Lecture MBBS

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2. Life Finds A Way:
Just Don’t Give Up

3. Life Finds A Way:
Just Don’t Give Up …

4. Life Finds A Way:
Just Don’t Give Up …

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Life Finds A Way:
Just Don’t Give Up …

8. WELCOME ALL
A R I

10. SIGNS OF RESPIRATORY DISTRESS

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Definition of A R I (Acute Resp. Infection)
This term is used by HW to indicate ac. Inf. of
respiratory system in Under-5y children
In this age group such inf. are often not anatomically
localized, rather spreads rapidly to adjacent parts
An U-5 child gets 3-6 ARIs/y regardless of living
standard
HW: health worker. U-5: under 5 years of age. Inf.: infection

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Clinical Anatomy
Respiratory Tract is divided into 3 parts:
1. URT: nose  trachea (PNS, mouth, tonsils,
pharynx, auditory T, middle-ear, larynx)
2. LRT: trachea  bronchi  air ducts
3. Lung parenchyma

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Normal Defence of RS
These are unique!
• Breathing, coughing, sneezing
• Mucosal antibodies (IgA)
• Ciliary sweeping
• Phagocytes
• Physical filtering
(Think how less often you catch cold and cough!)

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Physical filter

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Unique brooms!

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ARI in Children Spread Rapidly:
• Shorter and narrower RT
• Cough not strong
• Less immune
• Auditory tube is:
– shorter
– narrower
– straighter
RT: respiratory tract

25. Sites of Infections (A R I)
• Rhinitis
• Sinusitis
• Tonsillitis
• Pharyngitis
• Epiglottitis
• Laryngitis
• AOM
• Tracheitis
• Bronchitis
• Bronchiolitis
• Pneumonia
• Bronchitis & Pn.
(Br.Pn.)
Children usually have combinations:
Ac. rhinopharyngotonsillitis +/- AOM, ac. LTB
(croup), bronchopneumonia (Br.Pn.), etc.

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ARI is a syndrome:
– cough, breath rate
– chest indrawing, stridor
– +/- 4 general danger signs (IMCI)
No Dr, no stethoscope, no lab.!

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Normal breathing rate
Age Br. Rate Fast
breathing
<2mo <60/min ≥60
(preterm 70)
2-12mo <50/min ≥ 50
1-5y <40/min ≥ 40
Counting Breathing
• The child must be calm
• Count full 1 minute
• Count the abdominal swelling in inspiration

28. Chest indrawing:
• Suprasternal, supraclavicular retraction/recession
• Intercostal space (interspace) ,,
• Subcostal ,,
4 General Danger signs:
• Lethargic/unconscious
• Poor feeding/not feeding at all
• Vomits everything
• Convulsion
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DANGER
SIGNS
CONVULSIONS
INABILITY TO DRINK
OR BREASTFEED
VOMITING
LETHARGY
UNCONSCIOUSNESS

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Additional SS of ARI for Doctors
• Cold, sore throat
• Sputum
• Nasal flare
• Voice change
• Grunting
• Cyanosis
• Asymmetry of chest &
its movement
• Tracheal deviation
• Displaced heart
• Auscultation:

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Auscultatory Findings
• Poor or unequal air entry
• Prolonged expiration
• Wheeze/ronchi
• Fine or coarse crepitations
• Bronchial breath sound
• Post-tussive creps/or ronchi

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Depth of ARI Problem
• Pneumonia is the biggest U-5 killer (0.9million/y; 16% of
total: more than AIDS, malaria & TB combined)
90% in L&MICs (70% in Africa & SEA)
• Commonest admission (12-45%)
• OPD: 20-60% A R I
• V. imp. precipitator of malnutrition, VADX
• National Health Index of a country
(5.4 million U-5 death in 2017: 16,000/d. 70% from inf.)

