Acute lower respiratory tract

infection(ALRTI)
Yoseph
Public health
 Pnuemonia
• Is an inflammation of the parenchymal
structure of the lungs, such as the alveoli and
the bronchioles.
 Epidemiology

• Pneumonia is responsible for 70-80% deaths

that occur due to acute respiratory infections
worldwide.
• In Ethiopia, pneumonia is the cause of one
third of infant mortality and one fifth of under
5 mortality.
• Pneumonia is more severe in developing
countries due to the high prevalence of risk
factors such as:
-Malnutrition, including Vitamin A and D
deficiencies
-Overcrowding and indoor-air pollution
• Intercurrent infections such as measles,
whooping cough, malaria and diarrhea and
Immune-deficient states
• Severe forms of pneumonia are commonly
encountered in children between the age of 6
months and 3 years.
 Clinical manifestations
• The common manifestations in bacterial
pneumonia are:
• In infants, Cough, sudden onset of fever, and
signs of respiratory distress. i.e rapid and
difficult of breathing,
• nasal flaring,
• intercostal retraction,
• chest indrawing and cyanosis.
 On physical examination
• Crepitation,
• diminished breath sounds,
• bronchial breathing and dullness on
percussion.
• Fast breathing (2-12mon—50bpm or more.for
age 12mon-5yrs 40bpm or more)
 Severity Assessment
• Features of Severe Pneumonia:
• Tachypnea (>70 bpm under 12 months age,
>50bpm over 12 months)
• Moderate/severe recession (<12 months)
• Severe difficulty breathing (>12 months)
• Grunting
• Nasal Flaring
• Apnoea (<12 months)
• Cyanosis
• Tachycardia (>170 bpm under 6 months, >160
bpm 6-12 months, >150 bpm 1-3 years, >140 3-
5 years, >120 5-12 year, >100 over 12)
• Capillary Refill Time ≥ 2 secs
• Hypoxaemia (sustained oxygen saturation <92%
in room air)
• Not feeding (< 12 months)
• Signs of dehydration (>12 months)
 Diagnosis

• Diagnosis is mainly
reached on the basis of
clinical features.
• A chest X-ray may be
helpful in patients who
fail to respond to
treatment to check for
complications such as
pleural effusion,
pneumatocele,
atelectasis, or abscess
formation.
 Diagnosis
• Chest X-RAY is gold standard: Consolidation
• Complete blood count (Elevated WBC)
• ESR and C–reactive protein (CRP): Higher
• Blood gas (Hypoxemia, hypercarbia)
• Isolation of an organism from the blood, pleural
fluid, or lung
• Culture of sputum is of little value in the
diagnosis of pneumonia in young children
 Treatment
Supportive: include administration of oxygen
nasally and hydration to replace insensible water
loss.
• Vitamin A.
• Antibiotics
• Children with pneumonia are treated at out
patient level with cotrimoxazole or amoxicillin
orally for 5 days
- Advise parents to come back if there is worsening.
• Children with severe
pneumonia are given:
- Intravenous antibiotics -
crystallin penicillin as a first
line drug
- Assess response after 48 to
72 hours, if there is no
improvement or if there is
worsening, add
chloramphenicole
 Bronchiolitis

• Inflammation and obstruction of the small

airways.
• Etiology - Respiratory syncitial virus in more
than 50%
- Parainfluenza
- Adenovirus
 Epidemiology
- Male sex, not breast fed are at risk
- Occurs during the first 2 years of life.
- Peak incidence at about 6 months
- Occurs both as epidemic or sporadic
 Pathophysiology

- Characterized by bronchial
obstruction due to edema
- Resistance in small airways
increased during expiration
- Atelectasis during
complete obstruction
- Ventilation- perfusion
mismatch
 Risk factors

• Immunocompromised host
• Anatomic abnormalities (TEF, Cleft palate)
• Chest deformity (rickets, congenital)
• Microenvironment (Ventilation of houses,
crowding, indoor smoking)
• Malnutrition
• Not breast feeding
 Clinical manifestations

 History - Exposure to patient with URTI

- Antecident URTI
- Fast breathing
- Fever
- Paroxysmal wheezy cough,
dyspnea, irritability
- Feeding difficulty
- Symptoms disappear in 2-3 days
 On examination

- Tachypnea
- - + Cyanosis
- Retraction
- Wheezing
- Palpable liver/spleen
 Diagnosis
- Clinical
- Chest X-ray -
hyperinflation
- rarely scattered
consolidation
 Treatment
- Supportive treatment (Maintenance of
adequate hydration, provision of respiratory
support as necessary, and monitoring for
disease progression)
- Antibiotics and bronchodilator have no place
 Prognosis and course

- Critical in the 1st 48-72 hour

- There after rapid improvement
- Case fatality rate is <1%
 CHILDHOOD ASTHMA
• Asthma is a chronic inflammatory condition of
the lung airways resulting in episodic airflow
obstruction
 Pathophysiology

-Airway hyperresponsivness(AHR)
-Epithelial damage
-Subepithelial collagen deposition
with basement membrane thickening and
-Mucus gland and smooth muscle
hypertrophy.
Asthma symptoms are usually associated
with wide spread but variable airflow
obstruction that is generally reversible
either spontaneously or with treatment
 Etiology
• It is thought to be an interplay b/n genetic &
environmental factors.
• Genetic
-linked with proinflammatory, proallergic gene in
chromosome 5(IL-4).
-ADAM 33 is another candidate gene
-74% concordance b/n monozygotic twins & 35%
concordance b/n dizagoitic twins.
 Environmental

