Acute Respiratory InfectionsPrepared by:

Laith Ali JeburSupervised by:

Dr. Ali Abdul Razzaq

Introduction• Definition of ARI..• Worldwide, (ARIs) are a major cause of

morbidity and mortality in emergencies especially in developing countries including Iraq.

• ARI responsible for 20% of childhood (< 5 years) Deaths ,90% from pneumonia.

• Six to eight respiratory tract infections per year (2-3years)

• 70% of which are upper respiratory infection, 30% are lower respiratory infections.

Anatomical Classification

Upper Respiratory Infections

Lowe Respiratory Infections

Acute Otitis Media

RHINITIS (COMMON COLD OR CORYZA)

BRONCHIOLITIS

SINUSITIS PNEOMONIA

ACUTE PHARYNGITIS

CROUP

PERTUSSIS

TONSILITIS

TRACHEITIS

STEPS TO BE TAKEN IN ASSESSMENT OF ARI

History• Age• onset, duration, SOB• Is the child coughing? For how long?• Is the child able to drink or feed well?• Has the child had fever ? For how long?• Has the child had convulsions?• Does the child have any other complaints?In addition to:(noisy breathing, sleeping, bluish discoloration, paroxysmal cough, mental state)

Ask about risk factors of ARI

Exposure to cold weatherHx of bith problemsPoor nutritional statusEarly weaningImmunizationPoor socio-economic statusParental smokingChronic use of drugs (affect immunity)Family history

Look & Listen Respiratory rate• Tachypnea 3 months > 60

3 months – 1 year > 50 1year –4 years > 40 >5y >20 Chest indrawing Listen for stridor Listen for wheeze. Is it recurrent? Look for cyanosis See if the child is abnormally sleepy, difficult to wake,

or restless Body temperature Signs of malnutrition (Marasmus, Kwashiorkor)

Severity – Plan (WHO)Severity C\F Managemen

tNo pneumonia

(mild ARI)Cough

Not tachypnoeaSupportive measuresAntipyretic

No antibiotics

PneumoniaOr (moderate ARI)

CoughTachypnoea

No rib or sternalretraction

Supportive measuresAntipyreticAntibiotics

Severe pneumonia CoughTachypnoea

Rib and sternalretraction

Supportive measuresAntibiotics

Refer to hospital

Very severepneumonia

CoughTachypnoeaChest wall retraction

Unable to drinkCyanosis

Supportive measuresOxygen

AntibioticsImmediate referral

Upper ARIs

Acute Nasopharyngitis (Common Cold)

• Most common infectious condition in children in the first 2 years.

• Third of cases caused by Rhinovirus .

• Average of 5-8 infections per year.

• May involve (Nasopharynx, paranasal sinuses, middle ear).

Clinical features

Symptoms:• nasal obstruction• Rhinorrhea• sore throat• occasional non-productive cough• Parenteral diarrheaSigns:• nasal mucosa may reveal swollen, erythematous

nasal turbinate's• Sign of moderate respiratory distress in infants• Ear drum is congested 2-3 days

Diagnostic Measures:• Laboratory studies often are not helpful• A nasal smear for eosinophils .

Treatment:(No specific therapy)1.Bed rest2.Actamenophen1st 1-2 days3.Relieve nasal obstruction:

* Normal saline , xylometazoline nasal drops* Phenylephrine 0.25% nasal drops* highly humidified environment to prevent

drying.4.Rhinorrhea, cough : antihistamins.

Acute Pharyngitis

• It is an inflammation of the throat.• the most common cause of a sore throat.• Include: (tonsillitis &pharyngotonsillitis)• Commonly caused by viral infections

(Adenovirus, influenza v, EBV)• Others caused

by bacterial infections(Group A-B hemolytic strptococcus ), fungal infections. 

