ari

Life Finds A Way:Life Finds A Way:Just Don’t Give UpJust Don’t Give Up

ARIARI

SIGNS OF RESPIRATORY DISTRESSSIGNS OF RESPIRATORY DISTRESS

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Definition of ARI Definition of ARI (Acute Resp. Infection)(Acute Resp. Infection)

This term is This term is usedused by HW to indicate ac. Inf. of by HW to indicate ac. Inf. of resp. system in U-5y childrenresp. system in U-5y children

In this age group such inf. are often not anatomically In this age group such inf. are often not anatomically localized, rather spreads rapidly to adjacent partslocalized, rather spreads rapidly to adjacent parts

An U-5 child gets 3-6 ARIs/y regardless of living An U-5 child gets 3-6 ARIs/y regardless of living standardstandard

HW: health worker. U-5: under 5 years of age. Inf.: infectionHW: health worker. U-5: under 5 years of age. Inf.: infection

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Clinical AnatomyClinical Anatomy

• RT is divided into 3 parts:RT is divided into 3 parts:

URT:URT: nose nose trachea trachea (PNS, mouth, tonsils, (PNS, mouth, tonsils, pharynx, auditory T, pharynx, auditory T, mid-earmid-ear, larynx), larynx)

LRT:LRT: tracheatrachea bronchi bronchi air ductsair ducts

Lung parenchymaLung parenchyma

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Normal Defence of RSNormal Defence of RS

These are unique!These are unique!• Breathing, coughing, sneezingBreathing, coughing, sneezing• Mucosal antibodiesMucosal antibodies• Ciliary sweepingCiliary sweeping• PhagocytesPhagocytes• Physical filteringPhysical filtering

(Think how less often you catch cold and cough)(Think how less often you catch cold and cough)

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Physical filterPhysical filter

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Unique brooms!Unique brooms!

GobletGoblet

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ARI in Children Spread Rapidly:ARI in Children Spread Rapidly:

• Shorter and narrower RTShorter and narrower RT• Cough not strongCough not strong• Less immuneLess immune• Auditory tube is: Auditory tube is:

– shortershorter– narrowernarrower– straighter straighter

Sites of Infections (ARI)Sites of Infections (ARI)

• RhinitisRhinitis• TonsillitisTonsillitis• PharyngitisPharyngitis• EpiglottitisEpiglottitis• LaryngitisLaryngitis

• AOMAOM• TracheitisTracheitis• BronchitisBronchitis• BronchiolitisBronchiolitis• Pn./Br.PnPn./Br.Pn

Children usually have combinations:Children usually have combinations:Ac. rhinopharyngotonsillitis +/- AOM, ac. LTB (croup) Ac. rhinopharyngotonsillitis +/- AOM, ac. LTB (croup)

Br.Pn, etc.Br.Pn, etc.

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ARI is a syndrome:ARI is a syndrome:

– cough, cough, breath ratebreath rate– chest indrawing, chest indrawing, stridorstridor– +/-+/- 4 general 4 general danger signdanger signs (IMCI)s (IMCI)

NoNo Dr, Dr, nono stethoscope, stethoscope, nono lab! lab!

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Normal breathing rateNormal breathing rate

AgeAge RRRR Fast breathingFast breathing<2mo<2mo <60/min <60/min ≥≥6060

(preterm 70)(preterm 70)

2-12mo2-12mo <50/min<50/min ≥ 50 ≥ 501-5y1-5y <40/min<40/min ≥ 40≥ 40

Counting BreathingCounting Breathing• The child must be calmThe child must be calm• Count full 1 minuteCount full 1 minute• Count the abdominal swelling in inspirationCount the abdominal swelling in inspiration

Chest indrawing:Chest indrawing:• Suprasternal, supraclavicular retraction/recessionSuprasternal, supraclavicular retraction/recession• Intercostal space Intercostal space ,,,,• SubcostalSubcostal ,,,,

4 4 General Danger signs:General Danger signs:• Lethargic/unconsciousLethargic/unconscious• Poor feeding/not feeding Poor feeding/not feeding at allat all• Vomits everythingVomits everything• ConvulsionConvulsion

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DANGERSIGNS

CONVULSIONS

INABILITY TO DRINKOR BREASTFEED

VOMITING

LETHARGYUNCONSCIOUSNESS

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SS of ARI for Doctors SS of ARI for Doctors

