INFEKSI RESPIRATORIK AKUT (IRA) ATAS

Finny Fitry Yani Respirologi Bagian IKA RS M Djamil-FK Unand

The upper respiratory tract consists of the parts outside the chest cavity: the air passages of the nose, nasal cavities, pharynx, larynx, and upper trachea
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COMMON COLD

...COMMON COLD

an acute, self limited, mild upper respiratory viral illness sneezing, nasal congestion and discharge (rhinorrhea), sore throat, cough, low grade fever, headache and malaise. to be distinguished from influenza, pharyngitis, acute bronchitis, acute bacterial sinusitis, allergic rhinitis, and pertussis.
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Viral cause of the common cold

Virus Rhinoviruses Coronaviruses
Influenza viruses Respiratory syncytial virus Parainfluenza viruses Adenoviruses Enteroviruses Metapneumovirus Unknown

Estimated annual proportion of cases (percent)

30-50 10-15 5-15 5

5 <5 <5
Unknown 20-30

...COMMON COLD

Viral transmission may occur via

inhalation of small particle aerosols, deposition of large particle droplets on nasal or conjunctival mucosa, or direct transfer via hand-to-hand contact

...COMMON COLD

Symptoms usually appear 1-2 days after viral inoculation symptoms are not the result of viral destruction of the nasal mucosa. nasal epithelium remains intact, although there is an influx of PMNs into the nasal submucosa and epithelium viral infection increases vascular permeability in the nasal submucosa, releasing albumin and kinins
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...COMMON COLD

Colored nasal discharge

~ increased presence of PMNs increase in positive bacterial culture presence of PMNs (yellow or white color) or of PMN enzymatic activity (green color)

TREATMENT

...COMMON COLD

Supportive therapy is the only recommended treatment Antihistamines, decongestants, antitussives, and expectorants, singly and in combinations, are all marketed for symptomatic relief in children. few clinical trials of these products in infants and children and none that demonstrate benefit for treatment of the symptoms

...COMMON COLD

Symptomatic therapy
may include antipyretics, saline nasal irrigation, adequate hydration, and the use of a humidifier Children with reactive airway disease or asthma should use beta-agonist medications to relieve associated bronchospasm.

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...COMMON COLD

Antipyretics
Acetaminophen (or ibuprofen, in children greater than 6 months of age) may be used to alleviate fever during the first few days

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...COMMON COLD

Saline irrigation
In infants, bulb suction with saline nose drops may help to temporarily remove nasal secretions in the older child, a saline nose spray may be used.

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...COMMON COLD

Antihistamines
The anticholinergic effects of 1st generation AH (eg, diphenhydramine) may help to reduce the secretions in controlled trials, AH have been ineffective in relieving the symptoms, in combination with decongestants or as monotherapy

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 Decongestants
sympathomimetic medications that cause vasoconstriction of the nasal mucosa. available in oral and topical formulations. pseudoephedrine HCl, and phenylephrine HCl, and oxymetazoline.

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...COMMON COLD

In adults: decrease nasal congestion and increase patency, no studies demonstrating the effectiveness of these medications in children. Side effects may include tachycardia, elevated diastolic blood pressure, and palpitations.

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...COMMON COLD

Because of the substantial risks of these products without proven benefit

not recommended for pediatric use.

It is conceivable that the older adolescent may benefit as an adult would from the use of a decongestant, such as pseudoephedrine

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...COMMON COLD

Antibiotic therapy
There is no role for antibiotics in the treatment does not prevent secondary bacterial infection may cause significant side effects, contribute to increasing bacterial antimicrobial resistance.

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 The use of antibiotics should be reserved for clearly diagnosed secondary bacterial infections, including bacterial otitis media, sinusitis, and pneumonia

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...COMMON COLD

PREVENTION
The best methods for preventing transmission from one person to another are to practice frequent handwashing and to avoid touching one's nose and eyes.

