ARIARI

Dr Mirza Inam Ul HaqDr Mirza Inam Ul Haq

ACUTE RESPIRATORY ACUTE RESPIRATORY INFECTIONINFECTION Acute respiratory infections are the most common of Acute respiratory infections are the most common of

the human ailments.the human ailments. In most instances it runs a natural course in older In most instances it runs a natural course in older

children and adults without treatment and without children and adults without treatment and without complications.complications.

In young infants, young children, elderly and those In young infants, young children, elderly and those with impaired respiratory tract there is increased with impaired respiratory tract there is increased morbidity and mortality.morbidity and mortality.

TYPES TYPES

ARI may be divided into two groupsARI may be divided into two groups Acute Upper Respiratory InfectionsAcute Upper Respiratory Infections.. Mild cough, cold, pharyngitis, otitis media, and Mild cough, cold, pharyngitis, otitis media, and

allergic rhinitis. allergic rhinitis. Acute Lower Respiratory InfectionsAcute Lower Respiratory Infections.. Epiglottis, laryngitis, laryngotracheitis, bronchitis, Epiglottis, laryngitis, laryngotracheitis, bronchitis,

bronchiolitis, pneumonia.bronchiolitis, pneumonia.

PROBLEM STATEMENTPROBLEM STATEMENT

Every child (< 5 years of age) both in developed and Every child (< 5 years of age) both in developed and developing countries in the world suffer from at least developing countries in the world suffer from at least 5-8 episodes of Acute Respiratory Infections 5-8 episodes of Acute Respiratory Infections annually in urban area.annually in urban area.

About 5 million children die annually due to About 5 million children die annually due to pneumonia ad more than 90% of these occur in pneumonia ad more than 90% of these occur in developing world.developing world.

ARI accounts for 30-70% of the health visits by the ARI accounts for 30-70% of the health visits by the children to the heath facilities. The mean duration of children to the heath facilities. The mean duration of illness is 7-9 daysillness is 7-9 days

PROBLEM STATEMENTPROBLEM STATEMENT ARI is the leading cause of disability as well i.e. debilitating

respiratory disease, and deafness following otitis media.

Incidence of ARI in developing countries ranges between 10-20% as compared to 3-4% in the developed countries.

Diarrhoea, Pneumonia, and Protein calorie malnutrition are the three biggest killers of children under five years

National ARI Control Programme was launched late in 1989 in collaboration with international agencies like WHO, UNICEF, and USAID

OBJECTIVES OF NATIONAL OBJECTIVES OF NATIONAL ARI CONTROL PROGRAMMEARI CONTROL PROGRAMME To reduce the mortality under 5 years of age To reduce the mortality under 5 years of age

due to pneumonia.due to pneumonia. To reduce the severity of and mortality from To reduce the severity of and mortality from

pneumonia in childrenpneumonia in children To reduce the incidence of acute lower To reduce the incidence of acute lower

respiratory infections (ALRI)respiratory infections (ALRI) To reduce the severity and complications To reduce the severity and complications

from acute upper respiratory infection (AURI)from acute upper respiratory infection (AURI) To rationalize the use of drugs in ARI To rationalize the use of drugs in ARI

Control StrategyControl Strategy

Correct Case ManagementCorrect Case Management: this is achieved : this is achieved through intense training of health staff to through intense training of health staff to identify and manage the cases of ARI.identify and manage the cases of ARI.

The health staff includes, the supervisory The health staff includes, the supervisory staff, the trainers, hospital based medical staff, the trainers, hospital based medical officers, medical officers working at the THQ officers, medical officers working at the THQ hospitals, RHCs, BHUs, and LHWs.hospitals, RHCs, BHUs, and LHWs.

AGENT FACTORSAGENT FACTORS

Two most common agents areTwo most common agents are Bacterial organism.Bacterial organism. Viral organism Viral organism

Agents of Upper Respiratory Agents of Upper Respiratory Tract InfectionsTract Infections Common cold (rhinitisCommon cold (rhinitis))

Many viruses; rhino, corona, adeno, influenzaMany viruses; rhino, corona, adeno, influenza Pharyngitis and laryngotracheitisPharyngitis and laryngotracheitis

Streptococcus pyogenesStreptococcus pyogenes Corynebacteria diphtheriaeCorynebacteria diphtheriae Neisseria gonorrheaNeisseria gonorrhea Many virusesMany viruses

EpiglottitisEpiglottitis Haemophilus influenzaeHaemophilus influenzae

BronchitisBronchitis Bordetella pertussisBordetella pertussis Many virusesMany viruses

