Acute Respiratory Infection

The beginnings…

• The most serious problem was that of high ARI mortality

in young children in developing countries, mostly

attributable to bacterial pneumonia.

• Central strategy of an ARI programme should involve

case management to prevent mortality

Pioneering work in ARI

Shann et al. on work done in Papua New Guinea, published a paper

that has become the cornerstone of the current case management

strategy for the control of ARIs in children

Shann F, Hart K, Thomas D. Acute lower respiratory tract infections in children:possible criteria for selection of

patients for antibiotic therapy and hospital admission. Bulletin of the World Health Organization 1984;62:749-53

Pioneering work in ARI

• More objective and reliable criteria were employed in

subsequent studies:

– radiology

– a combination of radiological and clinical data

– clinical judgement of paediatricians with access to radiology

Resp. rate

All of these studies suggested that

• A single threshold of 50 was unsatisfactory as a sign of pneumonia in children aged under 5 years.

• The best combination of sensitivity (78–82%) and specificity (73–89%) was achieved by using thresholds of – 50 breaths per minute for children aged 2–11 mo

– 40 breaths per minute for 1–4 years

Resp. rate

WHO introduced the three age-related

definitions into the ARI protocol in order to

ensure the treatment of at least 80% of

children with pneumonia.

Resp. rate

The WHO definitions remained independent of

any other variable that might modify the

respiratory rate, such as the body temperature,

the nutrition status and the geographical altitude

• The respiratory rate, to some extent, depends on body

temperature in children with febrile illnesses.

• Studies in the Gambia showed that

– The mean respiratory rate increased by 2.5 breaths per minute

with every rise in temperature of 1oC in children with cough

– The corresponding increase was 3.7 breaths per minute in

children with pneumonia or malaria

Temperature and resp.rate

Nutrition and resp. rate

• Malnourished children may not have the strength to

increase the respiratory rate adequately if their lungs are

affected by pneumonia.

• For a given sensitivity and specificity they produce about

5 breaths per minute fewer than well-nourished children

Altitude and resp. rate

At over 2500 metres above sea level in Colombia and

Peru, fast breathing was less useful than at low altitudes

as an indicator of radiographic pneumonia because of

physiological adaptation to low oxygen pressure at the

age of 3 or 4 years.

WHO recommend that the cut-off rates be

used without adjustment.

Work in the Philippines and Swaziland - improve the

definition of chest indrawing as a sign of severe

pneumonia.

– Intercostal or supraclavicular retractions - not signs of severe

pneumonia.

– Chest indrawing is present if, in a calm child, the lower part of

the chest moves in or retracts when inhalation occurs. The

correct term, therefore, is ‘‘lower chest wall indrawing’’

– ‘‘subcostal indrawing’’ and ‘‘subcostal retraction’’ are

inappropriate expressions

• The simple protocol was designed in Papua New Guinea for

identifying childhood pneumonia

• Intervention studies conducted in Bangladesh, India, Indonesia,

Nepal, Pakistan, the Philippines, and the United Republic of

Tanzania

– The protocol was applicable by properly trained health workers even in

the poorest rural areas

– It produced an epidemiological impact despite differences in designs

and methods

– A significant effect on pneumonia-specific mortality was reflected in

reduced overall childhood mortality

By the end of 1994 the original Papua

New Guinean guidelines on the case

management of pneumonia in children, as

recommended by WHO and UNICEF, had

been adopted, with slight modifications by

ARI programmes in 130 developing

countries

Pneumonia - Recognition

• Recognize pneumonia based on two simple

clinical end points:

– fast breathing

– lower chest wall indrawing

• Rely on the mother or caregiver to recognize

cough or difficult breathing — that’s the entry

point into assessment

• 95 percent of children with pneumonia will have a cough

• A small proportion will have no cough but will have

difficult breathing.

• Therefore, when assessing for pneumonia, you use

“cough OR difficult breathing”

not “cough AND difficult breathing”

Many causes of difficult breathing not related to

cough.

