1

(Acute respiratory tract infection in children,

ARIC)
5

Acute respiratory infection (ARI)

4
Upper respiratory infection (URI)

acute URI (common cold acute
nasopharyngitis) (acute otitis media)
(acute sinusitis) (acute pharyngitis)
(acute tonsillitis)
Lower respiratory infection (LRI)

LRI (acute bronchitis)

(acute bronchiolitis) (acute
pneumonia)
(croup syndrome) LRI
acute laryngotracheobronchitis, acute epiglottits, bacferial tracheitis
retropharyngcal abscess
.. 2530
5 2.9

5 .. 2536 52
5 1 25

5 15/100,000 .. 2533 9.6/100,000 ..
2537
()



-

-
-

-

1. , , , ,

.
. 2533; 11: 129-39.
2. . . : .
. ( 1) :
; 2540 : 503-506, 517-530.

(Guideline for the management of acute upper respiratory tract infections in young children or AURI)

( Acute rhinitis , acute nasopharyngitis , common cold )

Rhinovirus Coronavirus
3 3
2-3
60-80% 1-3
mucopurulent
sinus ( viral rhinosinusitis ) 2 - 7
31% 35% 2
3-8 10-15% 12
Day care center

1.

2.
2.1 380 paracetamol 10 mg / kg / dose
46 3

2.2



0.9 % NSS 1 2

6
Decongestant nasal mucosa nasal
discharge 2
oral decongestant pseudoephedrine 1 mg/kg/dose 34
confusion,
hallucination, aggression, hypertension dystonia 1
. topical decongestant % ephedrine
3 5 rhinitis medicamentosa,
rebound congestion rhinorrhea rebound congestion
obstructive apnea
systemic absorption
antihistamine

allergic rhinitis
metholated balms
2.3
: oral hydration

: soothing remedies

: ( expectorant ) WHO
Guaifenesin glyceryl guaiacolate side effect
ammonium chlorate, terpine hydrate, syrup
ipecac
: ( mucolytic drug )

: ( cough suppressant ) codiene, dextromethorphan

1

7
3. (Specific treatment)
:

resistant organism
4.

( Acute pharyngitis, tonsillitis, pharyngotonsillitis )

hemolytic streptococcus group A acute
rheumatic fever, acute glomerulonephritis
Streptococcal sorethroat 3
tonsils pharynx tonsils
(cervical lymphadenitis) soft palate
()
adenovirus, infectious mononucleosis

1. (Specific treatment)
Streptococcal sorethroat Penicillin V 50,000
100,000 units / kg / day Amoxycillin 30 50 mg / kg / day 10
Penicillin Erythromycin 30 50 mg / kg / day 10 14
2.
-
- Soothing remedies
lozenges, , xylocaine gel antiseptic

5

Acute otitis media

S. pneumoniae, H. influenzae, M. catarrhalis
virus, mycoplasma pneumonia chlamydia pneumonia

otoscope tympanic membrane tympanic membrane

1. (Specific treatment)
: amoxycillin, cotrimoxazole, rythromycin
5 7
- 10-14
- 2
-
- recurrent otitis media
- craniofacial abnormalities
- immunocompromised host
: 48
2nd generation cephalosporin, amoxycillin / clavulanate
: serous effusion
serous otitis media
3 70% effusion 2 50% 1
20% 2 serous effusion 3

2.
1

9
3 4 decongestant antihistamine

Acute sinusitis
bacterial sinusitis complication
0.5 5% S. pneumoniae, H. influenzae Gr. A.
Streptococcus 10

paranasal sinus

Bacterial sinusitis
1. amoxycillin, erythromycin cotrimoxazole 10 14
48 2nd generation
cephalosporin, amoxycillin/clavulanate
2. 3
3.

