Acute Respiratory Infection (ARI) In Children ALL.pptx

ppt

1. Respiratory system disorders Leweyehu.A ( BScN , MSc PHN,MSc nutrition) 1

2. Learning objectives : At the end of this session the students will be able to Definition Etiology/risk factor of Respiratory disorders P athophysiology , classification of Respiratory disorders C/M,DDX of Respiratory disorders I nvestigation , Complication N ursing care and medical treatment of respiratory system disorder 2

3. Out line Introduction Upper respiratory tract infection Acute Tonsilopharyngitis Epiglottitis Croup Bacterial Tracheitis Otitis media Lower respiratory infections Bronchiolitis Pneumonia 3

4. Introduction Acute respiratory Infection (ARI) Is acute infection of air way ranging from nose to parenchyma of the lung Leading cause of morbidity and mortality in < 5 children Nearly 20% of ARI cases are acute lower respiratory tract infections, mainly pneumonia. 4

5. Respiratory Pathophysiology and Respiratory Pathophysiology The main function of the respiratory system is to supply sufficient oxygen to meet metabolic demands and remove carbon dioxide. A variety of processes including ventilation, perfusion, and diffusion are involved in tissue oxygenation and carbon dioxide removal. 5

6. Patho ..Con… Abnormalities in any one of these mechanisms can lead to respiratory failure. The pathophysiologic manifestations of respiratory disease processes are influenced by A ge- and growth, C hanges in the physiology and anatomy of the respiratory control mechanisms, A irway dynamics, and lung parenchymal characteristics. Smaller airways,and poor hypoxic drive render a younger infant more vulnerable compared to an older child with similar severity of disease. 6

7. DIFFERENCES 7

8. Child presenting with an airway or severe breathing problem Onset of symptoms: slowly developing or sudden onset Previous similar episodes Upper respiratory tract infection Cough -duration in days & type of cough History of choking Voice change Presence of fever Present since birth, or acquired Immunization history Family history of asthma Cough - quality of cough Cyanosis Chest indrawing Respiratory rate count Grunting Stridor, abnormal breath sounds Nasal flaring Swelling of the neck Crepitations Wheezing Reduced air entry History Examination 8

9. RESPIRATORY DISTRESS Cyanosis N asal flaring G runting , Tachypnea, wheezing , C hest wall retractions, and stridor. A child who appears in respiratory distress may not have a respiratory illness Respiratory failure can be present without respiratory distress 9

10. anatomy of respiratory system The upper respiratory tract includes: Nose Nasal cavity Sinuses The lower respiratory tract includes: Voice box (larynx ) Windpipe (trachea) Lungs Airways (bronchi and bronchioles) Air sacs (alveoli) 10

11. anatomy of respiratory system…. 11

12. Risk factors Pollution Lack of breast feeding Congenital abnormalities of heart /lung Immunodeficiency Malnutrition Young infants Poor socio-economic status 12

13. Classification of ARI 1.Acute upper respiratory tract infection common Cold Otitis media Pharyngtitis Retropharyngeal abscess peritonsillar abscess Sinusitis Epiglottis Acute laryngotracheobronchitis( croup) Acute lower respiratory tract infection Acute laryngotracheobronchitis( croup) Bronchiolitis Pneumonia 13

14. Peculiarities of airway in children The cricoids ring is the narrowest part of the airway in the child; the vocal cords are in the adult Large tongue Large omega shaped epiglottis Anterior larynx which is at a higher level Large head Short trachea, greater angle of carina; left main bronchus more horizontal The nasal passage which is approximately the same size as the cricoid ring in children Obligate nose breathers 14

15. 15 INFANT ADULT Narrowest point = cricoid cartilage

16. Acute upper respiratory tract infection 1.Common Cold rhinorrhea and nasal obstruction systemic symptoms and signs such as headache, myalgia, and fever are absent or mild. Rhinosinusitis-involvement of the sinus mucosa Etiologies Rhinoviruses (Frequent) ,Coronaviruses ,RSV, Parainfluenza viruses ,Adenoviruses Many viruses that cause rhinitis are also associated with other symptoms and signs such as cough, wheezing, and fever. 16