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ARI
54%
Diarrhoea
85%
Malaria
79%
Measles
89%
Percentage of deaths occurring among:
Global Disease Burden Borne by U-5 (Y 2000)

35. Key facts: Pneumonia
Kills by hypoxia due to pus & fluid in alveoli
• C/by viruses, bacteria or fungi. Bacteria can be Rx with ABs,
but only 30% of children get it
• Rx with low-cost, low-tech. drugs & care
• Px. by immunization, nutrition & clean environment
Death from diarrhea has been dramatically lowered by
successful ORT
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36. ARI mortality/morbidity highest in U-5y
– Lack of breast feeding
– Formula feeding, bottle feeding
– Poor education, overcrowding, poor clothing
– Weaned early
– HIV
– <2y of age
– Lack of vaccination
– Malnutrition
– VADX
– Difficult access to healthcare, medication

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Death from ARI is Declining*
• Br. feeding
• No bottle feeding
• Socioeconomic &
environ. change
• Falling malnutrition
• HPVAC distribution
• EPI
HPVAC: high potency vitamin A capsule
• Family planning
• Modern health care
• Better and cheap drugs
• Female literacy
• Health awareness
*Previously 4million, now 0.9

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Aetiology of A R I
• Viruses
• Bacteria
• Mycoplasma
• Fungus
• Parasites, worms

39. Aetiology …
• Varies: age, immune status, where contracted
• Community acquired pneumonia (CAP)
– L&MICs
•Viruses 40%
•S. pneumoniae, Hib, S aureus, Moraxella,
Mycoplasma, Chlamydia in 60%
–HICs
•Bacteria: 5-10%

40. Etiology Based on Age
Age Organism
Neonates GBS, E coli, Klebsiella, S
aureus
Infants Pneumococcus, Chlamydia,
RSV, Hib, Staph.
1-5y Viruses, Pneumococcus, Hib
Chlamydia, Mycoplasma,
Staph., GAS
5-18y Mycoplasma, Pneumococcus,
Chlamydia, Hib

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Viruses
• Rhinoviruses
• RSV
• Adenoviruses
• Influenza, parainfluenza A B C
• Myxoviruses
• Corona viruses (SARS, MERS)
• Boca virus, metapneumovirus

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Common Bacteria
• *S. pneumoniae
• *Hib
• S. pyogenes
• S. aureus
• *M. tuberculosis
• *C diphtheriae
• Enteric bacilli
• Pseudomonas
• Klebsiella
• Moraxella
*Vaccine available

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Others
• Chlamydia
• Mycoplasma
• Fungus: C. albicans, Histoplasma
• Miscellaneous: P. carinii, worms

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How A R I Harms
Hypoxia: convulsion, death
• Malnutrition & VADX:
• Chest: collapse, consolidation, effusion, abscess,
bronchiectasis, pneumothorax
• Blood: sepsis, deranged ABB, dyselectrolytemia
• Meningitis, IgA nephropathy
VADX: Vitamin A defi. and xerophthalmia. ABB: acid base balance

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ARI Causes Malnutrition & VADX
• Poor feeding
• Negative nitrogen balance
• Vomiting, diarrhea, fever: dehydration
• Exhaustion of Vitamin A
• Faulty feeding, taboo
Mn.: Malnutrition. VD: vomiting diarrhoea. F: fever. VA: vitamin A

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Dehydration in ARI:
• Fast breathing
• Fever
• NVD
• Runny nose
• Poor/faulty feeding
NVD: nausea vomiting diarrhea

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How A R I kills
Acute
• Hypoxia
• Hypoglycemia, convulsion, cardiac failure
• Septicemia, dehydration
Late
• Malnutrition, VADX
• Suffocation, aspiration

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Hospital Picture
• Out of 1690 cases admitted in BMCH pediatric
ward 400 (23.7%) had ARI
• Peak incidence during Oct-Nov

49. Management
According to
IMCI[[
IMCI: integrated management of childhood illnesses

50. History Taking
1. General Danger Signs
2. Main Symptoms
a. Cough 
b. Diarrhea
c. Fever
d. Ear Problems
3. Nutritional Status
4. Immunization Status
5. Other Problems
IMCI Record Form

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Assess whether the child has
• No pneumonia (cold-cough; chr. cough)
• Pneumonia or
• Severe Pneumonia
In babies <2mo
any pneumonia is severe pneumonia

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Fast breathing +
chest indrawing or
Stridor in a calm
child. (Any GD sign)
Severe Pneumonia
or
(Very Severe Disease)
Fast breathing Pneumonia
No signs of
pneumonia or very
severe disease
No pneumonia:
cough or cold

