INFEKSI RESPIRATORIK AKUT

(IRA) ATAS

Finny Fitry Yani

Respirologi Bagian IKA
RS M Djamil-FK Unand
The upper
respiratory tract
consists of the parts
outside the chest cavity:
the air passages of the
nose, nasal cavities,
pharynx, larynx, and
upper trachea
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COMMON COLD

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 ...COMMON COLD

• an acute, self limited, mild upper respiratory

viral illness
• sneezing, nasal congestion and discharge
(rhinorrhea), sore throat, cough, low grade
fever, headache and malaise.
• to be distinguished from influenza,
pharyngitis, acute bronchitis, acute bacterial
sinusitis, allergic rhinitis, and pertussis.

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 ...COMMON COLD

• An estimated 25 million individuals seek

medical care for uncomplicated URI annually
in the US
• Approx. 30 % of these visits result in a
prescription for antibiotics.
– Inaccurate perceptions that bacteria cause colds
and that antibiotics improve outcome
• Infants and children are affected more often
and experience more prolonged symptoms

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 ...COMMON COLD

• many viral pathogens can cause the symptoms

of the common cold
– the most common : > 100 serotypes of
rhinoviruses.
• Common cold may occur at any time of year,
high prevalence during the fall and winter

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Viral cause of the common cold

Virus Estimated annual proportion of cases (percent)

Rhinoviruses 30-50
Coronaviruses 10-15
Influenza viruses 5-15
Respiratory syncytial virus 5
Parainfluenza viruses 5
Adenoviruses <5
Enteroviruses <5
Metapneumovirus Unknown
Unknown 20-30

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 ...COMMON COLD

• Viral transmission may occur via

– inhalation of small particle aerosols,
– deposition of large particle droplets on nasal
or conjunctival mucosa,
– or direct transfer via hand-to-hand contact

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 ...COMMON COLD

• Symptoms usually appear 1-2 days after viral

inoculation
• symptoms are not the result of viral destruction
of the nasal mucosa.
• nasal epithelium remains intact, although there is
an influx of PMNs into the nasal submucosa and
epithelium
• viral infection increases vascular permeability in
the nasal submucosa, releasing albumin and
kinins
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Proposed sequence of events during rhinovirus infection of
nasal epithelium

Infection of nasal epithelial cell

Infected cells undergo apoptosis Signalling within cells occur via NF-kB
and are extruded from the mucosa (and perhaps other pathways)

Elaboration of pro inflammatory cytokines

Initiation of plasma exudation Recruitment of PMNs to

from submucosal capilaries nasal epithelium (IL-8)

Pappas DE, Hendley JO. Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections.
Up to date. Last updated February 2008 10
 ...COMMON COLD

• Colored nasal discharge

– ~ increased presence of PMNs
– ≠ increase in positive bacterial culture
– presence of PMNs (yellow or white color) or of
PMN enzymatic activity (green color)

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 ...COMMON COLD
TREATMENT
• Supportive therapy is the only recommended
treatment
• Antihistamines, decongestants, antitussives, and
expectorants, singly and in combinations, are all
marketed for symptomatic relief in children.
• few clinical trials of these products in infants and
children and none that demonstrate benefit for
treatment of the symptoms

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 ...COMMON COLD

• Symptomatic therapy
– may include antipyretics, saline nasal irrigation,
adequate hydration, and the use of a humidifier
– Children with reactive airway disease or asthma
should use beta-agonist medications to relieve
associated bronchospasm.

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 ...COMMON COLD

• Antipyretics
– Acetaminophen (or ibuprofen, in children greater
than 6 months of age) may be used to alleviate
fever during the first few days

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 ...COMMON COLD

• Saline irrigation
– In infants, bulb suction with saline nose drops may
help to temporarily remove nasal secretions
– in the older child, a saline nose spray may be
used.

