ACUTE RESPIRATORY

INFECTIONS
Immediate Causes of Death in Underfive
Children, WPR
Source: Child Health Epidemiologist and research group (CHERG) estimates of under-five
deaths, 2000-03
Under-
nutrition
53%
6
3




Parts of the Respiratory System
BACKGROUND
Normal Respiratory Control
Properties:
1. Gas exchange= at alveolar-capillary interface
2 processes: ventilation (gas flow)
perfusion (blood flow)
2. Mechanical breathing apparatus
involved: lung compliance (recoil, resistive)
: resistance
elastic recoil of the lungs and chest wall
(restrictive resistance)
flow resistance of the airways/tissues
( obstructive resistance)
3. Neural Control


BACKGROUND
Neural Control
CNS
afferent limb efferent limb

receptors respiratory muscles
- chemo (O2, H+,CO2) -diaphragm
- irritant -intercostals
- O2



respiratory rate/depth
BACKGROUND
How can respiratory functions be impaired?
I Pulmonary factors
Infection (edema, congestion, secretion)
lung compliance airway obstruction
work of breathing
O2 consumption
hypoxemia
BACKGROUND
Pulmonary factors
1. Infection
2. Non-infection airway obstruction
(partial or complete) CO2 retention
respiratory acidosis respiratory failure
3. Respiratory muscle fatigue as a result of
increased respiratory workload
BACKGROUND
HOST DEFENSES
1. Anatomic defenses
2. Physiologic defenses
3. Immunologic defenses
BACKGROUND
ANATOMIC DEFENSES
Nose= convoluted nasal passages
= long hairs
= mucous trap
Cilia = nose to bronchioles
= beat in constant, rhythmic,
synchronous manner
Mucus= mucus blanket
= facilitates ciliary action
= contains: secretory IgA, lyzozyme, interferon,
complement
= protects epithelium from irritants, ph changes, and
degradation
= humidifies inspired air

BACKGROUND
Anatomic defenses
Physiologic defenses
Sneeze reflex
Closure of the larynx
Cough reflex
def: a violent, expiratory blast that takes place
against a closed glottis
purpose: protects the tracheobronchial tree
Immunologic defenses
BACKGROUND
Factors that impair host defenses?
1. Viral infection
2. Malnutrition
3. Smoke
4. Chronic illness= infectious/non-infectious
Recurrent infections=respiratory/non
respiratory

BACKGROUND
VIRAL INFECTION
1. Breaks the natural barrier in the respiratory
mucosa allows other infection to penetrate
the epithelium
2. Destroys mucociliary function
3. HOW? =Viral intracellular multiplication
destroys/lyzes the cell
= viruses deplete Vit A stores
BACKGROUND
MALNUTRITION
Complement/infection interaction
Inflammatory responses
Levels of IgA
Levels of T cell lymphocyte
Antibody response
Defective chemotactic/microbial killing
ability of neutrophils
Defective granulation formation
BACKGROUND
SMOKE
Destroys the integrity of mucosa
Paralyzes the cilia=disrupts mucociliary
function
Promotes bacterial adherence and
penetration into respiratory lining
CHRONIC/RECURRENT ILLNESS

BACKGROUND
Why infants are at RISK to respiratory dysfunction?
1. Anatomic factors
> relatively large tongue
> large soft palate
> floppy epiglottis
> high-positioned larynx
less cartilaginous support
> sternum is soft, pliable
provides unstable base for ribs
> intercostals poorly developed
> trachea small in diameter
> alveoli-relatively large : prone to collapse
BACKGROUND
1. Anatomic factors
2. Physiologic factors:
> obligate nose breathers
> distended abdomen

Restrictive vs Obstructive
findings restrictive obstructive
extra intra
breath rate inc. dec. normal,inc
breath IN reduced prolonged unchanged
breath OUT reduced unchanged prolonged
accesory inspiratory inspiratory inspiratory
muscles and expiratory
retractions present present often present
amplitude shallow normal or normal or
of breathing reduced reduced
auscultation crackles, stridor wheezing
grunt
X-ray dec. lung normal inc. lung
volume, densities volume





ACUTE RESPIRATORY
INFECTIONS
ACUTE RESPIRATORY
INFECTIONS
LECTURE CONTENT:
1. EPIDEMIOLOGY
2. LRTI ( Bronchitis, Bronchiolitis,
Pneumonia)
A. ETIOLOGY
B. ASSESSMENT
= SIGNS
= CLASSIFY
C. TREATMENT=AB/OXYGEN
ACUTE RESPIRATORY
INFECTIONS
LECTURE CONTENT:
3. URTI
A. VIRAL URTI
B. BACTERIAL URTI
= SORE THROAT(PHARYNGITIS)
= ACUTE EAR INFECTION/MASTOIDITIS
(CHRONIC EAR INFECTION)
= BACTERIAL SINUSITIS
= STRIDOR (Croup)
- Epiglotittis -Laryngitis -Laryngotracheitis

ACUTE RESPIRATORY
INFECTIONS
LECTURE CONTENT:
4. OTHER PROBLEMS
A. WHEEZING
B. FEVER

Main symptoms of 478 children
VSMMC
0
10
20
30
40
50
60
70
COUGH
FEVER DIARRHEA EAR PROBLEM
Main symptoms of 450 sick children


