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TOPIC 1.
INTRODUCTION
ARI management training
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CONTENTS
Introduction
Definition and scope of ARI
Epidemiology & burden of ARI
Common cold - acute rhinopharyngitis
Croup - laryngotracheobronchitis
Acute otitis media
DEFINITION AND SCOPE
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CLASSIFICATION
ANATOMICALLY : (ARNOLD,1996)
ACUTE UPPER RESPIRATORYINFECTIONS(AURI)
INDONESIAN :
INFEKSI RESPIRASI AKUT ATAS ( IRA-A)
ACUTE LOWER RESPIRATORY INFECTIONS
(ALRI)
INDONESIAN :
INFEKSI RESPIRASI AKUT BAWAH (IRA-B)
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AURI (IRA-A) : COMMON COLD (RHINITIS, RHINOPHARYNGITIS) PHARYNGITIS - TONSILOPHARYNGITIS RHINO-SINUSITIS OTITIS MEDIA
ALRI (IRA-B) :
EPIGLOTITIS LARYNGO-TRACHEOBRONCHITIS BRONCHITIS BRONCHIOLITIS PNEUMONIA
The most common illnesses in childhood,
comprising as many as 50% of all
illnesses in children less than 5 years old
and 30% in children aged 5 - 12 years.
EPIDEMIOLOGY AND BURDEN
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MORBIDITY
50% OF ALL ILLNESS DISEASE IN CHILDREN
UNDER 5 YEARS; 30% IN CHILDREN 5 -12 YEARS
MOST INFECTIONS ARE LIMITED TO UR TRACT, ABOUT
5% LR TRACT
EPISODE IN URBAN 5-8, RURAL 3-5/YEAR
PNEUMONIA IN DEVELOPING COUNTRY IS MORE THAN
IN DEVELOPED COUNTRY
IN INDONESIA
MORBIDITYESTIMATION IN CHILDREN 5 YEARS OF
AGE 10-20% ( 2.33 - 4.66 MILLION)
MORTALITY
>> PNEUMONIA
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WHO ARI control program (included in
IMCI Algorithm ) uses simple clinical sign
are Respiratory rateand Chest
indrawing for ARI classification
WHO ARI classfication :
2 months - 5 tahun of age
1. SEVERE PNEUMONIA2. PNEUMONIA
3. NO PNEUMONIA
until 2 months of age
1.SEVERE PNEUMONIA
2.NO PNEUMONIA
ETIOLOGY AURI : >> VIRUS ( 90%)
COMMON VIRUSES
AURI (IRA -A) : Rhinovirus, Corona virus,
Adenovirus, Entero virusALRI (IRA -B) : RSV, Para influenza 1,2,3;
Corona virus,
Adeno virus, Enterovirus
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Common cold
COMMON COLD
an acute, self limited, mild upper respiratory
viral illness
sneezing, nasal congestion and discharge
(rhinorrhea), sore throat, cough, low gradefever, headache and malaise.
to be distinguished from influenza,
pharyngitis, acute bronchitis, acute bacterial
sinusitis, allergic rhinitis, and pertussis.
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many viral pathogens can cause the
symptoms of the common cold
the most common : > 100 serotypes of
rhinoviruses.
Common cold may occur at any time ofyear, high prevalence during the fall and
winter
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...COMMON COLD
An estimated 25 million individuals seekmedical care for uncomplicated URI annuallyin the US
Approx. 30 % of these visits result in a
prescription for antibiotics. Inaccurate perceptions that bacteria cause colds
and that antibiotics improve outcome
Infants and children are affected more oftenand experience more prolonged symptoms
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...COMMON COLD
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many viral pathogens can cause the
symptoms of the common cold
the most common : > 100 serotypes of
rhinoviruses.