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 ...COMMON COLD

• Antihistamines
– The anticholinergic effects of 1st generation AH (eg,
diphenhydramine) may help to reduce the
secretions
– in controlled trials, AH have been ineffective in
relieving the symptoms, in combination with
decongestants or as monotherapy

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 ...COMMON COLD

• Antitussives
– Cough is a common complaint during the
course
– For many children, effective cough suppression
could result in mucus plugging
– No cough suppressants have proven effective
in children.

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 ...COMMON COLD

• In a study comparing placebo, DMP, and codeine

for treatment of cough in children 18 mo - 12 y 
no difference found between the groups, and all
three groups showed significant improvement
within three days
• Insomnia was reported in 3 of 33 children in the
dextromethorphan group.

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 ...COMMON COLD

• Because of the potential serious toxicities and

the lack of proven efficacy, these medications
are not recommended for pediatric use.

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• Decongestants
– sympathomimetic medications that cause
vasoconstriction of the nasal mucosa.
– available in oral and topical formulations.
– pseudoephedrine HCl, and phenylephrine HCl, and
oxymetazoline.

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 ...COMMON COLD

– In adults: decrease nasal congestion and increase

patency,
– no studies demonstrating the effectiveness of
these medications in children.
– Side effects may include tachycardia, elevated
diastolic blood pressure, and palpitations.

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 ...COMMON COLD

 Because of the substantial risks of these products

without proven benefit
  not recommended for pediatric use.
 It is conceivable that the older adolescent may
benefit as an adult would from the use of a
decongestant, such as pseudoephedrine

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 ...COMMON COLDv

• Zinc
– The efficacy for treatment of the common cold
remains unclear.
– for every study that demonstrates benefit,
there is another that shows none.
– Randomized trials in children also have shown
conflicting results,
– Side effects may include bad taste, nausea,
throat irritation, and diarrhea

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 ...COMMON COLD

• Other treatments
– Echinacea
– Vitamin C
– Honey
– Antibiotics

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 ...COMMON COLD

• Antibiotic therapy
– There is no role for antibiotics in the treatment
– does not prevent secondary bacterial infection
– may cause significant side effects, contribute to
increasing bacterial antimicrobial resistance.

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• The use of antibiotics should be reserved for
clearly diagnosed secondary bacterial
infections, including bacterial otitis media,
sinusitis, and pneumonia

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 ...COMMON COLD

• PREVENTION
– The best methods for preventing transmission
from one person to another are to practice
frequent handwashing and to avoid touching
one's nose and eyes.

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ALLERGIC RHINITIS

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 ...allergic rhinitis

• the occurrence of annoying nasal symptoms

including discharge, itching, sneezing,
congestion, and pressure

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 ...allergic rhinitis

• Allergic rhinitis
– associated with a symptom complex characterized
by paroxysms of sneezing, rhinorrhea, nasal
obstruction, and itching of the eyes, nose, and
palate.
– It is also frequently associated with postnasal drip,
cough, irritability, and fatigue

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 ...allergic rhinitis

• must be distinguished from the other forms of

rhinitis
• Episodic exposure to inhaled allergens such as
cat salivary proteins, horse dander, murine
urinary proteins, pollen, or house dust mite
feces may provoke acute allergic symptoms

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 ...allergic rhinitis

• Allergic, seasonal, and perennial

• Perennial nonallergic
• Infectious
• Miscellaneous categories, which include
combinations of the above

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 ...allergic rhinitis

• Allergic rhinitis is classified as seasonal if symptoms typically

occur at a particular time of the year,
• or perennial if symptoms occur year round.

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 ...allergic rhinitis

• Seasonal allergic rhinitis may be diagnosed by

the history alone.
– if allergen exposure is seasonal, for example, tree
and grass pollen in the spring (rose fever) or
ragweed pollen exposure in the fall (hay fever) are
the most likely culprits, and the symptoms are
predictable and reproducible.

