ACUTE RESPIRATORY INFECTIONS
Dr Deepak UpadhyayAssistant ProfesorDept of Community Medicine
Epidemiology• ARI RESPONSIBLE FOR 20% OF CHILDHOOD (<
5 YEARS) DEATHS (IN WHICH 90% FROM PNEUMONIA)
• ARI MORTALITY HIGHEST IN CHILDREN-• HIV-infected• Under 2 year of age• Malnourished• Weaned early• Poorly educated parents• Difficult access to healthcare
• OUT- PATIENT VISITS• 20-60%• ADMISSIONS• 12-45%
ACUTE RESPIRATORY INFECTIONS(ARI)• May cause the inflammation of respiratory
tract anywhere from nose to alveoli.• May be classified as – AURI – Acute Upper Respiratory
Infection (common cold, pharyngitis, epiglottitis & otitis media
etc.)
or ALRI – Acute Lower Respiratory Infection (laryngitis, layngotracheitis, bronchitis, bronchiolitis &
pneumonia)
Anatomy of the Respiratory system
Upper Respiratory Tract Infections• Rhinitis (Common Cold Or Coryza)– Rhinoviruses, Enteroviruses, Coronaviruses
• Ear Infections (Acute Otitis Media)– Viruses, Pneumococcus, Gabhs,
Hemophilus Influenza, Moraxella Catarrhalis • Acute Epiglottitis (Suprglottitis)• Sinusitis– Viral/Bacterial
Upper Respiratory Tract Infections• Acute Pharyngitis– ADENOVIRUS, ENTEROVIRUS,
RHINOVIRUS, GROUP A BETA HEMOOLYTIC Streptococcus(older Children)
• Tonsillitis– Group A Beta Hemolytic Streptococci,
EBV
Lower Respiratory Tract Infections• Acute Infectious Laryngitis– Viral/Diptheria
• Croup (Acute Laryngotracheobronchitis)• Bronchitis/Bronchiolitis• Pneumonia
VIRUSES AGE GROUP AFFECTED
CHRACTERISTIC CLINICAL FEATURES
Enterovirus All ages Febrile pharyngitis
Influenza A, B, C All ages variable
Measles Young children variable
Parainfluenza 1, 2, 3 Young children variable
Respiratory Syncytial Virus
Infants and young children
Severe bronchiolitis and pneumonia
Rhinovirus All ages Common cold
Coronavirus All ages Common cold
AGENT FACTORS
AGENT FACTORSBACTERIA AGE GROUP
AFFECTEDCHRACTERISTIC CLINICAL FEATURES
Bordetella pertussis Infants & young children Poroxysmal cough
Corynebacterium diphtheriae Children diphtheria
Hemophilus influenzae
AdultsChildren
Acute ex of ch bronchitisAcute epiglottitis
Klebsiella pneumoniae Adults Lobar pneumonia
Legionella pneumophila Adults Pneumonia
Staph. pyogenes All ages Lobar and bronchopneumonia
Strep. pneumoniae All ages Pneumonia
Strep. Pyogenes All ages Acute pharyngitis and tonsillitis
Factors Affecting Type of Illness and Physical Response in Acute
Respiratory Infections:
Agent Factor• Nature of infectious agent: – Bacteria > viruses
• Size and frequency of dose: – The larger the dose – More frequent the exposure
Host Factor• Age of child: – Children of preschool and school age – Airways are smaller in young children – considerable narrowing from edema
• Nutritional status of children• Immunization status• Birth weight of children
• Presence of great conditions: – Malnutrition, anemia, fatigue, chilling of the
body and immune deficiencies • Presence of disorders affecting respiratory
tract: – Allergies, cardiac abnormalities and cystic
fibrosis Environmental factors• Air pollution: Indoor • Smoking: Passive• Seasons: – During winter and spring months
• Living conditions
• Primodial prevention (Adoption of healthy life style)
• Primary prevention (Reduction of risk factors)–Health promotion– Specific protection
• Secondary prevention (Early diagnosis & Treatment)
– IMNCI approach– F – IMNCI integration
• Tertiary prevention–Disease limitation–Rehabilitation »Medical » Psychological » Social »Vocational
Prevention of Hypertension
Quaternary prevention Prevention of
over diagnosis Prevention of
resistance
Primodial Prevention• Healthy life style – Good antenatal care– Early initiation of breast feeding– Exclusive Breast feeding– Proper complementary feeding– Proper nutrition
• Achieve through health promotion & health education
Primary prevention• Health promotion
• Adequate nutrition• Parenthood counselling• Reduction of passive smoking• Reduction of indoor pollution• Improved living condition
• Specific protection• Vaccination• Chemoprophylaxis
• Vaccination• Diphtheria & Pertussis• Measles• Hib Vaccine• Pneumococcal Vaccine• SARS vaccine• Influenza vaccine
• Chemoprophylaxis • Vitamin A supplementation• Antibiotic prophylaxis
Secondary prevention• Early diagnosis & treatment– IMNCI– F - IMNCI
