1. ACUTE RESPIRATORY TRACT
INFECTIONS
BY
DR SYED AWAIS UL HASSAN SHAH
TRAINEE PAEDIATRICS

2. INTRODUCTION
• Š ARI responsible for 20% of childhood (< 5 years) deaths
– 90% from pneumonia
• Š ARI mortality highest in children
– HIV-infected
– Under 2 year of age
– Malnourished
– Weaned early
– Poorly educated parents
– Difficult access to healthcare
• Š Out- patient visits
– 20-60%
• Š Admissions
– 12-45%

3. INTRODUCTION
• In Pakistan ARI constitutes 30-60% of patients
in a hospital OPD
– 80% - acute upper respiratory infections
– 20% - acute lower respiratory infections
• 250,000 children < 5 yrs of age die due to
pneumonia in Pakistan every year
• Bacterial pneumonia is more common in
Pakistan. In contrast, pneumonia in developed
countries is mostly viral

4. INTRODUCTION
• Š Upper and lower respiratory tract separated at base of
epiglottis
• Upper respiratory tract consists of airways from the nostrils
to the vocal cords in the larynx, including the paranasal
sinuses and the middle ear
• The lower respiratory tract covers the continuation of the
airways from the trachea and bronchi to the bronchioles
and the alveoli
• The children < 5 yrs of age get an average of three to six
episodes of ARIs annually regardless of where they live or
what their economic situation
• The severity of LRIs in children under five is worse in
developing countries

5. UPPER RESPIRATORY TRACT
INFECTIONS
• ACUTE EPIGLOTTITIS (SUPRGLOTTITIS)
• CROUP (ACUTE LARYNGOTRACHEOBRONCHITIS)
• RHINITIS (COMMON COLD OR CORYZA)
– RHINOVIRUSES, ENTEROVIRUSES, CORONAVIRUSES
• EAR INFECTIONS (ACUTE OTITIS MEDIA)
– VIRUSES, PNEUMOCOCCUS, GABHS, HEMOPHILUS INFLUENZA, MORAXELLA CATARRHALIS
• ACUTE INFECTIOUS LARYNGITIS
– VIRAL/DIPTHERIA
• ACUTE PHARYNGITIS
– ADENOVIRUS, ENTEROVIRUS, RHINOVIRUS, GROUP A BETA HEMOOLYTIC STREPTOCOCCUS(older
children)
• TONSILLITIS
– GROUP A BETA HEMOLYTIC STREPTOCOCCI, EBV
• SINUSITIS
– VIRAL/BACTERIAL

6. ACUTE EPIGLOTTITIS
• LIFE-THREATNING INFECTION OF THE EPIGLOTTIS, THE
ARYEPIGLOTTIC FOLDS AND ARYTENOID SOFT TISSUE
• OCCURS MOSTLY IN WINTERS
• PEAK INCIDENCE :- 1 – 6 YEARS
• MALE AFFECTED MORE
• BACTERIAL INFECTION (HEMOPHILUS INFLUENZA TYPE
b)
• CONCOMITANT BACTEREMIA, PNEUMONIA, OTITIS
MEDIA, ARTHRITIS AND OTHER INVASIVE INFECTIONS
CAUSED BY H.INFLUENZA TYPE b MAY BE PRESENT

7. ACUTE EPIGLOTTITIS
• CLINICAL FEATURES
– HIGH FEVER,SORE THROAT,DYSPNEA,RAPIDLY
PROGRESSING RESPIRATORY OBSTRUCTION
– PATIENT MAY BECOME TOXIC, DIFFICULT
SWALLOWING,LABOURED
BREATHING, DROOLING,HYPEREXTENDED NECK
– TRIPOD POSITION (SITTING UPRIGHT AND
LEANING FORWARD)
– CYANOSIS , COMA, DEATH
– STRIDOR IS A LATE FINDING

8. EXAMINATION
• DO NOT EXAMINE THE THROAT
• ASSESSMENT OF SEVERITY
– DEGREE OF STRIDOR
– RESP RATE
– H.R
– LEVEL OF CONSCIOUSNESS
– PULSE OXIMETRY

9. ACUTE EPIGLOTTITIS
• DIAGNOSIS:
– “CHERRY RED”APPEARANCE OF EPIGLOTTIS ON
LARYNGOSCOPY
– THUMB SIGN ON LATERAL NECK RADIOGRAPH

