13-10 topic 1. introduction

8/13/2019 13-10 Topic 1. Introduction

1/37

03/10/2013

1

TOPIC 1.

INTRODUCTION

ARI management training


2/37

03/10/2013

2

CONTENTS

Introduction

Definition and scope of ARI

Epidemiology & burden of ARI

Common cold - acute rhinopharyngitis

Croup - laryngotracheobronchitis

Acute otitis media

DEFINITION AND SCOPE


3/37

03/10/2013

3

CLASSIFICATION

ANATOMICALLY : (ARNOLD,1996)

ACUTE UPPER RESPIRATORYINFECTIONS(AURI)

INDONESIAN :

INFEKSI RESPIRASI AKUT ATAS ( IRA-A)

ACUTE LOWER RESPIRATORY INFECTIONS

(ALRI)

INDONESIAN :

INFEKSI RESPIRASI AKUT BAWAH (IRA-B)


4/37

03/10/2013

4

AURI (IRA-A) : COMMON COLD (RHINITIS, RHINOPHARYNGITIS) PHARYNGITIS - TONSILOPHARYNGITIS RHINO-SINUSITIS OTITIS MEDIA

ALRI (IRA-B) :

EPIGLOTITIS LARYNGO-TRACHEOBRONCHITIS BRONCHITIS BRONCHIOLITIS PNEUMONIA

The most common illnesses in childhood,

comprising as many as 50% of all

illnesses in children less than 5 years old

and 30% in children aged 5 - 12 years.

EPIDEMIOLOGY AND BURDEN


5/37

03/10/2013

5

MORBIDITY

50% OF ALL ILLNESS DISEASE IN CHILDREN

UNDER 5 YEARS; 30% IN CHILDREN 5 -12 YEARS

MOST INFECTIONS ARE LIMITED TO UR TRACT, ABOUT

5% LR TRACT

EPISODE IN URBAN 5-8, RURAL 3-5/YEAR

PNEUMONIA IN DEVELOPING COUNTRY IS MORE THAN

IN DEVELOPED COUNTRY

IN INDONESIA

MORBIDITYESTIMATION IN CHILDREN 5 YEARS OF

AGE 10-20% ( 2.33 - 4.66 MILLION)

MORTALITY

>> PNEUMONIA


6/37

03/10/2013

6

WHO ARI control program (included in

IMCI Algorithm ) uses simple clinical sign

are Respiratory rateand Chest

indrawing for ARI classification

WHO ARI classfication :

2 months - 5 tahun of age

1. SEVERE PNEUMONIA2. PNEUMONIA

3. NO PNEUMONIA

until 2 months of age

1.SEVERE PNEUMONIA

2.NO PNEUMONIA

ETIOLOGY AURI : >> VIRUS ( 90%)

COMMON VIRUSES

AURI (IRA -A) : Rhinovirus, Corona virus,

Adenovirus, Entero virusALRI (IRA -B) : RSV, Para influenza 1,2,3;

Corona virus,

Adeno virus, Enterovirus


7/37

03/10/2013

7

Common cold

COMMON COLD

an acute, self limited, mild upper respiratory

viral illness

sneezing, nasal congestion and discharge

(rhinorrhea), sore throat, cough, low gradefever, headache and malaise.

to be distinguished from influenza,

pharyngitis, acute bronchitis, acute bacterial

sinusitis, allergic rhinitis, and pertussis.

4


8/37

03/10/2013

8

many viral pathogens can cause the

symptoms of the common cold

the most common : > 100 serotypes of

rhinoviruses.

Common cold may occur at any time ofyear, high prevalence during the fall and

winter

6

...COMMON COLD

An estimated 25 million individuals seekmedical care for uncomplicated URI annuallyin the US

Approx. 30 % of these visits result in a

prescription for antibiotics. Inaccurate perceptions that bacteria cause colds

and that antibiotics improve outcome

Infants and children are affected more oftenand experience more prolonged symptoms

5

...COMMON COLD


9/37

03/10/2013

9

many viral pathogens can cause the

symptoms of the common cold

the most common : > 100 serotypes of

rhinoviruses.

