Acute Respiratory Infections - for UGs

Approach to a child with acute respiratory infections

1. A CUTE R ESPIRATORY I NFECTIONS A R I

2. Ari – what is it? An infection of any part of respiratory tract anywhere from nose to alveoli, with a wide range of combination of symptoms and signs lasting less than 30 days (15 days for otitis media)

3. ARI - Burden National Family Health Survey (NFHS) studies reported an overall ARI prevalence of 6.5%, 19.0% and 5.8% among under-five children in the preceding two weeks before the survey in three surveys at three time-periods over last two decade

4. India is predicted to have over 700 million episodes of ARI and over 52 million episodes of pneumonia every year. The Central Bureau of Health Intelligence of the MoHFW reported ARI mortality ranging from 3200 to 6900 each year, giving a mortality rate of 0.32 to 0.61 deaths per l00,000 population. The WHO / UNICEF estimated an ARI case fatality rate of 0.93% In India: 10-50 children die per 10,000 episodes of ARI Joseph L Mathew, Ashok K Patwari, et al; Acute Respiratory Infection and Pneumonia in India: A Systematic Review of Literature for Advocacy and Action: UNICEF-PHFI Series on Newborn and Child Health, India ; Indian Pediatrics , Volume 48__March 17, 2011: 191-218 ARI - Burden

5. Risk factors and determinants of ARI Low level of literacy, Suboptimal breast feeding, Malnutrition, Unsatisfactory level of immunization coverage, Cooking fuel used other than liquefied petroleum gas  WHO (1995), The Management of acute respiratory infections in children, Practical guidelines for out patient care, WHO, Geneva

6. Ari – classification Acute Upper Respiratory Tract Infections (AUR T I) Common cold, Epiglottitis, Laryngotracheobronchitis Otitis media, etc. Acute Lower Respiratory Tract Infections(ALR T I) Bronchitis, Bronchiolitis, Pneumonia, etc ,

7. 8 episodes / year is avg in children Etiologies: Rhinoviruses (30-35%), Corona viruses(10%), Misc (20%) Clinical: Sore throat, running nose, nasal congestion, myalgia, fatigue. Seasonal variations Transmission: Direct contact, droplet, fomites Incubation period 12-72 hrs Diagnosis: R/o serious infections like Strep throat, adenovirus and diphtheria Treatment: Symptomatic A U R T I s - Common Cold

8. Life threatening infection of epiglottis Peak age 1 to 6 years Cause : Hemophilus infleunza type B Concomitant bacteremia, pneumonia, otitis media, arthritis or other invasive infection by HiB may be present Clinical : High fever, sore throat, dyspnea, rapidly progressive respiratory obstruction. Patient becomes toxic, difficult swallowing and labored breathing. Drooling and hyperextended neck. Tripod position while sitting, cyanosis, coma and death Stridor – late finding OE : Cherry red appearance of epiglottis, Thumb sign on lateral neck X ray U R T I s - Acute Epiglottitis

9. U R T I s - Acute Epiglottitis

10. Treatment: Admit in ICU Fluid and electrolyte support IV Ampicillin 100 mg/kg/d in div doses OR IV Ceftrioxazone 100 mg /kg/d in div doses Prophylaxis: Rifampicin – to close contacts U R T I s - Acute Epiglottitis

11. Etiology : Influenza, parainfluenza and RSV Common age: 6 mo to 6 yrs Clinical: Rhinorrhea, mild cough, fever, barking cough, hoarseness of voice, nasal congestion Symptoms worsen at night and on lying Spontaneous resolution in a week Diagnosis: Clinical. Steeple Sign on X Ray Treatment: Symptomatic Humidified air Nebulized racemic epinephrine Corticosteroids A R T I s - Acute laryngotracheobronchitis (croup)

12. Etiology : Most often respiratory syncytial virus (RSV) Common age: 6 mo to 2 yrs Clinical: Coryza, vomiting, irritability, wheeze, feeding difficulty, episodes of apnea Physical Signs Tachypnoea, flaring of alae nasi, cyanosis or pallor, use of accessory muscles f respiration, expiratory wheeze, grunting, hyper resonant percussion note, Liver and spleen may be palpable Diagnosis: X Ray Chest: Hyperinflation of chest, increased bronchovesicular markings Pulse oximetry: to assess hypoxia Nasopharyngeal swabs – for RSV culture or antibody titers A L R T I s - Bronchiolitis

