Acute Respiratory Tract

Infections (ARI)

Prepared by-
Dr. Sunil M. Sagare
Specific learning objectives(SLOs)

Identify / diagnose ARI case as early as

possible.
Assess clinically to diagnose ARI and classify
appropriately.
Apply appropriate management measures
depending upon seriousness of disease.
 Acute Respiratory Infections
(ARI)
Definition:
Acute infection of respiratory tract caused by various
bacteria, viruses & other agents & clinically
characterized by –

Fever
Cough
Sore throat
Running nose
Difficulty in breathing &
Ear problems
 Classification
 UPPER RESPIRATORY  LOWER RESPIRATORY
TRACT INFECTION. TRACT INFECTION.(LRTI)
(URTI)
e.g. e.g.
 Common cold  Epiglottitis
 Pharyngitis  Laryngitis,
 Otitis media Laryngotracheitis
 Bronchitis, Bronchiolitis
 Pneumonia
 PROBLEM STATEMENT

 Common cause of death in children < 5 yrs of age in developing

countries

 India + Bangladesh + Indonesia + Nepal - Contribute 40% of global

ARI burden

 ARI responsible for

 30-50% visits to health facility &
 20-40% hospital admissions
 Incidence of Pneumonia -
 Developed countries - 3-4%
 Developing countries - 20-30%

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 PROBLEM STATEMENT CoNTD….

 In World -
 Deaths- 3.9 millions
 90% of ARI deaths - due to pneumonia (Usually bacterial)
 < 5 yrs Children - 5 episodes of ARI/child/year

 In India -
 Deaths - 9.87 lakhs (WHO estimates)
(9.69 lakhs due to ALRI & 10,000 due to AURI & 9000 due to
Otitis Media)
 DALYs lost was 25.5 million
 13 % inpatient deaths - due to ARI in pediatric wards

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Epidemiological DETERMINANTS
A. AGENT FACTORS
 Bacteria
 Bordetella Pertussis
 Cornybacterium diphtheria,
 H. Influenzae
 Klebsiella pneumoniae
 Strptococcus pneumoniae
 Viruses
 Adenovirus-endemic type (1,2,5) & epidemic type (3,4,7)
 Enterovirus- ECHO & Coxsackie
 Influenza A,B,C, & Parainfluenza 1,2,3
 Corona virus, Rhinovirus
 Respiratory syncytial virus
 Measles
 Other agents.
 Chlamydia type B (Psittacosis)
 Coxiella burnetti (Q fever)
 Mycoplasma Pneumoniae
 Severity of illness is determined by whether or not
secondary bacterial infection occurs(LRTI)
 B. Host factors

 Age
 Young infants & malnourished children - Higher morbidity &
mortality rates
 Children < 3 yrs affected more often & more severely
 Adult women experience more illness than men.

C. Risk Factors
 Overcrowding
 Poor nutrition
 LBW
 Intense indoor smoke pollution
 Level of industrialization and socioeconomic development
 Low socioeconomic conditions
 Maternal cigarette smoking
 Preschool children attending day care canters
 MODE OF TRANSMISSION
 Direct
 Droplet infection
 Droplet nuclei

PORTAL OF ENTRY
 Respiratory tract
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 CONTROL OF ARI
 Improving primary medical care services

 Development of better methods for early

detection, treatment & where possible, prevention of
ARIs is best strategy

 In INDIA - Recommendations by WHO for

management of ARIs in children & the practical
guidelines for outpatient care are followed.
 Clinical Assessment
 Very imp. in management of ARI –

 History taking &

 Clinical assessment

 During History taking we ask for -

 Age of child
 Duration of coughing & fever
 Whether the child is able to –
 Drink (4 mths to 5 yrs) OR
 Feeding well (<4 mths)
 Whether child is drowsy or difficult to wake,
If yes - how long?
 Convulsions - present or not
 Irregular breathing (short periods of not breathing)
 Colour of baby- Blue or not
 Physical Examination/Clinical Assessment
1. Look & listen -
Count the breaths in one minute

Fast breathing present when-

 ≥ 60 breaths/min in child < 2 months (Young infant)

 ≥ 50 breaths/min in child - aged 2-12 months

 ≥ 40 breaths/min in child - aged 12 mths-5 yrs

2. Look for chest indrawing:

Occours when the effort required to breath in, is much greater than
normal
3) Look & Listen stridor: (Breathing in)

Stridor- a harsh noise when breathing in

Indicates narrowing of the larynx, trachea or epiglottis- interfere
entry of air

4. Look for wheeze: (Breathing out)

Wheeze- Soft whistling noise heard when breathing out

Ask about H/O previous episode of wheeze

5. See whether child is abnormally sleepy or
difficult to wake.

6. Feel for fever or low body temperature.

7. Cyanosis- Bluish coloration of skin.
8. Check for sever malnutrition.
 Weight -Less than expected
 Response to hypoxia - Absent
 Cough reflex - Weak or absent 14
Physical Examination/Clinical
Assessment
 Fast breathing

 Chest indrawing

 Stridor

 Wheeze

 Abnormally sleepy or difficult to

wake.