17. Pathogenesis Viruses that cause the common cold are spread by three mechanisms: direct hand contact (self-inoculation of one's own nasal mucosa or conjunctivae after touching a contaminated person or object), inhalation of small-particle aerosols that are airborne from coughing, deposition of large-particle aerosols that are expelled during a sneeze and land on nasal or conjunctival mucosa 17

18. Con….. Studies of HRV and RSV indicate that direct contact is an efficient mechanism of transmission of these viruses, although transmission by largeparticle aerosols can also occur. By contrast, influenza viruses and coronaviruses appear to be most efficiently spread by small-particle aerosols. 18

19. Clinical Manifestations typically occurs 1-3 days after viral infection. sore or scratchy throat, followed by nasal obstruction and rhinorrhea. Cough is associated with ∼30% of colds Influenza viruses, RSV, and adenoviruses are more likely associated with fever and other constitutional symptoms The usual cold persists for about 1 wk, although 10% last for 2 wk Physical findings Increased nasal secretion is usually obvious Swollen, erythematosus nasal turbinate's, although this finding is nonspecific and of limited diagnostic value. Anterior cervical lymphadenopathy may also occur 19

20. Diagnosis exclude other conditions that are potentially more serious or treatable 20

21. Treatment Primarily symptomatic treatment Maintaining adequate oral hydration Topical nasal saline may temporarily remove secretions No need of antibiotics The use of oral non-prescription therapies (often containing anti- histamines,anti - tussives , and decongestants) for cold symptoms in children is controversial The sore throat treat with mild analgesics indicated Aspirin-Not given to children with respiratory infections, because of the risk of Reye syndrome 21

22. Complication Otitis media Sinusitis Exacerbation of asthma Pneumonia 22

23. 2.SINUSITIS Inflammation of the sinuses. There are 2 types of acute sinusitis: viral and bacterial 23 Sinus Age of pneumatization (aeration) Ethmoidal At birth Maxillary 4yrs Sphenoidal 5 yrs Frontal 7-8yrs

24. Type of sinus 24

25. Etiology The bacterial pathogens include Streptococcus pneumoniae nontypable Haemophilus influenzae Moraxella catarrhalis M. catarrhalis, S. pneumoniae, and coagulase-negative staphylococci are commonly recovered from children with chronic sinus disease 25

26. Clinical Manifestations nasal congestion, purulent nasal discharge (unilateral or bilateral), fever, and cough. Less-common symptoms include bad breath ( halitosis ), a decreased sense of smell (hyposmia), and periorbital edema Physical examination might reveal erythema and swelling of the nasal mucosa with purulent nasal discharge Sinus tenderness may be detectable in adolescents and adults. 26

27. Diagnosis Based on history Severe respiratory symptoms, including temperature of at least (39?C) and purulent nasal discharge for 3-4 consecutive days, suggest a complicating acute bacterial sinusitis. Sinus aspirate culture chronic sinusitis :- persistent respiratory symptoms, including cough, nasal discharge, or nasal congestion, lasting >90 days. Radiographic studies (sinus plain films, CT scans) Opacification , mucosal thickening, Presence of an air-fluid level 27

28. 28

29. Treatment Amoxicillin-1 st line treament alternatives trimethoprim- sulfamethoxazol / cotrimoxazole , clarithromycin, or azithromycin The duration of therapy for sinusitis has yet to be determined; individualization of therapy is a reasonable approach, with treatment recommended for 7 days after resolution of symptoms. Complications Periorbital cellulitis and orbital cellulitis Intracranial complications epidural abscess meningitis cavernous sinus thrombosis subdural empyema, and brain abscess 29

30. 3.Acute Tonsilopharyngitis Tonsillopharyngitis - acute infection of the pharynx, palatine tonsils, or both Approximately 30% of URTI illnesses feature a sore throat as the primary symptom The most important agents causing pharyngitis are viruses Adenoviruses, enteroviruses,rhinoviruses,RSV,EBV Bacterial group A β- hemolytic streptococcus Other organisms Mycoplasma pneumoniae Neisseria gonorrhoeae , Fusobacterium necrophorum Corynebacterium diphtheriae 30

