Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
Indian J Pediatr. 2011 Sep;78(9):1127-35. doi: 10.1007/s12098-011-0412-2. Epub 2011 May 4.
Community acquired pneumonia is the leading killer of children under the age of 5 years. In ER, a diagnosis of pneumonia may be made and the severity graded on basis of WHO's classification for pneumonia in children up to 5 years of age. It relies on age-specific respiratory rate, presence of lower chest indrawing and signs of severe illness. A diagnosis of pneumonia is made if a febrile child has history of cough and difficult or rapid breathing and a respiratory rate above age specific threshold; however, signs of airway obstruction should be ruled out. Severe pneumonia is diagnosed if with the above features lower chest wall retraction is present; nonetheless, all infants below 2 months and children with moderate to severe malnutrition with pneumonia are categorized as having severe pneumonia. A chest radiograph is indicated only if the diagnosis is in doubt; complications are suspected and there is severe/very severe or recurrent pneumonia. Non-severe pneumonia is treated at home with oral amoxicillin for 3-5 days. If there is no improvement in 48 h it is changed to amoxicillin-clavulanate. Azithromycin is added for atypical pneumonia. Indications for hospitalization include age <2 months, treatment failure on oral antibiotics, severe/very severe or recurrent pneumonia, shock, hypoxemia, severe malnutrition, immunocompromised state. Severe pneumonia is treated with injectable ampicillin; Cloxacillin is added if clinical/radiographic features suggest Staphylococcal infection. On review after 48 h, if improved, the child may be sent home on oral amoxicillin for 5 more days; if not, it is treated as very severe pneumonia. Very severe pneumonia is treated with injectable Ampicillin plus gentamicin. If improved after 48 h, oral amoxicillin and gentamicin are continued for 10 days. If not, respiratory support is enhanced, antibiotics are changed to intravenous ceftriaxone and amikacin and further work up is planned. Children with chronic diseases and recurrent pneumonia require specific antibiotics depending on the underlying cause.
社区获得性肺炎是 5 岁以下儿童的主要致死原因。在急诊科，可能会根据世界卫生组织（WHO）针对 5 岁以下儿童肺炎的分类，基于儿童的年龄、呼吸频率、是否存在下胸部凹陷和严重疾病的体征来诊断肺炎并进行严重程度分级。如果发热儿童有咳嗽、呼吸困难或呼吸急促病史，且呼吸频率超过特定年龄的阈值，同时伴有气道阻塞的体征，可诊断为肺炎。如果存在上述特征并伴有下胸部壁凹陷，则可诊断为严重肺炎；然而，所有 2 个月以下的婴儿和患有中重度营养不良合并肺炎的儿童均被归类为严重肺炎。如果诊断有疑问、怀疑有并发症或存在严重/非常严重或复发性肺炎，则需要进行胸部 X 线检查。非严重肺炎可在家口服阿莫西林治疗 3-5 天。如果 48 小时后无改善，则更换为阿莫西林克拉维酸。如果怀疑为非典型肺炎，则可添加阿奇霉素。需要住院治疗的指征包括年龄<2 个月、口服抗生素治疗失败、严重/非常严重或复发性肺炎、休克、低氧血症、严重营养不良、免疫功能低下。严重肺炎采用注射用氨苄西林治疗；如果临床/影像学特征提示金黄色葡萄球菌感染，则添加氯唑西林。治疗 48 小时后进行复查，如果病情改善，则可让患儿继续口服阿莫西林 5 天；否则，按非常严重肺炎治疗。非常严重肺炎采用注射用氨苄西林加庆大霉素治疗。如果治疗 48 小时后病情改善，可继续口服阿莫西林和庆大霉素 10 天。否则，应增强呼吸支持，更换抗生素为静脉用头孢曲松和阿米卡星，并计划进一步检查。患有慢性疾病和复发性肺炎的儿童需要根据潜在病因使用特定的抗生素。
