eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Pneumonia: Follow-up
Updated: Jan 12, 2009
Follow-up
Further Outpatient Care
If therapy fails to elicit a response, the whole treatment approach must be reconsidered. After initiating therapy, the most important tasks are resolving the symptoms and clearing the infiltrate. With successful therapy, symptoms resolve much sooner that the infiltrate. In a study of adults with pneumococcal pneumonia, the infiltrate did not completely resolve in all patients until 8 weeks after therapy (although it was sooner in most patients).
In a patient who is clinically doing well, follow-up radiography should be performed after 8 weeks. Although some pneumonias are destructive (eg, adenovirus) and can cause permanent changes, most childhood pneumonias have complete radiologic clearing. If a significant abnormality persists, consideration of an anatomic abnormality is appropriate.
Transfer
Severe respiratory compromise may require intubation and transfer to a suitable ICU for more intensive monitoring and therapy. Indications for transfer include refractory hypoxia, decompensated respiratory distress (eg, lessening tachypnea due to fatigue, hypercapnia), and systemic complications such as sepsis. Transfer may need to be initiated at a lower threshold for infants or young children, as decompensation may be rapid. Transfer of very sick infants or young children to a pediatric ICU is best done with a specialist pediatric transfer team, even if that entails a slightly longer wait, compared with conventional medical transport or even air transport.
Deterrence/Prevention
Aside from avoiding infectious contacts (difficult for many families who use daycare facilities), vaccination is the primary mode of prevention. Since the introduction of the conjugated H Influenzae type B (HIB) vaccine, the rates of HIB pneumonia have significantly declined. However, it should still be considered in unvaccinated persons, including those younger than 2 months, who have not received their first shot.
Conjugated and unconjugated polysaccharide vaccines for S pneumoniae have been developed for infants and children, respectively. The pneumococcal 7-valent conjugate vaccine (diphtheria CRM197 protein; Prevnar) contains epitopes to 7 different strains. Pneumococcal vaccine polyvalent (Pneumovax) covers 23 different strains.
Influenza vaccine is recommended for children aged 6 months and older. The vaccine exists in 2 forms: inactivated vaccine (various products), administered as an intramuscular injection, and a cold-adapted attenuated vaccine (FluMist [made by MedImmune]), administered as a nasal spray, which is currently licensed only for persons aged 2-49 years.
Although the vaccine is especially recommended for children at high risk, such as those with bronchopulmonary dysplasia (BPD), cystic fibrosis, or asthma, the use of FluMist is cautioned in persons with known asthma because of reports of transient increases in wheezing episodes in the weeks after administration. However, in years when vaccine strains have been mismatched with the circulating influenza strains, FluMist has provided good protection (approximately 70%), even when the inactivated vaccine was entirely useless.
Clinical trials are ongoing to lower the age of administration of Fluzone (made by Aventis Pasteur), one of the inactivated intramuscular vaccines, to 2 months (currently approved for children 6 months or older) to help protect this high-risk, but unvaccinated, population. The safety and efficacy of this approach remains unknown.
Respiratory syncytial virus (RSV) prophylaxis consists of monthly intramuscular injections of a monoclonal humanized antibody, palivizumab (Synagis [made by MedImmune]) at a dose of 15 mg/kg (maximum volume 1 mL per injection; multiple injections may be required per dose). Monthly injections during the RSV season approximately halve the rate of serious RSV disease that leads to hospitalization. This expensive therapy is generally restricted to infants at high-risk, such as children younger than 2 years with chronic lung disease of prematurity, premature infants younger than 6 months (or with other risk factors), and children with significant congenital heart disease.
A new monoclonal antibody (motavizumab [Numax; also made by MedImmune]) is in phase III clinical trials for similar indications and, if approved, will likely replace Synagis. In an worldwide comparison between Numax and Synagis during the 2004-2006 RSV seasons, Numax showed a 26% improvement in preventing hospitalizations due to RSV and a 52% reduction in outpatient medically attended lower-tract RSV infections compared with Synagis. Numax remains an investigational drug at this time with no plans for licensure for the 2007-2008 RSV season.
Synagis has no role in the treatment of RSV infection. One study of intubated patients showed a reduction in viral titers but no change in clinical status, perhaps reflective of a large inflammatory component to the disease process. In addition, Synagis has not been shown to reduce upper-respiratory infections with RSV. It reduces only the serious complications of infection. Preliminary results from animal and small-scale human studies suggest that Numax may be effective in reducing RSV viral load in the upper and lower airways. Clinical studies to evaluate the safety and efficacy of Numax in the setting of treating RSV infection in hospitalized children are ongoing.
