1

(Acute respiratory tract infection in children, ARIC) 5 Acute respiratory infection (ARI) 4 Upper respiratory infection (URI) acute URI (common cold acute nasopharyngitis) (acute otitis media) (acute sinusitis) (acute pharyngitis) (acute tonsillitis) Lower respiratory infection (LRI) LRI (acute bronchitis) (acute bronchiolitis) (acute pneumonia) (croup syndrome) LRI acute laryngotracheobronchitis, acute epiglottits, bacferial tracheitis retropharyngcal abscess .. 2530 5 2.9

2

5 .. 2536 52 5 1 25 5 15/100,000 .. 2533 9.6/100,000 .. 2537 ()

-

- -

-

3

4

1. , , , , . . 2533; 11: 129-39.

2. . . : . . ( 1) : ; 2540 : 503-506, 517-530.

5

(Guideline for the management of acute upper respiratory tract infections in young children or AURI)

( Acute rhinitis , acute nasopharyngitis , common cold ) Rhinovirus Coronavirus 3 3 2-3 60-80% 1-3 mucopurulent sinus ( viral rhinosinusitis ) 2 - 7 31% 35% 2 3-8 10-15% 12 Day care center

1.

2. 2.1 380 paracetamol 10 mg / kg / dose

46 3

2.2

0.9 % NSS 1 2

6

Decongestant nasal mucosa nasal discharge 2

oral decongestant pseudoephedrine 1 mg/kg/dose 34 confusion, hallucination, aggression, hypertension dystonia 1

. topical decongestant % ephedrine 3 5 rhinitis medicamentosa, rebound congestion rhinorrhea rebound congestion obstructive apnea systemic absorption

antihistamine allergic rhinitis

metholated balms 2.3

: oral hydration

: soothing remedies

: ( expectorant ) WHO Guaifenesin glyceryl guaiacolate side effect ammonium chlorate, terpine hydrate, syrup ipecac

: ( mucolytic drug )

: ( cough suppressant ) codiene, dextromethorphan 1

7

3. (Specific treatment) :

resistant organism

4. ( Acute pharyngitis, tonsillitis, pharyngotonsillitis )

hemolytic streptococcus group A acute rheumatic fever, acute glomerulonephritis

Streptococcal sorethroat 3 tonsils pharynx tonsils (cervical lymphadenitis) soft palate () adenovirus, infectious mononucleosis

1. (Specific treatment) Streptococcal sorethroat Penicillin V 50,000

100,000 units / kg / day Amoxycillin 30 50 mg / kg / day 10 Penicillin Erythromycin 30 50 mg / kg / day 10 14

2. - - Soothing remedies

lozenges, , xylocaine gel antiseptic 5

8

Acute otitis media

S. pneumoniae, H. influenzae, M. catarrhalis virus, mycoplasma pneumonia chlamydia pneumonia

otoscope tympanic membrane tympanic membrane

1. (Specific treatment) : amoxycillin, cotrimoxazole, rythromycin

5 7 - 10-14 - 2 - - recurrent otitis media - craniofacial abnormalities - immunocompromised host : 48

2nd generation cephalosporin, amoxycillin / clavulanate : serous effusion

serous otitis media 3 70% effusion 2 50% 1 20% 2 serous effusion 3

2. 1

9

3 4 decongestant antihistamine Acute sinusitis

bacterial sinusitis complication 0.5 5% S. pneumoniae, H. influenzae Gr. A. Streptococcus 10 paranasal sinus Bacterial sinusitis

1. amoxycillin, erythromycin cotrimoxazole 10 14 48 2nd generation cephalosporin, amoxycillin/clavulanate

2. 3 3.

10

1. 2.

,2542. 2. Dowell SF, Marcy SM, Phillips WR, et al. Principles of judicious use of antimicrobial

agents for pediatric upper respiratory tract infections. Pediatrics 1998; 101 (1) : 163-165. 3. Dowell SF, Marcy SM, Phillips WR, et al. Otitis media - Principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (1): 165 171. 4. Dowell SF, Schwartz B, Phillips WR and The pediatric URI consensus team. Appropriate

use of antibiotics for URZs in children : part I. Otitis media and acute sinusitis. Am Fam Phys 1998; 58 (5): 1113 1138, 1123.