• Cold, sore throatCold, sore throat• CoughCough, , sputumsputum• Nasal flareNasal flare• Chest indrawingChest indrawing • StridorStridor, , voice change, voice change,

grunting grunting • Tachypnoea Tachypnoea

• CyanosisCyanosis• Asymmetry of chest and Asymmetry of chest and

its movementits movement• Tracheal deviationTracheal deviation• Displaced heartDisplaced heart• Auscultation:Auscultation:

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Auscultatory FindingsAuscultatory Findings

• Poor or unequal air entryPoor or unequal air entry• Prolonged expirationProlonged expiration• Wheeze/ronchiWheeze/ronchi• Fine +/-coarse crepitationsFine +/-coarse crepitations• Bronchial breath soundBronchial breath sound• Post-tussive creps/or ronchi Post-tussive creps/or ronchi

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Depth of ARI as ProblemDepth of ARI as Problem

• Biggest U-5 killer (pneumonia: 0.9million/y: 15% of all Biggest U-5 killer (pneumonia: 0.9million/y: 15% of all deaths); 90% in L&MICs (deaths); 90% in L&MICs (70% in Africa and SEA)70% in Africa and SEA)

• Commonest admission (Commonest admission (12-45%). OPD: 20-60%12-45%). OPD: 20-60%• V. imp. precipitator of Mn, VADXV. imp. precipitator of Mn, VADX

• National National Health Index Health Index of a countryof a country((5.9 million U-5 death in 2015: 16,000/d.5.9 million U-5 death in 2015: 16,000/d.

70%70% from infectin) from infectin)

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ARI

54%

Diarrhoea

85%

Malaria

79%

Measles

89%

Percentage of deaths occurring among:

Global Disease Burden Borne by U-5 (Y 2000)

Key factsKey facts Pneumonia Pneumonia

•15% of all U-5 deaths: 15% of all U-5 deaths: 900k in 2015900k in 2015•Kills by hypoxia due to pus and fluid in alveoliKills by hypoxia due to pus and fluid in alveoli•C/by viruses, bacteria or fungiC/by viruses, bacteria or fungi•Rx with low-cost, low-tech drugs and care (1/3Rx with low-cost, low-tech drugs and care (1/3rdrd children children

with pneumonia get AB)with pneumonia get AB)

•Preventable by immunization, nutrition and clean Preventable by immunization, nutrition and clean environmentenvironment

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ARI mortality/morbidity highest in U-5yARI mortality/morbidity highest in U-5y

– Lack of breast feedingLack of breast feeding– Bottle feeding, weaned earlyBottle feeding, weaned early– HIVHIV– <2y of age<2y of age– Lack of vaccinationLack of vaccination– Mn., VADXMn., VADX– Poor education, overcrowding, poor clothingPoor education, overcrowding, poor clothing– Difficult access to healthcare, medicationDifficult access to healthcare, medication

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Aetiology of ARIAetiology of ARI

• VirusesViruses• BacteriaBacteria• MycoplasmaMycoplasma• FungusFungus• Parasites, wormsParasites, worms

Aetiology …Aetiology …• Varies: age, immune status, where contractedVaries: age, immune status, where contracted• Community acquired (CAP)Community acquired (CAP)

– Developing countriesDeveloping countries• Viruses Viruses 40%40%• S. pneumoniae, Hib, S aureus, Moraxella, S. pneumoniae, Hib, S aureus, Moraxella,

Mycoplasma, Chlamydia in Mycoplasma, Chlamydia in 60%60%

– Developed countriesDeveloped countries• Bacteria: Bacteria: 5-10%5-10%

Etiology Based on AgeEtiology Based on AgeAgeAge OrganismOrganismNeonatesNeonates GBS, E coli, Klebsiella, S GBS, E coli, Klebsiella, S

aureusaureus

InfantsInfants Pneumococcus, Chlamydia, Pneumococcus, Chlamydia, RSV, Hib, StaphRSV, Hib, Staph

1-5y1-5y Viruses, Pneumococcus, HibViruses, Pneumococcus, HibChlamydia, Mycoplasma, Chlamydia, Mycoplasma, Staph, GASStaph, GAS

5-18y5-18y Mycoplasma, Pneumococcus, Mycoplasma, Pneumococcus, Chlamydia, HibChlamydia, Hib

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VirusesViruses• RhinovirusesRhinoviruses• RSVRSV• AdenovirusesAdenoviruses• Influenza, parainfluenza A B C Influenza, parainfluenza A B C • MyxovirusesMyxoviruses• Corona viruses (SARS, MERS)Corona viruses (SARS, MERS)• Boca virus, metapneumovirusBoca virus, metapneumovirus

