Symptoms of hospitalized (nosocomial) pneumonia in children

Staphylococcal pneumonia - rapid increase in intoxication, high fever (39-40 °C), grayish skin color, lethargy, poor appetite. In the lungs, percussion reveals a significant area of tone shortening (often massive dullness), auscultation - weakened breathing with a bronchial tint, crepitant wheezing. From the blood - significant leukocytosis, neutrophilia with a pronounced shift to the left and a sharply increased ESR, toxic granularity of neutrophils often appears.

The radiograph shows an infiltrate occupying a lobe with involvement of the pleura. A complication of staphylococcal pneumonia, pyopneumothorax, a breakthrough of an abscess communicating with the lumen of the bronchus into the pleural cavity, poses a particular threat to the child's life. The picture is so characteristic that one can name the exact time of the catastrophe in the child's condition. The moment of the abscess breakthrough into the pleural cavity occurs suddenly. The patient's already serious condition sharply worsens, motor agitation, frequent breathing (up to 70-80 or more per 1 min), pronounced pallor, quickly replaced by cyanosis, cold clammy sweat, tachycardia (up to 200 beats per minute, weak pulse) appear. On the diseased side of the lung, a box-like sound is detected during percussion (the previously determined dullness disappears), respiratory sounds are sharply weakened or not audible. The heart is displaced to the opposite side, its tones are muffled. In the next few hours, the degree of mediastinal displacement mainly determines the severity of the patient's condition.

In young children, pyopneumothorax is accompanied by abdominal distension and often vomiting. In pyopneumothorax, urgent puncture of the pleural cavity and aspiration of the contents are indicated. In the presence of a functioning bronchial fistula, thoracotomy and underwater drainage are required, which ensures the release of air and pus from the pleural cavity. Active aspiration of air from the pleural cavity is necessary to achieve complete straightening of the lung.

Klebsiella pneumonia begins acutely. Intoxication symptoms are expressed. In the lungs, infiltration often has a confluent character, but not segmental (focal-confluent pneumonia). Shortening of the percussion sound is clearly expressed, scanty, moist fine-bubble rales are heard. On the radiograph, an intense shadow of darkening, localized more often in the upper parts of the lungs (posterior parts of the upper lobes, upper parts of the lower lobes). The tendency to abscess formation is extremely pronounced. A very high ESR is characteristic.

Complications: lung abscess, pleural empyema, pyelonephritis, sepsis.

Pneumonia caused by Pseudomonas aeruginosa. A typical hospital infection, especially in patients with immune deficiencies. The course is acute. The condition is severe, intoxication and fever, cyanosis and tachycardia are expressed. Rapid spread of the infiltration focus and the appearance of new foci in the lungs are characteristic. Necrotic changes are observed in the bronchi and lungs, due to which early complications appear - lung abscess, pleurisy. From the blood side - leukocytosis with neutrophilia, a significant increase in ESR.

Pneumonia caused by Haemophilus influenzae. In acute respiratory viral infection, nasopharyngitis and cough without sputum are expressed. Temperature reaction is expressed. Lung damage is focal, pneumonia often develops in the area of atelectasis caused by obstruction of small bronchi. There may be confluent infiltrates - focal-confluent form of pneumonia. Predominance of purulent bronchitis is characteristic. Variability, "mosaic" of percussion and auscultatory data is noted. From the blood side, leukocytosis with neutrophilia, increased ESR.

Legionella pneumonia (Legionella pneumophila). The causative agent is a gram-negative bacillus transmitted by aerosol (nests in aerosol devices, air conditioners). The disease begins acutely with chills and malaise. The temperature rises to 38.5-40 C on the 2nd-3rd day. Headache and myalgia are noted. Diarrhea often precedes fever. Infectious toxic shock may develop. In the first days, the cough is dry, then the sputum becomes purulent. Dyspnea and cyanosis are noted. During an objective examination, there is an uneven shortening of the percussion sound in the lungs, during auscultation, breathing is weakened, small and medium bubbling rales are heard. On the radiograph - focal and confluent infiltrates, sometimes capturing a lobe of the lung. From the cardiovascular system - tachycardia, muffled heart sounds.

In the blood - leukocytosis, ESR 60-80 mm/h and relative or absolute lymphopenia. Kidney damage is not uncommon; urine analysis reveals proteinuria, leukocyturia, erythrocytes and cylinders.

Pneumocystis pneumonias are parasitic diseases. Pneumocystae carinii are fungi close to yeast fungi. They can occur in the form of epidemics and are observed in departments for infants and premature babies. In the occurrence of pneumocystosis, a general weakening of the body as a result of prematurity, hypotrophy, dyspepsia and other diseases is of great importance, and in patients of any age receiving glucocorticosteroids, cytostatics, with an immunodeficiency state, severe pneumonia develops.

Characteristic symptoms: severe dyspnea (up to 100 or more breaths per minute); cyanosis around the mouth and acrocyanosis; discharge of foamy contents and dyspnea with severe cough. There is no toxicosis.