5. Dowell SF, Schwartz B, Phillips WR and The pediatric URI consensus team. Appropriate use of antibiotics for URIs in children : part II. Cough, pharyngitis and the common cold. Am Fam Phys 1998; 58 (6): 1335 1342, 1345.

6. Hendeles L. Efficacy and safety of antihistamines and expectorants in nonprescription cough

and cold preparations. Pharmacotherapy 1993; 13 (2): 154 158. 7. O Brien KL, Dowell SF, Schwartz B, et al. Acute sinusitis Principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (1): 174 178. 8. Rosenstein N, Phillips WR, Gerber MA, et al. The common cold Principles of judicious

use of antimicrobial agents. Pediatrics 1998; 101 (1): 181 184. 9. Schwartz B, Marcy SM, Phillips WR, et al. Pharyngitis Principles of judicious use of antimicrobial agents. Pediatrics 1998; 101 (1): 171 174.

11

(Guideline for the management of acute lower respiratory infections in young children or ALRI)

Acute epiglottitis () supraglottic epiglottis, aryepiglottic fold ventricular band 2-6

Hemophilus influenzae type B

(Stridor) 24 ( 1)

epiglottis (cherry red epiglottis) epiglottis glottis

(lateral neck X-ray) epiglottis aryepiglottic fold

air trapping oropharynx

endotracheal (Ampicillin, Amoxicillin Chloramphenical

12

Ampicillin second or third generation cephalosporin) 1 Clinical characteristics differentiating acute laryngotracheobronchitis from acute

epiglottitis Characteristic LTB Epiglottitis Age 6 month-3 years 2-6 years Onset Gradual Rapid Etiology Viral Bacterial Swelling site Subglottic Supraglottic Symptoms

Cough voice Hoarse cough No cough Muflfled voice

Posture Any position Sitting Mouth Closed : nasal flaring Open-chin forward, drooling Fever Absent to high High

Appearance Often not acutely ill Anxious, acutely ill X-ray Narrow subglottic area Swollen epiglottis and

supraglottic structures Palpation larynx Non tender Tender Recurrence May recur Rarely recurs Reference : Backofen DE, Roger MC. Upper airway disease. In : Rogers MC, ed.

Textbook of pediatric intensive Care. 1987, p 190

13

Acute laryngotracheobronchitis (Viral croup) 6 3

parainfluenza virus type 1, 2, 3 influenza virus A, B, respiratory syncytial virus measles

1-3 subglottic (stridor) stridor croup score 0 1 2 (barking

cough) Stridor

Chest retraction & nasal flaring

nasal flaring & suprasternal retraction

1 subcostal & intercostal retraction

40% Harsh with rhonchi < 4 = 4-7 = > 7 = ( Downes JJ. Acute upper airway obstruction. In : Annual refresher course lectures. A.S.A. annual meeting 1980 ; 535)

14

(croup score < 4)

() (croup score 4-7) dexamethasone 0.6 mg/kg adrenaline 1:1000 0.5 ml/kg 4 = 2.5 ml / dose dilute 3 ml NSS (Group score > 7) viral croup Croup obstruction score 4 > 4 7 > 7

OPD Treatment Admitted Admitted ICU Epinephrine 1 : 1000 ( 0.05 0.5 ml/kg ) max. dose 2.5 ml

4 3 30 Dexamethasone 0.6 mg/kg/dose Support Endotracheal In tubation

Croup

15

Bacterial tracheitis

1-3 staphylococcus aureus, group A -hemolytic streptococcus H. influenzae (brassy cough) clear airway maintain airway Cloxacillin 100 mg/kg/day Cephalosporin IV (Cefazolin 75 mg/kg/day) 2-3 (intermittent tracheal suction) Retropharyngeal abscess 3 posterior pharyngeal wall prevertebral fascia nasopharynx retropharyngeal space median raphe buccopharyngeal fascia prevertebral fascia B hemolytic group A streptococcus S. aureus

16

(stridor) (meningismus) posterior pharyngeal wall lateral neck X-ray retropharyngeal space cervical lordosis

direct laryngoscopy Penicillin Penicillinase resistant penicillin Gramstain

17

1. , Acute Waryngotracheoburn chitis, :

. , . . . . . . 2541 : 401 5.