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Common BacteriaCommon Bacteria

• **S. pneumoniaeS. pneumoniae• **HibHib• S. pyogenesS. pyogenes• S. aureusS. aureus• **M. tuberculosisM. tuberculosis

• **C diphtheriaeC diphtheriae• Enteric bacilliEnteric bacilli• PseudomonasPseudomonas• KlebsiellaKlebsiella• Moraxella Moraxella

*Vaccine available

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Others

• Chlamydia• Mycoplasma• Fungus: C. albicans, Histoplasma• Miscellaneous: P. carinii, worms

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How ARI Harms How ARI Harms

• Malnutrition andMalnutrition and VADX: VADX: • HypoxiaHypoxia: convulsion, death: convulsion, death• ChestChest: collapse, consolidation, effusion, L. abscess, : collapse, consolidation, effusion, L. abscess,

bronchiectasis, pneumothoraxbronchiectasis, pneumothorax• Blood: Blood: sepsis, deranged ABB, dyselectrolytemia, sepsis, deranged ABB, dyselectrolytemia,

meningitis, IgA nephropathymeningitis, IgA nephropathy

VADX: Vitamin A defi. And xerophthalmiaVADX: Vitamin A defi. And xerophthalmia

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ARI Causes Mn. and VADXARI Causes Mn. and VADX

• Poor feedingPoor feeding• Negative nitrogen balanceNegative nitrogen balance• VD, F, dehydrationVD, F, dehydration• Exhaustion of VAExhaustion of VA• Faulty feeding, tabooFaulty feeding, taboo

Mn.: Malnutrition. VD: vomiting diarrhoea. F: fever. VA: vitamin AMn.: Malnutrition. VD: vomiting diarrhoea. F: fever. VA: vitamin A

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Dehydration in ARIDehydration in ARI::

• fast breathingfast breathing• FF• NVDNVD• runny noserunny nose• poor /faulty feedingpoor /faulty feeding

NVD: nausea vomiting diarrheaNVD: nausea vomiting diarrhea

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How ARI killsHow ARI kills

AcuteAcute• HypoxiaHypoxia• HHypoglycemia, convulsion, cardiac failureypoglycemia, convulsion, cardiac failure• Septicemia, dehydrationSepticemia, dehydration

LateLate• Mn., VADXMn., VADX• Suffocation, aspirationSuffocation, aspiration

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Hospital PictureHospital Picture

• Out of 1690 cases admitted in BMCH pediatric Out of 1690 cases admitted in BMCH pediatric ward 400 (23.7%) had ARI ward 400 (23.7%) had ARI

• Peak incidence during Oct-NovPeak incidence during Oct-Nov

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Death from ARI is DecliningDeath from ARI is Declining**

• Br. FeedingBr. Feeding• No bottle feedingNo bottle feeding• Socioeconomic and Socioeconomic and

environmental changeenvironmental change• Falling Mn.Falling Mn.• HPVAC distributionHPVAC distribution• EPIEPI

• Family planningFamily planning• Modern health careModern health care• Better and cheap drugsBetter and cheap drugs• Female literacyFemale literacy• Health awarenessHealth awareness

*Previously 4mn, now 0.9Previously 4mn, now 0.9

Management Management According to According to

IMCIIMCI[[[[

IMCI: integrated management of childhood illnessesIMCI: integrated management of childhood illnesses

History TakingHistory Taking1. General Danger Signs1. General Danger Signs2. Main Symptoms2. Main Symptoms

a. Cougha. Coughb. Diarrheab. Diarrheac. Feverc. Feverd. Ear Problemsd. Ear Problems

3. Nutritional Status3. Nutritional Status4. Immunization Status4. Immunization Status5. Other Problems5. Other Problems

IMCI Record FormIMCI Record Form

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Assess whether the child hasAssess whether the child has

• No pneumonia (cold-cough; chr. cough)No pneumonia (cold-cough; chr. cough)• Pneumonia orPneumonia or• Severe Pn.Severe Pn.

In babies < 2 mo any pneumonia is taken as In babies < 2 mo any pneumonia is taken as severe pn.severe pn.