31. Epidemiology Streptococcal pharyngitis is relatively uncommon before 2-3 yr of age has a peak incidence in the early school years, and declines in late adolescence and adulthood. Illness occurs most often in winter and spring and spreads 31

32. Clinical features Rapid onset of fever, Vomiting, sore throat, absence of cough Enlarged and tenderness anterior cervical lymphnodes Hyperemic pharynx Edematous Tonsils with w hite non adhérent exudates EBV pharyngitis - there may be prominent tonsillar enlargement with exudate, cervical lymphadenitis, 32

33. Cont’d… 33

34. Scarlet fever 34 Scarlet fever manifested by: red finely papular rash strawberry tongue erythematous pharyngitis with exudates

35. Diagnosis Clinical Throat culture-gold standard Rapid antigen detection tests Serologic tests 35

36. Complications 1. Non-suppurative complications Acute Rheumatic fever Acute Glomerulonephritis Suppurative complications Acute otitis media Acute sinusitis Retropharyngeal abscess Peritonsillar abscess Suppurative cervical lymphadenitis Récurrent pharyngitis → Hypertrophied Tonsills → Upper airway Obstruction( Obstructve sleep apnea ) 36

37. Treatment Antibiotics Penicillines/Erythromycine-10 days Antipyretics Fluid Tonsillectomy when indicated The primary benefit of treatment is the prevention of acute rheumatic fever , which is almost completely successful if antibiotic treatment is instituted within 9 days of illness . Tonsillectomy lowers the incidence of pharyngitis for 1-2 yr among children with recurrent tonsilitis 37

38. ACUTE INFLAMMATORY UPPER AIRWAY OBSTRUCTION Croup Epiglottitis Laryngitis Bacterial Tracheitis 38

39. 4.Acute Inflammatory Upper Airway Obstruction/Airway Emergencies Inflammation involving the vocal cords and structures inferior to the cords is called laryngitis, laryngotracheitis , or laryngotracheobronchitis . Stridor is a harsh, high-pitched respiratory sound, which is usually inspiratory but can be biphasic and is produced by turbulent airflow 39

40. Cont’d… Upper airway obstruction is accounting for approximately 15% of all critically ill patients. Infectious etiologies account for 90% of these, with viral croup accounting for 80%. Epiglotti s accounts for 5% of severe cases Other significant causes include other infectious etiologies (bacterial tracheitis, tonsillar pathology, and diphtheria) 40

41. Common causes of upper airway obstruction Causes of acute upper airway obstruction that are potentially life-threatening 41

42. Retropharyngeal Abscess/Lateral pharyngeal abscess Most commonly occurs in children <3-4 year of age Up to 67% have or a recent history of ear, nose or throat infection The lymph nodes in the deep neck spaces communicate with each other, allowing bacteria from either cellulitis or node abscess to spread to other nodes. Infection of the retropharyngeal nodes can result from: Usually from extension of a localized oropharygeal infection Dental infection Penetrating trauma to the oropharynx 42

43. Etiology Polymicrobial:( GABHS,Oropharyngeal -anaerobic bacteria,Staphylococcal aureus) Clinical Features Fever Irritability Reduced oral intake ,Drooling of saliva Neck stiffness Limitation of neck movement Sore throat & neck pain Muffled voice Stridor Respiratory distress 43

44. Diagnosis Bulging of posterior pharynx Cervical LAP Lateral neck X-ray Incision and drainage of pus provides definite diagnosis CT scan DDx Acute epiglottitis Foreign body aspiration Meningitis Hematoma Vertebral osteomyelitis 44

45. 45

46. Treatment IV antibiotics with/without surgical drainage A 3rd-generation cephalosporin combined with ampicilline . Vancomycin and clindmycin Parenteral treatment is maintained until the patient is afebrile and clinically improved. Oral therapy should be continued to complete a 14-day course. Surgical drainage 46

47. Complications Upper air way obstruction Rupture→ aspiration pneumonia → mediastinitis Thrombophlebitis of internal jugular vein Erosion of carotid artery sheath and septic emboli 47

48. Acute Epiglottitis (Supraglottitis) Life threatening infection Age groups affected 2-7 yrs Etiology most common cause H. influenzae type b(pre vaccination era) Now Streptococcus pyogenes S.pneumoniae S. aureus 48

49. Clinical manifestation Sudden onset/medical emegency Rapidly progressing respiratory obstruction Fever Toxicity sore throat Voice/cry - muffled Soft Stridor Drooling of saliva Hyper extended neck 49

50. 50 This child's "tripod" positioning (trunk leaning forward, neck hyperextended, chin thrust forward) is indicative of epiglottitis.

