1. ACUTE RESPIRATORY TRACT INFECTIONS
(ARI)
Dr. Yordanos G(MD)
For Anesthesia 2nd yr students
5/11/2018
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2. GENERAL CONSIDERATIONS
Acute respiratory infection (ARI) is the leading cause
of morbidity and mortality in children under 5years of
age.
ARI accounts for about 28% of under 5 mortality in
Ethiopia.
ARI involves both upper and lower respiratory tract
infections
Nearly 20% of ARI develop acute lower respiratory
tract infections, mainly pneumonia.
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3. RISK FACTORS FOR ARI
Pollution
lack of breast feeding
Congenital abnormalities heart or Lung
Immuno deficiency
Malnutrition
Young infants
Poor socio-economic status
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4. ANATOMIC CLASSIFICATION
OF AIRWAY
Upper Airway
all structures/ the part of air way above thoracic inlet,
Supraglottic area(nasopharynx, epiglottis, larynx,
aryepiglottic folds, and false vocal cords)
Glottic and subglottic area (extends from the vocal cords
to the extra thoracic segment of the trachea)
Lower Airway –
Intrathoracic trachea and into the lungs
intrathoracic-extrapulmonary airway extends from the
thoracic inlet to the main stem bronchi
the intrapulmonary airway is within the lung parenchyma
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Upper
Airway
Lower
Airways
5. UPPER RESPIRATORY TRACT INFECTIONS
1. Acute Pharyngitis
- refers to inflammation of the pharynx,
including erythema,edema, exudates, or
enanthem (ulcers, vesicles)
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6. COMMON ETIOLOGIES
Viruses Bacterial
Adenovirus
Coronavirus
Cytomegalovirus
Epstein-Barr
Enteroviruses
Herpes simplex virus
Human immunodeficiency virus
Human metapneumovirus
Influenza viruses
Measles virus
Parainfluenza viruses
Respiratory syncytial virus
Rhinoviruses
Streptococcus pyogenes
(Group A streptococcus)
Arcanobacterium haemolyticum
Fusobacterium necrophorum
Corynebacterium diphtheriae
Neisseria gonorrhoeae
Group C streptococci
Group G streptococci
Francisella tularensis
Chlamydophila pneumoniae
Chlamydia trachomatis
Mycoplasma pneumoniae
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7. GROUP A STREPTOCOCCUS
EPIDEMIOLOGY
Strept. Pharyngitis uncommon before 2-3yrs,
has a peak incidence in the early school
years, and declines in late adolescence and
adulthood
Peaks during winter and spring
Group C strept. and Arcanobacterium-
haemolyticum are causes in adults.
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8. PATHOGENESIS OF ACUTE
PHARYNGITIS
Major virulent factor of GABHS is the M-protein
Type specific immunity develops and provides protection
from subsequent infection by the same M-type.
Scarlet fever is caused by GABHS that produce one of the
three streptococcal pyrogenic exotoxins(SPE)-A,B,C.
SPE-A is mostly(strongly) associated.
Infection with one clade confers immunity to the same clade
& hence infection can occur up to three times.
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9. CLINICAL MANIFESTATIONS OF ACUTE
PHARYNGITIS
Rapid onset with prominent sore throat & fever
Headache and GI symptoms are common
Pharynx is red &tonsils are enlarged & classically covered
with yellow blood tinged exudates
Doughnut lesions or petechae on the soft palate and
posterior pharynx
Uvula is red and swollen
Tender and swollen ant. Cervical nodes
Some may manifest with Scarlet fever-circumoral pallor,
strawberry tongue &red and finely papular rash that feels
like sandpaper & with goose pimples
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10. CONT……
Onset of viral pharyngitis has more insidious onset
Adeno virus(pharyngoconjuctival fever)
Coxakie virus-herpangina1-2mm grayish vesicles
and punched out ulcers in the posterior pharynx
/acute lymphonodular pharyngitis3-6mm yellowish
white nodules on post. Pharynx.
EBV has systemic manifestations as part of
infectious mononucleosis syndrome
HSV- high grade fever and gingivostomatitis
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11. DIAGNOSIS
Throat culture and rapid antigen-detection
tests (RADTs) are the diagnostic tests for
GAS available in routine clinical care.