2. Barone MA. The Harriet Lane Handbook. A manual for pediatric house officers. The Harriet Lane Service Childrens Medical and Surgical Center of The Johns Hopkins Hospital. 14th ed. St. Louis. Baltimore : Mosby Year Book. 1996; 532 3.

3. Klassen TP. Group : A current perspective. Pediatr Clin North Am 1999 ; 46 (6) : 1167 77.

4. Sumboonnanonda A, Suwanjutha S, Sirinawin S. Randomized controlled trial of Dexainethasone in Infectious group. J Med Assoc Thai. 1997 ; 8 : 262 - 5

5. Waisman Y, Kleikn BL and Boenning DA, et al. Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of Laryngotracheitis (Croup) 1992 ; 89 : 302 6.

18

Acute Bronchiolitis ()

(Bronchiolitis) (bronchioles) 6-24

respiratory syncytial virus (RSV) parainfluenza, adenovirus type 7, 3, 21, rhinovirus, influenza virus 5 739 ..2529-2530 25 11 ( 44) RSV 32, parainfluenza virus type 3 8, influenza virus type 6 4

2-3 (diminished vesicular breath sound) wheezing fine crepitation

19

generalized hyperinflation interstitial infiltration

Respiratory rate 60 retraction chest wall

monitor oxygen saturation Oxygen saturation 94% oxygen (35-40% by mask or hood)

Apnea 2 prematurity underlying cardio pulmonary disease immunosuppression deficiency

()

(General supportive c are) RSV humidified oxygen hypoxemia monitor

Pulse-oximeter oxygen saturation 94% hydration (-, )

expiratory wheezes bronchospasm beta-2 agonists

asthma clinical signs generalized air trapping debris edema

20

nasal CPAP (continuous positive airway pressure)

(Specific treatment) epinephrine 1:1000 0.05-0.5 ml/kg NSS 3 ml

( 4 =2.5 ml/dose)

Wheezing child

nebulized beta 2 agonist 10 15 try second dose bronchodilator 10 15 Rx as asthma Dx Acute Bronchiolitis Rx Admit , humidified O2 Supportive care

nebulized epinephrine AB pneumonia

Support ventilation (nasal CPAP, Ventilator)

Wheezing child

21

Pneumonia ()

terminal respiratory bronchiole alveoli 8-10 5 , ( 1) 1

Pathogen 5 years Streptococcus pneumoniae Viruses Enteric bacilli Group B streptococci Chlamydia trachomatis Staphylococcus aureus Haemophilus influenzae Group A streptococci Mycoplasma pneumoniae Chlamydia pneumoniae

+++ +++ +++ +++ +++ ++ + - + -

+++ +++

+ - + +

+++ +

++ +

+++ ++ + - + + + +

+++ ++

+++, very frequent; ++, moderately frequent, +, rare, +, very rare; -, absent. Ref: Pechre. Community-acquired pneumonia in children. Cambridge Medical Publication 1995;P30

13 .. 2513-2523 54.6

22

lung aspirates blood culture lung aspirates S. pneumoniae 45.5 H. influenzae S. aurens 28.4 9.4 incidence S. pneumoniae H. influenzae = 24.8 15.5 % respiratory syncytial virus 17.7-35.8 ( 2) 2 RSV

RSV (% LRI )

