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7/27/2019 002 Assesment for Cough and Difficult Breathing
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“Approach to Sick Child
Under 5 Years Old ” (IMCI)
PRE-CONFERENCE WORKSHOP 1
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Assessment and Managementof Children with
Cough and Difficult Breathing
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Introduction
• A child with cough or difficult breathing may havepneumonia or another severe respiratoryinfection.
• Both bacteria and viruses can cause pneumonia
• In developing countries, pneumonia is often dueto bacteria.
• The most common are Streptococcus
pneumoniae and Hemophilus influenzae.• Children with bacterial pneumonia may die from
hypoxia or sepsis .
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Introduction..
• There are many children who come to the clinicwith less serious respiratory infections. Mostchildren with cough or difficult breathing have
only a mild infection.• For example, a child who has a cold may cough
because nasal discharge drips down the back of the throat or bronchitis.
• These children are not seriously ill. They do notneed treatment with antibiotics. Their familiescan treat them at home.
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Introduction…
• Health workers need to identify the few, very
sick children with cough or difficult breathing
who need treatment with antibiotics.
• Fortunately, health workers can identify
almost all cases of pneumonia by checking for
these two clinical signs: fast breathing and
chest indrawing.
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Presenting complaint or sign can be
associated with a number of conditions;
Presenting compliant Possible cause/ associated condition
Cough and/or PneumoniaFast breathing Severe anaemia
P. falciparum malaria
Drowsy or Cerebral malariaUnconsciousness Meningitis
Severe dehydrationVery severe pneumonia
Measles rash PneumoniaDiarrhoeaEar infection
‘Very sick’ young infant Pneumonia
MeningitisSepsis04/07/2013 7
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IMCI Case Management Process
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IMCI Case Management Process
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IMCI Case Management Process
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THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
IF YES, ASK: LOOK, LISTEN, FEEL:
For how long ·
. Count the breaths in one minute
· Look for chest indrawing
· Look and listen for stridor· Look and listen for wheeze
Child
must
becalm}if wheezing and either fast breathing or chest
indrawing:
Give a trial of inhaled Salbutamol for up to
three times 15-20 minutes apart. Count thebreaths and look for chest indrawing again
and then classify
IMCI Case Management Process
If the child is: fast breathing is:
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more04/07/2013 11
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LOOK for chest indrawing
• When the child breathes IN (lower ribs). The
child has chest indrawing if the lower chest
wall goes IN when the child breathes IN .
• Chest indrawing is lower chest wall indrawing.
It does not include "intercostal
indrawing.“(soft tissue between the rib goes
in)
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• For chest indrawing to be present, it must be
clearly visible and present all the time.
• If chest indrawing only present when the child
is crying or feeding, the child does not have
chest indrawing.
LOOK for chest indrawing
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LOOK for chest indrawing
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LOOK and LISTEN for stridor
• Is a harsh noise made when the child breathes
IN, happens when there is a swelling of the
larynx, trachea or epiglottis.
• This swelling interferes with air entering the
lungs. It can be life-threatening when the
swelling causes the child's airway to be
blocked.
• A child who has stridor when calm has a
dangerous condition.
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LOOK and LISTEN for wheeze
• Is a musical noise heard when the child breathes
OUT.
• Occurs when the air flow from the lungs is
obstructed due to narrowing of the small airways.• If the child is wheezing and has either fast breathing
or chest indrawing, give a trial of inhaled Salbutamol
for three times; every 15 -20 minutes apart.
• 15 minutes after completing the 3rd dose of inhaled
Salbutamol, count the breaths and look for chest
indrawing again and re-classifying.