Throat culture is un imperfect gold standard for Dx of
GABHS pharyngitis (high false –ve and false +ve)
Rapid test(less sensitive and highly specific) ,If +ve –
treat and - ve(strong clinical ground)- throat culture
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12. MANAGEMENT
nonspecific, symptomatic therapy can be an important part of the
overall treatment plan( with anti-pyretics,analgesics,local anesthetics)
• Antibiotic therapy should be started immediately without culture for
children with symptomatic pharyngitis and a positive rapid
streptococcal antigen test, a clinical diagnosis of scarlet fever, a
household contact with documented streptococcal pharyngitis, a past
history of acute rheumatic fever, or a recent history of acute rheumatic
fever in a family member
Penicillin v or amoxicillin for 10 days
Erythromycin (if allergic to the above drugs)
Clindamycin and Azithromycin clear carriers
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13. RECURRENT PHARYNGITIS
Recurrent streptococcal pharyngitis can represent :
- relapse with an identical strain if type-specific antibody
has not yet developed.
- Poor compliance
If GABHS is detected by repeat culture a few days after
completing treatment, therapy to eliminate carriage is
recommended.
Prolonged pharyngitis (>1-2 wk) suggests another disorder
such as neutropenia or recurrent fever
syndromes,autoimmune diseases.
Tonsillectomy lowers the incidence of pharyngitis for 1-2 yr
among children with recurrent episodes
culture-positive GABHS pharyngitis that has been severe and frequent
(>7 episodes in the previous year, or >5 in each of the preceding 2 yror
≥3 in each of the previous 3 yr)
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14. COMPLICATION OF PHARYNGITIS:
Otitis media
Local suppurative complications like parapharyngial
abscess
ARF and AGN
Poststreptococcal reactive arthritis
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15. 2. RETROPHARYNGEAL AND PARA
PHARYNGEAL ABSCESS
Neck contains deeply located LNs including retro
&lateral pharyngeal nodes w/c drain the upper air way
&digestive tract
Retropharyngeal space is located between the pharynx
& the cervical vertebrae extending down to superior
mediastinum.
Lateral pharyngeal space is bounded by pharynx
medially carotid sheath posteriorly & muscles of styloid
process laterally.
The two spaces communicate with each other.
Infection usually extends from infection of oropharnyx
Once infected, the nodes progress through 3 stages
cellulitis,phlegmon and abscess
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16. ETIOLOGIES
Usually polymicrobial
Usual pathogens include group A strept.,
oropharyngeal anaerobes and S.aures
Hib, klebsiella andMycobacterium avium-
intracellulare( MAI) are other causes
EPIDIMIOLOGY
Common b/n 3-4yrs of age
Males are affected more than females
Rare after 5yrs b/c retropharyngeal nodes
involute at this age
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17. Retropharyngeal cellulites or abscess results from:-
oropharygeal infection
dental infection
vertebral osteomyelitis
Trauma to the oropharynx
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18. CLINICAL MANIFESTATIONS
Retropharyngeal abscess
Fever,irritability,decreased oral intake and drooling of saliva
Neck stiffness,tortocolis &refusal to move the neck
Muffled voice,stridor and respiratory distress
Bulging of posterior pharyngeal wall
Cervical adenopathy may be present
Lateral pharyngeal abscess
Fever,dysphagia &prominent bulge on the lateral pharyngeal
wall
Sometimes there is medial displacement of tonsils
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19. INVESTIGATIONS
Culture from the pus
CT
X-ray(wide retropharyngeal space >1/2 the thickness of
adjoining vertebrae
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21. MANAGEMENT
IV Abcs with or without drainage
Cephalosporine plus Ampicillin-Sulbactam or
Chloramphenicol
Clindamycin/cloxacillin
50% of Pts do not need drainage
Indications for drainage
obstruction
failure to respond to IV Abcs
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22. CONT…..
