Academic journal article International Journal of Child and Adolescent Health

Pulmonary Disorders in Adolescence

Academic journal article International Journal of Child and Adolescent Health

Pulmonary Disorders in Adolescence

Article excerpt

Introduction

This chapter reviews the pharmacologic management of paramount respiratory conditions in the adolescent patient: community-acquired pneumonia, asthma, and cystic fibrosis. A brief discussion of the definition, epidemiology, and differential diagnosis precedes consideration of pharmacologic management of each disorder. The management is generally based on national or international guidelines developed by expert panels of professional groups that include the American Thoracic Society, the U.S. Infectious Disease Society and the British Thoracic Society for community-acquired pneumonia, the U.S. National Asthma Education and Prevention Program (NAEP) of the National Institutes of Health, and the U.S. Cystic Fibrosis Foundation.

Community acquired pneumonia

Community-acquired pneumonia (CAP) is defined as pneumonia acquired outside of the hospital setting as opposed to nosocomial pneumonia acquired in the hospital (1). Streptococcus pneumoniae, Mycoplasma pneumoniae and Chlamydophila (formerly Chlamydia) pneumoniae appear to be the most frequently encountered pathogens in CAP. These organisms also cause CAP in adults. Other bacterial pathogens that can cause CAP include Staphylococcus aureus and Haemophilus influenzae. Legionella pneumophila is a less common pathogen.

"Atypical pneumonia" refers to pneumonia that does not present with the usual clinical picture of "typical" pneumonia due to S pneumoniae infection that includes high fever, productive cough, and chills. The term atypical pneumonia is frequently used to describe adolescents with CAP. The clinical presentation of CAP can be highly variable, depending on the causative agent. However, the clinical picture does not always predict the infecting organism. It is probably inaccurate to use the term atypical pneumonia and preferable instead to refer to more atypical pathogens as common causes of CAP.

CAP may also be caused by several viruses, which cause 20% of CAP cases. The most common viruses are influenza, parainfluenza, respiratory syncytial virus, metapneumovirus, and adenovirus. Less common viruses causing significant illness include chicken pox, severe acute respiratory syndrome (SARS) virus, avian flu, and hantavirus.

Epidemiology

The incidence of pneumonia caused by specific pathogens is not well known for the ado-lescent population with CAP. Adolescents are often grouped together with young children or adults in epidemiologic studies, which may obscure the results (2). Wide variability in diagnostic testing methods may also affect the incidence reported in studies (3).

An estimated annual incidence of CAP in older children and adolescents is 6 to 12 cases per 1000. In patients between 10 and 16 years of age, S pneumoniae cause approximately 30% of cases of CAP. Mycoplasma pneumoniae is the cause in 15% to 40% of cases and C. pneumoniae comprise 14% to 35% of cases. Non-typable H influenzae, influenza A or B, adenovirus, metapneumovirus and other respiratory viruses are found less frequently.

Diagnosis

The diagnosis of CAP is based on clinical history, physical examination, radiographic studies, and laboratory evaluation (1,4). For teaching purposes, clinical features have been classified to differentiate between bacterial pneumonia, atypical bacterial pneumonia, or viral pneumonia. However, the clinical features of pneumonias caused by different microorganisms frequently overlap and cannot be used reliably to establish etiology. In addition, as many as 50% of infections may be mixed bacterial/viral infections.

"Typical" bacterial pneumonia, usually resulting from S. pneumoniae infection, is abrupt in onset, with fever, and an ill-appearing, sometimes toxic patient. Respiratory distress may be moderate or severe; auscultation may reveal crackles and egophony, limited to the involved anatomic segment. Pleural involvement with pleuritic pain and pleural friction rub on auscultation are suggestive of bacterial etiology, as these findings are rarely present in nonbacterial pneumonia. …

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