Pneumonia
Pneumonia (J18) is the acute non-specific inflammation of the pulmonary tissue with accompanying infectious toxicosis, the respiratory insufficiency, the disordered water-electrolytic balance, and other metabolic disorders with the pathologic shifts involving various organs and systems in the child’s body.
According to other concepts, the pneumonias mean the group of the acute focal infectious inflammatory diseases of the lungs varying in etiology, pathogenesis, and morphological features with the obligate intra-alveolar inflammatory exudation.
Most cases of pneumonia are caused by microorganisms, noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions, and drug- or radiation-induced pneumonitis.
EPIDEMIOLOGY
Incidence of acute pneumonia among the children in Ukraine amounts to 4-20 per 1000 of children population; among the children of the first year of life: 10-15 cases per 1000 of children population; among the children aged 1-3 years: 15–20 cases per 1000 of children population. Incidence of acute pneumonia among the children aged over 5 years: 5-6 cases per 1000 of children population. Acute pneumonia develops in 1% of the patients with the acute respiratory viral infections. The lethality of acute pneumonia is 1.5-6 causes per 10 000 of children population. The respiratory diseases make up to 3 –5 % in the structure of lethality in the children aged below one year.
Pneumonia is a substantial cause of morbidity and mortality in childhood (particularly among children <5 year of age) throughout the world, rivaling diarrhea as a cause of death in developing countries. With an estimated 146–159 millioew episodes per year in developing countries, pneumonia is estimated to cause approximately 4 million deaths among children worldwide. Currently, the incidence of community-acquired pneumonia in developed countries is estimated to be 0.026 episodes per child-year compared to 0.280 episodes per child-year in developing countries.
ETIOLOGY
Although most cases of pneumonia are caused by microorganisms, noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. The cause of pneumonia in an individual patient is often difficult to determine because direct culture of lung tissue is invasive and rarely performed. Cultures performed on specimens obtained from the upper respiratory tract or “sputum” often do not accurately reflect the cause of lower respiratory tract infection. With the use of state-of-the-art diagnostic testing, a bacterial or viral cause of pneumonia can be identified in 40-80% of children with community-acquired pneumonia.
The age of the patient may help to identify possible pathogens ( Table 2 ).
Table 2 — Etiologic Agents Grouped by Age of the Patient
|
Age group |
Frequent pathogens (in order of frequency) |
|
Neonates (<1 month) |
Group B streptococcus, Escherichia coli, other gram-negative bacilli, Streptococcus pneumoniae, Haemophilus influenzae (type b, nontypable) |
|
1–3 month |
|
|
Febrile pneumonia |
Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b, nontypable) |
|
Afebrile pneumonia |
Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, cytomegalovirus |
|
3–12 month |
Respiratory syncytial virus, other respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b, nontypable), C. trachomatis, Mycoplasma pneumoniae, group A streptococcus |
|
2–5 years |
Respiratory viruses (parainfluenza viruses, influenza viruses, adenoviruses), S. pneumoniae, H. influenzae (type b, nontypable), M. pneumoniae, Chlamydophila pneumoniae, S. aureus, group A streptococcus |
|
5–18 year |
M. pneumoniae, S. pneumoniae, C. pneumoniae, H. influenzae (type b, nontypable), influenza viruses, adenoviruses, other respiratory viruses |
Lower respiratory tract viral infections in Ukraine are much more common in the fall and winter, related to the seasonal epidemics of respiratory viral infection that occur each year. The typical pattern of these epidemics usually begins in the fall when parainfluenza infections appear and most often manifest as croup. Later in winter, RSV and influenza viruses cause widespread infection, including upper respiratory tract infections, bronchiolitis, and pneumonia. RSV attacks infants and young children, whereas influenza virus causes disease and excess hospitalization for acute respiratory illness in all age groups. The knowledge of the prevailing viral epidemic may lead to a presumptive initial diagnosis.
The routes for infecting the lungs:
1) aerogenous: along the airways into the respiratory divisions;
2) hematogenous: through the vessels of the systemic circulation (septic and intrauterine acute pneumonias);
3) lymphogenous: due to the breach of the barrier function of the lymphoid pharyngeal ring.