Agents Agents Tuberculosis: Mycobacterium tuberculosisTuberculosis: Mycobacterium tuberculosis PneumoniaPneumonia

BacteriaBacteria Streptococcus pneumoniaeStreptococcus pneumoniae Mycoplasma pneumoniaeMycoplasma pneumoniae Staphylococcus aureusStaphylococcus aureus

VirusesViruses InfluenzaInfluenza MeaslesMeasles Many othersMany others

FungiFungi ManyMany

HOST FACTORSHOST FACTORS

Most vulnerable groups are the young children, young Most vulnerable groups are the young children, young infants, elderly persons, and the malnourished infants, elderly persons, and the malnourished children.children.

The Infant Mortality Rates in the developing countries The Infant Mortality Rates in the developing countries are high and may exceed 20/1000 and contributing are high and may exceed 20/1000 and contributing factor is mainly malnutrition.factor is mainly malnutrition.

AURI are higher in children than in adults. Incidence of AURI are higher in children than in adults. Incidence of Pharyngitis and Otitis Media increases from infancy to Pharyngitis and Otitis Media increases from infancy to 5years of age.5years of age.

RISK FACTORSRISK FACTORS

Low Birth WeightLow Birth Weight MalnutritionMalnutrition Specific nutritional deficienciesSpecific nutritional deficiencies Climatic conditionsClimatic conditions Housing (over crowding, poor housing Housing (over crowding, poor housing

conditions)conditions) Level of IndustrializationLevel of Industrialization Socio-economic LevelSocio-economic Level LBWLBW Indoor Pollution (air pollution)Indoor Pollution (air pollution) Maternal cigarette smoking.Maternal cigarette smoking.

MODES OF TRANSMISSIONMODES OF TRANSMISSION

Air BorneAir Borne Direct- person to person.Direct- person to person.

POLICYPOLICY

Who in1976 adopted a policy of Who in1976 adopted a policy of Improving Living Conditions.Improving Living Conditions. Better Nutrition.Better Nutrition. Reduce smoke pollutionReduce smoke pollution Other factors areOther factors are MCH careMCH care Immunization (to prevent pneumonia which Immunization (to prevent pneumonia which

occur as complication of vaccine preventable occur as complication of vaccine preventable diseases).diseases).

CLINICAL ASSESSMENTCLINICAL ASSESSMENT

1.BREATHING RATE/MINUTE.1.BREATHING RATE/MINUTE. 2.LOOK FOR CHEST INDRAWING.2.LOOK FOR CHEST INDRAWING. 3.LOOK AND LISTEN FOR STRIDOR.3.LOOK AND LISTEN FOR STRIDOR. 4.LOOK FOR WHEEZE.4.LOOK FOR WHEEZE. 5.LOOK IF THE CHILD IS DROWSY.5.LOOK IF THE CHILD IS DROWSY. 6.FEEL FOR FEVER.6.FEEL FOR FEVER. 7.CHECK FOR SEVERE MALNUTRITION.7.CHECK FOR SEVERE MALNUTRITION. 8. LOOK FOR CYANOSIS.8. LOOK FOR CYANOSIS.

CLASSIFICATION OF CLASSIFICATION OF ILLNESSILLNESS

A, Child aged 2 months up to 5 years. A, Child aged 2 months up to 5 years. Depending upon the type and severity of the Depending upon the type and severity of the illness it may be classified as under.illness it may be classified as under. Very severe disease.Very severe disease. Severe Pneumonia.Severe Pneumonia. Pneumonia not Severe.Pneumonia not Severe. No Pneumonia: cough or cold.No Pneumonia: cough or cold.

CLASSIFICATION OF CLASSIFICATION OF ILLNESSILLNESS

A, Child aged (0- 2 months) A, Child aged (0- 2 months) Depending upon the type and severity of the Depending upon the type and severity of the

illness it may be classified as under.illness it may be classified as under. Very severe disease.Very severe disease. Severe Pneumonia.Severe Pneumonia. No Pneumonia: cough or cold.No Pneumonia: cough or cold.

2-5 YRS2-5 YRS Very Severe DiseaseVery Severe Disease Danger signs areDanger signs are

Child is unable to drinkChild is unable to drink ConvulsionsConvulsions Strider in the calm childStrider in the calm child Severe malnutritionSevere malnutrition

Severe PneumoniaSevere Pneumonia Respiratory rateRespiratory rate 60 or more/minute60 or more/minute

age<2mage<2m age 2-12 m age 2-12 m 50 50

1-5 yrs 1-5 yrs 40 or more/minute age40 or more/minute age

2-5 yrs2-5 yrs

Chest in drawingChest in drawing Nasal flaringNasal flaring GruntingGrunting CyanosisCyanosis Pneumonia not severePneumonia not severe Fast breathing without chest in drawing.Fast breathing without chest in drawing. No Pneumonia: (Cough & ColdNo Pneumonia: (Cough & Cold).).