10

1. 2.
,2542.
2. Dowell SF, Marcy SM, Phillips WR, et al. Principles of judicious use of antimicrobial
agents for pediatric upper respiratory tract infections. Pediatrics 1998; 101 (1) : 163-165.
3. Dowell SF, Marcy SM, Phillips WR, et al. Otitis media - Principles of judicious use of
antimicrobial agents. Pediatrics 1998; 101 (1): 165 171.
4. Dowell SF, Schwartz B, Phillips WR and The pediatric URI consensus team. Appropriate
use of antibiotics for URZs in children : part I. Otitis media and acute sinusitis. Am Fam
Phys 1998; 58 (5): 1113 1138, 1123.
5. Dowell SF, Schwartz B, Phillips WR and The pediatric URI consensus team. Appropriate
use
of antibiotics for URIs in children : part II. Cough, pharyngitis and the common cold. Am
Fam Phys 1998; 58 (6): 1335 1342, 1345.
6. Hendeles L. Efficacy and safety of antihistamines and expectorants in nonprescription
cough
and cold preparations. Pharmacotherapy 1993; 13 (2): 154 158.
7. O Brien KL, Dowell SF, Schwartz B, et al. Acute sinusitis Principles of judicious use of
antimicrobial agents. Pediatrics 1998; 101 (1): 174 178.
8. Rosenstein N, Phillips WR, Gerber MA, et al. The common cold Principles of judicious
use
of antimicrobial agents. Pediatrics 1998; 101 (1): 181 184.
9. Schwartz B, Marcy SM, Phillips WR, et al. Pharyngitis Principles of judicious use of
antimicrobial agents. Pediatrics 1998; 101 (1): 171 174.

11

(Guideline for the management of acute lower respiratory infections in young children or ALRI)

Acute epiglottitis ()
supraglottic epiglottis, aryepiglottic
fold ventricular band 26

Hemophilus influenzae type B

(Stridor)

24 ( 1)

epiglottis (cherry red epiglottis)

epiglottis glottis

(lateral neck X-ray) epiglottis aryepiglottic fold
air trapping oropharynx

endotracheal
(Ampicillin, Amoxicillin Chloramphenical

12
Ampicillin second or third generation cephalosporin)

1 Clinical characteristics differentiating acute laryngotracheobronchitis from acute

epiglottitis
Epiglottitis
Characteristic
LTB
Age

6 month-3 years

2-6 years

Onset

Gradual

Rapid

Etiology

Viral

Bacterial

Swelling site

Subglottic

Supraglottic

Cough voice

Hoarse cough

Posture

Any position

No cough
Muflfled voice
Sitting

Mouth

Closed : nasal flaring

Open-chin forward, drooling

Fever

Absent to high

High

Appearance

Often not acutely ill

Anxious, acutely ill

X-ray

Narrow subglottic area

Palpation larynx

Non tender

Swollen epiglottis and

supraglottic structures
Tender

Recurrence

May recur

Rarely recurs

Symptoms

Reference : Backofen DE, Roger MC. Upper airway disease. In : Rogers MC, ed.
Textbook of pediatric intensive Care. 1987, p 190

13
Acute laryngotracheobronchitis

(Viral croup)

6 3

parainfluenza virus type 1, 2, 3

influenza virus A, B, respiratory syncytial virus measles

1-3
subglottic
(stridor) stridor
croup score

(barking
cough)
Stridor

Chest retraction & nasal

nasal flaring &
1
flaring
suprasternal
subcostal &
retraction
intercostal retraction

40%

Harsh with rhonchi

< 4 =
4-7 =
> 7 =
( Downes JJ. Acute upper airway obstruction. In : Annual refresher course lectures.
A.S.A. annual meeting 1980 ; 535)

14

(croup score < 4)

(
)
(croup score 4-7)

dexamethasone 0.6 mg/kg
adrenaline 1:1000 0.5 ml/kg 4 = 2.5 ml / dose dilute 3
ml NSS (Group score > 7)

viral croup
Croup
obstruction score
4

>47

OPD Treatment

>7

Admitted
Admitted ICU
Epinephrine 1 : 1000
( 0.05 0.5 ml/kg )
max. dose 2.5 ml
4
3 30
Dexamethasone
0.6 mg/kg/dose

