Presentation on

Acute Respiratory Tract Infection

Chairperson For
Session
Prof. Dr. ARM Lutful Kabir
Professor
Department of Paediatrics

Co-ordinator of Presentation
Dr. Sukhamoy Kangshu Banik
Associate Professor, Neonatology

Presented By

Elora Tanni
Sakeef Rahman
Amit Bikram Mondal
Mehedi Hassan
Junayed Safar Mahmud

Acute Respiratory tract Infection (ARI)

Acute Respiratory tract infections include:
Upper Respiratory Tract
Infections
Lower Respiratory Tract
Infections

Upper Respiratory Tract Infection

Upper Respiratory Tract Infections are those
affecting the structures above the larynx.
These include:
Common Cold
Acute Pharyngitis
Acute Otitis Media
Acute Tonsillitis
Croup Causing Condition ( eg. Epiglottitis)

Lower Respiratory Tract Infection

Lower Respiratory Tract Infections Are those
affecting the structures below and including
the larynx. These include:
Pneumonia
Acute Bronchiolitis
Acute laryngotracheobronchitis

Prevalence of ARI
The incidence of clinical pneumonia in children
aged less than 5 years in developing countries
worldwide is close to 0.29 episodes per childyear.
This equates to 151.8 million new cases every
year due to ARI
8.7% of which are severe enough to require
hospitalization.
In addition, only 4 million cases occur in
developed countries worldwide.

Prevalence: The Global Picture

Prevalence of ARI in Bangladesh

Only 15 countries in the world combined provide
the 3/4th of the new cases to appear throughout
the world. Bangladesh is one of them providing
more than 6 million new cases each year.

According to the study in the year 2005, in

Bangladesh the total under 5 children death
numbered 2,88,000 children. Of these deaths,
ARI related deaths were about 51,000 cases,
which stands responsible for around 19% of the
total death toll.

Diagram showing percentage of

Respiratory disease in relation to other
Diseases

Specific Topics of Discussion

Pneumonia
Acute Bronchiolitis
Acute Laryngotracheobronchitis

Pneumonia

 Pneumonia is defined as an acute respiratory

illness that affect the lung parenchyma
associated with recently developed
radiological pulmonary shadowing which may
be segmental, lobar or multilobar.

Dont Be Fooled: Pneumonia is a killer

Types of Pneumonia
Pathologically , It is of two types,
Bronchopneumonia
Lobar pneumonia

Types of Pneumonia
In view of source of the pathogen and public
health importance, Pneumonia can be of
three types:
Community acquired pneumonia
Nosocomial or Hospital acquired pneumonia
Pneumonia in special situation (ie. Aspiration
Pneumonia, Pneumonia in immunocompromised
patients)

Etiology of Pneumonia
Common organisms for ARI includes:

AGE
Neonatal Period
After Neonatal Period

Beyond 5 Years

ORGANISMS
E. Coli
K. pneumoniae,
Group B streptococci
S. Pneumoniae
H. Influenzae
S. Aureus
And several viruses
Mycoplasma,
Chlamydia

Pathogenesis of Pneumonia
Healthy
lungs

Stage of red
hepatization

Stage of gray
hepatization
COMPLICATION

RECOVERY

Clinical
Manifestation
of Pneumonia

Symptoms of Pneumonia
Symptoms:
Fever
Cough
Respiratory Distress

Signs of Pneumonia
And there is several General danger signs that
indicates severe disease in children, also
evident in Pneumonia. They are,
Not able to drink or breastfeed.
Lethargic or unconscious.
Vomits everything.
Convulsion

GENERAL DANGER SIGNS (2M-5YR)

Lethargic/ Unconscious

Convulsion

Vomits everything

Not able to drink or breastfed

Signs of Pneumonia
General examination

Fast breathing
Features of Hypoxaemia (Cyanosis, Head nodding)
Chest Wall Inspection

Chest Indrawing

Movement of Chest

Restricted on the affected side

Position of trachea

Central

Position of Apex Beat

Normal position

Vocal Fremitus

Increased

Percussion note

Woody Dull

Breath sounds

Bronchial

Vocal resonance

Increased

Added sound

Coarse crepitation

Inspection

Respiratory
System
Examination

Palpation

Percussion
Auscultation

 FAST BREATHING is the single most sensitive and specific

among clinical signs of pneumonia in under 5 children. Cut
of rates for fast breathing depend on the childs age:
Upto 2 months : 60 breaths per minute or more
From 2 months to 1 year : 50 breaths per minute or more
From 1 year to 5 years : 40 breaths per minute or more

CHEST INDRAWING, defined as the inward movement of

the lower chest wall with inspiration,
Chest indrawing should only be considered present if it is
consistently present in a calm child.
Agitation, a blocked nose or breastfeeding can cause
temporary chest indrawing.

