By DR. Laith Ali Jebur M.B.CH.B University of Baghdad \ Alkindy college of medicine

1. Prepared by:
Laith Ali Jebur
Supervised by:
Dr. Ali Abdul Razzaq

2. • Definition of ARI..
• Worldwide, (ARIs) are a major cause of morbidity
and mortality in emergencies especially in
developing countries including Iraq.
• ARI responsible for 20% of childhood (< 5 years)
Deaths ,90% from pneumonia.
• Six to eight respiratory tract infections per year
(2-3years)
• 70% of which are upper respiratory
infection, 30% are lower respiratory infections.

4. Upper Respiratory
Infections
Acute Otitis Media
RHINITIS (COMMON
COLD OR CORYZA)
SINUSITIS
ACUTE PHARYNGITIS
CROUP
PERTUSSIS
TONSILITIS
TRACHEITIS
Lowe Respiratory
Infections
BRONCHIOLITIS
PNEOMONIA

5.  History
• Age
• onset, duration, SOB
• Is the child coughing? For how long?
• Is the child able to drink or feed well?
• Has the child had fever ? For how long?
• Has the child had convulsions?
• Does the child have any other complaints?
In addition to:
(noisy breathing, sleeping, bluish discoloration,
paroxysmal cough, mental state)

6. Exposure to cold weather
Hx of bith problems
Poor nutritional status
Early weaning
Immunization
Poor socio-economic status
Parental smoking
Chronic use of drugs (affect immunity)
Family history

7.  Respiratory rate
• Tachypnea 3 months > 60
3 months – 1 year > 50
1year –4 years > 40
>5y >20
 Chest indrawing
 Listen for stridor
 Listen for wheeze. Is it recurrent?
 Look for cyanosis
 See if the child is abnormally sleepy, difficult to wake, or
restless
 Body temperature
 Signs of malnutrition (Marasmus, Kwashiorkor)

8. Severity
CF
Management
No pneumonia
(mild ARI)
Cough
Not tachypnoea
Supportive measures
Antipyretic
No antibiotics
Pneumonia
Or (moderate ARI)
Cough
Tachypnoea
No rib or sternal
retraction
Supportive measures
Antipyretic
Antibiotics
Severe pneumonia
Cough
Tachypnoea
Rib and sternal
retraction
Supportive measures
Antibiotics
Refer to hospital
Very severe
pneumonia
Cough
Tachypnoea
Chest wall retraction
Unable to drink
Cyanosis
Supportive measures
Oxygen
Antibiotics
Immediate referral

10. • Most common
infectious condition in
children in the first 2
years.
• Third of cases caused
by Rhinovirus .
• Average of 5-8
infections per year.
• May involve
(Nasopharynx,
paranasal sinuses,
middle ear).

11. Symptoms:
• nasal obstruction
• Rhinorrhea
• sore throat
• occasional non-productive cough
• Parenteral diarrhea
Signs:
• nasal mucosa may reveal swollen, erythematous nasal
turbinate's
• Sign of moderate respiratory distress in infants
• Ear drum is congested 2-3 days

12. Diagnostic Measures:
• Laboratory studies often are not helpful
• A nasal smear for eosinophils .
Treatment:
(No specific therapy)
1.Bed rest
2.Actamenophen1st 1-2 days
3.Relieve nasal obstruction:
* Normal saline , xylometazoline nasal drops
* Phenylephrine 0.25% nasal drops
* highly humidified environment to prevent drying.
4.Rhinorrhea, cough : antihistamins.

13. •
•
•
•
It is an inflammation of the throat.
the most common cause of a sore throat.
Include: (tonsillitis &pharyngotonsillitis)
Commonly caused by viral infections
(Adenovirus, influenza v, EBV)
• Others caused
by bacterial infections(Group A-B hemolytic
strptococcus ), fungal infections.