0
10
20
30
40
50
60
70
80
90
100
82.5%
45%
92.5 %
8.4%
Cough
Diarrhea
Fever
Ear problems
Main symptoms of 450 sick children
(Gambia)
ARI
STATS:ARI
ARI occur more frequently than any other
illness
Incidence of ARI in developing and developed
countries are similar
Urban areas> rural areas
25-42 percent of outpatient visits by young
children in developing countries
STATS: PNEUMONIA
20-25% of deaths = 1
st
month
66-75 % of deaths (ARI)=PNEUMONIA
50-60 % of deaths due to ARI= < 1 year
1/3 of all admissions (inpatient)
3-4/100 children develops pneumonia in a yr.
(developed countries)
7-18/100 children develops pneumonia in a yr
(developing countries)
Duration of illness is short: 3-5 days from
onset to death
96 % of deaths due to ARI occur in
developing countries


ARI
Impt to remember!!
1. Primary infection of the lung parenchyma is
LESS common
2. Secondary BACTERIAL infections
complicating a viral upper respiratory
infection is MORE common.
3. The most common event that breaks the
defense mechanism of the lung is a VIRAL
INFECTION
Risk Factors to developing pneumonia
1. lung disease e.g. asthma
2 anatomic problem
3 GER
4 neurologic disorders
5 altered immune system
ARI
VIRAL PNEUMONIA
1. RSV
2. Parainfluenzae
3. Influenza
4. Adenovirus
ARI
BACTERIAL PNEUMONIA
1. Gm + = Pneumococcal pneumonia
Streptococcal pneumonia
Staphylococcal pneumonia
2. Gm - = Hemophilus influenzae
Klebsiella pneumonia
Pseudomonas aeroginosa
ARI
PATHOLOGY
1. Necrosis= at the tracheobronchial tree, bronchial
mucosa, alveoli, insterstitium, pleura
2. Edema/congestion
3. Exudates/secretion/cellular debris
4. Hemorrhage
5. Abscess formation/cavity formation
6. Pleura fluid
ARI-ETIOLOGY
ISOLATION STUDIES-PNEUMONIA
BACTERIA IN 55% OF UNDERFIVE
CHILDREN
Most common organisms:
=2mos to <5 Streptococcus pneumoniae
Haemophilus influenzae
= 0- < 2 mos Group B Streptococcus
E. coli
ARI-ETIOLOGY
Etiologic agent diagnosis can be established
only in < 25% of children hospitalized in
developed countries
therefore the decision to treat is based on
clinical suspicion rather than laboratory
confirmation
antibiotics are started IMMEDIATELY and
given EMPIRICALLY
ARI
SIGNS/SYMPTOMS
Respiratory:
1. Cough
may be absent INITIALLY in lobar
pneumonias and in young infants< 2 months
2. Chest pain- commonly because of pleural
involvement

ARI
3. Chest findings
>diminished breath sounds affected side
tubular breath sounds on the unaffected side
> rales
> dullness
> fremitus= increased
> expansion: unequal, lag on the affected side
> pleural fluid: pyo or empyema
decreased breath sounds
dullness
decreased fremitus
> pneumatoceles/bullae/blebs/abscesses/cavity formation
best demonstrated by Xray

ARI
Non-respiratory
1. Constitutional signs of infection
2. Pleuritis: splinting, abdominal pain, neck
rigidity
3. Skin lesions= Staphylococcus
4. Viral exanthem
5. Extra pulmonary extension = meninges

ARI
Signs of Respiratory Distress
1. Flaring of the alae nasi
2. Retractions
chest indrawing
intercostal
others- use of the sternocleidomastoid
muscle( head bobbing)
3. Grunting
ARI
Signs of respiratory distress
4. Tachypnea/tachycardia
5. Cyanosis/pallor
6. Constitutional signs:
- anxiety
- restlessness
- sensorial changes
- not able to drink/feed
- convulsions =HIE(hypoxic ischemic encephalopathy)

7. Other systems= GI

head bobbing
a sign of respiratory distress in an infant. It occurs
when the infant uses the scaleni and
sternocleidomastoid muscles to assist ventilation.
the contraction of these muscles causes the head
to bob because the neck extensor muscles are
not strong enough to stabilize the head.


ARI
DIAGNOSIS
1. History= URTI (rhinitis/cough) then worsens
2. P.E.
3. Chest X-ray
4. CBC, blood culture
5. Isolation studies from the respiratory =
sputum, tracheal aspirates, bronchial
aspirates, lung tap
ARI
TECHNICAL BACKGROUND
1. 6 study centers global studied 29 signs
to identify the most sensitive and specific
clinical predictors of PNEUMONIA
2. The entry criteria:
COUGH OR DIFFICULT BREATHING
3. Gold standard:Chest X Ray/Bacteriology
ARI
CLINICAL SIGNS THAT INDICATE
PNEUMONIA
1. FAST BREATHING
= RR 60/min or more in 0 to less than 2
months (counted twice)
= RR 50/min or more in 2 mos to 11 mos
= RR 40/min or more in 12 mos to 59 mos