– Acidosis in children with diarrhoea

– Chronic difficulty in breathing in children with congenital

heart disease

– Rickets

– Congenital malformations

Pneumonia — Fast Breathing

• Fast breathing based on age-specific thresholds

• Respiratory rates to indicate pneumonia

– > 50 per minute in infants up to 12 months of age

– > 40 per minute in children aged 12 months up to 5 years

• If the respiratory rate is below these cut-offs

+ There are no danger signs

+ No chest wall indrawing,

The classification is no pneumonia, cough and cold.

• The optimal method of obtaining a respiratory rate is the

use of a timing device

• Important to count the respiratory rate for one full minute

• Best time to count the respiratory rate is when the child

is in a quiet and alert state

• Respiratory rate is also influenced by temperature

– cut-off rates be used without adjustment

Severe Pneumonia – Lower Chest Wall Indrawing

• multiple definitions of “retractions” – suprasternal retractions– intercostal retractions – xiphoid retractions– subcostal retractions

• Suprasternal and xiphoid retractions was very rare and

occurred in only the most severely ill children

• Intercostal retractions are very subtle (even with blocked

noses and URTI)

• Subcostal retractions indicate diaphragmatic and

abdominal muscle use in a distressed child

• “Lower chest wall indrawing” best identifies these children

Rationale for choosing antibiotics to be used

Cotrimoxazole

• Least expensive

• Twice a day – good compliance

• Drug rashes

• Drug eruptions

• BM suppression

• Increasing resistance to S.

pneumoniae and H.influenza

Amoxicillin

• Expensive

• Thrice daily – poor compliance

• Diarrhea

• Effective clinically against resistant

S.pneumoniae

• H.influenza reported to be resistant

Severe Pneumonia or Very Severe Disease Antibiotics

Penicillin

• Inexpensive

• Widely available

• Acts against S.pneumoniae and

H.influenza

• Does not penetrate meninges well

• Penetrates only in inflamed

meninges

Chloramphenicol

• PO, IV, IM

• Much broader range of organisms

• Includes S. aureus and H.influenza

• Penetrates intact and inflamed

meninges

• Idiosyncratic aplastic anemia - rare

TREATMENT• If coughing > 30 days refer for

assessment• Assess and treat ear problem or

sore throat, if present• Assess other problems• Advise mother to give home care• Treat fever, if present• Treat wheezing, if present

NO PNEUMONIA – Cough or cold

SIGNS• No chest indrawing

• No fast breathing

• Respiratory rate

< 50/mt (2-12 months)

< 40/mt (12 mo - 5 yrs)

REASSESS in 2 days, a child who is taking an antibiotic for pneumonia

TREATMENT• Advise mother to give

home care• Give an antibiotic• Treat fever, if present• Treat wheezing, if present

(Return for reassessment after 2 days or earlier if the child is getting worse)

PNEUMONIA

SIGNS• No chest indrawing

• No fast breathing

• Respiratory rate

> 50/mt (2-12 months)

> 40/mt (12 mo - 5 yrs)


TREATMENT• Refer urgently to hospital• Give first dose of antibiotic• Treat fever, if present• Treat wheezing, if present

(If referral is not possible, treat with antibiotic and watch closely)

SEVERE PNEUMONIA

SIGNS• Chest Indrawing

If wheezing, go directly to TREAT WHEEZING

• Reassessment important to reduce mortality due to – Inadequate treatment– Resistance to antimicrobials