13. Complications : Pneumonia Pneumothorax Dehydration Respiratory acidosis Heart failure Prolonged apneic spells leading to death A L R T I s - Bronchiolitis

14. Treatment : Supportive Prop up 30 to 40 Limit oral feeds / Parenteral fluids to avoid dehydration Correct acidosis and electrolyte imbalance Nebulized racemic adrenaline Mechanical ventilation A L R T I s - Bronchiolitis

15. Inflammation of lung parenchyma and consolidation of alveolar spaces Etiology: In developed world: Mostly viral, low mortality In developing world: Bacteria and PCP in 65%, Common cause of death A L R T I s - PNEUMONIAS

16. CBC: WBC > 15 000 Blood C/s : positive in 25% cases Sputum: Gram’s stain, AFB Pleural fluid: exam if present ASO titers – for Strep Tuberculin skin test Viral titers, cultures/antigen tests A L R T I s – PNEUMONIAS - labs

17. Bacterial Poorly demarcated opacities with air bronchogram Lobar or segmental opacification Specific: Staphylococcal: areas of breakdown Klebsiella: Cavitation, median fissure effusion Tuberculosis: Pleural effusion, mediastinal glands A L R T I s – PNEUMONIAS - Radiology Viral Perihilar streaking Interstitial changes Air trapping

18. Bacterial Poorly demarcated opacities with air bronchogram Lobar or segmental opacification Specific: Staphylococcal: areas of breakdown Klebsiella: Cavitation, median fissure effusion Tuberculosis: Pleural effusion, mediastinal glands A L R T I s – PNEUMONIAS - Radiology

19. Empyema Lung abscess Pnumothorax Pleural effusion Delayed resolution Respiratory failure Metastatic septic lesions Meningitis Otitis media Sinusitis septicemia A L R T I s – PNEUMONIAS - Complications

20. Under 5 deaths by leading infectious diseases 2000 and 2015 in millions Source: WHO and MCEE provisional estimates 2015

21. Antibiotics: Amoxicillin, co – amoxiclav, cefaclor, macrolides For Severe pneumonia: IV Co-amoxiclav, Cefotaxime of Cefuroxime Special categories As per the suspected organism sensitivity Oxygen Hydration Temp control Hydration Chest drain – if empyema + A L R T I s – PNEUMONIAS - Treatment

22. WHO recommendation for management of ARI ARI Case Management : 84% reduction in mortality ARI control program was started in India during 1990. ARI strategy an integral to the Child Survival and Safe Motherhood (CSSM) program in 1992; continued into the RCH Phase I project in 1997. Maternal education and Referral are integral part of the programme Under this program, cotrimoxazole tablets are made available at health facilities above the level of sub- centers F-IMNCI focuses on appropriate inpatient management of birth asphyxia, sepsis and low birth weight among neonates and pneumonia, diarrhea , malaria, meningitis, and severe malnutrition in children.

23. WHO recommendation for management of ARI Physical examination Count the breaths in one minute  Breathing count depends on the age of the child  Count respiratory rate for a minute Age of the Child Fast Breathing < 2 mo 60 breaths / min 2 mo to 12 mo 50 breaths / min 12 mo to 5 years 40 breaths / min

24. WHO recommendation for management of ARI Breathing OUT is difficult due to narrowing of the air passages Wheeze Occurs when the effort required to breath in, is much greater than normal Chest indrawing Occurs due to narrowing of trachea, larynx or epiglottis Stridor Sign of hypoxia Cyanosis Underlying Risk factor Malnutrition

25. ARI control programme WHO protocol comprises 4 steps : Case finding & Assessment Case Classification Institution of appropriate therapy Follow-up of cases

26. Step 1 : Case finding & Assessment Ask - How old is the child? - Is the child coughing or having difficulty of breathing? - For how long? Age of the Child H/o. Danger Signs Age 2 months to 5 years Is the child able to drink? Age less than 2 months Has the child stopped feeding? For how long? Has the child had convulsions? Has the child had fever?

