ACUTE RESPIRATORY INFECTION

1. EPIDEMIOLOGY
OF ARI
DR. MAHESWARI JAIKUMAR.
maheswarijaikumar2103@gmail.com

2. ACUTE RESPIRATORY
INFECTION

3. • Infection of the respiratory tract
is called ARI.
• ARI may cause inflammation of
the respiratory tract anywhere
from nose to alveoli with a range
of combination of symptoms
depending on the site of
infection.

4. • ARI is often classified by clinical
syndromes depending on the site
of infection.
• ARI may be (AURI) – Acute Upper
Respiratory Infection or (ALRI) –
Acute Lower Respiratory
Infection.

5. • The lower respiratory tract
infections include epiglottitis,
laryngintitis, laryngotracheitis,
bronchitis, bronchiolitis and
pneumonia.
• The upper respiratory infection
include common cold,
pharyngitis and otitis media.

8. • Clinical features include running
nose, cough, sore throat, difficult
breathing and ear problem.
• Fever is also common in acute
ARI.

9. • Most children have minor
symptoms such as cold or cough.
• However some children may
have pneumonia which is a
major cause of death.

10. • Some times measles and
whooping cough are important
causes of severe respiratory tract
infection.

11. EPIDEMIOLOGICAL
FACTORS

12. AGENT

13. • The microbial agents' that cause
ARI are numerous.
• They could be classified as
bacteria, virus and other agents.

14. BACTERIA
Bordetella pertussis Cornybacterium
diphtheriae
Haemophilus
influenzae
Klebsiella
pneumoniae
Legionella
pneumophilia
Staphylococcus
pyogenes
Sreptococcus
pneumoniae
Sreptococcus
pyogenes

15. VIRUS
ADENO VIRUS ENTERO VIRUSES
INFLUENZA (A,B,C) MEASLES
PARAINFLUENZA RESPIRATORY
SYNCYTIAL VIRUS
RHINO VIRUS CORONA VIRUS

17. HOST FACTORS

18. • Small children succumb to the
disease within a matter of days.
• Case fatality rates are higher in
young infants and malnourished
children.

19. • Adults are also affected and the
symptoms tend to be more
among females.

20. RISK FACTORS
• Climatic conditions and housing
are noted as a major risk factor.
• Overcrowding, poor nutrition,
Low Birth Weight and intense
indoor smoke pollution
underline the high rates.

21. • Children from low
socioeconomic status tend to
have more episodes of ARI.
• The infection is common in
preschool children attending day
care centers.

22. • Infections tend to be more in
urban communities than in rural
communities.
• Maternal smoking has been
linked to increased occurrence of
respiratory tract infections
during the first year of life.

23. MODE OF TRANSMISSION
• The organisms are transmitted
by the airborne route.
• The chain of infection is
maintained by direct person to
person contact.

24. CLINICAL ASSESSMENT
• History taking and clinical
assessment is very important in
the management.

25. NOTE THE FOLLOWING
• Age of the child.
• Duration of cough.
• Whether the child is able to
drink (2-5 Mo).
• has the young infant stopped
feeding well (child less than 2
Mo)

26. • Any antecedent illness such as
measles.
• If the child is excessively drowsy
or difficult to wake.
• Did the child have convulsions.
• Is there irregular breathing.

27. • Short periods of apnoea.
• History of child turning blue.
• History of treatment during
illness.
• Fever if any.

28. PHYSICAL EXAMINATION
• Look and listen to the following :
• COUNT THE BREATHS IN ONE
MINUTE…..
• As the children get older their
breathing rates slows down.

29. • Therefore the cutoff point used
to determine if a child has fast
breathing will depend on the age
of the child.

30. • Count the respiratory rate one
full minute using second’s hand
of the watch looking at he
abdominal movement or lower
chest when the child is calm.

31. • The chest and the abdomen
must be exposed for counting.
• Increased respiratory rate (RR) is
significant only if it persists.

32. FAST BREATHING IS
PRESENT WHEN RR is

33. • 60 breaths /min or more in a
child less than 2 Mo.
• 50 breaths /min or more in a
child aged 2 Mo up to 12 Mo.
• 40 breaths /min or more in a
child aged 12 Mo up to 5 years.

34. • Repeat the count for a young
infant (age less than 2 Mo) if the
count is 60 breaths /min or
more.
• This is important because the
breathing rate of young infant is
often erratic.