( 2541-2542)**

22.7 20.3 17.7 35.8

** 1 . ( 2529- 2530) 41.2 RSV 53.6 10.96 S. pneumoniae 8.96

< 2 60 2 - 11 50 1-5 40

chest wall retraction, flaring ala nasi

23

fine medium crepitation sonorous rhonchi bronchial breath sound consolidation

(> 15,000 / cu.mm.) shift to the left toxic granules neutrophils

parahilar peribroonchial (interstitial) infiltration lobar consolidation S. pneumoniae pneumatocele S. aureus pleural effusion S. aureus, S. pneumoniae, H. influenzae, mycoplasma

sputum nasopharyngeal aspiration sensitive specific

nasopharyngeal aspiration colonization

Hemoculture 20

antigen nasopharyngeal aspirate respiratory syncytial virus, adenovirus, influenza virus

24

antigen , nasopharynx pleural effusion

Pleural fluid gram stain culture pleural effusion effusion

Cold agglutinin of mycoplasma titer mycoplasma Tuberculin test (Specific treatment)

1. supportive care

2.

(1) 2 5 Amoxicillin 40-50 mg/kg/day 3 Penicillin Erythromycin 30-40 mg/kg/day 2 5-7 H.influenzae S.pneumoniae S.aureus Cefuroxime axetil Amoxicillin-clavulanic acid Cefprozil Cefaclor ( 1 3) 6 Chlamydia trachomatis Erythromycin 14 5 15 Amoxicillin Penicillin V 5-7 Mycoplasma pneumoniae Chlamydia pneumoniae Erythromycin 14

25

( 2) 2 Penicillin Ampicillin Aminoglycoside third generation cephalosporin Cefotaxime Ceftriaxone 7-10 14-21 S.aureus Cloxacillin 3 2 5 Ampicillin I.V. 6 3 Amoxicillin 7 Ampicillin Aminoglycoside Cephalosporins H.influenzae Cefuroxime Cefotaxime Amoxicillin clavulanic acid 10-14 Staphylococcal pneumonia Cloxacillin 3 5 15 Penicillin G, I.V. 6 3 Penicillin V Amoxicillin 3 Penicillin Erythromycin S.pneumoniae Penicillin 200,000-300,000 units/kg/day Cefotaxime Ceftriaxone Staphylococcal pneumonia Cloxacillin 100-150 mg/kg/day S.aureus 3 empyema pleural effusion Cloxacillin 200-300 mg/kg/day

( General supportive care ) 1.

2. (

70 ) 3. wheeze rhonchi

26

4.

5. ( Chest physical therapy ) (Vibration)

6. 7. (Endotracheal intubation) 2 (moderately sever respiratory distress) hypoxemia

S. aureus (pleural effusion, empyema, lung abscess)

27

1 :

2 5 5 15 Amoxicillin Amoxicillin Erythromycin Pen V. Erythromycin 2 2 5-7 5-7 Admit S.pneumoniae Admit & H.influenzae Pen. Amoxicillin clavulanic acid Cefuroxime P.O

Cefprozil P.O Mycoplasma S.pneumoniae Cefaclor P.O Chlamydia pneumoniae Amoxicillin +

Erythromycin clavulanic acid 14 Amoxicillin

(double dose) Cefuroxime

P.O Cefprozil P.O

28

Cefaclor P.O 2 : / / Admit + Supportive care

< 2 2 5 5 15 PGS Ampicillin I.V.* + Aminoglycoside Ampicillin I.V. Penicillin G, I.V. Cefotaxime 2-3 S.aureus Ceftriaxone 2-3 * cloxacillin Cloxacillin S.aureus Ampicillin Ampicillin Pen V S.pneumoniae Amoxicillin + Aminoglycoside Amoxicillin 7 Cefuroxime I.V. 7

Cefotaxime I.V. PGS high dose Amoxicillin + Cefotaxime clavulanic acid Ceftriaxone

29

1 : *

(mg/kg/day)

Amoxicillin Erythromycin Amoxicillin + Clavulanic acid Cefuroxime axetil Cefprozil Cefaclor

40-50 30-40 40-50 40-50 30-40 40-50

3 /

3-4 / 2-3 / 2 / 2 / 3 /

* , MIC, bioavailability in vivo study 2 :

(mg/kg/day)

Ampicillin Amoxicillin + clavulanic acid Cloxacillin** Penicillin G Sodium Gentamicin Amikacin Cefuroxime Cefotaxime Ceftriaxone