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CLASSIFY cough or difficult breathing
• There are four possible classifications for a
child with cough or difficult breathing;
SEVERE PNEUMONIA OR VERY SEVERE
DISEASE or
PNEUMONIA or
WHEEZE or
COUGH OR COLD
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IMCI Case Management Process
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Classification table for cough or
difficult breathingSIGNS CLASSIFY AS TREATMENT
(Urgent pre-referral treatment are in bold print)
Any general danger sign or
Chest indrawing or
Stridor in calm child
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
Give first dose of an appropriate antibiot ic
Refer URGENTLY to ho spital*
Give oxyg en if available
Treat wheeze if present with inh aled Salbutamol
Fast breathing
PNEUMONIA
Give oral antibiot ic for 5 days
Treat wheeze with inhaled Salbutamol and continuewith oral Salbutamol for 5 days
Soothe the throat and relieve cough with safe remedy
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Advise mother when to return immediately
Follow up in 2 days
Wheeze
WHEEZE
Treat wheeze with inhaled Salbutamol and continue
with oral Salbutamol for 5 days Soothe throat and relieve cough with safe remedy
Advise mother when to return immediately
Follow up in 5 days
No signs of pneumonia
or very severe disease
COUGH OR COLD
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Soothe the throat and relieve the cough with
a safe remedy
Advise mother when to return immediately Follow-up in 5 days if not improving
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TREAT THE CHILDGive an Appropriate Oral Antibiotic FOR PNEUMONIA, ACUTE EAR INFECTION, MASTOIDITIS OR VERY SEVERE DISEASE:
FIRST-LINE ANTIBIOTIC: AMOXCYCILLIN (25 mg/kg/dose)
SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE (4mg/kg/dose)
AMOXYCILLIN
Give TWO times daily for 5 days
COTRIMOXAZOLE
(Trimethoprime +
Sulphamethoxazole)Give TWO times daily for 5 days
AGE or WEIGHT Syrup 125 mg/5 ml Syrup 40 mg Trimethoprim + 200
mg Suphamethoxazole/5 ml
2 months up to 4 months
(4 - <6 kg)
5 ml 2.5 ml
4 months up to 12 months
(6- <10 kg)
7.5 ml 5 ml
12 months up to 5 years
(10- <19 kg)
10 – 15 ml 7.5 – 10 ml
FOR SEVERE PNEUMONIA OR VERY SEVERE DISEASE/ MASTOIDITIS: If the child can take orally givedouble the dose of Amoxycillin before urgent referral. Do not use Cotrimoxazole.04/07/2013 20
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GIVE THESE TREATMENT IN CLINIC ONLY
• Treat Wheeze in the Child
1. Use of Nebuliser • Dilute 0.5 ml Salbutamol solution (5mg/ml) with 3.5 ml normal saline in a
nebulizer chamber.
• Place the mask to cover the child’s nose and mouth.
• Give the oxygen flow of 6-8 liters/min.
• Nebulise until the liquid is used up or for at least 15 minutes.
2. Use of Spacer or Aerochamber
• Remove the inhaler cap.
• Shake the inhaler well.
• Insert mouthpiece of the inhaler into spacer or Aerochamber.
• Depress the canister down to actuate the spray once.
• Gently place the mask of the spacer to cover the mouth and nose.
• Ask the patient to breathe for at least 10 breaths (infants), 6 breaths (child).
• Give 2 puffs (100mcg/puff), allow at least 30 seconds between each puff.
• Replace inhaler cap.04/07/2013 21
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Classification table for cough or
difficult breathing Any general danger sign or
Chest indrawing or
Stridor in calm child
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
Give first dose of an appropriate antibio t ic
Refer URGENTLY to ho spital*
Give oxyg en if available
Treat wheeze if present with inh aled Salbutamol
Fast breathing
PNEUMONIA
Give oral antibiot ic for 5 days
Treat wheeze with inhaled Salbutamol and continue
with oral Salbutamol for 5 days Soothe the throat and relieve cough with safe remedy
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Advise mother when to return immediately
Follow up in 2 days
Wheeze
WHEEZE
Treat wheeze with inhaled Salbutamol and continue
with oral Salbutamol for 5 days
Soothe throat and relieve cough with safe remedy Advise mother when to return immediately
Follow up in 5 days
No signs of pneumonia
or very severe disease
COUGH OR COLD
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Soothe the throat and relieve the cough with
a safe remedy
Advise mother when to return immediately
Follow-up in 5 days if not improving04/07/2013 22
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TREAT THE CHILDGive an Appropriate Oral Antibiotic FOR PNEUMONIA, ACUTE EAR INFECTION, MASTOIDITIS OR VERY SEVERE DISEASE:
FIRST-LINE ANTIBIOTIC: AMOXCYCILLIN (25 mg/kg/dose)
SECOND-LINE ANTIBIOTIC: COTRIMOXAZOLE (4mg/kg/dose)
AMOXYCILLIN
Give TWO times daily for 5 days
COTRIMOXAZOLE
(Trimethoprime +
Sulphamethoxazole)Give TWO times daily for 5 days
AGE or WEIGHT Syrup 125 mg/5 ml Syrup 40 mg Trimethoprim + 200
mg Suphamethoxazole/5 ml
2 months up to 4 months
(4 - <6 kg)
5 ml 2.5 ml
4 months up to 12 months
(6- <10 kg)
7.5 ml 5 ml
12 months up to 5 years
(10- <19 kg)
10 – 15 ml 7.5 – 10 ml
FOR SEVERE PNEUMONIA OR VERY SEVERE DISEASE/ MASTOIDITIS: If the child can take orally givedouble the dose of Amoxycillin before urgent referral. Do not use Cotrimoxazole.04/07/2013 23
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GIVE THESE TREATMENT IN CLINIC ONLY
• Treat Wheeze in the Child
1. Use of Nebuliser • Dilute 0.5 ml Salbutamol solution (5mg/ml) with 3.5 ml normal saline in a
nebulizer chamber.