14. Viral infection
1. All ages
2. Gradual onset
3. Low grade fever
4. cough
5. Hoarseness of voice
6. Redness of the
pharynx
7. Conjunctivitis(Adenovi
rus)
8. Herpangina(coxachie
virus)
Bacterial infection
1. 5-15 year old
2. Sudden onset
3. High grade fever
4. Sore throat &
difficulty in
swallowing
5. Exudates
6. Ant. Cervical LN
tenderness

16. • It is hard to differentiate a
viral and a bacterial cause
of a sore throat based on
symptoms alone.
• Throat swab and culture.
(Gold Standard)
• Detection for streptococcal
antigen (specific 80 –
85%)
• WBC, ESR, CRP count is
elevated.

17. • Viral pharyngitis need no antibiotics, only
supportive
• Streptococcal pharyngitis
1. Oral penicillin V (125-250)mg 3/day 10 days
2. Benzathine penicillin or procaine penicillin G
single IM injection
3. Erythromycin 40 mg/kg/day for 10 days
4. Oral amoxicillin 50 mg/kg/day for 6 days

18. •
1.
2.
3.
4.
5.
6.
7.
8.
9.
Complications are low with viral infection
O.M.
Mastoiditis.
Peritonsillar abscess
Sinusitis
Involvement of lower respiratory tract
Trigger asthma
Meningitis
Acute GN
Mesenteric adenitis

19. • is a respiratory condition that is
usually triggered by an acute
infection of the upper airway. The
infection leads to swelling inside
the throat produces the classical
symptoms of a
"barking" cough, stridor, and
hoarseness.
• 75% parainfluenza virus, others
inluenza A&B , RSV.
• Bacterial
infection(epiglotitis,diphtheria,trach
eitis)
• Usual age 6m – 5y, males, winter &

20. •
•
•
•
•
•
•
1.Laryngotracheobronchitis.
2.Acute epiglottitis.
3.Acute infectious laryngitis.
4.spasmodic croup.
5.Bacterial tracheitis.
6.Diphtheritic croup.
7.Measles croup.

21. • The most common type. Involve the glottic and
subglottic regions.
• Manifestations of Upper infection + croup
• Severe at night
• Relieved by sitting
• Neck X-Ray showing
subglottic narrowing
(Steeple sign)

23. • Almost all cases caused by viral infection.
• It involves mainly subglottic area.
• Characterized by URTI then sore throat and
croup.
• It is generally mild and respiratory distress
unusual except in infants.
• In severe cases: Hoarsness, stridor, dyspnea.
• Laryngoscope shows inflammed vocal cord &
subglottic tissue.

24. •
•
•
•
•
•
•
•
Commonly caused by H.influenzae b.
Affect 2-7 years old.
Male to female 3:2.
It is a medical emergency because of the
risk of sudden airway obstruction.
Characterized by high fever, dyspnea,
dysphagia, sore throat, drooling.
stridor and tripod position.
the mouth is opened, and the jaw thrust
forward (sniffing position)
Barking cough is rare.

25. Diagnosis:
• Lateral neck X-ray shows enlarged epiglottis (thumb print
sign)
• Direct laryngoscope my show a cherry red epiglottis
(supraglottis) but it is not recommended because of
laryngeal spasm.

26. •
•
•
•
•
•
•
Progressive stridor at rest
Temp>39c
Respiratory distress
Cyanosis & pallor
Hypoxia & restlessness
Impaired consciousness
Toxic appearing child

27. • Put the child in cold steam from nebulizer or hot steam
from vaporizer may relieve symptoms.
• Monitoring of respiratory rate and respiratory distress.
• IV fluid to reduce insensible water loss from tachypnea.
• Oxygen in moderate to severe respiratory distress.
• Tracheostomy & intubation if there is deterioration.
• Sedatives are contraindicated. Cough expectorants are
unhelpful.

28. • Age less than 3 years age.
• caused by S. aureus.
• Characterized by barking cough, high fever, stridor,
copious thick purulent discharge, toxic appearance.
• The usual treatment of croup is ineffective.
Diagnosis:
• culture of the thick, mucopurulent subglottic debris.
Treatment:
• Antibiotics against Staphylococcus like cloxacillin,
methicillin, third generation cephalosporin or vancomycin.
• Endotracheal intubation or tracheostomy.
• Oxygen .

