Acute Respiratory Tract Infection

Retno Asih S

Respirology Division
Department of Child Health-Faculty of Medicine
Airlangga University-Dr Soetomo Hospital
 Level of Competency
Acute otitis media 4A
Acute rhinitis 4A
Pharyngitis, tonsillitis, laryngitis 4A
Sinusitis 3A
Bronchiolitis 3B
Pneumonia 4
Acute bronchitis 4
 References
1. Nelson text book of pediatric
2. Buku Ajar Respirologi Anak
3. Pocket book of pediatric –WHO
4. Buku Pedoman Pneumonia Kemenkes

3
 Common Cold
• Viral illness, rhinitis
• Rhinorrhea and nasal obstruction : prominent
• Systemic symptom and sign (headache, myalgia,fever) : absent
or mild

• Etiology : rhinovirus (>>>), the others: coronavirus, RSV,

influenzae virus

• Epidemiology :
– Year round, seasonal (RV:August-Oct; RSV : Dec-April)
– Young children: 6-8 colds per year ; adulthood: 2-3 illnesses
– Out of home day care : incidence >>
Pathogenesis :
• Spread by small particle aerosol, large particle
aerosol, and direct contact (RSV, RV: direct contact)
• Have different mechanisms to avoid host defences :
– RV serotype specific protective immunity
– Influenzae viruschange antigen presented on
the surface
– RSV  protective immunity doesn’t developed
• Destruction of epithelium lining acute
inflammation response (inflammatory citokines,
inflammatory cells) symptoms  obstruct sinus
ostium or eustachian tube
Clinical manifestation
• The onset of symptoms : 1-3 after viral infection
• The 1st symptoms: sore throatnasal obstruction
and rinorrhea
• Cough: 30%, after nasal symptoms
• Persists for about 1 week (10%: 2 weeks)
• Physical finding:
– increased nasal secretion
– a change in the color or consistency : not indicate
sinusitis or bacterial superinfection
– Nasal cavity : swollen, erythematous nasal
turbinates
Laboratory finding:
• Routine lab -> not helpful
• Etiology : PCR, culture, serology

Differential diagnosis
• Allergic rhinitis
• Foreign body
• Sinusitis
• Streptococcal faringitis
Treatment :
• Antiviral : not effective
• Antibacterial : no benefit
• Symptomatic treatment: antipyretic, decongestan,
analgesic for sore throat
Complication:
• Sinusitis
• Asthma exacerbation
Prevention:
• Immunization
• Handwashing
 Sinusitis
• An inflammation of the mucosa lining of the
nasal passage and paranasal sinuses
• Common illnes in childhood and adolescence
• Etiology : allergy, viral infection and/or bacteria.
• Bacterial pathogen: Streptococcus pneumoniae,
Haemophyllus influenzae, Moraxella catarrhalis
• United Airway Disease consept
– Inflammation theory
– Impact on therapy
9
 Definition
• Acute sinusitis : lasting less than 30 days in
which symptoms resolve completely
• Sub acute sinusitis : lasting between 30 and 90
days in which symptoms resolve completely
• Chronic sinusitis : lasting more than 90 days,
have persistent residual respiratory symptoms
• Acute sinusitis superimposed on chronic
sinusitis : residual respiratory symptoms
develop new respiratory symptoms
 Epidemiology
Acute bacterial sinusitis
• can occur at any age
• Predisposing : viral infection, allergic rhinitis,
cigarette smoke exposure
 Acute bacterial versus Viral Rhinosinusitis

Acute bacterial if
• Onset with persistent symptoms or sign compatible with
acute rhinosinusitis, lasting for ≥ 10days without clnical
improvement
• Onset of severe symptoms or signs of high fever (≥39oC)
and purulent nasal discharge or facial pain lasting for at
least 3-4 consecutive days at the beginning of illlness
• Onset with worsening symptoms and sign (new onset of
fever, headache or increase in nasal discharge) following a
typical viral upper respiratory infection lasted 5-6 days and
were initially improving (double sickening)
 Diagnosis
• Clinical diagnosis bacterial sinusitis based on history
• Gold standard acute bacterial sinusitis : bacteria in
sinus aspirate  invasive procedure
• Finding in radiographic procedure ( opacification,
thickening mucosa, presence of an air fluid level) are
not diagnostic and not recommendation