13. ACUTE EPIGLOTTITIS
• EPIGLOTTITIS IS A MEDICAL EMERGENCY

14. TREATMENT (ACUTE EPIGLOTTITIS)
• NEED TO BE MANAGED IN ICU WITH ENDOTRACHEAL
INTUBATION
• HELP FROM ANAESTHETIST AND ENT SURGEON
• BLOOD CULTURES
• FLUID AND ELECTROLYTE SUPPORT
• INTRAVENOUS AMPLICILLIN 100 mg/kg/day OR
CEFTRIAXONE 100 mg/kg/day .
• OTHER OPTIONS
– (CEFUROXIME OR CEFOTAXIME) TOTAL TREATMENT :-7-10 DAYS
– CHOLRAMPHENICOL 50-75 mg/kg/day IV
• RIFAMPICIN PROPHYLAXIS TO CLOSE CONTACTS

15. ACUTE LTB (VIRAL CROUP)
• VIRAL INFECTION LEADING TO MUCOSAL
INFLAMMATION OF THE GLOTTIC AND
SUBGLOTTIC REGIONS
• COMMONLY DUE TO INFLUENZA (TYPE
A), PARAINFLUENZA(1, 2, 3) AND RSV
• AGE :- 6 MONTHS – 6 YEARS

16. ACUTE LTB
• CLINICAL FEATURES
– INITIAL :- RHINORRHEA, MILD COUGH, FEVER(LOW
GRADE)
– LATER (24-48 HOURS) :-
• BARKING COUGH
• HOARSENESS OF VOICE
• NOISY BREATHING (MAINLY ON INSPIRATION)
– SYMPTOMS WORSEN AT NIGHT AND ON LYING DOWN
– CHILDREN PREFER TO BE HELD UPRIGHT OR SIT IN
BED
– SYMPTOMS RESOLVE WITHIN A WEEK

17. ACUTE LTB
• CLINICAL EXAMINATION
– HOARSE VOICE
– NORMAL TO MODERATELY INFLAMMED PHARYNX
– SLIGHTLY INCREASED RESP RATE WITH
PROLONGED INSPIRATION AND INSPIRATORY
STRIDOR

18. ACUTE LTB
• DIAGNOSIS
– MAINLY A CLINICAL DIAGNOSIS
– RADIOGRAPH NECK :- STEEPLE SIGN (UNRELIABLE)

20. ACUTE LTB
• TREATMENT
– MOIST OR HUMIDIFIED AIR
– STEROIDS
• REDUCE THE SEVERITY AND DURATION / NEED FOR
ENDOTRACHEAL INTUBATION
• PREDNISOLONE PO 2mg/kg/day FOR 3 DAYS
• NEBULIZED BUDESONIDE 2mg STAT
– NEBULIZED ADRENALINE (EPINEPHRINE)

21. DIFFRENTIATING BETWEEN ACUTE LTB
AND ACUTE EPIGLOTTITIS
CROUP EPIGLOTTITIS
TIME COURSE DAYS HOURS
PRODROME CORYZA NONE
COUGH BARKING SLIGHT IF ANY
FEEDING CAN DRINK NO
MOUTH CLOSED DROOLING SALIVA
TOXIC NO YES
FEVER <38.5 C >38.5 C
STRIDOR RASPING SOFT
VOICE HOARSE WEAL OR SILENT

22. LOWER RESPIRATORY TRACT
INFECTIONS
• BRONCHITIS/BRONCHIOLOITIS
• PNEUMONIA

23. BRONCHIOLITIS
• INFLAMMATORY DISEASE OF THE
BRONCHIOLES
• PEAK AGE OF ONSET : 6 MONTHS
• MOST COMMON AGENT :- RSV
• MALE : FEMALE :- 2:1
• OCCURS MOSTLY IN WINTER/SPRING

24. CLINICAL FEATURES
• CORYZA WITH COUGH FOLLOWED BY
WORSENING BREATHLESSNESS
• VOMITING
• IRRITABILITY
• WHEEZE
• FEEDING DIFFICULTY
• EPISODES OF APNOEA

25. EXAMINATION FINDINGS IN
BRONCHIOLITIS
• RAPID SHALLOW BREATHING (60-80/MIN)
• CYANOSIS / PALLOR
• FLARING OF ALAE NASI
• USE OF ACCESSORY MUSCLES OF RESPIRATION
– SUBCOSTAL /INTERCOSTAL RECESSIONS
• EXPIRATORY WHEEZE / GRUNTING
• PROLONGED EXPIRATION
• HYPER-RESONANT PERCUSSION NOTES
• CHEST HYPERINFLATION
• LIVER/SPLEEN PALPABLE
• BRONCHIOLITIS OBLITERANS

