Control of Acute Respiratory Infections (ARI) Program

Acute respiratory tract infection (ARI) is considered as one of the major

public health problems and it is recognized as the leading cause of
mortality and morbidity in many developing countries. The greatest
problem for developing countries is the mortality from ARI in children
less than five year of age. In most countries, ARI occurs more frequently
than any other acute illness, including diarrhea and other tropical
diseases.In developing countries 30% of all patients' consultation and
25% of all pediatric admission are of ARI. Most infections are limited to
the upper respiratory tract and 5% involve the lower respiratory tract.
Incidence of ARI is almost the same all over the world: 5-7 episodes per
child per years in urban areas and 3-5 episodes in rural area.
ARI is mostly caused by both viruses and bacteria. Viral agents account
for 90% of upper respiratory tract infection (URIs), however most of
these infections do not result in fatal sever disease; they are mild and self-
limited illnesses. While bacterial pulmonary infections are common in
developing countries associated with a greater risk of death.

Standard Case Management of ARI

History taken ask about:
a. Age of the patient.
b. Duration of cough.
c. If the child able to drink (2 month to 5 years), or if infant stop feeding
well (< 2 months).
d. If child had fever and was difficult to be awake (for how long).
e. If child had convulsion , difficult breathing and history of cyanosis.
f. History of associated disease like measles and history of treatment.
Physical examination:
a. Count breaths per one minute : Fast breathing is present when
respiratory rate is:
1. 60 or more per one minute for (age <2 months).
2. 50 or more per one minute for (age 2 months up to one year).
3. 40 or more per one minute for (age 1 up to 5 year).
b. Look for chest indrawing :
The child has chest indrawing when lower chest wall goes in when child
breath in. This occur when effort need for breathing more than normal.
c. Look and listen for strider:
Strider is harsh sound when child breathing in. This occurs as a result of
narrowing of upper respiratory passages including (trachea, larynx and
epiglottis).
d. Look and listen for wheeze:
Wheeze is soft musical sound when child breathing out. This occurs as a
result of narrowing of lower respiratory passages.
e. See: if child abnormally sleep or difficult to be a wake.
f. Feel for fever or low body temperature.
g. Check for malnutrition.
H. Check for cyanosis.

Case Classification:
1. Child age less than 2 months: classify into
a. Very severe disease: when any of the following danger signs is
detected:
1. Stop feeding well.
2. Convulsions.
3. Abnormally sleep or difficult to be awake.
4. Strider in previously calm child.
5. Wheezing.
6. Fever or low body temperature.
Treatment: Refer urgently to hospital, keep the infant warm and give
first dose of antibiotic.
b. Severe pneumonia: When the child presented with severe chest
indrawing or fast breathing (≥ 60 / minute).
Treatment: Refer urgently to hospital, keep the infant warm and
give first dose of antibiotic.

c. No pneumonia (cough and cold): when there was no chest

indrawing and no fast breathing.
Treatment: advise the mother about home care including (keep
warm, continue breast feeding, clear nose).Return back to health
 center if breathing become difficult or faster or occurrence of any
danger signs.

2. Child age 2 months to 5 years : classify into

a. Very severe disease: when any of the following danger signs is
detected:
1. Not able to drink.
2. Convulsions.
3. Abnormally sleep or difficult to be awake.
4. Strider in previously calm child.
5. Severe malnutrition.
Treatment: Refer urgently to hospital, keep the child warm and
give first dose of antibiotic. Treat fever or wheeze if present.
b. Severe pneumonia: When the child presented with chest indrawing.
Treatment: Refer urgently to hospital, keep the child warm and
give first dose of antibiotic. Treat fever or wheeze if present.
c. Pneumonia: When the child presented with only fast breathing (≥
50 / minute for child age from 2months up to 1 year , ≥ 40 / minute
for child age 1year up to 5 year ) , no chest indrawing.
Treatment: advise the mother about home care including (keep warm,
continue breast feeding, clear nose).Give antibiotic, treat fever and
wheeze if present. Reassess in 2 days (if child improve continue with
treatment for 5 days, if child present with same condition change
antibiotic, if worse refer to hospital).
d. No pneumonia (cough and cold): when there was no chest
indrawing and no fast breathing.
Treatment: advise the mother about home care including (keep warm,
continue breast feeding, clear nose). Treat fever or wheeze if present.
Assess and treat ear or throat problems when present.
Questions:
1. 2 years old female child was brought to PHC with history of
cough and fever for 4 days and not able to drink. On
examination the baby had fever and RR=45/minute. From
above data how you diagnose and treat that patient?

2. 3 years old male child was brought to PHC with history of

cough and fever for 2 days. On examination the baby had fever
and RR=38 /minute and baby had chest indrawing. From above
data how you diagnose and treat that patient?

3. 30 months old male child was brought to PHC with history of

cough and difficulty of breathing for 3 days. On examination
RR=55 /minute and no chest indrawing. From above data how
you diagnose and treat that patient?

4. 10 days old neonate complains from sneezing. On examination

the RR=40/minute, no chest indrawing. Enumerate lines of
treatment.