Pathogenesis of acute pneumonia in children.
The lower respiratory tract is normally kept sterile by physiologic defense mechanisms, including the mucocil iary clearance, the properties of normal secretions such as secretory immunoglobulin A (IgA), and clearing of the airway by coughing. Immunologic defense mechanisms of the lung that limit invasion by pathogenic organisms include macrophages that are present in alveoli and bronchioles, secretory IgA, and other immunoglobulins.
Viral pneumonia usually results from spread of infection along the airways, accompanied by direct injury of the respiratory epithelium, resulting in airway obstruction from swelling, abnormal secretions, and cellular debris. The small caliber of airways in young infants makes them particularly susceptible to severe infection. Atelectasis, interstitial edema, and ventilation-perfusion mismatch causing significant hypoxemia often accompany airway obstruction. Viral infection of the respiratory tract can also predispose to secondary bacterial infection by disturbing normal host defense mechanisms, altering secretions, and modifying the bacterial flora.
Bacterial pneumonia most often occurs when respiratory tract organisms colonize the trachea and subsequently gain access to the lungs, but pneumonia may also result from direct seeding of lung tissue after bacteremia. When bacterial infection is established in the lung parenchyma, the pathologic process varies according to the invading organism. M. pneumoniae attaches to the respiratory epithelium, inhibits ciliary action, and leads to cellular destruction and an inflammatory response in the submucosa. As the infection progresses, sloughed cellular debris, inflammatory cells, and mucus cause airway obstruction, with spread of infection occurring along the bronchial tree, as it does in viral pneumonia.
S. pneumoniae produces local edema that aids in the proliferation of organisms and their spread into adjacent portions of lung, often resulting in the characteristic focal lobar involvement.
Group A streptococcus infection of the lower respiratory tract results in more diffuse infection with interstitial pneumonia. The pathology includes necrosis of tracheobronchial mucosa; formation of large amounts of exudate, edema, and local hemorrhage, with extension into the interalveolar septa; and involvement of lymphatic vessels and the increased likelihood of pleural involvement.
S. aureus pneumonia manifests in confluent bronchopneumonia, which is often unilateral and characterized by the presence of extensive areas of hemorrhagic necrosis and irregular areas of cavitation of the lung parenchyma, resulting in pneumatoceles, empyema, or, at times, bronchopulmonary fistulas.
Recurrent pneumonia is defined as 2 or more episodes in a single year or 3 or more episodes ever, with radiographic clearing between occurrences. An underlying disorder should be considered if a child experiences recurrent pneumonia (Table 3).
Classification
The working classification is used, which was approved by the order of the Ministry of Health of Ukraine dated January 13th 2005 (Table 4).
Table 4. Classification of pneumonia
|
Origin |
Clinico-roentgenological form |
Localization |
Severity |
Clinical course |
|
Community-acquired pneumonia (ambulatory) Nosocomial (hospital-acquired)* Ventilation pneumonia: -early** -late Pneumonia, associated with immunodeficiency Pneumonia of newborn: Congenital pneumonia*** Postnatal (acquired) community-acquired and hospital-acquired |
Bronchopneumonia (pneumonia with confluent foci)
Segmentary pneumonia (mono- and polysegmentary)
Croupous pneumonia (lung fever)
Interstitial pneumonia |
Unilateral pneumonia Bilateral pneumonia Diffuse pneumonia -lung -lobe -segment |
Noncomplicated pneumonia Complicated pneumonia: toxic; purulent: -pulmonary (destruction abscess pleurisy pyopneumothorax) -extrapulmonary (osteomyelitis otitis meningitis pyelonephritis etc.). |
Acute (до(less than 6 weeks)
Prolonged (from 6 weeks to 6 months) |
* which developed in 72 hours after the patient has been admitted to hospital or in 72 hours after his discharge from hospital
** early – the first 72 hours of artificial lung ventilation, late – 4 and more days of artificial lung ventilation; *** which developed during the first 72 hours of life.
