Acute Respiratory Infection

(2)
Kiagus Yangtjik
DEPARTMENT OF CHILD HEALTH
FACULTY OF MEDICINE

SRIWIJAYA UNIVERSITY/DR.MOHAMAD HUSIN HOSPITAL

PALEMBANG 2015

1.Acute Bronchiolitis
2.Bronkopneumonia / Pneumonia.

3.Pneumonia Aspirasi
4.Pertusis

Acute Bronchiolitis
Clinical features
Affects children at < 24 months old, mainly between 1 to 6
months of range. Usually preceeded by upper respiratory tract
symptoms

Subfever (38-39)

Cough

Respiratory distress (RR > 70/min) + Retractions

Wheezing and (fine rales (47%)

Difficult feeding

Chest hyperinflation with subcostal retractions, fine freckles, +

ronchi. Young infants (especially premature babies) may
present with apnea. Cyanosis may occur in severe cases.

An X-Ray of child wih RSV showing the typical bilateral

perihilar fullness of bronchiolitis

Bronkiolitis Acute

Acute Bronchiolitis
Common Pathogens

RSV (respiratory syncytial virus) predominant

cause(70%). Other viruses eg parainfluenza virus
human pneumo virus occasionally responsible.

Bacterial superinfection is uncommon

Increased :

Prematurity (<35 weeks), LBW, CHD

Not Breastfeeding

Caesarean birth

Acute Bronchiolitis
Clinical course

Most infants recover within a week and 10

days
Some infants may have persistent coughs
for up to 30 weeks

Diagnosis

RSV testing by Direct Immunofluorescence

(nasopharyngel aspirate , Sesitivity 61%, Specificity
89%)
*

Acute Bronchiolitis
Management guidelines
Antibiotics are not indicated ( RSMH profilaxis antibiotic)

Bronchodilators may be beneficial in some infants but should be

driven by oxygen ( in more severe cases) to prevent worsening
hypoxia from V/Q mismatch

Inhaled epinephrine (racemic epinephrine)

Monoclonal antibodies ( eg.palivizumab)

Antiviral agents ( eg. Ribavirin)

Theophylline and steroids have not been shown to be beneficial

Nebulized hypertonic saline (3%) (SABRE 2014) no evidence

Prevention :
Handwashing
Avoiding exposure..

Acute Bronchiolitis
Important notes

High risk patients ( for respiratory failure)

Underlying congenital heart disease

Immunodeficiency

Immunosuppresive therapy

Neuromuscular disease

These patient are likely to require hospitalization

for monitoring

PNEUMONIA

Pneumonia is a number 1 killer for

infants

Pneumonia

Lobar Pneumonia

Bronkopneumonia dan
pneumonia labaris

 WHO ARI control program (included in

IMCI Algorythm ) uses simple clinical sign
are Respiratory rate and Chest
indrawing for ARI classification
WHO ARI classfication :
2 months - 5 years of age
1. SEVERE PNEUMONIA
2. PNEUMONIA
3. NO PNEUMONIA
until 2 months of age
1.SEVERE PNEUMONIA
2.NO PNEUMONIA

ESTABLISHING ETIOLOGY OF
PNEUMONIA IN CHILDREN

Difficult
Bronchoalveolar lavage and lung
puncture for culture not usually done
Results of culture can be misleading

Etiologi pneumonia (Common)

VIRALS

Respiratory Syncytial Virus

Influenza A atau B
Parainfluenza 1,2 dan 3
Adenovirus
Rinovirus.
Morbilli
Bacterials
Streptococcus pneumoniae
Haemophilus influenzae
Stafilococcus aureus
Streptococcus grup B
Mycoplasma pneumonia
Clamidya trachomatis
Klamidia pneumoniae

Etiologi pneumonia (RARE)

Virus
Varisela-zoster
Coronavirus SARS
Paramyxovirus SARS
Enterovirus (coxsackie echo)
Cytomegalovirus
Herpes simpleks, dll
Bakteri
Anaerob (S mileri, peptostreptokok)
Klebsiela pneumonae
E.koli
Neiseria meningitidis
Legionela
Pseudomonas spp
Leptospira, dll
Fungus
Histoplasma kapsulatum, dll
Blastomises dermatitidis

Etiologi pneumonia
(age < 3 month)

