Acute respiratory tract infections (ARIs) are a major cause of morbidity and mortality in children, especially in developing countries like Pakistan. ARIs account for 20% of childhood deaths under 5 years of age, with 90% of those deaths being due to pneumonia. This document discusses the classification, signs, symptoms, risk factors, diagnosis, and management of various ARIs that commonly affect children, including acute nasopharyngitis, acute pharyngitis, croup, acute sinusitis, pertussis, and acute bronchiolitis. Physical examination focuses on respiratory rate, chest indrawing, wheezing, fever, and other danger signs. Management involves home care, antibiotics, nebulizers, oxygen

1. ACUTE RESPIRATORY
TRACT INFECTIONS
BY DR SANA ANUM

2. Introduction
• Definition of ARI..
• Worldwide, (ARIs) are a major cause of
morbidity and mortality in emergencies
especially in developing countries
including PAKISTAN
• ARI responsible for 20% of childhood (< 5
years) Deaths ,90% from pneumonia.
• Six to eight respiratory tract infections per
year (2-3years)
• 70% of which are upper respiratory
infection, 30% are lower respiratory
infections.

6. ANATOMICAL CLASSIFICATON
Upper Respiratory
Infections
Lower Respiratory
Infections
Acute Otitis Media
RHINITIS (COMMON
COLD OR CORYZA)
BRONCHIOLITIS
SINUSITIS PNEOMONIA
ACUTE PHARYNGITIS PULMONARY TB.
CROUP HAEMOPTYSIS
PERTUSSIS HAEMETMESIS
TONSILITIS
TRACHEITIS

7. STEPS TO BE TAKEN IN ASSESSMENT
OF ARI:
 History
• Age
• 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)

8. Physical examination
1:count the breaths in one minute
• Breathing count depends on the age of
the child
• Count respiratory rate for a minute
• Fast breathing is present when RR is
-60 breaths /min or more in a child less than
two months of age
-50/min or more in child aged 2months upto
12 months
-40 breaths/min or more in a child aged 12
months upto 5 years

9. Chest indrawing
• Look for chest indrawing when child
breaths IN
• Child has indrawing if the lower chest
wall goes in when the child breaths IN
• Occurs when the effort required to
breath in ,is much greater than normal
Stridor
• Harsh noise while breathing IN is stridor
• Occurs due to narrowing of trachea
,larynx or epiglottis
• These conditions often called croup

10. Wheeze
• A child with wheeze makes a soft whistling noise
OR
• shows signs that breathing OUT is difficult
• This is due to narrowing of the air passages
Fever
• Check for body temperature
Cyanosis
• Sign of hypoxia

11. Malnutrition
• If malnutrition is present its high risk
and case fatality rates are higher
• In severely malnourished:
1) children with pneumonia, fast breathing
and chest indrawing may not be
evident
2)Impaired or absent response to hypoxia
and a weak or absent cough
reflex
3)Careful evaluation and
mangement

12. DANGER SIGNS
• PERSISTANT VOMITTING
• RELUCTANCE TO FEED
• CONVULSIONS

13. OTHERS
• Sign of respiratory distress; nasal flaring &
chest indrawing
• Younger than 2 months
• Decreased level of consciousness
• Stridor when calm
• Severe malnutrition
• Associated symptomatic HIV/AIDS

14. ASK ABOUT RISK FACTORS:
Exposure to cold weather
Hx of bith problems
Poor nutritional status
Early weaning
Immunization
Poor socio-economic status
Parental smoking
Chronic use of drugs (affect immunity)
Family history

15. LOOK AND LISTEN
 Respiratory rate
• Tachypnea 3 months > 60
3 months – 1 year > 50
1year –4 years > 40
>5y >20
 Chest indrawing
 Listen for stridor
 Listen for wheeze. Is it recurrent?
 Look for cyanosis
 See if the child is abnormally sleepy, difficult to
wake, or restless
 Body temperature
 Signs of malnutrition (Marasmus, Kwashiorkor)

16. NO
PNEUMONIA
COUGH
NO
TACHYPNEA
-HOME CARE
-SOOTHE THE
THROAT AND
RELIEVE COUGH
-ADVISE MOTHER
WHEN TO RETURN
-FOLLOWUP IN 5
DAYS IF NOT
IMPROVING
PNEUMONIA -COUGH
-TACHYPNEA
-NO RIB OR
STERNAL
RETRACTION
-ABLE TO
DRINK
- NO
CYANOSIS
-HOME CARE
-ANTIBIOTICS FOR 5
DAYS
-SOOTHE THE
THROAT AND
RELIEVE COUGH
-ADVISE MOTHER
WHEN TO RETURN
-FOLLOWUP IN 2

