1

(Acute

infection in children, ARIC)

respiratory

tract

Acute respiratory infection (ARI)

Upper respiratory infection

(URI)

acute URI

acute nasopharyngitis)

(common cold

media)

(acute

pharyngitis)

(acute

(acute otitis

sinusitis)

(acute

tonsillitis)
Lower respiratory infection (LRI)

LRI

bronchitis)

(acute pneumonia)

(acute bronchiolitis)

(acute

2
(croup

LRI

acute

syndrome)

acute laryngotracheobronchitis,

epiglottits,

bacferial

tracheitis

retropharyngcal

abscess
. . 2530

2.9

. . 2536

52

25

9.6/100,000

15/100,000

. . 2537

. . 2533

3
-

1.

2.

2533; 11: 129-39.

:
1)

; 2540 : 503-506, 517-530.

(Guideline for the management of acute upper respiratory tract

infections in young children or AURI)

( Acute rhinitis , acute nasopharyngitis ,

common cold )

Coronavirus

Rhinovirus

sinus

mucopurulent

2 - 7

60-80% 1-3

2-3

31%

viral rhinosinusitis )

35%

3-8

10-15%

12

Day care center

1.

2.

8
2.1

10 mg / kg / dose

38

46

paracetamol

2.2

0.9 % NSS

1 2

mucosa

nasal discharge

mg/kg/dose

hypertension

34

rhinorrhea

pseudoephedrine 1

confusion,
dystonia

hallucination,

aggression,

rhinitis

2. topical decongestant

nasal

oral decongestant

Decongestant

% ephedrine

3 5

medicamentosa, rebound congestion

rebound congestion

obstructive apnea

systemic absorption

antihistamine

allergic rhinitis

metholated balms
2.3

: oral hydration

: soothing remedies

WHO

( expectorant )

Guaifenesin

glyceryl guaiacolate

side effect

ammonium chlorate, terpine hydrate, syrup ipecac

( mucolytic drug )

dextromethorphan

( cough suppressant )

codiene,

10
3.

(Specific treatment)

resistant organism

4.

( Acute pharyngitis, tonsillitis,

pharyngotonsillitis )

hemolytic streptococcus group A

acute rheumatic fever, acute glomerulonephritis

Streptococcal sorethroat

soft palate

tonsils

pharynx

tonsils

(cervical lymphadenitis)

()

adenovirus, infectious mononucleosis

1. (Specific treatment)

11

Streptococcal

sorethroat

Penicillin V 50,000 100,000 units / kg / day

Amoxycillin 30 50 mg / kg / day
Penicillin
14

10

Erythromycin 30 50 mg / kg / day

10

2.
-

- Soothing remedies

lozenges,

antiseptic

, xylocaine gel

Acute otitis media

M.

catarrhalis

pneumonia

S. pneumoniae, H. influenzae,

virus,

mycoplasma

chlamydia pneumonia

otoscope

tympanic membrane

tympanic membrane

12

1. (Specific treatment)
:

cotrimoxazole, rythromycin
-

5 7

recurrent otitis media

craniofacial abnormalities

immunocompromised host

10-14

amoxycillin,

nd

48

generation cephalosporin, amoxycillin /

clavulanate
:
effusion

50%

serous effusion
2.

serous otitis media

70%

20%

1
3

effusion

serous

decongestant

antihistamine

13

Acute sinusitis

complication

pneumoniae, H. influenzae

10

bacterial sinusitis
0.5 5%

Gr. A. Streptococcus

S.

paranasal sinus

Bacterial sinusitis

1. amoxycillin, erythromycin
cotrimoxazole 10 14

nd

48

2 generation

cephalosporin, amoxycillin/clavulanate
2.
3.

14

1.

2.

2.

,2542.

Dowell SF, Marcy SM, Phillips WR, et al. Principles

of judicious use of antimicrobial agents for pediatric

upper respiratory tract infections. Pediatrics 1998; 101

(1) : 163-165.
3.

Dowell SF, Marcy SM, Phillips WR, et al. Otitis

media - Principles of judicious use of

antimicrobial agents. Pediatrics 1998; 101 (1): 165

171.

4.

Dowell SF, Schwartz B, Phillips WR and The

pediatric URI consensus team. Appropriate use of

antibiotics for URZs in children : part I. Otitis media

and acute sinusitis. Am Fam Phys 1998; 58 (5): 1113

1138, 1123.

