ARI (Acute respiratory infection), PSM, Community Medicine

1. ARI and CB-IMNCI
DR NARENDRA KUMAR YADAV
MD Community Medicine & Tropical Diseases, BPKIHS

2. ARI:
Outline of the Chapter:
Community-Based Integrated Management of Newborn and Childhood
Illness(CB-IMNCI)
Burden of ARI
Risk factors for ARI
Classification of Illness
Prevention of ARI

3. Case-Scenario:
Q. A male child of one month of age is brought to an OPD with a cough and cold for 2
days. The child has difficulty in breathing and widening the nose during inspiration.
On examination, the dark bluish coloration of the skin is noticed and respiratory rate is
72/minute.
A. What is your diagnosis? Justify your diagnosis.
B. Explain the danger signs of very severe disease as per CB-IMNCI in children.
C. Write the management for the above illness.
D. Write on vaccines which help in preventing this condition.
D. Discuss the prevention and control of acute respiratory illness.
E. What is CB-IMNCI? What are the problems covered under CB-IMNCI?

4. What is CB-IMNCI? What are the problems covered under CB-
IMNCI?
Community-Based Integrated Management of Newborn and Childhood
Illness(CB-IMNCI): CB-IMCI + CB-NCP
CB-IMNCI is an integration of CB-IMCI and CB-NCP (MoH on 2071.6.28)
Aim: To reduce neonatal and under 5 years children morbidity and
mortality………
CB-IMCI = Community-Based Integrated Management of Childhood Illness
CB-NCP = Community-Based New Born Care Program

5. What are the problems covered under CB-IMNCI?
This integrated package addresses the major problems of sick
newborn: Birth asphyxia, Bacterial infection, LBW, Hypothermia,
Jaundice and Counseling of breastfeeding.
This integrated package also addresses the major childhood illness:
Pneumonia, Diarrhoea, Malaria, Measles and Malnutrition among
under 5 years children.

6. ACUTE RESPIRATORY INFECTIONS(ARI):
ARI: Acute respiratory infection is an infection of the respiratory tract
anywhere from the nose to the alveoli, with a wide range of
combination of symptoms and signs.
AURI ALRI
Upper respiratory tract infection: Nasal
cavity, Pharynx, Paranasal sinuses,
middle ear
Lower respiratory tract infection: Epiglottis,
Larynx, Trachea, Bronchi, lungs
 Rhinitis, Pharyngitis, Sinusitis and
Otitis media.
 Epiglottitis, Laryngitis, Laryngotracheitis, Bronchitis,
Bronchiolitis and Pneumonia.
C/F: Running nose, Cough, Sore throat, Difficult breathing, Ear problem and Fever

7. Burden of Disease:
ARI is a common illness affecting approximately 450 million people a year
and occurring in all parts of the world (Developing countries > developed
countries).
A/C to the WHO, respiratory infections account for 6% of the total global
disease burden.
ARI is an important cause of morbidity and mortality in the children
Around 6.6 million, under-five aged children die each year worldwide
95 % of them belong to low-income countries

8. Epidemiological triad of ARI:
Agent factors: Bacteria (M/C: Streptococcus Pneumoniae), virus, mycoplasma,
fungus
Host factors:
Rates are greatest in children less than five, and older than 75 years
LBW, Malnutrition, Vitamin A deficiency
Environment factors:
Indoor smoke population
Overcrowding
Poor socioeconomical status

9. Risk factors for ARI:
Indoor smoke population
Poor nutrition
Vitamin A deficiency
Overcrowding
Poor socioeconomical status
LBW: A LBW child is highly susceptible for any infection.
Young infant (i.e. Neonatal period)
Lack of primary immunization

10. Fast breathing: Respiratory rate cut off for the fast breathing
 Rule of 60, 50, 40 for fast breathing:
Birth to <2 months: RR ≥ 60 breath/min
2 months- 12 months: RR ≥ 50 breath/min
12 months – 5 years: RR ≥ 40 breath/min