ARI
1. Fast Breathing
how?
Count the breaths in one full minute
Child is calm, not crying, not feeding
Clin. Signs that indicate PNEUMONIA
ARI
1. Fast breathing
2. Chest indrawing
= lower chest wall goes IN when
the child breathes in
= there is obvious effort to breath IN
= child should be lying flat, not bent on
the waist, visible ALL the time
= child is calm not crying, not feeding
= clogged nose: should be cleared, before
assessing
= MILD chest indrawing is normal in infants < 2mos
Clin. Signs that indicate PNEUMONIA
ARI
1. Fast breathing
2. Chest indrawing
3. Cyanosis= central
4. Not able to drink ( 2 mos to 59 mos)
- not able to drink AT ALL
- swallowing reflex lost
- too drowsy or too weak to drink bec. of
respiratory distress
5. Not able to feed (0 to 59 days)
- able to consume only half the usual feeds

Clin. Signs that indicate PNEUMONIA
ARI
CLASSIFICATION
1. Classification process is used ONLY
for children aged 0-59 mos.
2. ONLY for community acquired ARI
was able to rule out hospital acquired exposure
within 72 hours of onset of symptoms
2. ONLY when the child has COUGH or
DIFFICULTY IN BREATHING

ARI

Most IMPT! Classification is hierarchical

1. Only ONE classification for pneumonia is possible
2. The classification is made by exclusion
3. The most SEVERE classification is chosen even if
signs are identified across
classification categories


ARI
DANGER SIGNS
Def: clinical signs which indicate a systemic,
severe illness
when DANGER SIGNS accompany
cough or difficult breathing, a serious illness is
considered, NOT just PNEUMONIA
ARI
DANGER SIGNS
2mos- 59 mos
1. Stridor
2. Convulsions
3. Drowsiness or lethargy
4. Severe malnutrition

ARI
DANGER SIGNS
0-59 days
1. Fever= temp. 37.5C and above
2. Hypothermia= 35.5 C and below
3. Stridor
4. Wheezing
5. Drowsiness/lethargy
6. Convulsions


axillary
ARI
STRIDOR-Diff. Dx
1. VIRAL
Acute Infectious Croup
Laryngitis, ALTB
2. DIPHTHERIA
3. BACTERIA
Acute epiglotitis
Acute tracheitis
4. Foreign Body

5. Congenital anomalies




ARI
CLASSIFICATION-2 mos. to 59 mos
1. Very Severe Disease
Basis: Cough or difficult breathing
Any danger sign present
2. Very Severe Pneumonia
Basis: Cough or difficult breathing
No danger sign present
Central cyanosis or not able to
drink
ARI
CLASSIFICATION- 2mos to 59 mos
3. Severe Pneumonia
Basis: Cough or difficult breathing
No danger sign
No cyanosis
Able to drink
Chest indrawing

ARI
CLASSIFICATION- 2 mos to 59 mos
4. Non-severe pneumonia/Pneumonia
Basis: Cough or difficult breathing
No danger sign
No cyanosis
Able to drink
No chest indrawing
Fast breathing

ARI
Fast breathing:

2mos-11 months= 50 breaths/min or more
12mos-59 months= 40 breaths/min or
more
ARI
CLASSIFICATION- 2mos to 59 mos

5. No pneumonia
Cough or difficult breathing
No signs of very severe disease, very severe
pneumonia, severe pneumonia and non-
severe pneumonia
ARI
CLASSIFICATION= 0 to 59 days old

1. Very Severe Disease
Basis: Cough or difficult breathing
Any danger sign present
2. Very Severe Pneumonia
Basis: Cough or difficult breathing
No danger sign present
Cyanosis or not able to feed

ARI
3. Severe Pneumonia
Basis: Cough or difficult breathing
No danger sign
No cyanosis
Able to feed
Severe chest indrawing OR
Fast breathing

ARI

Fast breathing in young infants!

1. 60 breaths/min or more

2. COUNTED TWICE!!

ARI
CLASSIFICATION

4. No pneumonia
Basis: Cough or difficult breathing
No signs of very severe disease,
Very severe pneumonia,
and severe pneumonia
ARI
SUMMARY OF CLASSIFICATIONS
2-59 MOS
1. Very severe disease
2. Very severe pneumonia
3. Severe pneumonia
4. Non-severe pneumonia/pneumonia
5. No pneumonia
ARI
SUMMARY OF CLASSIFICATIONS
0-59 days
1. Very severe disease
2. Very severe pneumonia
3. Severe pneumonia
4. No pneumonia


Neonatal
Pneumonia
Steps in making an empiric decision on the presence and severity of
pneumonia ( 2 MONTHS TO 59 MONTHS)
Step 1 Is there cough or difficult breathing?
if YES, proceed to Step 2
Step 2 Are there any danger signs?
if YES, classify: VERY SEVERE DISEASE
if NO, proceed to step 3
Step 3 Is there cyanosis or not able to drink?
if YES, classify: VERY SEVERE PNEUMONIA
if NO, proceed to Step 4
Step 4 Is there chest indrawing?
if YES, classify: SEVERE PNEUMONIA
if NO, proceed to Step 5
Step 5 Is there fast breathing?
if YES, classify: NON-SEVERE PNEUMONIA
if NO, proceed to Step 6
Step 7 Are there no signs of VERY SEVERE DSS, VERY SEVERE PNEUMONIA, SEVERE
PNEUMONIA, NON-SEVERE PNEUMONIA?
if YES, classify as NO PNEUMONIA