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 ...allergic rhinitis

• perennial allergic rhinitis

– more than 2 hours per day and for > 9 mos of the
year
– usually reflects allergy to indoor allergens like dust
mites, cockroaches, or animal dander

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 ...allergic rhinitis

• Nasal inflammation  obstruction of the sinus osteomeatal

complex
• predisposing to bacterial infection of the sinuses.
• Symptoms of bacterial sinusitis may include nasal congestion,
purulent rhinorrhea or postnasal drip, facial or dental pain,
and cough. Purulent rhinorrhea, purulent postnasal drip, or
pain in a maxillary tooth and persistent cough in children are
the most useful predictors of bacterial sinusitis

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 ...allergic rhinitis

• The diagnosis is made on clinical grounds based upon the

characteristic history (including presence of consensus risk
factors), symptoms and signs on physical examination,
• and (if indicated) the confirmed presence of allergen-specific
IgE
• Symptoms should also be reproducible on exposure to
allergens to which the patient has been sensitized.

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 ...allergic rhinitis

• "Intermittent" – symptoms are present less than four days per week or for
less than four weeks
• "Persistent" – symptoms are present more than four days per week and
for more than four weeks
• "Mild" – None of the items listed below for "moderate-severe" are present
• "Moderate-severe" – One or more of the following items is present:
– - Sleep disturbance
– - Impairment of school or work performance
– - Impairment of daily activities, leisure and/or sport activities
– - Troublesome symptoms

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 ...allergic rhinitis

• Nasal examination : nasal mucosa frequently displays a pale

bluish hue or pallor along with turbinate edema, (not a
universal finding)

• flexible fiberoptic rhinoscopy (> 5 years of age) may facilitate

examination
Clear rhinorrhea may be visible anteriorly or, with nasal
obstruction, dripping down a posterior pharynx that resemble
cobblestones

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 ...allergic rhinitis

• Allergen-specific testing
– properly performed skin testing may provide an in
vivo assessment of biologically relevant IgE
antibodies. It is the most convenient and least
expensive screening method to detect allergic
sensitization. Other tests are less useful.

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 ...allergic rhinitis

• ALLERGEN AVOIDANCE — The treatment of all

patients with allergic rhinitis ideally begins
with the identification and avoidance of
allergic triggers

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 ...allergic rhinitis
Allergen
identification
> 1 of the 4 major
allergen categories that
trigger allergic rhinitis
 careful environmental  Pollens
history  Insects
 Reviewing home and  Animal allergens
work environments  Molds

• The most common indoor allergens among patients with

allergic rhinitis or asthma are dust mites and cat and dog
dander

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 ...allergic rhinitis

• PHARMACOLOGIC OPTIONS
– Most patients require pharmacotherapy, in
addition to allergen avoidance, for satisfactory
symptom control

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 ...allergic rhinitis
Therapy
• topical intranasal corticosteroids
• oral antihistamines
• topical nasal antihistamines
• mast cell stabilizers
• leukotriene modifiers
• ipratropium

Nasal decongestant sprays and systemic glucocorticoids

should NOT be used for routine treatment of allergic rhinitis

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 ...allergic rhinitis
Intranasal glucocorticoids
( INGCs)
• Topical INGCs are presently the most effective single
maintenance therapy and cause few side effects at
the recommended doses.
• particularly effective in the treatment of nasal
congestion.
• beclomethasone, flunisolide, budesonide, fluticasone
propionate, mometasone furoate, and fluticasone
furoate.

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 ...allergic rhinitis
Second generation
antihistamines

• include loratadine, cetirizine, and azelastine

• Onset of action is within 1 hour for most agents,
and peak serum levels are attained in 2 - 3 hours
• less impact on nasal congestion compared to
INGCs.

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ACUTE BACTERIAL SINUSITIS IN
CHILDREN

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 ...acute bacterial sinusitis

DEFINITIONS
• Sinusitis is inflammation of the mucosal lining of
one or more of the paranasal sinuses

common during URI, when there is

usually spontaneously secondary bacterial
resolves infection of the sinuses

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 ...acute bacterial sinusitis

• A viral infection associated with the common

cold is the most frequent etiology of acute
sinusitis  viral rhinosinusitis.
• Appr. 6 - 13 % of viral rhinosinusitis in children
is complicated by ABS

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 ...acute bacterial sinusitis

• Uncomplicated viral rhinosinusitis usually resolves

without treatment in 7 - 10 days.
• Although untreated ABS also may resolve without
treatment

antibiotics hastens recovery and may decrease

the risk for orbital and intracranial complications.

