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ARI management training

TOPIC 1. INTRODUCTION

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CONTENTS
Introduction
Definition and scope of ARI Epidemiology & burden of ARI Common cold - acute rhinopharyngitis Croup - laryngotracheobronchitis Acute otitis media

DEFINITION AND SCOPE

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CLASSIFICATION
ANATOMICALLY :
(AURI)
(ARNOLD,1996)

ACUTE UPPER RESPIRATORYINFECTIONS


INDONESIAN :

INFEKSI RESPIRASI AKUT ATAS ( IRA-A)

ACUTE LOWER RESPIRATORY INFECTIONS (ALRI)


INDONESIAN :

INFEKSI RESPIRASI AKUT BAWAH (IRA-B)

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AURI (IRA-A) : COMMON COLD (RHINITIS, RHINOPHARYNGITIS)


PHARYNGITIS - TONSILOPHARYNGITIS RHINO-SINUSITIS OTITIS MEDIA

ALRI (IRA-B) : EPIGLOTITIS


LARYNGO-TRACHEOBRONCHITIS BRONCHITIS BRONCHIOLITIS PNEUMONIA

EPIDEMIOLOGY AND BURDEN


The most common illnesses in childhood, comprising as many as 50% of all illnesses in children less than 5 years old and 30% in children aged 5 - 12 years.

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MORBIDITY
50% OF ALL ILLNESS DISEASE IN CHILDREN UNDER 5 YEARS; 30% IN CHILDREN 5 -12 YEARS MOST INFECTIONS ARE LIMITED TO UR TRACT, ABOUT 5% LR TRACT EPISODE IN URBAN 5-8, RURAL 3-5/YEAR PNEUMONIA IN DEVELOPING COUNTRY IS MORE THAN IN DEVELOPED COUNTRY

IN INDONESIA
MORBIDITY

ESTIMATION IN CHILDREN 5 YEARS OF AGE 10-20% ( 2.33 - 4.66 MILLION) MORTALITY >> PNEUMONIA

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WHO ARI control program (included in


IMCI Algorithm ) uses simple clinical sign are Respiratory rate and Chest indrawing for ARI classification WHO ARI classfication :
2 months - 5 tahun of age 1. SEVERE PNEUMONIA 2. PNEUMONIA 3. NO PNEUMONIA until 2 months of age 1.SEVERE PNEUMONIA 2.NO PNEUMONIA

ETIOLOGY
AURI : >> VIRUS ( 90%) COMMON VIRUSES AURI (IRA -A) : Rhinovirus, Corona virus, Adenovirus, Entero virus ALRI (IRA -B) : RSV, Para influenza 1,2,3; Corona virus, Adeno virus, Enterovirus

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Common cold

COMMON COLD

an acute, self limited, mild upper respiratory viral illness sneezing, nasal congestion and discharge (rhinorrhea), sore throat, cough, low grade fever, headache and malaise. to be distinguished from influenza, pharyngitis, acute bronchitis, acute bacterial sinusitis, allergic rhinitis, and pertussis.
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...COMMON COLD

many viral pathogens can cause the symptoms of the common cold

the most common : > 100 serotypes of rhinoviruses.

Common cold may occur at any time of year, high prevalence during the fall and winter
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...COMMON COLD

An estimated 25 million individuals seek medical care for uncomplicated URI annually in the US Approx. 30 % of these visits result in a prescription for antibiotics.

Inaccurate perceptions that bacteria cause colds and that antibiotics improve outcome

Infants and children are affected more often and experience more prolonged symptoms
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...COMMON COLD

many viral pathogens can cause the symptoms of the common cold

the most common : > 100 serotypes of rhinoviruses.