29. • Age: second 6 months
• Caused by:
1- H.influenzae.
2- Strept.pneumonae.
3- Moraxella catarrhalis.
• It is very common in children.
Symptoms:
• earache, convulsions, sometimes diarrhea & vomiting,
continuos crying (irritability) & sleep disturbances.
Signes:
• Otorrhea or bulged , congested TM.
• The tympanic membrane is intact in infants.

30. Treatment:
• Broad-spectrum antibiotics.
• Analgesics.
• vasoconstrictive nasal drops .
• Aural toilet, Myringotomy.

31. • Age only 1% of infants.
5% of children.
15% of adolescent.
• Allergic rhinitis is the most
common predisposing factor.
• Anatomical abnormalities:
• Deviated septum
• Polypoid mass

32. •
•
•
•
•
•
•
•
•
•
Cough mainly at night
Rhinorrhea
Nasal speech
Halitosis
Facial pain, tender
Facial swelling
Headache
Fever
Irritability
Trigger asthma & O.M

33. • Culture
• Plain X ray
• CT scan
May show sinus clouding
Mucosal thichening
Air fluid level.
• Antibiotics
• Suportive therapy

34. • Bordetella pertussis
• Affect young children, non immunized.
• Spread by droplet, direct or indirect contact with nasal
scretions.
• Manifestations:
• Catarrhal stage..1-2 w URTI.
• Paroxysmal stage..2-4w parox. Cough, whooping.
• Convalescent stage..1-2w only cough for months.
• Investigations:
• CBC: WBC mainly lymph.
• CXR prehilar infiltrate.
• Culture, PCR, IFA.

35. • Admit severe cases
• Erythromycine 2w
• Azithromycin or
clarithromycin 1w
• TMP-Sulfa
•
•
•
•
Pneumonia
Super infection
Atelactasis
seizures

37. •
•
•
•
It is a common inflammation of the bronchioles.
AGE less than two years With a peak at age 6th month.
( RSV ) more than 50% .
Rarely by mycoplasma.
* There is Bronchiolar obstruction
due to edema & accumulation of
mucous & cellular debris
& by invasion by viruses.

38. • Presents as a progressive respiratory
illness that is similar to the common cold in
its early phase with cough, dyspnea and
rhinorrhea.
• It progresses over 3 to 7 days to noisy
breathing with noisy breathing.
• fever accompanied in young children by
irritability.
• May have apnea as the first sign of
infection.

39. • Tachypnea, falaring of ala nasi
• intercostal retractions &subcostal retractions .
• air trapping with hyper expansion of the lungs
with hepatosplenomegaly by dispacement.
• percussion of the chest reveals hyper
resonance.
• Auscultation reveals prolonged expiratory phase
with diffuse wheezes and crepitation.
• In more severe cases cyanosis.

40. • WBC & differential counts are normal.
• Antigen tests (IFA or ELISA) of nasopharyngeal
secretions for RSV, para-influenza, influenza viruses, and
adenoviruses are the most sensitive tests to confirm.
• Chest X-ray shows:
1- signs of hyper expansion
of the lungs, including increased
lung radiolucency.
2-flattened or depressed diaphragms.

41. •
•
•
•
•
•
•
1- bronchial asthma.
2- congestive heart failure.
3- foreign body in the trachea.
4- pertusis.
5- cystic fibrosis.
6- bacterial bronchopneumonia.
7- obstructive emphysema.

42. 1. Young age<3 month old.
2. Moderate to marked resp. distress
3. Hypoxemia(PO2<60mmHg or Oxygen
saturation<92% on room air).
4. Apnea
5. Inability to tolerate oral feeding
6. Lack of appropriate care available at home.