Clinical Features

Viral infection Bacterial infection1. All ages2. Gradual onset3. Low grade fever4. cough5. Hoarseness of

voice6. Redness of the

pharynx7. Conjunctivitis(Aden

ovirus)8. Herpangina(coxach

ie virus)

1. 5-15 year old2. Sudden onset3. High grade fever4. Sore throat &

difficulty in swallowing

5. Exudates6. Ant. Cervical LN

tenderness

Headache, Abdominal pain and vomting

Inflammed oropharynx

Strept. throat

Investigations:

• It is hard to differentiate a viral and a bacterial cause of a sore throat based on symptoms alone.

• Throat swab and culture.

(Gold Standard)• Detection for

streptococcal antigen (specific 80 – 85%)

• WBC, ESR, CRP count is elevated.

Treatment:• Viral pharyngitis need no antibiotics, only

supportive• Streptococcal pharyngitis1. Oral penicillin V (125-250)mg 3/day 10

days2. Benzathine penicillin or procaine penicillin

G single IM injection3. Erythromycin 40 mg/kg/day for 10 days4. Oral amoxicillin 50 mg/kg/day for 6 days

Complications:• Complications are low with viral infection1. O.M.2. Mastoiditis.3. Peritonsillar abscess4. Sinusitis5. Involvement of lower respiratory tract6. Trigger asthma7. Meningitis8. Acute GN9. Mesenteric adenitis

Croup•  is a respiratory condition that is

usually triggered by an acute infection of the upper airway. The infection leads to swelling inside the throat produces the classical symptoms of a "barking" cough, stridor, and hoarseness.

• 75% parainfluenza virus, others inluenza A&B , RSV.

• Bacterial infection(epiglotitis,diphtheria,tracheitis)

• Usual age 6m – 5y, males, winter & family history.

DDx of croup:• 1.Laryngotracheobronchitis.• 2.Acute epiglottitis.• 3.Acute infectious laryngitis.• 4.spasmodic croup.• 5.Bacterial tracheitis.• 6.Diphtheritic croup.

• 7.Measles croup.

Laryngotracheobronchitis

• The most common type. Involve the glottic and subglottic regions.

• Manifestations of Upper infection + croup• Severe at night• Relieved by sitting• Neck X-Ray showing subglottic narrowing (Steeple sign)

Steeple Sign

Acute Infectious Laryngitis

• Almost all cases caused by viral infection.• It involves mainly subglottic area.• Characterized by URTI then sore throat and

croup.• It is generally mild and respiratory distress

unusual except in infants.• In severe cases: Hoarsness, stridor,

dyspnea.• Laryngoscope shows inflammed vocal cord

& subglottic tissue.

Acute Epiglottitis

• Commonly caused by H.influenzae b.• Affect 2-7 years old.• Male to female 3:2.• It is a medical emergency because of the

risk of sudden airway obstruction.• Characterized by high fever, dyspnea,

dysphagia, sore throat, drooling. • stridor and tripod position.• the mouth is opened, and the jaw thrust forward (sniffing position)• Barking cough is rare.

Diagnosis:• Lateral neck X-ray shows enlarged epiglottis

(thumb print sign)• Direct laryngoscope my show a cherry red

epiglottis (supraglottis) but it is not recommended because of laryngeal spasm.

Indications of admission • Progressive stridor at rest• Temp>39c• Respiratory distress• Cyanosis & pallor• Hypoxia & restlessness• Impaired consciousness• Toxic appearing child

At hospital…

• Put the child in cold steam from nebulizer or hot steam from vaporizer may relieve symptoms.

• Monitoring of respiratory rate and respiratory distress.

• IV fluid to reduce insensible water loss from tachypnea.

• Oxygen in moderate to severe respiratory distress.

• Tracheostomy & intubation if there is deterioration.

• Sedatives are contraindicated. Cough expectorants are unhelpful.

Acute Bacterial tracheitis• Age less than 3 years age.• caused by S. aureus. • Characterized by barking cough, high fever, stridor,

copious thick purulent discharge, toxic appearance. • The usual treatment of croup is ineffective.

Diagnosis:• culture of the thick, mucopurulent subglottic debris.