100-200 40-50

100-150 100,000-200,000

units/Kg/day 5-7

15-30 100-150 100-150 50-80

6 8 6 6

8

8-12 6-8 6-8 8-12

** empyema pleural effusion pneumatocele 200-300 mg/kg/day

30

3 : Minimal inhibitory concentration (MIC) penicillin MIC (mg/l)

S.pneumoniae H.influenzae S.aureus bioavalability Cephalexin Cefaclor Cefuroxime Amoxicillin - clavulanic acid

2.0 2.0

0.06 -

16.0 4.0 0.25 0.5

4.0 2.6 0.25

-

80% 50% 50%

-

( Pechre JC. Community acquired pneumonia in children. Cambridge Medical Publication 1995; pp. 81-82)

31

Acute bronchiolitis 1. American Academy of Pediatrics : Reassessment of the indications for ribavirin therapy in

respiratory syncytial virus infections. American Academy of Pediatrics Committee on Infectious Diseases. Pediatrics 1996 Jan; PT-REVIEW, TUTORIAL(1): 137-40[Medline].

2. De Boeck K, Van der Aa, Van Lierde S : Respiratory syncytial virus bronchiolitis : a double-blind dexamethasone efficacy study. J Pediatr 1997; 131(6): 979-921[Medline].

3. Flores G, Horwitz RI : Efficacy of beta2-agonists in bronchiolitis: a reappraisal and meta-analysis. Pediatrics 1997; 100(2): 233-239[Medline].

4. Kellner JD, Ohlsson A, Gadomski AM: Efficacy of bronchodilator therapy in bronchiolitis: A meta-analysis. Arch Pediatr Adolesc Med 1998; 150(11): 1166-1172[Medline].

5. Klassen TP, Sutcliffe T, Watters LK: Dexamethasone in salbutamol-treated in patients with acute broncholitis: a randomized, controlled trial. J Pediatr 1997; 130(2): 191-196[Medline].

6. McConnochie KM, Roghmann KJ: Predicting clinically significant lower respiratory tract illness in childhood following mild bronchiolitis. Am J DisChild 1985; 139: 625-631[Medline].

7. Suwanjutha S, Chantarojanasiri T, Preutthipan A, et al. Incidence of respiratory syncytial virus lower respiratory tract infection in under-5-year-dd children at a rural community of Thailand. Final report to RTG-WHO Collaborative Programme Ref no 000068 ; Jan 31, 2000.

8. Van Woensel JB, Wolfs TF, van Aalderen WM: Randomised double blind placebo controlled trial of prednisolone in children admitted to hospital with respiratory syncytial virus bronchiolitis. Thorax 1997 Jul; 52(7): 634-7[Medline].

9. Weber MW, Mulholland EK, Greenwood BM: Respiratory syncytial virus infection in tropical and developing countries. Trop Med Int Health 1998; 3(4): 268-280[Medline].

Pneumonia 1. , .. ,

..2526 2527 2528 ; 10 (1) : 31-35 2.

2 2542 3. , RSV

LRI . ( 1 )

32

4. , . Pneumonia : . . . . Ambulatory Pediatrics 2. . . 2542 : 544-50

5. Campbell PW. Pneumonia. In : Rudolph AM, ed. Rudolphs Pediatrics. 20 th ed. London :Prentice Hall International 1996 ; 56-77

6. Chantarsjanasiri T, Suwanjutha S, Wattanakasetr S, Etiology, treatment and outcome of hospitalized pneumonia in young children at Ramathibodi Hospital. I Med Assoe Thai 1993; 76 (Suppl 2) : 156 64.

