Acute Respiratory Infections in Children (ARI) by awais

ACUTE RESPIRATORY TRACT INFECTIONS

BYDR SYED AWAIS UL HASSAN SHAH

TRAINEE PAEDIATRICS

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

• Out- patient visits�– 20-60%

• Admissions�– 12-45%

INTRODUCTION

• In Pakistan ARI constitutes 30-60% of patients in a hospital OPD– 80% - acute upper respiratory infections– 20% - acute lower respiratory infections

• 250,000 children < 5 yrs of age die due to pneumonia in Pakistan every year

• Bacterial pneumonia is more common in Pakistan. In contrast, pneumonia in developed countries is mostly viral

INTRODUCTION• 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

UPPER RESPIRATORY TRACT INFECTIONS

• ACUTE EPIGLOTTITIS (SUPRGLOTTITIS)• CROUP (ACUTE LARYNGOTRACHEOBRONCHITIS)• RHINITIS (COMMON COLD OR CORYZA)

– RHINOVIRUSES, ENTEROVIRUSES, CORONAVIRUSES

• EAR INFECTIONS (ACUTE OTITIS MEDIA)– VIRUSES, PNEUMOCOCCUS, GABHS, HEMOPHILUS INFLUENZA, MORAXELLA CATARRHALIS

• ACUTE INFECTIOUS LARYNGITIS– VIRAL/DIPTHERIA

• ACUTE PHARYNGITIS– ADENOVIRUS, ENTEROVIRUS, RHINOVIRUS, GROUP A BETA HEMOOLYTIC STREPTOCOCCUS(older

children)

• TONSILLITIS– GROUP A BETA HEMOLYTIC STREPTOCOCCI, EBV

• SINUSITIS– VIRAL/BACTERIAL

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)

DIFFRENTIATING BETWEEN ACUTE LTB AND ACUTE EPIGLOTTITIS

CROUP EPIGLOTTITIS

TIME COURSE DAYS HOURS

PRODROME CORYZA NONE

COUGH BARKING SLIGHT IF ANY

FEEDING CAN DRINK NO

MOUTH CLOSED DROOLING SALIVA

TOXIC NO YES

FEVER <38.5 C >38.5 C

STRIDOR RASPING SOFT

VOICE HOARSE WEAL OR SILENT

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• 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

• Developing world�– Common cause of death– Bacteria and PCP in 65%

• 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

• Vary according to �– Age, immune status, where contracted

• 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%

ETIOLOGY ACCORDING TO AGEAGE GROUP CAUSATIVE ORGANISM

NEONATES GROUP B STREPTOCOCCUSE.COLIKLEBSIELLASTAPH AUREUS

INFANTS PNEUMOCOCCUSCHLAMYDIARSVH.INFLUENZA TYPE b

CHILDREN 1 TO 5 YRS RESPIRATORY VIRUSESPNEUMOCOCCUSH.INFLUENZA TYPE bC.TRACHOMATISM.PNEUMONIAES.AUREUSGP A STREPTOCOCCUS

CHILDREN 5 TO 18 YRS M.PNEUMONIAEPNEUMOCOCCUSC.PNEUMONIAEH.INFLUENZA TYPE b

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

HIGH RISK CHILDREN FOR PNEUMONIA

• CONGENITAL LUNG CYSTS• CHRONIC LUNG DISEASE• IMMUNODEFICIENCY• CYSTIC FIBROSIS• SICKLE CELL DISEASE• TRACHEOSTOMY IN SITU

Danger Signs (IMCI)

• 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

Radiology

Bacterial– Poorly demarcated

alveolar opacities with air bronchograms

– Lobar or segmental opacification

Radiology

� Viral– Perihilar streaking, interstitial changes, air trapping

Radiology

• Clues to other specific �organisms– Staphylococcus – areas of

break-down– Klebsiella, anaerobes, H.

influenza or TB –cavitating or expansile pneumonia

– TB, S. aureus, H. influenza • pleural effusion and

empyema

Diagnosis• White cell count and CRP

– >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

COMPLICATIONS OF PNEUMONIA• EMPYEMA• LUNG ABSCESS• PNEUMOTHORAX• PNEUMATOCELE• PLEURAL EFFUSION• DELAYED RESOLUTION• RESPIRATORY FAILURE• METASTATIC SEPTIC LESIONS

– MENINGITIS– OTITIS MEDIA– SINUSITIS– SPETICAEMIA

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 groupsGROUP ORGANISMS ANTIBIOTICS

IMMUNOCOMPROMISED -GRAM NEGATIVE-S. AUREUS-OPPORTUNISTIC PNEUMOCYSTIS JIROVECI-M. TUBERCULOSIS

AMPICILLIN + CLOXACILLIN +AMINOGLYCOSIDE

LESS THAN 3 MONTHS -GRAM NEGATIVE-GROUP B STREPTOCOCCUS-S.AUREUS

AMPICILLIN +AMINOGLYCOSIDE

HOSPITAL ACQUIRED PNEUMONIA

-GRAM NEGATIVE-METHICILLIN RESISTANT S. AUREUS

AMINOGLYCOSIDE + VANCOMYCIN + CEPHALOSPORIN (3RD GENERATION)

Treatment (contd)• Oxygen�

– When? – Methods of delivery

• Hydration�– 50 – 80ml/kg/day

• Temperature control�• Airway obstruction�• Chest drain :- for fluid or pus collection in chest (empyema)

Failure to respond

• Incorrect or inadequate dose of antibiotic�• Resistant or not suspected organism�• Empyema or other complication�• TB�• Suppressed immunity�• Underlying cause�– e.g. foreign body or bronchiectasis

• Left heart failure and not pneumonia� Refer if no improvement after 3 – 5 days

Prognosis

• Most children recover without residual �damage

• Incorrect treatment leads to tissue �destruction and bronchiectasis

• Half of children with pneumonia secondary to �measles or adenovirus have persistent airway obstruction

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