CHAPTER 3

CASE DISCUSSION

Pneumonia

Definition

Pneumonia is an inflammation of the lung parenchyma. It is caused by microorganisms or

infections (viral, bacterial, or fungal) and a small percentage by other or noninfectious causes
(e.g. aspiration, chemical exposure, or orthostatic).Pneumonia is divided into 2 parts namely
Community Acquired Pneumonia or nosocomial pneumonia or Hospital Acquired Pneumonia
(HAP)&.Ventilator Asscoiated Pneumonia (VAP)5 In this case, we will discuss more about
Community Acquired Pneumonia.

Risk factors

Risk factors for pneumonia in children under 5 years old are as follows: males more than
females, environmental factors such as low socio-economic status (crowded houses), air
pollution, malnutrition, inadequate breastfeeding and nutrition, exposure to cigarette smoke or
household smoke such as exposure to gas stove smoke, while factors related to heart problems
and other medical conditions such as congenital heart disease, brochopulmonary dysplasia,
chronic lung disease, diabetes mellitus, asthma, neuromuscular disorders, and other
6
immunodeficiency conditions. According to a study by Wiharjo et al, low birth weight,
exclusive breastfeeding, nutritional status, immunization status, and comorbid conditions can
increase the risk of pneumonia by 3.5 times compared to pediatric patients who do not have these
risk factors. 7

In this case, can be further reviewed that the risk factors for bronchopneumonia in this child are
in terms of environmental factors, it can be seen that the risk factors are in the form of poor
socio-economic conditions, as well as the risk of exposure to cigarette smoke by his father's
smoking habit.

Etiology
The age of the patient is a factor that plays an important role in the differences and peculiarities
of pediatric pneumonia, especially in the etiological spectrum, clinical features, and treatment
strategies. The spectrum of causative microorganisms in neonates and young infants is different
from older children. In older infants and toddlers, pneumonia is often caused by Streptococcus
pneumoniae, Haemophillus influenzae type B, and Staphylococcus aureus infections. Clinically,
bacterial pneumonia is generally difficult to distinguish from viral pneumonia.

Table 3.1 Etiology of Pneumonia

Pathophysiology
Generally, the causative microorganisms are sucked into the peripheral lung through the
respiratory tract. At first, edema occurs due to tissue reactions that facilitate the proliferation and
spread of germs to surrounding tissues. The affected part of the lung undergoes consolidation,
where PMN cells, fibrin, erythrocytes, edema fluid, and germs are found in the alveoli. This
stage is called the red hepatization stage. Furthermore, fibrin deposition increases, there is fibrin
and PMN leukocytes in the alveoli and a rapid phagocytosis process occurs. This stage is called
the gray hepatization stage. Furthermore, the number of macrophages increases in the alveoli,
cells degenerate, fibrin thins, germs and debris disappear. This stage is called the resolution
stage. The bronchopulmonary system of unaffected lung tissue will remain normal.

Inflammation of the lung parenchyma causes part of the alveoli space to be unable to fun
ction, lung volume decreases, and ventilation is impaired, causing impaired gas diffusion resultin
g in hypoxemia. Hypoxemia is the main sign of pneumonia. It can be practically recognized by
measuring peripheral saturation which is less than 92%.

Diagnosis
Clinical Manifestations
The clinical condition of pneumonia can vary from mild to moderate with certain conditions
being manageable on an outpatient basis. There are several criteria for hospitalization of
pneumonia patients, namely those with severe clinical symptoms of pneumonia. There are
several factors that influence the clinical condition of pneumonia in children including anatomic
and immunologic immaturity, a wide range of causative microorganisms, sometimes atypical cli
nical symptoms especially in infants, limited use of invasive diagnostic procedures, and frequent
noninfectious etiologies. Clinical symptoms of pneumonia in children include shortness of breath
accompanied by fever and cough. Shortness of breath conditions such as increased respiratory
effort that can be accompanied by intercostal, subcostal, and suprasternal retractions, lobe breathi
ng, and the use of respiratory muscles are often found. On auscultatory examination, fine rales an
d wheezing can be found, but they do not always correspond to the location of the local inflamm
ation of the pneumonia.9
 Table 3.2 WHO Bronchopneumonia Classification

Indications For Hospitalisation In Paediatric Patients With Pneumonia

Criteria for hospitalization in Pneumonia

The criteria for hospitalization in children with pneumonia are of course different in infants and
children in this case can be distinguished in infants and children the following criteria 10

Baby:
 Oxygen saturation <92%, cyanosis
 Breathing frequency > 60 times/minute
 Respiratory distress, intermittent apnea
 Grunting
 Does not want to drink/eat
 Family cannot care at home

Children
 Oxygen saturation <92%, cyanosis
 Breathing frequency > 50 times/minute
 Respiratory distress
 Grunting
 Does not want to drink/eat
 Signs of dehydration
 Respiratory distress Criteria

In this case, it was found that the patient had symptoms of fever, decreased oxygen saturation
which was 93% at room temperature, increased respiratory effort such as increased breathing
rate, there was an increase in respiratory muscle assistance such as a picture of subcostal
retraction, besides that, fine wet rales were also obtained in both lung fields so it can be
concluded that with risk factors and anamnesis and physical examination and the clinical picture
obtained that the child can be categorized as pneumonia which is included in the criteria for
hospitalization.

