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Risk Classification of Pneumonia Essay

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Pneumonia is defined as the inflammation of lung tissue caused by an infectious agent that results in acute respiratory signs and symptoms. It can either be acquired outside (community-acquired) or within the hospital (hospital-acquired) ? Who shall be considered as having community-acquired Pneumonia? ? For ages 3 months to 5 years are tachypnea and/or chest indrawing For ages 5 to 12 years are fever, tachypnea, and crackles ? Who shall be considered as having community-acquired Pneumonia? Beyond 12 years of ages are the presence of the following features: y Fever, tachypnea, and tachycardia y At least one abnormal chest findings of diminished breathing sounds, ronchi, crackles or wheezes ? Tachypnea is still the best predictor of pneumonia Who will require admission? ? A patient who is at moderate to high risk to develop pneumonia-related mortality should be admitted A patient who is minimal to low risk can be managed on an outpatient basis ? Risk Classification of Pneumonia

Variables PCAP A Minimal risk None Yes Possible None Able >11 mos PCAP B Low risk Present Yes Possible Mild Able >11 mos PCAP C Moderate risk Present No Not possible Moderate Unable 50/min >40/min >30/min >60/min >50/min >35/min >70/min >50/min >35/min Risk Classification of Pneumonia Variables PCAP A Minimal risk PCAP B Low risk PCAP C Moderate risk PCAP D High risk Signs of respiratory failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f.

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Sensorium None None None None None Awake None None None None None Awake Intercostal/Subcostal Present Present None None Irritable Supraclavicular/Interco stal/Subcostal Present Present Present Present Lethargic/Stuporous/ Comatose Complication (effusion, pneumothorax) Action Plan None None Present Present OPD follow up at end of treatment OPD follow up after 3 days Admit to regular ward Admit to ICU Refer to specialist ? The presence of retraction on admission was the best single predictor of death ? Inability to cry, head nodding and a respiratory rate of >60/min were the best predictors of hypoxemia

Diagnostic Tools Chest X-Ray PA-lateral ? White cell count ? Acute Phase Reactants ? y ESR and CRP have not been demonstrated to differentiate viral from bacterial infection Diagnostic Tools ? Microbiology y Blood C/S y Plueral fluid C/S y Tracheal aspiration C/S y Sputum C/S ? Oxygen saturation and/or Blood Gas y To help the clinician in deciding the appropriate intervention What diagnostic aids are requested for a patient classified as PCAP A or PCAP B? ? No diagnostic aids are initially requested for a patient classified as either PCAP A or PCAP B who is being managed in an ambulatory setting

What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D? ? The following should be routinely requested: y Chest x-ray PA-lateral y White blood cell count y Culture and sensitivity of Blood for PCAP D Pleural fluid Tracheal aspirate upon initial intubation Blood gas and/or pulse oximetry What diagnostic aids are initially requested for a patient classified as either PCAP C or PCAP D? ? The following may be requested: y Culture and sensitivity of sputum for older children ? The following should not be routinely requested: Erythrocyte sedimentation rate y C-reactive protein When is antibiotic recommended? ? For a patient classified as either PCAP A or B and is: y Beyond 2 years of age y Having high grade fever without wheeze ? For a patient classified as PCAP C and is: y Beyond 2 years of age y Having high grade fever without wheeze y Having alveolar consolidation in the CXR y Having WBC > 15,000 ? For a patient classified as PCAP D Etiology ? First 2 years: viruses As age increases bacterial pathogens become more prevalent ? ? PCAP managed as an outpatient: Bacterial pathogen is more common y Streptococcus pneumoniae is the pathogen in more than half (Others: M. pneumoniae, C. pneumoniae) ? PCAP managed as an inpatient: y Bacterial pathogen is more common y Streptococcus pneumoniae is the pathogen in little more than half (Others: H. influenzae b, M. pneumoniae, C. pneumoniae) ? Haemophilus influenzae type b should be given in patient below 5 years of age who has not completed the primary series of Hib immunization Bacterial vs Viral Features Fever Wheeze Bacterial T>38. 5°C Absent Viral T

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