14
 Radiologic Assesment
• Not be routinely in initial management
• Abnormalities of paranasal sinuses: found frequently on
coventional radiographs and CT scans in children without
clinical evidence of sinusitis
• Presence URI alone can result in mucosal thickening and
abnormal findings in plain radiograph
• Radiologic studies :
– Unsuccessful therapy
– Evidence of orbital complication
– Evidence of intracranial complication
 Laboratory Assesment
• Complete blood count or nasopharyngeal culture not be
obtained in the initial evaluation in children in
uncomplicated rhinosinusitis
• Organisms from nasopharyngeal and throat culture do not
reflect the organism in sinus aspirate
• Sinus aspiration and bacterial culture may be considered :
– Severe illness or toxic looking child
– Immunocompromised child
– Presence of suppurative or intracranial complication
• Patogen : Streptococcus pneumonia, Hemophilus
influenzae, Moraxella catharalis
 Treatment
• Antibiotic
– Bacterial sinusitis
– Amoxicillin (45mg/kgBB/day divided bid),
alternatif for penicillin alergy: cefixim
– Azithromycin not recommended
– Duration of treatment : 10-14 days
• Not recommended : corticosteroid intranasal,
antihistamine, decongestan
• Complication: orbital and intracranial
complication
17
 ACUTE PHARYNGITIS
• Inflammation of the pharynx
• The most important agent: viruses and group A
β hemolytic streptococcus
• Streptococcal pharyngitis :
– relatively uncommon before 2-3 year of age
– peak incidence in early school
– decline in late adolescence

18
Pathogenesis :
• Colonization by GABHS : asympthomatic
carriege-acute infection
• M protein : virulence factor resistance to
phagocytosis by PMN  type specifc
immunity  protective immunity to
subsequent infection with paticular M
serotype
Clinical manifestation : streptococcal pharyngitis
• Onset streptococcal pharyngitis: rapid
• Incubation periode : 2-5 days
• Prominent sore throat and fever, abcence cough
• Pharynx: red, tonsil enlarged, classical covered with a yellow
blood tinged exudate.
• Petechiae or doughnut lession on the soft pallate and posterior
pharynk ; strawberry tongue
• Anterior cervical lympnode: enlarged and tender
Clinical manifetation of viral pharyngitis:
• Gradual
• Symptoms : rhinorrhea, cough, diarrhea
• Viral etiology suggested by: conjunctivitis, coryza, hoarseness
and cough
Diagnosis
• Clinical manifestation of streptococcal and
viral: overlap
• Laboratory testing : useful in identifying
children who are most likely to benefit from
antibiotic therapy
• Gold standard : throat culture
• The specificity of Rapid test to detect
streptococcal antigen : high
 DIAGNOSIS
Modifikasi Skor Centor dan Pedoman
Pemeriksaan kultur
( Mc Isaac WJ, 2004 ) ( I A)

Kriteria Point
Temperatur > 38°C 1
Tidak ada batuk 1
Pembesaran kelenjar leher anterior 1
Pembengkakan/eksudat tonsil 1
Usia:
3-14 tahun 1
15 – 44 th 1
≥ 45 tahun -1
22
Skor Resiko infeksi Tatalaksana
streptokokus
≤ 0 1 - 2,5 % Kultur tidak dilakukan,
Antibiotik (-)
1 5 – 10% Kultur tidak dilakukan,
Antibiotik (-)
2 1- 17 % Kultur dilakukan,
Antibiotik jika kultur (+)
3 28 – 35% Kultur dilakukan,
Antibiotik jika kultur (+)
≥4 51- 53 % Kultur dilakukan,
Antibiotik empiris/ sesuai kultur
23
Treatment
Most untreated streptococcal pharyngitis: resolve
unevenfully in a few day
Oral antipyretic/analgesic: reieve fever and sore throat
Early antibiotic: clinical recovery 12-42hr
The primary benefit of the treatment : prevention of
acute rheumatic fever
GABHS : susceptible to penicillin
Penicillin V (10 days)
Oral amoxicillin (10 days)
A single im benzathine penicillin
24
For patient allergic to penicillin:
– Erythromycin (10 days)
– Azithromycin (5 days)
– Clarithromycin (10 days)
– Clindamycin (10days)
– Narrow spectrum cephalosporin: cephalexin,
cefadroxil
• For eradicating streptoccoal carriage : clindamycin
for 10 days
• Specific therapy is unavailable for most viral
pharyngitis
Recurrent streptococcal pharyngitis :
– Relapse with an identical strain if type specific antibody has not
yet developed
– Can be caused by different strain resulting from new exposures
or can represent pharyngitis of another cause accompanied by
streptococcal carriage
– If compliance with antibiotics poor  im benzatin penicillin
Complication and prognosis:
• Viral pharyngitis  midldle ear infection
• Streptococcal pharyngitis  local suppurative and non
suppurative illness
Prevention :
• Multivalent streptococcal vaccine
Etiology :
• Most caused by viruses
• Parainfluenzae virus type 1,2,3 (~75%)
• Influenza virus A,B; adenovirus; RSV
• Diphteria, bacterial tracheitis, epiglottitis
• The other caused upper airway obstruction : allergy,
corpus alineum

Characteristic sign and symptoms : barking

cough, hoarseness, inspiratory stridor.