Support
Croup

Endotracheal
In tubation

15
Bacterial tracheitis
1-3

staphylococcus aureus, group A hemolytic streptococcus H. influenzae

(brassy cough)

clear airway maintain airway

Cloxacillin 100 mg/kg/day Cephalosporin IV
(Cefazolin 75 mg/kg/day) 2-3 (intermittent tracheal
suction)
Retropharyngeal abscess
3 posterior pharyngeal wall prevertebral
fascia nasopharynx
retropharyngeal space
median raphe
buccopharyngeal fascia prevertebral fascia

B hemolytic group A streptococcus S.

aureus

16

(stridor)
(meningismus)
posterior pharyngeal wall
lateral neck X-ray retropharyngeal space cervical lordosis

direct laryngoscopy
Penicillin Penicillinase resistant penicillin
Gramstain

17

1.

2.

3.
4.
5.

, Acute Waryngotracheoburn chitis, :

. , . .
. . . . 2541 : 401 5.
Barone MA. The Harriet Lane Handbook. A manual for pediatric house officers. The
Harriet Lane Service Childrens Medical and Surgical Center of The Johns Hopkins
Hospital. 14th ed. St. Louis. Baltimore : Mosby Year Book. 1996; 532 3.
Klassen TP. Group : A current perspective. Pediatr Clin North Am 1999 ; 46 (6) : 1167
77.
Sumboonnanonda A, Suwanjutha S, Sirinawin S. Randomized controlled trial of
Dexainethasone in Infectious group. J Med Assoc Thai. 1997 ; 8 : 262 - 5
Waisman Y, Kleikn BL and Boenning DA, et al. Prospective randomized double-blind
study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of
Laryngotracheitis (Croup) 1992 ; 89 : 302 6.

18
Acute Bronchiolitis

()

(Bronchiolitis)
(bronchioles) 6-24

respiratory syncytial virus (RSV)

parainfluenza, adenovirus type 7, 3, 21, rhinovirus, influenza virus
5 739
..2529-2530 25
11 ( 44) RSV 32, parainfluenza virus
type 3 8, influenza virus type 6 4

2-3

(diminished vesicular
breath sound) wheezing
fine crepitation

19

generalized hyperinflation
interstitial infiltration

Respiratory rate 60 retraction chest wall

monitor oxygen saturation Oxygen saturation 94%
oxygen (35-40% by mask or hood)
Apnea
2 prematurity
underlying cardio pulmonary disease immunosuppression deficiency
()

(General supportive c
are)
RSV

humidified oxygen hypoxemia monitor
Pulse-oximeter oxygen saturation 94%
hydration (-, )

expiratory wheezes bronchospasm beta-2 agonists
asthma clinical signs generalized
air trapping debris edema

20

nasal CPAP (continuous positive airway pressure)

(Specific treatment)
epinephrine 1:1000 0.05-0.5 ml/kg NSS 3 ml
( 4 =2.5 ml/dose)


Wheezing child
nebulized beta 2 agonist
10 15

Rx as asthma

try second dose
bronchodilator 10 15

Dx Acute Bronchiolitis
Rx Admit , humidified O2
Supportive care
nebulized epinephrine
AB
pneumonia
Support ventilation (nasal
CPAP, Ventilator)

Wheezing child

21
Pneumonia

()

terminal
respiratory bronchiole alveoli 8-10

5

( 1)
1
>5 years
Pathogen
<3 months 3 months 5 years
+++
+++
+++
Streptococcus pneumoniae
++
+++
+++
Viruses
+
+++
+
Enteric bacilli
+++
Group B streptococci
+
+
+++
Chlamydia trachomatis
+
++
+
Staphylococcus aureus
+++
+
+
Haemophilus influenzae
+
+
Group A streptococci
++
+
+++
Mycoplasma pneumoniae
+
++
Chlamydia pneumoniae
+++, very frequent; ++, moderately frequent, +, rare, +, very rare; -, absent.
Ref: Pechre. Community-acquired pneumonia in children. Cambridge Medical Publication
1995;P30
13 .. 2513-2523
54.6

