ACUTE RESPIRATORY INFECTIONS

Dr Mallikarjuna DStudy PhysicianDepartment of Community MedicineKMC,Manipal

Learning Objectives• Introduction• Epidemiological determinants• Mode of Transmission• Clinical Assessment• Classification of Illness• Treatment• Prevention of Acute respiratory infections

INTRODUCTION• It causes inflammation of the respiratory tract anywhere

from nose to alveoli with combination of signs and symptoms

It is classified depending upon the site:• Acute Upper Respiratory Infections (AURI)• Acute Lower Respiratory Infections (ALRI)

Introduction…

• AURI includes common cold, pharyngitis and otitis media

• ALRI includes epiglottitis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis and pneumonia.

Burden of ARI

ARI deaths attributable to Undernutrition

Importance

Epidemiological DeterminantsAGENT FACTORS:

The microbial agents that cause ARI are numerous and include bacteria and viruses

• Even within species they show wide diversity of antigenic type

• Severity of illness is determined by whether secondary bacterial infection occurs or not

Bacterial agentsAgent Age groups frequently

affectedCharacteristic clinical features

Bordetella pertusis Infant, young children Paroxysmal cough

Corynebacterium diphtheriae

children Nasal/tonsillar/pharyngeal membraneous exudate, severe toxemia

Streptococcus pneumoniae All ages specifically under 5 children

Lobar and multilobular pneumonia, acute exacerbations of chronic bronchitis

Streptococcus pyogenes All ages Acute pharyngitis and tonsillitis

Staphylococcus pyogenes All ages Lobar and bronchopneumonia, lung abscess

Haemophilus inflenzae children Acute epiglottitis (type B)

Klebsiella pneumoniae Adults Lobar pneumonia , lung abscess

Legionella pneumoniae Adults Pneumonia

Viral agentsAgent Age group frequently

affectedCharacteristic clinical features

Adenovirus endemic types(1,2,5)

Young children LRTI

Epidemic types(3,4,7) Older children , young adults

Pharyngitis , flu like illness

Influenza A, B,C All ages, school children Variable respiratory symptoms, occasional primary pneumonia

Parainfluenza 1,2,3 Young children and infants

Croup

Respiratory syncytial virus

Infants, young children Severe bronchilitis and pneumonia

Rhinovirus All ages Common cold

Corona virus All ages Common cold

Measles Young children Variable respiratory with rash

Host factors• Case fatality rates are higher in young infants and

malnourished children• In developing countries like India, malnutrition and low

birth weight is often a major problem, the rates are highest in those children

• The rates of pharyngitis and otitis media increase from infancy to peak at the age of 5 years

Risk factors• Climatic conditions• Housing• Level of industrialization• Socio economic development• Overcrowded dwellings• Poor nutrition• Low birth weight• Intense indoor smoke pollution

Mode of transmission

• Air borne route

• Chain of transmission is maintained by direct person-person contact

Clinical assessment• History to be elicited:• Age of the child• Since how long the child is coughing• Young infant stopped feeding well (less than 2 months)• The child is able to drink (2 months to 5 years)• H/O fever• Child is excessively drowsy/difficult to wake• Irregular breathing• Convulsions • The child turning blue

Physical examination

• Count the breaths in one minute

• Fast breathing depend upon the age of the child

• It should be seen for 1 full minute looking at the abdominal movement or lower chest when the child is calm

Fast Breathing

Age Fast breathing

Less than 2months 60 breaths /more

2months to 1 year 50 breaths/more

1 to 5 years 40 breaths/more

Look for chest indrawing• The child has chest indrawing if the lower chest wall goes in when the child breathes in

• It occurs when the effort required to breathe in is much greater than normal

Look and listen for stridor

• Stridor makes a harsh noise when the child breaths IN

• It occurs when there is narrowing of the larynx, trachea or epiglottis which interferes with air entering the lungs

• This condition is called croup

Look for wheeze• Wheezing is soft whistling noise when the child breathes

OUT• It is caused by narrowing of air passage in lung• Breathing out phase takes longer than normal and effort• Elicit H/O previous history of wheezing• If so, the child is classified as having recurrent wheeze

Other Signs

• See if the child is abnormally sleepy or difficult to wake

• Feel for fever or lower body temperature

• Cyanosis is a sign of hypoxia, must be checked in good light

Check for severe malnutrition• High risk factor• Case fatality rates are higher in these children• In a severely malnourished children with pneumonia, fast

breathing and chest indrawing may not be as evident • Impaired/absent response to hypoxia and a weak/absent

cough reflex

• These children need careful evaluation and management for pneumonia

Classification of illness

Child aged 2 months – 5 years:• Very severe disease• Severe pneumonia• Pneumonia• No pneumonia

Infants less than 2 months:• Very severe pneumonia• Severe pneumonia• No pneumonia

Child aged 2 months to 5 years

Very severe disease:

•Signs : not able to drink, convulsions, abnormally sleepy or difficult to wake, Stridor in calm child and Severe malnutrition

