Recurrent pneumonia
Darmawan B Setyanto
Respirology WG
CS, girl, 3 yo, 11 kg
Risk Factors
§ VSD
§ Tracheostomy
§ Dysphagia
The patient underwent Presenting to ED with:
tracheostomy due to § Cyanosis
prolonged intubation History of hospitalization § Saturation: 92-94% on O2
following heart surgery Jan-Feb 2023 due to CAP 29-Jul-2023 supp: Trachvent 3 lpm
Onset of complaint:
Aug 2021
History of hospitalization 9-18 - § Fever
09-Aug-2023
due to CAP Jul-2023 § Cough Blood culture:
§ Tachypnea - Enterobacter sp
§ Dyspnea - P. aeruginosa
CXR: bilateral infiltrate
BGA: metabolic alkalosis
DA, girl, 13 yo, 21.5 kg
Risk factors:
• Persistent asthma
• Pulm hypertension
• Malnutrition
CXR: bilateral infiltrate
BGA: compensated resp acidosis
Dyspnea,
Fever & cough 3 days Presenting to ED:
History of 10-Apr-2023 • Fever, cough, coryza
recurrent • Dyspnea, cyanosis
2018
pneumonia Jan 2023 Jul 2023 • Sat O2: 76%
(7 yrs old)
2013 Diagnosed as: Admitted due to pneumonia Aug 2023
(2 yrs old) • Persistent asthma 4x in 6 months
• Chronic lung dis
• Pulm hypertension
DBS
Medical problem pathway
Diagnosis & Treatment
Symptomatology*
pathophysiology
pathology
adaptive
responses
2022-01-20
*Symptomatology = symptom & sign
= clinical manifestation insults
DBS
ARI case definition
ARI case definition
[Aligns with the European Commission/ European CDC case definition]
Sudden onset of symptoms AND At least 1 of 4
respiratory symptoms: cough, sore throat, shortness of breath,
coryza AND A clinician’s judgement that the illness is due to an
infection
So many different terms,
definitions & classifications
DBS
Respiratory anatomy – physiology related
Naso-
Respiratory pharyngeal Upper
Allergic AIRWAY
airway airway
Inflammation Air passage
Airflow Larynx Lower
airway
United Conducting Tracheo-
Airway zone bronchial
Concept tree
Respiratory Zone Lung,
Respiratory
Infection parenchyme
Inflammation Diffusion
Twist
DBS
ARI definition & classification
Infection inflammation of respiratory tract [system] in any or all part from
nose to alveoli & the adnexa due to pathogen [virus, bacteria or fungi],
which lasting less than a month.
AURI
Acute upper respiratory infection
ALRI
Acute lower respiratory infection
Common cold, rhinitis
Tracheitis
Rhinosinusitis
Bronchitis
Acute otitis media
ARI in CZ Tonsilo-pharyngitis Bronchiolitis
Broncho-pneumonia ARI in RZ
Epiglottitis
Pneumonia
Morbidity Laryngitis Mortality
DBS
Pneumonia definition
an acute infection of the lung parenchyma by one or co-infecting pathogens
an infection of the as inflammation in the lung
pulmonary parenchyma caused by an infectious
agent that stimulates a
caused by various response resulting in
organisms damage to lung tissue.
DBS
Pneumonia pathogenesis
Common cold / rhinitis / Viruses reach
M icro-aspiration rhino-pharyngitis / naso-pharyngitis the lower airways
from the upper AIRWAY through contiguous
resp tract is the Rhino-sinusitis
Air passage spread and
most common replication
mechanism for
U
Airflow Acute otitis media
(Tonsilo)-pharyngitis AC
most bacterial
pneumonia
Conducting
zone Croup (acute laryngitis)
Common Cold (Rhino)-bronchitis
[ARI in CZ]
precede Respiratory Zone
Pneumonia Pneumonia
Diffusion
DBS
A
signs & symptoms CLINICAL
symptoms diagnosis
pathophys
pathology
WD/. BP -TB
adaptive
response Pneumonia
60 – late neonate
50 – infant TYPICAL
40 – pre-school symptoms
Tachypnea 30 – school Dyspnea
Insults 20 – adolescence
Pneumonia, DIAGNOSIS
Combination of all aspects
symptoms n Clinical course
n Symptomatology, typical A clinical
pathophys n Pathophysiology: hypoxemia – diagnosis
Blood gas analysis, pulse oxymetry
n Pathology – imaging ------ potential diagnosis pitfall ð
pathology
n Adaptive response – blood, inflammation marker
adaptive n Insults – definitive, but dificult, specimen availability.
response Blood culture – not a representative specimen
WD/. BP -TB
Insults
Burden of ARI
World Health Organization (WHO) estimated 3.5% of the global disease burden
is caused by ARI, and is responsible for between 30-50% of all pediatric
outpatient visits and more than 30% of pediatric admissions in low and
middle-income countries.
