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Acute Respiratory Infection

Pediatrics of Guangxi Medical University


Nong Guangmin
Introduction
The most common disease in the childhood.
Almost 50% of deaths in children under age 1 year
About 20% of all hospitalizations of children under
15 years
More than 70% of all pediatric outpatients

Why ?
Answers:
一、Anatomy
(一)Upper respiratory tract (cricoid cartilage)

1) Nose
No hairs of vestibule of nose, narrowed nasal cavity,
rich blood vessels in mucosa
Auditory tube is short, wide and horizontal
tympanitis
2) Pharynx
Pharyngeal tonsil develops well at 4—10 years
old, after 13—15years old it atrophy

3) Throat
narrowed cavity, rich blood vessels in mucosa
asphyxia
(二)Lower respiratory tract
1) Trachea and bronchia
narrowed tube, rich blood vessels in mucosa, the movement of
cilia is weak

2) Lung
20 million alveoli at birth, 200 million by 3 years of age,
200—600 million in adult
rich capillaries and pulmonary interstitium

failure of lung function


in a normal adult the surface of area of the air—
blood interface is approximately 70-fold greater
than the surface of the skin

underdeveloped elastic fibers pulmonary


atelectasis
二、Physiological basis of pulmonary function

1) The rate of respiration is rapid, as metabolic rate


of infant is correspondingly higher than that of
adult

2) Total lung capacity(TLC) is lower in infant than


that of adult, 50-70ml/kg
3) The volume of tidal volume(TV) is lower in
infant than that of adult,

4) The resistance of the airway in infant is higher


than that of adult
三、Immunology

1) The nonspecific immune reaction is low, for


example, coughing reflection ,movement of
cilia ,the function of alveolar macrophage

2) The specific immune reaction is low, for example,


sIgA IgA ,IgG ,IgM
Acute Upper Respiratory Infection,AURI

〔 Etiology〕
Rhinovirus Streptococcus
Respiratory syncytial virus Staphylococcus
Influenza virus S.pneumoniae aureus
Parainfluenza virus Haemophilus Influenzae
Coronavirus
Adenovirus
Enterovirus
〔 Clinical manifestations 〕

1 、Systematic: fever, headache, myalgia, malaise


diarrhea

2 、Local: nasal irritation, nasal discharge, sneezing,


sore throat, cough
3 、Two special types
Herpangina:
Coxsackievirus
fever+laryngitis+discrete ulcerative lesion in the mouth

Pharyngo-conjunctival fever
adenovirus 3,7 type
fever+ laryngitis+conjunctivitis
〔 Complications〕
otitis media, sinusitis, enlarged lymph nodes

〔 Diagnosis and differential diagnosis〕


Nasopharyngitis (both nasal congestion and pharyngitis)
A key decision in evaluating children with URI is to
determine whether the illness is just a common cold or
whether a secondary infection
〔 Treatment〕
For most URI the best treatment is no pharmacologic
treatment.

1) Nonpharmacologic therapy:
elevating head(older children), parents ceasing
smoking,
frequent intake of fluid.
2) When children with URI are uncomfortable, the
most bothersome symptoms are fever and malaise,
nasal discharge or nasal congestion,therapy should
be directed toward a specific symptom that
causing discomfort. Acetaminophen or ibuprofen
is often helpful in relieving the constitutional
symptoms and the fever.

Antihistamines, decongestants, cough suppressants


3)Antibiotics
In general, it does not shorten the duration of cold
symptoms and does not reduce the risk of
complications except with bacteria infection.
〔 Prevention〕
1) Since URI is transmitted by contaminated hands or by
sneeze, frequent hand washing after contact with an
infected person reduces the risk of secondary
infection.Avoidance, such as keeping children out of child
care, is usually impractical.Neither ascorbic and
multivitamins are effective agents.

2) Vaccines have been difficult to produce.


Acute infectious laryngitis
〔 Etiology〕
〔 Clinical manifestations 〕
 hoarseness due to inflammation of the vocal cords
 a barking cough like a sea lion
 a variable degree of dyspnea

The degree of subcostal, intercostal and substernal


recession is a more useful indicator of severity of upper
airways obstruction than the respiratory rates.
This recession only occurs in the inspiration
The severity of upper airways obstruction is best
assessed clinically by

the degree of substernal and subcostal recession


respiratory rate

heart rate
increasing agitation

drowsiness, tiredness,exhaustion
central cyanosis indicating severity hypoxaemia and
the need for urgent intervention
〔 Treatment〕