5. Dowell SF, Schwartz B, Phillips WR and The pediatric

URI consensus team. Appropriate use

of antibiotics for URIs in children : part II. Cough,

pharyngitis and the common cold. Am Fam Phys 1998;

58 (6): 1335 1342, 1345.

15
6. Hendeles L. Efficacy and safety of antihistamines and

expectorants in nonprescription cough

and cold preparations. Pharmacotherapy 1993; 13

(2): 154 158.

7. O Brien KL, Dowell SF, Schwartz B, et al. Acute

sinusitis Principles of judicious use of

178.

antimicrobial agents. Pediatrics 1998; 101 (1): 174

8. Rosenstein N, Phillips WR, Gerber MA, et al. The

common cold Principles of judicious use

of antimicrobial agents. Pediatrics 1998; 101 (1):

181 184.

9. Schwartz B, Marcy SM, Phillips WR, et al. Pharyngitis

Principles of judicious use of

174.

antimicrobial agents. Pediatrics 1998; 101 (1): 171

16
(Guideline for the management of acute lower respiratory
infections in young children or ALRI)

Acute epiglottitis

( )
supraglottic

aryepiglottic

fold

ventricular
2-6

band

red epiglottis)

glottis

24

epiglottis

( 1)

type

(Stridor)

influenzae

epiglottis,

Hemophilus

(cherry

epiglottis

17

aryepiglottic

oropharynx

X-ray)

endotracheal

Chloramphenical
third

fold

neck

air

epiglottis

trapping

or

(lateral

(Ampicillin,

generation

Amoxicillin

Ampicillin

cephalosporin)

second

Clinical

characteristics

differentiating

laryngotracheobronchitis from acute epiglottitis

Characteristic

LTB

Epiglottitis

Age

6 month-3 years

2-6 years

Onset

Gradual

Rapid

Etiology

Viral

Bacterial

Swelling site

Subglottic

Supraglottic

Hoarse cough

No cough

Symptoms
Cough voice

Muflfled voice
Posture

Any position

Sitting

acute

18
Mouth

Closed

Fever
Appearance

nasal Open-chin

flaring

forward, drooling

Absent to high

High

Often not acutely Anxious,

ill

X-ray

acutely

ill

Narrow

subglottic Swollen

area

and

epiglottis

supraglottic

structures
Palpation larynx

Non tender

Tender

Recurrence

May recur

Rarely recurs

Reference :

Backofen

disease.
pediatric

DE,

Roger

In : Rogers

MC,

intensive Care.

Acute laryngotracheobronchitis

MC.

Upper

airway

ed. Textbook
1987, p

190

(Viral croup)

of

19

1,

2,

syncytial

influenza

virus

parainfluenza
virus

subglottic

B,

type

respiratory

measles

A,

virus

1-3

(stridor)

stridor

croup

score

(barking
cough)

Stridor

Chest

nasal

retraction &

flaring &

subcostal &

nasal flaring

suprasternal

intercostal

retraction

retraction

20

Harsh with

40%

rhonchi

< 4 =

4-7 =

> 7 =

( Downes JJ. Acute upper airway obstruction.

Annual refresher course lectures.

In :

A.S.A. annual meeting

1980 ; 535)

(croup score < 4)

()

0.6

mg/kg

ml

NSS

(croup score 4-7)

dexamethasone

adrenaline 1:1000

0.5

2.5 ml / dose

dilute

7)

ml/kg

(Group score

viral croup
Croup

21
obstruction score
4

4 7

OPD Treatment
Admitted ICU

Admitted
Epinephrine 1 : 1000
( 0.05 0.5 ml/kg )
max. dose 2.5 ml
4
3 30
Dexamethasone
0.6 mg/kg/dose

Support

Endotracheal

Bacterial

tracheitis
1-3

Croup

In tubation

22

group

A -hemolytic

streptococcus

staphylococcus

aureus,

H. influenzae

(brassy cough)

airway
100

clear

airway

mg/kg/day

mg/kg/day)
tracheal

suction)

2-3

Cloxacillin

Cephalosporin

maintain

IV

(Cefazolin

75

(intermittent

Retropharyngeal abscess

pharyngeal

wall

prevertebral

fascia

nasopharynx

posterior

retropharyngeal

space

23

buccopharyngeal

fascia

streptococcus

hemolytic

S.

aureus

(stridor)

(meningismus)

pharyngeal wall

fascia

group

posterior

retropharyngeal space

direct laryngoscopy

resistant penicillin

raphe

lateral neck X-ray

cervical lordosis

prevertebral

median

Penicillin

Gramstain

Penicillinase

24

1.