Common cold may occur at any time ofyear, high prevalence during the fall and

winter

6

...COMMON COLD

Virus

Rhinoviruses

Coronaviruses

Influenza viruses

Respiratory syncytial virus

Parainfluenza viruses

Adenoviruses

Enteroviruses

Metapneumovirus

Unknown

Estimated annual proportion of cases (percent)

30-50

10-15

5-15

5

5


10/37

03/10/2013

10

Viral transmission may occur via

inhalation of small particle aerosols,

deposition of large particle droplets on

nasal or conjunctival mucosa,

or direct transfer via hand-to-hand contact

8

...COMMON COLD

Symptoms usually appear 1-2 days after viralinoculation

symptoms are not the result of viral destruction

of the nasal mucosa.

nasal epithelium remains intact, although there

is an influx of PMNs into the nasal submucosaand epithelium

viral infection increases vascular permeability in

the nasal submucosa, releasing albumin andkinins

9

...COMMON COLD


11/37

03/10/2013

11

Infected cells undergo apoptosis

and are extruded from the mucosa

Signalling within cells occur via NF-kB

(and perhaps other pathways)

Elaboration of pro inflammatory cytokines

Initiation of plasma exudation

from submucosal capilaries

Recruitment of PMNs to

nasal epithelium (IL-8)

Proposed sequence of events during rhinovirus infection of

nasal epithelium

Infection of nasal epithelial cell

Pappas DE, Hendley JO. Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections.

Up to date. Last updated February 2008 10

Colored nasal discharge

~ increased presence of PMNs

presence of PMNs (yellow or white color) orof PMN enzymatic activity (green color)

11

...COMMON COLD


12/37

03/10/2013

12

Supportive therapy is the only recommended

treatment

Antihistamines, decongestants, antitussives, and

expectorants, singly and in combinations, are all

marketed for symptomatic relief in children.

few clinical trials of these products in infants

and children and none that demonstrate benefit

for treatment of the symptoms

12

...COMMON COLD

TREATMENT

Symptomatic therapy

may include antipyretics, saline nasal irrigation,

adequate hydration, and the use of a humidifier

Children with reactive airway disease or asthmashould use beta-agonist medications to relieve

associated bronchospasm.

13

...COMMON COLD


13/37

03/10/2013

13

Antipyretics

Acetaminophen (or ibuprofen, in children

greater than 6 months of age) may be used to

alleviate fever during the first few days

14

...COMMON COLD

Saline irrigation

In infants, bulb suction with saline nose drops

may help to temporarily remove nasal

secretions

in the older child, a saline nose spray may be

used.

15

...COMMON COLD


14/37

03/10/2013

14

Antihistamines

The anticholinergic effects of 1st generation AH

(eg, diphenhydramine) may help to reduce the

secretions

in controlled trials, AH have been ineffective inrelieving the symptoms, in combination with

decongestants or as monotherapy

16

...COMMON COLD

Antitussives

Cough is a common complaint during the

course

For many children, effective cough

suppression could result in mucus plugging

No cough suppressants have proven effective

in children.

17

...COMMON COLD


15/37

03/10/2013

15

In a study comparing placebo, DMP, and

codeine for treatment of cough in children 18

mo - 12 y.o

- no difference found between the

groups, and all three groups showed significant

improvement within three days

Insomnia was reported in 3 of 33 children in the

dextromethorphan group.

18

...COMMON COLD

Because of the potential serious toxicities

and the lack of proven efficacy, these

medications are not recommended for

pediatric use.

19

...COMMON COLD


16/37

03/10/2013

16

Decongestants

sympathomimetic medications that cause

vasoconstriction of the nasal mucosa.

available in oral and topical formulations.

pseudoephedrine HCl, and phenylephrine HCl,and oxymetazoline.

20

In adults: decrease nasal congestion and

increase patency,

no studies demonstrating the effectiveness of

these medications in children.

Side effects may include tachycardia, elevated

diastolic blood pressure, and palpitations.

21

...COMMON COLD


17/37

03/10/2013

17

Because of the substantial risks of these

products without proven benefit

not recommended for pediatric use.

It is conceivable that the older adolescent may

benefit as an adult would from the use of a

decongestant, such as pseudoephedrine

22

...COMMON COLD

Zinc

The efficacy for treatment of the common

cold remains unclear.

for every study that demonstrates benefit,

there is another that shows none.