Common cold may occur at any time of year, high prevalence during the fall and winter
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Viral cause of the common cold


Virus Rhinoviruses Coronaviruses Influenza viruses Respiratory syncytial virus Parainfluenza viruses Adenoviruses Enteroviruses Metapneumovirus Unknown Estimated annual proportion of cases (percent) 30-50 10-15 5-15 5 5 <5 <5 Unknown 20-30

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...COMMON COLD

Viral transmission may occur via


inhalation of small particle aerosols, deposition of large particle droplets on nasal or conjunctival mucosa, or direct transfer via hand-to-hand contact

...COMMON COLD

Symptoms usually appear 1-2 days after viral inoculation symptoms are not the result of viral destruction of the nasal mucosa. nasal epithelium remains intact, although there is an influx of PMNs into the nasal submucosa and epithelium viral infection increases vascular permeability in the nasal submucosa, releasing albumin and kinins
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Proposed sequence of events during rhinovirus infection of nasal epithelium


Infection of nasal epithelial cell

Infected cells undergo apoptosis and are extruded from the mucosa

Signalling within cells occur via NF-kB (and perhaps other pathways)

Elaboration of pro inflammatory cytokines

Initiation of plasma exudation from submucosal capilaries

Recruitment of PMNs to nasal epithelium (IL-8)

Pappas DE, Hendley JO. Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections. Up to date. Last updated February 2008

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...COMMON COLD

Colored nasal discharge


~ increased presence of PMNs presence of PMNs (yellow or white color) or of PMN enzymatic activity (green color)

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...COMMON COLD

TREATMENT

Supportive therapy is the only recommended treatment Antihistamines, decongestants, antitussives, and expectorants, singly and in combinations, are all marketed for symptomatic relief in children. few clinical trials of these products in infants and children and none that demonstrate benefit for treatment of the symptoms
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...COMMON COLD

Symptomatic therapy

may include antipyretics, saline nasal irrigation, adequate hydration, and the use of a humidifier Children with reactive airway disease or asthma should use beta-agonist medications to relieve associated bronchospasm.

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...COMMON COLD

Antipyretics

Acetaminophen (or ibuprofen, in children greater than 6 months of age) may be used to alleviate fever during the first few days

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...COMMON COLD

Saline irrigation

In infants, bulb suction with saline nose drops may help to temporarily remove nasal secretions in the older child, a saline nose spray may be used.

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...COMMON COLD

Antihistamines

The anticholinergic effects of 1st generation AH (eg, diphenhydramine) may help to reduce the secretions in controlled trials, AH have been ineffective in relieving the symptoms, in combination with decongestants or as monotherapy

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...COMMON COLD

Antitussives

Cough is a common complaint during the course For many children, effective cough suppression could result in mucus plugging No cough suppressants have proven effective in children.

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...COMMON COLD

In a study comparing placebo, DMP, and codeine for treatment of cough in children 18 mo - 12 y.o - no difference found between the groups, and all three groups showed significant improvement within three days Insomnia was reported in 3 of 33 children in the dextromethorphan group.

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...COMMON COLD

Because of the potential serious toxicities and the lack of proven efficacy, these medications are not recommended for pediatric use.

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Decongestants

sympathomimetic medications that cause vasoconstriction of the nasal mucosa. available in oral and topical formulations. pseudoephedrine HCl, and phenylephrine HCl, and oxymetazoline.

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...COMMON COLD

In adults: decrease nasal congestion and increase patency, no studies demonstrating the effectiveness of these medications in children. Side effects may include tachycardia, elevated diastolic blood pressure, and palpitations.

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...COMMON COLD

Because of the substantial risks of these products without proven benefit


not recommended for pediatric use.

It is conceivable that the older adolescent may benefit as an adult would from the use of a decongestant, such as pseudoephedrine

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...COMMON COLDv

Zinc

The efficacy for treatment of the common cold remains unclear. for every study that demonstrates benefit, there is another that shows none. Randomized trials in children also have shown conflicting results, Side effects may include bad taste, nausea, throat irritation, and diarrhea
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...COMMON COLD

Other treatments

Echinacea Vitamin C Honey Antibiotics

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...COMMON COLD

Antibiotic therapy

There is no role for antibiotics in the treatment does not prevent secondary bacterial infection may cause significant side effects, contribute to increasing bacterial antimicrobial resistance.
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The use of antibiotics should be reserved for clearly diagnosed secondary bacterial infections, including bacterial otitis media, sinusitis, and pneumonia

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...COMMON COLD

PREVENTION

The best methods for preventing transmission from one person to another are to practice frequent handwashing and to avoid touching one's nose and eyes.

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How Colds Are Spread ?

How Colds Are Spread ?

