History
Newborns with pneumonia rarely cough; more commonly they present with poor feeding and irritability, as well as tachypnea, retractions, grunting, and hypoxemia. Grunting in a newborn suggests a lower respiratory tract disease and is due to vocal cord approximation as they try to provide increased positive end-expiratory pressure (PEEP) and to keep their lower airways open.
After the first month of life, cough is the most common presenting symptom of pneumonia. Infants may have a history of antecedent upper respiratory symptoms. Grunting may be less common in older infants; however, tachypnea, retractions, and hypoxemia are common and may be accompanied by a persistent cough, congestion, fever, irritability, and decreased feeding. Any maternal history of Chlamydia trachomatis infection should be determined.
Infants with bacterial pneumonia are often febrile. But those with viral pneumonia or pneumonia caused by atypical organisms may have a low-grade fever or may be afebrile. The child's caretakers may complain that the child is wheezing or has noisy breathing. Toddlers and preschoolers most often present with fever, cough (productive or nonproductive), tachypnea, and congestion. They may have some vomiting, particularly post-tussive emesis. A history of antecedent upper respiratory tract illness is common.
Older children and adolescents may also present with fever, cough (productive or nonproductive), congestion, chest pain, dehydration, and lethargy. In addition to the symptoms reported in younger children, adolescents may have other constitutional symptoms, such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms.
Travel history is important because it may reveal an exposure risk to a pathogen more common to a specific geographic area (eg, dimorphic fungi). Any exposure to tuberculosis (TB) should always be determined. In addition, possible exposure to birds (psittacosis), bird droppings (histoplasmosis), bats (histoplasmosis), or other animals (zoonoses, including Q fever, tularemia, and plague) should be considered.
In children with evidence for recurrent sinopulmonary infections, a careful history to determine the underlying cause is needed. The recurrent nature of the infections may serve to unveil an innate or acquired immune deficiency, an anatomic defect, or another genetic disease (eg, cystic fibrosis, ciliary dyskinesia).
Tuberculosis
A history of TB exposure to possible sources should be obtained in every patient who presents with signs and symptoms of pneumonia (eg, immigrants from Africa, certain parts of Asia, and Eastern Europe; contacts with persons in the penal or detention system; close contact with known individuals with TB). Children with TB usually do not present with symptoms until 1-6 months after primary infection. These may include fever, night sweats, chills, cough (which may include hemoptysis), and weight loss.
Physical Examination
The signs and symptoms of pneumonia are often nonspecific and vary widely based on the patient’s age and the infectious organisms involved. Tachypnea is the most sensitive finding in patients with diagnosed pneumonia.
Initial evaluation
Early in the physical examination, identifying and treating respiratory distress, hypoxemia, and hypercarbia are important. Visual inspection of the degree of respiratory effort and accessory muscle use should be performed to determine both the presence and severity of respiratory distress. The examiner should simply observe the patient's respiratory effort and count the respirations for a full minute. In infants, observation should include an attempt at feeding, unless the baby has extreme tachypnea.
Pulmonary findings in all age groups may include accessory respiratory muscle recruitment, such as nasal flaring and retractions at subcostal, intercostal, or suprasternal sites. Signs such as grunting, flaring, severe tachypnea, and retractions should prompt the clinician to provide immediate respiratory support. Retractions result from an effort to increase intra-thoracic pressure in order to compensate for decreased compliance.
An emergency department (ED)-based study conducted in the United States found that respiratory rate alone and subjective clinical impression of tachypnea did not discriminate children with and without radiographic pneumonia. [26]
The World Health Organization (WHO) clinical criteria for pneumonia have also been reported to demonstrate poor sensitivity (34.3%) in diagnosing radiographic pneumonia in children presenting to the pediatric ED. [27] However, children with tachypnea as defined by WHO respiratory rate thresholds were more likely to have pneumonia than were children without tachypnea. The WHO thresholds are as follows:
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Children younger than 2 months: Greater than or equal to 60 breaths/min
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Children aged 2-12 months: Greater than or equal to 50 breaths/min
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Children aged 1-5 years: Greater than or equal to 40 breaths/min
Airway secretions may vary substantially in quality and quantity but are most often profuse and progress from serosanguineous to a more purulent appearance. White, yellow, green, or hemorrhagic colors and creamy or chunky textures are not infrequent. If aspiration of meconium, blood, or other proinflammatory fluid is suspected, other colors and textures reflective of the aspirated material may be observed.
Infants may have external staining or discoloration of skin, hair, and nails with meconium, blood, or other materials when they are present in the amniotic fluid. The oral, nasal and, especially, tracheal presence of such substances is particularly suggestive of aspiration.
An assessment of oxygen saturation by pulse oximetry should be performed early in the evaluation of all children with respiratory symptoms. Cyanosis may be present in severe cases. When appropriate and available, capnography may be useful in the evaluation of children with potential respiratory compromise.
Cyanosis of central tissues, such as the trunk, implies a deoxyhemoglobin concentration of approximately 5 g/dL or more. This is consistent with severe derangement of gas exchange from severe pulmonary dysfunction as in pneumonia. However, congenital structural heart disease, hemoglobinopathy, polycythemia, and pulmonary hypertension (with or without other associated parenchymal lung disease) must also be considered.