Randomized trials in children also have shown

conflicting results,

Side effects may include bad taste, nausea,

throat irritation, and diarrhea

23

...COMMON COLDv


18/37

03/10/2013

18

Other treatments

Echinacea

Vitamin C

Honey

Antibiotics

24

...COMMON COLD

Antibiotic therapy

There is no role for antibiotics in the

treatment

does not prevent secondary bacterialinfection

may cause significant side effects, contribute

to increasing bacterial antimicrobial

resistance.

25

...COMMON COLD


19/37

03/10/2013

19

The use of antibiotics should be reserved

for clearly diagnosed secondary bacterial

infections, including bacterial otitis media,

sinusitis, and pneumonia

26

PREVENTION

The best methods for preventing transmission

from one person to another are to practice

frequent handwashing and to avoid touching

one's nose and eyes.

27

...COMMON COLD


20/37

03/10/2013

20

How Colds Are Spread?

How Colds Are Spread ?


21/37

03/10/2013

21

Laryngotracheobronchitis

DEFINITION

Primarily pediatric viral respiratory tract illness

that affect larynx, trachea, and bronchi

Characteristic : hoarseness, a seal-like barking

cough, inspiratory stridor with or without

variable degree of respiratory distress


22/37

03/10/2013

22

EPIDEMIOLOGY

Accounting for approximately 15% of clinic and emergency

department visits for pediatric respiratory tract infections

Incidence: 6 months old 6 years old with peak

incidence: 1-2 years old

The male-to-female ratio for croup is approximately 3:2

The disease is most common in late fall and early winterbut may occur at any time of year

Approximately 5% of children experience more than 1

episode

ETIOLOGY

Human Parainfuenza virus type 1,2,3,4

Virus influenza A and B 60%

Adenovirus

Respiratory syncytial virus (RSV)

Enterovirus

Human bocavirus

Coronavirus[3]

Rhinovirus

Echovirus

Reovirus

Metapneumovirus[4]

Influenza A and B

Rarer causes - Measles virus, herpes simplex virus, varicella


23/37


24/37

03/10/2013

24

CLASSIFICATION

Based on the level of emergency:

1. Mild: sometimes barking cough, no stridor, mildretraction

2. Moderate: often barking cough, stridor, mildretraction, no respiratory distress

3. Severe: often barking cough, inspiratory stridor

when take a rest, sometimes expiratory stridor,retraction, respiratory distress

4. Threatening life respiratory failure: cough, stridor,

decrease of conciousness, letragy

CLASSIFICATION


25/37

03/10/2013

25

CLINICAL MANIFESTATION

Nonspecific respiratory symptomsrhinorrhea, sorethroat, and cough

Fever is generally low grade (38-39C) but can exceed40C

Within 1-2 days, the characteristic signs of hoarseness,barking cough, and inspiratory stridor develop, often

suddenly, along with a variable degree of respiratorydistress

Symptoms worsening at night, with most ED visitsoccurring between 10 pm and 4 am resolve within 3-7days but can last as long as 2 weeks

Skor Croup Westley

Total score: 0 -17 points.

Stridor (0 = none, 1 = with agitation only, 2 = at rest)

Retractions (0 = none, 1 = mild, 2 = moderate, 3 = severe)

Cyanosis (0 = none, 4 = cyanosis with agitation,

5 = cyanosis at rest)

Level of consciousness (0 = normal [including asleep],

5 = disorientated)

Mild croup: 0-2

Moderate croup: 35.

Severe croup: 611.

