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 ARI

Dr.sneha varkki
 Classification based on site of
involvement
• Upper respiratory tract
nasal cavity,paranasal sinuses,middle ear
,tonsillo pharyngeal
• Lower respiratory tract-
airways,parenchyma,pleura
 Etiology -What causes ARI: Viruses
• Respiratory Syncytial Virus • Rhinovirus

• Adenovirus
• Parainfluenza/Influenza
 What causes ARI: Bacteria
• Streptococcus pneumoniae:
– most common cause, may be complicated by empyema
– Conjugated vaccine protects - up to 70% effective in infants
• Haemophilus influenzae, usually type B
– Most common cause in infants before HiB vaccine introduced
– High level of protection from HiB vaccine
• Staphylococcus aureus
– Varies in prevalence, common as a secondary infection after measles,
chicken pox, influenza
– Often severe, multifocal, complicated by empyema
• Mycoplasma pneumoniae
– Difficult to diagnose, may be most common cause in school aged children.
 Pneumonia -causes
• Group B streptococcus and Gram negative
organisms in neonates
• Other viruses like measles ,varicella cause
pneumonia
• Fungal and opportunistic pathogens in special
situations
 Pneumonia causative agent-based on
age
• 0-1 month: E coli,Klebsiella,S.aureus,Gr B
strep,Listeria
• 1mn-5 yr: Pneumo, H flu,Gr A strep
uncommon- staph (>1 year),Kleb,chlamydia
• Over 5 yrs : Pneumo,H flu,mycoplasma
• Bronchiolitis -2mn -2 years
• Fungal-depending on predisposition
 Pathology
• Bronchopneumonia
• Lobar pneumonia
• Bronchiolitis
• Tracheobronchitis
• Pleural infections
 Anatomy of airway symptoms
Irritati n bstruction

Inspiratory
stridor

Cough
Expiratory
Wheeze
Hyperexpansion

Chest Expiratory
pain grunting
 Clinical features-signs
• Work of breathing-
• Features of inflammation
• Systemic effects-hypoxia,
• Specific signs of pathology
• Signs of complications
 Radiology
• Opacification
• Airbronchogram
• Bronchial wall thickening
• Round pneumonia
• Volume loss,collapse
• Hyperinflation
• Silhouette of the solid organs
• complications
Upper lobar pneumonia
Bronchopneumonia
 Other investigations
• White Blood count/ESR/CRP - usually raised
but not specific
• Blood cultures - positive in <10% of cases
• Sputum or bronchial lavage cultures - positive
in <10% cases
• Lung aspiration/biopsy - most specific but
most invasive test.
 Clinical decision making
• WHO ARI criteria
• Uses 2 simple clin signs-tachypnoea,chest
retractions
• No pneumonia/fast breathing and or chest
indrawing pneumonia/verysevere pneumonia
 Clinical signs
• Fast breathing >60 under 2 months age
>50 between 2 to12 month
>40 between 1 to 5 years
• Chest retractions
• Danger signs -cyanosis,inability to drink (or
persistent vomiting), seizures,drowsiness,
stridor,malnutrition
• Also look for grunting,lethargy
 Revised WHO criteria
• Recommendation 1 Children with fast breathing pneumonia with
no chest indrawing or general danger sign should be treated with
oral amoxicillin: at least 40mg/kg/dose twice daily (80mg/kg/day)
for five days
• Recommendation 2 Children age 2–59 months with chest
indrawing pneumonia should be treated with oral amoxicillin: at
least 40mg/kg/dose twice daily for five days.
• Recommendation 3 Children aged 2–59 months with severe
pneumonia should be treated with parenteral ampicillin (or
penicillin) and gentamicin as a first-line treatment. —
Ceftriaxone should be used as a second-line treatment in children with
severe pneumonia having failed on the first-line treatment.
 Case Scenario

• Muthu, aged 18 months, has a 5 day history of

fever and cough and his breathing is getting
faster,he has not been drinking .
• He has no wheeze, but he is tachypnoeic -RR
60/min, has a short expiratory grunting noise and
is lethargic.
• Diagnosis

• Management—
oxygen,Antibiotics(Ampi+Genta),IV fluids
• Careful feeding
 Case Scenario-2
• Muthu’s brother 4 year old Lokesh has had fever for 5 days
and cough,He is munching a biscuit and playing with a toy car
in the clinic
• His temp is 100oF, His RR is 44/min.He is not using accessory
muscles of respiration.
• Diagnosis-pneumonia
• Treatment-antibiotic-amoxycillin 80mg/kg in 2 divided
doses,can go home
• Review –after 2 days
Diagnosis of Pneumonia: WHO criteria