35. • Occasionally young infants stop
breathing for a few seconds, and
then breath very rapidly for a
short period.

36. LOOK FOR CHEST
INDRAWING
• Look for chest indrawing when
the child breaths IN.

37. • The child has indrawing of the
chest if the lower chest wall goes
in while the child breaths in.
• Chest in drawing occurs when
the effort required to breath in,
is much grater than normal.

38. LOOK AND LISTEN FOR
STRIDOR
• A child with stridor makes a
harsh noise when breathing IN.

39. • Stridor occurs when there is
narrowing of the larynx, trachea
or epiglottis which interferes
with the air entering the lungs.
• These conditions are often called
croup.

40. LOOK FOR WHEEZE
• A child with wheeze makes a soft
noise or shows signs that
breathing OUT is difficult,
wheezing is caused by narrowing
of the air passage in the lungs.
• The breathing-out phase takes
longer than normal and requires
effort.

41. • The breathing-out phase takes
longer than normal and requires
effort.
• If the child has wheezing, ask the
mother if her child had a
previous episode of wheezing
within the past year.

42. • If so, the child should be classified
as having recurrent wheeze.
• See if the child is abnormally
sleepy or difficult to wake. An
abnormally sleepy child is drowsy
most of the time when he or she
should be awake and alert.

43. • Feel for fever or low body
temperature.

44. LOOK FOR SEVERE
MALNUTRITION
• Malnutrition when present is a
high risk factor and case fatality
rates are higher in such children.

45. • In severely malnourished
children with pneumonia, fast
breathing and chest in drawing
may not be as evident as in
other children.

46. • A severely malnourished child
may have an impaired or absent
response to hypoxia and a weak
or absent cough reflex.
• These children need careful
evaluation for pneumonia as
well as careful management.

47. • Cyanosis is a sign of hypoxia.
• Cyanosis must be checked in
good light.

48. CLASSIFICATION OF ARI
1. VERY SEVERE DISEASE.
2. SEVERE PNEUMONIA.
3. PNEUMONIA (Not Severe).
4. No pneumonia : cough or
cold.

49. 1.VERY SEVERE DISEASE
• The child presents the following
manifestations:
• NOT ABLE TO DRINK.
• CONVULSIONS.
• STRIDOR.
• SEVERE MALNUTRITION.

50. NOT ABLE TO DRINK
• A child who is not able to drink
could have severe pneumonia or
bronchiolitis, septicaemia, throat
abcess, meningitis or cerebral
malaria.

51. CONVULSIONS
• Convulsions, abnormally sleepy
or difficult to wake : A child with
these signs may have severe
pneumonia resulting in hypoxia,
sepsis, cerebral malaria or
meningitis.

52. • Meningitis can develop as a
complications of pneumonia or it
can occur on its own.

53. STRIDOR IN CALM CHILD
• If a child has stridor when calm,
the child may be in danger of life
threatening obstruction of the
airway from swelling of pharynx,
trachea or epiglottis.

55. SEVERE MALNUTRITION
• A severely malnourished child is
at high risk of developing and
dying from pneumonia.
• In addition, the child may not
show typical signs of the illness.

56. 2.SEVERE PNEUMONIA
• Respiratory rate is the most
important sign to consider
when assessing the child for
pneumonia.
• Presence of chest indrawing
should also be noted.

59. • A child classified under
pneumonia has other signs such
as: nasal flaring, when the nose
widens as the child is breathing.
• Grunting, the short sounds made
with the voice when the child
has difficulty in breathing.

60. • Cyanosis, a dark bluish or
purplish colouration of the skin
caused by hypoxia.
• Some children with chest in
drawing also have wheezing.

61. 3.PNEUMONIA (NOT SEVERE)
• A child who has fast breathing but
no chest in drawing is classified as
having pneumonia (not severe).
• Most children are classified under
this category if they are brought
early for treatment.

62. 4.NO PNEUMONIA :COUGH
OR COLD
• Most children with a cough or
difficult breathing do not have
any danger signs of pneumonia
(chest indrawing/ fast
breathing).

63. • These children have simple
cough/cold.
• They do not need any antibiotic.
The child gets better in 1-2
weeks.

