ARI

1. ARI Dr Mirza Inam Ul Haq

2. ACUTE RESPIRATORY INFECTION Acute respiratory infections are the most common of the human ailments. In most instances it runs a natural course in older children and adults without treatment and without complications. In young infants, young children, elderly and those with impaired respiratory tract there is increased morbidity and mortality.

4. TYPES ARI may be divided into two groups Acute Upper Respiratory Infections. Mild cough, cold, pharyngitis, otitis media, and allergic rhinitis. Acute Lower Respiratory Infections. Epiglottis, laryngitis, laryngotracheitis, bronchitis, bronchiolitis, pneumonia.

5. PROBLEM STATEMENT Every child (< 5 years of age) both in developed and developing countries in the world suffer from at least 5-8 episodes of Acute Respiratory Infections annually in urban area. About 5 million children die annually due to pneumonia ad more than 90% of these occur in developing world. ARI accounts for 30-70% of the health visits by the children to the heath facilities. The mean duration of illness is 7-9 days

6. PROBLEM STATEMENT ARI is the leading cause of disability as well i.e. debilitating respiratory disease, and deafness following otitis media. Incidence of ARI in developing countries ranges between 10-20% as compared to 3-4% in the developed countries. Diarrhoea, Pneumonia, and Protein calorie malnutrition are the three biggest killers of children under five years National ARI Control Programme was launched late in 1989 in collaboration with international agencies like WHO, UNICEF, and USAID

7. OBJECTIVES OF NATIONAL ARI CONTROL PROGRAMME To reduce the mortality under 5 years of age due to pneumonia. To reduce the severity of and mortality from pneumonia in children To reduce the incidence of acute lower respiratory infections (ALRI) To reduce the severity and complications from acute upper respiratory infection (AURI) To rationalize the use of drugs in ARI

8. Control Strategy Correct Case Management: this is achieved through intense training of health staff to identify and manage the cases of ARI. The health staff includes, the supervisory staff, the trainers, hospital based medical officers, medical officers working at the THQ hospitals, RHCs, BHUs, and LHWs.

9. AGENT FACTORS Two most common agents are Bacterial organism. Viral organism

10. Agents of Upper Respiratory Tract Infections Common cold (rhinitis) Many viruses; rhino, corona, adeno, influenza Pharyngitis and laryngotracheitis Streptococcus pyogenes Corynebacteria diphtheriae Neisseria gonorrhea Many viruses Epiglottitis Haemophilus influenzae Bronchitis Bordetella pertussis Many viruses

11. Agents Tuberculosis: Mycobacterium tuberculosis Pneumonia Bacteria Streptococcus pneumoniae Mycoplasma pneumoniae Staphylococcus aureus Viruses Influenza Measles Many others Fungi Many

12. HOST FACTORS Most vulnerable groups are the young children, young infants, elderly persons, and the malnourished children. The Infant Mortality Rates in the developing countries are high and may exceed 20/1000 and contributing factor is mainly malnutrition. AURI are higher in children than in adults. Incidence of Pharyngitis and Otitis Media increases from infancy to 5years of age.

13. RISK FACTORS Low Birth Weight Malnutrition Specific nutritional deficiencies Climatic conditions Housing (over crowding, poor housing conditions) Level of Industrialization Socio-economic Level LBW Indoor Pollution (air pollution) Maternal cigarette smoking.

14. MODES OF TRANSMISSION Air Borne Direct- person to person.

16. POLICY Who in1976 adopted a policy of Improving Living Conditions. Better Nutrition. Reduce smoke pollution Other factors are MCH care Immunization (to prevent pneumonia which occur as complication of vaccine preventable diseases).

17. CLINICAL ASSESSMENT 1.BREATHING RATE/MINUTE. 2.LOOK FOR CHEST INDRAWING. 3.LOOK AND LISTEN FOR STRIDOR. 4.LOOK FOR WHEEZE. 5.LOOK IF THE CHILD IS DROWSY. 6.FEEL FOR FEVER. 7.CHECK FOR SEVERE MALNUTRITION. 8. LOOK FOR CYANOSIS.

