ACUTE RESPIRATORY TRACT INFECTIONS BY DR Aso faeq salih Pediatric department

INTRODUCTION ARI responsible for 20% of childhood (< 5 years) deaths 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

INTRODUCTION Š Upper and lower respiratory tract separated at base of epiglottis Upper respiratory tract consists of airways from the nostrils to the vocal cords in the larynx, including the paranasal sinuses and the middle ear The lower respiratory tract covers the continuation of the airways from the trachea and bronchi to the bronchioles and the alveoli The children < 5 yrs of age get an average of three to six episodes of ARIs annually regardless of where they live or what their economic situation The severity of LRIs in children under five is worse in developing countries

ACUTE EPIGLOTTITIS LIFE-THREATNING INFECTION OF THE EPIGLOTTIS, THE ARYEPIGLOTTIC FOLDS AND ARYTENOID SOFT TISSUE OCCURS MOSTLY IN WINTERS PEAK INCIDENCE :- 1 – 6 YEARS MALE AFFECTED MORE BACTERIAL INFECTION (HEMOPHILUS INFLUENZA TYPE b) CONCOMITANT BACTEREMIA, PNEUMONIA, OTITIS MEDIA, ARTHRITIS AND OTHER INVASIVE INFECTIONS CAUSED BY H.INFLUENZA TYPE b MAY BE PRESENT

ACUTE EPIGLOTTITIS CLINICAL FEATURES HIGH FEVER,SORE THROAT,DYSPNEA,RAPIDLY PROGRESSING RESPIRATORY OBSTRUCTION PATIENT MAY BECOME TOXIC, DIFFICULT SWALLOWING,LABOURED BREATHING, DROOLING,HYPEREXTENDED NECK TRIPOD POSITION (SITTING UPRIGHT AND LEANING FORWARD) CYANOSIS , COMA, DEATH STRIDOR IS A LATE FINDING

EXAMINATION DO NOT EXAMINE THE THROAT ASSESSMENT OF SEVERITY DEGREE OF STRIDOR RESP RATE H.R LEVEL OF CONSCIOUSNESS PULSE OXIMETRY

ACUTE EPIGLOTTITIS DIAGNOSIS: “CHERRY RED”APPEARANCE OF EPIGLOTTIS ON LARYNGOSCOPY THUMB SIGN ON LATERAL NECK RADIOGRAPH

ACUTE EPIGLOTTITIS EPIGLOTTITIS IS A MEDICAL EMERGENCY

TREATMENT (ACUTE EPIGLOTTITIS) NEED TO BE MANAGED IN ICU WITH ENDOTRACHEAL INTUBATION HELP FROM ANAESTHETIST AND ENT SURGEON BLOOD CULTURES FLUID AND ELECTROLYTE SUPPORT INTRAVENOUS AMPLICILLIN 100 mg/kg/day OR CEFTRIAXONE 100 mg/kg/day . OTHER OPTIONS (CEFUROXIME OR CEFOTAXIME) TOTAL TREATMENT :-7-10 DAYS CHOLRAMPHENICOL 50-75 mg/kg/day IV RIFAMPICIN PROPHYLAXIS TO CLOSE CONTACTS

ACUTE LTB (VIRAL CROUP) VIRAL INFECTION LEADING TO MUCOSAL INFLAMMATION OF THE GLOTTIC AND SUBGLOTTIC REGIONS COMMONLY DUE TO INFLUENZA (TYPE A), PARAINFLUENZA(1, 2, 3) AND RSV AGE :- 6 MONTHS – 6 YEARS

ACUTE LTB CLINICAL FEATURES INITIAL :- RHINORRHEA, MILD COUGH, FEVER(LOW GRADE) LATER (24-48 HOURS) :- BARKING COUGH HOARSENESS OF VOICE NOISY BREATHING (MAINLY ON INSPIRATION) SYMPTOMS WORSEN AT NIGHT AND ON LYING DOWN CHILDREN PREFER TO BE HELD UPRIGHT OR SIT IN BED SYMPTOMS RESOLVE WITHIN A WEEK

ACUTE LTB CLINICAL EXAMINATION HOARSE VOICE NORMAL TO MODERATELY INFLAMMED PHARYNX SLIGHTLY INCREASED RESP RATE WITH PROLONGED INSPIRATION AND INSPIRATORY STRIDOR

ACUTE LTB DIAGNOSIS MAINLY A CLINICAL DIAGNOSIS RADIOGRAPH NECK :- STEEPLE SIGN (UNRELIABLE)

ACUTE LTB TREATMENT MOIST OR HUMIDIFIED AIR STEROIDS REDUCE THE SEVERITY AND DURATION / NEED FOR ENDOTRACHEAL INTUBATION PREDNISOLONE PO 2mg/kg/day FOR 3 DAYS NEBULIZED BUDESONIDE 2mg STAT NEBULIZED ADRENALINE (EPINEPHRINE)

LOWER RESPIRATORY TRACT INFECTIONS BRONCHITIS/BRONCHIOLOITIS PNEUMONIA

BRONCHIOLITIS INFLAMMATORY DISEASE OF THE BRONCHIOLES PEAK AGE OF ONSET : 6 MONTHS MOST COMMON AGENT :- RSV MALE : FEMALE :- 2:1 OCCURS MOSTLY IN WINTER/SPRING