11. A/C to CB-IMNCI,
The danger signs of very severe disease:
1. Not able to drink (Unable to feed)
2. Lethargic/Unconscious
3. H/O Convulsions
4. Stridor in calm child
5. Severe malnutrition
6. Hypothermia

12. WHO Classification of Respiratory Illness/ARI or Pneumonia:
Age group Classification of Diseases
Child (2 months-
5 years)
No Pneumonia(Cough
or Cold)
Pneumonia
(Not Severe)
Severe
Pneumonia
Very Severe
Disease
Young Infant
(0-2 months)
No Pneumonia(Cough
or Cold)
------------------- Severe
Pneumonia
Very Severe
Disease

13. Classification and management of Respiratory Illness/ARI in Child (2 months-5 years):
No Pneumonia(Cough or
Cold
Pneumonia (Not
Severe)
Severe Pneumonia Very Severe Disease
 Cough/Cold
 No Fast breathing
 No Chest indrawing
 No danger signs
 Fast breathing (+)
(Based on RR)
 No Chest indrawing
 No danger signs
 Chest indrawing (+)
 ± Fast breathing
 Also has sign of: Nasal
flaring, Grunting, Cyanosis.
Any one of the danger sign
present: Not able to drink,
Lethargic/Unconscious, Strider
in calm child, Convulsions,
Severe malnutrition,
Hypothermia.
 Home Management:
 They do not need any
antibiotic
 Inhaled BD x 5 days
 Antipyretic(Paracetamol)
 Breast feeding
 Keep the child warm
 F/U in 5 days
 PHC:
 Inhaled BD x 5 days
 Antipyretic(Paraceta
mol)
 Oral Amoxicillin x 5
days
 Breast feeding
 Keep the child warm
 F/U in 2 days
Refer URGENTLY to the HOSPITAL:
 Give first dose of referral antibiotics (inj Ampicillin + inj
Gentamycin)
 Inhaled BD x 5 days
 Antipyretic(Paracetamol)
 Iv Dextrose
 Diazepam
 Antibiotics (inj Ampicillin + inj Gentamycin)
 Keep the child warm

14. Classification and management of ARI in Young Infant (0-2months):
No Pneumonia(Cough or
Cold)
Severe Pneumonia Very Severe Disease
 Cough/Cold
 No Fast breathing
 No Chest indrawing
 No danger signs
 Chest indrawing (+) and/or
 Fast breathing(+)
 No danger signs
Any one of the danger sign present:
Not able to drink, Lethargic/
Unconscious, Strider in calm child,
Convulsions, Severe malnutrition,
Hypothermia
 Home Management:
 They do not need any antibiotic
 Inhaled BD x 5 days
 Antipyretic(Paracetamol)
 Breast feeding
 Keep the child warm
 F/U in 5 days
Refer URGENTLY to the HOSPITAL:
 Give first dose of referral antibiotics (inj Ampicillin + inj Gentamycin)
 Inhaled BD x 5 days)
 Antipyretic(Paracetamol)
 Iv Dextrose
 Diazepam
 Antibiotics(Inj Ampicillin + Inj Gentamycin)
 Keep the child warm

15. ARI: Physical examination:
Look and listen for the following:
1. Count the breaths (RR) in one minute
2. Body temperature
3. Look for chest indrawing
4. Nasal flaring, Grunting, Cyanosis.
5. Look and listen for wheeze and stridor
6. Convulsion
7. Check for severe malnutrition

16. Prevention and Control of ARI:
A. HEALTH PROMOTION:
1. Health education of mother about ARI
2. Reduction of indoor smoke population
3. Adequate Nutrition:
4. Exclusive Breastfeeding
5. Improvement in the living conditions (Housing and Sanitation)
6. Limit the size of the family to prevent overcrowding

17. Prevention and Control of ARI:
B.SPECIFIC PROTECTION:
7. Immunization: Immunization is an important measure to reduce
cases of pneumonia which occur as a complication of vaccine
preventable disease
Ex: Measles vaccine, HIB vaccine, PCV vaccine
8. Vitamin A supplementation

18. MCQ
Q. Diseases covered under IMNCI are all except
a. Measles
b. Malaria
c. Malnutrition
d. Tuberculosis

19. Ans: d (Tuberculosis)
Q. What are the problems covered under CB-IMNCI?
This integrated package addresses the major problems of sick
newborn: Birth asphyxia, Bacterial infection, LBW, Hypothermia,
Jaundice and Counseling of breastfeeding.
This integrated package also addresses the major childhood illness:
Pneumonia, Diarrhoea, Malaria, Measles and Malnutrition among
under 5 years children.