51. Diagnosis Clinical,P /E Laryngoscopy large, swollen cherry red epiglottis swollen epiglottis – thumb sign NB- avoid oral examination – risk of reflex laryngeal spasm 51

52. 52 Cherry red epiglottis Classic radiographs of a child who has epiglottitis show the “thumb sign”

53. Treatment Precaution Do not manipulate the throat Do not put patient in supine positions is a medical emergency and warrants immediate treatment with an artificial airway placed under controlled conditions Endotracheal intubation Tracheostomy E pinephrine and corticosteroids are ineffective IV cephalosporins for 7-10 days. Ceftriaxone and vancomycin in patients with MRSA 53

54. .Croup (laryngotracheobronchitis) It is a common cause of upper airway obstruction in children and is characterised by hoarseness, barking cough, inspiratory stridor and variable respiratory distress. These symptoms occur as a result of oedema of the larynx and trachea, which has been triggered by a recent viral infection. Para influenza virus type 1 is the agent most commonly identified in cases of croup. 54

55. Croup …con… It most commonly occurs in children aged from 6 months to 6 years. The annual incidence of croup in children younger than six years ranges from 1.5 to 6%. Symptoms are typically worse at night. Most croup will be dealt with in primary care but up to 30% of cases will require hospitalization , of these less than 2% need intubation . 55

56. Croup …con… Morbidity is secondary to narrowing of the larynx and trachea below the level of the glottis ( subglottic region), causing the characteristic audible inspiratory stridor . 56

57. Anatomy of larynx 57

58. pencil sign of the proximal trachea evident on this anteroposterior film. 58

59. Etiology Viral Parainfluenza viruses ( 75% of cases).  influenza A and B, Measels , adenovirus & RSV Bacterial Mycoplasma Pneumonea Allergy Spasmodic croup 59

60. pathophysiology 60

61. Clinical manifestation Prior to obstruction upper respiratory tract infection with rhinorrhea pharyngitis mild cough low grade fever After obstruction barking cough hoarseness inspiratory stridor fever coryza inflamed pharygitis Tachypnea 61

62. CM cont …   sever nasal flaring suprasternal , infrasternal and intercostal retraction continuous stridor hypoxia, decreased oxygen saturation (<95%) The diagnosis of croup is clinical History and physical examination 62

63. The modified Westley clinical scoring system for croup Inspiratory stridor : -Not present - 0 -When agitated/active - 1 At rest - 2 points. Intercostal recession : Mild - 1 point. Moderate - 2 points. Severe - 3 points. Air entry : Normal - 0 Mildly decreased - 1 Severely decreased - 2 points Cyanosis : None - 0 . With agitation/activity - 4 points. At rest - 5 points. Level of consciousness : Normal - 0 point. Altered - 5 points <4 = mild croup, 4-6 = moderate croup >6 =severe croup 63

64. Management Neubilised epinephrine O.5mg/kg 1:1000 dilution inhaled over 15-20 minute PRN Corticosteroids dexamethasone used a single dose of 0.15- 0.6 mg/kg IM/IV/Oral stat Antibiotic Incase of bacterial croup 64

65. Management….. In child with severe croup who is deteriorating, consider Intubation and tracheotomy If there are signs of airway obstruction, such as - Severe indrawing of the lower chest wall and restlessness , intubate the child immediately. If this is not possible , transfer the child urgently to a hospita where intubation or emergency tracheotomy can be done. 65

66. suportive care • If the child has fever (≥ 39 ° C or ≥ 102.2 ° F) which appears to be causing distress, give paracetamol . • Encourage breastfeeding and oral fluids. • Children on croup tent should be on iv fluid till they are out of it • Encourage the child to eat as soon as food can be taken. MONITORING The child’s condition, especially respiratory status, should be assessed by nurses every 3 hours The child should occupy a bed close to the nursing station , so that any sign of incipient airway obstruction can be detected as soon as it develops. 66

