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03/10/2013

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 :

(ARNOLD,1996)

ACUTE UPPER RESPIRATORYINFECTIONS


(AURI)

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

Estimated annual proportion of cases (percent)

Rhinoviruses

30-50

Coronaviruses

10-15

Influenza viruses

5-15

Respiratory syncytial virus

Parainfluenza viruses

Adenoviruses

<5

Enteroviruses

<5

Metapneumovirus

Unknown

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

THANK
YOU...
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