22
lung aspirates blood culture lung aspirates
S. pneumoniae 45.5 H. influenzae S. aurens
28.4 9.4 incidence S. pneumoniae H. influenzae = 24.8
15.5 %

respiratory syncytial virus 17.7-35.8 ( 2)
2 RSV
RSV

(% LRI )

22.7

20.3

17.7
( 2541-2542)**
35.8
** 1
. ( 2529- 2530)
41.2 RSV 53.6
10.96 S. pneumoniae 8.96

< 2 60
2 - 11 50
1-5 40
chest wall retraction, flaring ala nasi

23
fine medium crepitation
sonorous rhonchi bronchial breath sound
consolidation

(> 15,000 / cu.mm.) shift to the left
toxic granules neutrophils




parahilar peribroonchial (interstitial) infiltration
lobar consolidation S.
pneumoniae pneumatocele S. aureus pleural effusion
S. aureus, S. pneumoniae, H. influenzae, mycoplasma

sputum nasopharyngeal aspiration

sensitive specific

nasopharyngeal aspiration

colonization
Hemoculture
20
antigen nasopharyngeal aspirate
respiratory syncytial virus, adenovirus, influenza virus

24

antigen ,
nasopharynx pleural effusion
Pleural fluid gram stain culture pleural effusion effusion

Cold agglutinin of mycoplasma titer mycoplasma
Tuberculin test

(Specific treatment)
1. supportive care

2.

(1)
2 5
Amoxicillin 40-50 mg/kg/day 3
Penicillin Erythromycin 30-40 mg/kg/day 2
5-7

H.influenzae
S.pneumoniae S.aureus Cefuroxime axetil Amoxicillin-clavulanic
acid Cefprozil Cefaclor ( 1 3)
6
Chlamydia trachomatis Erythromycin 14
5 15
Amoxicillin Penicillin V 5-7
Mycoplasma pneumoniae Chlamydia pneumoniae Erythromycin 14

25
( 2)
2
Penicillin
Ampicillin Aminoglycoside third generation cephalosporin Cefotaxime
Ceftriaxone 7-10
14-21
S.aureus Cloxacillin
3
2 5
Ampicillin I.V. 6 3
Amoxicillin 7
Ampicillin
Aminoglycoside Cephalosporins H.influenzae Cefuroxime
Cefotaxime Amoxicillin clavulanic acid 10-14
Staphylococcal pneumonia
Cloxacillin 3
5 15
Penicillin G, I.V. 6 3
Penicillin V Amoxicillin 3 Penicillin Erythromycin

S.pneumoniae Penicillin
200,000-300,000 units/kg/day Cefotaxime Ceftriaxone
Staphylococcal pneumonia
Cloxacillin 100-150 mg/kg/day S.aureus
3 empyema pleural effusion Cloxacillin
200-300 mg/kg/day
( General supportive care )
1.

2. (
70 )
3. wheeze rhonchi

26
4.

5. ( Chest physical therapy )

(Vibration)

6.
7.
(Endotracheal intubation)

2
(moderately sever respiratory distress)
hypoxemia

S. aureus
(pleural effusion, empyema, lung abscess)

27
1 :

2 5

5 15

Amoxicillin
Erythromycin

Amoxicillin
Pen V.
Erythromycin
2

5-7

Admit
S.pneumoniae
& H.influenzae

Pen.

5-7

Admit

Amoxicillin clavulanic acid

Cefuroxime P.O
Cefprozil P.O
Mycoplasma
Cefaclor P.O
Chlamydia
pneumoniae
Erythromycin
14

S.pneumoniae

Amoxicillin +
clavulanic acid
Amoxicillin
(double dose)
Cefuroxime

P.O
Cefprozil P.O

28
Cefaclor P.O
2 : /

Admit + Supportive care

< 2

2 5

5 15

PGS Ampicillin I.V.*

+ Aminoglycoside
Ampicillin I.V.