, Acute Waryngotracheoburn chitis,

. 2541 : 401 5.

25
2.

Barone MA. The Harriet Lane Handbook. A manual

for pediatric house officers. The Harriet Lane Service
Childrens Medical and Surgical Center of The Johns
th

Hopkins Hospital. 14 ed. St. Louis. Baltimore : Mosby

Year Book. 1996; 532 3.
3. Klassen TP. Group : A current perspective. Pediatr
Clin North Am 1999 ; 46 (6) : 1167 77.
4. Sumboonnanonda
Randomized

A,

controlled

Suwanjutha
trial

of

S,

Sirinawin

S.

Dexainethasone

in

Infectious group. J Med Assoc Thai. 1997 ; 8 : 262 5

5.

Waisman Y, Kleikn BL and Boenning DA, et al.

Prospective randomized double-blind study comparing
L-epinephrine and racemic epinephrine aerosols in the
treatment of Laryngotracheitis (Croup) 1992 ; 89 : 302
6.

26

Acute Bronchiolitis

6-24

()

(Bronchiolitis)

(bronchioles)

respiratory syncytial
adenovirus type 7,

virus (RSV) parainfluenza,

3, 21, rhinovirus, influenza virus
5
739

..2529-2530
25
11 ( 44)
RSV
32,
parainfluenza virus type 3 8, influenza virus
type 6 4

27

(diminished

2-3

vesicular breath sound)

wheezing
fine
crepitation

generalized

hyperinflation

interstitial

infiltration

Respiratory rate
chest wall
saturation

60

monitor

Oxygen saturation

oxygen (35-40% by

retraction

oxygen

94%

mask or hood)

Apnea

underlying

prematurity

cardio

immunosuppression

pulmonary

deficiency

disease

28

(General supportive c

are)

()

RSV

humidified oxygen
monitor

Pulse-oximeter

hydration

beta-2

agonists

clinical signs

debris

edema

airway

(Specific

bronchospasm

asthma

(continuous

positive

nasal CPAP

pressure)

generalized air trapping

oxygen saturation

expiratory wheezes

(-,

hypoxemia

94%

treatment)

29

epinephrine 1:1000

ml/kg

0.05-0.5

NSS 3 ml ( 4

=2.5

ml/dose)

Wheezing child
nebulized beta 2 agonist

10 15

10 15

try second dose

bronchodilator

Rx as asthma

Dx Acute

Bronchiolitis

Rx Admit ,

humidified O2

Supportive

care
epinephrine

pneumonia

nebulized

AB

Support
ventilation (nasal

30
Ventilator)
Wheezing child

Pneumonia

()

respiratory bronchiole

8-10

CPAP,

alveoli

terminal

( 1)

Pathogen

<3

3 months

>5 years

months

5 years

Streptococcus pneumoniae

+++

+++

+++

Viruses

+++

+++

++

Enteric bacilli

+++

31
Group B streptococci

+++

Chlamydia trachomatis

+++

Staphylococcus aureus

++

Haemophilus influenzae

+++

Group A streptococci

Mycoplasma pneumoniae

++

+++

Chlamydia pneumoniae

++

+++, very frequent; ++, moderately frequent,

+, rare,

very rare; -, absent.

Ref: Pechre. Community-acquired pneumonia in children.
Cambridge Medical Publication 1995;P30

. . 2513-2523

54.6

13

45.5

9.4

lung aspirates

lung aspirates

influenzae = 24.8

H. influenzae

incidence
15.5 %

blood culture

S. pneumoniae

S. aurens

S. pneumoniae

28.4

H.

2)

respiratory syncytial virus

17.7-35.8 (

+,

32
2

RSV

(%

LRI

2542)
**

53.6

20.3

( 2541-

**

17.7
35.8

2530)

22.7

RSV

10.96

41.2

( 2529-

S. pneumoniae

RSV

8.96

< 2

1-5

nasi

- 11

60

40

50

chest wall retraction, flaring ala

33

sonorous

bronchial

breath

fine

medium crepitation

rhonchi
sound

consolidation

1.

cu.mm.)

neutrophils
2.

