1. ACUTE RESPIRATORY TRACT INFECTIONSBY
DR Aso faeq salih
Pediatric department

2. 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

3. 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

4. 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

5. 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

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

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

9. ACUTE EPIGLOTTITIS
EPIGLOTTITIS IS A MEDICAL EMERGENCY

10. 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 mg/kg/day IV
RIFAMPICIN PROPHYLAXIS TO CLOSE CONTACTS

11. 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

12. 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

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

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

16. 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)

17. LOWER RESPIRATORY TRACT INFECTIONS
BRONCHITIS/BRONCHIOLOITIS
PNEUMONIA

18. 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

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

20. 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

21. 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)

22. 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

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

24. 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)

25. 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

26. 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%

27. 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

28. VERY SEVERE PNEUMONIA

29. SIGNS OF RESPIRATORY DISTRESS

30. SIGNS OF RESPIRATORY DISTRESS

31. 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

32. 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)

33. 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)

34. 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)

35. 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

36. THANKYOU