• Presentation with fever and cough

• Tachypnea and indrawing without wheeze

• These criteria are designed to reduce mortality in

areas where bacterial pneumonia is common and
access to treatment is poor

• The criteria will identify many viral infections as

pneumonia but reduction of mortality is the
advantage.
 Treatment-overview
• Identification
• Assess severity
• Decide where to manage
• Supportive treatment ( home/hospital)
• Hydration/nutrition
• Careful feeding
 Treatment -antibiotics
• Home management-
Amoxycillin,septran,macrolides,cephalosporin
• Hospital-Ampicillin,Penicillin
cefuroxime,co amoxy clav

• ARI progromme-
• If staph inf suspected-clox used
• Very sick patients,immunosuppressed patients
are exceptions
Special situations
 Case Scenario

• Shanti is a 2 month old baby, born prematurely

• She has had 3 days runny nose,low grade fever cough,
wheeze and rapid breathing .
• On examination she has respiratory distress, marked chest
retractions ,expiratory wheeze, hyperexpansion,
auscultatory crepitations throughout the chest and an
oxygen saturation 91%
 Bronchiolitis epidemiology

• Acute wheezing illness of infants < 1 year. May also have

viral consolidation/collapse in alveoli
• Tend to worsen on third and fourth day of illness
• Annual monsoon epidemic
• Caused by viruses, predominantly respiratory syncytial
virus (RSV).
• Severe in children with lung disease of prematurity
,congenital heart disease
• Sec bact infection with severe cases
 Bronchiolitis treatment
• Humidified O2
• Fluid management
• Feeding
• Saline or 3% saline nebs
• Bronchodilators-continue if beneficial
• Steroids –not needed
• Antibiotics
 Case Scenario
• Ramesh (12 months & previously well) has
had 1 day of and noisy breathing
• The illness started with a runny nose
• He has a loud, barking cough, inspiratory
breathing noise, inspite of this he is happy
to play with the stethescope!
 Viral croup: epidemiology
• What viruses cause it?
– Parainfluenza 1-3
– Most other respiratory viruses can
• Age & Sex predominance?
– 1-2 years, 70% males
• Differential-Foreign body
Treatment- mild case observation
– Mod/severe-oral dexa,nebulised adrenaline,airway Mx
 Case Scenario
• Deepak is a 1.5 month old baby
• He has had 3 days of runny nose, then started getting
apneas and paroxysmal cough
• He coughs whenever he is fed or crying
• He can’t catch his breath when coughing. He goes red in
the face and sometimes vomits or has an apnea
• On examination at rest he is afebrile and has no
respiratory distress or chest signs
 Whooping cough (Pertussis)
• Organism?
– Bordetella pertussis
– Infectivity?
– High - any age, immunity short lived
– Spread around children and young adults
• Virulence?
– High for young babies (apnea, cardiorespiratory arrest). Low for older
• Duration of symptoms?
– Many weeks or months with gradual resolution
– May relapse slightly with intercurrent URTIs

Treatment-supportive treatment, Erythromycin shortens infective period

Epiglottitis: clinical presentation
• Age & sex predominance
– Both sexes, pre-school
• Typical features
– Rapid onset over hours
– Fever, lethargy, stertor, sitting posture, drooling, pallor
• Aetiology
– Haemophilus influenzae Group B
Epiglottitis

Normal
Epiglottis
 epiglottitis
• Mortality
– High if not intubated promptly
• Management
• Judicious investigation
throat examination under controlled
conditions
expert intubation, antibiotics
 URTI
• Recognition based on ARI criteria
• Avoid antibiotics and un necessary meds
• Comfort measures
• May need antibiotics in certain situations
 Complications
• Hypoxia
• Spread of infection-systemic
• Local –empyema
• Pneumothorax
 prevention
• Risk factors
• Specific strategies
 Risk factors for pneumonia in
developing world
• Malnutrition
• Low birth weight(2500gm)
• Non exclusive breast feeding (<4/12)
• Lack of measles vaccination
• Indoor air pollution
• crowding
 Vaccination

• DPT
• Measles
• HIB
• Pneumo
• Flu vaccine
• Tb
 Persistence or recurrence
• Identify persistence /recurrence
• Cause-
aspiration,CHD,obstruction,immunodef,defenc
e mechanism defect,congenital anomalies
• Careful work up and follow up
• Recommendation 1 Children with fast breathing pneumonia with
no chest indrawing or general danger sign should be treated with
oral amoxicillin: at least 40mg/kg/dose twice daily (80mg/kg/day)
for five days
• Recommendation 2 Children age 2–59 months with chest
indrawing pneumonia should be treated with oral amoxicillin: at
least 40mg/kg/dose twice daily for five days.
• Recommendation 3 Children aged 2–59 months with severe
pneumonia should be treated with parenteral ampicillin (or
penicillin) and gentamicin as a first-line treatment. —
Ceftriaxone should be used as a second-line treatment in children with
severe pneumonia having failed on the first-line treatment.