On the chest X-ray there are focal confluent shadows in both lung fields - "cotton wool lungs", interstitial changes. In the blood - leukocytosis, neutrophilia, increased ESR.

In diagnostics, the detection of pneumocysts in mucus from the upper respiratory tract, which is taken from the trachea with a catheter, is of particular importance.

Classification of pneumonia in children (1995)

Morphological form	Conditions of infection	Flow	Complications
			Pulmonary	Extrapulmonary
Focal	Out-of-hospital	Acute	Synpneumonic pleurisy	Infectious toxic shock
Segmental	Intra-hospital	Protracted	Metampneumonic pleurisy	DIC syndrome
Focal-confluent	In case of perinatal infection		Pulmonary destruction	Cardiovascular failure
Croupous	In patients with immunodeficiency		Lung abscess	Respiratory distress syndrome
Interstitial			Pneumothorax Pyopneumo-thorax

According to the classification of clinical forms of bronchopulmonary diseases in children, in addition to the form of pneumonia, community-acquired and hospital-acquired pneumonia are distinguished.

Hospital-acquired (nosocomial) pneumonia is considered to be that which manifests itself 48-72 hours after hospitalization, excluding infections that could have been in the incubation period at the time of admission to the hospital.

The course is acute and protracted; complications are pulmonary and extrapulmonary.

A protracted course of pneumonia is diagnosed when there is no resolution of the pneumonic process within 6 weeks to 8 months from the onset of the disease; this should be a reason to search for possible causes of such a course.

If pneumonia recurs (excluding re- and superinfection), the child must be examined for cystic fibrosis, immunodeficiency, chronic food aspiration, etc.

To establish the etiology of pneumonia, medical personnel of the admission department of hospitals, outpatient departments, and visiting nurses at the pediatric site (when treating a child at home) must take sputum from the patient and send it for bacterioscopy of a Gram-stained sputum smear. Then, sputum is cultured for flora, using quantitative methods for assessing the bacterial content in 1 ml of sputum; concentrations of 10 ⁶ -10 ⁸ have diagnostic significance. Indicators of 10 ³ and less are characteristic of concomitant microflora.

The most promising methods are those for rapid detection of the etiologic agent, methods that allow detection of bacterial pathogen antigens in sputum, blood and other pathological materials - these are counterimmunoelectrophoresis, coagglutination. It is important that with these research methods the result is not affected by prehospital administration of antibiotics.

The distinction between bacterial and viral infections can be considered as the determination of serum C-reactive protein (CRP) at a level of 40 μg/ml for viral infections, and 8.0 μg/ml and higher for bacterial infections. The upper limit of the CRP norm is 20 μg/ml.

In cases of effective therapy, a rapid decrease in the CRP level to 20 μg/ml is observed, which is accompanied by a decrease in body temperature, disappearance of intoxication and radiological reduction of pneumonic infiltration. Long-term maintenance of high CRP numbers indicates the ineffectiveness of pneumonia treatment. Detection of a second wave of increased CRP in pneumonia indicates the development of complications, in particular, metapneumonic pleurisy.

For the etiological decoding of chlamydial, mycoplasmal, legionella pneumonia, so-called non-cultural methods are used. Specific antibodies to these pathogens are determined using the indirect immunofluorescence reaction, the complement fixation reaction, or more modern methods - the ELISA test (detection of specific antibodies of the IgM, IgG, IgA classes to mycoplasma and chlamydia).

One of the extrapulmonary complications of pneumonia in young children is the development of adult respiratory distress syndrome (ARDS).

Adult respiratory distress syndrome is a complication of pneumonia. It is characterized by refractory hypoxemia that is not eliminated by a hyperoxic test, radiological signs of interstitial and alveolar pulmonary edema (expansion of the vascular pattern of the lungs with edema of the interlobar pleura, decreased pneumatization and focal-like shadows - "fluffy lungs", segmental and lobar edema, "air bronchogram").

The essence of ARDS is that there is a lesion of the respiratory system, which makes it impossible to carry out physiological gas exchange, i.e. the lung loses the ability to convert venous blood into arterial blood. The dominant syndrome in pneumonia complicated by ARDS is the syndrome of respiratory hemodynamic failure.

Clinically, it is characterized by: pale skin with a marbled pattern, gray or earthy tint, widespread cyanosis, severe dyspnea with shallow, moaning, grunting breathing, participation of accessory muscles in the act of breathing, tachycardia, enlarged liver, neurological disorders (precoma, coma, convulsive syndrome), peripheral circulatory failure, hemorrhagic syndrome (skin hemorrhages, gastrointestinal bleeding), multiple organ failure with oliguria or anuria. Blood pressure is elevated in some children, and decreased in others.

Fever and hypothermia, DN III, and less frequently DN II are observed with approximately equal frequency. The presence of ARDS in pneumonia is confirmed by the appearance of radiological signs of interstitial alveolar edema.

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