Acute respiratory infection

1. ACUTE RESPIRATORY
INFECTIONS
Dr Mallikarjuna D
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 causes inflammation 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 includes common
cold, pharyngitis and otitis
media
• ALRI includes epiglottitis,
laryngitis,
laryngotracheitis,
bronchitis, bronchiolitis
and pneumonia.

5. Burden of ARI

6. ARI deaths attributable to Undernutrition

7. Importance

8. Epidemiological Determinants
AGENT FACTORS:
The microbial 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 Age groups 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 Age group 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
• Case fatality 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
• Climatic conditions
• 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
• History to 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
• Count the 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 Fast breathing
Less than 2months 60 breaths /more
2months to 1 year 50 breaths/more
1 to 5 years 40 breaths/more

19. Look for chest indrawing
• 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 listen for 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
• See if 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 severe malnutrition
• 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
Child aged 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 2 months 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 child after 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 than 2 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: cough or 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/weight Paediatric 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 severe pneumonia
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 severe pneumonia…
• 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 than 2 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. Prevention of ARI

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 conjugate vaccines 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 positive and 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