Treatment:• Antibiotics against Staphylococcus like cloxacillin,

methicillin, third generation cephalosporin or vancomycin.

• Endotracheal intubation or tracheostomy.• Oxygen .

Acute Otitis Media• Age: second 6 months• Caused by:1- H.influenzae.2- Strept.pneumonae.3- Moraxella catarrhalis.• It is very common in children. Symptoms:• earache, convulsions, sometimes diarrhea &

vomiting, continuos crying (irritability) & sleep disturbances.

Signes: • Otorrhea or bulged , congested TM.• The tympanic membrane is intact in infants.

Treatment:• Broad-spectrum antibiotics.• Analgesics.• vasoconstrictive nasal drops .• Aural toilet, Myringotomy.

Acute Sinusitis

• Age only 1% of infants. 5% of children. 15% of adolescent.• Allergic rhinitis is the

most common predisposing factor.

• Anatomical abnormalities:

• Deviated septum• Polypoid mass

CLINICAL MANIFESTATIONS:

• Cough mainly at night• Rhinorrhea• Nasal speech• Halitosis• Facial pain, tender• Facial swelling• Headache• Fever• Irritability• Trigger asthma & O.M

Investigations:

• Culture• Plain X ray• CT scan May show sinus clouding Mucosal thichening Air fluid level.

Treatment:• Antibiotics• Suportive therapy

Pertussis• Bordetella pertussis• Affect young children, non immunized.• Spread by droplet, direct or indirect contact with

nasal scretions.• Manifestations:• Catarrhal stage..1-2 w URTI.• Paroxysmal stage..2-4w parox. Cough, whooping.• Convalescent stage..1-2w only cough for months.• Investigations:• CBC: WBC mainly lymph.• CXR prehilar infiltrate.• Culture, PCR, IFA.

Treatment:

• Admit severe cases• Erythromycine 2w• Azithromycin or

clarithromycin 1w• TMP-Sulfa

Complications:• Pneumonia• Super infection• Atelactasis• seizures

Lower ARIs

Acute bronchiolitis• It is a common inflammation of the bronchioles. • AGE less than two years With a peak at age 6th

month.• ( RSV ) more than 50% .• Rarely by mycoplasma.

* There is Bronchiolar obstruction due to edema & accumulation of mucous & cellular debris & by invasion by viruses.

Symptoms:• Presents as a progressive respiratory

illness that is similar to the common cold in its early phase with cough, dyspnea and rhinorrhea.• It progresses over 3 to 7 days to

noisy breathing with noisy breathing. • fever accompanied in young children

by irritability.• May have apnea as the first sign of

infection.

Signs:• Tachypnea, falaring of ala nasi• intercostal retractions &subcostal retractions .• air trapping with hyper expansion of the lungs

with hepatosplenomegaly by dispacement.• percussion of the chest reveals hyper

resonance. • Auscultation reveals prolonged expiratory

phase with diffuse wheezes and crepitation. • In more severe cases cyanosis.

Investigations:• WBC & differential counts are normal.• Antigen tests (IFA or ELISA) of nasopharyngeal

secretions for RSV, para-influenza, influenza viruses, and adenoviruses are the most sensitive tests to confirm.

• Chest X-ray shows:1- signs of hyper expansion of the lungs, including increased lung radiolucency. 2-flattened or depressed diaphragms.

Differential Diagnosis:• 1- bronchial asthma.• 2- congestive heart failure.• 3- foreign body in the trachea.• 4- pertusis.• 5- cystic fibrosis.• 6- bacterial bronchopneumonia.• 7- obstructive emphysema.

Indications of hospitalization:

1. Young age<3 month old.2. Moderate to marked resp. distress3. Hypoxemia(PO2<60mmHg or Oxygen

saturation<92% on room air).4. Apnea5. Inability to tolerate oral feeding6. Lack of appropriate care available at

home.