Laboratory and Radiology Examination

Complete Blood Blood

Leukocyte counts can be useful in distinguishing viral from bacterial pneumonia. In viral and my
coplasmal pneumonia the leukocyte cell count may be normal or elevated, but not exceeding 15,
000/ml, with a lymphocytic predominance. Bacterial pneumonia is often associated with elevated
leukocytes between 15,000 - 40,000/ml with a predominance of netrophil cells. Typical laborator
y patterns consistent with bacterial pneumonia include elevated leukocyte counts, shift to the left
or predominantly rod counts, and elevated acute phase reactants. The presence of pleural effusio
n, lobar consolidation, and high fever at the onset of illness also support a bacterial etiology.

Culture
Blood culture should be performed in children who do not respond well to initial antibiotic thera
py in outpatients. In hospitalized patients, culture should be done to determine the bacterial cause
of pneumonia.

Imaging
Infiltrates on chest radiograph support the diagnosis of pneumonia. There are interstitial infiltrate
s characterized by increased bronchovascular pattern (perivascular and peribronchial), peribronc
hial cuffing, and hyperaeration or alveolar infiltrates which are diffuse images evenly distributed
in both lungs, in the form of patches of infiltrates to poorly demarcated consolidation, accompani
ed by air bronchogram, which can extend to the peripheral areas of the lung. Other features that c
an be found are consolidation generally located in the lower field of the lung, enlarged hilum, lob
ar/segmental atelectasis.

In this case, it was found that this patient had an increase in leukocytes to 17,500 and an
increase in platelets to 506,000 which might be thought to lead to bacteria, besides that it can
also be seen through the segment type count that there is a picture of a shift to the left which
indicates that the condition leads to a bacterial infection condition. Blood culture has not been
done in this patient because this patient's condition is not recurrent bronchopneumonia so the use
of first-line antibiotics without blood culture examination. Radiological examination of the
patient showed infiltrates in the left and right perihilar lungs, as well as the right paracardial
where this condition does lead to pneumonia in children.

Management 10
Patients with oxygen saturation <92% when breathing room air should be given oxygen therapy
with a nasal cannula, head box or mask to maintain oxygen saturation above 92%.
 In severe pneumonia or inadequate oral intake, intravenous fluids are given and strict
fluid balances are performed.
 Chest physiotherapy is not beneficial and is not recommended in children with
pneumonia
 Antipyretics and analgesics may be given to prevent patient comfort and control cough.
 Patients receiving oxygen therapy should be observed at least every 4 hours including
oxygen saturation checks.

Antibiotic administration 10
 Amoxicillin is the first choice for oral antibiotics in children <5 years old because it is
effective against most pathogens that cause pneumonia in children.
 Intravenous antibiotics are recommended for pneumonia patients who cannot receive oral
antibiotics or severe pneumonia, including ampicillin and gentamicin, and
chloramphenicol, co-amoxiclav, ceftriaxone, cefuroxime, and cefotaxime.
WHO Recommendations for the administration of antibiotics for childhood pneumonia
In this case, the therapy given was appropriate because the WHO recommendations for children
aged 2 months-59 months who were hospitalized, for the first line of antibiotics given were
ampicillin and gentamicin where the dose given to this patient was ampicillin at a dose of 50
mg / kgbb / 6 hours and gentamicin 7.5 mg / kgbb / day. Oxygen administration has also been
given for the management of decreased saturation in patients and of course periodic monitoring
in accordance with the recommended non-medicamentous management has also been carried out
in this patient. Other drugs given in the form of paracetamol antipyretics are also in accordance
with the recommendations of medical service guidelines that are given as symptomatic drugs to
patients.
 REFERENCE

1. Profil Kesehatan Indonesia tahun 2019. Dapat diunduh melalui

https://pusdatin.kemkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/
Profil-Kesehatan-indonesia-2019.pdf
2. Harelina T. Setyoningrum RA, Sembiring YE. Faktor risiko pneumonia pada anak
dengan penyakit jantung. Sari Pediatri.2020;21(5): 276-81
3. Alzomor O, Alhajjar S, Aljobair F, Alenizi A, Alodyani A, Alzahrani M. Management of
community-acquired pneumonia in infants and children: Clinical practice guidelines
endorsed by the Saudi Pediatric Infectious Disease Society. Int J Pediatr Adolesc Med.
2017;4(4):153-158
4. WHO. Revised WHO Classification and Treatment of Childhood Pneumon

ia at Health Facilities. 2014 [cited 2021 May 13]. Available from : https://apps.

who.int/iris/bitstream/handle/10665/ 137319/9789241507813_eng.pdf;jsessi

onid=28F53239464E98D836E10FD9548CEE4A?sequence=1
5. Hadisuwarno W, Setyoningrum RA, Umiastuti P. Host factors related to pneumonia in
children under 5 years of age. Pediatr Indones.2015;55(5): 248-51
6. Ebeledike C. Pediatric Pneumonia. In: Ahmad T, editor. StatPearls. 2020[cited 2021 May
14]. Available from: https://www.statpearls.com/ArticleLibrary/viewarticle/27365
7. Said M. Pneumonia. In: Rahajoe N, Supriyatno B, Setyanto D, editors. Buku Ajar
Respirologi Anak. 1st Ed. Jakarta: Badan Penerbit IDAI; 2018. p..350-62
8. Pudjiadi, AH, Hegar B, Handryastuti. S, Idris NS, Gandaputra EP, Harmoniati ED.et al.
Pedoman Pelayanan Medis. Jakarta: Ikatan Dokter Anak Indonesia. 2009; p.243-46

9. Messinger AI, Kupfer O, Hurst A, Parker S. Management of Pediatric Community-

acquired Bacterial Pneumonia. Pediatrics in review. 2017; 38(9):394