Steps in making an empiric decision on the presence and severity of
pneumonia ( BIRTH TO 59 DAYS)
Step 1 Is there cough or difficult breathing?
if YES, proceed to Step 2
Step 2 Are there any danger signs?
if YES, classify: VERY SEVERE DISEASE
if NO, proceed to step 3
Step 3 Is there cyanosis or not able to feed?
if YES, classify: VERY SEVERE PNEUMONIA
if NO, proceed to Step 4
Step 4 Are there fast breathing or severe chest indrawing?
if YES, classify: SEVERE PNEUMONIA
if NO, proceed to Step 5
Step 5 Are there no signs of VERY SEVERE DSS, VERY SEVERE PNEUMONIA,
SEVERE PNEUMONIA ?
if YES, classify as NO PNEUMONIA

ARI
TREATMENT-GEN. PRINCIPLES
1. Presumptive etiology
> resistance/susceptibility
2. Host factors
>age
>severity of illness incl. complications
>concomitant illness
>immunocomptence
ARI
Treatment - Gen. Principles
1. Presumptive etiology
2. Host factors
3. Drug factors
>spectrum of activity
>pharmacokinetics
>interactions
>benefit/risk ratio
>cost/benefit ratio

ARI
Treatment - Gen. Principles
1. Presumptive etiology
2. Host factors
3. Drug factors
4. Hospitalization vs Outpatient
5. Availability of O2
6. Others
ARI
TREATMENT
Very Severe Disease
1. Hospital for further assessment
Pre-referral treatment
> 1
st
dose of antibiotic
> prevent hypoglycemia
> treat fever
> fluids/feed
> O2 if available
> referral note
ARI
TREATMENT
Very Severe Pneumonia
1. Hospital for treatment
2. Pre-referral treatment
Severe Pneumonia
1. Hospital for treatment
2. Pre-referral treatment
ARI
TREATMENT
Non-Severe Pneumonia or Pneumonia
1. Home care
2. Oral antibiotics for 5 days
3. Treat other problems: wheezing, fever
4. Reassess after 2 days

ARI
Reassessment of Non-Severe Pneumonia after 2
Days:
1. If WORSENS: signs of very severe ds., very
severe and severe pneumonia
Hospital
2. If SAME: with fast breathing
Change to second line AB
3. If IMPROVED:
Home, continue present AB

ARI
TREAMENT
No Pneumonia
1. Home care
2. Treat other problems=fever, wheezing
3. Treat specific URTI
4. Teach family/caregiver:
signs to come back IMMEDIATELY=
fast breathing, difficult breathing, seems not
getting any better (development of NEW
signs/symptoms probably pneumonia)
ARI
TREATMENT
Home Care (Supportive Measures)
1. Encourage the child to drink plenty of fluids
2. Cont. BF
3. Encourage the child to eat (small frequent feeds
4. Keep the child warm but not overwrapped
5. Keep the nostrils clear to facilitate breathing
6. DO NOT give: cough suppressants, antihistamines, and
mucolytics
7. Practice simple chest physiotherapy

ARI
CHEST PHYSIOTHERAPY
Indication: where excessive bronchial secretions
are not removed by normal ciliary activity and
cough
ARI
CHEST PHYSIOTHERAPY
1. Bronchial drainage
position: head/chest down
2. Deep breathing to reinforced cough
ask child to cough reinforced by hands encircling/synchronously
compressing the sides of the lower half of the chest
3. Chest clapping/cupping
PRINCIPLE: compression of the cupped hand and the chest wall results to
the compression wave transmitted to the underlying bronchi which
enhanced the flow of bronchial secretions
PROCEDURE: repeatedly, vigorously, clap the chest wall with the cupped
hand, the ENTIRE CIRCUMFERENCE of the hand touching the chest wall
at the SAME TIME
correct if: hollow sound is produced


ARI
Home Care
Simple cough/colds remedies:
1. Calamansi
2. Ginger
3. Tamarind

ARI
TREATMENT
Very Severe Pneumonia/Severe Pneumonia
1. Antibiotics X 10 days (7 days for Severe Pneumonia, 21 days
for Staphylococcal pneumonia)
2. O2 if indicated
3. Treat fever, wheezing
4. Monitor/reassess response
5. Monitor for complications
6. Chest X ray if with complications, then treat



ARI
INDICATIONS FOR O2 INHALATION
1. Central cyanosis
2. Severe chest indrawing
3. Restlessness- if O2 relieves the restlessness
4. Breath rate 75/min or more
5. Grunting in 0 to 59 days old
ARI
Criteria for Good Response (after 48 to 72 hrs)
1. Less or no more fever
2. Less or no more cough
3. Improved signs
RR decreasing
Chest indrawing decreased or disappeared
4. Less or no more chest pain
5. General well-being improved


