Laith Ali Jebur
Dr. Ali Abdul Razzaq
• 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
• 70% of which are upper respiratory
infection, 30% are lower respiratory infections.
• 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)
Exposure to cold weather
Hx of bith problems
Poor nutritional status
Poor socio-economic status
Chronic use of drugs (affect immunity)
• Tachypnea 3 months > 60
3 months – 1 year > 50
1year –4 years > 40
Listen for stridor
Listen for wheeze. Is it recurrent?
Look for cyanosis
See if the child is abnormally sleepy, difficult to wake, or
Signs of malnutrition (Marasmus, Kwashiorkor)
Or (moderate ARI)
No rib or sternal
Rib and sternal
Refer to hospital
Chest wall retraction
Unable to drink
• Most common
infectious condition in
children in the first 2
• Third of cases caused
by Rhinovirus .
• Average of 5-8
infections per year.
• May involve
• nasal obstruction
• sore throat
• occasional non-productive cough
• Parenteral diarrhea
• nasal mucosa may reveal swollen, erythematous nasal
• Sign of moderate respiratory distress in infants
• Ear drum is congested 2-3 days
• Laboratory studies often are not helpful
• A nasal smear for eosinophils .
(No specific therapy)
2.Actamenophen1st 1-2 days
3.Relieve nasal obstruction:
* Normal saline , xylometazoline nasal drops
* Phenylephrine 0.25% nasal drops
* highly humidified environment to prevent drying.
4.Rhinorrhea, cough : antihistamins.
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.
1. All ages
2. Gradual onset
3. Low grade fever
5. Hoarseness of voice
6. Redness of the
1. 5-15 year old
2. Sudden onset
3. High grade fever
4. Sore throat &
6. Ant. Cervical LN
• It is hard to differentiate a
viral and a bacterial cause
of a sore throat based on
• Throat swab and culture.
• Detection for streptococcal
antigen (specific 80 –
• WBC, ESR, CRP count is
• Viral pharyngitis need no antibiotics, only
• Streptococcal pharyngitis
1. Oral penicillin V (125-250)mg 3/day 10 days
2. Benzathine penicillin or procaine penicillin G
single IM injection
3. Erythromycin 40 mg/kg/day for 10 days
4. Oral amoxicillin 50 mg/kg/day for 6 days
Complications are low with viral infection
Involvement of lower respiratory tract
• 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
• 75% parainfluenza virus, others
inluenza A&B , RSV.
• Usual age 6m – 5y, males, winter &
• The most common type. Involve the glottic and
• Manifestations of Upper infection + croup
• Severe at night
• Relieved by sitting
• Neck X-Ray showing
• Almost all cases caused by viral infection.
• It involves mainly subglottic area.
• Characterized by URTI then sore throat and
• It is generally mild and respiratory distress
unusual except in infants.
• In severe cases: Hoarsness, stridor, dyspnea.
• Laryngoscope shows inflammed vocal cord &
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.
• Lateral neck X-ray shows enlarged epiglottis (thumb print
• Direct laryngoscope my show a cherry red epiglottis
(supraglottis) but it is not recommended because of
• 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
• 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.
• culture of the thick, mucopurulent subglottic debris.
• Antibiotics against Staphylococcus like cloxacillin,
methicillin, third generation cephalosporin or vancomycin.
• Endotracheal intubation or tracheostomy.
• Oxygen .
• Age: second 6 months
• Caused by:
3- Moraxella catarrhalis.
• It is very common in children.
• earache, convulsions, sometimes diarrhea & vomiting,
continuos crying (irritability) & sleep disturbances.
• Otorrhea or bulged , congested TM.
• The tympanic membrane is intact in infants.
• Plain X ray
• CT scan
May show sinus clouding
Air fluid level.
• Suportive therapy
• Bordetella pertussis
• Affect young children, non immunized.
• Spread by droplet, direct or indirect contact with nasal
• Catarrhal stage..1-2 w URTI.
• Paroxysmal stage..2-4w parox. Cough, whooping.
• Convalescent stage..1-2w only cough for months.
• CBC: WBC mainly lymph.
• CXR prehilar infiltrate.
• Culture, PCR, IFA.
• Admit severe cases
• Erythromycine 2w
• Azithromycin or
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.
• Presents as a progressive respiratory
illness that is similar to the common cold in
its early phase with cough, dyspnea and
• It progresses over 3 to 7 days to noisy
breathing with noisy breathing.
• fever accompanied in young children by
• May have apnea as the first sign of
• 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
• Auscultation reveals prolonged expiratory phase
with diffuse wheezes and crepitation.
• In more severe cases cyanosis.
• 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
2-flattened or depressed diaphragms.
1. Young age<3 month old.
2. Moderate to marked resp. distress
3. Hypoxemia(PO2<60mmHg or Oxygen
saturation<92% on room air).
5. Inability to tolerate oral feeding
6. Lack of appropriate care available at home.
• consists of supportive therapy, including:
1-Nebulizer, control of fever
3- upper airway suctioning and oxygen
4- I.V. fluid indicated in case of sever tachypnea
which interrupt feeding.
5-Ribavirin is anti viral agent administered by
6-Temperorary use of bronchodilators may
improve wheezing &respiratory distress.
• 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.
1-Viral: RSV 70%, influenza, parainfluenza or
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
• After 3 years of age common bacteria include S.
pneumonia and staphylococci.
3-Atypical organism: Chlamydia and Mycoplasma.
4-Pnemuocystis carinii: causes pneumonia in imunnocompromised children.
• 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
• WBC leukocytosis with neutrophilia.
• S. pneumoniae often resulting in focal lobar
• Group A. streptococcus infection results in
• S. aureus causes bronchopneumonia which is
often unilateral with cavitations.
1. Sputum for gram stain and culture.
2. blood culture.
3. virological study by culture &florescent
4. in case of pleural effusion aspirate pleural
fluid for gram stain and culture also for
acid fast bacilli.
• 1-less than 3 month of age.
• 2- moderate to sever respiratory
• 3- failure of out patient treatment.
• 4-immunocompromised patient.
• 5- neonate with congenital
• 6- staphylococcal pneumonia.
• 7- complications like pleural effusion,
• The empiric treatment of suspected bacterial pneumonia is
parenteral cefotaxim or ceftriaxone.
• If clinical features suggest staphylococcal
• 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. 3antipyretic for fever. ribavirin for RSV.