67. croup tent 67

68. Complications of uao Inability to relieve the obstruction can cause: Brain damage Breathing failure Pulmonary edema pneumothorax 68

69. OTITIS MEDIA Commonest childhood infection second only to common cold Over 80% of children will have experienced at least one episode of otitis media (OM) by the age of 3 yr. The peak incidence and prevalence of OM is during the 1st 2 yr of life. OM is the leading reason for physician visits and for use of antibiotics and figures importantly in the differential diagnosis of fever. 69

70. Definitions Acute otitis media -inflammation of the middle ear presenting with rapid onset of symptoms(Lasting <2weeks) Chronic otitis media -persistent discharge from the middle ear for 2 weeks or longer 70

71. Predisposing factors Young age Incidence greater in boys than in girls Low socioeconomic status Immunodeficiency Passive smoking Congenital Anomalies OM is universal among infants with unrepaired palatal clefts Cold weather months 71

72. Cont’d… Sibling with recurrent otitis media Down syndrome (craniofacial dysmorphism) URTI (viral, bacteria) Breast feeding reduces incidence of otitis media 72

73. Etiology Common pathogens: Streptococcus pneumoniae (50%) Haemophilus influenzae (25-45%) Moraxella catarrhalis (10-15%) Less common causes Staph.aureus (acute, chronic) Pseu.aeruginosa (chronic) Anaerobic organisms Group A streptococcus 73

74. Pathogenesis Bacteria gain access to the middle ear when the normal patency of Eustachian tube is blocked by: Local infection Pharyngitis Enlarged adenoids Obstruction of secretions from the middle ear to the pharynx, result in middle ear infection The shorter and more horizontal orientation of the tube in infants and young children may increase the likelihood of reflux from the nasopharynx and impair passive gravitational drainage through the eustachian tube. 74

75. Clinical Features Neonates & infants may be asymptomatic or may present with non-specific manifestations: Fever Irritability Vomiting Diarrhea Ear pulling Older children present with Fever Irritability Vomiting/Diarrhea URTI Pain (one, both ears) Ear discharge 75

76. Cont’d… Chronic otitis media Foul-smelling ear discharge Perforation of tympanic membrane Impaired hearing 76

77. Diagnosis Clinical Otoscopy and tympanometry: Structural changes include scars, perforations, retraction pockets, and a more severe complication of OM, Culture of ear discharge 77

78. Treatment Acute Antibiotics Antipain /Antipyretic Ear Wicking First line antibiotics Amoxicillin = high dose for 10 days. Azithromycin (for penicillin allergy) Chronic Ear wicking Topical antibiotics ( ciprofloxacilin ) Surgery 78

79. Complications Chronic suppurative otitis media Acute/Chronic mastoiditis Facial palsy Chronic tympanic perforation Hearing loss (conductive, SNHL) 79

80. Cont’d… Intracranial complication Meningitis epidural abscess subdural abscess focal encephalitis brain abscess 80

81. Acute Lower Respiratory Tract Infections Bronchiolitis Pneumonia B. Asthma TB 81

82. 1.Bronchiolitis Inflammatory obstruction of small air ways characterized by bronchiolar obstruction with edema, mucus, and cellular debris Peak age-3-6 months may be followed by bacterial super infection 82

83. Etiology RSV Most common cause (>50% of cases) virtually the only etiology during epidemics(80%) Para influenza virus I,II,III (25%) Others: adenovirus, Mycoplasma , Rhino viruses, Influenza virus Risk factors common in those who have not been breast-fed, and those who live in crowded conditions Older family members are a common source of infection Infants with pre-existent smaller airways and diminished lung function have a more-severe course 83

84. Clinical Manifestations Symptoms of mild URTI Fever (subnormal to markedly elevated) Respiratory distress with paroxysmal wheezy Cough, dyspnea ,Poor feeding Apnea may be more prominent than wheezing early in the course of the disease, particularly with very young infants (<2 mo old) or former premature infants. Retraction, nasal flaring, cyanosis overt wheezes , with prolongation of the expiratory phase of breathing. Ventilation-perfusion mismatch-Hypoxemia 84