The classification distinguishes two groups of pneumonias: primary and secondary. In case of primary pneumonia the pathological process develops in the pulmonary tissue and is classified as fundamental disease; in case of secondary pneumonia – the pathological process complicates other pulmonary diseases (chronic ones) or diseases of other organs. The severity of pneumonia (mild, moderately-severe, severe) depends on the severity of toxicosis, cardiovascular changes and respiratory compromise.
Classification of respiratory compromise (RC). RC I – the dyspnea occurs during considerable physical activity; RC II – the dyspnea occurs during insignificant physical activity; RC III – the dyspnea occurs during rest.
Classification of RC in children of early age
The 1st degree is marked by dyspnea, tachycardia during physical activity (for infants – physical activity is breast feeding, cry, restlessness). Oxygen partial pressure in the arterial blood is 80–65 mm of the mercury column.
The 2nd degree is marked by dyspnea, tachycardia at rest, increasing considerably during physical activity. Mild labial cyanosis, acrocyanosis. Blowing of the nose wings, retraction of intercostal spaces at respiration. The child is slack, restless. The oxygen partial pressure in the arterial blood is 65–50 mm of the mercury column.
The 3rd degree – dyspnea with breathing rate reaching 80–100 per minute at rest. General cyanosis of the skin and mucous tunics. The supplementary muscles take part in respiration. Hypoxic encephalopathy may develop (impairment of consciousness, convulsions). The oxygen partial pressure is less than 50 mm of the mercury column.
An example of the diagnosis: Pneumonia, acute course, primary, community-acquired, bronchopneumonia, right-sided S-10, noncomplicated, of moderate severity, RC 0.
Clinical Manifestations
Viral and bacterial pneumonias are often preceded by several days of symptoms of an upper respiratory tract infection, typically rhinitis and cough. In viral pneumonia, fever is usually present; temperatures are generally lower than in bacterial pneumonia. Tachypnea is the most consistent clinical manifestation of pneumonia. Increased work of breathing accompanied by intercostal, subcostal, and suprasternal retractions, nasal flaring, and use of accessory muscles is common. Severe infection may be accompanied by cyanosis and respiratory fatigue, especially in infants. Auscultation of the chest may reveal crackles and wheezing, but it is often difficult to localize the source of these adventitious sounds in very young children with hyperresonant chests. It is ofteot possible to distinguish viral pneumonia clinically from disease caused by Mycoplasma and other bacterial pathogens.
Bacterial pneumonia in adults and older children typically begins suddenly with a shaking chill followed by a high fever, cough, and chest pain. Other symptoms that may be seen include drowsiness with intermittent periods of restlessness; rapid respirations; anxiety; and, occasionally, delirium. Circumoral cyanosis may be observed. In many children, splinting on the affected side to minimize pleuritic pain and improve ventilation is noted; such children may lie on one side with the knees drawn up to the chest.
Physical findings depend on the stage of pneumonia. Early in the course of illness, diminished breath sounds, scattered crackles, and rhonchi are commonly heard over the affected lung field. With the development of increasing consolidation or complications of pneumonia such as effusion, empyema, and pyopneumothorax, dullness on percussion is noted and breath sounds may be diminished. A lag in respiratory excursion often occurs on the affected side. Abdominal distention may be prominent because of gastric dilation from swallowed air or ileus. Abdominal pain is common in lower lobe pneumonia. The liver may seem enlarged because of downward displacement of the diaphragm secondary to hyperinflation of the lungs or superimposed congestive heart failure.
Symptoms described in adults with pneumococcal pneumonia may be noted in older children but are rarely observed in infants and young children, in whom the clinical pattern is considerably more variable. In infants, there may be a prodrome of upper respiratory tract infection and diminished appetite, leading to the abrupt onset of fever, restlessness, apprehension, and respiratory distress. These infants appear ill, with respiratory distress manifested as grunting; nasal flaring; retractions of the supraclavicular, intercostal, and subcostal areas; tachypnea; tachycardia; air hunger; and often cyanosis. Results of physical examination may be misleading, particularly in young infants, with meager findings disproportionate to the degree of tachypnea. Some infants with bacterial pneumonia may have associated gastrointestinal disturbances characterized by vomiting, anorexia, diarrhea, and abdominal distention secondary to a paralytic ileus. Rapid progression of symptoms is characteristic in the most severe cases of bacterial pneumonia.