•Treatment:• Refer urgently to hospital• Give first dose of antibiotic• Treat fever, if present• Treat wheezing ,if present• If cerebral malaria is present, give an antimalarial

Severe pneumonia• Signs : chest indrawing, recurrent wheezing

Treatment:• Refer urgently to hospital• Give first dose of antibiotic• Treat fever, wheezing if present• If referral is not feasible treat with an antibiotic and follow

closely

Pneumonia• Signs : fast breathing and no chest indrawing

Treatment:• Advice mother to give home care• Give an antibiotic• Treat wheezing / fever if present• Advice mother to return with child after 2 days for

reassessment/ earlier if the child is getting worst

Reassessment Re-assess the child after 2 days

Worse same improving

Not able to drink Breathing slower,less Has chest indrawing fever, eating better danger signs

Refer URGENTLY to change antibiotic / refer finish 5 days of Hospital antibiotic

Infants less than 2 years

Very severe pneumonia:• Signs : stopped feeding well, convulsions, abnormally

sleepy, stridor, wheezing, fever or hypothermia

Treatment :• Refer URGENTLY to hospital• Keep young infant warm• Give first dose of an antibiotic

Severe pneumonia• Signs : severe chest indrawing or fast breathing (60

breaths per minute or more)

• Treatment :• Refer URGENTLY to hospital• Keep young infant warm• Give first dose of antibiotic• If referral is not feasible treat with an antibiotic and follow

closely

No pneumonia: cough or cold• Signs : no chest indrawing and no fast breathing

• Treatment :• Advice mother to give the following home care – keep

young infant warm, breast feed frequently, clear nose if it interferes with feeding

• Return if any danger signs- breathing becomes difficult/fast, not feeding, and infant becomes sicker

Treatment - Pneumonia

Age/weight Paediatric tabletSulfamethoxazole 100 mg, Trimethoprim 20 mg

Paediatric syrup5ml –sulfamethoxazole 200mg, trimethoprim 40 mg

<2 months/3-5 kg 1 tablet twice a day Half spoon (2.5 ml) twice a day

2- 12 months/6-9 kg 2 tablets twice a day One spoon (5ml) twice a day

1-5 years/10-19 kg 3 tablets twice a day One and half spoon (7.5ml) twice a day

Treatment of severe pneumoniaAntibiotics Dose Interval ModeA. First 48 hoursBenzyl penicillin OR

50000 IU/kg/dose 6 hourly IM

Ampicillin 50mg/kg/dose 6 hourly IMChloramphenicol 25mg/kg/dose 6 hourly IM

B. If condition IMPROVES

Then for the next 48 hours

Procaine penicillin 50,000 IU/kg once IM

Ampicillin 50mg/kg/dose 6 hourly oralChloramphenicol 25mg/kg/dose 6 hourly oral

Treatment of severe pneumonia…• If there is no improvement ,then for the next 48 hours

change antibiotic

• Provide symptomatic treatment for fever and wheezing

• Monitor fluid and food intake

• Advice mother on home management on discharge

Infants less than 2 monthsAntibiotic Dose Frequency in

age <7daysFrequency in age 7 days to 2 months

Inj.Benzyl penicillin

50000 IU/kg/dose 12 hourly 6 hourly

Inj.Ampicillin 50mg/kg/dose 12 hourly 8 hourly

Inj.Gentamycin 2.5mg/kg/dose 12 hourly 8 hourly

Management of AURI

• DO NOT require treatment with antibiotics

• Causative agents are viruses

• Increase resistant strains and cause side effects

• Symptomatic treatment and care at home

Prevention of ARI

Prevention of ARI• ARI control programme is the part of RCH programme• Improved living conditions• Better nutrition• Reduction of smoke pollution indoors• Better Maternal Child Health care• Immunization• Health promotional activities

Immunization

• Measles vaccine

• HIB vaccine

• Pneumococcal pneumonia vaccine

Pneumococcal Pneumonia vaccine

• PPV23:• It is a polysaccharide, non conjugate vaccine containing

capsular antigens of 23 serotypes, available for children above 2 years and adults

• Single IM / subcutaneous dose is given in deltoid muscle• It should never be mixed with other vaccines in the same

syringe, it can be given at the same time as separate injection in other arm

PCV• Two conjugate vaccines are available PCV10 and PCV 13• Storage temperature : 2-8degrees• It is given in infants as 3 primary doses/2 primary and 1

booster dose• Initiated as early as 6 weeks with an interval of 4-8 weeks• Doses at 6,10,14 weeks/2,4,6 months• One booster dose is given at 9-15 months

PCV…• HIV positive and preterm babies who have received 3

primary doses in 1 year, require booster dose in 2nd year• When primary immunization is initiated with one of

vaccines, it is recommended that remaining doses are administered with the same product

• WHO recommends inclusion of PCVs in UIP worldwide, particularly in countries with high under5 mortalities

Thank you