7. Long SS. Pneumonia in older infants children and adolescents. In : Schidlow DV, Smith DS, eds. A practical guide to pediatric respiratory diseases. Hanley & Belfus, Inc 1994 : 91

8. Pornkul R, Suwanjutha S, Ruangkanchanasetr S. Correlation of roentgenologic diagnosis and etiologic agents of pneumonia in Thai childrn under 5 years of age. Med Assoc Thai 1993 ;76 (Suppl 2) : 178-186

9. Sunakorn P, Chuenchit L, Niltawat S, et al. Epidemilolgy of acute respiratory infection in young children from Thailand. Pediatr Infect Dis J 1990 ; 9 (12) : 873-877

10. Suwanjutha S, Chantarojanasiri T, Wattana-kasetr S, et al. A study of nonbacterial agents of acute lower respiratory tract infection in Thai children. Review Infect Dis 1990 ; 12 (Supp 8) : Nov-Dec page?

33

Wheezing associated respiratory illness Wheezing physical sign asthma acute respiratory infections viral infections bacterial infections bronchitis pneumonia bronchodilators antibiotics wheezing acute respiratory tract infections asthma Terminology wheezing bronchitis wheezing bronchitis asthma wheezing asthma .. 1990 wheezing first attack wheezing acute respiratory infections asthma asthma recurrent wheezing viral infection WHO/ARI/93.29 first wheezing bronchiolitis 1 possible asthma recurrent wheezing asthma .. .. 2529 2530 lower respiratory infections 560 wheezing 12.7% wheezing 50.7% pneumonia .. 2541-2542 .. lower respiratory infections 215 wheezing 56.3% pneumonia 88 wheezing 50% wheezing associated respiratory illness Wheezing soft musical sound ( oscillation ) wheeze small airways positive intrapleural pressure ( negative pressure) pressure trachea large airways secondary compression trachea large airways wheeze

34

polyphonic wheezing single airway monophonic wheezing wheezing wheezing recurrent wheezing 1 2

1 Causes of wheezing in children Infancy Older child / adolescent Acute :- Bronchiolitis Acute :- Asthma Asthma Foreign body Chronic:- Asthma Allergic reaction Recurrent aspiration Chronic:- Asthma Vascular ring/sling Retained foreign body Tracheal stenosis Cystic fibrosis (rare) Tracheomalacia Vascular ring / sling Cystic fibrosis Tracheomalacia Environmental exposure Allergic bronchopulmonary - - passive smoking -aspergillosis Pulmonary hemosiderosis Psychogenic

2 Causes of recurrent or persistent wheezing in children Reactive airway disease Atopic asthma Infection associated airway reactivity Exercise-induced asthma Salicylate-induced asthma and nasal polyposis Other hypersensitivity reactions :

35

Hypersensitivity pneumonitis Tropical eosinophilia Visceral larva migrans Allergic aspergillosis Aspiration : Foreign body Food, saliva, gastric contents Laryngo-tracheoesophageal cleft Tracheoesophageal fistula, H-type Pharyngeal incoordination or neuromuscular weakness Cystic fibrosis Ciliary dyskinesis Cardiac failure Bronchiolitis obliterans Extrinsic compression of airways Vascular ring Enlarged lymph node Mediastinal tumor Lung cysts Tracheobronchomalacia Endobronchial masses Gastroesophageal reflux Pulmonry hemosiderosis Sequelae of bronchopulmonary dysplasia Hysterical airway closure Cigarette smoke, other environmental insults Wheezing in ARI Wheezing 1 3 3 wheezing URI viral infection wheezing 60% wheezing 3

36

6 wheezing associated atopy asthma wheezing in ARI 1. Viruses RSV, parainfluenza, adenovirus, coronavirus rhinovirus, influenza A 2 IgE response viral infection RSV bronchiolitis recurrent wheezing early episode asthma 2. Bacteria 3 Chlamydia pneumoniae, Mycoplasma pneumoniae S. pneumoniae, H. influenzae 3. Mixed viral bacterial infection wheezing ARI acute bronchiolitis asthma ARI 1 wheezing 1. respiratory distress rapid-acting bronchodilator (inhaled beta-2 agonist) 30 wheezing - fast breathing oral bronchodilator 3-5 - fast breathing pneumonia oral bronchodilator antibiotic 5

2. respiratory distress 2.1 First episode of wheezing ( 1 )

