>Pathway for Evaluation and Treatment of Child with Community-Acquired Pneumonia

Assess Patient for Presence and Severity of Pneumonia

History and Physical examination:

The clinical diagnosis of pneumonia is a challenging one, but requires historical and/or physical evidence of acute infection with fever and signs or symptoms of respiratory distress. Generally, combinations of signs and symptoms have been shown to be more accurate than individual features alone. Although there are no proven clinical definitions, the following features have been shown to be suggestive of pneumonia:

Age Respiratory Rate (breaths/min)
0-2 months 60
2-12 months 50
1-5 years 40
> 5 years 40

Severity of Pneumonia

Mild Pneumonia
(Outpatient Treatment)
Moderate-Severe Pneumonia
(Inpatient Treatment)
Severe Pneumonia
(ICU Treatment)
  • Age > 3 months
  • Absence of:
    • Retractions
    • Grunting
    • Nasal flaring
    • Apnea
  • Pulse oximetry > 90% in room air
  • Non-toxic appearance
  • Ability to tolerate oral medications and fluids
  • Adequate observation/follow-up care

(any of the below signs or symptoms)

  • Age < 3 months
  • Moderate-severe dyspnea
    • Retractions
    • Grunting
    • Nasal flaring
    • Apnea
  • Pulse oximetry < 90% in room air
  • Alteration in mental status
  • Moderate to large parapneumonic effusion
  • Concern for inadequate outpatient care/observation/follow-up
  • Dehydration, vomiting, or inability to take oral medication
  • Clinical concern for inpatient-level observation/care
  • Failure of initial outpatient treatment 1

(any of the below signs or symptoms)

  • Need for mechanical ventilator support with artificial airway
  • New or increased CPAP or BiPap support
  • Apnea, inadequate ventilation, severe respiratory distress
  • Hypoxemia despite significant O2 defined as:
    • O2 Saturation < 92 on 40% high flow nasal cannula or 50% face
    • Cannot transition from 100% non-rebreather mask
  • Systemic signs of inadequate perfusion (change in mental status, hemodynamic instability)
  • Parapneumonic effusion requiring emergent drainage
  • Clinical concern for impending respiratory failure
  1. After > 48 hours of therapy with high dose amoxicillin in a patient that was tolerating the outpatient PO regimen