Persistent - Recurrent Pneumonia

Persistent/Recurrent
Pneumonia
Dr Chirag Thakur
DM Senior resident
Pediatric Pulmonology
Persistent Pneumonia
• Significant challenge to Paediatrician.
• Recurrent Pneumonia: defined as two episodes of pneumonia in 1 year
or three episodes in any time frame with symptom free interval and
radiological clearance.
• Persistent Pneumonia: It is defined as persistence of symptoms and
radiographic abnormalities for more than 1 month.
• However the speed of radiographic resolution depends on the etiologic
agent; 2 weeks with respiratory syncytial virus (RSV) or parainfluenza
virus infection to as long as 12 months with adenovirus infection.
• It is difficult to arrive at one particular cut-off for defining persistent
pneumonia.
Kabra et al.Indian Pediatrics.2000;37:1085-92

CASE
• Miss-D
• 8 month
• Girl
Presenting complaints
• Noisy breathing since 1 ½ month of age
• Cough on & off since 1 ½ month of age
• On & off Fever since 1 ½ month of age

HOPI
• Noisy breathing: harsh sound, more pronounced in sleep , aggravated
if there is coryza, no diurnal /postural variation.
• Cough: Insidious in onset, spasmodic type, associated with post

tussive vomiting sometimes, aggravated with coryza, relived with
some oral medications. It was associated with fast breathing chest
indrawing.
• Each episode used to be associated with low grade fever.

Negative history
• No h/o recurrent loose stool/ skin lesions/Eczema/ear discharge

• No h/o oily stool, bulky stool
• No seasonal variation.
• No h/o chocking while feeding/abdominal distension after feed.
• No h/o suck rest suck cycle or feeding diaphoresis.
Past history
She had 2 admissions -1st at 4 month of age was treated as Pneumonia
2nd admission – at 7 month of age treated with nebulisations and IV
antibiotics , Pneumonia
• Birth history: Preterm Vaginal delivery/cried immediately/2kg/admitted
1 day in NICU. No h/o delayed passage of meconium
• Developmental history: Appropriate for age.
• Immunization: Immunized for age.
• Family history: No consanguinity, No h/o Allergy, asthma or similar illness

in family.
?Possibilities
• ? Congenital anomaly -Airway ? Laryngomalacia
• ? Preschool wheeze
• ? GERD
• ? Foreign body
Examination
Alert, Conscious
•Vitals: Temp: 97.9 deg F
RR: 70/min
HR: 160/min
SPo2 : 90 % off o2
CFT < 3 sec
No Pallor/icterus/cyanosis/clubbing/lymphadenopathy
•Anthropometry:
•W/A <-3 SD
•L/A = -2 to -3 SD
•W/L= <-3 SD
Systemic examination
• Subcostal and substernal retraction
• Biphasic stridor ( more pronounced in expiration)
• B/L crepitations and wheeze
• CVS: S1S2+ No murmur
• P/A : Soft, no organomegaly
• CNS: WNL
Investigations:
• Chest x-ray:
Bronchoscopy
• Tracheomalacia near carina (>50%) with mild laryngomalacia.
• Diagnosis: Severe Tracheomalacia with laryngomalacia with

Pneumonia.
Treatment given
Supportive measures
Ipravent nebulization
IV antibiotics
2nd admission
• 1 month after the 1st admission

• Cough and increased noisy breathing x 3 days
• 1 episode of fever 3 days back.
Evaluation
• Mild respiratory distress with stridor

• Chest x-ray
• Managed supportively as Viral LRTI
3rd admission (1 ½ month after 2nd)
• Cough and noisy breathing x 3 days

• Decrease oral acceptance.
• Respiratory part was managed accordingly
2-D echo
2-D ECHO
Trachea
RIGHT RIGHT
LEFT LEFT
Cardiac CT Angio
ARCHES
Left Right
Arch Aortic
Arch TRACHEA
Final diagnosis
• Severe Tracheomalacia secondary to Vascular ring (double aortic arch)
with laryngomalacia with recurrent Pneumonia
Persistent Pneumonia
Congenital Malformation:
Airway:
• Cleft palate Aspirations:
• Laryngeal cleft • Laryngeal cleft
• TEF
• GERD
• Tracheo-bronchomalacia
Lungs:
• Swallowing dysfunction
• Sequestration • Foreign body aspiration
• CPAM • Esophageal motility disorder
• Bronchogenic cyst
• Congenital heart disease
Defects in clearance of airway Immunodeficiency

• CGD
secretions
• Hyper IgE
• Cystic fibrosis
• SCID
• PCD
• HIV
• Airway compression
Lodha R, Kabra SK. Recurrent/Persistent Pneumonia.Essential Pediatric pulmonology,3 rd ed.2018.P.106-09.