64. EACH DISEASE CLASSIFICATION
HAS A CORRESPONDING
TREATMENT PLAN

65. CLASSIFICATION SEVERE PNEUMONIA,
COUGH, COLD
SIGNS CHEST INDRAWING,
WITH OR WITHOUT
WHEEZE
TREATMENT 1.TREAT FEVER IF
PRESENT.
2.TREAT WHEEZING.
3.IF REFERAL IS NOT
AVAILBALE TREAT
WITH ANTIBIOTICS
AND FOLLOW
CLOSELY.

66. CLASSIFICATION
SEVERE PNEUMONIA, COUGH, COLD.

67. SIGNS
CHEST INDRAWING, WITH OR
WITHOUT WHEEZE

68. TREATMENT
• REFER URGENTLY TO HOSPITAL & GIVE
FIRST DOSE OF ANTIBITIC.
• TREAT FEVER IF PRESENT.
• TREAT WHEEZING.
• IF REFERAL IS NOT AVAILBALE TREAT
WITH ANTIBIOTICS AND FOLLOW
CLOSELY.

69. CLASSIFICATION
PNEUMONIA

70. SIGNS
• NO CHEST IN DRAWING AND FAST
BREATHING.
• (50/min or MORE if child 2 months
up to 12 months; 40 per min or
more if child 12 months up to 5
years)

71. TREATMENT
• ADVISE MOTHER TO GIVE HOME
CARE.
• ADMINSTER ANTIBIOTIC.
• TREAT FEVER IF PRESENT.

72. • TREAT WHEEZING IF PRESENT.
• ADVISE MOTHER TO RETURN
WITH CHILD IN 2 days for
reassessment or earliest if the
child is getting WORSE.

73. CLASSIFICATION
NO PNEUMONIA, COUGH,COLD

74. SIGNS
• NO CHEST IN DRAWING.
• NO FAST BREATHING (LESS THAN
50/min if child 2 Mo up to 12
Mo; Less than 40 per min if child
is 12 Mo up to 5 years).

75. TREATMENT
• Assess and treat ear problem or
sore throat of present.
• Assess and treat other problems.

76. • Advise mother to give home
care.
• Treat fever, if present.
• Treat wheezing if present.

77. RE - ASSESSMENT
• Re-assess in 2 days a child who is
taking an antibiotic for
pneumonia.

78. RE ASSESSMENT
PARAMETER WORSE THE SAME IMPROVING
SIGNS Not able to
drink.
Has chest
indrawing.
Has other
danger signs.
------- -------
------ --------
Breathing
slower.
Less Fever.
Eating
better.
TREATMENT Refer
URGENTLY to
hospital
Change
antibiotic or
refer
Finish 5 days
of antibiotics

79. TREATMENT OF
PNEUMONIA

80. TREATMENT - INDIA
• Co-trimoxazole is the drug of
choice for the treatment of
pneumonia.
• Co-trimoxazole is less expensive
with few side effects.

81. DOSAGE SCHEDULE
AGE/WEIGHT PAEDIATRIC
TABLET:SULPHAM
ETHOXAZOLE 100
mg &
TRIMETHOPRIM
20 mg.
PAEDIATRIC
SYRUP: each
spoon (5ml) :
TABLET:SULPHAM
ETHOXAZOLE 200
mg &
TRIMETHOPRIM
40 mg.
< 2 Mo Wt. 3-5 Kg. ONE TABLET
TWICE DAILY
HALF SPOON (2.5
ml TWICE A DAY)

82. DOSAGE SCHEDULE
AGE/WEIGHT PAEDIATRIC
TABLET:SULPHAM
ETHOXAZOLE 100
mg &
TRIMETHOPRIM
20 mg.
PAEDIATRIC
SYRUP: each
spoon (5ml) :
TABLET:SULPHAM
ETHOXAZOLE 200
mg &
TRIMETHOPRIM
40 mg.
2 -12 Mo Wt. 6-9
Kg.
TWO TABLETS
TWICE DAILY
ONE SPOON (5 ml
TWICE A DAY)

83. DOSAGE SCHEDULE
AGE/WEIGHT PAEDIATRIC
TABLET:SULPHAM
ETHOXAZOLE 100
mg &
TRIMETHOPRIM
20 mg.
PAEDIATRIC
SYRUP: each
spoon (5ml) :
TABLET:SULPHAM
ETHOXAZOLE 200
mg &
TRIMETHOPRIM
40 mg.
1-5 YRS. Wt. 10-19
Kg.
THREE TABLETS
TWICE DAILY
ONE & HALF
SPOON (7.5 ml
TWICE A DAY)