15,000

toxic granules

shift to the left

(>

peribroonchial (interstitial) infiltration

lobar consolidation

pneumatocele

effusion

S.

parahilar

S. pneumoniae

aureus

pleural

S. aureus, S. pneumoniae, H.

influenzae, mycoplasma

34
3.

sputum

sensitive
4.

specific

5.

6.

antigen

20

nasopharyngeal aspirate

respiratory

syncytial virus, adenovirus, influenza virus

nasopharynx
7.

antigen

pleural effusion

Pleural fluid gram stain

effusion

nasopharyngeal aspiration

colonization

Hemoculture

nasopharyngeal aspiration

effusion

culture

pleural

8. Cold agglutinin of mycoplasma titer

mycoplasma

9. Tuberculin test

(Specific treatment)

35
1.
care

supportive

2.

(1)

Penicillin

Amoxicillin 40-50 mg/kg/day

Erythromycin 30-40 mg/kg/day

5-7

H.influenzae
Cefuroxime
Cefprozil

S.pneumoniae

axetil

Cefaclor ( 1
6

5 15

S.aureus

acid

3)

Chlamydia trachomatis

pneumoniae

Amoxicillin-clavulanic

Erythromycin

14

Amoxicillin

Penicillin V

Mycoplasma pneumoniae

Erythromycin

14

5-7

Chlamydia

36

Penicillin

Ampicillin

generation cephalosporin
7-10

( 2)

Aminoglycoside

Cefotaxime

third

Ceftriaxone

Cloxacillin

5
Ampicillin I.V.
Amoxicillin 7

S.aureus

14-21

Ampicillin

Aminoglycoside

Cephalosporins

H.influenzae Cefuroxime Cefotaxime
Amoxicillin clavulanic acid 10-14
Staphylococcal
pneumonia
Cloxacillin

3
5 15
Penicillin G, I.V. 6 3
Penicillin V Amoxicillin 3
Penicillin Erythromycin

S.pneumoniae

Penicillin 200,000-300,000 units/kg/day Cefotaxime
Ceftriaxone

37
Staphylococcal pneumonia
Cloxacillin 100-150 mg/kg/day

S.aureus 3

empyema pleural effusion Cloxacillin 200300 mg/kg/day

( General supportive care )
1.

2. (
70 )
3. wheeze rhonchi

4.

5. ( Chest physical therapy )

(Vibration)
6.
7.

(Endotracheal intubation)

1. 2

2. (moderately sever respiratory

distress)

hypoxemia

3.

38
4. S. aureus

(pleural effusion, empyema, lung abscess)

5.
6.

1 :

5 15

Amoxicillin
Amoxicillin
Erythromycin
Pen V.

Erythromycin

39

5-7

Admit

Admit

5-7

S.pneumoniae
& H.influenzae

Pen.

Amoxicillin clavulanic acid

Cefuroxime P.O
Cefprozil P.O
Mycoplasma
S.pneumoniae
Cefaclor P.O Chlamydia
pneumoniae

Amoxicillin +
Erythromycin

Amoxicillin

clavulanic acid
14
(double
dose)

Cefuroxime P.O

40
P.O
P.O

2 :

Cefprozil

Cefaclor

Admit +
Supportive care

15

PGS

< 2

Ampicillin I.V.*

41
+ Aminoglycoside

Penicillin G, I.V.

Cefotaxime

Ceftriaxone

2-3

cloxacillin

Ampicillin I.V.
2-3

S.aureus

Cloxacillin

S.aureus

Pen V

Ampicillin

Ampicillin

S.pneumoniae
Amoxicillin

Aminoglycoside

Amoxicillin

Cefuroxime I.V.

Cefotaxime I.V.

