ARI Dr Mirza Inam Ul Haq Dr Mirza Inam Ul Haq

ACUTE RESPIRATORY INFECTION Acute respiratory infections are the most common of the human ailments. Acute respiratory infections are the most common of the human ailments. In most instances it runs a natural course in older children and adults without treatment and without complications. In most instances it runs a natural course in older children and adults without treatment and without complications. In young infants, young children, elderly and those with impaired respiratory tract there is increased morbidity and mortality. In young infants, young children, elderly and those with impaired respiratory tract there is increased morbidity and mortality.

TYPES ARI may be divided into two groups ARI may be divided into two groups Acute Upper Respiratory Infections. Acute Upper Respiratory Infections. Mild cough, cold, pharyngitis, otitis media, and allergic rhinitis. Mild cough, cold, pharyngitis, otitis media, and allergic rhinitis. Acute Lower Respiratory Infections. Acute Lower Respiratory Infections. Epiglottis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis, pneumonia. Epiglottis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis, pneumonia.

PROBLEM STATEMENT Every child (< 5 years of age) both in developed and developing countries in the world suffer from at least 5-8 episodes of Acute Respiratory Infections annually in urban area. Every child (< 5 years of age) both in developed and developing countries in the world suffer from at least 5-8 episodes of Acute Respiratory Infections annually in urban area. About 5 million children die annually due to pneumonia ad more than 90% of these occur in developing world. About 5 million children die annually due to pneumonia ad more than 90% of these occur in developing world. ARI accounts for 30-70% of the health visits by the children to the heath facilities. The mean duration of illness is 7-9 days ARI accounts for 30-70% of the health visits by the children to the heath facilities. The mean duration of illness is 7-9 days

PROBLEM STATEMENT ARI is the leading cause of disability as well i.e. debilitating respiratory disease, and deafness following otitis media. Incidence of ARI in developing countries ranges between 10-20% as compared to 3-4% in the developed countries. Diarrhoea, Pneumonia, and Protein calorie malnutrition are the three biggest killers of children under five years National ARI Control Programme was launched late in 1989 in collaboration with international agencies like WHO, UNICEF, and USAID

OBJECTIVES OF NATIONAL ARI CONTROL PROGRAMME To reduce the mortality under 5 years of age due to pneumonia. To reduce the mortality under 5 years of age due to pneumonia. To reduce the severity of and mortality from pneumonia in children To reduce the severity of and mortality from pneumonia in children To reduce the incidence of acute lower respiratory infections (ALRI) To reduce the incidence of acute lower respiratory infections (ALRI) To reduce the severity and complications from acute upper respiratory infection (AURI) To reduce the severity and complications from acute upper respiratory infection (AURI) To rationalize the use of drugs in ARI To rationalize the use of drugs in ARI

Control Strategy Correct Case Management: this is achieved through intense training of health staff to identify and manage the cases of ARI. Correct Case Management: this is achieved through intense training of health staff to identify and manage the cases of ARI. The health staff includes, the supervisory staff, the trainers, hospital based medical officers, medical officers working at the THQ hospitals, RHCs, BHUs, and LHWs. The health staff includes, the supervisory staff, the trainers, hospital based medical officers, medical officers working at the THQ hospitals, RHCs, BHUs, and LHWs.

AGENT FACTORS Two most common agents are Two most common agents are Bacterial organism. Bacterial organism. Viral organism Viral organism

Agents of Upper Respiratory Tract Infections Common cold (rhinitis) Common cold (rhinitis)  Many viruses; rhino, corona, adeno, influenza Pharyngitis and laryngotracheitis Pharyngitis and laryngotracheitis  Streptococcus pyogenes  Corynebacteria diphtheriae  Neisseria gonorrhea  Many viruses Epiglottitis Epiglottitis  Haemophilus influenzae Bronchitis Bronchitis  Bordetella pertussis  Many viruses