Criteria of the typical acute pneumonia diagnostics
1. Anamnestic: dry or moist cough, pain in chest, temperature rise above 38°C, intoxication. Association with acute respiratory viral infections, overcooling factor.
2. Clinical syndromes:
– respiratory syndrome with acuter respiratory viral infection symptoms, deep cough with mucous or purulent-mucous sputum discharge or with only dry cough;
– toxicosis syndrome of different degree with possible toxic complication from the inner organs. The temperature exceeds 38°C during three days and more;
– respiratory compromise syndrome: dyspnea exceeding 60 per minute in children under 2 months, 50 per minute – from 2 months to 1 year, 40 per minute – from 1 year to 5 years old (the data of the WHO). Retracting of the yielding places on the chest without any bronchial obstruction (bronchial obstruction usually makes it possible to exclude typical acute pneumonia and accompanies atypical, nosocomial and viral acute pneumonias).
– bronchopulmonary syndrome with local physical changes in the lungs: short percussion sound, dullness, weak respiration or bronchial respiration; local, constant fine moist rales, crepitation.
3. Paraclinical:
– In bacterial pneumonia cases the leucocytosis exceeds 12.0´109/l, rod-nuclear neutrophils exceed 5%, erythrocyte sedimentation rate exceeds 20 mm/hour. In cases of mycoplasma, pneumocystic pneumonias these changes are less marked.
– The X-ray study confirms the clinical diagnosis and specifies more exactly the form of the pneumonia: homogenous shadows (polysegmentary, lobular, brnochopneumonias) are characteristic of bacterial pneumonias; non-homogenous – of acute pneumonias, initiated by mycoplasma; disseminated processes (interstitial lesion with alveolar infiltration suggests clamidiosis or pneumocystosis); infiltration with confluent foci is characteristic of pneumonia, complicated by destruction. The X-ray control of non-complicated pneumonia, which as a rule resolves in 2–4 weeks, needs not be done.
Characteristics of clinico-roentgenological forms of acute pneumonia
Bronchopneumonia is the most common form, often occurs in early age and is as a rule a complication of the viral infection, developing in the form of tracheobronchitis with its peculiar clinical picture.
The clinical picture of bronchopneumonia may progress gradually with slow development of the characteristic symptoms at the end of the 1st – on the 2nd week of the disease. It may also occur suddenly, when the clinical picture allows to diagnose pneumonia during the first three days. The child with acute respiratory viral infection after a short-term improvement acquires intoxication symptoms. The cough becomes moister, the dyspnea occurs during physical activity or at rest, the respiration rate does not correspond to the body temperarure. The palpation shows increased voice trembling in case of the expanded process. The short percussion sound is observed above the lesion focus. The lung auscultation reveals hard breath with “bronchial” rales. The respiration above the lesion focus is weakened or hard (but the bronchophony is increaed), constant fine moist rales and crepitation are noticed. The blood test reveals moderate neutrophilic leucocytosis, the erythrocyte sedimentation rate is high. The X-ray study shows multifocal infiltrative shadows in one lung.
In children patients of the early age the most prominent symptoms of bronchopneumonia are RC, intoxication, and local changes in the lungs are found somewhat later: the process is seldom of a bilateral character.
Segmentary (polysegmentary) pneumonias (bronchopneumonias) unlike focal bronchopneumonia, involve the tissues of the whole segment, being as a rule in the subatelectasis or atelectasis state, in the inflammatory process. That is why the involution of the pulmonary changes is torpid (with clinical symptoms disappearing quickly), bearing the risk of pulmonary fibrosis formation. The term “segmentary pneumonia” indicates the qualitative difference of this form from bronchopneumonia, it should not be used to denote the distribution of pneumonic process. It most frequently occurs in 3–7 year old children and schoolchildren and has the most widespread monosegmentary character (usually on the right side). The disease begins suddenly, with temperature reaching high levels, marked intoxication symptoms appearing, rare coughing. Stomachaches and pain in chest are often observed. The percussion sound is locally short, the local respiration weakening, increased bronchophony, crepitation are registered. Segmentary pneumonia is distinguished by acute inflammatory changes in the peripheral blood. The X-ray picture shows homogenous shadows with clear linear borders, corresponding to one or several segments, and decrease in the lung root structure on the lesion side. Pleural lesions are frequent (in 50% of children). Polysegmentary pneumonias are usually more severe and more often occur in children of the first and second year.