85. Diagnosis Clinical , particularly in a previously healthy infant presenting with a first-time wheezing episode during a community outbreak CXR- can reveal hyperinflated lungs with patchy atelectasis PCR, rapid immunofluorescence, or viral culture) is helpful if the diagnosis is uncertain or for epidemiologic purposes 85

86. DDX Bronchial asthma Bacterial Pneumonia CHF, Congenital heart disease Foreign body aspiration, Aspiration pneumonia One or more of the following favors the diagnosis of asthma Repeated episodes of wheezing Absence of a viral prodrome(sudden onset with out a preceding infection) Family history of asthma or atopy Eosinophilia An immediate favorable response to a single dose of aerosolized albuterol/salbutamol 86

87. Treatment Most cases are self limiting Achild with experiencing respiratory distress (hypoxia, inability to take oral feedings, extreme tachypnea) should be hospitalized Supportive care Humidified Oxygen Fluid -NPO/ NGT feeds to avoid risk of aspiration Bronchodilators/ Nebulized epinephrine Antibiotics- if bacterial superinfection 87

88. Course and Prognosis Most critical phase –First 48-72 hours after the onset of cough and dyspnea Recovery -10-12 days Case Fatality Rate <1%, with death attributable to apnea, respiratory arrest, or severe dehydration. After this critical period, symptoms can persist Poor prognostic factors C ongenital heart disease B ronchopulmonary dysplasia/ imature lung Immunodeficiency age <12 wk, preterm birth 88

89. CHILDHOOD ASTHMA 89

90. BRAINSTORMING What do you mean? Atopy Allergen Hypersensitivity 90

91. INTRODUCTION The word asthma comes from the Greek word for "panting." People with asthma pant(breath quickly) and wheeze because they can’t get enough air into their lungs. A chronic inflammatory disease of the airways that Characterized by three components : Reversible airway obstruction Airway inflammation Airway hyper responsiveness to a variety of stimuli . 91

92. INTRODUCTION ... In susceptible individuals, airway inflammation may cause recurrent or persistent bronchospasm , which causes symptoms that include wheezing, breathlessness, chest tightness, and cough, particularly at night (early morning hours) or after exercise. 92

93. Pathophysiology Interactions between environmental and genetic factors result in airway inflammation , which limits airflow and leads to functional and structural changes in the airways in the form of bronchospasm , mucosal edema , and mucus plugs. 93

94. ETIOLOGY Usually has not been determined , contemporary research implicates a combination of : Environmental exposures Inherent biological and Genetic vulnerabilities 94

95. Types of Childhood Asthma Main types of childhood asthma: Recurrent wheezing in early childhood Chronic asthma associated with allergy that persists into later childhood and often adulthood. Triad asthma associated with hyperplastic sinusitis /nasal polyposis and hypersensitivity to aspirin and non-steroidal anti-inflammatory medications (ibuprofen), rarely has its onset in childhood. The most common persistent form of childhood asthma is that associated with allergy 95

96. C /M Primary symptoms include: Shortness of breath Wheezing -usually begins suddenly; -may be worse at night or early in the morning; -can be made worse by cold air, exercise, and heartburn; is relieved by using bronchodilators (drugs that open the airways) Chest tightness Cough (dry or with sputum) 96

97. C/M con… If children have any of these symptoms, seek emergency treatment: Extreme difficulty breathing or stopping breathing Bluish color ( cyanosis) Rapid pulse Excessive sweating Decreased level of consciousness, such as drowsiness or confusion 97

98. Differential Diagnosis Infectious Infectious Pneumonia Bronchiolitis Chlamydia infection Laryngotracheobronchitis Sinusitis Mechanicals Foreign body Vocal cord dysfunction MISCELLANEOUS Pulmonary edema Gastro esophageal reflux (GERD) 98

99. Asthma Predictive Index One major criterion Parent with asthma Atopic dermatitis/eczema Aero-allergen sensitivity Two minor criteria Food sensitivity eosinophilia (≥4%) Wheezing not related to infection ≥4 wheezing episodes in the past year (at least one must be diagnosed) PLUS OR Modified from: Castro-Rodriguez JA, Holberg CJ, Wright AL, et al. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med . 2000;162(4 Pt 1):1403–1406 99