27
Clinical manifestation :
• Croup
• Epiglottitis
• Spasmodic croup
 Croup (Laryngotracheobronchitis)

• Mostly caused by virus

• Upper respiratory infection (rhinorrhea,
pharyngitis, mild cough, low grade fever) 1-3days
 upper airway obstruction (barking cough,
hoarseness, inspiratory stridor
• Temperature can reach 39-40oC
• Symptoms are characteristically worse at night,
resolve completely within a week
 Laryngotracheobronchitis

• Physical examination:
– Hoarse voice, coryza, normal to moderately inflamed
pharynk
– Increased respiratory rate, Inspiratory stridor
– Complete airway obstruction  hypoxia (cyanotic, pale) 
immediate airway management
• Croup : clinical diagnosis, not require radiograph of the
neck
• Radiograph of the neck: steeple sign (subglottic
narrowing)  may be present in normal patient
• Radiograph not correlate with disease severity
 Acute Epiglottitis
• Acute rapidly progressive and potentially fulminating
course of high fever, sore throat, dyspnea and rapidly
progressing respiratory obstruction
• Healthy child suddenly developeds sore throat and fever
 within hours : toxic, difficulty swallowing, drooling,
breathing is labored
• Stridor : late finding  nearcomplete airway obstruction
• Complete airway obstruction: death unless adequate
treatment
• Barking cough is rare
 Acute Epiglottitis

• Physical examination: a large, cherry red,

swollen epiglottis
• Classic radiograph : thumb sign
• Establishing an airway: nasotracheal
intubation or tracheostomy
• Response to antibiotics : rapid
 Spasmodic croup
• Most often in children 1-3 yr of age
• Clinically similar to acute laryngotracheobronchitis
• The history of viral prodrome and fever are often
absent
• Causes : viral, allergic, psychologic factors
• Commonly in the evening or night time.
 Spasmodic croup

• Suddent onset, may be preceded by mild-

moderate coryza hoarseness
• Awakens with barking metallic cough, noisy
inspiration, respiratory distress and appear
anxious, afebrile
• Diminishes within several hours, the following
days appear well
• Such episodes often recur several times
 Differential diagnosis
Infectious Upper Airway Obstruction
• Bacterial tracheitis
• Diptheritic croup
• Foreign body
• Retropharyngeal or peritonsillar abcess
• Angioedema
 Complication of Infectious Upper Airway
Obstruction
• The most common: extension of the infection
process to other region respiratory tract :
– midlle ear
– terminal bronchioles
– pulmonary parenkim
• Bacterial tracheitis
 Treatment of Infectious Upper Airway
Obstruction
• Airway management and treatment of hypoxia
• Nebulized racemic epinephrine  constriction of the
precapillary arteriols through β adrenergic receptors 
fluid resorption from the intertitial space and a decrease in
the laryngeal mucosal edema
• Corticosteroid (oral, im dexamethason, nebulized
budesonide)  decrease edema laryngeal mucosa through
anti inflammatory action
• Antibiotics : acute epiglottitis  ampicillin ( H.influenzae
10-40% resistant to ampicillin) , ceftriaxon, cefotaxim
 Risk factors PNEUMONIA
Low birth weight

Not breastfed Malnutrition

Incomplete Vit A deficiency

immunization

PNEUMONIA
Young age Cold weather

High prevalence
Other illnesses pathogen carrier
Exposure to indoor &
outdoor pollution
ETS, biomass fuel, vehicle &
industry pollution
 Classification
• Source of infection
o Community acquired pneumonia (CAP)
o Hospital acquired pneumonia (HAP)
o Ventilator associated pneumonia (VAP)
• Diagnosis
o Clinical -- mostly
o Radiological -- supporting
o Etiology – difficult, specimen
• Severity – WHO classification
 Pneumonia, etiology
 Virus
 Bacteria
Depends on age
 Fungi
 Atypical pathogen
Neonates 1-2 months 3-12 months 1-5 years >5 years
Streptococcus Chlamydia Viruses Viruses S pneumoniae
group B trachomatis
Enteric gram Ureaplasma Streptococcus S pneumoniae M pneumoniae
negative urealyticum pneumoniae
Viruses H influenzae Mycoplasma C pneumoniae
pneumoniae
Bordetella Staphylococcus Chlamydia
pertussis aureus pneumoniae
Moraxella
catharrhalis
Disorders of resp tract in children, Kendig’s, 2012
 Pneumonia, symptomatology
• A range of symptoms depending on their age and the cause of
the infection.
• Bacterial pneumonia : severely ill with high fever and rapid
breathing.
• Viral infections : gradually and may worsen over time.
• Some common symptoms : rapid or difficult breathing, cough,
fever, chills, headaches, loss of appetite and wheezing.
• Children under five with severe cases: struggle to breathe, with
their chests moving in or retracting during inhalation (known as
‘lower chest wall indrawing’)
• Young infants may suffer convulsions, unconsciousness,
hypothermia, lethargy and feeding problems
 Pneumonia, DIAGNOSIS
Combination of all aspects
• Clinical course
• Symptomatology
• Hypoxemia – BGA, pulse oxymetry
• Pathology – imaging
• Blood, inflammation marker
• Definitive, but dificult, specimen availability.
• Blood culture – not a representative specimen
• Chest X-rays and laboratory tests are used to confirm
the presence of pneumonia, including the extent and
location of the infection and its cause.
• But in resource-poor settings without access to these
technologies, suspected cases of pneumonia are
diagnosed by their clinical symptoms.
• Children and infants are presumed to have
pneumonia if they exhibit a cough and fast or
difficult breathing
 Tatalaksana Anak Batuk atau Kesukaran
Bernapas