COMPLICATIONS
Upper air way obstruction
Rupture leading to aspiration pneumonia
Mediastinitis
Thrombophlebitis of internal jugular vein(Lemierre Ds)
Lemierre syndrome is a serious complication of F.
necrophorum pharyngitis and is characterized by
septic thrombophlebitis of the internal jugular veins with
septic pulmonary emboli,
producing hypoxia and pulmonary infiltrates
Erosion of carotid artery sheath
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23. 3. PERITONSILLAR ABSCESS
More common than deep neck infections
Caused by invasion through the capsule of the tonsils
ETIOLOGY
Group A strept,mixed oropharyngeal anaerobes
Clinical manifestation
An adolescent with a recent history of acute pharyngotonsillitis
Sore,fever,trismus &dysphagia
Asymmetric tonsillar bulge with displacement of uvula (this is
diagnostic)
INVESTIGATION
CT is helpful for revealing the abscess
Culture from the pus
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24. MANAGEMENT
Surgical drainage & Abcs
Surgical drainage could be accomplished via
Needle aspiration(resolution in 95%)
5% who fail after aspiration require incision and drainage
Indications for tonsillectomy
Failure to improve after 24hrs
Recurrent abscess or tonsillitis
Complications
COMPLICATIONS
Feared complication is rupture and aspiration pneumonia
There is 10% risk of recurrence
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25. 4.CROUP(LARYNGEOTRACHEOBRONCH
ITIS)
An acute respiratory illness characterized by
- distinctive barking cough, hoarseness, and inspiratory
stridor in a young child, usually between 6 months and 3
years old.
This syndrome results from inflammation of varying
levels of the upper respiratory tract, which sometimes
spreads to the lower respiratory tract, producing
concomitant lower respiratory tract findings.
Croup is primarily laryngotracheitis, and encompasses a
spectrum of infections from laryngitis to
laryngotracheobronchitis and sometimes
laryngotracheobronchopneumonitis.
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26. CROUP(LARYNGEOTRACHEOBRON
CHITIS)
Minor reduction in cross
sectional area due to mucosal
edema or other inflammatory
processes cause an
exponential increase in air way
resistance
The cricoid cartilage defines
the narrowest portion of the
upper air way in a child<10yrs
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ADULT
INFANT
27. ETIOLOGY
Para influenza virus(types 1,2,3)-75% of cases
Influenza(A &B),adenovirus,RSV&measles
Rarely mycoplasma pneumonae
EPIDEMIOLOGY
Age -3 months – 5years
Peak is in the second year of life
Males are more frequently affected
Common in winter
Recurrence common till 3-6yrs and decreases with age
15 %have strong family history of croup
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28. Clinical manifestation
Most common cause of upper resp. tract obstruction
Pts usually have rhinorrhea,pharyngitis,mild cough &low grade fever
Symptoms are worse at night
Sms resolve with in a week
Other Fx members may have mild resp. illness
INVESTIGATIONS
PA chest X-ray steeple sign or inverted pencil sign
Laryngoscope-erythematous edema with destruction of mucosal
epithelium
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29. RADIOGRAPH OF AN AIRWAY OF A PATIENT WITH
CROUP, SHOWING TYPICAL SUBGLOTTIC NARROWING
(STEEPLE SIGN).
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30. CROUP SCORING
SYSTEM:WESTLEY
Level of consciousness: Normal, including
sleep = 0; disoriented = 5
Cyanosis: None = 0; with agitation = 4; at
rest = 5
Stridor: None = 0; with agitation = 1; at rest =
2
Air entry: Normal = 0; decreased = 1;
markedly decreased = 2
Retractions: None = 0; mild = 1; moderate = 2; severe =
3
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31. CONT……
Mild croup is defined by a Westley croup
score of ≤2
Moderate croup is defined by a Westley
croup score of 3 to 7
Severe croup is defined by a Westley croup
score of ≥8
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32. MANAGEMENT
Mild croup _ home management
Moderate to sever croup needs admission for Mx
Steam therapy
Dexamethasone
Nebulized epinephrine
Humidified Oxygen
Fluid
Artificial air way -Tracheostomy
Complications:
Otitis media
Bacterial trachitis
Pneumonia
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33. 6. EPIGLOTITIS
Life threatening infection
HIB is the most common cause
Clinical manifestation
Sudden on set
Rapidly progressing respiratory obstruction
Fever, Toxicity, sore throat
Voice/cry - muffled
Soft stridor
Drooling of saliva
Hyper extended neck
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34. CONT…
Diagnosis:
Clinical with out throat examination
Blood culture
Lateral cervical X-ray “thumb sign’’→→
Never use spatula to examine"epiglottis
Large *cherry red* epiglottis (laryngoscope)
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35. MANAGEMENT
Precaution
Do not manipulate the throat
Do not put patient in supine positions
Do not send for X-ray
Do not put on steam in halation, steroid or
epinephrine
Maintenance IV fluid
IV CAF/ Ampicilin/cephalosporins
Endotracheal intubation
Tracheostomy
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36. 7. BACTERIAL TRACHEITIS
Bacterial tracheitis is an acute bacterial infection of the
upper airway that is potentially life threatening.