Agents Tuberculosis: Mycobacterium tuberculosis Tuberculosis: Mycobacterium tuberculosis Pneumonia Pneumonia  Bacteria Streptococcus pneumoniae Streptococcus pneumoniae Mycoplasma pneumoniae Mycoplasma pneumoniae Staphylococcus aureus Staphylococcus aureus  Viruses Influenza Influenza Measles Measles Many others Many others  Fungi Many Many

HOST FACTORS Most vulnerable groups are the young children, young infants, elderly persons, and the malnourished children. Most vulnerable groups are the young children, young infants, elderly persons, and the malnourished children. The Infant Mortality Rates in the developing countries are high and may exceed 20/1000 and contributing factor is mainly malnutrition. The Infant Mortality Rates in the developing countries are high and may exceed 20/1000 and contributing factor is mainly malnutrition. AURI are higher in children than in adults. Incidence of Pharyngitis and Otitis Media increases from infancy to 5years of age. AURI are higher in children than in adults. Incidence of Pharyngitis and Otitis Media increases from infancy to 5years of age.

RISK FACTORS Low Birth Weight Low Birth Weight Malnutrition Malnutrition Specific nutritional deficiencies Specific nutritional deficiencies Climatic conditions Climatic conditions Housing (over crowding, poor housing conditions) Housing (over crowding, poor housing conditions) Level of Industrialization Level of Industrialization Socio-economic Level Socio-economic Level LBW LBW Indoor Pollution (air pollution) Indoor Pollution (air pollution) Maternal cigarette smoking. Maternal cigarette smoking.

MODES OF TRANSMISSION Air Borne Air Borne Direct- person to person. Direct- person to person.

POLICY Who in1976 adopted a policy of Who in1976 adopted a policy of Improving Living Conditions. Improving Living Conditions. Better Nutrition. Better Nutrition. Reduce smoke pollution Reduce smoke pollution Other factors are Other factors are MCH care MCH care Immunization (to prevent pneumonia which occur as complication of vaccine preventable diseases). Immunization (to prevent pneumonia which occur as complication of vaccine preventable diseases).

CLINICAL ASSESSMENT 1.BREATHING RATE/MINUTE. 1.BREATHING RATE/MINUTE. 2.LOOK FOR CHEST INDRAWING. 2.LOOK FOR CHEST INDRAWING. 3.LOOK AND LISTEN FOR STRIDOR. 3.LOOK AND LISTEN FOR STRIDOR. 4.LOOK FOR WHEEZE. 4.LOOK FOR WHEEZE. 5.LOOK IF THE CHILD IS DROWSY. 5.LOOK IF THE CHILD IS DROWSY. 6.FEEL FOR FEVER. 6.FEEL FOR FEVER. 7.CHECK FOR SEVERE MALNUTRITION. 7.CHECK FOR SEVERE MALNUTRITION. 8. LOOK FOR CYANOSIS. 8. LOOK FOR CYANOSIS.

CLASSIFICATION OF ILLNESS A, Child aged 2 months up to 5 years. Depending upon the type and severity of the illness it may be classified as under. A, Child aged 2 months up to 5 years. Depending upon the type and severity of the illness it may be classified as under.  Very severe disease.  Severe Pneumonia.  Pneumonia not Severe.  No Pneumonia: cough or cold.

CLASSIFICATION OF ILLNESS A, Child aged (0- 2 months) A, Child aged (0- 2 months) Depending upon the type and severity of the illness it may be classified as under. Depending upon the type and severity of the illness it may be classified as under.  Very severe disease.  Severe Pneumonia.  No Pneumonia: cough or cold.

2-5 YRS Very Severe Disease Very Severe Disease Danger signs are Danger signs are  Child is unable to drink  Convulsions  Strider in the calm child  Severe malnutrition Severe Pneumonia Severe Pneumonia Respiratory rate60 or more/minute age<2m Respiratory rate60 or more/minute age<2m age 2-12 m 50 age 2-12 m yrs 40 or more/minute age 1-5 yrs 40 or more/minute age

2-5 yrs Chest in drawing Chest in drawing Nasal flaring Nasal flaring Grunting Grunting Cyanosis Cyanosis Pneumonia not severe Pneumonia not severe Fast breathing without chest in drawing. Fast breathing without chest in drawing. No Pneumonia: (Cough & Cold ). No Pneumonia: (Cough & Cold ).