APPROACH
History: Clinical evaluation starts by careful history
HOPI:
Pointer Implication
Detailed cough history, pattern, relation May point towards GERD,

to food or exercise, following colds seasonal asthma, reactive airway disease
variations, nocturnal symptoms or pneumonia
colour of sputum if productive.
Frequent posseting /regurgitation with occasional Suggest laryngospasm or
cyanosis post feeds, Cough while feeding ,arching GERD
Paroxysmal cough May suggest foreign body

Inhalation or pertusis
Frequent loose and offensive , bulky , oily ,bowel Suggestive of cystic fibrosis
motions with failure to thrive
Approach
Feeding history:
Pointer Implication
Choking During feeds Aspiration
Not able to swallow Swallowing dysfunction
Swallowing but coughing after TEF or laryngeal cleft
swallow
Cough after 1-2 hour after feeds GER
Birth History:
Pointer Implications
Term or preterm? • Rule out chronic lung disease
• Required intubation/oxygen like BPD
support
Delay in passage of meconium Cystic fibrosis
Approach
• Past history:
Pointer Implication
Age at which infections commenced If at younger age, may indicate

congenital malformations
Any pattern of previous infections like Reactive airway disease
following viral illness/in particular
season
History of persistent diaharroea, Immunodeficiency
cutaneous infections/abscess/boils etc.
Persistent perennial rhinitis /wet cough Primary ciliary dyskinesia
since infancy
Approach
• Family History: consanguinity/similar illness in family.
TB in family. Sibling death due to respiratory illness
• Environmental history: Exposure to birds/animals

Environmental pollutants.
Approach
• Clinical Examination:
Pointer Implication
Lymphadenopathy Tuberculosis
Clubbing Chronic lung disease
Nasal polyp Cystic fibrosis
Oral thrush /ear Immunodeficiency
discharge/absence tonsil
Murmur Cardiovascular disease
Situs inversus Primary ciliary dyskinesia
Chest deformities Recurrent infections
Severity
• The following features suggest a severe disorder:
• Failure to thrive
• Limitation of activity
• Persistent fever
• Persistent tachypnea and respiratory distress
• Persistent hyper-inflation
• Significant/sustained hypoxemia
Montella S, Corcione A, Santamaria F. Recurrent pneumonia in children: a reasoned diagnostic approach and a single centre experience. International journal of
molecular sciences. 2017 Jan 29;18:296.
Algorithm
History, Examination, chest x-ray
Rule out TB/FB aspirations.
Difficulty in Infections Associated No clues from

feeding, in other malabsorption, history/
chocking/coughing sites Pseudomonas in airway examination
GER studies, Immunodeficiency Sweat Bronchoscopy/

Esophageal ph work-up chloride CTChest/GER-studies/
Barium swallow Sweatchloride/
Direct laryngoscopy immunodeficiency
Investigations:
• Chest x-ray : Serial Chest x-ray has importance : Unilobar/Multifocal
Cystic lesion : Bronchogenic cyst/CPAM
• Fiberoptic bronchoscopy: important tool for diagnostic work-up.

Airway anomaly/intraluminal pathology.
To obtain BAL.
• CT chest: Investigation of choice for structural malformation. Like cyst ,

sequestration. Not to be done each and every case
When to do immunological work-up?
• Most children referred because of recurrent pneumonias do not have
specific immunologic defect.
• Various minor defect have been identified in these children.
• When the prevalence of HIV infection is rapidly increasing effort
should be made to look for risk factors for HIV infection.
• A systemic immunodeficiency is suspected if in addition to recurrent
pneumonias, there is evidence of infection at other sites e.g., skin,
gut, Abscess
Unilobar(localized disease)
Yousif IT et al, Sudanese Journal of Paediatrics, 2015

Management
• Antibiotics for current episode
• Treatment of underlying disease whenever possible
THANK YOU!

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Persistent/Recurrent

Kabra et al.Indian Pediatrics.2000;37:1085-92

• Cough on & off since 1 ½ month of age

• On & off Fever since 1 ½ month of age

• Cough: Insidious in onset, spasmodic type, associated with post

• Each episode used to be associated with low grade fever.

• No h/o recurrent loose stool/ skin lesions/Eczema/ear discharge

• Developmental history: Appropriate for age.

• Immunization: Immunized for age.

• Family history: No consanguinity, No h/o Allergy, asthma or similar illness

• Diagnosis: Severe Tracheomalacia with laryngomalacia with

• 1 month after the 1st admission

• Mild respiratory distress with stridor

• Cough and noisy breathing x 3 days

Defects in clearance of airway Immunodeficiency

Lodha R, Kabra SK. Recurrent/Persistent Pneumonia.Essential Pediatric pulmonology,3 rd ed.2018.P.106-09.

Detailed cough history, pattern, relation May point towards GERD,

Paroxysmal cough May suggest foreign body

Age at which infections commenced If at younger age, may indicate

• Environmental history: Exposure to birds/animals

Difficulty in Infections Associated No clues from

GER studies, Immunodeficiency Sweat Bronchoscopy/

• Fiberoptic bronchoscopy: important tool for diagnostic work-up.

• CT chest: Investigation of choice for structural malformation. Like cyst ,

Yousif IT et al, Sudanese Journal of Paediatrics, 2015

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