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Fast breathing +Fast breathing +chest indrawing orchest indrawing orStridor in a calm Stridor in a calm child. (Any GD sign)child. (Any GD sign)

SevereSevere Pneumonia Pneumoniaoror

(very severe disease)(very severe disease)

Fast breathingFast breathing PneumoniaPneumonia

No signs of No signs of pneumonia or very pneumonia or very severe diseasesevere disease

No pneumonia:No pneumonia: cough or coldcough or cold

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Limitations …Limitations …Pneumonia in IMCI may bePneumonia in IMCI may be• BronchiolitisBronchiolitis• Br. AsthmaBr. Asthma• DiphtheriaDiphtheria• PertussisPertussis• HGF, CCFHGF, CCF

No pneumonia may be TBNo pneumonia may be TB

PneumoniaPneumonia• Fast breathingFast breathing• Inflam. of lung parenchyma + consolidationInflam. of lung parenchyma + consolidation• Developed world: Developed world: viral:viral: Low morbidity mortality Low morbidity mortality• Developing world:Developing world:

– Bacteria in 65%Bacteria in 65%– Cheap, oral ABT: Co-trimoxazole, Amoxycillin can Cheap, oral ABT: Co-trimoxazole, Amoxycillin can

cause 84% reduction in deathcause 84% reduction in death

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Severe PneumoniaSevere Pneumonia

• Very sick, Very sick, not able to feednot able to feed• Tachypnoea, Tachypnoea, tachycardiatachycardia• Chest indrawingChest indrawing • DrowsinessDrowsiness• Creps, wheezeCreps, wheeze• Cyanosis, convulsionCyanosis, convulsion

+/- Fever+/- Fever

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Lab. Dx. of Pneumonia Lab. Dx. of Pneumonia

(not for HW/IMCI)(not for HW/IMCI)

• CXRCXR• CBC filmCBC film• CS of blood, tracheal and lung aspirateCS of blood, tracheal and lung aspirate• Throat swabThroat swab

56S. pneumoniae

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Pneumococcal pneumoniaPneumococcal pneumoniaR upper lobe consolidation with Air BronchogramR upper lobe consolidation with Air Bronchogram

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Air-fluid level in Lung Abscess. Note small free PE in R Air-fluid level in Lung Abscess. Note small free PE in R pleural cavitypleural cavity

Complications of pneumoniaComplications of pneumonia

IntrathoracicIntrathoracic• P. effusion, empyemaP. effusion, empyema• Collapse, consolidationCollapse, consolidation• L. abscess, pneumatoceleL. abscess, pneumatocele• PneumothoraxPneumothorax

ExtrathoracicExtrathoracic• Septicemia, meningitisSepticemia, meningitis• Dehydration, myocarditisDehydration, myocarditis• Pericarditis, acidosis, dyselectrolytemiasPericarditis, acidosis, dyselectrolytemias

65Consolidated lungConsolidated lung

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Rx: General PrinciplesRx: General Principles

• O2, air way careO2, air way care• Nebulized beta-agonist, anticholinergicNebulized beta-agonist, anticholinergic• Antibiotics (parenteral)Antibiotics (parenteral)• Feeding, warmth, FEBFeeding, warmth, FEB• Vitamin A, Zn Vitamin A, Zn • Counseling, FUCounseling, FU

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Rx. Severe PneumoniaRx. Severe Pneumonia

• Admission, Admission, OO22 • Airway patency: Airway patency:

– suction clearancesuction clearance– Nebulized bronchodilator, anti-secretoryNebulized bronchodilator, anti-secretory

• Parenteral ABParenteral AB• Lowering HGFLowering HGF• Feeding, FEB, warmthFeeding, FEB, warmth• Vitamin A, zinc Vitamin A, zinc

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Antibiotics in Pneumonia Antibiotics in Pneumonia

Mostly viral but 2y infx. is commonMostly viral but 2y infx. is common

• Injectable: usually Injectable: usually >1 AB>1 AB• Minimum 10dMinimum 10d• Penicillin +genta/amikacin are goodPenicillin +genta/amikacin are good• Staph coverage for babies <2yrStaph coverage for babies <2yr

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When You Defer ABWhen You Defer AB

• The child is stable, playful, no HGFThe child is stable, playful, no HGF• EBF, no bottle feedingEBF, no bottle feeding• Taking feeds normallyTaking feeds normally• SupervisedSupervised

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Rx for Cough and Cold (no pn.)Rx for Cough and Cold (no pn.)

• Exclude AOMExclude AOM• Ensure feedingEnsure feeding• Treat feverTreat fever• Clean noseClean nose• Steam therapySteam therapy• Honey+tulsiHoney+tulsi

Chr./rec. CoughChr./rec. Cough• TB?TB?• Congenital HD?Congenital HD?• FB?FB?• Reactive airway?Reactive airway?• GERD?GERD?

