UPPER RESPIRATORY TRACT INFECTIONS.(URIs) BRONCHIOLITIS. PNEUMONIA. Perpared by : DR. SALMA ELGAZZAR UPPER RESPIRATORY TRACT INFECTIONS.(URIs) Acute respiratory infections (ARIs) are classified as upper respiratory tract infections (URIs) or lower respiratory tract infections (LRIs). The upper respiratory tract consists of the airways from the nostrils to the vocal cords in the larynx, including the paranasal sinuses and the middle ear. URIs are infections primarily affecting respiratory tract structures above the larynx. ETIOLOGY OF (URIs) URIs are the most common infectious diseases. They include rhinitis (common cold), sinusitis, ear infections, acute pharyngitis or tonsillopharyngitis, epiglottitis, and laryngitis. Of which ear infections and pharyngitis cause the more severe complications (deafness and acute rheumatic fever, respectively). The vast majority of URIs have a viral etiology. More than 200 viruses can cause URIs. The most important ones are Rhinoviruses. Rhinoviruses account for 25 to 30 percent of URIs; (1/3 of cases). Respiratory syncytial viruses (RSVs), parainfluenza and influenza viruses, human metapneumovirus, and adenoviruses for 25 to 35 percent. Corona viruses for 10 percent; and unidentified viruses for the remainder. Because most URIs are self-limiting, their complications are more important than the infections. Acute viral infections predispose children to bacterial infections of the sinuses and middle ear,and aspiration of infected secretions and cells can result in LRIs. ACUTE NASOPHARYNGITIS Etiology: There are more than 100 different varieties of rhinovirus, the type of virus responsible for the greatest number of colds. Other viruses that cause colds include enteroviruses (echovirus and coxsackieviruses) and coronavirus. Seasonal patterns : Any time of year, although most colds occur during the fall and winter months. Transmission : -direct contact. -contact with the virus in the environment. Colds are most contagious during the first two to four days. PATHOGENESIS CLINICAL PICTURE The signs and symptoms of a cold usually begin one to two days after exposure. In young infant (more severe disease): - Fever, irritability, sneezing. - Nasal obstruction (snoring) + discharge. - Difficult feeding. - Congested ear drums. - +/- vomiting, diarrhea. In older children ( milder disease): -No Fever, or low grade fever, sneezing. -Body aches and headache. -Nasal obstruction, no respiratory distress. -Nasal discharge : thin thick purulent +/- cough. -Mouth breathing dry mouth and soreness. DIFFERENTIAL DIAGNOSIS: - Prodrome of viral infections ( as measles,mumps,poliomyelitis, etc). - Allergic rhinitis: No fever Sneezing and itching. Pale mucous membrane. Eosinophils in secretion. Discharge is watery, not purulent. Improves on antihistaminic. COMPLICATIONS: More in young infants. I.Otitis media (in 25 % of young infants). II.Sinusitis, mastoiditis, peritonsillar cellulitis, cervical adenitis. III.Lower respiratory tract infection (laryngotracheobronchitis, bronchiolitis, pneumonia). IV.Triggers asthma in children with hyper-reactive airways. TREATMENT NO SPECIFIC TREATMENT Antibiotics DO NOT AFFECT THE COURSE and DO NOT REDUCE INCIDENCE OF BACTERIAL COMPLICATIONS. Maintain good nutrition and fluid intake. Paracetamol or ibuprofen but avoid aspirin. Relieve nasal obstruction : Sterile saline, or phenylephrine ( %) nasal drops administered 15 minutes before feeding and at bed time for not more than 5 days. Suction with a soft rubber bulb can help in clearing nasal obstruction in young infants. Herbal and alternative treatments: Zinc, and herbal products such as echinacea. There is some evidence that prophylactic use of vitamin C may decrease the duration of the common cold in children and adults. ASPIRIN + INFLUENZA INFECTION THE RISK OF REYE SYNDROME ACUTE PHARYNGITIS AND TONSILLOPHARYNGITIS (SORE THROAT) Pharyngitis is redness, pain, and swelling of the throat (pharynx). Tonsillitis is inflammation of the tonsils. The tonsils are a pair of tissue masses on either side of the back of the throat. Children may have pharyngitis, tonsillitis, or both (pharyngotonsillitis). Pharyngitis is part of most common URIs,however,in the strict sense, acute pharyngitis refer to conditions in which the principal involvement is in the throat. AGE: Peak incidence 4-7 years of age. Uncommon before 1 year. ETIOLOGY: in children 2 years: mostly viral (rhinovirus, adenovirus, coronavirus,enterovirus) in children 5 years: Mostly bacterial, group A hemolytic streptococci (GABHS). in school aged children and adolescents : Mycoplasma. CLINICAL PICTURE: GENERAL SYMPTOMS AND SIGNS: Fever, sore throat, dysphagia, abdominal pain (due to mesenteric adenitis ),vomiting,throat erythema (redness),palatine petechiae,enlarged tonsils, exudates and anterior cervical lymphadenopathy. It is often impossible to distinguish clinically between streptococcal and non-streptococcal sore throat. Streptococcal sore throat should be suspected if there is: Fever and/or sore throat and 2 of the following signs: 1.Redness (congestion) of the throat. 