Croupous pneumonia (lung fever) is relatively rare. It is more characteristic to children of the school age, sometimes to 2–5 year old children, and is marked by the lobular lesion (most often – superior and inferior lobe of the right lung). The disease is most often initiated by pneumococcus and is a hyperergic allergic reaction with characteristic fibrinous inflammation, which develops in the organism, sensibilized by pneumococcus. In some cases the disease can be provoked by overcooling, physical or psychical trauma.
The disease is not preceded by an acute respiratory viral infection. It begins with sudden temperature rise up to 39–40°C, chill, headache, pain in the chest or right rise of the abdomen, acute disturbance of the general state. The cough is absent on the first days; sometimes it can be dry and rare. The abdominal syndrome is frequent to develop. Croupous pneumonia typically has cyclic development.
The blood tests show clearly marked leucocytosis, neutrophillosis with the shift to the left, the increase in the erythrocyte sedimentation rate to 20–40 mm/hour. The X-ray also reveal the stage dynamics: the congestion stage (1st–2nd day) is marked by the increase of the vascular pattern prominence and restriction in the diaphragm mobility; the hepatization stage (2nd–7th day) is distinguished by homogenous shadows with clear borders, corresponding to the lobe, with the root and the adjacent pleura being involved into the process; in the resolution stage the infiltration gradually disappears.
This diagnosis has a prognostic value, because prescribing the antibiotic, affecting the pneumococcus, gives fast clinical effect.
Interstitial pneumonia is the most rare form and is caused by viruses, mycoplasma, clamidia, pneumocysts and other fungi. It is usually observed in prematurely born and newborn children, and in the older age – in weakened children – it is associated with dystrophy, anemia, diathesis, immunodeficiency states. Interstitial cells lesion can be of a local or diffuse character, of an acute or prolonged form. The clinical picture includes a tetrad of symptoms: dyspnea, hypoxemia, cough, diffuse interstitial infiltration. Even when the disease has a favorable development, the roentgenological changes in the lungs remain for a long time – 6–8 weeks or more. Such form of pneumonia may end either by complete recovery or by pulmonary fibrosis formation.
Diagnosing primary viral pneumonias.
The viral pneumonia diagnosis is confirmed by the positive results of the immunofluorescent analysis of the nasopharynx lavage and by the X-ray picture of the lungs showing non-homogenous pneumonic shadow without clear borders, without any changes in the hemogram, characteristic of bilateral pneumonia.
The pneumonia, caused by influenza, appears in the first hours of the disease on the background of the severe state with hypethermia and has a type of bronchopneumonia or segmentary pneumonia. Physical data are scanty and moderately marked. The patient recovers in 2–3 weeks. Parainfluenza, adenovirus, respiratory-syncytial pneumonias are often accompanied by the obstructive syndrome, focal infiltration of the lung tissue and tend to have a prolonged course. Parainfluenza pneumonia has the symptoms of laryngitis.
The differential diagnosis must be made first of all with bronchitis and bronchiolitis. Pneumonias must be differentiated from the respiratory tract obstruction (foreign body, aspiration, larynx malformations, laryngospasm), pleurisy, tuberculosis, lung lesions associated with helminthiasis. Inferior lobe pneumonias must be differentiated from appendicitis, intestinal obstruction, peritonitis; superior lobe pneumonias – with meningitis.
Treatment
Bed rest should last for the whole fever period. The temperature normalizing, the regime becomes less strict during 2–3 days, and in 3–4 days the child can go for a walk, gradually increasing its length (from 20 minutes).
Indications for admission to a hospital are noted in Table 5.
