Acute Respiratory

Infection
Anum Mazhar Qureshi
Topics to be discussed

 IMCI/ARI
 Childhood Asthma
 Croup in Child
Integrated Management of Neonatal
and Childhood Illness (IMNCI)
 IMNCI is an integrated approach to child health that focuses on the wellbeing
of the whole child. IMNCI aims to reduce death, illness and disability, and to
promote improved growth and development among children under five years
of age.
 The three components of IMNCI
1. improve health workers' skills
2. improve health systems
3. improve family and community practices.

https://www.who.int/maternal_child_adolescent/documents/pdfs/imci_adaptat
ion_guide_2c.pdf?ua=1
IMNCI Management
Integrated Management of Childhood Illness
(IMNCI) for Acute Respiratory Infection
Antibiotic Doses
Childhood Asthma
Introduction and Epidemiology
 Asthma is a condition in which your airways narrow and swell and produce
extra mucus. This can make breathing difficult and trigger coughing,
wheezing(whistling sound when exhaling) and shortness of breath.
 For some people, asthma is a minor nuisance. For others, it can be a major
problem that interferes with daily activities and may lead to a life-
threatening asthma attack.
 Asthma is the most common chronic respiratory disorder in childhood,
affecting 15–20% of children.
 Diagnosing asthma in preschool children is often difficult. Approximately half
of all children wheeze at some time during the first 3 years of life.
Etiology
 It isn't clear why some people get asthma and others don't, but it's probably due to a
combination of environmental and genetic (inherited) factors.
 Exposure to various irritants and substances that trigger allergies (allergens) can trigger signs
and symptoms of asthma. Asthma triggers are different from person to person and can
include:
 Airborne substances, such as pollen, dust mites, mold spores, pet dander or particles of
cockroach waste
 Respiratory infections, such as the common cold
 Physical activity (exercise-induced asthma)
 Cold air
 Air pollutants and irritants, such as smoke
 Certain medications, including beta blockers, aspirin, ibuprofen and naproxen
 Strong emotions and stress
 Sulfites and preservatives added to some types of foods and beverages, including shrimp,
dried fruit, processed potatoes, beer and wine
 Gastroesophageal reflux disease (GERD)
Pathophysiology of asthma
Clinical features of Asthma
Asthma signs and symptoms include:
 Shortness of breath
 Chest tightness or pain
 Trouble sleeping caused by shortness of breath, coughing or wheezing
 A whistling or wheezing sound when exhaling (wheezing is a common sign of
asthma in children)
 Coughing or wheezing attacks that are worsened by a respiratory virus, such
as a cold or the flu
Asthma Exacerbation Severity
Investigations
 Asthma can usually be diagnosed from the history and examination and no investigations are
needed but sometimes, specific investigations are required to confirm the diagnosis.
 Some investigations are
1. Methacholine challenge: Methacholine is a known asthma trigger that, when inhaled, will
cause mild constriction of airways in asthmatic patients.
2. Skin-prick testing : for common allergens is often considered both as an aid to the diagnosis
of atopy and to identify allergens which may be acting as triggers.
3. Sputum eosinophils :Eosinophils are present when symptoms develop and become visible
when stained with eosin.
4. PEFR: Uncontrolled asthma leads to increased variability in peak flow, with both diurnal
variability (morning PEFR usually lower than evening PEFR) and day-to-day variability.
5. Spirometry :This test estimates the narrowing of bronchial tubes by checking expiratory
volume after a deep breath and rate of breathing. Spirometry provides
another diagnostic measure by quantifying whether airway obstruction reverses after the
patient is given a dose of a bronchodilator.
6. Provocative testing for exercise and cold-induced asthma.
7. Chest X-ray: is usually normal but may help to rule out other conditions.
Classification of Asthma
Management of Asthma
Management of Acute Asthma
 Croup
(laryngotracheobronchitis)
Introduction and Epidemiology

