Clinical Presentation
Pneumonia - Community-Acquired Pediatric_Initial Assesment 1Symptoms of childhood pneumonia may include fever, dyspnea, cough, chest or abdominal pain with or without vomiting, and headache. Patients with cough or difficulty of breathing with lower chest indrawing, nasal flaring, or grunting are considered to have severe pneumonia. Patients with cough or difficulty of breathing with either cyanosis, severe respiratory distress, inability to drink or vomiting everything, or lethargy, unconsciousness, or convulsions have very severe pneumonia.
Tiền sử bệnh
The diagnosis of childhood pneumonia is primarily based on history and physical findings (eg signs and symptoms of respiratory distress and fever). Laboratory and radiographic exams may aid in the diagnosis of severe cases or in patients who failed to show clinical improvement after initiation of antibiotic therapy.
Note the patient’s age and immunization status. Age is a good predictor of the causative agent. Viruses are often linked to up to 50% of pneumonia in young children. S pneumoniae, followed by atypical pneumonia (eg Mycoplasma, Chlamydia), is the most likely pathogen in older children with pneumonia of bacterial origin. Immunization status is important because children fully immunized against Haemophilus influenzae type b and S pneumoniae are less likely to be infected with these pathogens.
One should also take note of the season of the year, daycare attendance, exposure to tobacco smoke or infectious diseases (eg tuberculosis), history of travel, coexisting illnesses (ie cardiac or pulmonary disorders [eg history of severe or recurrent pneumonia, bronchopulmonary dysplasia, cystic fibrosis, congenital heart disease], immunodeficiencies, or neuromuscular diseases [eg severe cerebral palsy]), and nutritional status.
Khám thực thể
The combination of clinical findings is more predictive in diagnosing community-acquired pneumonia. Check for the patient’s temperature. Fever in viral pneumonia is generally lower than in bacterial pneumonia. Bacterial pneumonia presents with persistent or recurrent temperatures of ≥38.5°C over the prior 24-48 hours.
Pneumonia - Community-Acquired Pediatric_Initial Assesment 2
A study shows a significant correlation between respiratory rate (RR) and oxygen saturation. This is less sensitive and specific in the first 3 days of illness. Tachypnea may be a marker for respiratory distress and/or hypoxemia but may also be secondary to fever, dehydration, or concurrent metabolic acidosis. Increased work of breathing is associated with changes radiologically.
The criteria for tachypnea based on age as defined by the World Health Organization (WHO) are as follows:
- >60 breaths/minute in <2 months old
- >50 breaths/minute in 2-11 months old
- >40 breaths/minute in 1-5 years old
- >20 breaths/minute in >5 years old
Respiratory signs may include intercostal, subcostal, or suprasternal retractions; nasal flaring; and crackles or wheezing on auscultation. Decreased breath sounds, scattered crackles, or rhonchi are usually heard over the affected lung field in the early course of illness. Dullness on percussion and decreased breath sounds are usually appreciated when increased consolidation and complications develop.
Screening
Severity Assessment
Assessing the severity is necessary to identify patients who may be effectively treated as outpatients and who may need hospitalization. The patient’s history, presentation, and physical examination are the major determinants of the severity of illness and appropriate site of care. The severity should be based on the patient's overall clinical appearance and behavior (eg degree of alertness and eagerness to feed).
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Infants |
Older Children |
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Mild to Moderate CAP |
Severe CAP |
Mild to Moderate CAP |
Severe CAP |
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Temperature |
<38.5°C |
≥38.5°C |
<38.5°C |
≥38.5°C |
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Respiratory rate |
<50 breaths/minute |
>70 breaths/minute |
<50 breaths/minute |
>50 breaths/minute |
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Breathing effort |
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Other features |
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Reference: Harris M, Clark J,
Coote N, et al, on behalf of the British Thoracic Society Standards of Care
Committee. British Thoracic Society guidelines for the management of community
acquired pneumonia in children: update 2011.
Thorax. 2011 Oct;66(2):ii16.