17. 17
SIGNS
 STOPPED
FEEDING
WELL
 CONVULSIONS
 ABN. SLEEPY
 STIDOR IN
CALM CHILD
 WHEEZE
 FEVER/LOW
BODY TEMP.
 SEVERE
CHEST
IDRAWING
 FAST
BREATHING
 NO SEVERE
CHEST
INDRAWING
 NO FAST
BREATHING
CLASSIFY AS VERY SEVERE
DISEASE
SEVERE
PNEUMONIA
NO PNEUMONIA
TREATMENT REFER URGENTLY
KEEP WARM
GIVE FIRST DOSE
OF ANTIBIOTIC
REFER URGENTLY
KEEP WARM
GIVE FIRST DOSE
OF ANTIBIOTIC
ADVICE FOR
HOME CARE
EXPLAIN DANGER
SIGNS
MANAGEMENT OF ARI
CHILDREN BELOW 2 MONTHS

18. 18
MANAGEMENT OF ARI
CHILD AGED 2 MONTHS UPTO 5 YEARS
SIGNS
 NOT ABLE TO
DRINK
 CONVULSIONS
 ABNORMALLY
SLEEPY OR
DIFFICULT TO
WAKE
 STRIDOR IN A
CALM CHILD
 SEVERE
MALNUTRITIO
N
 FAST
BREATHING
 CHEST
INDRAWIN
G
 NASALFLAR
ING
 GRUNTING
 FAST
BREATHING
ONLY
 NO CHEST
INDRAWIN
G
 NO FAST
BREATHING
 NO CHEST
INDRAWIN
G
CLASSIFY AS VERY SEVERE
DISEASE
SEVERE
PNEUMONIA
PNEUMONIA NO PNEUMONIA/
COLD & COUGH
TREATMENT REFER URGENTLY
GIVE FIRST DOSE
OF ANTIBIOTIC
TREAT FEVER, IF
PRESENT
TREAT WHEEZE, IF
REFER
URGENTLY
GIVE FIRST
DOSE OF
ANTIBOTIC
TREAT FEVER
TREAT WHEEZE
ADVICE FOR
HOME CARE
GIVE ANTIBIOTIC
TREAT FEVER
TREAT WHEEZE
ASSESS AND
TREAT EAR
PROBLEM/ SORE
THROAT
TREAT FEVER
TREAT WHEEZE

19. URI:

21. Acute Nasopharyngitis (Common
Cold)
• Most common
infectious condition in
children in the first 2
years.
• Third of cases caused
by Rhinovirus .
• Average of 5-8
infections per year.
• May involve
(Nasopharynx,
paranasal sinuses,
middle ear).

22. CLINICAL FEATURES:
Symptoms:
• nasal obstruction
• Rhinorrhea
• sore throat
• occasional non-productive cough
• Parenteral diarrhea
Signs:
• nasal mucosa may reveal swollen,
erythematous nasal turbinate's
• Sign of moderate respiratory distress
in infants
• Ear drum is congested 2-3 days

23. Diagnostic Measures:
• Laboratory studies often are not helpful
• A nasal smear for eosinophils .
Treatment:
(No specific therapy)
1.Bed rest
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.

24. Acute Pharyngitis
• 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.

26. Clinical Features
1. All ages
2. Gradual onset
3. Low grade fever
4. cough
5. Hoarseness of voice
6. Redness of the
pharynx
7. Conjunctivitis(Adenovi
rus)
8. Herpangina(coxachie
virus)
1. 5-15 year old
2. Sudden onset
3. High grade fever
4. Sore throat &
difficulty in
swallowing
5. Exudates
6. Ant. Cervical LN
tenderness
Headache, Abdominal pain and vomting

27. Pharyngeal Congestion Palatal Petechae
Strawberry Tongue Follicular Tonsillitis

28. • INLFLAMED
NASOPHARYNX:
• STREPT. THROAT

29. Investigations:
• It is hard to
differentiate a viral
and a bacterial cause
of a sore throat based
on symptoms alone.
• Throat swab and
culture.
(Gold Standard)
• Detection for
streptococcal antigen
(specific 80 – 85%)
• WBC, ESR, CRP
count is elevated.