 STRIDOR is a harsh sound heard during inspiration due

to obstruction of upper airway. Stridor in a calm child
is an acute emergency.
WHEEZE is a musical sound heard during expiration.
Wheezing sound is most often associated with asthma
and bronchiolitis. Sometimes it is difficult to
differentiate between children with bronchiolitis and
those with pneumonia.

Classification of Pneumonia according

to IMCI
As a leading cause of death, WHO considered
all under 5 children with cough and difficulty
in breathing as possible pneumonia and
classified for management according to their
severity into three categories:
No Pneumonia : Cough or cold
Pneumonia
Severe Pneumonia or Very Severe Disease.

Classification of Pneumonia according

to IMCI
SIGN OR SYMPTOMS

CLASSIFICATION

No sign of Severe or non-severe NO PNEUMONIA

Pneumonia.
COUGH OR COLD
SIGN OR SYMPTOMS

Fast Breathing
SIGN OR SYMPTOMS

General Danger Sign

or
Chest Indrawing
Stridor in a calm child.

CLASSIFICATION

PNEUMONIA
CLASSIFICATION

Severe Pneumonia or
Very Severe Disease

Management

Management
When a child suffers from signs & symptoms
of acute respiratory distress initial assessment
is done according to IMCI.
IMCI assessment governs whether the patient
will be treated at home , at the hospital or will
be referred to specialized centers.

Management According to IMCI

SIGN OR SYMPTOMS

CLASSIFICATION

TREATMENT

If Wheezing (even if
disappeared after rapidly acting
bronchodialator) give an
No sign of Severe NO PNEUMONIA bronchodialator for 5 days.
or non-severe
COUGH OR COLD Soothe the throat and relieve
Pneumonia.
the cough with a safe remedy.
If coughing more than three
weeks or recurrent wheezing is
present, refer for Tb or asthma.
Advise is given to mother when
to return immediately.
Follow up in 5 days.

Management According to IMCI (Contd.)

SIGN OR SYMPTOMS

Fast Breathing

CLASSIFICATION

PNEUMONIA

TREATMENT

An appropriate antibiotic for 5

days.
If Wheezing (even if
disappeared after rapidly acting
bronchodialator) give an
bronchodialator for 5 days.
Soothe the throat and relieve
the cough with a safe remedy.
If coughing more than three
weeks or recurrent wheezing is
present, refer for Tb or asthma.
Advise is given to mother when
to return immediately.
Follow up in 2 days.

Management According to IMCI (Contd.)

SIGN OR SYMPTOMS

General Danger
Sign

or
Chest Indrawing
Stridor in a calm
child.

CLASSIFICATION

Severe
Pneumonia or
Very Severe
Disease

TREATMENT

Give first dose of an appropriate

antibiotic, preferably Ampicillin
(50 mg/kg) and/or Gentamicin
(7.5 mg/kg)
Treat the child to prevent low
blood suger.
URGENT referral to a hospital

Investigation
X-ray Chest P/A view:
In Consolidation: Homogeneous Radio Opacity in any
area of lung field
In Bronchopneumonia: Patchy opacities are seen in
different areas of lung field.

Consolidation (Lobar Pneumonia)

Bronchopneumonia

Investigation
Complete Blood Count:
Polymorphoneuclear
Leukocytosis

Sputum C/S
Blood Culture &
Sensitivity

Treatment

Counsel the parents about the disease.