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Follow up for PneumoniaFollow up for Pneumonia• Count breath (most important single sign)Count breath (most important single sign)• Watch activities: smiles, plays, feeds. Urine outputWatch activities: smiles, plays, feeds. Urine output

If the child stays at homeIf the child stays at home• Teach mom how to observe SoB, count breathTeach mom how to observe SoB, count breath• Nose cleaning, feeding, warmthNose cleaning, feeding, warmth• Ask to return immediately:Ask to return immediately:

s/of deterioration (fast br., chest indrawing)s/of deterioration (fast br., chest indrawing)poor feedingpoor feeding

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HumidificationHumidification

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Prevention of ARIPrevention of ARI

• Breast feedingBreast feeding• No feederNo feeder• ImmunizationImmunization• HPVAC, ZincHPVAC, Zinc• Rx malnutritionRx malnutrition• Warmth, warm clothingWarmth, warm clothing• No air pollutionNo air pollution• No smokingNo smoking

• Female literacyFemale literacy• Family Planning, Family Planning,

birth spacingbirth spacing• SanitationSanitation• No overcrowdingNo overcrowding

ACUTE EPIGLOTTITISACUTE EPIGLOTTITIS

• Life-threatening inf. of epiglottis, Life-threatening inf. of epiglottis, aryepiglottic folds and arytenoidaryepiglottic folds and arytenoid (sudden suffocation)(sudden suffocation)

• mostly in wintersmostly in winters• peak :-1–6 y old. M:F 3:2peak :-1–6 y old. M:F 3:2• Commonly bacteria: Hib. Concomitant bacteremia, pn., Commonly bacteria: Hib. Concomitant bacteremia, pn.,

AOM, arthritis, etc. by Hib may be presentAOM, arthritis, etc. by Hib may be present

ACUTE EPIGLOTTITISACUTE EPIGLOTTITISaka supraglottitisaka supraglottitis

• CFCF– HGF, sore throat, SoB, rapidlyHGF, sore throat, SoB, rapidly

progressing res. obstructionprogressing res. obstruction– toxic, dysphagia, chest indrawing, drooling, toxic, dysphagia, chest indrawing, drooling,

hyper extended neck, tripod positionhyper extended neck, tripod position– stridor is a late finding; cyanosis , coma, deathstridor is a late finding; cyanosis , coma, death– mouth is open, jaw thrust forward mouth is open, jaw thrust forward ((sniffing sniffing

positionposition). ). Barking cough is rareBarking cough is rare

EXAMINATIONEXAMINATION• Do not Do not examine the throatexamine the throat• Assess severityAssess severity

– degree of stridor, resp. rate, HRdegree of stridor, resp. rate, HR– pulse oximetry, arousalpulse oximetry, arousal

• Dx:Dx:– ““cherry red” epiglottischerry red” epiglottis– ‘‘thumb sign’ on lateral neck XRthumb sign’ on lateral neck XR– blood cultures, electrolytesblood cultures, electrolytes

• Direct laryngoscopy: Direct laryngoscopy: cherry red cherry red epiglottisepiglottis• But not recommendedBut not recommended

ACUTE EPIGLOTTITIS …ACUTE EPIGLOTTITIS …

Lateral neck XR: Lateral neck XR: (thumb sign)(thumb sign)

Rx (AC. EPIGLOTTITIS)Rx (AC. EPIGLOTTITIS)

A medical emergency!A medical emergency!• ICUICU• endotracheal intubation may be neededendotracheal intubation may be needed• help from anaesthetist and ENT surgeonhelp from anaesthetist and ENT surgeon• IV Amplicillin /Ceftriaxone (100 mg/kg/d) x10dIV Amplicillin /Ceftriaxone (100 mg/kg/d) x10d• O2, ABB, IVF, nutritionO2, ABB, IVF, nutrition• Rifampicin prophylaxis to close contactsRifampicin prophylaxis to close contacts

ALTB (croup)ALTB (croup)• Mucositis of glottis-subglottisMucositis of glottis-subglottis; ; usually viral:usually viral:

commonlycommonly: : parainfluenza 1,2,3 (75%), parainfluenza 1,2,3 (75%), influenza A,B; influenza A,B; RSV, RSV, epiglottitis, diphtheria, tracheitisepiglottitis, diphtheria, tracheitis

• Age :- 6 mo–6yAge :- 6 mo–6y

ALTB: Ac. Laryngotracheobronchitis ALTB: Ac. Laryngotracheobronchitis (CROUP)(CROUP)