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Limitations …
Pneumonia in IMCI may be actually
• Bronchiolitis
• Br. Asthma
• Diphtheria
• Pertussis
• HGF
• CCF
No pneumonia may be TB, otitis media

54. Pneumonia
• Inflam. of lung parenchyma ± consolidation
• Fast breathing
• HICs: viral: Low morbidity-mortality
• L&MICs:
–Bacteria in 65%
– Cheap oral ABT: Amoxicillin can cause 84%
reduction in death

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Severe Pneumonia
• Very sick, not able to feed
• Tachypnoea, tachycardia
• Chest indrawing
• Creps, wheeze
• Cyanosis, convulsion
• Drowsiness
+/- Fever

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Lab. Dx. of Pneumonia
(not for HW/IMCI)
• CXR
• CBC film
• CS of blood, tracheal & lung aspirate
• Throat swab

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S. pneumoniae

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Pneumococcal pneumonia
R upper lobe consolidation with Air Bronchogram

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Air-fluid level in Lung Abscess

61. Cavitary lung lesions by the mnemonic "CAVITY“:
Carcinoma: squamous cell, melanoma, cervical, sarcoma metastasis
Autoimmune: Wegener’s, rheumatoid lung
Vascular: bland/septic emboli
Infection: TB, coccidio-, aspergillosis, cryptosporidia, nocardia, GNR, staph, strep
Trauma
Young: in young pts., these are often congenital, such as bronchogenic cyst or
communicating sequestration

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63. Complications of pneumonia
Intrathoracic
• Pleural effusion, empyema
• Collapse, consolidation
• Lung abscess, pneumatocele
• Pneumothorax
Extrathoracic
• Septicemia, meningitis
• Dehydration
• Myocarditis, pericarditis
• Acidosis, dyselectrolytemias

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Right Middle Lobe Atelectasis

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Consolidated lung

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Rx: General Principles
O2
– Air way care
– Nebulized beta-agonist, anticholinergic
• Antibiotics (parenteral)
• Feeding, warmth
• FEB
• Vitamin A
• Zinc
Counseling
FU

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Rx. Severe Pneumonia
Admission must
O2
– suction clearance
– Nebulized bronchodilator, anti-secretory
• Parenteral ABT
• Lowering fever
• Feeding, FEB, warmth
• Vitamin A, zinc
FEB: fluid and electrolyte balance

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Antibiotics in Pneumonia
Pneumonia is mostly viral but 2y infx. is common
• Injectable: usually >1 AB
• Minimum 10d. Up to 3w
• Penicillin + gentamicin/amikacin are good
• Staph coverage for babies <2yr
AB: antibiotic. Staph: staphylococcus

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When You Defer AB
• The child is stable, playful, no HGF
• EBF, no bottle feeding
• Taking feeds normally
• Supervised adequately

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Rx for Cough and Cold (No pn.)
• Exclude AOM
• Ensure feeding
• Treat fever
• Clean nose
• Steam therapy
• Honey+tulsi
Chr./rec. Cough
• TB?
• Congenital HD?
• FB?
• Reactive airway?
• GERD?

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Follow up for Pneumonia
• Count breath (most important single sign)
• Watch activities: smiles, plays, feeds. Urine output
If the child stays at home
• Teach mom how to count breath
• Nose cleaning, feeding, warmth
• Ask to return immediately:
fast breathing, chest indrawing
poor feeding, lethargic or cyanosis (hypoxia)
SOB: short of breathing

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Humidification

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Prevention of A R I
• Breast feeding
• No formula, no feeder (baby
killer)
• Immunization
• HPVAC, Zinc
• Rx malnutrition
• Warmth, warm clothing
• No air pollution
• No smoking!
• Female literacy
• Family Planning,
birth spacing
• Sanitation
• No overcrowding

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78. ACUTE EPIGLOTTITIS
• Life-threatening inf. of epiglottis,
aryepiglottic folds & arytenoid
(sudden suffocation)
• Now rare! (HIB vaccine)
• Mostly in winters
• Peak : 1–6 y old. M:F 3:2
• Commonly bacteria: Hib. Concomitant bacteremia, pn.,
AOM, arthritis, etc. by Hib may be present

