lateral decubitus film may provide information about the quality and the quantity (as little as 50 mL) of the effusion.


  familiarize

  
• Parapneumonic Effusion – Treatment and Management

  Uncomplicated effusion - appropriate antibiotic therapy
• Parapneumonic Effusion – Treatment and Management

  Complicated parapneumonic effusion (empyema) - administration of empiric antibiotic therapy

  • Until the condition is diagnosed, broad-spectrum antibiotics are warranted due to the high morbidity and mortality associated with empyema.
  • Intravenous antibiotics should be continued until the child is afebrile for at least 7 to 10 days, has been weaned from supplemental oxygen, and no longer appears ill.
  • Oral antibiotics subsequently are administered for 1 to 3 weeks
• Parapneumonic Effusion – Treatment and Management

  Complicated parapneumonic effusion (empyema) - administration of antibiotics

  1. Thoracentesis or by closed thoracostomy tube.
  2. Introduction of streptokinase (SK) or urokinase (UK) into the empyema cavity (to lyse adhesions, enhance drainage, and resolve the symptoms)

  Lung decortication or pleural debridement with video assisted thoracoscopy (VATS)

  1. Considered if the patient still has respiratory difficulty, daily fever, and persistent leukocytosis following antibiotic therapy.
• VATS

  familiarizew