ARI

Dr Mirza Inam Ul Haq

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.

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.

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

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

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

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.

AGENT FACTORS

Two most common agents are

Bacterial organism.
Viral organism

Agents of Upper Respiratory

Tract Infections

Common cold (rhinitis)

Pharyngitis and laryngotracheitis

Streptococcus pyogenes
Corynebacteria diphtheriae
Neisseria gonorrhea
Many viruses

Epiglottitis

Many viruses; rhino, corona, adeno, influenza

Haemophilus influenzae

Bronchitis

Bordetella pertussis
Many viruses

Agents

Tuberculosis: Mycobacterium tuberculosis

Pneumonia
Bacteria
Streptococcus pneumoniae
Mycoplasma pneumoniae
Staphylococcus aureus
Viruses
Influenza
Measles
Many others
Fungi
Many

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.

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.

MODES OF TRANSMISSION

Air Borne
Direct- person to person.

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).

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.

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.

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.

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

2-5 yrs

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

0-2 months

Danger signs are

Convulsions
Stridor
Stopped feeding well
Wheezing
Fever/ Low body temperatures

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

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.

Pneumonia Protocol: Infants and Children > 2 months

Very Severe Pneumonia

Severe Pneumonia

Improvement after 48 hours?

No

Yes

Improvement after 48 hours?

Yes

No

Look for
complications like
Effusion/empysema

Look for
complications

Consider
cloxacillin
(50mg/kg IV
QID)
If the child
improves on
cloxacillin
continue
cloxacillin
orally 4 times
a day for a
total course

After 5 days if the

child has
responded well
change to oral
amoxicillin and
oral
chloramphenical
for a further 5 days

Oral
amoxicillin for
5 days

Change to
ceftriaxone
50-100mg/kg BID
for 10 days

Treat complications if found

Complications include:

Empyaema*
Pleural effusion*
Lung abscess*

Antibiotic
treatment can be changed by a doctor
*
when blood culture results are available

Very Severe Pneumonia

Severe Pneumonia

Ceftriaxone (50-100
Give ampicillin
mg/kg IV divided Bid
(100 mg/kg IV/IM
(may give IM if no IV
every 6 hours) and
access)
chloramphenical
The child
(50 mg/kg every 8
MUST be
hours) for at least
discussed
48 hours
with a doctor
and reviewed Obtain a chest x-ray
Child should
as soon as
be checked
possible
by a nurse
tor and ensure oxygen saturations >90%
every 6

Pneumonia

Give oral amoxicillin

(or IV ampicillin)
Give the first dose in
the clinic
**)Weight

Fluid
ml/hour

2kg

4kg

16

hours and
6kg
by a doctor
8kg
or medic
Ensure that the child is receiving
every day
adequate fluid
10kg
Encourage breastfeeding and oral
12kg
fluids
If child cannot drink:
14kg
For Severe Pneumonia: pass a
16kg
nasogastric tube and give
maintenance fluid in one hourly
18kg
Pneumonia
Protocol:
Infants
and
Children
<
2
amounts,
or, as needed up to 4 times a day) for fever
paracetamol
(15mg/kg
months
For Very Severe Pneumonia give
IV

25
33
42
46
50
54
58

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

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.