Treatment:

• consists of supportive therapy, including:1-Nebulizer, control of fever 2-good hydration3- upper airway suctioning and oxygen administration.4- I.V. fluid indicated in case of sever tachypnea which interrupt feeding.5-Ribavirin is anti viral agent administered by aerosol.6-Temperorary use of bronchodilators may improve wheezing &respiratory distress.

Pneumonia• inflammation of the parenchyma

of the lungs. classified anatomically as :

• Lobar or lobular.• Bronchopnemonia:is involvement

of the bronchi & the surrounding alveolar tissue which is more profuse & bilateral.

• interstitial pneumonia.• Pathologically there is

consolidation of alveoli or infiltration of the interstitial tissue with inflammatory cell or both.

Etiology:1-Viral: RSV 70%, influenza, parainfluenza or adenovirus.2-Bacterial: In first 2 months the common agents include klebsiella, E. coli, and staphylococci. • Between 3 month to 3 years common bacteria

include S. pneumonia, H. influenza and staphylococci.

• After 3 years of age common bacteria include S. pneumonia and staphylococci.

3-Atypical organism: Chlamydia and Mycoplasma.4-Pnemuocystis carinii: causes pneumonia in imunno- compromised children.

Clinical features: • Onset of pneumonia may be insidious starting

with URTI or may be acute with high fever, dypsnea and grunting respiration. Respiratory rate is always increased.

• Rarely pneumonia may be present with acute abdominal emergency which is due to referred pain from the pleura.

• On examination there is flaring of alae nasi, retraction of lower chest and intercostal spaces.

• Signs of consolidation(diminished expansion, dull percussion note, increased tactile vocal fremitus/vocal resonance, bronchial breathing with localized crepitation ) can be seen in lobar pneumonia.

• Viral pneumonia :- low grade fever, cough, wheeze .the lesion is usually diffuse and bilateral. its broncho pneumonia.

• WBC is not so high with lymphocytosis.• Bacterial pneumonia:- patient presented

with high fever,herpetic lesion at the lips, pleuretic chest pain.

• WBC leukocytosis with neutrophilia.• S. pneumoniae often resulting in focal

lobar involvement.• Group A. streptococcus infection results

in interstitial pneumonia.• S. aureus causes bronchopneumonia

which is often unilateral with cavitations.

Diagnosis:• Diagnosis mainly clinical.• 1- chest x- ray:

Lobar p. Broncho p.Staph. P.

1. Sputum for gram stain and culture. 2. blood culture. 3. virological study by culture

&florescent antibody technique.4. in case of pleural effusion aspirate

pleural fluid for gram stain and culture also for acid fast bacilli.

Diagnosis:

Indications for admission to hospital:• 1-less than 3 month of age.• 2- moderate to sever respiratory distress.• 3- failure of out patient treatment.• 4-immunocompromised patient.• 5- neonate with congenital pneumonia.• 6- staphylococcal pneumonia.• 7- complications like pleural effusion, empyema.

Treatment:• The empiric treatment of suspected bacterial

pneumonia is parenteral cefotaxim or ceftriaxone.• If clinical features suggest staphylococcal pneumonia,

vancomycin.• For mildly ill children amoxicillin (80–90 mg/kg/24 hr).• For school-aged children and in those in whom

infection with M. pneumoniae a macrolide antibiotic such as azithromycin.

• In adolescents, a respiratory fluoroquinolone (levofloxacin) may be considered for atypical pneumonias.

• If viral pneumonia is suspected, it is reasonable to withhold antibiotic therapy. supportive by 1- oxygen 2- IVF. 3- antipyretic for fever. ribavirin for RSV.

Complications:

• A- Pulmonary complications• 1- pleural effusion.• 2- empyema.• 3- lung abscess.• 4- pneumatocele.• 5- pneumothorax.

• B- Extra pulmonary complications• 1- meningitis.• 2- arithritis.• 3- osteomyelitis.• 4- pericarditis.

Prevention of ARI• Health education.• Keep child warm.• Immunization.• Nutrition.• Prevent nearby smoking.• Personal hygiene.• Visit doctor.

Thank You