ARI
Very Severe/Severe Pneumonia
Response is SAME or WORSENED?
1. Change antibiotics
2. Check for chest complications
> what, where, extent (severity)
3. Check for extra-pulmonary extension




ARI
COMPLICATIONS?
1. Suspect if: upon reassessment= WORSENS!!
2. What?
= pleural effusion
= empyema
= lung abscess/pneumatocele
= pericarditis
= extra pulmonary extension
meningitis, septic arthritis, osteomyelitis
ARI
COMPLICATIONS:
3. What to do?
= Confirmed by DIAGNOSTIC PROCEDURES!
X-rays, ultrasound, CT scan, thoracentesis, cultures
= Surgical intervention
(chest tube, etc)
= Change antibiotics

ARI
Slowly resolving pneumonia or
Persistent pneumonia
Def: a pneumonia that persists after 10 days of AB
CAUSES:
1. Inadequate TX
> inappropriate choice of AB
> poor compliance
> resistant strains
2. Host defense impaired
> coexisting illness
> immunodeficiencies
3. Foreign body
4. Other non-infectious causes

ARI
WHEEZING
CLINICAL MANIFESTATIONS
1. effort to breath out
2. prolonged expiratory phase
3. hyperinflated chest
4. apneic episodes in 0-59 days old
5. chest indrawing
6. soft, musical sound on breathing OUT
ARI
WHEEZING-PATHOLOGY
Partial airway obstruction
HOW:
A. Viral infection: virus colonizes
bronchiolar epithelium necrosis T
lymphocyte/IgE production at peribronchial
tissue EDEMA, MUCUS SECRETION,
NECROTIC DEBRIS

BRONCHIOLAR LUMEN
ARI
WHEEZING-PATHOLOGY
B. Asthma
features:edema
mucus secretion
bronchial muscle spasm

BRONCHOCONSTRICTION
ARI
WHEEZING in ARI- CLIN. APPROACH
I Determine : First or Recurrent episode?

II Determine response to RAB

III Determine if PNEUMONIA is present
If wheezing is present in a child 2 months to 59
months with cough or difficult breathing

Step 1: Administer RAB (rapid acting
bronchodilator or inhaled bronchodilator,
usually salbutamol) 3 times 15 minutes apart,
then reassess
Step 2: Classify cough or difficult breathing

If wheezing is present in a young infant ( Birth
to 59 days) with cough or difficult breathing,
classify as VERY SEVERE DISEASE and REFER
TO HOSPITAL!!

WHEEZING IS A DANGER SIGN IN A YOUNG
INFANT!!


ARI
FEVER in ARI
def. =elevation of temp.37.5 C and above
(axillary)
mild to moderate elevations (37.5 to 38.5)
should not be treated
reason: improves performance of
immune system
High fever: increase O2 consumption
may cause convulsions

ARI
FEVER (cont)
Treatment of high fever(38.5 and above)
-Paracetamol
- ONLY for 2 mos -59 mos.
ANY FEVER IN 0-59 DAYS OLD IS NOT
TREATED!
ARI
FEVER(cont)
REASONS WHY PARACETAMOL IS NOT GIVEN TO 0-59
DAYS WITH FEVER
1. Fever improves body defenses
2. Convulsions secondary to fever is rare
3. Fever is a DANGER SIGN, an impt. indicator for
severity of illness
4. Immature liver
5. Thermal regulation at CNS immature, most young
infant assumes the temperature of the
environment

ARI
ACUTE BRONCHIOLITIS
Incidence: < 2 yrs, peak: 6 months
Agent: virus mainly, RSV
Pathology: necrosis= by viral multiplication
: edema, necrosis, mucus
secretion by T lymphocyte and
IgE response of the peribronchial
tissue
result? Partial airway obstruction
ARI
ACUTE BRONCHIOLITIS
Clinical Features:
Upper RTI associated with fever (other
constitutional signs/symptoms)
Lower RTI symptoms plus WHEEZE
Might be difficult to distinguish from
PNEUMONIA!!

ARI
ACUTE BRONCHIOLITIS
Chest X-ray= hyperinflated lungs
Other labs: may be normal
Course: 1
st
72 hrs is critical
ARI
ACUTE BRONCHIOLITIS
Intervention:
1. Hospital
2. Bronchodilator
3. Nebulized epinephrine
4. Corticosteroids?
5. Ribavirin
6. AB if superimposed with pneumonia
ARI
LARYNX, TRACHEA, BRONCHUS
Key feature: acute inflammation causing airway
obstruction
Gen. Char: brassy cough
: hoarseness
: stridor
: respiratory distress
(depends on the location, extent,
severity)
CROUP
ARI
STRIDOR-Diff. Dx
1. VIRAL
Acute Infectious Croup
Laryngitis, ALTB
2. DIPHTHERIA
3. BACTERIA
Acute epiglotitis
Acute tracheitis
4. Foreign Body

5. Congenital anomalies




ARI
CROUP
Etiology: gen. VIRAL except
1. diphtheria= C. diphtheriae
2. epiglottitis= H. influenzae
3. bacterial tracheitis=
Staphylococcus aureus
ARI
CROUP
Intervention
1. Airway Mx
from O2 to intubation/tracheotomy
2. Nebulized epinephrine
3. Cool mist
if wheezing is associated: may worsen
4. Corticosteroid
5. AB if bacterial
ARI
URTI
1. Upper respiratory infections are commonly
VIRAL
2. Antibiotics are RARELY indicated
ARI
URTI (BACTERIAL)
1. Acute Sinusitis
2. Streptococcal pharyngitis
3. Acute ear infections
Acute mastoiditis