 Mucosal inflammation and increased secretions produced by laryngeal and

tracheal infections affecting the airway, the oedema of the subglottic area
that is potentially dangerous in young children because it may result in
critical narrowing of the trachea.
 Viral croup accounts for over 95% of laryngotracheal infections. Croup affects
about 3% of children per year.
 Croup occurs from 6 months to 6 years of age but the peak incidence is in the
second year of life. It is commonest in the autumn.
Etiology
 Etiology is most commonly viral, with some cases caused by bacteria.
 Viral
 Parainfluenza virus most commonly causes viral croup or acute laryngotracheitis, primarily
types 1 and 2.
 Other causes include influenza A and B, measles, adenovirus, and respiratory syncytial virus
(RSV).
 Spasmodic croup is caused by viruses that also cause acute laryngotracheitis, but lack signs of
infection.
 Bacterial
 Bacterial croup is divided into laryngeal diphtheria, bacterial tracheitis,
laryngotracheobronchitis, and laryngotracheobronchopneumonitis.
 Laryngeal diphtheria is caused by Corynebacterium diphtheriae. Bacterial tracheitis,
laryngotracheobronchitis, and laryngotracheobronchopneumonitis typically begin as viral
infections, which worsen due to secondary bacterial growth.
 The common bacterial causes are Staphylococcus aureus, Streptococcus pneumoniae,
Hemophilus influenzae, and Moraxella catarrhalis.
Pathophysiology

 Croup causes swelling of the larynx, trachea, and large bronchi due to
infiltration of white blood cells.
 Swelling results in partial airway obstruction which, when significant, results
in dramatically increased work of breathing, and the characteristic turbulent,
noisy airflow known as stridor.
Clinical Features
 The typical features are a
1. Croup usually begins with nonspecific respiratory symptoms (ie, rhinorrhea,
sore throat, cough).
2. Fever is generally low grade (38-39°C) but can exceed 40°C.
 Within 1-2 days, the following characteristic signs develop
1. hoarseness
2. "seal-like barking" cough
3. inspiratory stridor develop, often suddenly, along with a variable degree of
respiratory distress.
4. Respiratory rate and heart rate may also be increased.
 The symptoms often start, and are worse, at night.
 Visual inspection of nasal flaring, retraction, and rarely cyanosis increases
suspicion for croup.
Diagnosis
 Croup is typically a clinical diagnosis based on signs and symptoms.
 Consider nasal washings for influenza, Respiratory syncytial virus, and
parainfluenza serologies.
 Rule out other obstructive conditions, such as epiglottitis, an airway foreign body,
subglottic stenosis, angioedema, retropharyngeal abscess, and bacterial tracheitis.
 A frontal x-ray of the neck may be considered but is not routinely performed. It
may show a characteristic narrowing of the trachea in 50% of cases, known as the
steeple sign, because of the subglottic stenosis, which resembles a steeple.
 Blood tests and viral culture are advised against, as they may cause unnecessary
agitation and lead to further airway swelling and obstruction.
 Viral cultures, via nasopharyngeal aspiration, can confirm the cause but are
usually restricted to research settings.
 Consider primary or secondary bacterial etiology if a patient is not responding
to standard treatments.
Evaluation
 The most commonly used system for
classifying the severity of croup is
the Westley score ranging from 0 to
17 points divided by five factors:
stridor, retractions, cyanosis, level of
consciousness, and air entry.
 Westley score less than or equal to 2
indicates mild croup.
 Westley score between 3 to 5
indicates moderate croup.
 Westley score between 6 to 11
indicates severe croup, and a score
greater than 12 indicates impending
respiratory failure.
 More than 85% of children present
with mild disease; severe croup is
rare (less than 1%).
X-Ray finding
Treatment / Management

 Treatment depends on the severity based on the Westley croup score.

 Children with mild croup defined as Westley croup score less than 2 are
given a single dose dexamethasone.
 Children with moderate to severe croup defined as a Westley croup score
greater than 3 are given nebulized epinephrine in addition to dexamethasone.
 Patients with diminished oxygen saturation should receive supplemental
oxygen.
 Moderate to severe cases require up to 4 hours of observation, and if the
symptoms do not improve, admission is required.
Important
differential
 Acute epiglottitis is a life-
threatening emergency due to the
high risk of respiratory
obstruction. It is caused by H.
influenzae type b.
 It is important to distinguish
clinically between epiglottitis and
croup (Table 16.1), as they require
quite different treatments.
References
 llustrated Textbook of. Paediatrics. Fourth Edition. Edited by. Dr Tom
Lissauer
 https://www.who.int/maternal_child_adolescent/topics/child/imci/en/
 https://www.who.int/maternal_child_adolescent/documents/pdfs/imci_adap
tation_guide_2c.pdf?ua=1
 https://jamanetwork.com/journals/jamapediatrics/fullarticle/205379
 https://www.mayoclinic.org/diseases-conditions/asthma/diagnosis-
treatment/drc-20369660
 https://www.ncbi.nlm.nih.gov/books/NBK431070/
THANK YOU
Any questions?