Complications
A thin layer of fluid (approximately 10 mL) is usually found between the visceral and parietal pleura and helps prevent friction. This pleural fluid is produced at 100 mL/h. Ninety percent of the fluid is reabsorbed on the visceral surface, and 10% is reabsorbed by the lymphatics. Pleural fluid accumulates when the balance between production and reabsorption is disrupted. A transudate accumulates in the pleural cavity when changes in the hydrostatic or oncotic pressures are not accompanied by changes in the membranes. Increased membrane permeability and hydrostatic pressure often result from inflammation and result in a subsequent loss of protein from the capillaries and an accumulation of exudates in the pleural cavity.
When a child with pneumonia develops a pleural effusion, thoracentesis should be performed for diagnostic and therapeutic purposes. The pleural fluid should be obtained to assess pH and glucose levels and a Gram stain and culture, CBC count with differential, and protein assessment should be performed. Amylase and lactase dehydrogenase (LDH) levels can also be measured but are less useful in a parapneumonic effusion than effusions of other etiologies. The results are helpful in determining if the effusion is a transudate or exudate and help to determine the best course of management for the effusion.
Severe coughing, especially in the context of necrotizing pneumonias or bullae formation, may lead to spontaneous pneumothoraces. These may or may not require treatment depending on the size of the pneumothorax and whether it is under tension and compromising ventilation and cardiac output.
Prognosis
Overall, the prognosis is good. Long-term alteration of pulmonary function is rare, even in children with pneumonia that has been complicated by empyema or lung abscess. Significant sequelae occur with adenoviral disease, including bronchiolitis obliterans. Death almost exclusively occurs in children with underlying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression.
Patient Education
For excellent patient education resources, visit eMedicine's Pneumonia Center. Also, see eMedicine's patient education articles Viral Pneumonia and Bacterial Pneumonia.
Miscellaneous
Medicolegal Pitfalls
Consideration of the patient's clinical condition, the likely organisms, local resistance patterns, and history of confounding factors (eg, foreign body aspiration) helps in avoiding medical/legal issues. The prime consideration for long-term management is follow-up radiography to ensure that the infiltrate completely clears and no underlying lung abnormality is present. Patients with respiratory syncytial virus (RSV) infections commonly have a relatively high neutrophil percentage and thrombocytosis, which can mislead one to consider a bacterial infection.
Special Concerns
Occasionally, a patient has pneumonia that continues to manifest clinically, radiographically (eg, 8 wk after antibiotic treatment), or both despite adequate medical management. Other patients may present with a history of recurrent pneumonias, defined as more than one episode per year or more than 3 episodes in a lifetime.
These patients merit special mention because they require a more extensive workup by a specialist. One useful way to categorize these patients is based on radiography findings with and without symptoms. This method places these children in 1 of 3 categories (see Table) that help narrow the differential diagnoses.
A careful history and examination are helpful to further narrow the differential diagnoses. However, more testing is often needed to confirm most of these diagnoses and is generally outside the scope of a primary care provider.
Categorizing Patients Based on Symptoms, Which Assists in Differential Diagnoses of Those With Recurrent PneumoniasOpen table in new window
Table
| Category | Laboratory and Imaging Findings | Clinical Findings | Differential Diagnoses |
1 | Persistent or recurrent radiologic findings | Persistent or recurrent fever and symptoms | Cystic fibrosis, immunodeficiencies, obstruction (intrinsic [eg, foreign body] or extrinsic [eg, compressing nodes or tumor]), pulmonary sequestration, bronchial stenosis, or bronchiectasis |
2 | Persistent radiologic findings | No clinical findings | Anatomic abnormality (eg, sequestration, fibrosis, pleural lesion) |
3 | Recurrent pulmonary infiltrates | No clinical findings | Asthma and atelectasis that has been misdiagnosed as a bacterial pneumonia; aspiration syndrome, hypersensitivity pneumonitis, idiopathic pulmonary hemosiderosis, or a mild immunodeficiency disorder |
| Category | Laboratory and Imaging Findings | Clinical Findings | Differential Diagnoses |
1 | Persistent or recurrent radiologic findings | Persistent or recurrent fever and symptoms | Cystic fibrosis, immunodeficiencies, obstruction (intrinsic [eg, foreign body] or extrinsic [eg, compressing nodes or tumor]), pulmonary sequestration, bronchial stenosis, or bronchiectasis |
2 | Persistent radiologic findings | No clinical findings | Anatomic abnormality (eg, sequestration, fibrosis, pleural lesion) |
3 | Recurrent pulmonary infiltrates | No clinical findings | Asthma and atelectasis that has been misdiagnosed as a bacterial pneumonia; aspiration syndrome, hypersensitivity pneumonitis, idiopathic pulmonary hemosiderosis, or a mild immunodeficiency disorder |
Some children who are immunocompromised, whether secondary to AIDS, an immune disorder, or drug-induced, are at risk for pneumonias with opportunistic agents. Such opportunistic agents include the following:
- Pneumocystis carinii pneumonia (PCP): PCP infection is common in this population of children and can lead to respiratory failure in those who are profoundly immunocompromised. PCP prophylaxis with trimethoprim-sulfamethoxazole 3 times a week is widely used and has all but eradicated this organism in patients receiving prophylaxis. If a child with immunosuppression contracts PCP infection, treatment with trimethoprim-sulfamethoxazole is increased to twice daily.
