Skip to content

Pneumonia Module


AuthorEllis Collins & Michelle Alisio
Duration1- 2 hrs
Equipment requiredNone

  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

Khan Academy: What is pneumonia? (9 mins) OR

Khan Academy: Classification of lung diseases. (restrictive, obstructive, ventilation and perfusion lung problems 11mins)

GPpaedstips: Diagnosing a lower respiratory tract infection (LRTI)

LITFL: Pneumonia in the ED

Paediatric clinical examinations- The respiratory system (7mins)

DFTB: Respiratory infections

RCH: Community Acquired Pneumonia

DFTB: The Mire of Mycoplasma

DFTB: POCUS and Pneumonia

ALiEM: Lung Ultrasound for diagnosing pneumonia

Substituting POCUS for CXR Podcast on using lung USS (11 mins)

Pathophysiology and background

According to the WHO pneumonia kills more children than any other illness – more than AIDS, malaria and measles combined. In 2017 pneumonia accounted for 15% of all deaths of children under 5 years old, killing 808 694 children and it accounts for nearly one in five child deaths globally. It should also be noted that pneumonia is one of the leading causes of deaths for children under the age of 5.

Pneumonia is an invasion of the lower respiratory tract, below the larynx by pathogens either by inhalation, aspiration, respiratory epithelium invasion, or hematogenous spread. There are barriers to infection that include anatomical structures (nasal hairs, turbinates, epiglottis, cilia), and humoral and cellular immunity. Once these barriers are breached, infection, either by fomite/droplet spread (mostly viruses) or nasopharyngeal colonization (mostly bacterial), results in inflammation and injury or death of surrounding epithelium and alveoli. This is ultimately accompanied by a migration of inflammatory cells to the site of infection, causing an exudative process, which in turn impairs oxygenation. In the majority of cases, the microbe is not identified, and the most common cause is of viral aetiology.

There are four stages of lobar pneumonia. The first stage occurs within 24 hours and is characterized by alveolar oedema and vascular congestion. Both bacteria and neutrophils are present.

Red hepatization is the second stage, and it has the consistency of the liver. The stage is characterized by neutrophils, red blood cells, and desquamated epithelial cells. Fibrin deposits in the alveoli are common.

The third of the grey hepatization stage occurs 2-3 days later, and the lung appears dark brown. There is an accumulation of hemosiderin and haemolysis of red cells.

The fourth stage is the resolution stage, where the cellular infiltrates are resorbed, and the pulmonary architecture is restored. If the healing is not ideal, then it may lead to parapneumonic effusions and pleural adhesions.

In bronchopneumonia, there is often patch consolidation of one or more lobes. The neutrophilic infiltrate is chiefly around the centre of the bronchi.

The WHO reclassified pneumonia in children into two categories; pneumonia with fast breathing and/or chest in-drawing, which requires home therapy with oral amoxicillin, and severe pneumonia, which is pneumonia with any general danger sign (i.e. hypoxaemia), which requires referral and injectable therapy.

The presentation of children with pneumonia can be very varied and may include cough, fever, tachypnea, and difficulty breathing. Young children may even present with abdominal pain only.

Features from the history and what they might mean

Prolonged duration of coughSecondary infection, abscess or empyema formation Longer admission, tertiary referral
ChokingAspiration of FB or foodBronchiole/lower airway obstruction, pneumonitis 
Birth complications- e.g. meconium or prematurityChronic lung disease for the newbornMore susceptible to infections/severe infections
ImmunisationIncomplete immunization/ no immunisationAt risk of acquiring bacterial infections, severe infections or viral complications from measles, chickenpox
Travel and exposureContact with unwell relative, contact with other childrenExposure to different pathogens with travel Contact with older/unwell children, or adults may be exposed to pathogens not yet immunized against, or atypical ones 

Mary is 3 years old and was referred to hospital from the GP with a 2 day history of coryzal symptoms, cough, fever and saturations of 91%. She is not eating but still drinking fluids well. On assessment in triage she is crying; her respiratory rate is 45, saturations are 96% and temperature is 37.8°.

The play therapist distracts her while you examine her chest on mum’s lap. You don’t see any use of accessory muscles or intercostal recessions at rest; you think you heard crackles but it could also be transmitted sounds.

What is the probability that Mary has pneumonia?

Should you do a chest x-ray?

Mary’s mother says the GP frightened her by referring her to hospital. She asks you whether Mary needs antibiotics. Should you prescribe antibiotics?

Mary is a well grown, fully immunised and a previously well child who now displays mild signs and symptoms of pneumonia. She does not need a CXR nor does she need antibiotics. The family requires reassurance that the child is safe, can be managed at home as well as be provided with illness specific information and when to return.

The value of clinical signs in diagnosing pneumonia

When to do a chest x-ray?

Martin is an 8 year old fit and healthy young boy who was brought in by his dad with three days of fever, a dry cough, shortness of breath, and abdominal pain, initially seen by the GP and started on amoxicillin. Today he was sent home from school because of breathing difficulties.

On assessment Martin is lying in bed, alert with a tracheal tug, use of accessory muscles, a respiratory rate of 37 breaths per minute, and oxygen saturations of 89% in room air. You also note that Martin has a rash on his lower legs.

Why is Martin not improving on appropriate antibiotics?

How should Martin be investigated and managed?

Why is this pneumonia not getting better?

What is atypical pneumonia?

What is mycoplasma pneumonia?

When should we admit?

Mimi is well known to the department. She has Trisomy 21 and had her VSD repaired at 3 months of age. She is now 10 months old and is brought in with a 2 day history of coryzal symptoms, cough and fever. Today her parents have noticed fast breathing, she is much more lethargic and off food. She is normally a very bright bubbly child.

On examination Mimi is tiring, she is cyanosed with oxygen saturations of 82%.

Which patients are at increased risk of a severe pneumonia?

Should we CPAP ‘trial’ or immediately intubate?

Who is in at risk group?

CPAP trial v intubation

A 4 year old child, Hannah, was diagnosed with pneumonia and admitted to the children wards on oxygen and commenced on IV antibiotics. After 48hr of initial therapy her oxygen requirements have increased, and she is still spiking fevers.

You have been called to review Hannah as the nursing staff are concerned that she is febrile again despite paracetamol. Her initial CXR showed a dense left lower lobe consolidation.

Would you repeat a chest x-ray?

Or are their alternative investigations?

Hannah has developed an empyema. Discuss your approach to inserting a chest drain.

POCUS in pneumonia

What other investigations should be considered?

Inserting a chest drain

Optimus Bonus Simulation Package – Paediatric sepsis

This simulation focuses on management of sepsis so would follow on from recognising complications or deteriorations in children with LRTI, recognising shock and when to escalate care.

A 5 year old is brought in with 3 day history of fever, lethargy and complaints of left sided abdominal pain. Normally fit and well, immunisations are up to date and they attend school.

In triage he is noted to have subcostal and intercostal recession, with SpO2 of 90% in air, the triage nurse moves him to a bay and asks for your urgent review.

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Please download our Facilitator and Learner guides



No data was found

Leave a Reply

Your email address will not be published. Required fields are marked *