DBS
Recurrent
1 2 episodes in 1 year
2 >3 episodes ever [+] separated by clinical &
radiological improvement
the challenge is to discriminate between children with self-limiting or minor problems,
that do not require a diagnostic work-up, and those with an underlying disease.
Unresolved
pneumonia
Persistent
pneumonia
Prolonged pneumonia [?]
Chronic pneumonia [?]
Prevalence of PRP
RP in children occurs
in 7.7–9% of children
with CAP.
MedicineToday
June 2008, Volume 9, Number 6
Prevalence &
risk factors
vary from
different studies
Risk factors / Underlying problems vary
Journal of Paediatrics and Child Health 49 (2013) E208–E212
Underlying problems vary
Med Res J 2019; 4 (1): 13–24
Journal of the Formosan Medical Association 121 (2022) 1073e1080
The importance of PRP
q It may indicate an underlying health issue or susceptibility to infections.
q It can lead to complications, such as lung damage, respiratory issues,
and decreased quality of life.
q Identifying & treating the underlying cause of recurrent pneumonia is
crucial to prevent future episodes and ensure the overall health & well-
being of the individual.
q This may involve investigating potential risk factors such as smoking,
weakened immune system, underlying lung conditions, or environmental
exposures.
Potential complications of PRP
n Chronic respiratory issues: frequent episodes of pneumonia can damage
the lungs & result in chronic respiratory problems such as bronchiectasis
or CLD.
n Impaired lung function: repeated lung infections can lead to scarring and
decreased lung function
n Delayed growth & development: poor growth & development due to the
body's increased energy demands to fight off infections.
n Increased risk of bronchitis and asthma: higher risk of developing other
respiratory conditions such as bronchitis or asthma.
n Hospitalization and serious infections: Severe cases of RP may require
hospitalization and can increase the risk of developing complications such
as sepsis or lung abscesses.
n Increased risk of death!!!
Basics of Pediatric recurrent pneumonia [RP]
Recurrent Pneumonia can be due to:
o Minor, self-limiting problems and unfortunate luck
o Underlying disease that may lead to significant morbidity or mortality.
LOWER risk of having underlying disease
n History of self limiting pneumonia
n Pneumonia WITHOUT other organ or system involvement
n Long period of clinical wellness between pneumonia episodes
n Normal growth and examination
n No family history of genetic or infectious disorders
n Quick response to treatment
n Complete recover after treatment
Int. J. Mol. Sci. 2017, 18, 296; doi:10.3390/ijms18020296
HIGHER risk of having underlying disease
Int. J. Mol. Sci. 2017, 18, 296; doi:10.3390/ijms18020296
DBS
Risk factors for Pediatric RP CNS: epilepsy, CP,
NMD, congenital defect,
CZ: airway malformation, malacia, stenosis, acquired brain lesion
multilevel obst, artificial airway, BE, CF,
PCD, Asthma --- RZ: CLD, CPAM, .. CVS: CHD left to right,
CHF, pulm hypertension
GIS – aerodigestive: dysphagia,
aspiration, LPR, GERD, IBS, Biliary atresia,
congenital anomalies hepatic cirrhosis
FB aspiration CAKUT, CKD, NS,
nephritis lupus
Hematology, oncology: ITP,
thalassemia, aplastic anemia, Immunology: malnutrition, allergy
blood Ca, solid tumor disease, auto-immune, PID, HIV
Pollutants: indoor [ETS, ,,,] Social: No Breast-F, no vacc, poverty,
& outdoor [PM 2.5, … ] Prematurity, BPD over-crowding, poor health access
DBS
Mechanism of Pediatric RP
Systemic
Local
Immunocompromise
Aspiration syndrome Resp def mech
disruption Hematology, oncology: ITP, Biliary atresia,
Airway clearance problem thalassemia, aplastic anemia, hepatic cirrhosis
Prematurity, blood Ca, solid tumor
CNS: epilepsy, CP, BPD
NMD, congenital defect, CAKUT, CKD, NS, Immunology: malnutrition, allergy
acquired brain lesion RZ: MLS, CLD, CPAM, nephritis lupus disease, auto-immune, PID, HIV
genetic hereditary, ..