Penicillin G, I.V.
Cefotaxime
2-3 S.aureus
Ceftriaxone
2-3
* cloxacillin
Cloxacillin

S.aureus
Ampicillin
Ampicillin
Pen V S.pneumoniae
Amoxicillin + Aminoglycoside
Amoxicillin

7 Cefuroxime I.V.
7
Cefotaxime I.V.
PGS high dose
Amoxicillin +
Cefotaxime
clavulanic acid
Ceftriaxone

29
1 : *

(mg/kg/day)
Amoxicillin
Erythromycin
Amoxicillin + Clavulanic acid
Cefuroxime axetil
Cefprozil
Cefaclor

40-50
30-40
40-50
40-50
30-40
40-50

3 /
3-4 /
2-3 /
2 /
2 /
3 /

* , MIC, bioavailability in vivo study

2 :

Ampicillin
Amoxicillin + clavulanic acid
Cloxacillin**
Penicillin G Sodium
Gentamicin
Amikacin
Cefuroxime
Cefotaxime
Ceftriaxone

(mg/kg/day)

100-200
40-50
100-150
100,000-200,000
units/Kg/day
5-7
15-30
100-150
100-150
50-80

6
8
6
6
8
8-12
6-8
6-8
8-12

** empyema pleural effusion pneumatocele 200-300 mg/kg/day

30

3 : Minimal inhibitory concentration (MIC)

penicillin

Cephalexin
Cefaclor
Cefuroxime
Amoxicillin - clavulanic acid

MIC (mg/l)
S.pneumoniae H.influenzae
2.0
2.0
0.06
-

16.0
4.0
0.25
0.5

S.aureus bioavalability
4.0
2.6
0.25
-

80%
50%
50%
-

( Pechre JC. Community acquired pneumonia in children. Cambridge Medical

Publication 1995; pp. 81-82)

31

Acute bronchiolitis
1. American Academy of Pediatrics : Reassessment of the indications for ribavirin therapy in
respiratory syncytial virus infections. American Academy of Pediatrics Committee on
Infectious Diseases. Pediatrics 1996 Jan; PT-REVIEW, TUTORIAL(1): 137-40[Medline].
2. De Boeck K, Van der Aa, Van Lierde S : Respiratory syncytial virus bronchiolitis : a
double-blind dexamethasone efficacy study. J Pediatr 1997; 131(6): 979-921[Medline].
3. Flores G, Horwitz RI : Efficacy of beta2-agonists in bronchiolitis: a reappraisal and metaanalysis. Pediatrics 1997; 100(2): 233-239[Medline].
4. Kellner JD, Ohlsson A, Gadomski AM: Efficacy of bronchodilator therapy in bronchiolitis:
A meta-analysis. Arch Pediatr Adolesc Med 1998; 150(11): 1166-1172[Medline].
5. Klassen TP, Sutcliffe T, Watters LK: Dexamethasone in salbutamol-treated in patients
with acute broncholitis: a randomized, controlled trial. J Pediatr 1997; 130(2): 191196[Medline].
6. McConnochie KM, Roghmann KJ: Predicting clinically significant lower respiratory tract
illness in childhood following mild bronchiolitis. Am J DisChild 1985; 139: 625631[Medline].
7. Suwanjutha S, Chantarojanasiri T, Preutthipan A, et al. Incidence of respiratory syncytial
virus lower respiratory tract infection in under-5-year-dd children at a rural community of
Thailand. Final report to RTG-WHO Collaborative Programme Ref no 000068 ; Jan 31,
2000.
8. Van Woensel JB, Wolfs TF, van Aalderen WM: Randomised double blind placebo
controlled trial of prednisolone in children admitted to hospital with respiratory syncytial
virus bronchiolitis. Thorax 1997 Jul; 52(7): 634-7[Medline].
9. Weber MW, Mulholland EK, Greenwood BM: Respiratory syncytial virus infection in
tropical and developing countries. Trop Med Int Health 1998; 3(4): 268-280[Medline].
Pneumonia
1. , .. ,
..2526 2527 2528 ; 10 (1) : 31-35
2.
2 2542
3. , RSV
LRI . ( 1 )