44. • consists of supportive therapy, including:
1-Nebulizer, control of fever
2-good hydration
3- upper airway suctioning and oxygen
administration.
4- I.V. fluid indicated in case of sever tachypnea
which interrupt feeding.
5-Ribavirin is anti viral agent administered by
aerosol.
6-Temperorary use of bronchodilators may
improve wheezing &respiratory distress.

45. • inflammation of the parenchyma
of the lungs. classified
anatomically as :
• Lobar or lobular.
• Bronchopnemonia:is involvement
of the bronchi & the surrounding
alveolar tissue which is more
profuse & bilateral.
• interstitial pneumonia.
• Pathologically there is
consolidation of alveoli or
infiltration of the interstitial tissue
with inflammatory cell or both.

46. 1-Viral: RSV 70%, influenza, parainfluenza or
adenovirus.
2-Bacterial: In first 2 months the common agents
include klebsiella, E. coli, and staphylococci.
• Between 3 month to 3 years common bacteria
include S. pneumonia, H. influenza and
staphylococci.
• After 3 years of age common bacteria include S.
pneumonia and staphylococci.
3-Atypical organism: Chlamydia and Mycoplasma.
4-Pnemuocystis carinii: causes pneumonia in imunnocompromised children.

47. • Onset of pneumonia may be insidious starting with URTI
or may be acute with high fever, dypsnea and grunting
respiration. Respiratory rate is always increased.
• Rarely pneumonia may be present with acute abdominal
emergency which is due to referred pain from the pleura.
• On examination there is flaring of alae nasi, retraction of
lower chest and intercostal spaces.
• Signs of consolidation(diminished expansion, dull
percussion note, increased tactile vocal fremitus/vocal
resonance, bronchial breathing with localized
crepitation ) can be seen in lobar pneumonia.

48. • Viral pneumonia :- low grade fever, cough,
wheeze .the lesion is usually diffuse and bilateral.
its broncho pneumonia.
• WBC is not so high with lymphocytosis.
• Bacterial pneumonia:- patient presented with
high fever,herpetic lesion at the lips, pleuretic
chest pain.
• WBC leukocytosis with neutrophilia.
• S. pneumoniae often resulting in focal lobar
involvement.
• Group A. streptococcus infection results in
interstitial pneumonia.
• S. aureus causes bronchopneumonia which is
often unilateral with cavitations.

49. • Diagnosis mainly clinical.
• 1- chest x- ray:

50. 1. Sputum for gram stain and culture.
2. blood culture.
3. virological study by culture &florescent
antibody technique.
4. in case of pleural effusion aspirate pleural
fluid for gram stain and culture also for
acid fast bacilli.

51. • 1-less than 3 month of age.
• 2- moderate to sever respiratory
distress.
• 3- failure of out patient treatment.
• 4-immunocompromised patient.
• 5- neonate with congenital
pneumonia.
• 6- staphylococcal pneumonia.
• 7- complications like pleural effusion,
empyema.

52. • The empiric treatment of suspected bacterial pneumonia is
parenteral cefotaxim or ceftriaxone.
• If clinical features suggest staphylococcal
pneumonia, vancomycin.
• For mildly ill children amoxicillin (80–90 mg/kg/24 hr).
• For school-aged children and in those in whom infection with
M. pneumoniae a macrolide antibiotic such as azithromycin.
• In adolescents, a respiratory fluoroquinolone (levofloxacin)
may be considered for atypical pneumonias.
• If viral pneumonia is suspected, it is reasonable to withhold
antibiotic therapy. supportive by 1- oxygen 2- IVF. 3antipyretic for fever. ribavirin for RSV.

53. •
•
•
•
•
•
A- Pulmonary complications
1- pleural effusion.
2- empyema.
3- lung abscess.
4- pneumatocele.
5- pneumothorax.
•
•
•
•
•
B- Extra pulmonary complications
1- meningitis.
2- arithritis.
3- osteomyelitis.
4- pericarditis.

54. •
•
•
•
•
•
•
Health education.
Keep child warm.
Immunization.
Nutrition.
Prevent nearby smoking.
Personal hygiene.
Visit doctor.