2.White or yellow exudates on the throat and tonsils. 3.Anterior cervical lymphadenopathy ( enlarged and tender anterior cervical lymph nodes) DIAGNOSIS OF GROUP A- HEMOLYTIC STREPTOCOCCI The goal of specific diagnosis is to identify GABHS infection to start prompt and adequate treatment THROAT SWAB IF +VE IF -VE etiology is - hemolytic do a throat culture COMPLICATIONS OF STREPTOCOCCAL PHARYNGITIS IMMEDIATE: Sinusitis. Otitis media. Peritonsillar abscess. Meningitis. DELAYED: Acute post-streptococcal glomerulonephritis. Rheumatic fever. TREATMENT OF ACUTE PHARYNGITIS GENERAL MEASURES: Bed rest. Antipyretics e.g. paracetamol or ibuprofen for fever and pain. Gargels with warm saline. Cool blank liquids. Very soft foods. SPECIFIC TREATMENT FOR BACTERIAL INFECTION: Penicillin is the drug of choice for - hemolytic streptococci. It can be given as IM procaine penicillin U /day for 10 days. Or single injection of U of long acting benzathine penicillin. Erythromycin & azithromycin are acceptable alternative to penicillin & can also treat mycoplasma. CHRONIC TONSILLITIS CLINICAL FEATURES: Recurrent or persistent sore throat. Recurrent or persistent obstruction to breathing in the form of snoring or apnea during sleep ( usually due to associated enlarged adenoids). Offensive breath. Persistent hyperemia (congestion) of anterior pillars + enlarged cervical lymph nodes. IDEAL AGE FOR TONSILLECTOMY: At the age of 5 years ( not before 2 years). INDICATIONS OF TONSILLECTOMY: Repeated acute tonsillitis ( 4 or more culture-proved -hemolytic strept.tonsillitis /year). Chronic tonsillitis. Peritonsillar (quinsy)/ retrotonsillar abscess. Markedly hypertrophied tonsils chronic obstruction (especially if there is sleep apnea). Acute Ear Infection Acute ear infection occurs with up to 30 percent of URIs. It may lead to perforated eardrums and chronic ear discharge in later childhood and ultimately to hearing impairment or deafness. Chronic ear infection following repeated episodes of acute ear infection is common in developing countries, affecting 2 to 6 percent of school-age children. The associated hearing loss may be disabling and may affect learning. Repeated ear infections may lead to mastoiditis, which in turn may spread infection to the meninges. RUPTURED EAR DRUM MASTOIDITIS BRONCHIOLITIS INTRODUCTION : Bronchiolitis is a lower respiratory tract infection that occurs in children younger than two years old. Usually caused by a virus inflammation of the small airways (bronchioles). The inflammation partially or completely blocks the airways, which causes wheezing. Bronchiolitis is a common cause of illness and is the leading cause of hospitalization in infants and young children. Bronchiolitis can cause serious illness in some children(very young Infants, born early, lung or heart disease). ETIOLOGY Bronchiolitis is typically caused by a virus. Respiratory syncytial virus (RSV) is the most common cause in 50% of cases. Common in winter and early spring. First 2 years of life ( peak between 3-6 months), more in males and in non breastfed. Children who are older than two years typically do not develop bronchiolitis, but can be infected with RSV. RSV infection is common in children older than two years. It usually causes symptoms similar to those of the common cold or mild wheezing and at times the illness is significant enough to require evaluation by a health care provider. OTHERS: Parainfluenza virus, adenovirus,influenza virus, mycoplasma PATHOGENESIS Acute infection respiratory obstruction of the small airways. Viral invasion of the smaller radicles of the bronchial tree edema+ accumulation of mucus and cellular debris bronchiolar obstruction. VIRAL INVASION OF BRONCHIOLES BRONCHIOLAR OBSTRUCTION EDEMA ACCUMULATION OF MUCUS CELLULAR DEBRIS INCOMPLETE OBSTRUCTION (BALL VALVE) COMPLETE OBSTRUCTION EARLY AIR TRAPPING DURING EXPIRATION ATELECTASIS OVER INFLATION HYPOVENTILATION IMPAIRED AIR EXCHANGE & HYPOXIA HYPERCAPNEA CLINICAL PICTURE SYMPTOMS : History of exposure to an older person with minor respiratory distress. Mild upper respiratory tract infection (URTI) for 2-3 days. Followed by gradual onset of respiratory distress: paroxysmal spasmodic cough, wheezes, dyspnea, irritability, feeding difficulty due to tachypnea. In mild cases symptoms resolve within 5-7 days. In severe cases the course is more protracted. SIGNS : INSPECTION: -Fast,shallow respiration. - R.R.60-80/minute. -Flaring ala nasi. - Chest indrawing. -Intercostal retraction. -Air