100. Classification of Asthma Severity CLASSIFICATION STEP DAYS WITH SYMPTOMS NIGHTS WITH SYMPTOMS Severe persistent 4 Continual Frequent Moderate persistent 3 Daily >1/wk Mild persistent 2 >2/ wk , but <1 time/day >2/mo Mild intermittent 1 ≤2/wk <2/mo 100

101. Four Components of Optimal Asthma Management 1 . Regular assessment and monitoring 2.Control of factors contributing to asthma severity 3. Asthma pharmacotherapy 4. patient education 101

102. Stepwise approach Rx. for Chronic Treatment of Asthma 102

103. Management of Asthma Exacerbations For patients with moderate to severe exacerbations that do not adequately improve within 1–2 hr of intensive treatment, overnight observation and/or admission to the hospital is likely to be needed. Supply frequently or continuously administered inhaled bronchodilator, S ystemic corticosteroid therapy are the conventional interventions for status asthmaticus Supplemental oxygen and with increasing SABA administration SABAs can be delivered frequently (every 20 min to 1 hr) or continuously (at 5–15 mg/hr). 103

104. complication Cardiac arrest Respiratory failure or arrest Pneumothorax Toxicity from medications Frequent hospitalizations and absence from school Psychologic impact of having a chronic illness Decline in lung function over time 104

105. 2.Pneumonia Inflammation of the parenchyma of the lungs Leading cause of under 5 mortality Accounts for ¾ of ARI deaths Incidence and mortality highest in infants Bacterial pneumonia are common in developing countries (60% in developing, and 10-30% in developed countries) 105

106. Epidemiology 158 million episodes of pneumonia per year of which ≈154 million are occurring in developing countries pneumonia is estimated to cause ≈3 million deaths, Incidence of pneumonia up to 10 times higher in developing countries Main cause of childhood morbidity and mortality( particularly in less than five years) 106

107. 107

108. Cont’d… In Ethiopia it accounts for 28% of under 5 children deaths. It is estimated that 65% of these pneumonia deaths could be prevented if appropriate preventive and treatment interventions were applied at national scale. Treatments such as oral antibiotics, in addition to the effective prevention interventions ( breastfeeding and adequate complementary feeding.) 108

109. Etiology Identifying organism a challenge: no reliable diagnostic method S. pneumoniae important bacterial cause regardless of age Viral pneumonia is also common. Mycoplasma pneumoniae and Chlamydia pneumoniae responsible for mild to severe LRIs, particularly for age > 5 yr 109

110. 110

111. Etiologic classification Viral pneumonia: Bacterial Atypical pneumonia: caused by pathogens other than the traditionally most common and readily cultured bacteria M. pneumoniae, Chlamydial pneumonia Mycobacterial TB Bacterial pneumonia: S. pneumoniae is the most common bacterial pathogen. Fungal : PCP(common in imuno compromized pt like HIV) 111

112. Anatomic classification Bronchopneumonia Can be throughout lungs Bronchioles and Alveoli Atypical or Interstitial pneumonia: Interstitium Lobar Pneumonia: Consolidation of whole lobe and most caused by S.Pneumoniae 112

113. Classification I. Clinically / seting 1. Community acquired pneumonia Typical/’’Classic’’ Pneumonia -S. pneumonia(90% of bacterial pneumonia), -HIB, S.aureus Atypical pneumonia-40-50% -Afebrile, clear chest, CXR-extensive infiltration -Viruses and mycoplasma 113

114. Cont’d… 2. Hospital acquired pneumonia - After 72 hours of admission or - within 5 days of hospital discharge 60% aerobic gram negative - mostly enterobactericae ( klebseilla,E.coli and enterobacter ) -Less commonly-Pseudomonas 10-15% -S. aureus 114

115. . Based on severity (IMNCI ) 1.Pneumonia fever, cough + fast breathing 2.Sever pneumonia- pneumonia and any of following Grunting Nasal flaring sub costal and intercostal retraction central cyanosis not able to drink or breast feed or vomiting everything convulsions, lethargy or unconsciousness 115 Cont’d…