18 bronchiolitis virus bacteria asthma oxygen nebulized beta-2 agonist 10-15 - wheeze second dose bronchodilator acute bronchiolitis admit supportive care nebulized epinephrine antibiotic pneumonia

37

- fast breathing pneumonia with wheezing reactive airway disease antibiotic 5 oral bronchodilator - wheeze bronchitis reactive airway disease asthma oral bronchodilator 3-5

2.2 Recurrent wheezing ( 2 ) asthmatic attack post bronchiolitic wheeze cyanosis oxygen bronchodilator cyanosis try bronchodilator OPD nebulized beta-2 agonist 2-3 10-15 oxygen response asthma - distress admit oxygen, inhaled short-acting beta-2 agonist 1-2 , systemic corticosteroids intravenous aminophylline antibiotics pneumonia pneumonia oral bronchodilator 1-2 - distress oral bronchodilator fast breathing pneumonia antibiotics recurrent wheezing investigate Rapid-acting bronchodilator liquid beta-2 agonist nebulizing solution salbutamol 0.05-0.15 ././ ( 2.5 ./) terbutaline 0.2-0.3 ././ ( 5 ./) medication nebulizer normal saline 2.5 3 . face mask mouth piece oxygen flow rate 6-8 / beta-2 agonist metered dose inhaler spacer 2-3 puffs 5 2 puffs Oral bronchodilators salbutamol 0.1 ././ ( 2 .) 3-4 terbutaline 0.075 ././ ( 2.5 .) 3-4

38

1

Rx of first wheezing with respiratory distress in young children

Nebulized 2-agonist 10-15 try second dose bronchodilator 10 -15 Dx - Acute bronchiolitis Rx - Admit, humidified O2 Dx - Pneumonia Dx - bronchitis - Supportive care c wheeze c wheeze - nebulized epinephrine Rx - oral bronchodilator asthma - AB + AB 5 Rx - oral bronchodilator pneumonia - chest indrawing 3 - 5 admit - First wheezing acute bronchiolitis, ARI c wheeze, first episode of asthma - AB = antibiotics

- second dose bronchodilator = nebulized 2 -agonist subcutaneous 2 - agonist,

adrenaline

wheeze, resp. distress wheeze

wheeze fast breathing chest

fast breathing chest

39

2

Rx of recurrent wheezing with respiratory distress in young children

Nebulized 2-agonist (1-3 10-15 ) response Rx - Admit Rx - oral bronchodilator - O2 ,supportive care - fast breathing - inhaled short-acting 2-agonist 1 - 2 hr pneumonia AB - Systemic corticosteroid asthma - IV aminophylline - - AB pneumonia 1 - 2

- oral bronchodilator 1-2 - prophylactic drug inhaled corticosteroid, cromolyn - MDI spacer 2 puffs 15 2-3 - Recurrent wheezing acute asthmatic attack post bronchiolitic wheeze

40

1. . 2 . 2542.

2. Bronchodilators and other medications for the treatment of wheeze- associated illnesses in young children. WHO / ARI / 93.29

3. Dorkin IH. Noisy Breathing. In : Loughlin MG, Figen H, eds. Respiratory Disease in Children : Diagnosisi and Management. Baltimore : Williams & Wilkins, 1994 : 167 73

4. Pasterkamp H. The History and Physical examination.In : Chernick V, Kendig El, Jr eds. Kendigs Disorders of the Respiratory tract in Children. 5 thed. Philadelphia : W.B. Saunders 1990 : 56-77.

5. Sunakorn P, Suwanjutha S, Nawanoparatkul S, et al. Sheezing, RSV and lower respiratory infection in children. (in press)

6. Stern CR. Approach to Recurrent or Persistent lower respiratory tract symptom in children. In : Behrman ER, Kliegman MR, Nelson EW, Voughan III CV, eds. Nelson Textbook of Pediatrics. 14 th ed. Philadelphia : WB Saunders, 1992 : 1102 - 6

7. Vangveeravong M, Suwanjutha S, Chantarojanasiri T. Natural course of wheezing children with lower respiratory tract infections. Bull Dept Med Serv 1993 ; 18(2) : 73 - 8