GIS – aerodigestive: dysphagia, Dysmorphic syndromic diseases
aspiration, LPR, GERD, IBS, CVS: CHD left to right,
congenital anomalies CHF, pulm hypertension
ExposureÇ
CZ: airway malacia, airway CKD, AKI – lung edema
Stenosis, multilevel obstr,
Social: No Breast-F, no vacc, poverty, Pollutants: indoor [ETS, ,,,]
artificial airway; Asthma, BE FB aspiration
over-crowding, poor health access & outdoor [PM 2.5, … ]
MRS, boy, 7 mo 21 d, 3.98 kg
§ Fever since 3 days before admission § Aterm baby (38 weeks),
§ During monitoring in NHCU, the patient was found to have inspiratory § BW 2900gr
Mar 27 -
stridor → upon performing RFL, patient was diagnosed with
Apr 17 § Labiognatopalatoschizis
laryngomalacia type I and laryngopharyngeal reflux
§ CXR: suggestive pneumonia, Leu 15.890, blood culture sterile § Bilateral subependymal cyst
§ Kidney abnormalities
§ Tachypnea, malaise, and fever since 2 days before admission (pelviectasis and
§ During treatment patient was found to be dyspneic and desaturated, nefrocalcinosis grade 3)
Apr 26 - CXR suggests pneumonia. Patient was intubated
May 2 § Upon performing IgGAME test, IgG was found to be low
§ CXR: bilateral infiltrate, blood culture: Klebsiella pneumoniae
§ Tachypnea, malaise, and fever since 2 days before admission. SpO2 → 90% on room air
§ Patient was treated in perinatology for 10 days and then moved to regular ward after improvement
May 18 § In the regular ward, patient experienced coughing again with new onset fever
- Jun 1 § CXR: bilateral infiltrate, blood culture sterile, GeneXpert MTB not detected
MRS, boy, 7 mo 21 d, 3.98 kg
§ Patient presented with dyspnea since 7 hours before admission
§ Upon arrival, the patient appeared restless with severe shortness
of breath and significant retractions. SpO2 → 87%. Patient was
intubated
Jun 11 – § On the second day, the patient was desaturated (SpO2: 3%) →
Jun 20 CPR for 30 minutes. Visualization with laryngoscope shows mucous
plug. Patient was then re-intubated and admitted to PICU
§ Patient was auto-extubated on day 4 in the PICU → observed with
stridor → placed on NIV and weaned gradually
§ CXR: worsening pneumonia, suggestive left lung atelectasis
§ Blood culture: Acinetobacter baumannii multi-resistant
11-Jun-2024
§ Patient presented with dyspnea and cyanosis since 1 hour before
Jul 9 - admission, cough and fever was present since 1 day ago
present § Upon arrival the patient appeared restless with dyspnea
§ CXR suggests worsening of pneumonia compared to previous result
Investigation
MedicineToday
June 2008, Volume 9, Number 6
Pathology to consider occurring in same lobe
Int. J. Mol. Sci. 2017, 18, 296; doi:10.3390/ijms18020296
Pathology to consider occurring in different/multiple lobe
Int. J. Mol. Sci. 2017, 18, 296; doi:10.3390/ijms18020296
Investigation
• Same Region:
o Fibreoptic Bronchoscopy is often first choice
o Chest CT may also be beneficial
• Different Lobes:
o Since the Ddx list includes a wide variety of systemic conditions, it is best to tailor
initial work up based on individual’s history and exam.
o Immune evaluation, Sweat Chloride testing, TB Testing, 24 hour pH probes,
Echocardiogram, etc. may all be necessary.
o Chest CT and bronchoscopy may be warranted still, but may be performed as
second line.
DBS
Risk factors for Pediatric RP [?]
CZ: airway malformation, malacia, stenosis,
multilevel obst, artificial airway, BE, CF,
PCD, Asthma --- RZ: CLD, CPAM, .. CVS: CHD left to right,
CHF, pulm hypertension
Underlying disease /
medical problem
as risk factors of PRP
2 most underlying:
asthma & aspiration
Asthma mis-diagnosis as
recurrent pneumonia [?]
Country %age
Canada 08.0
India 14.2
Spain 30.4
Turkey 32.0
Haiti 79.0
MedicineToday
June 2008, Volume 9, Number 6
DBS
Entry for asthma diagnosis
symptom It is about SYMPTOMATOLOGY!
pathophys
Acute dyspnea,
situation wheezing
pathology emergency
adaptive
response
Chronic cough &/ wheezing
condition [only]
outpatient Asthma?
Insult
2022-01-20
DBS Chronic reactive
lower airway
disease
Chronic Acute
asthma asthma
Out patient: chronic recurrent cough Emergency: acute dyspnea
WD. Bronchopneumonia
DD. Tuberculosis
TB, Broncho-
tuberculosis pneumonia
Treatment: O2 [without or short],
Treatment: anti-TB drugs >6mo
steroid IV, serial nebulization, AB
24-03-28
Chronic recurrent cough persists Getting better in just 2-3 days
Paediatr Child Health
Vol 18 No 9 November 2013
Summary
n Pneumonia is one of the leading cause of death especially in pre-school children
n Pneumonia is a clinical diagnosis, it would be not difficult to make the diagnosis
n Existence of one or more underlying disease or medical problem will increase the
risk of recurrency
n Pediatric recurrent pneumonia [PRP] is defined as 2 or more episodes of
pneumonia in a child within one year, or 3 episodes in total with interval of clinical
asymptomatic and clear chest X-rays.
n The prevalence of PRP is vary widely depends on level of health facilities
n The most common underlying cause also vary widely among health centers
n There are pointers to rise awareness of risk of PRP in children with underlying
medical problem
n Patient with PRP should be investigate thoroughly for all possible risk factors
n Should be aware of possible mis-diagnosis rather than really PRP with risk factors