 Fever or low body temperature.

 Check for sever malnutrition.

 Wt-Less than

expected

 Absent - Response to

hypoxia

 Cough reflex - weak

or absent

 Cyanosis: +/-
 Classification of illness

Child <2 months Child aged 2 months - 5 yrs

(Young Infant)

1. No pneumonia 1. No Pneumonia
2. Severe Pneumonia 2. Pneumonia
3. Very severe pneumonia 3. Severe pneumonia

4. Very sever pneumonia

Classification of illness
A) Child aged 2 months upto 5 years
1. No Pneumonia
2. Pneumonia
3. Severe pneumonia
4. Very sever pneumonia

1. No pneumonia
 Cough or cold
No fast breathing
No chest indrawing

2. Pneumonia
 Cough or cold
 Fast breathing
No Chest indrawing

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2. Severe pneumonia
 Chest indrawing
 Fast breathing - May/may not present
 Nasal flaring
 Grunting (Short snorting sound)
 Cyanosis

3. Very severe pneumonia

 Not able to drink
 Convulsions
 Abnormally sleepy or difficult to wake
 Stridor in calm child
 Severe malnutrition
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 B) Child aged below 2 months

1. No pneumonia
 Cough or cold
No chest indrawing or fast breathing

2. Severe pneumonia
 Severe chest indrawing or fast breathing

3. Very severe pneumonia

 Stop feeding well
 Convulsions
 Abnormally sleepy or difficult to wake
 Wheezing
 Fever or low body temp.

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 Treatment
A) Children aged 2 months – 5 yrs

1. No Pneumonia
 Symptomatic treatment

2. Pneumonia (Child With Cough & Fast Breathing)

 Advise about home care
 Give antibiotic i.e. Septran
 Treatment of fever, wheezing
 Follow-up in 2 days for reassessment of fever

Age Tab. Septran Syrup Septran

(Paed.)
< 2 months 1 BD ½ tsf BD
2-12 months 2 BD 1 tsf BD
1-5 years 3 BD 1& 1/2 tsf BD
3. Severe pneumonia
 Give first dose of antibiotic
 Treatment of fever & wheezing
 Refer urgently to specialized hospital
 Antibiotic- First 48 hrs
 Benzyl penicillin-50,000 IU/Kg/dose-6hrly-IM OR
 Ampicillin-50 mg/Kg/dose-6hrly-IM OR
 Chloramphenicol- 25 mg/Kg/dose-6hrly-IM
 If improvement then for next 3 days give
 Procain penicillin- 50,000 IU/Kg-once-IM OR
 Ampicillin-50 mg/Kg/dose-6hrly-Oral OR
 Chloramphenicol- 25 mg/Kg/dose-6hrly-Oral
 If no improvement- Change antibiotic
 Cloxacillin-25mg/Kg/dose-6hrly
 Gentamycin- 2.5mg/Kg/dose-8hrly
 Treatment of fever, wheezing
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4. Very severe pneumonia
Give first dose of antibiotic-

- Inj. Cloxacillin, Inj. Gentamycin

If fever- Antipyretic

Treat wheezing

Refer urgently to specialized hospital-oxygen

therapy
 B) Children aged <2 months
(Young Infants)
1. No pneumonia-
 Symptomatic Treatment
 No antibiotic required

2. Severe pneumonia-
 Refer urgently to hospital
 Keep young infant warm
 Give first dose of antibiotic
a) Inj. Benzyl Penicillin-50,000IU/Kg/Dose-12hrly (<7 days),6hrly
(7days-2months) OR
b) Inj. Ampicillin -50 mg /Kg/dose-12hrly,8hrly OR
c) Inj.Gentamycin-2.5 mg/Kg/dose-12hrly,8hrly
3. Very severe pneumonia-
 Refer urgently to specialized hospital
 Keep young infant warm
 Give first dose of antibiotic

Management of a case of wheezing-

 Case with Respiratory distress -
Oral Salbutamol-

 <10 Kg – give 1mg every 8 hrly

 10-19 kg- give 2 mg every 8 hrly
(Treatment only for few days)

 Respiratory distress with recurrent wheezing –

 Nebulised Salbutamol (5mg/ml) - 0.5 ml Salbutamol + 2 ml Sterile

water
(May repeat after 20 min.)
 Subcutaneous Epinephrine - adrenaline 1:1000=0.1%, 0.1 ml/Kg
 Subcutaneous terbutalin- 0.1ml/Kg

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 OTHER PREVENTIVE MEASURES
 Improved living conditions

 Better nutrition

 Reduction of indoor smoke pollution

 Immunization of vaccine preventable diseases

 Improving the primary medical care services

 Developing better methods for early detection, Treatment &

Prevention

 Acute Respiratory Disease Control Programme In India--Started in

1990

-In 1992-93, programme become part of CSSM

- In 1997, programme become part of RCH

 IMNCI (Integrated Management of Neonatal & Childhood Illnesses)25

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