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80. AC. EPIGLOTTITIS
aka supraglottitis
CF
– Usually nocturnal; midnight
– HGF, sore throat, SoB, rapidly
progressing respiratory obstruction
– toxic!, dysphagic, chest indrawing, drooling, hyper
extended neck, tripod position
– stridor is a late finding; cyanosis, coma, death
– mouth is open, jaw thrust forward (sniffing position).
Barking cough is rare

81. EXAMINATION
Do not examine the throat!
• Assess severity
– degree of stridor, resp. rate, HR
– pulse oximetry, arousal
•Dx:
– “cherry red” epiglottis
– ‘thumb sign’ on lateral neck XR
– blood CS, electrolytes

82. • Direct laryngoscopy: cherry red epiglottis
But not recommended!
ACUTE EPIGLOTTITIS …

83. (thumb sign)

84. Rx (AC. EPIGLOTTITIS)
A medical e m e r g e n c y !
ICU
• endotracheal intubation may be needed
help from anesthetist & ENT surgeon
• IV Amplicillin/Ceftriaxone (100 mg/kg/d) x10d
• O2, ABB, IVF, nutrition
• Rifampicin prophylaxis to close contacts

85. A L T B (croup)
• Mucositis of glottis-subglottis; usually viral:
parainfluenza 1,2,3 (75%), influenza A,B; RSV,
epiglottitis, diphtheria
• Tracheitis
• Age : 6mo–6y
ALTB: Ac. Laryngotracheobronchitis (CROUP)

86. • Classical: stridor, "barking or bovine“ cough,
hoarseness (within 1-2d)
• Features of URTI
• LGF, prolonged inspiration
• Severe at night, on lying
• Relieved by sitting up
• Neck XR: subglottic
narrowing (Steeple sign)

87. Dx: mainly clinical. XR
neck: steeple sign
(unreliable)

88. DD/causes of croup:
• ALTB
• Ac. infectious laryngitis
• Ac. epiglottitis
• Spasmodic croup
• Bacterial tracheitis
• Diphtheria
• Measles croup
Ac. Laryngotracheobronchitis (ALTB)

89. DD: Ac. LTB and Ac. Epiglottitis
Croup Epiglottitis
Course days hours
Prodrome coryza
Cough barking slight if any, thick
Feeding able no
Mouth closed drooling
Toxic no yes
Fever <38.50C >38.5 0C
Stridor rasping soft
Voice hoarse Weal/silent

90. A L T B: Rx
• humidified air
• steroids
• reduce severity and duration/need for
intubation
•prednisolone p.o. 2mg/kg/d x3d
• nebulized budesonide
• nebulized adrenaline

91. • Very common in children
• Age: 2-6 mo.:
– S. pneumoniae, Hib, M. catarrhalis
Symptoms:
• earache, inconsolable cry & sleep disturbances, fit,
sometimes DV
Signs:
• Otorrhea or bulged congested TM, PED
PED: perforated eardrum

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94. Dx
• History, autoscopy
• Myringotomy
• CBC, pus CS
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95. Treatment
• Broad-spectrum ABT
• Analgesic, decongestant (local/systemic)
• Saline nose wash
• Myringotomy SOS
• Local AB drop for PED
• No bath in PED

96. Complications of OM
• Mastoiditis
• Meningitis
• Brain abscess
• PED
• Deafness-dumbness, poor learning
• Convulsion
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MCQ
• HPVAC is an important intervention to prevent ARI
• Feeding bottle is a baby killer
• Cut-off mark of fast breathing at 9 mo is 40
• Any pneumonia in <6o-days of age is severe pn.
• O2 is the most important Rx for severe pn.

98. MCQ
• Parenteral ABT is recommended for severe pn.
• Zn has an imp. role in shortening of duration &
prevention of recurrence of ARI in children
• Commonest c/of ac. epiglottitis is Hib
• Ac. epiglottitis is usually Dx by direct laryngoscopy
• Croup means stridor, hoarseness, barking cough
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Diarrhea