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ACUTE

RESPIRATORY
INFECTIONS
Terminology
Acute respiratory infection(ARI)
Indonesian: IRA –ISPA
Acute --<2 weeks
any infection of the upper&/lowerresp system
Common cold (rhinitis, rhinopharyngitis) ----------
pneumonia
Acute upperrespiratory infection (AURI) --morbidity
Acute lowerrespiratory infections (ALRI) --include
severe infections, such as pneumonia–mortality
ARI epidemiology
Pediatric ARI’s are one of the MOST
COMMON reasons forphysician visits: in
industrialised countries up to 50%(much
more in developing countries)
80-90%of ARI’saffect the UPPER(AURI):
rhinitis, rhinosinusitis, pharyngitis, laryngitis,
otitis media,
10-20% of RTIs affect the
LOWER(ALRI)tracheitis,
bronchiolitis/bronchitis, bronchopneumonia,
pneumonia
Role of physicians: diagnosis, treatment &
Acute Respiratory Infections (ARI)

Developed and developing countries


High morbidity
5 – 8 episodes/year/child
30 – 50 % outpatient visit
10 – 30 % hospitalization
Developing countries
High mortality
30 – 70 times higher than in developed countries
1/4 - 1/3 death in children under five year of age
Magnitude of the Problem
in Indonesia
Pneumonia in children (< 5 years of age)
Morbidity Rate 10-20 %
Mortality Rate 6 / 1000
Pneumonias kill
 50.000 / a year
 12.500 / a month

 416 / a day = passengers of 1 jumbo jet plane

 17 / an hour

 1 / four minutes
RISK FACTORS FOR PNEUMONIA
OR DEATH FROM ARI
Malnutrition, poor
breast feeding
practices
Lack of immunization Vitamin A deficiency

Young age Low birth weight


Increase
risk of
ARI
Cold weather
Crowding or chilling

High prevalence Exposure to air pollution


of nasopharyngeal • Tobacco smoke
carriage of • Biomass smoke
pathogenic bacteria • Environmental air pollution
Spectrum of ARI

AIRWAY Common cold / rhinitis /


rhino-pharyngitis / naso-pharyngitis
Air passage
Rhino - sinusitis
Airflow
Acute otitie media
(Tonsilo) Pharyngitis
Conducting Croup – Acute Laryngitis
zone
(Rhino) bronchitis

Respiratory zone Pneumonia


Diffusion
Common cold, DIAGNOSIS
an acute, self-limitingviral infection of
the upper airway involving the nose,
sinuses, pharynx & larynx.
Canadian Med AsscJ, 2014, 186(3)

Fever, cough, rhinorrhea


Source of infection, easily transmitted
Common cold,
etiology
Relative frequency Virus

Most common Rhinovirus

Common Coronavirus
Influenzavirus*
Parainfluenzavirus*
Respiratory syncytialvirus

Occasional Adenovirus
Enterovirus
Rhino-sinusitis
Acute RS is an inflammation of the mucosal
lining of the nasal passage and paranasal
sinuses lasting <4 weeks
allergens,
environmentalirritants, and
infection by viruses,
bacteria, or fungi
A viral etiology or the
common cold is the most
frequent
cause of acute
rhinosinusitis
Acute rhino-sinusitis,
DIAGNOSIS
fever
rhinorrhoea
nasalcongestion
cough, throat
clearing
postnasal drip, itchy
throat
facial (maxillary)
pain
Ccold = Acute RS,
uncomplicated
Acute bacterial RS
A common cold that:
Severesymptoms than usual (high
fever, copious purulent discharge, peri-
orbital edema and pain)
Worseningsymptoms, after 5 days of
improvement (double sickening)
Persistentsymptoms, beyond 10 days
N Engl J Med 2012;367:1128-34.
IDSA Guideline for ABRS d CID 2012
Pediatrics 2013;132:e262
Acute otitis
media
an acute inflammation ofthe middle ear
caused by infections