FACTORS SUGGESTING NEED FOR HOSPITALIZATION OF CHILDREN WITH PNEUMONIA
Age <6 months
Sickle cell anemia with acute chest syndrome
Multiple lobe involvement
Immunocompromised state
Toxic appearance
Moderate to severe respiratory distress
Requirement for supplemental oxygen
Dehydration
Vomiting or inability to tolerate oral fluids or medications
No response to appropriate oral antibiotic therapy
Social factors (e.g., inability of caregivers to administer medications at home or follow up appropriately)
The diet must correspond to the child’s age. When the disease is in acute period, the food should be mechanically and chemically light. The liquid amount is increased by 20% in comparison with the age norms (fruit drinks, juices, tea with lemon etc.).
The etiotropic therapy of acute pneumonia is given taking into account the possible pathogens (viruses, bacteria), age, origin of the pneumonia, clinical picture.
The primary choice of antibacterial drug in case of bacterial pneumonia and its changing, when it proves to be ineffective, is almost always made empirically. For the antibacterial therapy to be successful it is important to register the effect of treatment and to change the drug if there is no effect.
Complete effect: the temperature falls under 38°C in 24–48 hours in case of non-complicated pneumonia and in 3–4 days in case of complicated pneumonia on the background of general condition and appetite improvement, decrease of dyspnea. Partial effect: the temperature remains on febrile level after the aforementioned period with toxicosis and dyspnea degree decreasing, appetite improvement and the negative roentgenological dynamics (destructive pneumonia, metapneumonic pleurisy) being absent. In this case there is no need to change the antibiotic. No effect: the temperature remains on febrile level, with the general condition aggravating and (or) pathological changes in the lungs and pleura increasing.
For the empiric (starting therapy) it is recommended to use “protected” penicillin, cephalosporin of the 2nd generation, more rarely (in case of hospital-acquired acute pneumonia of newborns) – cephalosporin of the 3rd generation, new macrolides; the latter are chosen to treat atypical pneumonias.
If the antibiotic has been chosen adequately and the effect has been reached quickly in case of non-complicated typical acute pneumonia it is sufficient to carry out the antibacterial therapy for 6–7 days (3–4 days after the temperature has normalized), in case of atypical pneumonia – 14–21 days. In case of complicated acute pneumonia the treatment is long (in case of abscesses formation – 42–56 days). It is usually considered that parenheral treatment should be continued at least for 2 days after the effect and then to pass to the peroral drug administration. In cases of non-complicated pneumonia peroral medications are preferable from the first days of the disease.
In cases of virus pneumonias syndrome and antiviral therapy is the most important (antigrippal immunoglobulin, in case of cytomegalovirus acute pneumonia – specific anticytomegalovirus immunoglobulin or gancyclovir, drugs of the interferon group).
The use of some antibiotics, taking into account their toxicity, is prohibited to the certain age: fluorinequinolons – to 12 years, tetracyclins – to 8 years.
In order to treat pneumonias in patients with immunodeficiency states, if the pneumonia is of a bacterial nature, cephalosporins of the 3rd and 4th generation or vancomycin in combination with aminoglycosides (netimycin, amicocin) are prescribed. In case of pneumocystal pneumonia Co-trimoxasol is chosen, tinidasol and metronidasol are less active. In case of fungal infection – antifungal drugs are chosen (fluconasol, amphotericin U).
It is necessary to mention that antistaphylococcus plasma and antistaphilococcus gamma-globulin must be included in the therapy to treat staphylococcus pneumonia.
The prescription of antifungal and biopreparations in combination with short courses of narrow-spectrum antibiotics is restricted to children of the first month and patients with immunosuppression.
Pathogenetic therapy is indicated, taking into consideration the general pathogenetic mechanisms of the disease development. It includes the usage of: 1) anti-inflammatory drugs (mefenamin acid, erespan etc.), which inhibit the inflammatory mediators’ activity; 2) antioxidants and membrane-stabilizing drugs (vitamins, especially A, E, dimephosphon essenciale etc. for 7–10 days); 3) the treatment of the respiratory compromise: supporting free conductivity of the respiratory tract, oxygen therapy with moistened oxygen, improving bronchial conductivity by injecting 2.4% aminophylline solution in single dose 4 mg/kg intravenously by drops; 4) treatment of the toxicosis: infusion therapy volume in case of pneumonia must not exceed 30–50 ml/kg per day, the ratio colloid/crystalloid must be 1:2, ratio of crystalloids – 10% of glucose solution to 0.9% physiological solution (Ringer solution) – when the child is under 2 months old – 4:1, when the child is under 1 year old – 3:1, more than 3 years old – 2:1, more – under the diuresis control. The speed is 10–15 drops per minute.