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 ...acute bacterial sinusitis

Distinguishing between acute viral

rhinosinusitis and ABS

• is important : antibiotics can be used

judiciously

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 ...acute bacterial sinusitis

Classification according to duration

and recurrence

• Acute: symptoms completely resolve in <30 days

• Subacute: symptoms completely resolve in ≥ 30 and <90
days
• Recurrent: >3 episodes of <30 days duration separated by
intervals of ≥ 10 days without symptoms in a 6-month
period, or >4 such episodes in a 12-month period;
individual episodes respond briskly to antibiotic therapy

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 ...acute bacterial sinusitis

• Chronic sinusitis is defined by episodes of

inflammation of the paranasal sinuses that last >90
days, during which patients have persistent
symptoms (cough, rhinorrhea, nasal obstruction).
• may be related to noninfectious conditions such as
allergy, cystic fibrosis, gastroesophageal reflux, or
exposure to environmental pollutants

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 ...acute bacterial sinusitis

• PATHOGENESIS — The paranasal sinuses are usually sterile However,

because the membranes that line the nose are continuous with the
membranes that line the sinus cavities, the paranasal sinuses may be
contaminated with bacteria that colonize the nasal mucosa and
nasopharynx. The contaminating bacteria are typically removed by
mucociliary clearance [1,4] . When mucociliary clearance is altered (eg, by
conditions that damage the ciliary epithelium or affect the number or
function of cilia, or the production or viscosity of mucous), the sinuses
may be inoculated with large numbers of microorganisms, and infection
may develop Once infection is present, inflammation may obstruct the
ostia, further complicating the infectious process

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 ...acute bacterial sinusitis

Risk factors
• Viral URI is the most important
• children who attend day care
• Allergic rhinitis
 Anatomic obstruction ( septal
deformities; craniofacial anomalies;
adenoidal hypertrophy)
 Mucosal irritants (dry air, tobacco smoke, Less
chlorinated water) common
 Sudden changes in atmospheric pressure
(descent in an airplane)
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 ...acute bacterial sinusitis

• Streptococcus pneumoniae, Haemophilus influenzae

(non-typeable), and Moraxella catarrhalis are the
predominant causes of ABS
• Because of its general effectiveness, safety, low cost,
and narrow spectrum, amoxicillin, with or without
clavulanate, generally is considered to be the first
line agent for the treatment of ABS in children

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 ...acute bacterial sinusitis
Antibiotics

• For children with uncomplicated ABS that is of mild

to moderate severity

– Amoxicillin (45 to 90 mg/kg per day in two divided doses),

or Amoxicillin-clavulanate (45 to 90 mg/kg per day of the
amoxicillin component in two divided doses)

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 ...acute bacterial sinusitis
Antibiotics

• For children who have uncomplicated ABS of

at least moderate severity
– Amoxicillin-clavulanate (80 to 90 mg/kg per day of
amoxicillin)
– Cefdinir (14 mg/kg per day in 1 or 2 doses), or
– Cefuroxime (30 mg/kg per day), or
– Cefpodoxime (10 mg/kg per day once daily)

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 ...acute bacterial sinusitis
Antibiotics

• children with vomiting that precludes

administration of oral antibiotics
– A single dose of ceftriaxone (at 50 mg/kg per day),
i.v. or i.m
– Therapy with an oral antibiotic should be initiated
24 hours later, provided the vomiting has
resolved.

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 ...acute bacterial sinusitis
Antibiotics
• Seriously ill children with ABS should be hospitalized for
intravenous antibiotics.
• Empiric therapy should provide coverage for highly resistant
pneumococci and penicillin resistant H. influenzae and M.
catarrhalis.
• Appropriate regimens include:
– Cefotaxime (100 - 200 mg/kg /day divided every 6 hs)
– Ceftriaxone (100 mg/kg /day divided every 12 hs)

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