fever, irritability, pain

•mainly affects children


•peak incidence 6-12 months of age
•caused by viruses &/ bacteria
•about 3 days, up to 1 week
•most cases get better within 3 days without AB
•complications such as mastoiditis are rare
Acute otitis media guideline NICE 2018
Acute otitis media,
DIAGNOSIS
moderate to severe bulging of the tympanic
membrane (TM) or new onset of otorrhea
mild bulging of the TM & recent (<48h) onset of ear
pain (holding, tugging, rubbing of the ear in a
nonverbal child)
Pharyngitis(sore throat)
an inflammatory process in the pharynx,
tonsils or nasopharynx;
not always caused by an infectious agent
mostly of viral origin, occur as a part of the
common cold Streptococcalpharyngitis
can be complicated by
acute rheumatic fever or
acute glomerulonephritis.
Pharyngitis epidemiology
Children experience >5 ARIs /year and an
average of one streptococcal infection every
4 yrs
Mostly caused by respiratory viruses
The most common viruses:rhinovirus &
adenovirus
The most significant bacterial agent causing
pharyngitis in both adults and children is
GASinfection (Streptococcus pyogenes)
15-30%of pharyngitis cases among school-
aged childrenin the cooler months are due to
GAS.
Pharyngitis,
clinical
Viral Streptococ
pharyngitis pharyngitis
Conjunctivitis Sudden onset
Coryza Age 5–15 years
Cough Fever
Diarrhea Headache
Hoarseness Nausea, vomiting, abd
Ulcerative pain
stomatitis Tonsillopharyngeal
Viral inflammation
exanthema Patchy exudates
Streptococcal pharyngitis,
clinical

Pathcy exudates Palatal Ptechiae


Croup –laryngo-trachea-
bronchitis
viral inflammation of upper airway,
larynx, trachea &bronchi;
compromising airflow through
theproximal airway
the mostcommon
are parainfluenza 1
& 2 and RVS

mostly affects
children between 6-36
months
Croup, DIAGNOSIS
Croup is a clinical syndrome of hoarse voice,
barking cough and inspiratory stridor in
young children.
The need for treatment is determined by the
severity of proximal airway obstruction.
Rhino-bronchitis
a clinical syndrome produced by
inflammation of
the trachea, bronchi, and bronchioles.

most often caused by a viral infection;


rhinovirus, enterovirus, influenza A &B,
parainfluenza, coronavirus, human
Acute (rhino)-bronchitis
in children, acute bronchitis usually occurs
in associationwith viral resp infection /
common cold
acute bronchitis is rarely a primary bacterial
infection in otherwise healthy children.
self-limited, with complete healing and full
return to function typically seen within 10-14
days following symptom onset
Am Fam Physician. 2016;94(7):560-565
emedicine.medscape.com/article/1001332-overview
Rhino-bronchitis,
DIAGNOSIS
Clinical!!!Symptomatology!
natural history: preceded by common cold,
rhinopharyngitis
acute, not recurrent –if recurrent: asthma !!!
cough is the predominant symptom; initially
is dry & may be harsh or raspy sounding, then
loosens & becomes productive
lower resp sign: crackles, ronchi, wheezing
of large airway;‘rattling sound’ in the chest
chest films generally appear normal in
patients with uncomplicated bronchitis –not
ARSmedical TREATMENT
Intranasal steroid
Nasal irrigation
Antihistamine
Decongestant, oral or intranasal
Erdosteine
Antibiotics, the most frequently used
therapeutic agents---is it needed ???
Acute bacterial RS, AB
TREATMENT
Antibiotics1stline:
Amoxicillin (+clavulanate) 40-80
mg/kgBW/day(1,2)

Alternative:
Cephalosporin: cefixime(1,2),
cefpodoxime (2)
Clindamycin (1,2)
Levofloxacin (1,2)
Linezolid (1)
Acute otitis media, TREATMENT
Consideration, evidence that:
AB make little difference to symptoms
AB make little difference to the development of
common complications
acute complications such as mastoiditis are rare
with or without AB
Paracetamol or ibuprofen
Anesthetic ear drop
No decongestant or antihistamin

When no antibiotic prescription is given, advice:


an antibiotic not being needed
Acute otitis media guideline NICE 2018
Acute otitis media, AB
TREATMENT
AB is needed if symptoms: worsenrapidly or
significantly, do not improve after 3 days, or the
child or becomes systemically very unwell. (1,2)
Amoxicillin, Amoxicillin clavulanate(1,2)
Clarithromycin (2)
No prophylactic antibiotic (1)
Exclusive breastfeeding (1)
Vaccine: PCV, influenza (1)
ETS avoidance (1)