18. CLASSIFICATION OF ILLNESS A, Child aged 2 months up to 5 years. Depending upon the type and severity of the illness it may be classified as under. Very severe disease. Severe Pneumonia. Pneumonia not Severe. No Pneumonia: cough or cold.

19. CLASSIFICATION OF ILLNESS A, Child aged (0- 2 months) Depending upon the type and severity of the illness it may be classified as under. Very severe disease. Severe Pneumonia. No Pneumonia: cough or cold.

20. 2-5 YRS Very Severe Disease Danger signs are Child is unable to drink Convulsions Strider in the calm child Severe malnutrition Severe Pneumonia Respiratory rate 60 or more/minute age<2m age 2-12 m 50 1-5 yrs 40 or more/minute age

21. 2-5 yrs Chest in drawing Nasal flaring Grunting Cyanosis Pneumonia not severe Fast breathing without chest in drawing. No Pneumonia: (Cough & Cold).

22. 0-2 months Danger signs are Convulsions Stridor Stopped feeding well Wheezing Fever/ Low body temperatures

23. 0-2 months Very Severe Disease Danger signs are Child is unable to drink Convulsions Stridor in the calm child Severe malnutrition Not Feeding well

24. O-2 Months Severe Pneumonia Respiratory rate 60 or more/minute Chest in drawing Nasal flaring Grunting Cyanosis Pneumonia Fast breathing without chest in drawing.

25. Pneumonia Protocol: Infants and Children > 2 months Very Severe Pneumonia Severe Pneumonia Improvement after 48 hours? Improvement after 48 hours? No Yes Yes No Look for complications like Effusion/empysema Look for complications Oral amoxicillin for 5 days Change to ceftriaxone 50-100mg/kg BID for 10 days Consider cloxacillin (50mg/kg IV QID) After 5 days if the child has responded well change to oral amoxicillin and oral chloramphenical for a further 5 days Treat complications if found Complications include: Empyaema* Pleural effusion* Lung abscess* * If the child improves on cloxacillin continue cloxacillin orally 4 times a day for a total course of 3 weeks Antibiotic treatment can be changed by a doctor when blood culture results are available

26. Very Severe Pneumonia Severe Pneumonia Pneumonia Ceftriaxone (50-100 mg/kg IV divided Bid (may give IM if no IV access) Give ampicillin (100 mg/kg IV/IM every 6 hours) and chloramphenical (50 mg/kg every 8 hours) for at least 48 hours Give oral amoxicillin (or IV ampicillin) Give the first dose in the clinic The child MUST be discussed with a doctor and reviewed as soon as possible **) Obtain a chest x-ray Child should be checked by a nurse every 6 hours and by a doctor or medic every day Monitor and ensure oxygen saturations >90% Ensure that the child is receiving adequate fluid Encourage breastfeeding and oral fluids If child cannot drink: For Severe Pneumonia: pass a nasogastric tube and give maintenance fluid in one hourly amounts, or, For Very Severe Pneumonia give IV flush* Pneumonia Protocol: Infants and Children < 2 months Give paracetamol (15mg/kg as needed up to 4 times a day) for fever

27. Management of very severe disease (2m- 5 yrs age) Treat fever Treat wheezing Antibiotic Inj Benzyl Penicillin Ist 48 hr 50000 IU 6 hr IM Inj Ampicillin 50mg/KG/Dose 6 Hrly IM/oral Chloramphenicol 25mg/KG/Dose 6Hrly IM/oral

28. CONT Treatment Nebulize 0.5ml+2ml N/S Salbutamol Epinephrine Subcutaneous 0.01ml/KG may repeat 20min (1:1000=0.1%) Sub-cut Terbutaline (0.1 mg/KG may repeat after 30 minutes).Total 0.3mg.