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ALLERGIC RHINITIS

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...allergic rhinitis

the occurrence of annoying nasal symptoms including discharge, itching, sneezing, congestion, and pressure

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...allergic rhinitis

Allergic rhinitis
associated with a symptom complex characterized by paroxysms of sneezing, rhinorrhea, nasal obstruction, and itching of the eyes, nose, and palate. It is also frequently associated with postnasal drip, cough, irritability, and fatigue

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...allergic rhinitis

must be distinguished from the other forms of rhinitis Episodic exposure to inhaled allergens such as cat salivary proteins, horse dander, murine urinary proteins, pollen, or house dust mite feces may provoke acute allergic symptoms

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...allergic rhinitis

Allergic, seasonal, and perennial Perennial nonallergic Infectious Miscellaneous categories, which include combinations of the above

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...allergic rhinitis

Allergic rhinitis is classified as seasonal if symptoms typically occur at a particular time of the year, or perennial if symptoms occur year round.

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...allergic rhinitis

Seasonal allergic rhinitis may be diagnosed by the history alone.

if allergen exposure is seasonal, for example, tree and grass pollen in the spring (rose fever) or ragweed pollen exposure in the fall (hay fever) are the most likely culprits, and the symptoms are predictable and reproducible.

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...allergic rhinitis

perennial allergic rhinitis

more than 2 hours per day and for > 9 mos of the year usually reflects allergy to indoor allergens like dust mites, cockroaches, or animal dander

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...allergic rhinitis

Nasal inflammation obstruction of the sinus osteomeatal complex predisposing to bacterial infection of the sinuses. Symptoms of bacterial sinusitis may include nasal congestion, purulent rhinorrhea or postnasal drip, facial or dental pain, and cough. Purulent rhinorrhea, purulent postnasal drip, or pain in a maxillary tooth and persistent cough in children are the most useful predictors of bacterial sinusitis

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...allergic rhinitis

The diagnosis is made on clinical grounds based upon the characteristic history (including presence of consensus risk factors), symptoms and signs on physical examination, and (if indicated) the confirmed presence of allergen-specific IgE Symptoms should also be reproducible on exposure to allergens to which the patient has been sensitized.

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...allergic rhinitis

"Intermittent" symptoms are present less than four days per week or for less than four weeks "Persistent" symptoms are present more than four days per week and for more than four weeks "Mild" None of the items listed below for "moderate-severe" are present "Moderate-severe" One or more of the following items is present:
- Sleep disturbance - Impairment of school or work performance - Impairment of daily activities, leisure and/or sport activities - Troublesome symptoms

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...allergic rhinitis

Nasal examination : nasal mucosa frequently displays a pale bluish hue or pallor along with turbinate edema, (not a universal finding) flexible fiberoptic rhinoscopy (> 5 years of age) may facilitate examination Clear rhinorrhea may be visible anteriorly or, with nasal obstruction, dripping down a posterior pharynx that resemble cobblestones

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...allergic rhinitis

Allergen-specific testing
properly performed skin testing may provide an in vivo assessment of biologically relevant IgE antibodies. It is the most convenient and least expensive screening method to detect allergic sensitization. Other tests are less useful.

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...allergic rhinitis

ALLERGEN AVOIDANCE The treatment of all patients with allergic rhinitis ideally begins with the identification and avoidance of allergic triggers

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Allergen identification

...allergic rhinitis
> 1 of the 4 major allergen categories that trigger allergic rhinitis Pollens Insects Animal allergens Molds

careful environmental history Reviewing home and work environments

The most common indoor allergens among patients with allergic rhinitis or asthma are dust mites and cat and dog dander

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...allergic rhinitis

PHARMACOLOGIC OPTIONS
Most patients require pharmacotherapy, in addition to allergen avoidance, for satisfactory symptom control

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Therapy
topical intranasal corticosteroids oral antihistamines topical nasal antihistamines mast cell stabilizers leukotriene modifiers ipratropium

...allergic rhinitis

Nasal decongestant sprays and systemic glucocorticoids should NOT be used for routine treatment of allergic rhinitis
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...allergic rhinitis

Topical INGCs are presently the most effective single maintenance therapy and cause few side effects at the recommended doses. particularly effective in the treatment of nasal congestion. beclomethasone, flunisolide, budesonide, fluticasone propionate, mometasone furoate, and fluticasone furoate.

