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Acute respiratory infections
- 1. ACUTE RESPIRATORY INFECTIONS Dr MallikarjunaD Study Physician Department of Community Medicine KMC,Manipal
- 2. Learning Objectives • Introduction •Epidemiological determinants • Mode of Transmission • Clinical Assessment • Classification of Illness • Treatment • Prevention of Acute respiratory infections
- 3. INTRODUCTION • It causesinflammation of the respiratory tract anywhere from nose to alveoli with combination of signs and symptoms It is classified depending upon the site: • Acute Upper Respiratory Infections (AURI) • Acute Lower Respiratory Infections (ALRI)
- 4. Introduction… • AURI includescommon cold, pharyngitis and otitis media • ALRI includes epiglottitis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis and pneumonia.
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- 6. ARI deaths attributableto Undernutrition
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- 8. Epidemiological Determinants AGENT FACTORS: Themicrobial agents that cause ARI are numerous and include bacteria and viruses • Even within species they show wide diversity of antigenic type • Severity of illness is determined by whether secondary bacterial infection occurs or not
- 9. Bacterial agents Agent Agegroups frequently affected Characteristic clinical features Bordetella pertusis Infant, young children Paroxysmal cough Corynebacterium diphtheriae children Nasal/tonsillar/pharyngeal membraneous exudate, severe toxemia Streptococcus pneumoniae All ages specifically under 5 children Lobar and multilobular pneumonia, acute exacerbations of chronic bronchitis Streptococcus pyogenes All ages Acute pharyngitis and tonsillitis Staphylococcus pyogenes All ages Lobar and bronchopneumonia, lung abscess Haemophilus inflenzae children Acute epiglottitis (type B) Klebsiella pneumoniae Adults Lobar pneumonia , lung abscess Legionella pneumoniae Adults Pneumonia
- 10. Viral agents Agent Agegroup frequently affected Characteristic clinical features Adenovirus endemic types(1,2,5) Young children LRTI Epidemic types(3,4,7) Older children , young adults Pharyngitis , flu like illness Influenza A, B,C All ages, school children Variable respiratory symptoms, occasional primary pneumonia Parainfluenza 1,2,3 Young children and infants Croup Respiratory syncytial virus Infants, young children Severe bronchilitis and pneumonia Rhinovirus All ages Common cold Corona virus All ages Common cold Measles Young children Variable respiratory with rash
- 12. Host factors • Casefatality rates are higher in young infants and malnourished children • In developing countries like India, malnutrition and low birth weight is often a major problem, the rates are highest in those children • The rates of pharyngitis and otitis media increase from infancy to peak at the age of 5 years
- 13. Risk factors • Climaticconditions • Housing • Level of industrialization • Socio economic development • Overcrowded dwellings • Poor nutrition • Low birth weight • Intense indoor smoke pollution
- 14. Mode of transmission •Air borne route • Chain of transmission is maintained by direct person- person contact
- 15. Clinical assessment • Historyto be elicited: • Age of the child • Since how long the child is coughing • Young infant stopped feeding well (less than 2 months) • The child is able to drink (2 months to 5 years) • H/O fever • Child is excessively drowsy/difficult to wake • Irregular breathing • Convulsions • The child turning blue
- 17. Physical examination • Countthe breaths in one minute • Fast breathing depend upon the age of the child • It should be seen for 1 full minute looking at the abdominal movement or lower chest when the child is calm
- 18. Fast Breathing Age Fastbreathing Less than 2months 60 breaths /more 2months to 1 year 50 breaths/more 1 to 5 years 40 breaths/more
- 19. Look for chestindrawing • The child has chest indrawing if the lower chest wall goes in when the child breathes in • It occurs when the effort required to breathe in is much greater than normal
- 20. Look and listenfor stridor • Stridor makes a harsh noise when the child breaths IN • It occurs when there is narrowing of the larynx, trachea or epiglottis which interferes with air entering the lungs • This condition is called croup
- 21. Look for wheeze •Wheezing is soft whistling noise when the child breathes OUT • It is caused by narrowing of air passage in lung • Breathing out phase takes longer than normal and effort • Elicit H/O previous history of wheezing • If so, the child is classified as having recurrent wheeze
- 22. Other Signs • Seeif the child is abnormally sleepy or difficult to wake • Feel for fever or lower body temperature • Cyanosis is a sign of hypoxia, must be checked in good light
- 23. Check for severemalnutrition • High risk factor • Case fatality rates are higher in these children • In a severely malnourished children with pneumonia, fast breathing and chest indrawing may not be as evident • Impaired/absent response to hypoxia and a weak/absent cough reflex • These children need careful evaluation and management for pneumonia