IMNCI• Integrated management of neonatal &
childhood illness• ACT– Assess– Classify– Treatment
Assess• Age – – < 2 months– 2 – 12 months– > 12 moths
• Respiratory rate (Tachypnea)– In < 2 months (>60 breaths / min)– In 2 – 12 months (>50 breaths / min)– In > 12 moths (>40 breaths / min)
• Chest in drawing• Stridor• Fever • Danger signs– Inability to drink or breast feed– Convulsions– Lethargy or unconsciousness– Stridor in calm child
SIGNS OF RESPIRATORY DISTRESS
SIGNS OF RESPIRATORY DISTRESS
Classify• In children < 2 months– Serious bacterial infection• Any danger sign• Chest in drawing• Tachypnea
– Bacterial infection (URTI)• Fever with sneezing / cough
• In children > 2 months– Very Severe pneumonia• Any danger sign
– Severe pneumonia• Chest in drawing• Stridor • Cyanosis • Nasal flaring
– Pneumonia • Tachypnea
– No Pneumonia
WHO Classification and managementNO PNEUMONIA COUGH
NO TACHYPNEA-HOME CARE-SOOTHE THE THROAT AND RELIEVE COUGH-ADVISE MOTHER WHEN TO RETURN-FOLLOWUP IN 5 DAYS IF NOT IMPROVING
PNEUMONIA -COUGH-TACHYPNEA-NO RIB OR STERNAL RETRACTION-ABLE TO DRINK- NO CYANOSIS
-HOME CARE-ANTIBIOTICS FOR 5 DAYS-SOOTHE THE THROAT AND RELIEVE COUGH-ADVISE MOTHER WHEN TO RETURN-FOLLOWUP IN 2 DAYS
SEVERE PNEUMONIA -COUGH-TACHYPNEA-RIB AND STERNAL RETRACTION-ABLE TO DRINK-NO CYANOSIS
-ADMIT IN HOSPITAL-GIVE RECOMMENDED ANTIBIOTICS-MANAGE AIRWAY-TREAT FEVER IF PRESENT
VERY SEVERE PNEUMONIA -COUGH-TACHYPNOEA-CHEST WALL RETRACTION-UNABLE TO DRINK-CENTRAL CYANOSIS
-ADMIT IN HOSPITAL-GIVE RECOMMENDED ANTIBIOTICS-OXYGEN-MANAGE AIRWAY-TREAT FEVER IF PRESENT
Treatment• Place of treatment
• No pneumonia• pneumonia Domiciliary treatment• Severe pneumonia• Very severe pneumonia Hospital treatment• Serious bacterial
infection Hospital treatment• Acute URTI Domiciliary treatment
• Type of Treatment• No pneumonia Symptomatic treatment• Pneumonia Oral Antibiotics + Symptomatic treatment• Severe
pneumoniaInjectable Antibiotics + Symptomatic treatment
• Very severe pneumonia
Injectable Antibiotics + Symptomatic treatment
• Serious bacterial infection
Injectable Antibiotics + Symptomatic treatment
• Acute URTI Symptomatic treatment
• Drugs usedSymptomatic treatment
Fever – Paracetamol Cough and sneezing – H-1 antagonist (not
preferred in children < 6 months)Nasal obstruction
Nasal saline dropsNasal decongestants (not preferred in
children < 6 monthsAntibiotics
Oral antibiotics - Cotrimoxazole Injectable antibiotics
Benzyl penicillinAmpicillin Chloramphenicol( preferred drug in Very
sever diseaseGentamycin
• Dosage of drugs• Symptomatic treatment– CPM(0.1 mg/kg wt/dose)– Paracetamol (15mg/kg/dose)
• Oral antibioticsOral Antibiotics (Cotrimoxazole) Age / Weight Paediatric tablet:
Sulphamethoxazole 100 mg & Trimethoprim 20 mg
Paediatric syrup; each spoon (5ml): Sulphamethoxazole 200 mg and Trimethoprim 40 mg
<2 months (Wt. 3-5 kg)
1 tablet BD Half spoon (2.5 ml) twice a day
2-12 months (wt 6-9 kg)
2 tablets BD One spoon (5 ml) twice a day
1-5 years (wt 10-19 kg)
3 tablets BD One & half spoon (7.5 ml) twice a day
Reassess the child after 48 hrsIf improved = continued antibiotics for 3 daysNo improvement = continued for another 48 hr (only one cycle) Deterioration = refer to hospital for injectable antibiotics
• Injectable antibioticsInjectable Antibiotics (2 Months - 5 Years) Dose Interv
alMode
First 48 hours – Benzyl penicillin OrAmpicillin OrChloramphenicol
50000lUper kg/dose50 mg/kg/dose25 mg/kg/dose
6 hourly6 hourly6 hourly
IMIMIM
1. If condition IMPROVES, then for the next 3 days give:Procaine penicillin OrAmpicillin or Chloramphenicol
50000 IU/kg (maximum 4 lac IU)50 mg/kg/dose25 mg/kg/dose
Once6 hourly6 hourly
IMOralOral
2. If NO IMPROVEMENT, then for the next 48 hour: CHANGE ANTIBIOTIC – If ampicillin is used change to chloramphenicol IM;If chloramphenicol is used, change to cloxacillin 25mg/kg/dose, every 6 hours along with gentamycin 2.5 mg/kg/dose, every eight hours.If condition improves continue treatment orally
• Injectable antibioticschildren aged less than 2 monthsANTIBIOTIC DOSE Frequency
< 7 days Age 7 days to 2 months
Inj. Benzyl penicillin or
50000IU/kg/dose 12 hourly 6 hourlyInj. Ampicillin 50 mg/kg/dose 12 hourly 8 hourly
andInj. Gentamycin 2.5 mg/kg/dose 12 hourly 8 hourly
Questions?
THANK YOU