ACUTE RESPIRATORY INFECTIONS

Pneumonia Bronchiolitis

Acute Respiratory Infections (ARI)

Developed and developing countries High morbidity 5 8 episodes/year/child 30 50 % outpatient visit 10 30 % hospitalization Developing countries High mortality 30 70 times higher than in developed countries 1/4 - 1/3 death in children under five year of age

ARIARI-ASSOCIATED DEATH RATE BY AGE TEKNAF, BANGLADESH, 1982-1985 1982Deaths per 1000 children

140 120 100 80 60 40 20 0 1-5 6-11 A i 12-23 M t 24-35 36-50

Distribution of 12.2 million deaths among children less than 5 years old in all developing countries, 1993

ARI/Malaria (1.6%) Malaria (6.2) ARI (26.9%)

Other (33.1%)

Malnutrition (29%)

ARI/Measles (5.2%) Measles (2.4%) Diarrhoea/measles (1.9%) Diarrhoea (22.8%)

RISK FACT RS F R PNEU F CT OR DEATH FROM ARI

Malnutrition, poor breast feeding practices Lack of immunization Young age

NIA

Vitamin A deficiency Low birth weight

Increase risk of ARI

Crowding High prevalence of nasopharyngeal carriage of pathogenic bacteria Cold weather or chilling Exposure to air pollution Tobacco smoke Biomass smoke Environmental air pollution

Magnitude of the Problem in Indonesia

Pneumonia in children (< 5 years of age) Morbidity Rate 10-20 % 10Mortality Rate 6 / 1000 Pneumonias kill
50.000 / a year  12.500 / a month  416 / a day = passengers of 1 jumbo jet plane  17 / an hour  1 / four minutes


Pneumonia is a no 1 killer for infants (Balita)

Pneumonia
Classifications
Anatomical classification
   

Lobar pneumonia Lobular pneumonia Intertitial pneumonia Bronchopneumonia Bacterial pneumonia Viral pneumonia Mycoplasma pneumonia Aspiration pneumonia Mycotic pneumonia

Etiological classification
    

Etiology of Pneumonia

Predominantly : bacterial and viral In developing countries: bacterial > viral

(Shann,1986): In 7 developing countries, bacterial 60 % (Turner, 1987): In developed countries, bacterial 19 % ; viral 39 %

Bacterial etiology
Streptococcus pneumoniae Hemophilus influenzae ta ylococc a re tre tococc gro B le iella e o iae e o o a aer gi o a la y ia yco la a e o iae

BACTERIA ISOLATED FROM LUNG ASPIRATES IN 370 UNTREATED CHILDREN WITH PNEUMONIA
%
50

40

30

20

10

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Characteristic features
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Simple Clinical Signs of Pneumonia (WHO)

Fast breathing (tachypnea)
Respiratory thresholds Age Breaths/minute < 2 months 0 2 - 12 months 50 1 - 5 years 0

Chest Indrawing
(subcostal retraction)

Pathology and Pathogenesis

a teriae eri heral l ng tiss es tiss es rea tion oede ato s ed e ati ation tadi al eoli onsist of : le o yte, fi rine,erythro yte, a teria rey e ati ation tadi fi rine de osition, hago ytosis esol tion tadi ne tro hil degeneration, loose of fi rine, a terial hago ytosis

Bronchopneumonia Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the alveolar spaces. The alveolar capillaries are distended and engorged.

Bronchopneumonia Acute bronchopneumonia. The alveolar spaces contain abundant PMNs and an inflammatory infiltrate rich in fibrin.

Acute Bronchopneumonia Acute bronchopneumonia; the alveolar spaces are full and distended with PMNs and a proteinaceous exudate. Only the alveolar septa allow identification of the tissue as lung.

Blood Gas Analysis & Acid Base Balance Hypoxemia (PaO2 < 80 mm Hg)
 

with O2 3 L/min without O2 (PaCO2 < 35 mmHg) (PaCO2 > 45 mmHg )

52,4 % 100 % 87,5 % 4.8 %

Ventilatory insufficiency


Ventilatory failure


Metabolic Acidosis


poor intake and/or hypoxemia 44,4 % (Mardjanis Said, et al. 1980)

Radiographic patterns
1. Diffuse alveolar and interstitial pneumonia (perivascular and interalveolar changes) 2. Bronchopneumonia (inflammation of airways and parenchyma) 3. Lobar pneumonia (consolidation in a whole lobe) . Nodular, cavity or abscess lesions (esp.in immunocompromised patients)

Management
Severe Pneumonia Hospitalization Antibiotic administration
 

Procain Pennicilline, Chloramphenicol Amoxycillin + Clavulanic Acid

Intra Venous Fluid Drip Oxygen Detection and management of complications

Complications
Pleural effusion (empyema) Piopneumothorax Pneumothorax Pneumomediastinum

Bronchiolitis
 

Bronchioles inflammation Clinical syndromes: fast breathing, retractions, wheezing Predominantly < 2 years of age (2 6 months) Difficult to differentiate with pneumonia

Bronchiolitis
Etiology Predominantly RSV (Respiratory Syncytial Virus), adenovirus etc. Diagnosis Etiological diagnosis


Microbiologic examination

Clinical diagnosis
  

Signs and symptoms Age Resource of infection

Bronchiolitis
linic l nif st tions r,f st r thin , r tr ction, co h, col , f h in , irrit l , o it s, oor int

h sic l in tions t ch n , t ch c r i , r tr ction, ir tion , h in , f r, h r n itis, conj ncti itis, otitis i .

Bronchiolitis
Radiologic examination
diffuse hyperinflation
  

flat diaphragm, subcostal > retrosternal space >

peribronchial infiltrates pleural effusion (rare)

Bronchiolitis
Management
 

 

Supportive Severe disease hospitalization intra venous fluid drip oxygen (antibiotics) Bronchodilator: controversial Corticosteroid: controversial

Bronchiolitis

Natural history & complications

 

Improved clinical findings : in 3-4 days 3Improved radiological features: in 9 days

Persistent respiratory obstruction : 20% Respiratory failure : 25 % Lung collaps (rare)

Bronchiolitis

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