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