Streptocooous grup B

Staphylococcus aureus

Chlamyidia trachomatis

Gram negative bacterials

Neonatus
infection from mother

Related with labour process

- meconium aspiration,
- from mother cervixs

Etiologi pneumonia
( 3 months - 5 years

old

Common
S. pneumoniae
H. influenzae
Rare
Streptokok grup A

Etiologi pneumonia
( > 5 years old)

MYcoplasma pneumoniae
Chlamydiaa pneumoniae
S pneumoniae
H influenzae

Others

CLINICAL MANIFESTATION
(Depend on age and etiology)

Fever
Cough
Chest pain
Dispneu

Retration/chest
indrawing

grunting
Tachypneu
Auscultation : rales,
ronchi
X Ray : infiltrate,
consololidation

CLINICAL MANIFESTION
(neonatus dan young infant)

Not specific
Neonatus
difficult to different
with sepsis dan
meningitis

Retraction/chest
indrawing

grunting
Tachypneu
Auscultation : rales,
ronchi
X Ray : infiltrate,
consololidation

Not well doing baby

TANDA
KLASIFIKASI
Ada
tanda
bahaya
PNEUMONIA
umum atau
BERAT
Tarikan dinding dada ke
dalam
Stridor

PENGOBATAN

Beri dosis pertama antibiotik yang

sesuai

Rujuk segera

Nafas cepat

PNEUMONIA

Tidak ada tanda-tanda BATUK BUKAN

pneumonia atau penyakit PNEUMONIA
sangat berat.

Beri antibiotik yang sesuai selama 5

hari
Beri pelega tenggorokan dan pereda
batuk yang aman
Nasihati ibu kapan harus kembali
segera
Kunjungan ulang setelah 2 hari
Jika batuk lebih dari 30 hari, rujuk
untuk pemeriksaan lebih lanjut
Beri pelega tenggorokan dan pereda
batuk yang aman
Nasihati ibu kapan harus kembali
segera
Kunjungan ulang dalam 5 hari jika
tidak membaik

SIMPLE SIGN PNEUMONIA (WHO)

Fast Breathing (takipnu)
RESPIRATION RATE
AGE

(x/MINUTE)

< 2 MONTHS
2 - 12 MONTHS
1 - 5 YEARS

DISPNEU

CHEST INDRAWING

60
50
40

INVESTIGATION
Non invasif
Chest X ray AP-lateral
Blood
Cultur of sputum and Gram stain
Cultur of blood (spesific, 10-15 %)
Fast detection antigen and serologic
Invasif
Pleural punction
Bronchoalveolar lavage
Transbronchial biopsy
Open lung biopsy

Pneumonia..
Clinical course

An elevated white cell count may be more indicative

of bacterial infections (usually >15.000/mm3)
Viral and Mycoplasma infections more often do not
have elevated white cell count.

Viral and Mycoplasma pneumonias may take 2 to 3

weeks to resolve

S. pneumoniae usually resolve within 7 to 10 days

S.aureus frequently slower to resolve

Indication for chest X-ray

1.

Suspected pneumonia

2.

Suspected foreign body aspiration

3.

Suspected lower respiratory tract

infection

Indications for
hospitalization :
1.

Inability to feed orally with risk of dehydration

2.

Difficulty in breathing with risk of respiratory

failure

3.

Clinical course not consistent with primary

diagnosis or child not responding to appropriate
therapy

4.

Suspected foreign body aspiration.

MEDICATION IN RESPIRATORY
INFECTION

ANTIBI0TICS
Antibiotic treatment of children with
URTI(common cold) does not influence
either the course of ilness or the
likelihood of suffering complication
( Tom, et al. Systemic review of the treatment

of upper respiratory tarct infection.,Arch Dis

Child 1998;79:225-30 )

Indicated treatment of children with ALRI and

AURI (Streptococcal Paryngitis)

When Are Antibiotics Necessary

?

The majority of URTIs are caused by

viruses.

Antibiotics are not usually necessary.

In fact meta-analysis of RCT have failed to
demonstrate that antibiotics prevent LRTI.
The issue of increasing resistant strains of
bacteria is becoming an alarming problem
worldwide.

Amoxicillin and kotrimoxsazol were

equally effective in non severe pneumonia
(Catchup study group,Arch Dis Child 2002, 86:113-18)

Chloramphenicol was effective treatment

of children with severe pneumonia
( Duke et al.Lancet 2002; 359:478-80)

Amoxicillin or amoxicillin-clavulanat
were effective treatment of children
with acute sinusitis
(Garbuttet al. Pediatrics 2001; 107:619-25)

Aspiration pneumonia

Aspiration pneumonia is bronchopneumonia that

develops due to the entrance of foreign materials into the bronchial

tree,[1] usually oral or gastric contents (including food, saliva, or
nasal secretions).