Supportive treatment
Specific treatment
Prevention and treatment of complication
Follow up

Specific Treatment (Antibiotics)

Pneumonia (2 months Upto 5 Years)
Amoxicillin (Oral, 30 mg/Kg 8 hourly for 5 days)
Severe Pneumonia (0 day upto 5 years)
Hospitalization
Ampicillin (I.V. 50 mg/Kg 6 hourly) or
Amoxicillin (I.V. 60 mg/Kg 6 hourly)

Supportive Treatment
Ensure appropriate nutrition (breast feeding &
other foods, fluid)
O Therapy: if cyanosis or saturation of oxygen
<92%
2

Paracetamol for Fever

Sulbutamol for Wheeze
Clear nose with normal saline drop
Soothe the throat, relief cough with a safe remedy
(warm water, Tulsi juice, lemon tea)

COMPLICATIONS

Pleural Effusion
Empyema
Lung abscess
Pneumothorax
Septicaemia and dissemination to Other organs
eg. Meninges, bones, joints

Prevention
Breast feeding
Hand washing
Immunization against Pneumococcus, Hib,
Measles, Diptheria, Tetanus.

Acute
Bronchiolitis

Acute Bronchiolitis
It is an acute viral infection of the bronchioles and is
characterized by, Cough, Respiratory distress and
Wheeze that start following an episode of Upper
Respiratory Catarrhal.
Age: This disease occurs in children of <2years (it
occurs mostly between 2-6 months)
Occurs in epidemics particularly during winter and rainy
seasons
Causative organisms:
Respiratory Syncytial Virus (Most common)
Others: Influenza, Para influenza.

Clinical Manifestation
Symptoms:
Severe respiratory Distress affecting feeding
Wheeze
Cough
Low grade fever or no fever
In many cases babies are otherwise playful and
afebrile (happy wheezer)

Respiratory System Examination

Inspection:
Fast breathing
Chest Indrawing
Hyperinflated chest

Percussion note:
Hyper resonant

Auscultation:
Breath sound is vesicular with prolonged expiration
Widespread Ronchi.
Sometimes fine crepitation are present

Investigation
X-ray Chest P/A view:
Hypertranslucency
Hyperinflation (horizontal ribs, Low set diaphrgm)

Treatment
Counsel the parents about the disease.
Mild Cases

Home care
Head up position
Normal feeding
Cleaning nose with normal saline drop
Bathing with Luke warm water.
When to return to Hospital
Central Cyanosis
Not able to drink

Restlessness
Severe chest indrawing and
Grunting.

Severe Cases

Hospitalization
Humidified O therapy
Nebulization with Salbutamol
Supportive management as in home care.
2

Acute
Laryngotracheobronchitis

Acute Laryngotracheobronchitis
Acute Laryngotracheobronchitis is a viral
inflammation of the lower airway accounting
for 15% of all respiratory tract infections.
Children between 6 months and 3 years Suffer
more.
It occurs mostly during early winter or late
falls.

Etiology
Virus:
Parainfuenza types 1 & 2 (Most common)

Others are,
Influenza A & B
Adenovirus
RSV
Metapneumovirus

Bacterial :
Mycoplasma (Rare)

Pathogenesis
In acute Laryngotracheobronchitis, tracheal
wall becomes oedematous with profuse
mucous secretions. This causes narrowing of
the airway.

In addition there is
also Laryngeal
muscle spasm due to
hypersensitivity
response towards
Para influenza virus

Classification
Depending on the extent of inflammation
there may be variable clinical severities, such
as:
Mild
Moderate
Severe

Cardinal Features of Acute

Laryngotracheobronchitis
Sudden onset of
Characteristic barking cough
Inspiratory stridor
Hoarseness of Voice
Respiratory distress
Suprasternal Recession
Cyanosis ()

Investigation
X-ray neck:
Steeple Sign
(Subglottic Narrowing of
Air column) at trachea is
characteristic.

Treatment
Treatment option include
Supportive
Others

Supportive Treatment
Keep the child as comfortable as possible
allowing the patient to remain in the arms of a
parent.
Avoid unnecessary painful interventions that
may cause hesitation and increase oxygen
requirements by the children.

Other Treatments
Oxygen inhalation
Steriod:
Dexamethasone or Prednisolone
Nebulized Budesonide

Adrenalin
Antibiotic:
Only in case of suspected secondary bacterial
infections