Paling banyak digunakan, Valid dalam menilai outcome pada

uji klinis penderita dengan croup (kappa 0,90)


26/37

03/10/2013

26

DIAGNOSIS

Diagnostic clues based on presenting history

and physical examination findings

Laboratory test resultsconfirming this

diagnosiscomplete blood cell (CBC) count is

usually nonspecific, although the white blood

cell (WBC) count and differential may suggest

a viral cause with lymphocytosis

PROCEDURES

Direct laryngoscopy if the child in not in acute

distress

Fiberoptic laryngoscopy

Bronchoscopy (for cases of recurrent croup to

rule out airway disorders)


27/37

03/10/2013

27

RADIOGRAPHY

Steeple or pencil sign

of the proximal

trachea (50%)

THERAPY

To overcome the obstruction or respiratory

tract

Most of croup didnt need to be hospitazed

1. Inhalation therapynebulized epinephrin

a. Racemic epinephrin

b. L-epinephrin 1:1000 5 ml


28/37

03/10/2013

28

THERAPY

2. Corticosteroidto reduce oedema mucosa of

the larynx

a. Dexamethason 0,6mg/kgbw/x

b. Budesonid nebulized 2-4mg (2ml)

3. Endotracheal intubationsevere croup4. Antibioticno need to be used except

laryngotracheobronchitis,

laryngotracheopneumonitis

PROGNOSIS

Excellent, and recovery is usually completeself limited disease

Hospitalization rates vary widely amongcommunities, ranging from 1.5-30% and

typically averaging 2-5% < 2% of hospitalized children require

intubation

10-year study found a mortality rate of lessthan 0.5% in intubated patients


29/37


30/37

03/10/2013

30

EPIDEMIOLOGY

85% children have acute otitis media 1 x in 1st yearof life

50% children have acute otitis media > 2 x

1st year of life having acute otitis media increasethe risk of having chronic or recurrent otitis media

The incidence decrease at age 6 years

United State all children experience otitis mediaat age 2 years and 3 episodes or more of acute otitismedia

Peak incidence 3-18 months

PATHOPHYSIOLOGY

Intrinsic mechanical obstruction caused byinfection and allergy

Extrinsic obstruction caused by adenoid andnasopharynx cancer

Functional obstruction caused by the amountand stiffness of cartilage of the tube, mostcommon in children

Eustachian tube obstruction pressure ofmiddle ear negativeif still persist, middle eartransudat effusion


31/37

03/10/2013

31

ETIOLOGY

Viral Pathogen : Respiratory Synctitial Virus

Bacterial Pathogen :

1. Streptococcus pneumoniae (50%)

2. Haemophillus influenzae (20%)

3. Moraxella catarrhalis (10%)


32/37

03/10/2013

32

RISK FACTORS

Prematurity and low birthweight

Young age

Early onset

Family history

Race - Native American, Inuit,

Australian aborigine Altered immunity

Craniofacial abnormalities

Neuromuscular disease

Allergy

Day care

Crowded living conditions

Low socioeconomic status

Tobacco and pollutant

exposure

Use of pacifier Prone sleeping position

Fall or winter season

Absence of breastfeeding,

prolonged bottle use

CLINICAL MANIFESTATION

Preceeding by upper respiratory tract infection

with fever, otalgia and hearing impairment

Baby : irritability, diarrhea, poor feeding, often

cry

Children : pain and uncomfortable in the ear


33/37


34/37

03/10/2013

34

DIFFERENTIAL DIAGNOSIS

External otitis

Dental pain

Temporomandibular joint pain

Acute viral pharyngitis

Trauma to the ear

TREATMENT

Depend on culture and sensitivity of thespecimen

1st line : Amoxycillin 40 mg/kgBW/24hours,3x/day,10 days

2nd line : Erytromicin 50mg/kgBW/24hours withsulfonamid (100mg/kgBW/24hours trisulfa or150mg/kgBW/24hours sulfisoksazol) 4x/day,sefaclor 40mg/kgBW/24hours 3xday, amoxycillin-clavulanat 40mgkgBW/24hours 3x/day, cefixim8mg/kgBW/24hours 1-2x/day


35/37

03/10/2013

35

TREATMENT

Acute otitis media without complication

antibiotic in 5 days

Supportive theray: analgesic, antipyretic,

decongestant

TYMPANOCENTESIS

Neonates who are younger than 6 weeks (andtherefore are more likely to have an unusual ormore invasive pathogen)

Patients who are immunosuppressed orimmunocompromised

Patients in whom adequate antimicrobialtreatment has failed and who continue to showsigns of local or systemic sepsis

Patients who have a complication that requires aculture for adequate therapy


36/37


37/37

13-10 topic 1. introduction

Documents