CLINICAL FEATURES CORYZA WITH COUGH FOLLOWED BY WORSENING BREATHLESSNESS VOMITING IRRITABILITY WHEEZE FEEDING DIFFICULTY EPISODES OF APNOEA

EXAMINATION FINDINGS IN BRONCHIOLITIS RAPID SHALLOW BREATHING (60-80/MIN) CYANOSIS / PALLOR FLARING OF ALAE NASI USE OF ACCESSORY MUSCLES OF RESPIRATION – SUBCOSTAL /INTERCOSTAL RECESSIONS EXPIRATORY WHEEZE / GRUNTING PROLONGED EXPIRATION HYPER-RESONANT PERCUSSION NOTES CHEST HYPERINFLATION LIVER/SPLEEN PALPABLE BRONCHIOLITIS OBLITERANS

BRONCHIOLITIS DIAGNOSIS CXR PULSE OXIMETRY HYPERINFLATION, INCREASED LUCENCY AND INCREASED BRONCHOVASCULAR MARKINGS AND MILD INFILTRATES PULSE OXIMETRY NASOPHARYNGEAL SWABS (VIRAL CULTURE) VIRAL ANTIBODY TITERS (IAT FOR RSV)

A chest X-ray demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis

BRONCHIOLITIS COMPLICATIONS PNEUMONIA PNEUMOTHORAX DEHYDRATION RESPIRATORY ACIDOSIS RESPIRATORY FAILURE HEART FAILURE PROLONGED APNEIC SPELLS  DEATH

BRONCHIOLITIS TREATMENT MAINLY SUPPORTIVE PROP UP (30 – 40 DEGREES) OXYGEN INHALATION (ACHIEVE O2 >92%) IF TACHYPNEIC, LIMIT THE ORAL FEEDS AND USE A NG TUBE FOR FEEDING PARENTERAL FLUIDS TO LIMIT DEHYDRATION CORRECT RESP ACIDOSIS AND ELECTROLYTE IMBALANCE BRONCHODILATORS FOR WHEEZE (NEBULIZED ADRENALINE) MECHANICAL VENTILATION (SEVERE RESP DISTRESS OR APNOEA)

Pneumonia Inflammation of the lung parenchyma and is associated with the consolidation of the alveolar spaces Developed world Viral infections Low morbidity and mortality Š Developing world Common cause of death Bacteria and PCP in 65% Š ARI case management WHO 84% reduction in mortality Respiratory rate, recession, ability to drink Cheap, oral and effective antibiotics Co-trimoxazole, amoxycillin Maternal education Referral

Etiology Š Vary according to Š Community acquired (CAP) Age, immune status, where contracted Š Community acquired (CAP) Developing countries S. pneumoniae, H. influenzae, S aureus Viruses 40% Other: Mycoplasma, Chlamydia, Moraxella Developed countries Viruses: RSV, Adenovirus, Parainfluenza, Influenza Mycoplasma pneumoniae and Chlamydia pneumoniae Bacteria: 5-10%

Danger Signs (IMCI) Š High risk of death from respiratory illness Younger than 2 months Decreased level of consciousness Stridor when calm Severe malnutrition Associated symptomatic HIV/AIDS

VERY SEVERE PNEUMONIA

SIGNS OF RESPIRATORY DISTRESS

SIGNS OF RESPIRATORY DISTRESS

Diagnosis White cell count and CRP Blood cultures >15,000 – 40,000/mm3 neutrophil predominance Blood cultures 25% positive NASOPHARYNGEAL ASPIRATE Viral immunoflorescence in infants Sputum specimen Gram staining Acid fast bacilli Pleural fluid examination (if present) ASO titer (in case of streptococcal pneumonia) Tuberculin skin test Viral Titres culture antigen

Treatment Antibiotics Under 5 yrs First line treatment :- amoxicillin Alternatives : coamoxiclav, cefaclor,(for typical) macrolides (for atypical) Over 5 yrs First line treatment :- amoxicillin or macrolides Alternatives :- macrolide or flucloxacillin + amoxicillin Severe pneumonia Co-amoxiclav, cefotaxime or cefuroxime Special categories (as per the suspected organism)

Treatment in special groups ORGANISMS ANTIBIOTICS IMMUNOCOMPROMISED -GRAM NEGATIVE -S. AUREUS -OPPORTUNISTIC PNEUMOCYSTIS JIROVECI -M. TUBERCULOSIS AMPICILLIN + CLOXACILLIN + AMINOGLYCOSIDE LESS THAN 3 MONTHS -GROUP B STREPTOCOCCUS -S.AUREUS AMPICILLIN + AMINOGLYCOSIDE HOSPITAL ACQUIRED PNEUMONIA -METHICILLIN RESISTANT S. AUREUS AMINOGLYCOSIDE + VANCOMYCIN + CEPHALOSPORIN (3RD GENERATION)

Treatment (contd) Oxygen Hydration Temperature control When? Methods of delivery Hydration 50 – 80ml/kg/day Temperature control Airway obstruction Chest drain :- for fluid or pus collection in chest (empyema)

Prognosis Most children recover without residual damage Incorrect treatment leads to tissue destruction and bronchiectasis ŠHalf of children with pneumonia secondary to measles or adenovirus have persistent airway obstruction

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