27. Look; Listen; and Feel Count the breaths in one minute Look for the chest indrawing Look and listen the stridor Look and listen the wheeze See if the child is abnormally sleepy or difficult to wake up Feel for fever or low body temperature Look for severe malnutrition Look for cyanosis Step 1 : Case finding & Assessment

28. Step 2: Case Classification Purpose : - To make decision about severity of disease - Choose line of action or treatment It is done on the basis of danger signs and respiratory rate

29. Revised classification and treatment for childhood pneumonia at health facility † Not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe malnutrition.

30. Step 3: Institution of appropriate antibiotic therapy Young infants aged less than 2 months Antibiotic Dose Frequency Age < 7 days Age 7 days to 2 mo Inj. Ampicillin AND 50 mg/kg/dose 12 hourly 8 hourly Inj.Gentamycin 2.5 mg/kg/dose 12 hourly 8 hourly

31. Young infants aged 2 months to 5 years Antibiotic Dose Interval Mode A Inj. Ampicillin 50 mg/kg/dose 6 hourly IM B If condition improves, then for next 3 days Ampiciline / Amoxicilline If no improvement for next 48 hrs – Change antibiotic 50 mg/kg/dose 6 hourly/ 8 hourly Oral C Provide symptomatic treatment for fever and wheezing, if present D Monitor fluid and food intake E Advise mother on home management on discharge. Step 3: Institution of appropriate antibiotic therapy

32. Treatment of Pneumonia Daily Dose Schedule of Cotrimoxazole Age / Weight Pediatric Tablet Sulfamethaoxazole 100 mg & Trimethoprim 20 mg Pediatric Syrup Each spoon (5 ml) contain Sulfamethaoxazole 200 mg & Trimethoprim 40 mg < 2 months ( wt : 3-5 kg) One tablet BD Half spoon BD 2 – 12 months (wt:6-9 kg) Two tab BD One spoon BD 1-5 yrs ( wt : 10-19 kg) Three tab BD One and half spoon BD Step 3: Institution of appropriate antibiotic therapy

33. Step 4: FOLLOW UP - Home Care Mother should – Keep the baby warm – Continue breast feeding and feeding the child – To increase feeding after recovery – To clear the nose if it interferes with feeding – Proper dose of antibiotic for 5 days – Cough can be relieved by home made decoctions – To bring back the child after 2 days for reassessment – to watch for danger signs

34. Prevention of ARI Feeding children with adequate amounts of nutritious food 5 Breastfeeding infants exclusively 1 Avoiding respiratory irritation by indoor air pollution 2 Avoid the use of dried cow dung as fuel for indoor fires. 3 Immunization of all children with the routine EPI Vaccines 4 Avoid contact with patients who have ARIs. 6

35. 3. HiB vaccine 2. Pneumococcal vaccine 1. Measles vaccine 4. Influenza Vaccine immunizatioins

36. The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea ( GAPPD ) The specific goals for 2025 are to: Reduce mortality from pneumonia in children < 5 yrs to < 3 per 1000 live births Reduce mortality from diarrhea in children < 5 yrs to < 1 per 1000 live births Reduce incidence of severe pneumonia & severe diarrhea by 75% in children < 5 yrs of age compared to 2010 levels 90% full dose coverage of each relevant vaccine (with 80% coverage in every district) 90% access to appropriate pneumonia and diarrhea case management At least 50% coverage of exclusive breast feeding during first 6 months Virtual elimination of pediatric HIV

37. The specific goals for 2030 are to: Universal access to basic drinking-water in health care facilities and homes Universal access to adequate sanitation in health care facilities by 2030 and in homes by 2040 Universal access to handwashing facilities (water and soap) in health care facilities and homes Universal access to clean and safe energy technologies in health care facilities and homes Ending Preventable Child Deaths from Pneumonia and Diarrhea By 2025, The Integrated Global Action Plan For Pneumonia And Diarrhea. WHO, UNICEF - 2013 The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea ( GAPPD )

38. Thank You Dr.C.S.N.Vittal