Chest pain may be observed with inflammation of or near the pleura. Abdominal pain or tenderness is often seen in children with lower lobe pneumonia. The presence and degree of fever depends on the microorganism involved, but high temperature (38.4°C) within 72 hours after admission and the presence of pleural effusion have both been reported to be significantly associated with bacterial pneumonia. [8]
Pneumonia may occur as a part of an alternate generalized etiology. Therefore, signs and symptoms suggestive of other disease processes, such as rashes and pharyngitis, should be sought during the examination.
Auscultation
Auscultation is perhaps the most important portion of the examination of the child with respiratory symptoms. The examination is often very difficult in infants and young children for several reasons. Babies and young children often cry during the physical examination, making auscultation difficult. The best opportunity for success lies in prewarming hands and instruments and the use of a pacifier to calm the infant. The opportunity to listen to a sleeping infant should never be lost.
Older infants and toddlers may cry because they are ill or uncomfortable. But, most often, they may experience stranger anxiety. For these children, it is best to spend a few minutes with the parents in the child's presence. If the child sees that the parent trusts the examining physician, then he or she may be more willing to let the examiner approach. A small toy may help to gain the child's trust.
Any part of the examination using instruments should be deferred as long as possible, because the child may find the medical equipment threatening. Occasionally, if the child is allowed to hold the stethoscope for a few minutes, he or she becomes less frightened. Even under the best of circumstances, examining a toddler is difficult. If the child is asleep when the physician begins the evaluation, auscultation should be performed early.
Children with respiratory symptoms may have a concomitant upper respiratory tract infection with copious upper airway secretions. This creates another potential problem: the transmission of upper airway sounds. In many cases, the sounds created by upper airway secretions can almost obscure true breath sounds and lead to erroneous diagnoses. If the origin of sounds heard through the stethoscope is unclear, the examiner should listen to the lung fields and then hold the stethoscope near the child's nose. If the sound patterns from both locations are approximately the same, the likely source of the abnormal breath sounds is the upper airway.
Even when the infant or young child is quiet and has a clear upper airway, the child's normal physiology may make the examination difficult. The minute ventilation is the product of the respiratory rate an
Patients With Recurrent Pneumonias
Occasionally, a patient has pneumonia that continues to manifest clinically (persistent or unresponsive pneumonia), radiographically (eg, 8 weeks after antibiotic treatment), or both despite adequate medical management. Studies have documented that the usual pathogens (eg, pneumococcus, non-typeable H influenza, Moraxella catarrhalis) may be the causative agents.
Other patients may present with a history of recurrent pneumonias, defined as more than 1 episode per year or more than 3 episodes in a lifetime, and again the organisms responsible are the aforementioned common pathogens.
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 radiographic findings with and without symptoms. This method places these children in 1 of 3 categories that help to narrow the differential diagnoses (see Table below).
A careful history and examination are helpful to further narrow the differential diagnosis. However, more testing is often needed to confirm most of such diagnoses and is generally outside the scope of a primary care provider.
Table. Categorizing Patients Based on Symptoms, to Assist in Differential Diagnosis of Patients With Recurrent Pneumonias (Open Table in a new window)
Category |
Laboratory and Imaging Findings |
Clinical Findings |
Differential Diagnosis |
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 with interval radiologic clearing |
No clinical findings |
Asthma and atelectasis that has been misdiagnosed (for example, as a bacterial pneumonia); aspiration syndrome, hypersensitivity pneumonitis, idiopathic pulmonary hemosiderosis, or a mild immunodeficiency disorder |
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(Left) Gram stain demonstrating gram-positive cocci in pairs and chains and (right) culture positive for Streptococcus pneumoniae.
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A breakdown of test results and recommended treatment for pneumonia with effusion. Gm = Gram; neg = negative; pos = positive; VATS = video-assisted thoracic surgery
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(A) Anteroposterior radiograph from a child with presumptive viral pneumonia. (B) Lateral radiograph of the same child with presumptive viral pneumonia.
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Radiograph from a patient with bacterial pneumonia (same patient as in the preceding image) a few days later. This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic pleural effusion.
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Right lower lobe consolidation in a patient with bacterial pneumonia.
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(A) Anteroposterior radiograph from a child with a left lower lobe infiltrate. (B) Lateral radiograph of the same child with a left lower lobe infiltrate.
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Anteroposterior radiograph from a child with a round pneumonia.
Tables
Category |
Laboratory and Imaging Findings |
Clinical Findings |
Differential Diagnosis |
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 with interval radiologic clearing |
No clinical findings |
Asthma and atelectasis that has been misdiagnosed (for example, as a bacterial pneumonia); aspiration syndrome, hypersensitivity pneumonitis, idiopathic pulmonary hemosiderosis, or a mild immunodeficiency disorder |
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- Overview
- Presentation
- DDx
- Workup
- Approach Considerations
- Complete Blood Cell Count
- Sputum Gram Stain and Culture
- Blood Culture
- Serology
- Inflammatory Markers
- Polymerase Chain Reaction
- Skin Testing
- Gastric Aspirates
- Cold Agglutinin Testing
- Urine Latex Agglutination Testing
- Direct Antigen Detection
- Imaging Studies
- Bronchoscopy
- Bronchoscopic Alveolar Lavage
- Protected Brush Tracheal Aspirate Sampling
- Lung Aspiration
- Lung Puncture
- Thoracentesis
- Histology
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