PGS high dose

Amoxicillin +

clavulanic acid

Ceftriaxone

Cefotaxime

42

43

1 :

(mg/kg/day)

Amoxicillin

40-50

Erythromycin

30-40

3-4

Amoxicillin + Clavulanic acid

40-50

2-3

Cefuroxime axetil

40-50

Cefprozil

30-40

Cefaclor

40-50

/
/

/
/
/

, MIC, bioavailability

in vivo study

2 :

Ampicillin

(mg/kg/day)

100-200

40-50

Cloxacillin**

100-150

Penicillin G Sodium

100,000-

Amoxicillin + clavulanic acid

44
200,000
Gentamicin

units/Kg/day

5-7

8-12

Cefuroxime

15-30

6-8

Cefotaxime

100-150

6-8

Ceftriaxone

100-150

8-12

Amikacin

50-80
**

empyema

pleural effusion

pneumatocele

200-300 mg/kg/day

3 : Minimal inhibitory concentration (MIC)

penicillin

MIC (mg/l)

S.pneum

H.influenz

S.aur bioavala

oniae

ae

eus

bility

Cephalexin

2.0

16.0

4.0

80%

Cefaclor

2.0

4.0

2.6

50%

Cefuroxime

0.06

0.25

0.25

50%

45
Amoxicillin -

0.5

clavulanic acid

( Pechre JC. Community acquired pneumonia in

children. Cambridge Medical
Publication 1995; pp. 81-82)

46
Acute bronchiolitis

1. American Academy of Pediatrics : Reassessment of the

indications for ribavirin therapy in respiratory syncytial
virus infections. American Academy of Pediatrics
Committee on Infectious Diseases. Pediatrics 1996 Jan;
PT-REVIEW, TUTORIAL(1): 137-40[Medline].
2. De Boeck K, Van der Aa, Van Lierde S : Respiratory
syncytial virus bronchiolitis : a double-blind
dexamethasone efficacy study. J Pediatr 1997; 131(6):
979-921[Medline].
3. Flores G, Horwitz RI : Efficacy of beta2-agonists in
bronchiolitis: a reappraisal and meta-analysis. Pediatrics
1997; 100(2): 233-239[Medline].
4. Kellner JD, Ohlsson A, Gadomski AM: Efficacy of
bronchodilator therapy in bronchiolitis: A meta-analysis.
Arch Pediatr Adolesc Med 1998; 150(11): 11661172[Medline].
5. Klassen TP, Sutcliffe T, Watters LK: Dexamethasone in
salbutamol-treated in patients with acute broncholitis: a
randomized, controlled trial. J Pediatr 1997; 130(2):
191-196[Medline].
6. McConnochie KM, Roghmann KJ: Predicting clinically
significant lower respiratory tract illness in childhood
following mild bronchiolitis. Am J DisChild 1985; 139:
625-631[Medline].
7. Suwanjutha S, Chantarojanasiri T, Preutthipan A, et al.
Incidence of respiratory syncytial virus lower respiratory
tract infection in under-5-year-dd children at a rural
community of Thailand. Final report to RTG-WHO
Collaborative Programme Ref no 000068 ; Jan 31,
2000.
8. Van Woensel JB, Wolfs TF, van Aalderen WM:
Randomised double blind placebo controlled trial of
prednisolone in children admitted to hospital with
respiratory syncytial virus bronchiolitis. Thorax 1997 Jul;
52(7): 634-7[Medline].

47
9. Weber MW, Mulholland EK, Greenwood BM: Respiratory
syncytial virus infection in tropical and developing
countries. Trop Med Int Health 1998; 3(4): 268280[Medline].
Pneumonia
1.

, ..

. .2526 2527

2528 ;

10 (1) : 31-35
2.

3.

RSV LRI
4.

2542

( 1 )

. Pneumonia

. Ambulatory Pediatrics 2.

2542 : 544-50
5. Campbell PW. Pneumonia. In : Rudolph AM, ed.
th
Rudolphs Pediatrics. 20 ed. London :Prentice Hall
International 1996 ; 56-77
6. Chantarsjanasiri T, Suwanjutha S, Wattanakasetr S,
Etiology, treatment and outcome of hospitalized
pneumonia in young children at Ramathibodi Hospital.
I Med Assoe Thai 1993; 76 (Suppl 2) : 156 64.
7. Long SS. Pneumonia in older infants children and
adolescents. In : Schidlow DV, Smith DS, eds. A
practical guide to pediatric respiratory diseases. Hanley
& Belfus, Inc 1994 : 91

48
8. Pornkul R, Suwanjutha S, Ruangkanchanasetr S.
Correlation of roentgenologic diagnosis and etiologic
agents of pneumonia in Thai childrn under 5 years of
age. Med Assoc Thai 1993 ;76 (Suppl 2) : 178-186
9. Sunakorn P, Chuenchit L, Niltawat S, et al.
Epidemilolgy of acute respiratory infection in young
children from Thailand. Pediatr Infect Dis J 1990 ; 9
(12) : 873-877
10. Suwanjutha S, Chantarojanasiri T, Wattana-kasetr S,
et al. A study of nonbacterial agents of acute lower
respiratory tract infection in Thai children. Review Infect
Dis 1990 ; 12 (Supp 8) : Nov-Dec page?