26. BRONCHIOLITIS
• DIAGNOSIS
– CXR
• HYPERINFLATION, INCREASED LUCENCY AND
INCREASED BRONCHOVASCULAR MARKINGS AND MILD
INFILTRATES
– PULSE OXIMETRY
– NASOPHARYNGEAL SWABS (VIRAL CULTURE)
– VIRAL ANTIBODY TITERS (IAT FOR RSV)

27. A chest X-ray demonstrating lung hyperinflation with a
flattened diaphragm and bilateral atelectasis in the right apical
and left basal regions in a 16-day-old infant with severe
bronchiolitis

28. BRONCHIOLITIS
• COMPLICATIONS
– PNEUMONIA
– PNEUMOTHORAX
– DEHYDRATION
– RESPIRATORY ACIDOSIS
– RESPIRATORY FAILURE
– HEART FAILURE
– PROLONGED APNEIC SPELLS  DEATH

29. BRONCHIOLITIS
• TREATMENT
– MAINLY SUPPORTIVE
– PROP UP (30 – 40 DEGREES)
– OXYGEN INHALATION (ACHIEVE O2 >92%)
– IF TACHYPNEIC, LIMIT THE ORAL FEEDS AND USE A NG
TUBE FOR FEEDING
– PARENTERAL FLUIDS TO LIMIT DEHYDRATION
– CORRECT RESP ACIDOSIS AND ELECTROLYTE IMBALANCE
– BRONCHODILATORS FOR WHEEZE (NEBULIZED
ADRENALINE)
– MECHANICAL VENTILATION (SEVERE RESP DISTRESS OR
APNOEA)

30. Pneumonia
• Inflammation of the lung parenchyma and is associated with the
consolidation of the alveolar spaces
• Developed world
– Viral infections
– Low morbidity and mortality
• Š Developing world
– Common cause of death
– Bacteria and PCP in 65%
• Š ARI case management WHO
– 84% reduction in mortality
– Respiratory rate, recession, ability to drink
– Cheap, oral and effective antibiotics
• Co-trimoxazole, amoxycillin
– Maternal education
– Referral

31. Etiology
• Š Vary according to
– Age, immune status, where contracted
• Š Community acquired (CAP)
– Developing countries
• S. pneumoniae, H. influenzae, S aureus
• Viruses 40%
• Other: Mycoplasma, Chlamydia, Moraxella
– Developed countries
• Viruses: RSV, Adenovirus, Parainfluenza, Influenza
• Mycoplasma pneumoniae and Chlamydia pneumoniae
• Bacteria: 5-10%

32. ETIOLOGY ACCORDING TO AGE
AGE GROUP CAUSATIVE ORGANISM
NEONATES GROUP B STREPTOCOCCUS
E.COLI
KLEBSIELLA
STAPH AUREUS
INFANTS PNEUMOCOCCUS
CHLAMYDIA
RSV
H.INFLUENZA TYPE b
CHILDREN 1 TO 5 YRS RESPIRATORY VIRUSES
PNEUMOCOCCUS
H.INFLUENZA TYPE b
C.TRACHOMATIS
M.PNEUMONIAE
S.AUREUS
GP A STREPTOCOCCUS
CHILDREN 5 TO 18 YRS M.PNEUMONIAE
PNEUMOCOCCUS
C.PNEUMONIAE
H.INFLUENZA TYPE b

33. WHO Classification and management
NO PNEUMONIA COUGH -HOME CARE
NO TACHYPNEA -SOOTHE THE THROAT AND
RELIEVE COUGH
-ADVISE MOTHER WHEN TO
RETURN
-FOLLOWUP IN 5 DAYS IF NOT
IMPROVING
PNEUMONIA -COUGH -HOME CARE
-TACHYPNEA -ANTIBIOTICS FOR 5 DAYS
-NO RIB OR STERNAL -SOOTHE THE THROAT AND
RETRACTION RELIEVE COUGH
-ABLE TO DRINK -ADVISE MOTHER WHEN TO
- NO CYANOSIS RETURN
-FOLLOWUP IN 2 DAYS
SEVERE PNEUMONIA -COUGH -ADMIT IN HOSPITAL
-TACHYPNEA -GIVE RECOMMENDED
-RIB AND STERNAL RETRACTION ANTIBIOTICS
-ABLE TO DRINK -MANAGE AIRWAY
-NO CYANOSIS -TREAT FEVER IF PRESENT
VERY SEVERE PNEUMONIA -COUGH -ADMIT IN HOSPITAL
-TACHYPNOEA -GIVE RECOMMENDED
-CHEST WALL RETRACTION ANTIBIOTICS
-UNABLE TO DRINK -OXYGEN
-CENTRAL CYANOSIS -MANAGE AIRWAY
-TREAT FEVER IF PRESENT