- 24. Classification of illness Childaged 2 months – 5 years: • Very severe disease • Severe pneumonia • Pneumonia • No pneumonia Infants less than 2 months: • Very severe pneumonia • Severe pneumonia • No pneumonia
- 25. Child aged 2months to 5 years Very severe disease: •Signs : not able to drink, convulsions, abnormally sleepy or difficult to wake, Stridor in calm child and Severe malnutrition •Treatment: • Refer urgently to hospital • Give first dose of antibiotic • Treat fever, if present • Treat wheezing ,if present • If cerebral malaria is present, give an antimalarial
- 26. Severe pneumonia • Signs: chest indrawing, recurrent wheezing Treatment: • Refer urgently to hospital • Give first dose of antibiotic • Treat fever, wheezing if present • If referral is not feasible treat with an antibiotic and follow closely
- 27. Pneumonia • Signs :fast breathing and no chest indrawing Treatment: • Advice mother to give home care • Give an antibiotic • Treat wheezing / fever if present • Advice mother to return with child after 2 days for reassessment/ earlier if the child is getting worst
- 28. Reassessment Re-assess the childafter 2 days Worse same improving Not able to drink Breathing slower,less Has chest indrawing fever, eating better danger signs Refer URGENTLY to change antibiotic / refer finish 5 days of Hospital antibiotic
- 29. Infants less than2 years Very severe pneumonia: • Signs : stopped feeding well, convulsions, abnormally sleepy, stridor, wheezing, fever or hypothermia Treatment : • Refer URGENTLY to hospital • Keep young infant warm • Give first dose of an antibiotic
- 30. Severe pneumonia • Signs: severe chest indrawing or fast breathing (60 breaths per minute or more) • Treatment : • Refer URGENTLY to hospital • Keep young infant warm • Give first dose of antibiotic • If referral is not feasible treat with an antibiotic and follow closely
- 31. No pneumonia: coughor cold • Signs : no chest indrawing and no fast breathing • Treatment : • Advice mother to give the following home care – keep young infant warm, breast feed frequently, clear nose if it interferes with feeding • Return if any danger signs- breathing becomes difficult/fast, not feeding, and infant becomes sicker
- 33. Treatment - Pneumonia Age/weightPaediatric tablet Sulfamethoxazole 100 mg, Trimethoprim 20 mg Paediatric syrup 5ml – sulfamethoxazole 200mg, trimethoprim 40 mg <2 months/3-5 kg 1 tablet twice a day Half spoon (2.5 ml) twice a day 2- 12 months/6-9 kg 2 tablets twice a day One spoon (5ml) twice a day 1-5 years/10-19 kg 3 tablets twice a day One and half spoon (7.5ml) twice a day
- 34. Treatment of severepneumonia Antibiotics Dose Interval Mode A. First 48 hours Benzyl penicillin OR 50000 IU/kg/dose 6 hourly IM Ampicillin 50mg/kg/dose 6 hourly IM Chloramphenicol 25mg/kg/dose 6 hourly IM B. If condition IMPROVES Then for the next 48 hours Procaine penicillin 50,000 IU/kg once IM Ampicillin 50mg/kg/dose 6 hourly oral Chloramphenicol 25mg/kg/dose 6 hourly oral
- 35. Treatment of severepneumonia… • If there is no improvement ,then for the next 48 hours change antibiotic • Provide symptomatic treatment for fever and wheezing • Monitor fluid and food intake • Advice mother on home management on discharge
- 36. Infants less than2 months Antibiotic Dose Frequency in age <7days Frequency in age 7 days to 2 months Inj.Benzyl penicillin 50000 IU/kg/dose 12 hourly 6 hourly Inj.Ampicillin 50mg/kg/dose 12 hourly 8 hourly Inj.Gentamycin 2.5mg/kg/dose 12 hourly 8 hourly
- 37. Management of AURI •DO NOT require treatment with antibiotics • Causative agents are viruses • Increase resistant strains and cause side effects • Symptomatic treatment and care at home
- 38.
- 39. Prevention of ARI •ARI control programme is the part of RCH programme • Improved living conditions • Better nutrition • Reduction of smoke pollution indoors • Better Maternal Child Health care • Immunization • Health promotional activities
- 40. Immunization • Measles vaccine •HIB vaccine • Pneumococcal pneumonia vaccine
- 41. Pneumococcal Pneumonia vaccine •PPV23: • It is a polysaccharide, non conjugate vaccine containing capsular antigens of 23 serotypes, available for children above 2 years and adults • Single IM / subcutaneous dose is given in deltoid muscle • It should never be mixed with other vaccines in the same syringe, it can be given at the same time as separate injection in other arm
- 42. PCV • Two conjugatevaccines are available PCV10 and PCV 13 • Storage temperature : 2-8degrees • It is given in infants as 3 primary doses/2 primary and 1 booster dose • Initiated as early as 6 weeks with an interval of 4-8 weeks • Doses at 6,10,14 weeks/2,4,6 months • One booster dose is given at 9-15 months
- 43. PCV… • HIV positiveand preterm babies who have received 3 primary doses in 1 year, require booster dose in 2nd year • When primary immunization is initiated with one of vaccines, it is recommended that remaining doses are administered with the same product • WHO recommends inclusion of PCVs in UIP worldwide, particularly in countries with high under5 mortalities