Refer urgently to

hospital

SIGNS

• Not able to drink

• Has chest indrawing

• Has other danger

signs

Change antibiotic

or refer

SIGNS

THE SAME

SIGNS

• Breathing slower

• Less fever

• Eating better

Finish 5 days of

antibiotic

WORSE SAME IMPROVING

TREATMENT• Refer urgently to a hospital

• Treat with an antibiotic

• Treat fever, if present

• Treat wheezing, if present

• Treat with antimalarial, if malaria

possible

VERY SEVERE DISEASE

SIGNS• Not able to drink

• Convulsions

• Abnormally sleepy or

difficult to wake

• Stridor in a calm child

• Severe malnutrition

Reassessment of very severe disease

Reassessment after 48 hrs

Improving

Change to oral drugs

Treat for 10 days

Not improving

Probable Staph pneumonia

Change to Clox + Genta

Recommendations for treatment of

Pneumonia in infants below 2 months of age

• Labeled as severe or very severe disease

• Danger of disease dissemination and risk of complications

• Should be admitted and treated

• Benzyl penicillin and gentamicin

• Term infants older than 1 week of age, chloramphenicol if

no aminoglycoside

• Benzylpenicillin + cotrimoxazole if not preterm or jaundiced.

Supportive management

Oxygen– Central cyanosis– Child is not able to drink– Restlessness which improves on oxygen– Severe chest indrawing

• Oxygen can be administered by nasal cannula or nasal catheter

Rate of flow• < 2 months of age the flow rate is kept at 0.5 litres/min• > 2 months of age 1 litre/min by a catheter

rate of 5 litres/min if it is given by a cannula


Feeding

1. Breast mild should be given frequently to these

infants

2. If a baby is unable suckle at the breast -

expressed breast milk

3. Frequent small calorie rich food like dalia,

khichdi can be given


4. Children requiring oxygen should not be fed since

there is a risk of aspiration

5. As soon as oxygen therapy is discontinued, oral or

nasogastric feeding should be initiated

6. After recovery from the illness, additional feeds must

be given to enable catch up growth

7. Growth monitoring of children recovering from measles

pneumonia, whooping cough or those who are

undernourished is vital.


IV fluids

– Cyanosis;

– Excessive irritability;

– Severe lower chest indrawing

– Grunting

– Shock and dehydration and poor oral intake

Signs indicating need for admission in children who may have pneumonia

• Pneumonia in children < 2 months of age

• Chest indrawing in a child who is not wheezing

• Unable to feed

• Convulsions

• Abnormally sleepy or lethargic child

• Stridor in a calm child


• Severe undernutrition

• Central cyanosis

• Wheezing child with respiratory distress

not relieved with bronchodilators

• Measles


• Pertussis in infants < 6 months of age

• Any child with

– Apneic or cyanotic spells

– Pneumonia

– Convulsions

– Dehydration

– Severe undernutrition

• Diphtheria

• Severe dehydration or shock

Assessment of the wheezing child

• Occurs when air flow from lungs is obstructed

due to narrowing of small airways.

• Common causes of wheeze include

– Asthma

– Bronchiolitis

– Respiratory infections including pneumonia.

• Both pneumonia and wheezing can cause chest

indrawing and fast breathing.

• Central cyanosis or ADMIT• Not able to drink Give oxygen

Give rapid-acting bronchodilatorsGive an antibiotic chloramphenicolTreat fever, if presentSupportive care

Respiratory distress persists with ADMIT• No central cyanosis and Give rapid-acting bronchodilators• Able to drink Give an antibiotic benzylpenicillin

Treat fever, if presentSupportive care

No respiratory distress +• Fast breathing ADVISE MOTHER TO GIVE HOME CARE

Give oral salbutamol at homeGive an antibiotic (at home)

(Cotrimoxazole, amoxycillin, ampicillin or Procaine penicillin)

• No fast breathing ADVISE MOTHER TO GIVE HOME CAREGive oral salbutamol at home

Guidelines for the management of

acute upper respiratory infections

Nasopharyngitis – common cold

• Fever • Nasal discharge

Treat at home• No antibiotics• Treat fever• Normal saline drops for nasal

block• No cough/cold remedies• Rule out ASOM, pneumonia

Sinusitis

• Persistent purulent nasal discharge

+ • Sinus tenderness, facial

or

Periorbital swelling

or

Persistent fever

• Cough

Sinusitis - treatment

• Treat at home

• Continue feeding

• Antibiotics (cotrimoxazole, ampicillin or amoxycillin)

only if

– suggestive of bacterial sinusitis• sinus tenderness

• facial or periorbital swelling

• persistent fever

• This is uncommon in children < 5 yrs of age

Acute otitis media (ASOM)