0-2 months 0-2 months

Danger signs are Danger signs are ConvulsionsConvulsions StridorStridor Stopped feeding wellStopped feeding well WheezingWheezing Fever/ Low body temperatures Fever/ Low body temperatures

0-2 months0-2 months

Very Severe DiseaseVery Severe Disease Danger signs areDanger signs are

Child is unable to drinkChild is unable to drink ConvulsionsConvulsions Stridor in the calm childStridor in the calm child Severe malnutritionSevere malnutrition Not Feeding well Not Feeding well

O-2 Months O-2 Months

Severe PneumoniaSevere Pneumonia Respiratory rateRespiratory rate 60 or more/minute60 or more/minute Chest in drawingChest in drawing Nasal flaringNasal flaring GruntingGrunting CyanosisCyanosis Pneumonia Pneumonia Fast breathing without chest in drawing.Fast breathing without chest in drawing.

Improvement after 48 hours?

Consider cloxacillin

(50mg/kg IV QID)

After 5 days if the child has

responded well change to oral amoxicillin and

oral chloramphenical

for a further 5 daysIf the child improves on cloxacillin continue cloxacillin orally 4 times a day for a total course of 3 weeks

Very Severe Pneumonia Severe Pneumonia

Look for complications

Improvement after 48 hours?

Change to ceftriaxone

50-100mg/kg BID for 10 days

YesNoNoYes

Oral amoxicillin for 5 days

Look for complications likeEffusion/empysema

Antibiotic treatment can be changed by a doctor when blood culture results are available

Treat complications if found

Complications include:

Empyaema*

Pleural effusion*

Lung abscess*

*

Pneumonia Protocol: Infants and Children > 2 months

Very Severe Pneumonia PneumoniaSevere Pneumonia

Ceftriaxone (50-100 mg/kg IV divided Bid (may give IM if no IV access)

Monitor and ensure oxygen saturations >90%

Give paracetamol (15mg/kg as needed up to 4 times a day) for fever

Ensure that the child is receiving adequate fluidEncourage breastfeeding and oral fluidsIf child cannot drink:For Severe Pneumonia: pass a nasogastric tube and give maintenance fluid in one hourly amounts, or,For Very Severe Pneumonia give IV flush*

Weight Fluid ml/hour

2kg 8

4kg 16

6kg 25

8kg 33

10kg 42

12kg 46

14kg 50

16kg 54

18kg 58

The child MUST be discussed

with a doctor and reviewed

as soon as possible

Obtain a chest x-ray

Give ampicillin (100 mg/kg IV/IM every 6 hours) and chloramphenical

(50 mg/kg every 8 hours) for at least

48 hours

Child should be checked by a nurse every 6 hours and by a doctor or medic every day

Give oral amoxicillin (or IV ampicillin)Give the first dose in the clinic

**)

Pneumonia Protocol: Infants and Children < 2 months

Management of very severe Management of very severe disease (2m- 5 yrs age) disease (2m- 5 yrs age)

Treat feverTreat fever Treat wheezingTreat wheezing

Antibiotic Antibiotic Inj Benzyl Penicillin Ist 48 hr Inj Benzyl Penicillin Ist 48 hr

50000 IU 50000 IU 6 hr 6 hr IMIM

Inj Ampicillin Inj Ampicillin 50mg/KG/Dose 6 Hrly50mg/KG/Dose 6 Hrly IM/oralIM/oral

ChloramphenicolChloramphenicol 25mg/KG/Dose 6Hrly 25mg/KG/Dose 6Hrly

IM/oralIM/oral

CONT CONT Treatment Treatment Nebulize Nebulize 0.5ml+2ml 0.5ml+2ml

N/S SalbutamolN/S Salbutamol Epinephrine Epinephrine

Subcutaneous Subcutaneous 0.01ml/KG may 0.01ml/KG may repeat 20min repeat 20min (1:1000=0.1%)(1:1000=0.1%)

Sub-cut Terbutaline Sub-cut Terbutaline (0.1 mg/KG may repeat (0.1 mg/KG may repeat after 30 minutes).Total after 30 minutes).Total 0.3mg.0.3mg.