- Toxoplasmosis: This opportunistic agent is occasionally found in children who are immunocompromised.
- Varicella-zoster virus: Children who are immunocompromised and have been exposed to varicella should receive varicella-zoster intravenous immunoglobulin and acyclovir.
- Herpes simplex virus: This is treated with acyclovir.
- Adenovirus: Infections can lead to bronchiolitis obliterans or hyperlucent lung syndrome in children who are immunocompetent or immunocompromised.
- Cytomegalovirus: This opportunistic agent poses a great risk to patients who are immunocompromised and is difficult to treat.
- Aspergillus and Zygomycetes species: Fungal infections occur in patients who undergo prolonged hospitalization, have neutropenia, and receive broad-spectrum antibiotics. Antifungal therapy is usually amphotericin (intravenous and nebulized).
Acute chest syndrome (ACS) occurs in 15-43% of patients with SCD. Infection or pneumonia is the most common cause of ACS and is characterized by fever, chest pain, dyspnea, cough, tachypnea, crackles, and an infiltrate on chest radiography.
The most common pathogens in the lungs of a patient with sickle cell disease (SCD) are viruses and atypical agents, such as Mycoplasma or Chlamydia species. Patients with SCD have problems with their complement system and have functional asplenia, which predisposes them to infection with encapsulated organisms such as S pneumoniae and H influenzae type B. However, the pneumococcal and HIB vaccines and penicillin prophylaxis have helped reduce the incidence of bacterial infections.
Many patients referred for evaluation by specialists for recurrent pneumonia are diagnosed with asthma. In emergency department studies, 35% of children with an asthma exacerbation have abnormalities visible on chest radiographs. In a child not yet diagnosed with asthma, these abnormalities are frequently interpreted as pneumonia. The right middle lobe is the most common site, but any part of the lung may be affected. Abnormalities found on chest radiography are usually the result of airway inflammation but do not require antibiotics. Inflammation, often triggered by viral infection, is part of the asthmatic response. Wheezing responsive to bronchodilators, a history of atopy, a family history of asthma, and a history of cough or wheeze with exercise may be helpful in identifying these patients.
More on Pneumonia |
| Overview: Pneumonia |
| Differential Diagnoses & Workup: Pneumonia |
| Treatment & Medication: Pneumonia |
 Follow-up: Pneumonia |
| Multimedia: Pneumonia |
| References |
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Further Reading
Keywords
pneumonia, lower respiratory tract infection, bronchopneumonia, pneumonitis, severe acute respiratory syndrome, SARS, impaired cough reflex, ciliary dyskinesia, bronchial obstruction, gastric fluid aspiration, altered pulmonary blood flow, pulmonary edema, obstruction of the airway, ventilation/perfusion mismatch, V/Q mismatch, hypoxemia, tachypnea, hypoxia, retractions, positive end-expiratory pressure, PEEP, nasal flaring, rales, pleural friction rub, respiratory syncytial virus, RSV, parainfluenza, aspiration pneumonia, Haemophilus influenzae infection, group B Streptococcus, Listeria monocytogenes, gram-negative rods, Escherichia coli, Klebsiella pneumoniae, Chlamydia pneumoniae, Ureaplasma urealyticum, Mycoplasma hominis, cytomegalovirus, Pneumocystis carinii, adenovirus, enterovirus, rhinovirus, coronavirus, herpesvirus