• Sudden persistent ear ache

• Pus discharge less than 2 weeks duration

• Ear rubbing is not a reliable sign in infants

Acute otitis media (ASOM)

• Treat at home• Treat fever• Keep ear dry• Start antibiotics - cotrimoxazole, ampicillin or

Amoxycillin• Reassess after 5 days. • If pain, fever, pus discharge are present, antibiotics

are continued for another 5 days.• Refer if no response after 10 days

Mastoiditis

• Painful swelling behind the ear

Or

• Above the ear in infants

• Admit

• Start antibiotics -

chloramphenicol x 10 days

• If the child has signs of brain

involvement refer for

neurosurgical evaluation

Pharyngitis

• Fever• Throat ache• Treat at home• Treat fever• Antibiotics only if

streptococcal pharyngitis suspected– Tender enlarged cervical

lymphnodes– White pharyngeal exudates– Absence of signs

suggestive of viral infection

Pharyngitis

• Give benzyl penicillin single dose – 0.6 lakhs in children < 5 yrs. – 1.2 lakhs in children > 5 yrs of age

Or

• Ampicillin.

• Amoxycillin

• Penicillin V

• Not cotrimoxazole.

Acute epiglottitis• Fever

• Drooling of saliva

• Stridor

• Admit

• Antibiotics - chloramphenicol

• Watch for signs of obstruction

– Severe chest indrawing

– Restlessness

– Cyanosis

to decide for tracheostomy

• If tracheostomy available, avoid oxygen

as it may mask signs of obstruction.

National ARI control programme

in India

National ARI Control programme

• The Govt. of India launched National ARI

Control programme in 1989

• Primary objective to reduce infant and

child mortality due to ARI

– By 20% by 1995

– By 40% by 2000.


• Taken up as a pilot project in 14 districts of the country in 1990.

• 10 more districts were added during 1991.

• Initially district teams of core trainers were trained

• They trained the doctors at sub-district level and the Primary

Health Centres.

• Training of paramedical staff was undertaken by the medical

officers.


• 51 districts were taken up in 1992-93 and 103 in 1993-94.

• 10 new districts were covered from 1994.

• An integrated clinical skills training course for physicians has

been started from June 1993.

• The training programme not only includes clinical practices

but also focuses on the need to improve referral services

from the peripheral health institutions.

Objectives

The National ARI Control Programme aims at:

1. Improving treatment practices in hospitals and health

centers to reduce mortality rates due to pneumonia and

to reduce the use of unnecessary and potentially harmful

drugs and overuse of antibiotics for the treatment of ARI

in children

Objectives

2. Early recognition and appropriate treatment of pneumonia

by the paramedical staff at the community level and timely

referral of the severe cases for treatment under medical

supervision and hospitalization when required

Objectives

3. Prevention of measles, pertussis, diphtheria

and tuberculosis with effective immunization.

Programme implementation

• ARI Control Programme is monitored by Ministry of Health

and Family Welfare with Joint Secretary (MCH) and

Dy.Commissioner (MCH) in the Ministry Head Quarters.

• The programme is implemented as part of the package of

MCH services by the State/UT Govt. in the identified

districts within the existing infrastructure of district hospitals,

primary health centers and other health facilities.

Programme implementation

• The flag bearer of the programme in the community is the

health/anganwadi worker.

• The implementation of the programme has been integrated

with the Child Survival and Safe Motherhood (CSSM)

programme after 1992.

• Operational research is still underway to evaluate the actual

implementation and impact of the programme in the Indian

setting.

Acute Respiratory Infection

Documents

Transcript of Acute Respiratory Infection