Staphylococcus aureus is the most commonly isolated
pathogen. Moraxella catarrhalis, nontypable H. influenzae,
and anaerobic organisms have also been implicated.
The mean age is between 5 and 7 yr.
Incidence and severity do not differ by sex.
Bacterial tracheitis often follows a viral respiratory infection
(especially laryngotracheitis), so it may be considered a
bacterial complication of a viral disease, rather than a
primary bacterial illness.
This life-threatening entity is more common than epiglottitis
in vaccinated populations
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37. CONT…
Clinical Manifestations
Typically, brassy cough
High fever and “toxicity” with respiratory distress can occur immediately
or after a few days of apparent improvement.
The patient can lie flat, does not drool, and does not have the dysphagia
associated with epiglottitis.
The usual treatment for croup (racemic epinephrine) is ineffective.
Intubation or tracheostomy may be necessary, but only 50-60% of
patients require intubation for management; younger patients are more
likely to need intubation..
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38. CONT….
The major pathologic feature appears to be mucosal
swelling at the level of the cricoid cartilage, complicated by
copious, thick, purulent secretions, sometimes causing
pseudomembranes.
The diagnosis is based on evidence of bacterial upper
airway disease, which includes high fever, purulent airway
secretions, and an absence of the classic findings of
epiglottitis. X-rays are not needed but can show the classic
findings
purulent material is noted below the cords during
endotracheal intubation
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39. LATERAL RADIOGRAPH OF THE NECK OF A
PATIENT WITH BACTERIAL TRACHEITIS,
SHOWING PSEUDOMEMBRANE
DETACHMENT IN THE TRACHEA.
(FROM STROUD RH, FRIEDMAN NR: AN
UPDATE ON INFLAMMATORY DISORDERS OF
THE PEDIATRIC AIRWAY: EPIGLOTTITIS,
CROUP, AND TRACHEITIS, AM J
OTOLARYNGOL 22:268–275, 2001. PHOTO
COURTESY OF THE DEPARTMENT OF
RADIOLOGY, UNIVERSITY OF TEXAS
MEDICAL BRANCH AT GALVESTON.)
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Thick tracheal membranes seen on rigid
bronchoscopy. The supraglottis was normal. A,
Thick adherent membranous secretions. B, The
distal tracheobronchial tree is unremarkable. In
contrast to croup, tenacious secretions are seen
throughout the trachea, and in contrast to
bronchitis, the bronchi are not affected
40. MANAGEMENT
Current empiric therapy recommendations for life-
threatening infections such as bacterial tracheitis
include vancomycin and a β-lactamase–resistant β-
lactam antimicrobial agent (e.g., naficillin or
oxacillin).
an artificial airway should be strongly considered.
Supplemental oxygen is usually necessary
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43. 1.BRONCHIOLITIS
Infection can cause obstruction to flow by
internal narrowing of the airways
Bronchiolitis is the most common acute viral lower
respiratory tract illness occurring during the first 2 years of
life
More common in 1-3months age
is predominantly a viral disease.
RSV is responsible for more than 50% of
cases. Other agents include
parainfluenza,adenovirus, rhinovirus, and
Mycoplasma.