Causes
Aspiration pneumonia is often caused by an incompetent swallowing
mechanism, such as occurs in some forms of neurological disease or
injury including multiple sclerosis, CVA (stroke), Alzheimer's disease
or intoxication. An iatrogenic cause is during general anaesthesia for
an operation and patients are therefore instructed to be nil per os
(NPO) (aka Nothing By Mouth) for at least four hours before surgery

Risk Factors :
Age, being male, poor dental hygiene, lung disease, swallowing
difficulties, diabetes mellitus, severe dementia, malnutrition,
Parkinsons disease, use of antipsychotic drugs, proton pump
inhibitors, and angiotensin-converting enzyme inhibitors.[3][4]
Reduced functional status,

Implicated bacteria
[[ anaerobic bacteria oral flora:
Bacteroides[6]
Prevotella[6]
Fusobacterium[6]
Peptostreptococcus[6]

Location
Generally, the right middle and lower lung lobes are the most
common
The right upper lobe is a common area of consolidation in alcoholics
who aspirate in the prone position.[7]

Diagnosis
Diagnosed by a combination of clinical circumstances (debilitated or
neurologically impaired patient),
Radiologic findings (right lower lobe pneumonia) and microbiologic cultures.
Some cases of aspiration pneumonia are caused by aspiration of food particles
or other particulate substances like pill fragments; these can be diagnosed by
pathologists on lung biopsy specimens.[8]

PERTUSIS

Outline

Bordetella Pertussis microbiology

Whooping Cough/Pertussis
Vaccine
Current problems with B. pertussis

Bordetella pertussis
Basics

Aerobic, Gram negative coccobacillus

Alcaligenaceae Family
Specific to Humans
Colonizes the respiratory tract
Whooping Cough (Pertussis)

http://microvet.arizona.edu/Courses/MIC420/lecture_notes/bordetella_pertussis/
gram_pertussis.html

Transmission

Very Contagious
Transmission occurs via respiratory
droplets

http://www.universityscience.ie/imgs/scientists/whoopingcough.gif

http://www.ratbags.com/rsoles/history/2000/12december.htm

Toxins

Pertussis Toxin
Adenylate Cyclase Toxin
Tracheal cytotoxin
Dermonecrotic toxin
Heat-labile toxin

www.ibl.fr/u447/u447.htm

Whooping Cough

Also known as Pertussis

Outbreaks first described in the 16th
Century
Major cause of childhood fatality prior
to vaccination

paaap.org/immunize/ course/slide27.html

Clinical Features

Incubation period 4-21 days

3 Stages
1st Stage- Catarrhal Stage 1-2 weeks
2nd Stage- Paroxysmal Stage 1-6 weeks
3rd Stage- Covalescent Stage weeksmonths

Pertussis Infection

gsbs.utmb.edu/ microbook/ch031.htm

Diagnosis

Isolation by culture
PCR
Direct fluorescent antibody
Serological testing

http://medinfo.ufl.edu/year2/mmid/bms5300/images/d7053.jpg

Treatment

Antibiotic therapy
Erythromycin
Azithromycin and clarithromycin

http://www.aboutthatbug.com/AboutThatBug/files/CCLIBRARYFILES/
FILENAME/0000000032/033_lg.jpg

http://www.vet.purdue.edu/bms/courses/lcme510/chmrx/macrohd.htm

Pertussis Vaccine

1st Pertussis vaccine- whole cell

Acellular vaccine now used
Combination vaccines

http://www.tdh.state.tx.us/immunize/providers.htm
http://www.nfid.org/publications/clinicalupdates/pediatric/pertussis.html

Vaccine problems

Complications/Safety
Multiple administration
Waning adolescent and adult immunity
Strain Variability

http://www.healthcareforhoosiers.com/Member/vaccineschedule.html

Conclusions

Reemerging in adult and adolescent

populations as worldwide vaccination
rates increase
High vaccination rates not enough
Better vaccine development needed

References
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Microbiology. 2004; 30(3): 187-196.
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Reference cont.
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Diseases. 2005;191: 81-88.
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TERIMAKASIH