116. Normally the lower respiratory tract is kept sterile by different defense mechanisms include Mechanical Filtration Mucociliary clearance Reflex Innate defence airway antimicrobial factors Alveolar macrophages Neutrophils Adaptive defence Secretaory IgA IgG 116 Pathogenesis

117. PP.. Viral pneumonia usually results from spread of infection along the airways, accompanied by direct injury of the respiratory epithelium, which results in airway obstruction from swelling, abnormal secretions, and cellular debris. Bacterial pneumonia Inhalation Aspiration Direct inoculation Blood borne 117

118. CLINICAL MANIFESTATION Cough: chief symptom Increased respiratory rate: WHO Infants younger than 2 months old 60 and more 2 months up to 12 mons 50 or more 12 months up to 5 years 40 or more Grunting Sign of severe distress and impending respiratory failure Nasal flaring (air hunger) Pulse oximetry spo2<90% 118

119. Cont’d… Retractions: intercostal, supraclavicular, subcostal Increased effort to breathe, decreased lung compliance Fever Auscultation: crackles at end of inspiration usually indicate parenchymal disease Decreased breath sounds 119

120. Bacterial pneumonia High grade fever Productive cough Chest pain elevated WBC count, in the range of 15,000-40,000/mm 3 Elevated ESR, and C-reactive protein (CRP) level Infants and young children less likely to have “classic”signs of pneumonia. Often: fever, tachypnea and subtle signs such as lethargy, irritability, vomiting, diarrhea and poor feeding. 120

121. Diagnosis Clinical CBC/ Leukocytosis C- reactive protein CXR Routine CXR is not necessary to confirm the diagnosis of suspected community-acquired pneumonia (CAP) in children with mild, uncomplicated lower respiratory tract infection (LRTI) who are well enough to be treated as outpatients. I ndicated in severe pneumonia Confirmation of the diagnosis when clinical findings are inconclusive when potential complications are suspected Exclusion of alternate explanations for respiratory distress deteriorating or unresponsive to antimicrobial therapy Recurrent pneumonia 121

122. Recurrent pneumonia is defined as 2 or more episodes in a single year or 3 or more episodes ever, with radiographic clearing between occurrences. An underlying disorder should be considered if a child experiences recurrent bacterial pneumonia 122

123. Management 1.out patient Antibiotics Amoxycillin Cotrimoxazole Ampicillin Augmentin oral cephalosporin Antiphyretics 123

124. 2.In patient management Age <6 mo   Sickle cell anemia with acute chest syndrome Multiple lobe involvement Immunocompromised state Toxic appearance Moderate to severe respiratory distress Dehydration Vomiting or inability to tolerate oral fluids or medications No response to appropriate oral antibiotic therapy ( failed OPD treatment) Social factors (e.g., inability of caregivers to administer medications at home or follow up appropriately) 124

125. Supportive treatment Bed rest Nutritional supplementation ( maintainace fluid) oxygen supplementation Antipyretics Physiotherapy and breathing exercise 125 Cont’d…

126. Cont’d… Neonate and imunocompromised Ampicillin +Gentamycin Children Crystalline penicillin If no improvement in 48hrs Ceftriaxone 126

127. 3.Treatment of complications Empyema-Antibiotics 4-6wks Chest tube drainage Chest physiotherapy Lung abscess-Broad spectrum antibiotics anaerobic coverage, 4-6wks Surgery chest physiotherapy 127

128. Reasons for poor response Complications, such as Empyema Bacterial resistance Nonbacterial etiologies such as viruses and aspiration of foreign bodies or food Bronchial obstruction from endobronchial lesions, foreign body, or mucous plugs Pre-existing diseases Other noninfectious causes NB:A repeat chest x-ray is the 1st step in determining the reason for delay in response to treatment. 128

129. Complications D irect spread of bacterial infection within the thoracic cavity parapneumonic effusion Empyema/ pyopneumothorax Lung abscess pericarditis Myocarditis H ematologic spread Septicemia septic arthritis Osteomylitis Meningitis 129

130. Ask 4 things while clerking a patient with pneumonia for prevention Immunization Nutrition HIV Housing condition(over crowding, sanitation ) 130