1 、Airway management
2 、Antibiotics
3 、Corticosteroid
4 、Phergan
5 、Tracheotomy
Acute bronchitis
〔 Etiology 〕
Bacteria and virus
Acute tracheobronchitis is commonly
associated with an upper respiratory tract
infection.
Some children appear to be far more susceptible to
acute tracheobronchitis than others. The reasons are
unknown, but allergy, climate, air pollution, and
chronic infection of the upper respiratory tract,
particularly sinusitis, maybe contributing factors.
〔 Clinical manifestations 〕
1 、Systematic
2 、Local: cough, sputum,
roughening of breath sounds
dry and/or moist rales,
changeable
3 、Asthmatic bronchitis
1) Atopic (eczema, allergic rhinitis)
2) Wheezing, rhonchi to be sharp in expiration,
prolonging expiration
3) Recurrent episodes
4) <3 years old
There is also disagreement over the use of this term,
many authorities define this as a presentation of
asthma, while others consider that the bronchial
inflammation and smooth muscle spasm are related
to the effect of the particular infectious organisms
affecting infants rather than to the child’s permanent
predisposition to bronchial hyperreactivity.
〔 Treatment 〕

1 、nonspecific therapy
2 、Antibiotics
3 、pulmonary drainage by frequent shifts in position,
cough suppressants (codeine),
drain sputum (ammonium chloride, acetylcyteine)
relieve wheezing (Bricany. amminophyllin)
Bronchiolitis

It is a common disease of the lower respiratory tract of


infants, results from inflammatory obstruction of the
small airway(75~300µm). It occurs during the first 2yr
of life, with peak incidence at approximately 6 mo of
age. The incidence is highest during the winter and
early spring. The illness occurs sporadically and
epidemically.
〔 Etiology〕
Respiratory syncytial virus,( RSV)
more than 50% of cases

Parainfluenza virus ,

adenovirus,

mycoplasmal pneumoniae

Human metal pneumoniae virus

(HMPV)
〔Pathology〕

Immunology:Virus indirectly damage the small


airway by the immune mechanism

antiRSV IgE small airway(75~300µm)


inflammatory mediators
(interleukine, leukotriene)
epithelium cells necrosis, mucoedema, hyperadenosis,
secretion increase obstruction of the small airway
〔 Clinical manifestations 〕
①< 2 years old, especially about 6 months
②diffuse wheezing
③ Low-grade fever
In severe case , cyanosis
〔Laboratory findings〕
1、Organism:
sample:nasal or pulmonary secretions
methods:fluorescent antibody staining 、ELISA、PCR
rapid detection of virus antigen or MP.

2、 Chest X-ray:Diffuse hyperinflation and peribronchiolar


thickening are most common,
atelectasis and patchy infiltrates also occur
〔 Treatment 〕

3 、Antivirus therapy
Ribavirin is given by a
1 、Humidified oxygen
nebulizer for 12-18 hours of
2 、intravenous hydration every day for 3-5 days
But there is controversy

about its efficacy,


4 、Bronchodilator therapy
nebulized salbutamol 0.1mg/kg every 2-6 hours as
needed

5 、 nebulized budesonide:
6、Humanized- RSV monoclonal antibody is now commended
to prevent severe disease in high-risk patient in epidemic
period.
Monthly intramuscular administration.

7、Treatment of complication
Acidosis,respiratory failure et al.

〔Prognosis〕
50% of hospitalized patients will wheeze later in
childhood, asthma.
Pneumonia
〔Definition〕
Pneumonia is an inflammation of the parenchyma of the
lung.
Most of the cases of pneumonia are caused by
microorganisms, but a number of noninfectious causes
sometimes need to be considered, aspiration of food or
gastric acid, foreign bodies, hydrocarbons and lipid
substances, and drug-or radiation induced pneumonitis .
〔Classification〕
1) Pneumonia has been classified on an anatomic basis as a
lobar or lobular, alveolar, or interstitial process
2) but classification of infectious pneumonia on the basis of
presumed or proven etiology is diagnostically more relevant.

3)<1 month ,acute, >3 months, chronic, 1~3 month, persistent


4)Severe pneumonia, mild pneumonia
5)<48 hours of hospitalization, community acquired
pneumonia
>48 hours of hospitalization, hospitalization acquired
pneumonia
Bronchopneumonia

〔 Etiology 〕
Respiratory syncytial virus s.pneumoniae
Adenovirus Streptococcus
Influenza virus Staphylococcus aureus
Parainfluenza virus Haemophilus Influenza
Enterovirus
Mycoplasma
Chlamydia
organisms(virus、bacteria) toxin

upper respiratory infection

bronchitis

pneumonia

Bronchial mucous tissue of lung


inflammation inflammation

Dysfunction of gas exchange toxinemia


Dysfunction of ventilation

hypercapnia hypoxemia

Pulmonary Pulmonary acidnosis


arterioles arterioles gastrointestinal bleeding
pressure contraction
toxic enteroparalysis
Heart failure Toxic
encephalopathy toxic myocarditis
〔 Clinical manifestations 〕
1. fever
2. cough

3. dyspnea (The respiratory


distress is manifested by
grunting,nasal
flaring,retraction

of the subclavicular
intercostal, and subcostal
areas,tachypnea and
tachycardia)
4 、cyanosis (peripheral and central)
5 、signs in lung:

Fixed,diffuse,fine moist rales

They are easy to find at bottom of lung and near


the vertebral column.
Severe pneumonia:

( 1 )Cardiology
after giving oxygen ,sedatives

1 )dysphoria extremely,serious cyanosis

2 ) HR>180 /min,heart sound low,or gallop rhythm

3 ) RR>60 /min

4 )liver enlarge quickly

5 )oliguria or anuria,edema
( 2 )Neurology:lethargy,coma,convulsion,bulging fontanelle,
( 3 )Gastroenterology:gastrointestinal bleeding, abdomen distension
〔 Complications〕:empyema, abscesses
pyopneumothorax
pneumatocele.
〔 Chest X-ay 〕:
patchy infiltrates,
atelectasis,
(frontal and lateral
views)
〔 Laboratory findings〕

1、Peripheral blood WBC count and classification

2 、Organism:virus、bacteria and others。


〔 Diagnosis and differential diagnosis〕

1. Bronchitis
2. TB
1 、Staphylococcus aureus pneumonia
①Patient’s condition changes abruptly,with the onset of
high fever, a rapid progression of symptoms

② the most common complications are abscesses,


empyema and pyopneumothorax

③ rash (similar to measles and scarlatina)


2 、Adenovirus pneumonia
① high fever

② the signs of lung appear later, rales


③ other systems are easy involved
④ wheezing

⑤ severe necrotizing pneumonia, resulting in the


development of pneumatocele
3、Hemophilus influenzae pneumonia
① Clinical presentation with lobar distribution may be
indistinguishable from pneumococal pneumonia,
although the onset usually is more insidious.
② The bronchiopneumonic variety may
mimic acute bronchiolitis during the early
stage,but increasing interstitial edema,
producing a “shaggy” appearance on
radiographs,should alert the physcian to the
presence of a bacteria infection
4 、(Mycoplasma pneumoniae pneumonia)

older child:cough is prominent usually but the


physical signs of the lung are mild
or lack of
infant:wheezing
The cold hemoglutinin titer may be elevated during the acute
presentation,a titer 1:64 or higher supports the diagnosis.
Acute and convalescent titers for M pneumonia
demonstrating a fourfold or greater rise in specific
antibodies confirm the diagnosis.

Chest X-ray:interstitial or bronchopneumonic


infiltrate,frequently in the middle or lobes.
(Nonspecial)
5 、Chlamydial pneumonia
Chlamydia trachomatis:
①<6 month old
②onset slowly without fever
③ X –ray: hyperinflated lung and
diffuse interstitial infiltrates
 It commonly is found in the female genital tract, and the
infants who are born to infected mothers have
approximately a 50% chance of having conjunctivitis and
a 10 to 20% chance of developing pneumonia.

 Pulmonary infection usually develops gradually


over the first weeks of life.
Often, it is preceded by a nasal or eye discharge.

 In some patients, the incubation period may be 2


to 3 months.

 Signs of pneumonia start with a nonproductive


cough and tachypnea, usually between 3 to 9
weeks old.
Chlamydia pneumonia:
①>5 years old
② onset slowly without fever ,cough lasts for 1 — 2 month
③bronchospasm is common

X –ray: infiltrates
〔 Treatment〕
Antimicrobial therapy
① Principle:depend on the organism isolated from the
patient,drug sensitive test, or clinical manifestations.

 staphylococcal aureus pneumonia,


a semisynthetical, penicillinllinase-resistant
penicillin should be administered
intravenously ,e.g.oxacillin.

sencond-generation cephalosporin(e.g cefuroxine).


 Pneumococcal pneumonia, penicillin G,and
third-generation cephalosporin(e.g. cefotaxine)
should be used in the isolated of S pneumoniae
is resistant to penicillin.

 Mycoplasmal pneumonia, e.g. axithromycin

 Chlamydia pneumonia, e.g. axithromycin


② The time of antibiotic therapy:
In general, the temperature is normal 3-5days
later, and symptoms and signs of the lung
disappear stop

Staphylococcal aureus pneumonia, the


temperature is normal two weeks later, and
symptoms and signs of the lung disappear, at
least 6 weeks’ course

Mycoplasmal pneumonia, a 2-4 weeks course


③ Antivirus therapy
 The only specific agents available for the treatment of
respiratory viral infection are oral amantadine and
aerosolized ribavirin. Amantadine is active against
influenza A isolates. Treatment appears to be beneficial
only if started within 48 hr of the onset of the infection.

 Ribavirin is active in vitro against RSV and appears to


be beneficial for selected infants hospitalized with lower
respiratory tract infection caused by RSV.
 Symptomatic measures :
 Oxygen therapy:nasal tube,flux 0.5-1 liter/ min,mask or

helmet,flux 3-5liter/min
 airway management:drain sputum,bronchodilator,
shift position

 Heart failure treatment:sedation,oxygen administered


cedilanid:
lasix(diuresis reduce afterload of
the heart )
regitine(reduce preload of the heart)
 Abdomen distension:
hypokalemia,supply kalium chlorid
toxic enteroparalysis, stop eating and give regitine

 The indication of corticosteroid:


wheezing,
empyema,pyopneumothorax
toxic encephalopathy
shock
The patients with staphylococcal aureus pneumonia may
occasionally recover completely without chest tube, emyema
or pyopneumothoax is the indication for immediate insertion
of a catheter into the pleural space.