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44. RISK FACTORS
boys,
in those who have not been breastfed,
crowded conditions.
mothers who smoked during pregnancy
The following children are at risk to develop severe
brochiolitis
Age <12 wk,
preterm birth, or
underlying comorbidity such as
cardiovascular,pulmonary, neurologic, or
immunologic disease.
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45. PATHOPHYSIOLOGY
characterized by bronchiolar obstruction with
edema, mucus, and cellular debris.
resistance is inversely proportional to the 4th
power of the radius of the bronchiolar passage.
radius of an airway is smaller during expiration,
early air trapping and
overinflation. complete obstruction,
atelectasis.
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46. CLINICAL MANIFESTATIONS
Symptoms of URTI
fever(low grade)
Cough, Poor feeding, tachypenia
Wheezing, signs of distress, cyanosis
Apnea may be more prominent early in the course
of the disease in young infants (<2 mo old) or
former premature infants.
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48. DIAGNOSIS
clinical,
CXR can reveal hyperinflated lungs with
patchy atelectasis
The white blood cell and differential counts
are usually normal.
PCR and radioimmunoassays
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50. PROGNOSIS
1st 48-72 hr after onset of cough and
dyspnea; air hunger, apnea, and
respiratory acidosis.
Median duration of symptoms is around 14
days
Recurrent wheezing among most children, the
episodes diminish or disappear before reaching
teenage years
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51. 2.PNEUMONIA
Pneumonia, defined as inflammation of the
lung parenchyma,
is the leading cause of death globally among
children younger than age 5 yr, accounting
for an estimated 1.2 million (18% total)
deaths annually
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52. CLASSIFICATION
Based on the anatomic or radiologic distribution
- Lobar pneumonia
- multilobar(bronchopneumonia)
- interstial pneumonia
• Based on the setting of acqusition of the infection
- community acquired pneumonia
- Hospital acquired pneumonia
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56. PATHOGENESIS
Viral pneumonia ,spread of infection along the airways,
accompanied by direct injury of the respiratory
epithelium, which results in airway obstruction from
swelling, abnormal secretions, and cellular debris
Atelectasis, interstitial edema, and ventilation-perfusion
mismatch causing significant hypoxemia often
accompany airway obstruction.
Viral infection of the respiratory tract can also predispose
to secondary bacterial infection by disturbing normal host
defense mechanisms, altering secretions, and modifying
the bacterial flora.
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57. CONT…..
In bacterial pneumonia organisms colonize the
trachea and subsequently gain access to the
lungs
pneumonia may also result from direct seeding
of lung tissue after bacteremia. When bacterial
infection is established in the lung parenchyma
M. pneumoniae – direct injury of airway epithelium
S. pneumoniae -characteristic focal lobar involvement.
Group A streptococcus - interstitial pneumonia
S. aureus -confluent bronchopneumonia
pneumatoceles, empyema
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58. CONT…..
Recurrent pneumonia is defined as 2 or more
episodes in a single year or 3 or more episodes
ever, with radiographic clearing between
occurrences. An underlying disorder should be
considered if a child experiences recurrent
pneumonia
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59. CLINICAL MANIFESTATIONS
Preceding URTI followed by Cough, fast breathing,
and Fever
-Grunting, lethargy
-Tachypnea
-Chest recession
-Crepitation/ Bronchial breath sounds,
-Dullness, signs of effusion
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60. CONT…
Severe pneumonia:
fast breathing (Tacypnea) + chest indrowing and grunting
HOSPITALIZATION OF CHILDREN WITH PNEUMONIA
Age <6 mo
Sickle cell anemia with acute chest syndrome
Multiple lobe involvement
Immunocompromised state
Toxic appearance
Moderate to severe respiratory distress
Complicated pneumonia*
Dehydration
Vomiting or inability to tolerate oral fluids or medications
No response to appropriate oral antibiotic therapy
Social factors (e.g., inability of caregivers to administer medications
at home or follow-up appropriately)
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62. RADIOGRAPHIC FINDINGS CHARACTERISTIC OF PNEUMOCOCCAL
PNEUMONIA IN A 14 YR OLD BOY WITH COUGH AND FEVER.