32
4. , . Pneumonia : .
. . . Ambulatory Pediatrics
2. . . 2542 : 544-50
5. Campbell PW. Pneumonia. In : Rudolph AM, ed. Rudolphs Pediatrics. 20 th ed. London
:Prentice Hall International 1996 ; 56-77
6. Chantarsjanasiri T, Suwanjutha S, Wattanakasetr S, Etiology, treatment and outcome of
hospitalized pneumonia in young children at Ramathibodi Hospital. I Med Assoe Thai
1993; 76 (Suppl 2) : 156 64.
7. Long SS. Pneumonia in older infants children and adolescents. In : Schidlow DV, Smith
DS, eds. A practical guide to pediatric respiratory diseases. Hanley & Belfus, Inc 1994 :
91
8. Pornkul R, Suwanjutha S, Ruangkanchanasetr S. Correlation of roentgenologic diagnosis
and etiologic agents of pneumonia in Thai childrn under 5 years of age. Med Assoc Thai
1993 ;76 (Suppl 2) : 178-186
9. Sunakorn P, Chuenchit L, Niltawat S, et al. Epidemilolgy of acute respiratory infection in
young children from Thailand. Pediatr Infect Dis J 1990 ; 9 (12) : 873-877
10. Suwanjutha S, Chantarojanasiri T, Wattana-kasetr S, et al. A study of nonbacterial agents
of acute lower respiratory tract infection in Thai children. Review Infect Dis 1990 ; 12
(Supp 8) : Nov-Dec page?

33

Wheezing associated respiratory illness

Wheezing physical sign asthma

acute respiratory infections viral infections
bacterial infections bronchitis pneumonia
bronchodilators antibiotics
wheezing acute respiratory tract infections asthma
Terminology wheezing bronchitis wheezing bronchitis
asthma wheezing
asthma .. 1990 wheezing
first attack wheezing acute respiratory infections
asthma
asthma
recurrent wheezing viral infection
WHO/ARI/93.29 first wheezing bronchiolitis
1 possible asthma recurrent wheezing asthma
.. .. 2529 2530
lower respiratory infections 560 wheezing 12.7% w heezing
50.7% pneumonia .. 2541-2542 ..
lower respiratory infections 215
wheezing 56.3% pneumonia 88 wheezing 50%
wheezing associated respiratory illness

Wheezing soft musical sound

( oscillation ) wheeze
small airways positive intrapleural pressure ( negative pressure)
pressure trachea large airways secondary compression
trachea large airways wheeze

34
polyphonic wheezing single airway
monophonic wheezing
wheezing

wheezing recurrent wheezing 1 2
1
Causes of wheezing in children
Infancy
Older child / adolescent
Acute :- Bronchiolitis
Acute :- Asthma
Asthma
Foreign body
Chronic:- Asthma
Allergic reaction
Recurrent aspiration
Chronic:- Asthma
Vascular ring/sling
Retained foreign body
Tracheal stenosis
Cystic fibrosis (rare)
Tracheomalacia
Vascular ring / sling
Cystic fibrosis
Tracheomalacia
Environmental exposure
Allergic bronchopulmonary - passive smoking
-aspergillosis
Pulmonary hemosiderosis
Psychogenic

2
Causes of recurrent or persistent wheezing in children
Reactive airway disease
Atopic asthma
Infection associated airway reactivity
Exercise-induced asthma
Salicylate-induced asthma and nasal polyposis
Other hypersensitivity reactions :

35
Hypersensitivity pneumonitis
Tropical eosinophilia
Visceral larva migrans
Allergic aspergillosis
Aspiration :
Foreign body
Food, saliva, gastric contents
Laryngo-tracheoesophageal cleft
Tracheoesophageal fistula, H-type
Pharyngeal incoordination or neuromuscular weakness
Cystic fibrosis
Ciliary dyskinesis
Cardiac failure
Bronchiolitis obliterans
Extrinsic compression of airways
Vascular ring
Enlarged lymph node
Mediastinal tumor
Lung cysts
Tracheobronchomalacia
Endobronchial masses
Gastroesophageal reflux
Pulmonry hemosiderosis
Sequelae of bronchopulmonary dysplasia
Hysterical airway closure
Cigarette smoke, other environmental insults
Wheezing in ARI
Wheezing 1 3 3
wheezing URI viral infection
wheezing 60% wheezing 3