• Infection(pneumonia,bronchiolitis..).
• Allergic exposure .
• Tobacco smoke, air pollutant .
• Cold dry air & strong odors can trigger
bronchoconstriction when airways are
irritated but do not worsen air way
inflammation or hyperresposiveness.
 EPIDEMIOLOGY
• Approximately 80% of asthmatics report
disease onset before 6 yrs of age.
• Allergy in young children has emerged as a
major risk factor for the persistence of
childhood asthma.
• World wide the prevalence of asthma is
increasing despite significant improvement in
management (50% per decade)
 What are the Triggering Factors?
• Domestic dust mites
• Air pollution
• Tobacco smoke
• Occupational irritants
• Cockroach
• Animal with fur
• Pollen
• Respiratory (viral)
infections
• Chemical irritants
• Strong emotional
expressions
• Drugs ( aspirin, beta
blockers)
 EARLY CHILDHOOD RISK FACTORS FOR
PERSISTENT ASTHMA
• Parental asthma
• Allergy
• Atopic dermatitis
• Allergic rhinitis
• Food allergy
• Inhalant allergen sensitization
• Food allergen sensitization
• Severe lower respiratory tract infection
• Pneumonia
 Clinical features
• Intermittent dry cough
• Wheezing which is severe at night
• Shortness of breath or chest tightness,
reported by older children
• Tachypnea
 Physical examination
• expiratory wheezing, prolonged expiratory phase,
↓ed breath sound in some of the lung field
commonly the right lower posterior lobe
• Crepitations & ronchi might be heard resulting
from excess mucus production & inflammatory
exudates in the airways
• In sever exacerbations biphasic wheeze and
manifestations of respiratory distress like
retractions, nasal flaring & use of accessory
muscles is common
 Danger signs during acute attacks
- Paradoxical breathing
- Profound diaphoresis
- Cyanosis
- Silent chest on auscultation
- Drowsiness or confusion
- Agitation
- Exhaustion
- Arrhythmia
 ASTHMA PREDICTIVE INDEX
Major
-Parental asthma/allergic rhinitis
-Eczema
-Positive inhalant allergen test(Inhalant allergen sensitization)
Minor
-Eosinophil count ≥4%
-Food allergen sensitization
-Self history of allergic rhinitis
-Wheeze apart from colds
One major criterion OR two minor criteria provide a high specificity
(97%) and positive predictive value (77%) for persistent asthma into
later childhood
 Non pharmacologic
– Oxygen: administer oxygen via mask or nasal
cannula.
– Positioning: upright or leaning position in
older children.
– Treatment of comorbid conditions: Treat
rhinitis, sinusitis or pneumonia as appropriate.
– Nutrition: Increase feeding and fluid intake as
appropriate.
 Pharmacologic
• First-line
• Salbutamol, 0.1-0.2mg/kg (1-2 puffs) 3-4 times a day or
0.075-0.1mg/kg P.O 3 times a day.
• Dosage form: Metered Dose Inhaler or MDI 100mcg/puff.
• OR Salbutamol Nebulizer, for 30 minutes (can be repeated
every 20 minutes till relief of symptoms. PLUS
• Prednisolone, 1-2mg/kg/24hrs for 4 days in addition to the
inhaled beta agonist.
• Alternatives Beclomethasone, 336-672μg (8 – 16puffs of
42μg/puff or >8puffs of 84μg/puff) daily in two divided
doses.
• If a child does not improve after 3 doses of
rapid acting bronchodilator given at short
intervals plus oral prednisolone, give:
• Aminophylline – initial dose of 5 – 6mg/kg (up
to maximum of 300mg), followed by a
maintenance dose of 5mg/kg every 6 hours.
• Weigh the child carefully and give the
intravenous dose over at least 20 minutes and
preferably over 1 hour.
 Asthma medications
QUICK – RELIEF MEDICATIONS
A - Short acting inhaled β-agonist
-Albuterol
-Levalbuterol
-Terbutaline
-Pirbuterol
-Metaproterenol

B - Inhaled anticholinergics
-Ipratropium
-Atropin

C - Short course systemic glucorticoids

-Prednisone
-Methylprednisolone
-Methylprednisolone sodium succinate
 Long Term Control Medications
A - NSAIDS E - Leukotrien modifiers

-Cromolyn -Montelukast
-Nedocromil -Zafirllukast
B – Inhaled glucocorticoids -Zileuton
(backbones of asthma Rx)
-Beclomethasone G - Oral glucorticoids
-Flunisolide -Prednisone
-Budisonide -Methylprednisone
-Fluticasone
-Triamcinolole
-Mometasone H - Immunomodulators

C - Sustained-release theophylline -Omalizumab (anti-IgE)

D - Long acting inhaled β-agonist

-Salmuterol
-Formoterol
 Management
Regular assessment & monitoring
-Asthma check ups
-Every 2–4 wk until good control is achieved
-2–4 per yr to maintain good control
-Lung function monitoring
This helps to classify asthma into intermittent and persistent
PATIENT EDUCATION
-Provide a two-part care plan
-Daily management
-Action plan for asthma exacerbations
THANK YOU