• Place the mask to cover the child’s nose and mouth.
• Give the oxygen flow of 6-8 liters/min.
• Nebulise until the liquid is used up or for at least 15 minutes.
2. Use of Spacer or Aerochamber
• Remove the inhaler cap.
• Shake the inhaler well.
• Insert mouthpiece of the inhaler into spacer or Aerochamber.
• Depress the canister down to actuate the spray once.
• Gently place the mask of the spacer to cover the mouth and nose.
• Ask the patient to breathe for at least 10 breaths (infants), 6 breaths (child).
• Give 2 puffs (100mcg/puff), allow at least 30 seconds between each puff.
• Replace inhaler cap.04/07/2013 24
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TREAT THE CHILD
• GIVE ORAL SALBUTAMOL
ORAL SALBUTAMOL
Give three times daily for 5 days
AGE or WEIGHT 2mg/5 ml syrup2 months up to 4 months (4 - <6 kg) 1 ml
4 months up to 12 months (6- <10 kg) 2 ml
12 months up to 3 years (10- <14 kg) 3.5 ml
3 years up to 5 years (14 - <19 kg) 5 ml
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TEACH THE MOTHER TO TREAT LOCAL
INFECTIONS AT HOME
Soothe the Throat, Relieve the Cough with a
Safe Remedy
• Safe remedies to recommend:
- Breastmilk for breastfed infant.
- Warm water if not breastfed.
•
Harmful remedies to discourage:- Cough syrup.
- Nasal decongestants.
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WHEN TO RETURN IMMEDIATELY
Advise mother to return immediately if the child has any of
these signs:
Any sick child • Not able to drink or breastfeed
• Becomes sicker • Develops a fever
If child has COUGH OR COLD, also
return if:
• Fast breathing
• Difficult breathing
If child has Diarrhoea, also return if:•
Blood in stool• Drinking poorly
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Advise the Mother When to Return
to Health Worker FOLLOW-UP VISIT
If the child has: Return for first follow-up visit
in:
•PNEUMONIA
•DYSENTRY
•MALARIA, if fever persists•FEVER-MALARIA UNLIKELY, if fever persists
•MEASLES WITH EYE OR MOUTH COMPLICATIONS
2 days
•WHEEZE
•PERSISTENT DIARRHOEA
•
ACUTE EAR INFECTION•CHRONIC EAR INFECTION
•FEEDING PROBLEM
• ANY OTHER ILLNESS, if not improving
5 days
• ANAEMIA
•VERY LOW WEIGHT FOR AGE
14 days
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Classification table for cough or
difficult breathing Any general danger sign or
Chest indrawing or
Stridor in calm child
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
Give first dose of an appropriate antibio t ic
Refer URGENTLY to ho spital*
Give oxyg en if available
Treat wheeze if present with inh aled Salbutamol
Fast breathing
PNEUMONIA
Give oral antibiot ic for 5 days
Treat wheeze with inhaled Salbutamol and continue
with oral Salbutamol for 5 days
Soothe the throat and relieve cough with safe remedy
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Advise mother when to return immediately
Follow up in 2 days
Wheeze
WHEEZE
Treat wheeze with inhaled Salbutamol and continue
with oral Salbutamol for 5 days
Soothe throat and relieve cough with safe remedy Advise mother when to return immediately
Follow up in 5 days
No signs of pneumonia
or very severe disease
COUGH OR COLD
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Soothe the throat and relieve the cough with
a safe remedy
Advise mother when to return immediately
Follow-up in 5 days if not improving04/07/2013 29
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GIVE THESE TREATMENT IN CLINIC ONLY
• Treat Wheeze in the Child
1. Use of Nebuliser • Dilute 0.5 ml Salbutamol solution (5mg/ml) with 3.5 ml normal saline in a
nebulizer chamber.