0-2 months Danger signs are Danger signs are Convulsions Convulsions Stridor Stridor Stopped feeding well Stopped feeding well Wheezing Wheezing Fever/ Low body temperatures Fever/ Low body temperatures

0-2 months Very Severe Disease Very Severe Disease Danger signs are Danger signs are  Child is unable to drink  Convulsions  Stridor in the calm child  Severe malnutrition  Not Feeding well

O-2 Months Severe Pneumonia Severe Pneumonia Respiratory rate Respiratory rate 60 or more/minute 60 or more/minute Chest in drawing Chest in drawing Nasal flaring Nasal flaring Grunting Grunting Cyanosis Cyanosis Pneumonia Pneumonia Fast breathing without chest in drawing. Fast breathing without chest in drawing.

Improvement after 48 hours ? Consider cloxacillin (50mg/kg IV QID) After 5 days if the child has responded well change to oral amoxicillin and oral chloramphenical for a further 5 days If the child improves on cloxacillin continue cloxacillin orally 4 times a day for a total course of 3 weeks Very Severe PneumoniaSevere Pneumonia Look for complications Improvement after 48 hours? Change to ceftriaxone mg/kg BID for 10 days YesNo Yes Oral amoxicillin for 5 days Look for complications like Effusion/empysema Antibiotic treatment can be changed by a doctor when blood culture results are available Treat complications if found Complications include: Empyaema* Pleural effusion* Lung abscess* * Pneumonia Protocol: Infants and Children > 2 months

Very Severe PneumoniaPneumoniaSevere Pneumonia Ceftriaxone ( mg/kg IV divided Bid (may give IM if no IV access) Monitor and ensure oxygen saturations >90% Give paracetamol (15mg/kg as needed up to 4 times a day) for fever Ensure that the child is receiving adequate fluid Encourage breastfeeding and oral fluids If child cannot drink: For Severe Pneumonia: pass a nasogastric tube and give maintenance fluid in one hourly amounts, or, For Very Severe Pneumonia give IV flush* WeightFluid ml/hour 2kg8 4kg16 6kg25 8kg33 10kg42 12kg46 14kg50 16kg54 18kg58 The child MUST be discussed with a doctor and reviewed as soon as possible Obtain a chest x-ray Give ampicillin (100 mg/kg IV/IM every 6 hours) and chloramphenical (50 mg/kg every 8 hours) for at least 48 hours Child should be checked by a nurse every 6 hours and by a doctor or medic every day Give oral amoxicillin (or IV ampicillin) Give the first dose in the clinic **) Pneumonia Protocol: Infants and Children < 2 months

Management of very severe disease (2m- 5 yrs age) Treat fever Treat fever Treat wheezing Treat wheezing Antibiotic Antibiotic Inj Benzyl Penicillin Ist 48 hr IU6 hr IM Inj Benzyl Penicillin Ist 48 hr IU6 hr IM Inj Ampicillin 50mg/KG/Dose 6 Hrly IM/oral Inj Ampicillin 50mg/KG/Dose 6 Hrly IM/oral Chloramphenicol Chloramphenicol 25mg/KG/Dose 6Hrly IM/oral 25mg/KG/Dose 6Hrly IM/oral

CONT Treatment Treatment Nebulize 0.5ml+2ml N/S Salbutamol Nebulize 0.5ml+2ml N/S Salbutamol Epinephrine Subcutaneous 0.01ml/KG may repeat 20min (1:1000=0.1%) Epinephrine Subcutaneous 0.01ml/KG may repeat 20min (1:1000=0.1%) Sub-cut Terbutaline (0.1 mg/KG may repeat after 30 minutes).Total 0.3mg. Sub-cut Terbutaline (0.1 mg/KG may repeat after 30 minutes).Total 0.3mg.