Wheezing associated respiratory illness

49
Wheezing
asthma

infections

acute respiratory infections

viral infections

bronchodilators

bronchitis

respiratory tract infections

wheezing

bronchitis

wheezing

asthma

. .

2530

wheezing

asthma

first attack

viral infection

first wheezing

possible asthma

asthma

. . 2529

lower respiratory infections

wheezing 12.7%

pneumonia

Terminology

. . 1990

recurrent wheezing

acute

WHO/ARI/93.29

bronchiolitis

bacterial

wheezing

recurrent wheezing

acute respiratory infections

asthma

wheezing

asthma

wheezing

pneumonia

asthma

bronchitis

antibiotics

physical sign

wheezing

. . 2541-2542

50.7%

560

. .

50
lower respiratory infections

215

pneumonia 88

wheezing

wheezing

associated respiratory illness

Wheezing

wheeze

56.3%

wheezing

50%

soft musical sound

( oscillation )

small airways

positive intrapleural pressure ( negative pressure)

pressure

trachea

secondary compression

wheeze

large

trachea

airways

large airways

polyphonic wheezing

single airway

monophonic wheezing

wheezing

wheezing

recurrent wheezing

51
Causes of wheezing in children
Infancy
Older child / adolescent
Acute :-

Bronchiolitis

Acute :-

Asthma
Asthma

Foreign body
Chronic:-

Asthma

Allergic reaction
Recurrent aspiration
Chronic:- Asthma
Vascular

ring/sling

Retained foreign body

Tracheal
Cystic fibrosis

stenosis

(rare)
Tracheomalacia

Vascular ring / sling

Cystic

fibrosis

Tracheomalacia
Environmental exposure
Allergic bronchopulmonary -

52
- passive smoking
-aspergillosis
Pulmonary hemosiderosis
Psychogenic

Causes of recurrent or persistent wheezing in children

Reactive airway disease
Atopic asthma
Infection associated airway reactivity
Exercise-induced asthma
Salicylate-induced asthma and nasal polyposis
Other hypersensitivity reactions :
Hypersensitivity pneumonitis
Tropical eosinophilia
Visceral larva migrans
Allergic aspergillosis
Aspiration :

53
Foreign body
Food, saliva, gastric contents
Laryngo-tracheoesophageal cleft
Tracheoesophageal fistula, H-type
Pharyngeal incoordination or neuromuscular
weakness
Cystic fibrosis
Ciliary dyskinesis
Cardiac failure
Bronchiolitis obliterans
Extrinsic compression of airways
Vascular ring
Enlarged lymph node
Mediastinal tumor
Lung cysts
Tracheobronchomalacia
Endobronchial masses
Gastroesophageal reflux
Pulmonry hemosiderosis
Sequelae of bronchopulmonary dysplasia
Hysterical airway closure

54
Cigarette smoke, other environmental insults
Wheezing in ARI
Wheezing

60%

asthma

wheezing

viral infection

wheezing

URI

wheezing

wheezing

associated atopy

wheezing in ARI

1. Viruses
adenovirus,

wheezing

2. Bacteria

rhinovirus,

IgE response

RSV bronchiolitis

Chlamydia pneumoniae,

parainfluenza,

infection

RSV,

coronavirus

influenza A

early episode

recurrent
asthma

Mycoplasma pneumoniae

S. pneumoniae,

H. influenzae

3. Mixed viral bacterial infection

viral

55

bronchiolitis

wheezing

ARI

asthma

1.

respiratory distress

bronchodilator (inhaled beta-2 agonist)

wheezing

fast breathing

3-5

fast breathing

oral bronchodilator
2.