30. Treatment:
• Viral pharyngitis need no
antibiotics, only supportive
• 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

31. Complications:
• Complications are low with viral infection
1.O.M.
2.Mastoiditis.
3.Peritonsillar abscess
4.Sinusitis
5.Involvement of lower respiratory tract
6.Trigger asthma
7.Meningitis
8.Acute GN
9.Mesenteric adenitis

32. Croup
• 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 "barking" cough, str
oidor, and hoarseness.
• 75% parainfluenza virus, others
inluenza A&B , RSV.
• Bacterial
infection(epiglotitis,diphtheria,trac
heitis)
• Usual age 6m – 5y, males, winter
& family history.

33. DDx of croup:
• 1.Laryngotracheobronchitis.
• 2.Acute epiglottitis.
• 3.Acute infectious laryngitis.
• 4.spasmodic croup.
• 5.Bacterial tracheitis.
• 6.Diphtheritic croup.
• 7.Measles croup.

34. Laryngotracheobronchitis
• The most common type. Involve
the glottic and subglottic regions.
• Manifestations of Upper infection
+ croup
• Severe at night
• Relieved by sitting
• Neck X-Ray showing
subglottic narrowing
(Steeple sign)

35. Steeple Sign

37. Acute Infectious
Laryngitis
• Almost all cases caused by viral infection.
• It involves mainly subglottic area.
• Characterized by URTI then sore throat
and croup.
• It is generally mild and respiratory distress
unusual except in infants.
• In severe cases: Hoarsness, stridor,
dyspnea.
• Laryngoscope shows inflammed vocal
cord & subglottic tissue.

38. Acute Epiglottitis
• 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)

39. Diagnosis:
• Lateral neck X-ray shows enlarged epiglottis
(thumb print sign)
• Direct laryngoscope my show a cherry red
epiglottis (supraglottis) but it is not
recommended because of laryngeal spasm.

40. Indications of admission
• Progressive stridor at rest
• Temp>39c
• Respiratory distress
• Cyanosis & pallor
• Hypoxia & restlessness
• Impaired consciousness
• Toxic appearing child

41. AT HOSPITAL
• 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

43. Acute Bacterial tracheitis
• 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.
Diagnosis:
• culture of the thick, mucopurulent subglottic
debris.
Treatment:
• Antibiotics against Staphylococcus like
cloxacillin, methicillin, third generation
cephalosporin or vancomycin.

44. Treatment:
• Broad-spectrum
antibiotics.
• Analgesics.
• vasoconstrictive nasal
drops .
• Aural toilet,
Myringotomy.

45. Acute Sinusitis
• Age only 1% of
infants.
5% of
children.
15% of
adolescent.
• Allergic rhinitis is the
most common
predisposing factor.
• Anatomical
abnormalities:

46. CLINICAL MANIFESTATIONS:
• Cough mainly at night
• Rhinorrhea
• Nasal speech
• Halitosis
• Facial pain, tender
• Facial swelling
• Headache
• Fever
• Irritability
• Trigger asthma & O.M

47. INVESTIGATIONS:
• Culture
• Plain X ray
• CT scan
May show sinus clouding
Mucosal thichening
Air fluid level.
Treatment:
• Antibiotics
• Suportive therapy

48. Pertussis
• Bordetella pertussis
• Affect young children, non immunized.
• Spread by droplet, direct or indirect contact with nasal
scretions.
• Manifestations:
• Catarrhal stage..1-2 w URTI.
• Paroxysmal stage..2-4w parox. Cough, whooping.
• Convalescent stage..1-2w only cough for months.
• Investigations:
• CBC: WBC mainly lymph.
• CXR prehilar infiltrate.
• Culture, PCR, IFA.

49. • TREATMENT:
• Admit severe cases
• Erythromycine 2w
• Azithromycin or
clarithromycin 1w
• TMP-Sulfa
• Complications:
• Pneumonia
• Super infection
• Atelactasis
• seizures

50. Lower ARIs

51. Acute bronchiolitis
• 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.

52. Symptoms:
• Presents as a progressive respiratory
illness that is similar to the common cold
in its early phase with cough, dyspnea and
rhinorrhea.
• It progresses over 3 to 7 days to noisy
breathing with noisy breathing.
• fever accompanied in young children by
irritability.
• May have apnea as the first sign of
infection.

53. Signs:
• 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
resonance.
• Auscultation reveals prolonged expiratory
phase with diffuse wheezes and
crepitation.
• In more severe cases cyanosis.

54. Investigations:
• 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
lung radiolucency.

55. Differential Diagnosis:
• 1- bronchial asthma.
• 2- congestive heart failure.
• 3- foreign body in the trachea.
• 4- pertusis.
• 5- cystic fibrosis.
• 6- bacterial bronchopneumonia.
• 7- obstructive emphysema.