ARI
URTI
Acute Sinusitis
Features:
1. Rhinitis duration >2 weeks
2. Rhinitis seems severe
3. Fever
4. Facial pain
5. Daytime cough
ARI
URTI
ACUTE EAR INFECTION
1. Ear pain OR
2. Ear discharge of < 2 weeks
3. Ear discharge of 2 weeks or more
Classify: CHRONIC EAR INFECTION


ARI
ACUTE EAR INFECTION
Treatment:
1. Cotrimoxazole/Amoxicillin
2. Wick the ear dry = tissue NOT cotton buds
3. Paracetamol for pain
ARI
CHRONIC EAR INFECTION
Treatment:
1. Topical antibiotic= quinolone
2. Wick the ear dry
3. Refer if complicated

ARI
Viral Pharyngitis Bactl Pharyngitis
Age < 1 yr. old > 2 yr old
Onset gradual acute
Assoc. sore throat sore throat
cough rare
hoarseness rare
rhinitis rare
tonsils: tonsils:
slight inflamed hyperemic
(-) exudates (+) exudates
(-) lymph nodes (+) lymph nodes, tender

ARI
Strep pharyngitis
Tx: Benzathine PCN IM
Oral Penicillin for 10 days
Complications of Strep Pharyngitis
1. Throat abscess
Treatment: Surgical drainage
Cover for gm
and anaerobes
2. Rheumatic fever

Acute Respiratory Infections
in Children with HIV-AIDS
1. Typical pathogens are common:
Streptococcus pneumonia, Hemophilus
influenzae, Moraxella catarrhalis
2 Unusual pathogens:
P. aeruginosa (in severely infected children),
yeast, anaerobes
3 Lymphocytic insterstitial pneumonitis(LIP)
is a common chronic respiratory infection assoc.
with nodular hyperplasia in the bronchial and
bronchiolar epithelium
Lymphocytic insterstitial
pneumonitis(LIP)
= typical Chest X-ray finding: diffuse
retilonodular pattern, may or may not be
assoc. with hilar lymphadenopathies
= chronic cough, insidious onset of tachypnea,
minimal chest P.E. findings, progressive
hypoxemia (clubbing of fingers )
= suspected organism: Epstein-Barr virus
infection
opportunistic organisms:
- Pneumocystis carinii pneumoniae (PCP)
: most common opportunistic infection
: peak incidence- 3 to 6 months old
: highest peak of mortality: < 1 year
: signs and symptoms
- fever, tchypnea, dyspnea, marked hypoxemia
(cyanosis),
- Chest X-ray: diffuse alveolar disease
nodular lesions, lobar infiltrates, pleular
effusions
- rapid progression
- Treatment: Trimethoprim-Sulfamethoxazole IV
and corticosteroids

-

TMP-SMZ prophylaxis for PCP
Indications:
1. All infants exposed to HIV-AIDS mother
should receive prophylaxis from age 6 weeks to 1 year old
regardless whether they are found to be infected or not.
2. All infants found to be infected from HIV-AIDS mother
should receive prophylaxis from from age 6 weeks to 1 year
old regardless of CD4 count
3 All infants after 1 year old, should receive prophylaxis
according to CD4 count if infected
1-5 yrs: CD4 count of < 500 cells/uL every 3 to 4 months
6-12yrs: CD4 count of < 200 cells/uL every 3 to 4 mos.





Other opportunistic organisms:
- cytomegalovirus (CMV)
- Aspergillus
- Histoplasma
- Cryptococcus
Common respiratory viruses:
- Respiratory syncytial virus (RSV)
- Influenza and Parainfluenza
- Adenovirus
Pulmonary and extra pulmonary TB (not as common
as in adults)
Pediatric Community Acquired
Pneumonia (PCAP)
Guidelines according to PPS and PAPP
3 age groups
1. 3 months to 5 years old
2. 5 to 12 years old
3. Beyond 12 years old
WHO: 2 age groups
1 birth to 59 days
2 2 months to 59 months
PPS/PAPP
Predictors of PCAP in a patient with cough
3 MONTHS TO 5 YEARS OLD:
= fast breathing and chest indrawing
(fast breathing definition is same as
WHO)
5 TO 12 YEARS OLD
= fever, tachypnea, and crackles (rales)
( tachypnea: 30 breaths/minute)
BEYOND 12 YEARS OLD
= fever, tachypnea, tachycardia, AND
(tachypnea: 30 breaths/minute)
AT LEAST ONE:
abnormal chest findings of= diminished breath
sounds, rhonchi, crackles, or wheezes