2 2.1

15

wheezing

rapid-acting
30

oral bronchodilator

pneumonia

antibiotic

respiratory distress

18

bacteria

oxygen

bronchiolitis

1 )

nebulized

First episode of wheezing (

virus

ARI

acute

beta-2 agonist

asthma

10-

bronchodilator

wheeze

second dose

acute bronchiolitis

56
admit

supportive

antibiotic
-

wheezing

airway disease
3-5

nebulized

pneumonia

fast breathing

pneumonia with

antibiotic

oral bronchodilator

wheeze

bronchitis

asthma

reactive

oral bronchodilator

2.2

Recurrent wheezing

asthmatic attack

post bronchiolitic wheeze

oxygen

cyanosis

agonist

response

cyanosis

2-3

2 )

bronchodilator

try bronchodilator

OPD

10-15

nebulized beta-2

distress

corticosteroids

aminophylline

pneumonia

1-2

antibiotics

1-2

oxygen

asthma

admit

inhaled short-acting beta-2 agonist

epinephrine

reactive airway disease

care

oxygen,
systemic

intravenous

pneumonia

oral bronchodilator

57
-

bronchodilator
pneumonia

fast breathing

Rapid-acting bronchodilator
nebulizing solution

./ ./

( 2.5

./ ./

( 5

normal saline

2-3 puffs

./

./

beta-2 agonist

./ ./

.)

( 2.5

salbutamol

0.05-0.15

terbutaline

0.2-0.3

medication nebulizer

2.5 3

oxygen flow rate 6-8

metered dose inhaler

5

Oral bronchodilators
( 2

liquid beta-2 agonist

mouth piece

recurrent wheezing

oral

antibiotics

investigate

distress

3-4
.)

face mask

spacer

2 puffs

salbutamol

3-4

terbutaline

0.1

./ ./

0.075

58

Rx of first wheezing with respiratory

distress in young children
Nebulized 2-agonist

10-15

wheeze, resp.

wheeze

try second dose bronchodilator

10 -15

wheeze

fast

breathing

fast

breathing

Dx - Acute bronchiolitis
Rx - Admit, humidified O2

Dx - Pneumonia

Dx - bronchitis
- Supportive care
wheeze

c
c wheeze

59
-

nebulized epinephrine

bronchodilator
-

AB

Rx - oral
asthma
+ AB

Rx - oral bronchodilator

pneumonia

indrawing

3 - 5

- First wheezing

chest

admit

acute bronchiolitis,

ARI c wheeze, first episode of asthma

- AB = antibiotics
- second dose bronchodilator =
-agonist

nebulized 2

subcutaneous 2 - agonist,
adrenaline

Rx of recurrent wheezing with respiratory

distress in young children
Nebulized 2-agonist

60
(1-3

10-15

response

ddistress

Rx - Admit

Rx -

oral

bronchodilator
- O2 ,supportive care
fast breathing

AB

AB

1 - 2

1 - 2 hr

IV aminophylline

2-agonist

Systemic corticosteroid

- inhaled short-acting
pneumonia

pneumonia

- oral bronchodilator 1-2

asthma
-

61
-

prophylactic drug

inhaled corticosteroid, cromolyn

MDI

spacer

puffs

15

2-3

- Recurrent wheezing
asthmatic attack

acute

post bronchiolitic wheeze

1. .

2542.

2. Bronchodilators and other medications for the treatment

of wheeze- associated illnesses in young children.
WHO / ARI / 93.29
3. Dorkin IH. Noisy Breathing. In : Loughlin MG, Figen H,
eds. Respiratory Disease in Children : Diagnosisi and
Management. Baltimore : Williams & Wilkins, 1994 :
167 73

62
4. Pasterkamp H. The History and Physical examination.In
: Chernick V, Kendig El, Jr eds. Kendigs Disorders of
th

the Respiratory tract in Children. 5 ed. Philadelphia :

W.B. Saunders 1990 : 56-77.
5. Sunakorn P, Suwanjutha S, Nawanoparatkul S, et al.
Sheezing, RSV and lower respiratory infection in
children. (in press)
6. Stern CR. Approach to Recurrent or Persistent lower
respiratory tract symptom in children. In : Behrman ER,
Kliegman MR, Nelson EW, Voughan III CV, eds.
Nelson Textbook of Pediatrics. 14

th

ed. Philadelphia :

WB Saunders, 1992 : 1102 - 6

7. Vangveeravong M, Suwanjutha S, Chantarojanasiri T.
Natural course of wheezing children with lower
respiratory tract infections. Bull Dept Med Serv 1993 ;
18(2) : 73 - 8

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