56. Indications of
hospitalization:
1.Young age<3 month old.
2.Moderate to marked resp. distress
3.Hypoxemia(PO2<60mmHg or Oxygen
saturation<92% on room air).
4.Apnea
5.Inability to tolerate oral feeding
6.Lack of appropriate care available at
home.

57. Treatment:

58. • consists of supportive therapy,
including:
1-Nebulizer, control of fever
2-good hydration
3- upper airway suctioning and oxygen
administration.
4- I.V. fluid indicated in case of sever
tachypnea which interrupt feeding.
5-Ribavirin is anti viral agent administered
by aerosol.
6-Temperorary use of bronchodilators may
improve wheezing &respiratory distress.

59. Pneumonia
• 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.

60. Etiology:
1-Viral: RSV 70%, influenza, parainfluenza or
adenovirus.
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
staphylococci.
• After 3 years of age common bacteria include
S. pneumonia and staphylococci.
3-Atypical organism: Chlamydia and Mycoplasma.

61. Clinical features:
• 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.

62. • 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 chest pain.
• WBC leukocytosis with neutrophilia.
• S. pneumoniae often resulting in focal
lobar involvement.
• Group A. streptococcus infection
results in interstitial pneumonia.
• S. aureus causes bronchopneumonia
which is often unilateral with cavitations.

63. Diagnosis:
• Diagnosis mainly clinical.
• 1- chest x- ray:

64. • LOBAR
PNEUMONIA:

65. • BRONCHO P.

66. • STREP. P.

67. Diagnosis:
1.Sputum for gram stain and culture.
2.blood culture.
3.virological study by culture &florescent
antibody technique.
4.in case of pleural effusion aspirate pleural
fluid for gram stain and culture also for
acid fast bacilli.

68. Indications for admission to
hospital:
• 1-less than 3 month of age.
• 2- moderate to sever respiratory distress.
• 3- failure of out patient treatment.
• 4-immunocompromised patient.
• 5- neonate with congenital pneumonia.
• 6- staphylococcal pneumonia.
• 7- complications like pleural effusion,
empyema.

69. TREATMENT:
• The empiric treatment of suspected bacterial
pneumonia is parenteral cefotaxim or ceftriaxone.
• If clinical features suggest staphylococcal
pneumonia, vancomycin.
• 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. 3- antipyretic for fever. ribavirin for RSV.

70. Complications:
• A- Pulmonary
complications
• 1- pleural effusion.
• 2- empyema.
• 3- lung abscess.
• 4- pneumatocele.
• 5- pneumothorax.
• B- Extra pulmonary
complications
• 1- meningitis.
• 2- arithritis.
• 3- osteomyelitis.
• 4- pericarditis.

71. ARI CONTROL PROGRAME
• AIM of the program is to identify children with
ARI at the community level by training the field
workers to recognize easily & reliably identifiable
clinical signs of ARI & early reference
WHO protocol comprises 3 steps:
1.Case finding & Assessment
2.Case Classification
3.Institution of appropriate therapy

72. Step 1: Case finding &
Assessment
• Cough & difficult breathing in children < 5 years age
• Fever is not an efficient criteria

73. Step 2: Case Classification
• Children grouped into 2:
• Infants < 2months & Older children
• Specific signs to be looked: In younger children like
feeding difficulty, lethargy, hypothermia, convulsions

74. In infants < 2 months
• Pneumonia is diagnosed if RR 60/min with
other clinical signs
• All should be hospitalized
• All should receive IV medications
• Minimum duration of 10 days
• Combination of Ampicillin & Gentamicin

75. step 3:Institution of appropriate
therapy
• ANTIBOTICS

76. PREVENTION:
• Breastfeeding infants exclusively (no other
food or drinks, not even water) for the first
six months breast milk has excellent
nutritional value and it contains the
mother’s antibodies which help to protect
the infant from infection.

77. • Avoiding irritation of the respiratory tract by
indoor air pollution, such as smoke from cooking
fires; avoid the use of dried cow dung as fuel for
indoor fires.
• Immunization of all children with the routine
Expanded Programme on Immunization
• Feeding children with adequate amounts of
varied and nutritious food to keep their immune
system strong.

78. • control the spread of respiratory bacteria
by educating parents to avoid contact as
much as possible between their children
and patients who have ARIs.
• people with ARIs should cough or
sneeze away from others, hold a cloth to
the nose and mouth to catch the airborne
droplets when coughing or sneezing
• Immunization also increases control, by
reducing the reservoir of infection in the

80. Prevention of ARI
• Health education.
• Keep child warm.
• Immunization.
• Nutrition.
• Prevent nearby smoking.
• Personal hygiene.
• Visit doctor.

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