hunger. - Restlesness. - Cyanosis. AUSCULTATION: air entry. -Harsh vesicular breathing with prolonged expiration. -Inspiratory and expiratory wheezes. -Inspiratory widespread fine crackles. PERCUSSION: Hyper resonant note due to over inflated lungs. TACHYPNEA RESPIRATORY DISTRESS WHEEZES HYPERINFLATION DIAGNOSIS Young infant with mild URI followed by : Respiratory distress + wheezes+ over inflated chest LAB FINDINGS: The diagnosis of bronchiolitis is based upon a history and physical examination. Blood tests and x-rays are not usually necessary. Leukocytosis count normal or mild decrease. PO2, PCO2 and PH may be measured to assess the severity of the disease. RSV may be demonstrated in nasopharyngeal secretions by immunofluroscence or PCR Rising antibodty titre to RSV in serum. X-ray finding hyperinflated lungs. In 30% scattered areas of opacity dt cosolidaton or atelectasis. An X-ray of a child with RSV showing the typical bilateral perihilar fullness of bronchiolitis. DIFFERENTIAL DIAGNOSIS Bronchial asthma. Cystic fibrosis Congestive heart failure Bacterial bronchopneumonia Organophosphrus poisoning. COMPLICATIONS Bacterial superinfection uncommon. Cardiac failure rare Death due to severe course TREATMENT The healthcare provider must determine if the child's illness is severe or if there is a risk of complications. In these cases, hospitalization is generally recommended to closely monitor the child and provide intravenous fluids or supplemental oxygen. Approximately 3 percent of children with bronchiolitis will require monitoring and treatment in a hospital. Discharge to home: Most children who require hospitalization are well enough to return home within three to four days. Children who require ventilator usually need to stay in the hospital for four to eight days or longer before they are ready to go home. AT HOME There is no cure for bronchiolitis, so treatment is aimed at the symptoms (eg, difficulty breathing, fever). Semi-sitting position (30-40 degrees) makes the infant more comfortable. Fever control : acetaminophen,Ibuprofen acetaminophenIbuprofen Nose drops or spray Encourage fluids Other therapies : such as antibiotics, cough medicines, decongestants, and sedatives, are not recommended. Monitoring at home involves observing the child periodically for signs or symptoms of worsening ( increased rate of breathing, worsening chest retractions, nasal flaring, cyanosis, a decreased ability to feed or decreased urine output). SUPPORTAIVE TREATMENT Semi-sitting position (30-40 degrees) makes the infant more comfortable. Oxygen: Cool humidified oxygen by nasal cannula, or by placing a face mask over the nose and mouth. For infants, an oxygen head box (a clear plastic box) may be used. If a child is severely ill and unable to breathe adequately on his or her own, or if the child stops breathing, an endotracheal tube may be inserted and connected to a ventilator that breathes for the child at a regular rate. The use of an endotracheal tube and ventilator is a temporary measure that is discontinued when the child improves. Fluids : parental + oral. In case of respiratory acidosis,suitable I.V. fluids are given to adjust PH and electrolytes. Avoid sedatives. Good nutrition Antiviral ( ribavarin) is given only to those with documented sever RSV disease or high risk infants.it is given by continuous inhalation by aerosol generator 10-12hr/day for 3-4 days. DEFINATION AND EPIDEMIOLOGY PNEUMONIA is a primary inflammation of lung parenchyma. (WHO) estimates there are 156 million cases of pneumonia each year in children younger than five years. Pneumonia affects more boys than girls. Mortality: The mortality rate in developed countries is low ( 38.5o C is a feature of bacterial pneumonia Oxygenation: Cyanosis indicates severe illness. Pulse oximetry identifies significant hypoxaemia (SaO2 50 breaths/min >12 months>40 breaths/min CLINICAL PICTURE (CONTU.) Work of breathing: Chest recession, nasal flaring and grunting nasal flaring and grunting are most sensitive in children aged 92% Fluids: restrict to 80% maintenance. Antipyretics Antibiotics: 5 years: a macrolide (erythromycin, clarithromycin or azithromycin) is the first choice oral antibiotic as mycoplasma infection is more likely. Oral antibiotics are safe and effective for many children with CAP, but in severe cases with sepsis, consolidation with effusion, failed response or intolerance to oral antibiotics IV treatment is indicated with a third-generation cephalosporin(e.g. cefuroxime) or ampicillin. A change to oral antibiotics can then be made if there is clear improvement. Treatment duration is between 5 and 10 days depending on severity. ASPIRATION PNEUMONIA Causes: Amniotic fluid or meconium (in newborns) Foreign body. Food. Lipoid material. Hydrocarbons kerosene pneumonia. THANK YOU