Blood tests findings

Basic laboratory tests and radiology may not be indicated for simple, uncomplicated pneumonia as it adds a little over careful clinical management of such cases.

• Complete blood count (CBC) with differential:
• Suggestive of infective process; patients with a bacterial infection tend to have leukocytosis with left shift; however septic patients may have a leukopenia
• Patients with B. pertussis generally have a markedly raised white blood cell (WBC) count with a predominance of lymphocyte in early disease
• Blood culture:
• Not indicated for uncomplicated pneumonia to be treated in the outpatient setting
• Recommended for all patients with severe community-acquired pneumonia, however the results are rarely positive and when positive rarely modify empiric therapy
• Indicated in all patients <1 month age due to the hematogenous origin and spread of organisms in this group
• Inflammatory markers:
• Inflammatory markers are useful in septic neonates. Although some recommendations for use of CRP to monitor the course of pneumonia exist; this hasn't been shown to be of any value over competent clinical assessment in most cases
• If performed; generally CRP is the most appropriate test due to its superior specificity and sensitivity. There is no value to obtaining both a CRP and ESR
• Note that these markers may have delayed rise in acute illness
• Serology:
• Can be used for diagnosis of species such as Chlamydia species, M. pneumoniae, and Legionella (low yield in cultures)
• Infection may be indicated by a four-fold increase in serum and convalescent titers

• Sputum (gram stain and culture)
• Sputum for gram stain and culture may be obtained in hospitalized patients with suspected bacterial infection. It is of highest value in complex cases such as severe disease, complicating factors (significant recent antibiotic use, cystic fibrosis, immunosuppression)
• In most cases this test fails to yield a definitive result nor impact empiric therapy
• Not used in patients <10 years as sputum generally not produced and if so likely to be contaminated by oral flora
• Rapid urinary antigen tests:
• Test provides high specificity and sensitivity
• Recommended in patients with severe disease
• Polymerase chain reaction (PCR):
• Noninvasive test which has advantages over bronchoalveolar lavage or lung aspirate. May facilitate a more rapid diagnosis for C. pneumonia or M. pneumoniae
• Cold agglutinin testing:
• Serologic test useful to support the diagnosis of M. pneumoniae infection
• Test has low specificity, and is positive in about 1 in 2 cases of mycoplasma infection
• Rapid viral diagnostic tests:
• Nasopharyngeal specimens are recommended for viral isolation
• More sensitive than culture, and may detect low quantities of viral ribonucleic acid (RNA)

Radiographic findings

• Chest radiograph:
• May not be required in uncomplicated cases where history and examination are consistent with pneumonia
• Chest x-ray is the modality of choice when pneumonia is suspected, but findings are inconsistent and/or complications are suspected
• The x-ray is abnormal at presentation in ~40% of pneumonia cases
• The typical pattern is that of alveolar/lobular infiltrates with air bronchograms
• Diffuse infiltrates are more common with atypical organisms or viruses
• The x-ray generally cannot differentiate between bacterial and viral pneumonia
• Computed tomography (CT):
• Most useful modality for defining extent of complications of pneumonia and/or in severe disease to which antibiotic treatment fails to elicit a response
• Chest CT can be used to monitor for lung nodules, or cavitation within a lung infiltrate and to evaluate for underlying neoplasm
• Chest CT is not a first line test due to the radiation dose. It is appropriate in complex, severe, unusual, or prolonged cases

Other diagnostic test findings

• Bronchoscopy:
• Bronchoscopic samples of lower respiratory secretions are indicated in patients with complications, persistent hypoxia, or no response to therapy or presence of pulmonary abscess
• Cultures of endotracheal aspirates or expectorated sputum may be used to assess for drug-resistant or atypical pathogens
• Thoracentesis:
• Performed for both diagnostic and therapeutic value in children with parapneumonic effusions

• Acute respiratory distress syndrome
• Afebrile pneumonia syndrome (infant pneumonitis)
• Agammaglobulinemia
• Alveolar-capillary dysplasia
• Alveolar proteinosis
• Asphyxiating thoracic dystrophy (Jeune syndrome)
• Aspiration syndromes
• Asthma
• Bacteremia
• Birth trauma
• Bronchiectasis
• Bronchiolitis
• Bronchitis
• Bronchogenic cyst
• Chest wall injury or anomaly
• Chylothorax
• Chronic granulomatous disease
• Coccidioidomycosis
• Combined B-Cell and T-Cell disorders
• Common variable immunodeficiency
• Complement deficiency
• Congenital diaphragmatic hernia
• Congenital heart disease
• Congenital pneumonia
• Congenital stridor
• Congestive heart failure
• Croup
• Cystic adenomatoid malformation
• Cystic fibrosis
• Empyema
• Esophageal atresia w/ or w/o tracheoesophageal fistula
• Foreign body in airway
• Gastroesophageal reflux disease
• Goodpasture's syndrome
• Hemosiderosis
• Hemothorax
• Histoplasmosis
• HIV infection
• Hypersensitivity pneumonitis
• IgA and IgG subclass deficiencies
• Inborn errors of metabolism
• Inhalation injury
• Lung tumor
• Metabolic acidosis
• Neonatal bowel obstruction
• Neural tube defects
• Persistent newborn pulmonary hypertension
• Pertussis
• Pleural effusion
• Pneumothorax
• Pulmonary atelectasis
• Pulmonary atresia
• Pulmonary edema
• Pulmonary embolism
• Pulmonary hemorrhage
• Pulmonary hypoplasia
• Pulmonary sequestration
• Sarcoidosis
• Sepsis
• Smoke inhalation
• Wegener's granulomatosis

General treatment items

• The age of the patient and severity of disease and other issues (hydration, hypoxia, need for IV therapy) determine the location (hospital versus home) and nature of treatment required
• Neonates are almost exclusively treated as inpatients
• Initial treatment:
• Identify and provide therapy for respiratory distress, hypoxemia or hypercarbia
• Pulse oximetry should be performed and oxygen should be administered to achieve saturations above 94-95%
• Monitor oxygen saturation by pulse oximeter continuously for children with increased work of breathing or significant distress
• Effectiveness of pulmonary ventilation can be assessed via a blood gas to evaluate the PCO2 (venous is adequate)
• Children who are severely ill i.e. unable to maintain adequate oxygenation, inadequate ventilation or who have a decreased level of consciousness, should undergo intubation for clinical respiratory failure
• Children with septic shock or severe sepsis may also benefit from intubation and ventilation
• IV hydration, correction of dehydration and resuscitation (0.9% NS or lactated ringers in 10 - 20 mL/kg boluses) is required if the patient is in shock or hypovolemic. In sepsis, multiple boluses and vasopressors are commonly requiredA bedside glucose should be obtained in all critically ill infants and toddlers. If hypoglycemic is present, administer dextrose 10% solution at 5 mL/kg intravenous (IV) bolus for neonates or dextrose 25% at 2 mL/kg IV bolus for toddlers
• Critically ill children requiring ventilation should be promptly administered appropriate antibiotics
• Delay may be associated with longer duration of ventilation, ICU stay and total length of hospitalization
• Children with reactive airway disease need specific treatment with bronchodilators (e.g. albuterol)
• Perform thoracocentesis if a significant pleural effusion is present surrounding the pneumonia, for both diagnostic and therapeutic purposes
• Empiric antibiotic treatment :
• Treatment should be based on likely etiology, age and clinical status of the patient
• Antibiotic treatment is usually not required in mild cases in preschool aged children as most cases are viral