Symptomatic therapy includes vasoconstictive drugs to treat rhinitis, drugs to treat cough, among which the “mucolytic” group is the most preferable – “mucolytic drugs with expectorant effect” and “expectorant drugs”.
Physiotherapeutic treatment. During the acute period of non-complicated pneumonia the ultra-high frequency electric field (5–6 séances, microwave therapy), inductothermia are prescribed. After that 10–15 séances of amplipulsophoresis with nicotine acid solution, calcium chloride, copper or magnesium sulfate are given. In case when the disease is lingering and the pulmonary fibrosis is suspected, inductothermia, diathermia, amplipulsophoresis with 3% potassium iodide solution, lidase are recommended. In case of purulent pulmonary complications the treatment by amplipulsophoresis with platiphillin and staphylococcus antiphagin or proteolytic enzymes is given at the certain stage of the therapy.
Therapeutic physical culture is begun after the toxicosis disappears and the temperature decreases to subfebrile level. It includes breathing gymnastics and chest massage (vibromassage, jar massage). It is useful to do warm and moist inhalations, inhalations with mucolytics, herbal decoctions, physiological solution.
The acute period over, adaptogens (eleuterococcus extraction, Echinacea, Schizandra) and vitamins C, A, E, of B group are prescribed for peroral administration.
The primary prevention includes child hardening from the first months of life, rational diet and care, sufficient staying in fresh air. It is necessary to prevent and treat in time chronic infection sources, treat diseases, provoking pneumonia (intractranial birth trauma, rachitis, anemia, hypotrophy, acute respiratory viral infections etc.). In order to contror hospital-acquired pneumonias, it is important to take wide range of measures to prevent cross-infection in the in-patient hospital department.
The secondary prevention includes timely and adequate treatment of acute pneumonia to reach the complete recovery. The aforementioned generally-strengthening therapy, which makes the inflammatory sources to dissolve, is continued for not less than 2–4 weeks after the discharge from the hospital (interchanging vitamin courses combined with plant adaptogens).
After pneumonia the child should be under the pediatrician’s observation during 6 months, after pneumonia in the neonatal period – during 1 year. The pediatrician must examine the child during the first three months, and the newborn – twice a month, than every month.
Prognosis. If the disease was diagnosed in time and the treatment was adequate, mild and moderately-severe forms of bronchopneumonia, segmentary and croupous pneumonia end in recovery in most cases. In several cases, burdened premorbid background, virus or bacterial reinfection, late or insufficient treatment may initiate lingering or chronic bronchopulmonary process. In case of destructive process and also in case if any pneumonia has a severe form, the prognosis is very serious.
Complications
Complications of pneumonia are usually the result of direct spread of bacterial infection within the thoracic cavity (pleural effusion, empyema, pericarditis) or bacteremia and hematologic spread. Meningitis, suppurative arthritis, and osteomyelitis are rare complications of hematologic spread of pneumococcal or H. influenzae type b infection.
S. aureus, S. pneumoniae, and S. pyogenes are the most common causes of parapneumonic effusions and of empyema (Table 392-6). The treatment of empyema is based on the stage (exudative, fibrinopurulent, organizing). Imaging studies including ultrasonography and CT are helpful in determining the stage of empyema. The mainstays of therapy include antibiotic therapy and drainage with tube thoracostomy. Additional approaches include the use of intrapleural fibrinolytic therapy (urokinase, streptokinase, tissue plasminogen activator) and selected video-assisted thoracoscopy (VATS) to debride or lyse adhesions, and drain loculated areas of pus. Early diagnosis and intervention, particularly with fibrinolysis or VATS, may obviate the need for thoracotomy and open debridement. Fibrinolysis may be more cost effective than VATS.
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