Common cold may occur at any time ofyear, high prevalence during the fall and
winter
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...COMMON COLD
Virus
Rhinoviruses
Coronaviruses
Influenza viruses
Respiratory syncytial virus
Parainfluenza viruses
Adenoviruses
Enteroviruses
Metapneumovirus
Unknown
Estimated annual proportion of cases (percent)
30-50
10-15
5-15
5
5
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Viral transmission may occur via
inhalation of small particle aerosols,
deposition of large particle droplets on
nasal or conjunctival mucosa,
or direct transfer via hand-to-hand contact
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...COMMON COLD
Symptoms usually appear 1-2 days after viralinoculation
symptoms are not the result of viral destruction
of the nasal mucosa.
nasal epithelium remains intact, although there
is an influx of PMNs into the nasal submucosaand epithelium
viral infection increases vascular permeability in
the nasal submucosa, releasing albumin andkinins
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...COMMON COLD
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Infected cells undergo apoptosis
and are extruded from the mucosa
Signalling within cells occur via NF-kB
(and perhaps other pathways)
Elaboration of pro inflammatory cytokines
Initiation of plasma exudation
from submucosal capilaries
Recruitment of PMNs to
nasal epithelium (IL-8)
Proposed sequence of events during rhinovirus infection of
nasal epithelium
Infection of nasal epithelial cell
Pappas DE, Hendley JO. Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections.
Up to date. Last updated February 2008 10
Colored nasal discharge
~ increased presence of PMNs
presence of PMNs (yellow or white color) orof PMN enzymatic activity (green color)
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...COMMON COLD
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Supportive therapy is the only recommended
treatment
Antihistamines, decongestants, antitussives, and
expectorants, singly and in combinations, are all
marketed for symptomatic relief in children.
few clinical trials of these products in infants
and children and none that demonstrate benefit
for treatment of the symptoms
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...COMMON COLD
TREATMENT
Symptomatic therapy
may include antipyretics, saline nasal irrigation,
adequate hydration, and the use of a humidifier
Children with reactive airway disease or asthmashould use beta-agonist medications to relieve
associated bronchospasm.
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...COMMON COLD
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Antipyretics
Acetaminophen (or ibuprofen, in children
greater than 6 months of age) may be used to
alleviate fever during the first few days
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...COMMON COLD
Saline irrigation
In infants, bulb suction with saline nose drops
may help to temporarily remove nasal
secretions
in the older child, a saline nose spray may be
used.
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...COMMON COLD
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Antihistamines
The anticholinergic effects of 1st generation AH
(eg, diphenhydramine) may help to reduce the
secretions
in controlled trials, AH have been ineffective inrelieving the symptoms, in combination with
decongestants or as monotherapy
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...COMMON COLD
Antitussives
Cough is a common complaint during the
course
For many children, effective cough
suppression could result in mucus plugging
No cough suppressants have proven effective
in children.
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...COMMON COLD
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In a study comparing placebo, DMP, and
codeine for treatment of cough in children 18
mo - 12 y.o
- no difference found between the
groups, and all three groups showed significant
improvement within three days
Insomnia was reported in 3 of 33 children in the
dextromethorphan group.
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...COMMON COLD
Because of the potential serious toxicities
and the lack of proven efficacy, these
medications are not recommended for
pediatric use.
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...COMMON COLD
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Decongestants
sympathomimetic medications that cause
vasoconstriction of the nasal mucosa.
available in oral and topical formulations.
pseudoephedrine HCl, and phenylephrine HCl,and oxymetazoline.
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In adults: decrease nasal congestion and
increase patency,
no studies demonstrating the effectiveness of
these medications in children.
Side effects may include tachycardia, elevated
diastolic blood pressure, and palpitations.
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...COMMON COLD
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Because of the substantial risks of these
products without proven benefit
not recommended for pediatric use.
It is conceivable that the older adolescent may
benefit as an adult would from the use of a
decongestant, such as pseudoephedrine
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...COMMON COLD
Zinc
The efficacy for treatment of the common
cold remains unclear.
for every study that demonstrates benefit,
there is another that shows none.