34. HIGH RISK CHILDREN FOR
PNEUMONIA
• CONGENITAL LUNG CYSTS
• CHRONIC LUNG DISEASE
• IMMUNODEFICIENCY
• CYSTIC FIBROSIS
• SICKLE CELL DISEASE
• TRACHEOSTOMY IN SITU

35. Danger Signs (IMCI)
• Š High risk of death from respiratory illness
• Younger than 2 months
• Decreased level of consciousness
• Stridor when calm
• Severe malnutrition
• Associated symptomatic HIV/AIDS

36. VERY SEVERE PNEUMONIA

37. SIGNS OF RESPIRATORY DISTRESS

38. SIGNS OF RESPIRATORY DISTRESS

39. Radiology
Bacterial
– Poorly demarcated
alveolar opacities
with air
bronchograms
– Lobar or segmental
opacification

40. Radiology
Š Viral
– Perihilar
streaking, interstit
ial changes,
air trapping

41. Radiology
• Š Clues to other specific
organisms
– Staphylococcus – areas
of break-down
– Klebsiella, anaerobes, H.
influenza or TB –
cavitating or expansile
pneumonia
– TB, S. aureus, H.
influenza
• pleural effusion and
empyema

42. Diagnosis
• White cell count and CRP
– >15,000 – 40,000/mm3 neutrophil predominance
• Blood cultures
– 25% positive
• NASOPHARYNGEAL ASPIRATE
– Viral immunoflorescence in infants
• Sputum specimen
– Gram staining
– Acid fast bacilli
• Pleural fluid examination (if present)
• ASO titer (in case of streptococcal pneumonia)
• Tuberculin skin test
• Viral Titres
– culture
– antigen

43. COMPLICATIONS OF PNEUMONIA
• EMPYEMA
• LUNG ABSCESS
• PNEUMOTHORAX
• PNEUMATOCELE
• PLEURAL EFFUSION
• DELAYED RESOLUTION
• RESPIRATORY FAILURE
• METASTATIC SEPTIC LESIONS
– MENINGITIS
– OTITIS MEDIA
– SINUSITIS
– SPETICAEMIA

44. Treatment
• Š Antibiotics
– Under 5 yrs
• First line treatment :- amoxicillin
• Alternatives : coamoxiclav, cefaclor,(for typical)
macrolides (for atypical)
– Over 5 yrs
• First line treatment :- amoxicillin or macrolides
• Alternatives :- macrolide or flucloxacillin + amoxicillin
– Severe pneumonia
• Co-amoxiclav, cefotaxime or cefuroxime
– Special categories (as per the suspected organism)

45. Treatment in special groups
GROUP ORGANISMS ANTIBIOTICS
IMMUNOCOMPROMISED -GRAM NEGATIVE AMPICILLIN +
-S. AUREUS CLOXACILLIN +
-OPPORTUNISTIC AMINOGLYCOSIDE
PNEUMOCYSTIS JIROVECI
-M. TUBERCULOSIS
LESS THAN 3 MONTHS -GRAM NEGATIVE AMPICILLIN +
-GROUP B STREPTOCOCCUS AMINOGLYCOSIDE
-S.AUREUS
HOSPITAL ACQUIRED -GRAM NEGATIVE AMINOGLYCOSIDE +
PNEUMONIA -METHICILLIN RESISTANT S. VANCOMYCIN +
AUREUS CEPHALOSPORIN
(3RD GENERATION)

46. Treatment (contd)
• Š Oxygen
– When?
– Methods of delivery
• Š Hydration
– 50 – 80ml/kg/day
• Š Temperature control
• Š Airway obstruction
• Chest drain :- for fluid or pus collection in chest (empyema)

47. Failure to respond
• Š Incorrect or inadequate dose of antibiotic
• Š Resistant or not suspected organism
• Š Empyema or other complication
• Š TB
• Š Suppressed immunity
• Š Underlying cause
– e.g. foreign body or bronchiectasis
• Š Left heart failure and not pneumonia
Refer if no improvement after 3 – 5 days

48. Prognosis
• Š Most children recover without residual
damage
• Š Incorrect treatment leads to tissue
destruction and bronchiectasis
• Š Half of children with pneumonia secondary
to measles or adenovirus have persistent
airway obstruction

49. THANKYOU