PPS/PAPP
RISK FACTORS TO MORTALITY

Variables


PCAP A
Minimal Risk
PCAP B
Low Risk
PCAP C
Moderate Risk
PCAP D
High Risk
1 Co-morbid
illness
None Present Present Present
2 Compliant
caregiver
Yes Yes No No
3 Ability to follow
up
Possible Possible Not possible Not possible
4 Presence of
dehydration
None Mild Moderate Severe
5 Ability to feed Able Able Unable Unable
6 Age > 11 months >11 mos. < 11 mos. < 11 mos.
7 RR
2-12 mos
1-5 yrs
> 5 yrs

50/min
40/min
30/min

>50/min
>40/min
> 30/min

>60 min
>50/min
> 35/min

>70 min
>50/min
> 35/min

PPS/PAPP
Risk factors to mortality

Variables PCAP A
Minimal
risk
PCAP B
Low Risk
PCAP C
Moderate Risk
PCAP D
High risk
8 Signs of respiratory
failure
a Retraction


b Head bobbing
c Cyanosis
d Grunting
e Apnea
f Sensorium


None


None
None
None
None
Awake


None


None
None
None
None
Awake


Intercostal/subcos
tal

Present
None
None
None
Awake


Supraclavicular/in
tercostal/sub
costal
Present
Present
Present
Present
Lethargic/stuporo
us/comatose
9 Complications
(effusion,
pneumothorax)
None None Present Present
10 ACTION PLAN OPD
f/up after
Tx
OPD
f/up after 3
days
Admit to regular
ward
Admit to CU
Refer to specialist
PPS/PAPP
Co morbid conditions:
1 malnutrition
2 asthma
3 congenital heart disease
4 others thay can directly affect respiratory
function
PPS/PAPP
IMPORTANT:
In case of overlapping parameters, assume the
next severe classification with only one
parameter present
Retraction is the best single predictor of death
(at 23-fold higher odds of mortality)
Cyanosis and head bobbing correlates well
with hypoxemia
sensitivity (59%) specificity (93%)
Grunting and apnea are manifestations of
respiratory failure requiring admission to
PICU.
RESPIRATORY DISEASES
Miscellaneous
A. Hydrocarbon pneumonia
commonly accidental
the lower the viscosity, the more possibility of aspiration
gastric lavage is CONTRAINDICATED
danger of more aspiration
relatively indicated:
1. large quantity
2. hydrocarbon contains another component that may be poisonous
Hypoxia is worsened by displacement of alveolar air with hydrocarbon
= chemical pneumonitis
In severe cases: convulsions, coma
Bacterial pneumonia a common complication
Steroids may be harmful

RESPIRATORY DISEASES
Miscellaneous
B. Atelectasis
def: imperfect expansion of the alveolar
sac
pathology: complete obstruction of flow
of air alveolar air trapped then
absorbed to the circulation

RESPIRATORY DISEASES
Miscellaneous
B. Atelectasis
How? EXTERNAL
>tumors, lymph nodes, effusions,
pneumothorax, cardiac enlargement
common site: Rt middle lobe
INTRABRONCHIAL/BRONCHIOLAR
> foreign body, tumors, granuloma,
secretions= common in BA, bronchiolitis
RESTRICTION IN RESPIRATION/PARALYSIS
> thoracic cage abnormalities, defective movement of the
diaphragm
Diagnosis? By X ray more reliable than P.E.
findings: consolidation
contracted area
mediastinal shift towards the AFFECTED SIDE


RESPIRATORY DISEASES
Atelectasis
Note: superimposed infection is common!!
Treatment:
Treat primary cause
Bronchoscopy- dxtic at the same time
Chest physiotherapy
AB
If BA- bronchodilator, steroids

RESPIRATORY DISEASES
EMPHYSEMA /OVERINFLATION
Def.= distention of the alveoli rupture
that is irreversible
(note: if rupture is reversible-
OVERINFLATION)
=may be localized or generalized
= obstructive overinflation (increased residual air)
occurs in BA, bronchiolitis
= DX: by X-ray
diaphragm is low is flattened
ribs are far apart
lungs are less dense
A-P diameter is increased
respiratory difficulty:EXPIRATORY
= LOCALIZED EMPHYSEMA
congenital= blebs, cyst
acquired= pneumatocele
= SUBCUTANEOUS EMPHYSEMA = air is in the subcutaneous tissue

RESPIRATORY DISEASES
PLEURAL EFFUSION
Secondary Event: to pneumonia, heart failure, metastasis, malignancy
Forms: dry, plastic- serofibrinous
plastic
Sx: pleuritic pain
respiratory distress: severity depends on amount of fluid, rate of accumulation
P.E.= dullness to flat
= decreased breath sounds
= decreased tactile fremitus
= mediatinal shift: OPPOSITE SIDE
Dx: X-ray
= widened intercostals
= density without lung markings
= costo/cardio phrenic angle: OBLITERATED
= shifting levels at different positions
TX
= treat primary disease
=repeated thoracentesis/chest tube drainage

