ARI
Dr Mirza Inam Ul Haq
ACUTE RESPIRATORY
INFECTION



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 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
Acute Upper Respiratory Infections.
Mild cough, cold, pharyngitis, otitis media, and
allergic rhinitis.
Acute Lower Respiratory Infections.
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.
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
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 1020% 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 severity of and mortality from
pneumonia in children
To reduce the incidence of acute lower
respiratory infections (ALRI)
To reduce the severity and complications
from acute upper respiratory infection (AURI)
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.
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
Bacterial organism.
Viral organism
Agents of Upper Respiratory Tract
Infections

Common cold (rhinitis)


Pharyngitis and laryngotracheitis





Streptococcus pyogenes
Corynebacteria diphtheriae
Neisseria gonorrhea
Many viruses
Epiglottitis


Many viruses; rhino, corona, adeno, influenza
Haemophilus influenzae
Bronchitis


Bordetella pertussis
Many viruses
Agents


Tuberculosis: Mycobacterium tuberculosis
Pneumonia
 Bacteria
 Streptococcus pneumoniae
 Mycoplasma pneumoniae
 Staphylococcus aureus
 Viruses
 Influenza
 Measles
 Many others
 Fungi
 Many
HOST FACTORS



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.
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
Malnutrition
Specific nutritional deficiencies
Climatic conditions
Housing (over crowding, poor housing
conditions)
Level of Industrialization
Socio-economic Level
LBW
Indoor Pollution (air pollution)
Maternal cigarette smoking.
MODES OF TRANSMISSION


Air Borne
Direct- person to person.
POLICY







Who in1976 adopted a policy of
Improving Living Conditions.
Better Nutrition.
Reduce smoke pollution
Other factors are
MCH care
Immunization (to prevent pneumonia which
occur as complication of vaccine preventable
diseases).
CLINICAL ASSESSMENT








1.BREATHING RATE/MINUTE.
2.LOOK FOR CHEST INDRAWING.
3.LOOK AND LISTEN FOR STRIDOR.
4.LOOK FOR WHEEZE.
5.LOOK IF THE CHILD IS DROWSY.
6.FEEL FOR FEVER.
7.CHECK FOR SEVERE MALNUTRITION.
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.




Very severe disease.
Severe Pneumonia.
Pneumonia not Severe.
No Pneumonia: cough or cold.
CLASSIFICATION OF ILLNESS


A, Child aged (0- 2 months)
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
Danger signs are






Child is unable to drink
Convulsions
Strider in the calm child
Severe malnutrition

Severe Pneumonia
Respiratory rate
60 or more/minute
age<2m
age 2-12 m
50

1-5 yrs


40 or more/minute age
2-5 yrs

Chest in drawing
Nasal flaring
Grunting
Cyanosis
Pneumonia not severe
Fast breathing without chest in drawing.

No Pneumonia: (Cough & Cold).





0-2 months






Danger signs are
Convulsions
Stridor
Stopped feeding well
Wheezing
Fever/ Low body temperatures
0-2 months
Very Severe Disease
Danger signs are








Child is unable to drink
Convulsions
Stridor in the calm child
Severe malnutrition
Not Feeding well
O-2 Months









Severe Pneumonia
Respiratory rate
60 or more/minute
Chest in drawing
Nasal flaring
Grunting
Cyanosis
Pneumonia
Fast breathing without chest in drawing.
Pneumonia Protocol: Infants and Children > 2 months
Very Severe Pneumonia
Severe Pneumonia
Improvement after 48 hours?
No
Improvement after 48 hours?
Yes
Yes
No
Look for
complications like
Effusion/empysema
Look for
complications
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
Oral amoxicillin
for 5 days
Change to ceftriaxone
50-100mg/kg BID for 10
days
Treat complications if found
Complications include:
If the child
improves on
cloxacillin
continue
cloxacillin orally 4
times a day for a
total course of 3
weeks
Empyaema*
Pleural effusion*
Lung abscess*
Antibiotic
treatment can be changed by a doctor
*
when blood culture results are available
Very Severe Pneumonia
Severe Pneumonia
Ceftriaxone (50-100 mg/kg
Give ampicillin (100
IV divided Bid (may give IM
mg/kg IV/IM every 6
if no IV access)
hours) and
chloramphenical (50
The child MUST
mg/kg every 8 hours)
be discussed with
for at least 48 hours
a doctor and
reviewed as soon
Obtain a chest x-ray
as possible
Child should be
checked by a
nurse every 6
Monitor and ensure oxygen saturations >90% hours and by a
doctor or medic
every day
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*
Pneumonia
Protocol:
Give paracetamol
(15mg/kg as needed
up to 4 timesInfants
a day) for and
fever
Pneumonia
Give oral amoxicillin (or IV
ampicillin)
Give the first dose in the
clinic
**)Weight
Fluid
ml/hour
2kg
8
4kg
16
6kg
25
8kg
33
10kg
42
12kg
46
14kg
50
16kg
54
18kg
Children < 2 months
58
Management of very severe disease (2m- 5
yrs age)



Treat fever
Treat wheezing




Antibiotic
Inj Benzyl Penicillin Ist 48 hr
50000 IU 6 hr
IM
Inj Ampicillin
50mg/KG/Dose 6 Hrly
IM/oral
Chloramphenicol
25mg/KG/Dose 6Hrly
IM/oral
CONT

Treatment



Nebulize 0.5ml+2ml
N/S Salbutamol
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.