Randomized trials in children also have shown
conflicting results,
Side effects may include bad taste, nausea,
throat irritation, and diarrhea
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...COMMON COLDv
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Other treatments
Echinacea
Vitamin C
Honey
Antibiotics
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...COMMON COLD
Antibiotic therapy
There is no role for antibiotics in the
treatment
does not prevent secondary bacterialinfection
may cause significant side effects, contribute
to increasing bacterial antimicrobial
resistance.
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...COMMON COLD
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The use of antibiotics should be reserved
for clearly diagnosed secondary bacterial
infections, including bacterial otitis media,
sinusitis, and pneumonia
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PREVENTION
The best methods for preventing transmission
from one person to another are to practice
frequent handwashing and to avoid touching
one's nose and eyes.
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...COMMON COLD
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How Colds Are Spread?
How Colds Are Spread ?
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Laryngotracheobronchitis
DEFINITION
Primarily pediatric viral respiratory tract illness
that affect larynx, trachea, and bronchi
Characteristic : hoarseness, a seal-like barking
cough, inspiratory stridor with or without
variable degree of respiratory distress
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EPIDEMIOLOGY
Accounting for approximately 15% of clinic and emergency
department visits for pediatric respiratory tract infections
Incidence: 6 months old 6 years old with peak
incidence: 1-2 years old
The male-to-female ratio for croup is approximately 3:2
The disease is most common in late fall and early winterbut may occur at any time of year
Approximately 5% of children experience more than 1
episode
ETIOLOGY
Human Parainfuenza virus type 1,2,3,4
Virus influenza A and B 60%
Adenovirus
Respiratory syncytial virus (RSV)
Enterovirus
Human bocavirus
Coronavirus[3]
Rhinovirus
Echovirus
Reovirus
Metapneumovirus[4]
Influenza A and B
Rarer causes - Measles virus, herpes simplex virus, varicella
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CLASSIFICATION
Based on the level of emergency:
1. Mild: sometimes barking cough, no stridor, mildretraction
2. Moderate: often barking cough, stridor, mildretraction, no respiratory distress
3. Severe: often barking cough, inspiratory stridor
when take a rest, sometimes expiratory stridor,retraction, respiratory distress
4. Threatening life respiratory failure: cough, stridor,
decrease of conciousness, letragy
CLASSIFICATION
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CLINICAL MANIFESTATION
Nonspecific respiratory symptomsrhinorrhea, sorethroat, and cough
Fever is generally low grade (38-39C) but can exceed40C
Within 1-2 days, the characteristic signs of hoarseness,barking cough, and inspiratory stridor develop, often
suddenly, along with a variable degree of respiratorydistress
Symptoms worsening at night, with most ED visitsoccurring between 10 pm and 4 am resolve within 3-7days but can last as long as 2 weeks
Skor Croup Westley
Total score: 0 -17 points.
Stridor (0 = none, 1 = with agitation only, 2 = at rest)
Retractions (0 = none, 1 = mild, 2 = moderate, 3 = severe)
Cyanosis (0 = none, 4 = cyanosis with agitation,
5 = cyanosis at rest)
Level of consciousness (0 = normal [including asleep],
5 = disorientated)
Mild croup: 0-2
Moderate croup: 35.
Severe croup: 611.