20. MCQ
Q. Respiratory rate can be diagnosed as fast breathing in a less than 2-
month-old-infant, if respiratory rate per minute is:
A. 29
B. 39
C. 49
D. 70

21. Ans: D (70)

22. MCQ
Q. Most important features to diagnosis severe pneumonia:
A. Cyanosis
B. Chest indrawing
C. Nasal flaring
D. Fast breathing

23. Ans: B (Chest indrawing)

24. MCQ
Q. Not evaluated in clinical evaluation pneumonia:
A. Respiratory rate
B. Inability to feed
C. Oxygen Saturation
D. Chest indrawing

25. Ans: C (Oxygen Saturation)

26. MCQ
Q. A 2 year-old female child was brought to a PHC with a history of cough and
fever for 4 days with inability to drink for last 12 hours. On examination, the child
was having weight of 5 kg and respiratory rate of 45/min with fever. The child will
be classified as suffering from:
a. Very severe disease
b. Severe Pneumonia
c. Pneumonia
d. No Pneumonia

27. Ans: a (Very severe disease)

28. MCQ
Q. A child aged 24 months was brought to the primary Health Centre with
complaints of cough, and fever for the past 2 days. On examination, the child
weighted 11 kg, respiratory rate was 38/min, chest indrawing was present.
The most appropriate line of management for this patient is?
a. Classify as pneumonia and refer urgently to secondary level hospital
b. Classify as pneumonia, start antibiotics and advice to report after 2 days
c. Classify as severe pneumonia, start antibiotics and refer urgently
d. Classify as severe pneumonia and refer urgently

29. Ans: c (Classify as severe pneumonia, start antibiotics and
refer urgently)

30. Asphyxia: Asphyxia or asphyxiation is a condition of deficient supply of
oxygen to the body which arises from abnormal breathing that results in
unconsciousness and often death
Birth asphyxia is the leading cause of neonatal deaths
 Lethargy: Drowsiness and an unusual lack of energy
Cyanosis: is bluish discoloration of the skin or mucous membranes that
appears when the capillary content of reduced Hb is greater than 5 gm/dl

31. Jaundice: (AKA: icterus): Jaundice is the yellowing of the skin,
mucous membranes and sclera due to high bilirubin levels in the
blood.
Convulsion: Convulsions are rapid, involuntary muscle contractions
that cause uncontrollable shaking and limb movement.
Nasal flaring: Nasal flaring occurs when the nostrils widen while
breathing. It is often a sign of trouble breathing.

32. Chest indrawing is the inward movement of the lower chest wall
when the child breathes in, and is a sign of respiratory distress.
Stridor is a harsh noise heard when a sick child breathes in.
Grunting is a noisy breathing sound. Grunting may sound like
snoring or singing.
 Wheezing is a high-pitched, whistling sound that occurs when a
person breathes in or out.

33. Fever: Who defined fever an axillary temp ≥ 99 F
, oral temp > 100 F and Rectal temp >100.4 or 100.8 F
Hypothermia: Body temp below 95 F(35 C)

34. Case-Scenario:
Q. A male child of one month of age is brought to an OPD with a cough and cold for 2
days. The child has difficulty in breathing and widening the nose during inspiration.
On examination, the dark bluish coloration of the skin is noticed and respiratory rate is
72/minute.
A. What is your diagnosis? Justify your diagnosis.
B. Explain the danger signs of very severe disease as per CB-IMNCI in children.
C. Write the management for the above illness.
D. Write on vaccines which help in preventing this condition.
D. Discuss the prevention and control of acute respiratory illness.
E. What is CB-IMNCI? What are the problems covered under CB-IMNCI?

35. The End