Intranasal glucocorticoids ( INGCs)

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...allergic rhinitis

Second generation antihistamines

include loratadine, cetirizine, and azelastine Onset of action is within 1 hour for most agents, and peak serum levels are attained in 2 - 3 hours less impact on nasal congestion compared to INGCs.

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ACUTE BACTERIAL SINUSITIS IN CHILDREN

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...acute bacterial sinusitis

DEFINITIONS
Sinusitis is inflammation of the mucosal lining of one or more of the paranasal sinuses

common during URI, usually spontaneously resolves

when there is secondary bacterial infection of the sinuses

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...acute bacterial sinusitis

A viral infection associated with the common cold is the most frequent etiology of acute sinusitis viral rhinosinusitis. Appr. 6 - 13 % of viral rhinosinusitis in children is complicated by ABS

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...acute bacterial sinusitis

Uncomplicated viral rhinosinusitis usually resolves without treatment in 7 - 10 days. Although untreated ABS also may resolve without treatment

antibiotics hastens recovery and may decrease the risk for orbital and intracranial complications.
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...acute bacterial sinusitis

Distinguishing between acute viral rhinosinusitis and ABS

is important : antibiotics can be used judiciously

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...acute bacterial sinusitis

Classification

according to duration and recurrence

Acute: symptoms completely resolve in <30 days Subacute: symptoms completely resolve in 30 and <90 days Recurrent: >3 episodes of <30 days duration separated by intervals of 10 days without symptoms in a 6-month period, or >4 such episodes in a 12-month period; individual episodes respond briskly to antibiotic therapy

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...acute bacterial sinusitis

Chronic sinusitis is defined by episodes of inflammation of the paranasal sinuses that last >90 days, during which patients have persistent symptoms (cough, rhinorrhea, nasal obstruction). may be related to noninfectious conditions such as allergy, cystic fibrosis, gastroesophageal reflux, or exposure to environmental pollutants

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...acute bacterial sinusitis

Risk factors
Viral URI is the most important children who attend day care Allergic rhinitis

Anatomic obstruction ( septal deformities; craniofacial anomalies; adenoidal hypertrophy) Mucosal irritants (dry air, tobacco smoke, chlorinated water) Sudden changes in atmospheric pressure (descent in an airplane)

Less common

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...acute bacterial sinusitis

Streptococcus pneumoniae, Haemophilus influenzae (non-typeable), and Moraxella catarrhalis are the predominant causes of ABS Because of its general effectiveness, safety, low cost, and narrow spectrum, amoxicillin, with or without clavulanate, generally is considered to be the first line agent for the treatment of ABS in children

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...acute bacterial sinusitis

Antibiotics
For children with uncomplicated ABS that is of mild to moderate severity
Amoxicillin (45 to 90 mg/kg per day in two divided doses), or Amoxicillin-clavulanate (45 to 90 mg/kg per day of the amoxicillin component in two divided doses)

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...acute bacterial sinusitis

Antibiotics For children who have uncomplicated ABS of at least moderate severity
Amoxicillin-clavulanate (80 to 90 mg/kg per day of amoxicillin) Cefdinir (14 mg/kg per day in 1 or 2 doses), or Cefuroxime (30 mg/kg per day), or Cefpodoxime (10 mg/kg per day once daily)

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...acute bacterial sinusitis

Antibiotics children with vomiting that precludes administration of oral antibiotics

A single dose of ceftriaxone (at 50 mg/kg per day), i.v. or i.m Therapy with an oral antibiotic should be initiated 24 hours later, provided the vomiting has resolved.

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...acute bacterial sinusitis

Antibiotics
Seriously ill children with ABS should be hospitalized for intravenous antibiotics. Empiric therapy should provide coverage for highly resistant pneumococci and penicillin resistant H. influenzae and M. catarrhalis. Appropriate regimens include: Cefotaxime (100 - 200 mg/kg /day divided every 6 hs) Ceftriaxone (100 mg/kg /day divided every 12 hs)

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