POSTEROANTERIOR (A) AND LATERAL (B) CHEST RADIOGRAPHS
REVEAL CONSOLIDATION IN THE RIGHT LOWER LOBE, STRONGLY
SUGGESTING BACTERIAL PNEUMONIA
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63. TREATMENT
Treatment of suspected bacterial pneumonia
is based on the presumptive cause and the
age and clinical appearance of the child
Out patient Mx:
- high doses of amoxicillin (80-90 mg/kg/24 h
other alternatives are augementin for 5-7
days.
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64. INPATIENT MANAGEMENT
• Neonate – Ampicillin +Gentamycine
Children _ Crystalin penicillin +/- chloramphenicol
antibiotic sensitivity pattern and causative agent
known:
Streptococcus-penicillin, Ceftriaxone, vancomycin
Staphylococcus- Cloxacillin ,vancomycin,
Cephalosporin (1st Gen.)
H.influenza-Chloramphenicol, Cephalosporin
Gram negative organisms
-Aminoglycosids, Cephalosporin
-If the patient is not improving after 24-48 hrs, shift to
second line
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68. PREVENTION
• Vaccination PCV10 vaccine.
has reduced the incidence of pneumonia
hospitalizations.
The expansion of influenza vaccine
recommendations to include all children >6
mo of age might be expected to affect
pneumonia hospitalization rates in a similar
fashion, and ongoing surveillance is
warranted
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69. FOREIGN BODY ASPIRATION
EPIDEMIOLOGY AND ETIOLOGY
Choking is a leading cause of morbidity and mortality
among children,especially those younger than age 4
yr
Children, younger than 3 yr of age, account for 73%
of cases.
The most common objects that children choke on are
food, coins, balloons, and toys.
One-third of aspirated objects are nuts, particularly
peanuts. Fragments of raw carrot, apple, dried beans,
popcorn, and sunflower or watermelon seeds are also
aspirated, as are small toys or toy parts.
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70. The majority of aspirated foreign bodies in
children are located in the bronchi (right
bronchus in 58%of the cases ) . Laryngeal
and tracheal foreign bodies are less
common.
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71. CLINICAL MANIFESTATIONS
Has 3 stages:
1.Initial event: Violent paroxysms of coughing, choking,
gagging, and possibly airway obstruction occur
immediately when the foreign body is aspirated.
2.Asymptomatic interval: foreign body dislodges and
the immediate irritating sympt subside. accounts for a
large percentageof delayed diagnoses and
overlooked foreign bodies.
3. Complications: Obstruction, erosion, or infection
develops; fever, cough, hemoptysis, pneumonia, and
atelectasis.
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72. CONT…..
Choking or coughing episodes accompanied by
new onset wheezing are highly suggestive of an
airway foreign body.
Physician should specifically inquire about nuts
since it is the most common foreign body
The signs and symptoms of FBA vary according
to the location of the FB
laryngotracheal FBs typically present with acute
respiratory distress, stridor, hoarseness,
increased respiratory effort, or complete airway
obstruction, which must be addressed promptly
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73. CONT….
Bronchial foreign bodies are the most
common. The usual symptoms are coughing
and wheezing; hemoptysis, dyspnea,
choking, shortness of breath, respiratory
distress, decreased breath sounds, fever,
and cyanosis may also occur
Tracheal foreign bodies are rare. Symptoms
of a tracheal foreign body include stridor,
wheeze, and dyspnea.
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74. DIAGNOSIS
A witnessed episode of choking: defined as
the sudden onset of
cough and/or dyspnea and/or cyanosis in a
previously healthy child, has a sensitivity of
76 to 92 percent for the diagnosis of FBA.
CXR:
most aspirated objects are radiolucent so
may nt be helpful
common radiographic findings in lower
airway FBA are hyperinflated lung,
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75. MANAGEMENT
If there is complete airway obstruction:
-back blows ,chest compressions in
infants, and the Heimlich maneuver in older
children, should be attempted
• Bronchoscopy
• Antibiotic and corticosteroids if the foreign
body has been retained for longer period
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77. PREVENTION
Hard and/or round foods should not be
offered to children younger than four years of
age
Children should be taught to chew their food
well;
Coins and other small items should not be
given to young children as rewards……
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