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Laryngotracheobronchitis

DEFINITION
Primarily pediatric viral respiratory tract illness that affect larynx, trachea, and bronchi Characteristic : hoarseness, a seal-like barking

cough, inspiratory stridor with or without variable degree of respiratory distress

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EPIDEMIOLOGY
Accounting for approximately 15% of clinic and emergency department visits for pediatric respiratory tract infections

Incidence: 6 months old 6 years old with peak incidence: 1-2 years old
The male-to-female ratio for croup is approximately 3:2 The disease is most common in late fall and early winter but may occur at any time of year Approximately 5% of children experience more than 1 episode

ETIOLOGY
Human Parainfuenza virus type 1,2,3,4 Virus influenza A and B 60% Adenovirus Respiratory syncytial virus (RSV) Enterovirus Human bocavirus Coronavirus[3] Rhinovirus Echovirus Reovirus Metapneumovirus[4] Influenza A and B Rarer causes - Measles virus, herpes simplex virus, varicella

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PATHOPHYSIOLOGY
Start at nasopharynx and spread to the epitel of trachea and larynx Diffuse inflamation, redness, and oedema of trachea wall irritate the mobility of vocal cords and subglottis areahoarsenessturbulence air flowstridorretractionhypoxia and hypercapnerespiratory failure

CLASSIFICATION
1. Viral croup: prodromal symptoms respiratory tract infection, obstruction (3-5 days) laryngotracheobronchitis 2. Spasmodic croup: atopic factor, without prodromal symptoms, suddenly occur obstruction especially at night for a moment back to normal

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CLASSIFICATION
Based on the level of emergency: 1. Mild: sometimes barking cough, no stridor, mild retraction 2. Moderate: often barking cough, stridor, mild retraction, no respiratory distress 3. Severe: often barking cough, inspiratory stridor when take a rest, sometimes expiratory stridor, retraction, respiratory distress 4. Threatening life respiratory failure: cough, stridor, decrease of conciousness, letragy

CLASSIFICATION

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CLINICAL MANIFESTATION
Nonspecific respiratory symptoms rhinorrhea, sore throat, and cough Fever is generally low grade (38-39C) but can exceed 40C Within 1-2 days, the characteristic signs of hoarseness, barking cough, and inspiratory stridor develop, often suddenly, along with a variable degree of respiratory distress Symptoms worsening at night, with most ED visits occurring between 10 pm and 4 am resolve within 3-7 days but can last as long as 2 weeks

Skor Croup Westley


Total score: 0 -17 points. Stridor (0 = none, 1 = with agitation only, 2 = at rest) Retractions (0 = none, 1 = mild, 2 = moderate, 3 = severe) Cyanosis (0 = none, 4 = cyanosis with agitation, 5 = cyanosis at rest) Level of consciousness (0 = normal [including asleep], 5 = disorientated) Mild croup: 0-2 Moderate croup: 35. Severe croup: 611. Paling banyak digunakan, Valid dalam menilai outcome pada uji klinis penderita dengan croup (kappa 0,90)

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DIAGNOSIS
Diagnostic clues based on presenting history and physical examination findings Laboratory test results confirming this diagnosis complete blood cell (CBC) count is usually nonspecific, although the white blood cell (WBC) count and differential may suggest a viral cause with lymphocytosis

PROCEDURES
Direct laryngoscopy if the child in not in acute distress Fiberoptic laryngoscopy Bronchoscopy (for cases of recurrent croup to rule out airway disorders)

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RADIOGRAPHY
Steeple or pencil sign of the proximal trachea (50%)

THERAPY
To overcome the obstruction or respiratory tract Most of croup didnt need to be hospitazed 1. Inhalation therapynebulized epinephrin a. Racemic epinephrin b. L-epinephrin 1:1000 5 ml

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THERAPY
2. Corticosteroid to reduce oedema mucosa of the larynx a. Dexamethason 0,6mg/kgbw/x b. Budesonid nebulized 2-4mg (2ml) 3. Endotracheal intubationsevere croup 4. Antibioticno need to be used except laryngotracheobronchitis, laryngotracheopneumonitis

PROGNOSIS
Excellent, and recovery is usually complete self limited disease Hospitalization rates vary widely among communities, ranging from 1.5-30% and typically averaging 2-5% < 2% of hospitalized children require intubation 10-year study found a mortality rate of less than 0.5% in intubated patients

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COMPLICATIONS
A secondary bacterial infection may result in pneumonia or bacterial tracheitis Pulmonary edema Pneumothorax Lymphadenitis Otitis media Dehydration