• Place the mask to cover the child’s nose and mouth.
• Give the oxygen flow of 6-8 liters/min.
•Nebulise until the liquid is used up or for at least 15 minutes.
2. Use of Spacer or Aerochamber
• Remove the inhaler cap.
• Shake the inhaler well.
• Insert mouthpiece of the inhaler into spacer or Aerochamber.
• Depress the canister down to actuate the spray once.
• Gently place the mask of the spacer to cover the mouth and nose.
• Ask the patient to breathe for at least 10 breaths (infants), 6 breaths (child).
• Give 2 puffs (100mcg/puff), allow at least 30 seconds between each puff.
• Replace inhaler cap.04/07/2013 30
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TREAT THE CHILD
• GIVE ORAL SALBUTAMOL
ORAL SALBUTAMOL
Give three times daily for 5 days
AGE or WEIGHT 2mg/5 ml syrup2 months up to 4 months (4 - <6 kg) 1 ml
4 months up to 12 months (6- <10 kg) 2 ml
12 months up to 3 years (10- <14 kg) 3.5 ml
3 years up to 5 years (14 - <19 kg) 5 ml
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TEACH THE MOTHER TO TREAT LOCAL
INFECTIONS AT HOME
Soothe the Throat, Relieve the Cough with a
Safe Remedy
• Safe remedies to recommend:
- Breastmilk for breastfed infant.
- Warm water if not breastfed.
•
Harmful remedies to discourage:- Cough syrup.
- Nasal decongestants.
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Advise the Mother When to Return
to Health Worker FOLLOW-UP VISIT
If the child has: Return for first follow-up visit
in:
•PNEUMONIA
•DYSENTRY
•MALARIA, if fever persists•FEVER-MALARIA UNLIKELY, if fever persists
•MEASLES WITH EYE OR MOUTH COMPLICATIONS
2 days
•WHEEZE
•PERSISTENT DIARRHOEA
•
ACUTE EAR INFECTION•CHRONIC EAR INFECTION
•FEEDING PROBLEM
• ANY OTHER ILLNESS, if not improving
5 days
• ANAEMIA
•VERY LOW WEIGHT FOR AGE
14 days
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Classification table for cough or
difficult breathing Any general danger sign or
Chest indrawing or
Stridor in calm child
SEVERE
PNEUMONIA
OR VERY
SEVERE DISEASE
Give first dose of an appropriate antibio t ic
Refer URGENTLY to ho spital*
Give oxyg en if available
Treat wheeze if present with inh aled Salbutamol
Fast breathing
PNEUMONIA
Give oral antibiot ic for 5 days
Treat wheeze with inhaled Salbutamol and continue
with oral Salbutamol for 5 days
Soothe the throat and relieve cough with safe remedy
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Advise mother when to return immediately
Follow up in 2 days
Wheeze
WHEEZE
Treat wheeze with inhaled Salbutamol and continue
with oral Salbutamol for 5 days
Soothe throat and relieve cough with safe remedy Advise mother when to return immediately
Follow up in 5 days
No signs of pneumonia
or very severe disease
COUGH OR COLD
If coughing more than 14 days or if having recurrent
wheezing, refer for assessment for TB or Asthma
Soothe the throat and relieve the cough with
a safe remedy
Advise mother when to return immediately
Follow-up in 5 days if not improving04/07/2013 35