EMPYEMA/PYOTHORAX PLEURAL FLUID IS PURULENT



RESPIRATORY DISEASES
HYDROTHORAX
Non-inflammatroy fluid in the pleural cavity
Other areas of body: may also have fluids
Causes: nutrititional, cardiac, renal, or
neoplasms
Mechanism: venous obstruction
RESPIRATORY DISEASES
PNEUMOTHORAX
Def: air in the pleural cavity
A common complication to Staphylococcal
pneumonia
If with assoc. with fluid: pyopneumothorax
Severity depends: 1ry disease
: extent of lung collapse
P.E.: percussion will be tympanitic
Tension pneumothorax: a fistula connects the pleural
cavity to a continuous supply of air
RESPIRATORY DISEASE
TENSION PNEUMOTHORAX
How to prove:
1. Amphoric breathing
2. Fluid is present (pyopneumothorax)
3. Gurgling sounds synchronous with breathing
4. Reaccumulation of air after it is aspirated
TX: Chest tube with end under water
RESPIRATORY DISEASES
PULMONARY EDEMA
Def: transudation of fluid from the pulmonary
capillaries into the alveolar spaces and bronchioles
Problem mainly: circulation
Common manifestation of left ventricular failure
(increased venous pressure)
Distinct sign: bubbly, moist rales
X-ray: perihilar infiltrates (butterfly sign)
Tx: O2, PEEP, CPAP, morphine sulfate, furosemide,
digitalis, bronchodilators
RESPIRATORY DISEASES
ADULT RESPIRATORY DISTRESS
SYNDROME (ARDS)
Non-cardiogenic pulmonary edema
Causes: primary pulmonary
: primary extrapulmonary
Examples: sepsis, hypovolemic shock,
DIC, drug overdose, aspiration,
smoke/toxic inhalation
RESPIRATORY DISEASES
ARDS
Pathophysiology: increased permiability of
the alveolo-capillary interface
What happens then? Leukocytes aggregate
within the capillaries potent mediators
are released:
O2 radicals, proteolytic enzymes,
arachidonic metabolites, fibrin degradation
products, PAF
RESPIRATORY DISEASES
RADICALS
damage the alveolar epithelium
fluid accumulates in the alveolar sac (also: WBC plugs)
fluid may also accumulate in the
instertitial spaces (insterstitial pulmonary
edema)
edema of the alveolar sac wall

cuboidal cells proliferate (increased cellularity)

FIBROSIS
RESPIRATORY DISEASES
CHRONIC/PERSISTENT COUGH
Cough occurs for 30 days
IMPORTANT!! Always consider ARI as superimposed so:
CLINICAL APPROACH
1. Assess whether cough is life threatening
2. Assess for PNEUMONIA
3. Treat the pneumonia if present
4. Determine the most likely cause of the
chronic cough
5. Treat the most likely cause
RESPIRATORY DISEASES
CHRONIC/PERSISTENT COUGH
DIAGNOSIS:
Box 370-1 p. 1402 Nelsons
Indicators that chronic cough is life
threatening
Box 370-2 p. 1402
Differential diagnosis



SUMMARY OF CLINICAL APPROACH TO
TREATING A CHILD BELOW FIVE YEARS OLD
WITH COUGH OR DIFFICULTY IN BREATHING

Assess the child
a. danger signs
b. cyanosis or not able to drink/feed
c. chest indrawing
d. fast breathing

STEP 1 (for 2 months to 59 mos)
Ask: Is there a danger sign?
if yes: classify as Very Severe disease
if no: proceed to STEP 3
STEP 2
Ask: is there cyanosis or not able to drink?
if yes: classify as Very Severe Pneumonia
if no: proceed to STEP 4

STEP 3
Ask: Is there chest indrawing
if yes: classify as Severe Pneumonia
if no: proceed to STEP 5
STEP 4
Ask: Is there fast breathing?
if yes: classify as Non-Severe Pneumonia
if no: classify as No Pneumonia
Sick young infant (below 2 months)
STEP 1
Ask: Is there danger sign?
if yes: classify as Very Severe Disease
if no: proceed to STEP 2
STEP 2
Ask: is there cyanosis or not able to feed?
if yes: classify as Very Severe Pneumonia
if no: proceed to STEP 3
STEP 3
Ask: Is there severe chest indrawing or fast
breathing?
if yes: classify as Severe Pneumonia
if no: classify as No pneumonia

OTHER PROBLEMS?
1. Wheezing
2. Fever
3. URTI

INTERVENTION:
1. Hospital
if hospital:
pre-referral treatment:
first dos antibiotic
treat fever
nebulize RAB
treat convulsions
treat or prevent hypoglycemia
O2
referral note
HOME?
1. Supportive home care
> cont. feeding
> increase fluid intake
> watch for worsening signs
2. Specific
> Antibiotics
> Simple cough cold remedies
> Clear clogged nose
> Chest physiotherapy
> Treat fever
> Treat wheezing
> Wick the ear dry
3. Follow up
> unscheduled if the child worsens
> scheduled
CASES:
1. A 3 month old infant: alert, wt: 4 kg, T= 37.9
C, RR= 56/min, no danger signs able to drink,
not cyanosis, no chest indrawing, no
wheezing, no signs of complications of
pneumonia

A 12 month old child with cough: wt: 6 kg, T=37
C, RR= 36/min, irritable, no stridor, no
convulsions, no cyanosis, able to drink, no
chest indrawing.
2 yrs old: cough few hrs ago, wt: 12 kg, T= 38 C,
RR= 52/min, severe chest indrawing, no
cyanosis, able to drink, no danger signs,
wheezing 2
nd
episode