2. Acute otitis media guideline NICE 2018


1. Pediatrics 2013;131:e964–e999
Strep pharyngitis,AB
TREATMENT

Patients with acute GAS pharyngitis should


be treatedwith an appropriate antibiotic at an
appropriate dosefor aduration(usually 10
days). Penicillinor amoxicillinis the
recommendeddrug of choice (strong, high)
in penicillin-allergic individualsshould
include a 1st gen cephalosporinfor 10 days,
clindamycinor clarithromycinfor 10 days, or
azithromycinfor 5 days(strong, moderate).
Croup,
TREATMENT
Parental anxiety should not be discounted: it is
often of significance, even if the child does not
appear especially unwell.
•Mild croup does not need pharmacological
treatment
•There is no RCT evidence to support the use of
mist therapy.
•Children with stridor & retractions should
receive corticosteroids: oral, IV, IM, neb; oral is
preferred
•moderately severecroup: nebulised adrenaline
& systemic corticosteroids
Rhino-bronchitis,treatment
Medical therapy generally targets
symptoms and includes use of analgesics
&antipyretics.
Antitussives& expectorantsare often
prescribed but have notbeen demonstrated
to be useful
In healthy individuals, antibiotics has no
benefit in relieving symptoms or improving
the natural history
Placebo-controlled studies using
doxycycline, erythromycin, and
trimethoprim-sulfamethoxazole have failedto
show significant benefit in patients with
Pneumonia is a no 1 killer for infants
(Balita)
Pneumonia
Classifications
Anatomical classification
 Lobar pneumonia
 Lobular pneumonia
 Intertitial pneumonia
 Bronchopneumonia
Etiological classification
 Bacterial pneumonia
 Viral pneumonia
 Mycoplasma pneumonia
 Aspiration pneumonia
 Mycotic pneumonia
Etiology of Pneumonia

Predominantly : bacterial and viral


In developing countries:
bacterial > viral
(Shann,1986): In 7 developing countries,
bacterial  60 %
(Turner, 1987): In developed countries,
bacterial 19 % ; viral 39 %
Bacterial etiology

Streptococcus pneumoniae
Hemophilus influenzae
Staphylococcus aureus
Streptococcus group A – B
Klebsiella pneumoniae
Pseudomonas aeruginosa
Chlamydia spp
Mycoplasma pneumoniae
BACTERIA ISOLATED FROM LUNG ASPIRATES
IN 370 UNTREATED CHILDREN WITH PNEUMONIA
%
50

40

30

20

10

0
S Pneumoniae H Influenzae S Aureus
Tabel 1 : Dugaan bakteri penyebab
pneumonia
Dugaan kuman Pneumonia Pneumonia dengan komplikasi
penyebab tanpa
komplikasi Efusi pleura Abses paru

S. Pneumoniae ++++ ++ +

H. Ifluenzae ++ ++ +

Streptococcus gr A + ++ +

Flora mulut + +++ ++++

S. aureus + ++ ++
Characteristic features

S pneumoniae
 mucosal inflammation lesion
 alveolar exudates
 frequently lobar pneumonia)
H influenzae, S viridans, Virus
 invasion and destruction of mucous membrane
Staphylococcus, Klebsiella
 destruction of tissues  multiple abscesses
Simple Clinical Signs of Pneumonia
(WHO)

Fast breathing (tachypnea)

Respiratory thresholds
Age Breaths/minute
< 2 months 60
2 - 12 months 50
1 - 5 years 40

Chest Indrawing
(subcostal retraction)
Manifestasi klinis pneumonia
Gejala Tanda pemeriksaan fisis
Demam Demam rokhi
napas cepat Takipnu mengi
Batuk Dispnu suara napas melemah
Muntah Retraksi pekak pada perkusi
tidak mau minum napas cuping hidung fremitus melemah
Iritabel Merintih meningismus
Letargi Sianosis pleural friction rub
nyeri dada

nyeri perut

nyeri bahu
Pedoman klinis membedakan
penyebab pneumonia
Pemeriksaan bakteri Virus mikoplasma
Anamnesis
 umur berapapun, bayi Berapapun usia sekolah
 awitan mendadak Perlahan tidak nyata
 sakit serumah tidak ya, bersamaan ya, berselang
 batuk produktif Nonproduktif kering
 gejala toksik mialgia,ruam, nyeri kepala,otot,
penyerta organ bermukosa tenggorok
Fisis
 keadaan klinis >temuan klinis ≤ temuan klinis < temuan
umum
 demam umumnya ≥ 390c umumnya < 390c umumnya < 390c
 auskultasi ronkhi ± suara ronkhi bilateral, ronkhi
napas melemah difus, mengi uniteral,mengi
Pathology and Pathogenesis
Bacteriae peripheral lung tissues
 tissues reaction  oedematous
Red Hepatization Stadium
alveoli consist of : leucocyte, fibrine,erythrocyte,
bacteria
Grey Hepatization Stadium
fibrine deposition, phagocytosis
Resolution Stadium
neutrophil degeneration, loose of fibrine,
bacterial phagocytosis
Bronchopneumonia
Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the
alveolar spaces. The alveolar capillaries are distended and engorged.
Bronchopneumonia
Acute bronchopneumonia. The alveolar spaces contain abundant PMNs and an
inflammatory infiltrate rich in fibrin.
Acute Bronchopneumonia
Acute bronchopneumonia; the alveolar spaces are full and distended with
PMNs and a proteinaceous exudate. Only the alveolar septa allow identification
of the tissue as lung.
Radiographic patterns
1. Diffuse alveolar and interstitial
pneumonia (perivascular and
interalveolar changes)
2. Bronchopneumonia
(inflammation of airways and
parenchyma)
3. Lobar pneumonia
(consolidation in a whole lobe)
4. Nodular, cavity or abscess lesions
(esp.in immunocompromised patients)
Blood Gas Analysis & Acid Base Balance