36
6 wheezing associated atopy asthma

wheezing in ARI
1. Viruses RSV, parainfluenza, adenovirus, coronavirus
rhinovirus, influenza A 2 IgE response viral infection
RSV bronchiolitis recurrent wheezing
early episode asthma
2. Bacteria 3 Chlamydia pneumoniae,
Mycoplasma pneumoniae S. pneumoniae, H. influenzae
3. Mixed viral bacterial infection
wheezing ARI acute bronchiolitis
asthma ARI

1
wheezing
1. respiratory distress rapid-acting bronchodilator (inhaled beta-2 agonist)
30 wheezing
- fast breathing oral bronchodilator 3-5
- fast breathing pneumonia oral bronchodilator
antibiotic 5
2. respiratory distress
2.1 First episode of wheezing ( 1 )
18 bronchiolitis virus
bacteria asthma
oxygen

nebulized beta-2 agonist 10-15

- wheeze second dose bronchodilator
acute bronchiolitis admit supportive care nebulized epinephrine
antibiotic pneumonia

37
- fast breathing pneumonia with wheezing reactive airway
disease antibiotic 5 oral bronchodilator
- wheeze bronchitis reactive airway disease asthma
oral bronchodilator 3-5
2.2 Recurrent wheezing ( 2 )
asthmatic attack post bronchiolitic wheeze
cyanosis oxygen bronchodilator
cyanosis try bronchodilator OPD nebulized beta-2 agonist
2-3 10-15 oxygen response
asthma
- distress admit oxygen, inhaled short-acting beta-2 agonist
1-2 , systemic corticosteroids
intravenous
aminophylline
antibiotics pneumonia pneumonia
oral bronchodilator 1-2
- distress oral bronchodilator fast breathing
pneumonia antibiotics
recurrent wheezing investigate

Rapid-acting bronchodilator liquid beta-2 agonist nebulizing solution

salbutamol 0.05-0.15 ././ ( 2.5 ./) terbutaline 0.2-0.3 ./
./ ( 5 ./) medication nebulizer normal saline
2.5 3 . face mask mouth piece oxygen flow rate 6-8 /
beta-2 agonist metered dose inhaler spacer 2-3 puffs 5
2 puffs
Oral bronchodilators salbutamol 0.1 ././ ( 2 .) 3-4
terbutaline 0.075 ././ ( 2.5 .) 3-4

38

1
Rx of first wheezing with respiratory distress in young children
Nebulized 2-agonist
10-15

wheeze, resp. distress

wheeze

try second dose bronchodilator

10 -15

wheeze

Dx - Acute bronchiolitis
Rx - Admit, humidified O2
- Supportive care
- nebulized epinephrine
- AB
pneumonia

fast breathing
chest
Dx - Pneumonia
c wheeze
Rx - oral bronchodilator
+ AB 5
- chest indrawing
admit

fast breathing
chest
Dx - bronchitis
c wheeze
asthma
Rx - oral bronchodilator
3 - 5

- First wheezing acute bronchiolitis, ARI c wheeze, first episode of

asthma
- AB = antibiotics
- second dose bronchodilator = nebulized 2 -agonist subcutaneous 2 agonist,
adrenaline

39

2
Rx of recurrent wheezing with respiratory distress in young children
Nebulized 2-agonist
(1-3 10-15 )
response

Rx - Admit
Rx - oral bronchodilator
- fast breathing
- O2 ,supportive care
- inhaled short-acting 2-agonist 1 - 2 hr
pneumonia AB
- Systemic corticosteroid asthma
- IV aminophylline
-
- AB pneumonia
1 - 2

- oral bronchodilator 1-2

- prophylactic drug
inhaled corticosteroid, cromolyn

- MDI spacer 2 puffs

15 2-3
- Recurrent wheezing acute asthmatic attack post bronchiolitic wheeze

40

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