• Inflam. swelling of throat: classical: Inflam. swelling of throat: classical: stridorstridor, , "barking" cough"barking" cough, , hoarseness hoarseness (within 1-2d)(within 1-2d)

• Features of URTI + croupFeatures of URTI + croup• LGF, Prolonged inspirationLGF, Prolonged inspiration• Severe at night, on lyingSevere at night, on lying• Relieved by sitting upRelieved by sitting up• Neck XR: subglottic Neck XR: subglottic

narrowing narrowing (Steeple sign)(Steeple sign)

Dx: mainly clinical. XR Dx: mainly clinical. XR neck: steeple sign neck: steeple sign (unreliable)(unreliable)

DD of croup:DD of croup:

• ALTBALTB• Ac. infectious laryngitisAc. infectious laryngitis• Ac. epiglottitisAc. epiglottitis• Spasmodic croupSpasmodic croup• Bacterial tracheitisBacterial tracheitis• DiphtheriaDiphtheria• Measles croupMeasles croup

Ac. Laryngotracheobronchitis (ALTB)Ac. Laryngotracheobronchitis (ALTB)

DD: Ac. LTB and Ac. EpiglottitisDD: Ac. LTB and Ac. EpiglottitisCroupCroup EpiglottitisEpiglottitis

CourseCourse daysdays hourshoursProdromeProdrome coryzacoryza nonenone

CoughCough barkingbarking slight if anyslight if any

FeedingFeeding ableable nono

MouthMouth closedclosed droolingdrooling

ToxicToxic nono yesyesFeverFever <38.5<38.500CC >38.5 >38.5 00CC

StridorStridor raspingrasping softsoft

VoiceVoice hoarsehoarse Weal/silentWeal/silent

ALTB: RxALTB: Rx

• humidified airhumidified air• steroidssteroids

• reduce severity and duration/need for reduce severity and duration/need for intubationintubation

•Prednisolone p.o. 2mg/kg/d x3dPrednisolone p.o. 2mg/kg/d x3d• nebulized budesonidenebulized budesonide

• nebulized adrenalinenebulized adrenaline

• Age: 2-6 mo. C/by:Age: 2-6 mo. C/by:– S. pneumoniaeS. pneumoniae, Hib, M. catarrhalis, Hib, M. catarrhalis

• It is v. common in children It is v. common in children

Symptoms:Symptoms:• earache,earache, inconsolable cry inconsolable cry & & sleep disturbances, fit, sleep disturbances, fit,

sometimes DVsometimes DV, ,

Signs: Signs: • Otorrhea or bulged congested TM, PEDOtorrhea or bulged congested TM, PED

PED: perforated eardrumPED: perforated eardrum

DxDx

• History, autoscopyHistory, autoscopy• MyringotomyMyringotomy• CBC, pus CSCBC, pus CS

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TreatmentTreatment

•Broad-spectrum ABTBroad-spectrum ABT•Analgesic, decongestant (local/systemic)Analgesic, decongestant (local/systemic)• Saline nose washSaline nose wash•Myringotomy SOSMyringotomy SOS•Local AB drop for PEDLocal AB drop for PED•No bath in PEDNo bath in PED

Complications of OMComplications of OM• MastoiditisMastoiditis• MeningitisMeningitis• Brain abscessBrain abscess• PEDPED• Deafness-dumbness, poor learningDeafness-dumbness, poor learning• ConvulsionConvulsion

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MCQMCQ

• HPVAC is an important intervention to prevent ARIHPVAC is an important intervention to prevent ARI• Feeding bottle is a baby killerFeeding bottle is a baby killer• Cut-off mark of fast breathing at 9 mo is 40Cut-off mark of fast breathing at 9 mo is 40• Any pneumonia in <6o-days of age is severe pn.Any pneumonia in <6o-days of age is severe pn.• O2 is the most important 1O2 is the most important 1stst Rx for severe pn. Rx for severe pn.

MCQMCQ

• Parenteral ABT is recommended for severe pn.Parenteral ABT is recommended for severe pn.• Zn has an imp. role in shortening of duration and Zn has an imp. role in shortening of duration and

prevention of recurrence of ARI in childrenprevention of recurrence of ARI in children• Commonest c/of ac. epiglottitis is HibCommonest c/of ac. epiglottitis is Hib• Ac. epiglottitis is usually Dx by direct laryngoscopy• Croup means stridor, hoarseness, barking cough

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