Paling banyak digunakan, Valid dalam menilai outcome pada
uji klinis penderita dengan croup (kappa 0,90)
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DIAGNOSIS
Diagnostic clues based on presenting history
and physical examination findings
Laboratory test resultsconfirming this
diagnosiscomplete blood cell (CBC) count is
usually nonspecific, although the white blood
cell (WBC) count and differential may suggest
a viral cause with lymphocytosis
PROCEDURES
Direct laryngoscopy if the child in not in acute
distress
Fiberoptic laryngoscopy
Bronchoscopy (for cases of recurrent croup to
rule out airway disorders)
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RADIOGRAPHY
Steeple or pencil sign
of the proximal
trachea (50%)
THERAPY
To overcome the obstruction or respiratory
tract
Most of croup didnt need to be hospitazed
1. Inhalation therapynebulized epinephrin
a. Racemic epinephrin
b. L-epinephrin 1:1000 5 ml
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THERAPY
2. Corticosteroidto reduce oedema mucosa of
the larynx
a. Dexamethason 0,6mg/kgbw/x
b. Budesonid nebulized 2-4mg (2ml)
3. Endotracheal intubationsevere croup4. Antibioticno need to be used except
laryngotracheobronchitis,
laryngotracheopneumonitis
PROGNOSIS
Excellent, and recovery is usually completeself limited disease
Hospitalization rates vary widely amongcommunities, ranging from 1.5-30% and
typically averaging 2-5% < 2% of hospitalized children require
intubation
10-year study found a mortality rate of lessthan 0.5% in intubated patients
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EPIDEMIOLOGY
85% children have acute otitis media 1 x in 1st yearof life
50% children have acute otitis media > 2 x
1st year of life having acute otitis media increasethe risk of having chronic or recurrent otitis media
The incidence decrease at age 6 years
United State all children experience otitis mediaat age 2 years and 3 episodes or more of acute otitismedia
Peak incidence 3-18 months
PATHOPHYSIOLOGY
Intrinsic mechanical obstruction caused byinfection and allergy
Extrinsic obstruction caused by adenoid andnasopharynx cancer
Functional obstruction caused by the amountand stiffness of cartilage of the tube, mostcommon in children
Eustachian tube obstruction pressure ofmiddle ear negativeif still persist, middle eartransudat effusion
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ETIOLOGY
Viral Pathogen : Respiratory Synctitial Virus
Bacterial Pathogen :
1. Streptococcus pneumoniae (50%)
2. Haemophillus influenzae (20%)
3. Moraxella catarrhalis (10%)
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RISK FACTORS
Prematurity and low birthweight
Young age
Early onset
Family history
Race - Native American, Inuit,
Australian aborigine Altered immunity
Craniofacial abnormalities
Neuromuscular disease
Allergy
Day care
Crowded living conditions
Low socioeconomic status
Tobacco and pollutant
exposure
Use of pacifier Prone sleeping position
Fall or winter season
Absence of breastfeeding,
prolonged bottle use
CLINICAL MANIFESTATION
Preceeding by upper respiratory tract infection
with fever, otalgia and hearing impairment
Baby : irritability, diarrhea, poor feeding, often
cry
Children : pain and uncomfortable in the ear
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DIFFERENTIAL DIAGNOSIS
External otitis
Dental pain
Temporomandibular joint pain
Acute viral pharyngitis
Trauma to the ear
TREATMENT
Depend on culture and sensitivity of thespecimen
1st line : Amoxycillin 40 mg/kgBW/24hours,3x/day,10 days
2nd line : Erytromicin 50mg/kgBW/24hours withsulfonamid (100mg/kgBW/24hours trisulfa or150mg/kgBW/24hours sulfisoksazol) 4x/day,sefaclor 40mg/kgBW/24hours 3xday, amoxycillin-clavulanat 40mgkgBW/24hours 3x/day, cefixim8mg/kgBW/24hours 1-2x/day
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TREATMENT
Acute otitis media without complication
antibiotic in 5 days
Supportive theray: analgesic, antipyretic,
decongestant
TYMPANOCENTESIS
Neonates who are younger than 6 weeks (andtherefore are more likely to have an unusual ormore invasive pathogen)
Patients who are immunosuppressed orimmunocompromised
Patients in whom adequate antimicrobialtreatment has failed and who continue to showsigns of local or systemic sepsis
Patients who have a complication that requires aculture for adequate therapy
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