Acute otitis media


Middle ear infection that have correlated with middle ear effusion

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EPIDEMIOLOGY
85% children have acute otitis media 1 x in 1st year of life 50% children have acute otitis media > 2 x 1st year of life having acute otitis media increase the risk of having chronic or recurrent otitis media The incidence decrease at age 6 years United State all children experience otitis media at age 2 years and 3 episodes or more of acute otitis media Peak incidence 3-18 months

PATHOPHYSIOLOGY
Intrinsic mechanical obstruction caused by infection and allergy Extrinsic obstruction caused by adenoid and nasopharynx cancer Functional obstruction caused by the amount and stiffness of cartilage of the tube, most common in children Eustachian tube obstruction pressure of middle ear negative if still persist, middle ear transudat effusion

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ETIOLOGY
Viral Pathogen : Respiratory Synctitial Virus Bacterial Pathogen : 1. Streptococcus pneumoniae (50%) 2. Haemophillus influenzae (20%) 3. Moraxella catarrhalis (10%)

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RISK FACTORS
Prematurity and low birth weight Young age Early onset Family history Race - Native American, Inuit, Australian aborigine Altered immunity Craniofacial abnormalities Neuromuscular disease Allergy

Day care Crowded living conditions Low socioeconomic status Tobacco and pollutant exposure Use of pacifier Prone sleeping position Fall or winter season Absence of breastfeeding, prolonged bottle use

CLINICAL MANIFESTATION
Preceeding by upper respiratory tract infection with fever, otalgia and hearing impairment Baby : irritability, diarrhea, poor feeding, often cry Children : pain and uncomfortable in the ear

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PHYSICAL EXAMINATION
Pneumatic otoscopy: the tympanic membrane signs of inflammation : reddening of the mucosa progressing to the formation of purulent middle ear effusion poor tympanic mobility The tympanic membrane may bulge in the posterior quadrants the superficial epithelial layer may exhibit a scalded appearance

PHYSICAL EXAMINATION
Perforation of the tympanic membrane is not unusual in posterior or inferior quadrants. Before or instead of a single perforation, an opaque serumlike exudate is sometimes seen oozing through the entire tympanic membrane. The discharge initially is purulent, though it may be thin and watery or bloody; pulsation of the otorrhea is common. Otorrhea from acute perforation normally lasts 1-2 days before spontaneous healing occurs. The bullae or blebs may contain serous or hemorrhagic fluid CT scan or MRI if there is complication

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DIFFERENTIAL DIAGNOSIS
External otitis Dental pain Temporomandibular joint pain Acute viral pharyngitis Trauma to the ear

TREATMENT
Depend on culture and sensitivity of the specimen 1st line : Amoxycillin 40 mg/kgBW/24hours, 3x/day,10 days 2nd line : Erytromicin 50mg/kgBW/24hours with sulfonamid (100mg/kgBW/24hours trisulfa or 150mg/kgBW/24hours sulfisoksazol) 4x/day, sefaclor 40mg/kgBW/24hours 3xday, amoxycillinclavulanat 40mgkgBW/24hours 3x/day, cefixim 8mg/kgBW/24hours 1-2x/day

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TREATMENT
Acute otitis media without complication antibiotic in 5 days Supportive theray: analgesic, antipyretic, decongestant

TYMPANOCENTESIS
Neonates who are younger than 6 weeks (and therefore are more likely to have an unusual or more invasive pathogen) Patients who are immunosuppressed or immunocompromised Patients in whom adequate antimicrobial treatment has failed and who continue to show signs of local or systemic sepsis Patients who have a complication that requires a culture for adequate therapy

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PERSISTENT EFFUSION MIDDLE EAR


Persist 10-14 days: 1. Another antibiotic 2. Decongestant, antihistamin 3. Systemic corticosteroid

RECURRENT OTITIS MEDIA


Therapy same as previous Frequently attack : prophylaxis antibiotic (amoxycillin 20mg/kgBW/24hours or sulfonamid 50mg/24hours) Myringotomi

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PROGNOSIS
Death rare Chilren with < 3 episodes of acute otitis media single course of antibiotic Middle ear effusion and conductive hearing loss persist well beyond the duration of the therapy : 70% effusion after 14 days, 50% at 1 month, 20% after 2 months, 10% after 3 months

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