Hypoxemia (PaO2 < 80 mm Hg)


 with O2 3 L/min 52,4 %
 without O2 100 %
Ventilatory insufficiency
 (PaCO2 < 35 mmHg) 87,5 %
Ventilatory failure
 (PaCO2 > 45 mmHg ) 4.8 %
Metabolic Acidosis
 poor intake and/or hypoxemia 44,4 %
(Mardjanis Said, et al. 1980)
Management
Severe Pneumonia
Hospitalization
Antibiotic administration
 Procain Pennicilline, Chloramphenicol
 Amoxycillin + Clavulanic Acid
Intra Venous Fluid Drip
Oxygen
Detection and management of
complications
TATA LAKSANA
Idealnya tatalaksana pneumonia sesuai dengan kuman
penyebabnya.

Semua pasien pneumonia diberikan antibiotik, tapi


pasien diberi antibiotik karena kesulitan membedakan
infeksi virus dengan bakteri, di samping itu kemungkinan
infeksi bakteri sekunder tidak dapat disingkirkan.

Streptokokus dan pneumokokus sebagai kuman gram


positif dapat dicakup oleh ampisilin, sedangkan hemofilus
suatu kuman gram negatif dapat dicakup oleh
kloramfenikol. Dengan demikian keduanya dapat dipakai
sebagai antibiotik lini pertama untuk pneumonia anak
tanpa komplikasi
TATA LAKSANA

Lama pengobatan : 10 -14 hari. Pedoman


lain adalah sampai 2-3 hari bebas demam.
Pada pasien pneumonia yang community
acquired, umumnya ampisilin dan
kloramfenikol masih sensitif.
Pilihan berikutnya adalah obat golongan
sefalosporin atau makrolid.
Anjuran antibiotik awal sesuai
dengan penyakitnya

Pneumonia Pneumonia dengan komplikasi


tanpa
komplikasi Efusi pleura Abses paru

Ampisilin + sefazolin
kloramfenikol

Sefuroksim Sefuroksim klindamisin


Ampisilin+ Ampisilin+ Ampisilin+
sulbaktam sulbaktam sulbaktam
Complications

Pleural effusion (empyema)


Piopneumothorax
Pneumothorax
Pneumomediastinum
Bronchiolitis

 Bronchioles inflammation
 Clinical syndromes:
fast breathing, retractions, wheezing
 Predominantly < 2 years of age
(2 – 6 months)
 Difficult to differentiate with pneumonia
Bronchiolitis
Etiology
Predominantly RSV (Respiratory Syncytial
Virus), adenovirus etc.
Diagnosis
Etiological diagnosis
 Microbiologic examination
Clinical diagnosis
 Signs and symptoms
 Age
 Resource of infection
Bronchiolitis

Clinical Manifestations
cough, cold, fever,fast breathing, retraction,
wheezing, irritable, vomitus, poor intake
Physical Examinations
tachypnea, tachycardia, retraction,
expiration >, wheezing, fever,pharyngitis,
conjunctivitis, otitis media.
Bronchiolitis

Radiologic examination
diffuse hyperinflation
 flat diaphragm,
 subcostal >
 retrosternal space >
peribronchial infiltrates
pleural effusion (rare)
Bronchiolitis
Management
 Supportive
 Severe disease
hospitalization
intra venous fluid drip
oxygen
(antibiotics)
 Bronchodilator: controversial
 Corticosteroid: controversial
Bronchiolitis

Natural history & complications


 Improved clinical findings : in 3-4 days
 Improved radiological features: in 9 days
Persistent respiratory obstruction : 20%
Respiratory failure : 25 %
Lung collaps (rare)
Bronchiolitis

Correlation with Asthma


 30 % - 50 % becomes asthmatic patients
 Similarity in : - pathogenic mechanisms
- pathologic disorders