84. TREATMENT OF
SEVERE PNEUMONIA
(2 Mo -5Yrs)

85. (A)
ANTIBIOTICS DOSE INTERVAL MODE
First 48 hrs
Benzyl penicillin
(OR)
Ampicillin (OR)
Chloramphenicol
50,000 IU
/kg/dose
50mg/kg/dose
25mg/kg/dose
6 hourly
6 hourly
6 hourly
IM
IM
IM

86. IF CONDITIONS IMPROVES, then for
the next 3 days give: (B)
ANTIBIOTICS DOSE INTERVA
L
MODE
PROCAINE
PENICILLIN (OR)
AMPICILLIN (OR)
CHLORAMPHENICOL
50,000 IU
/kg/dose
max 4 lac IU
50mg/kg/dose
25mg/kg/dose
ONCE.
6
HOURLY
6
HOURLY
IM
Oral
Oral

87. IF NO IMPROVEMENT; then for
the next 48 hrs CHANGE THE
ANTIBIOTIC (B)
• If ampicillin is used change to
chloramphenicol. (IM)
Cont….

88. • If chloramphenicol is used,
change to Cloxacillin 25
mg/kg/dose, every 6 hours along
with gentamycin 2.5
mg/kg/dose/8 hrs.
• If condition improves continue
treatment orally.

89. THE DOSES CAN BE ROUNDED OFF TO
NEAREST ADMINISTRABLE DOSE
• C - PROVIDE SYMPATOMATIC TREATMENT
FOR FEVER & WHEEZING, IF REQUIRED.
• D -MONITOR FOOD & FLUID
INTAKE.
• E - ADVISE MOTHER ON HOME
MANAGEMENT ON DISCHARGE.

90. TREATMENT OF
PNEUMONIA IN CHILDREN
AGED LESS THAN
2 MONTHS

91. ANTIBIOTIC DOSE AGE , 7
DAYS
AGE , 7
DAYS to 2
Mo
Inj BENZYL
PENICILLIN OR
Inj AMPICILLIN
AND
Inj Gentamycin
50,000
IU/kg/dose
50
mg/kg/dose
2,5
mg/kg/dose
12 hourly
12 hourly
12 hourly
6 hourly
8 hourly
8 hourly

92. MANAGEMENT OF CHILDREN
WITH NO PNEUMONIA
• Symptomatic treatment is given.
• DO NOT ADMINISTER
ANTIBIOTICS

93. PREVENTION OF ARI
• Immunization is an important
measure to reduce the incidence
of ARI.
• Health promotional activities
should be undertaken .

94. IMMUNIZATION
• Vaccine hold promise of saving
millions of children dying of
pneumonia.
• Three vaccines have potential of
reducing deaths from
pneumonia.

95. THEY ARE :
1. MEASELES VACCINE.
2. HIB VACCINE.
3.PNEUMOCOCCAL PNEUMONIA
VACCINE.

96. MEASLES VACCINE
• In India MMR – a trivalent
vaccine is administered to
infants on completing 9 months
of age.
• Pl refer Epidemiology of
measles.

97. HIB VACCINE
• Haemophilus influenza B (HIB) is an
important cause of pneumonia and
meningitis among children.
• It’s high cost has posed obstacle to
its utilization in the developing
countries.

99. • The vaccine is often given as a
combined preparation with DPT.
And polio vaccine.
• Three or four doses are given
depending the type of
manufacturers. (6,10,14 weeks
and booster dose at 14 months)

100. • The vaccine is not offered to
children aged more than 24
months.
• No serious side effects have
been recorded .

101. PNEUMOCOCCAL
PNEUMONIA VACCINE
• PPV23, a polysaccharide non
conjugate vaccine containing
capsular antigens of 23
serotypes against this infection is
available.

104. • A dose of 0.5ml of PPV23
contains 25 micrograms of
purified capsular antigen.
• PPV23 is administered as a single
IM dose preferably in the deltoid
muscle.

105. • Protective capsular type specific
antibody generally develop by
the third week following
vaccination.

106. • Two conjugate vaccines are
available since 2009 (PCV10 &
PCV13).
• The recommended storage
temperature is between 2 & 8
degree Celsius.

107. THANK YOU