• Menilai anak batuk atau kesulitan bernapas

• Membuat klasifikasi dan menentukan tindakan
yang sesuai
• Menentukan pengobatan dan rujukan
• Memberikan konseling pada ibu
• Memberi pelayanan tindak lanjut
Menilai anak batuk atau kesulitan bernapas

Tanyakan keluhan utama:

1. Apakah anak menderita batuk atau sukar bernapas?
Jika ya..berapa lama
2. Berapa umur anak?

Tanyakan tanda BAHAYA

1. Apakah anak umur 2 -59 bulan TIDAK BISA minum atau
menetek?
2. Apakah bayi < 2 bulan KURANG BISA minum atau
menetek?
3. Apakah anak pernah mengalami mengi? Apakah
berulang?
4. Apakah anak demam? Berapa lama?
5. Apakah anak kejang?
Menilai anak batuk atau kesulitan bernapas

Lihat (Anak harus kondisi tenang):

1. Adakah napas cepat?
2. Apakah terlihat tarikan dinding dada bagian bawah
ke dalam (TDDK)?
3. Apakah terlihat kesadaran menurun
4. Adakah tanda gizi buruk?
Raba
Apakah teraba demam atau terlalu dingin?
DENGAR:
1. Apakah terdengar stridor?
2. Apakah terdengar wheezing?
 Hitung Napas
Napas cepat
• < 2 bulan = > 60 x/mnt
• 2 bln–11 bln = > 50 x/mnt
• 1 – 5 tahun = > 40 x/mnt

Chest Indrawing
(subcostal retraction)
(tarikan dinding dada ke dalam)

48
Klasifikasi Umur 2-59 bulan
 • Berikan Amoksisilin oral
dosis tinggi 2 kali per hari
untuk 3 hari*
• Beri pelega tenggorokan dan
Kuning: pereda batuk yang aman
PNEUMONIA • Apabila batuk > 14 hari rujuk
• Napas cepat • Apabila wheezing berulang
rujuk
• Nasihati kapan kembali
segera
• Kunjungan ulang dalam 3
hari
• Obati wheezing bila ada

Dosis tinggi amoksisilin oral yaitu 90 (80-100) mg/kgBB/hari

dibagi 2 dosis selama 3 hari.
Di Daerah endemis HIV diberikan 5 hari
 • Beri pelega tenggorokan
dan pereda batuk yang
aman
• Tidak ada tarikan • Apabila batuk > 14 hari
dinding dada ke Hijau : rujuk
dalam BATUK • Apabila wheezing
BUKAN berulang rujuk
• Tidak ada napas PNEUMONIA • Nasihati kapan kembali
cepat segera
• Kunjungan ulang dalam
5 hari bila tidak ada
perbaikan
• Obati wheezing bila ada
 Tanda Bahaya Bayi < 2 bulan
• Napas cepat
• TDDK
• kurang mau minum
• demam
• kejang
• kesadaran menurun
• stridor
• tangan dan kaki teraba dingin
• Wheezing
• Tanda gizi buruk .
Seorang bayi berumur <2 bulan diklasifikasikan
menderita pneumonia berat bila dari
pemeriksaan ditemukan :
• Tarikan dinding dada bagian bawah ke dalam
yang kuat (TDDK kuat) ATAU
• Adanya napas cepat: 60 x/menit atau lebih
TINDA KAN
• Bayi yang mempunyai TDDK kuat serta napas cepat harus
dirujuk segera ke rumah sakit.
• Sebelum bayi meninggalkan Puskesmas, petugas kesehatan
dianjurkan memberi pengobatan pra rujukan, (misal atasi
demam, wheezing, kejang dan sebagainya)
• tulislah surat rujukan ke rumah sakit dan anjurkan pada ibu
agar anaknya dibawa ke rumah sakit sesegera mungkin.
• Berikan satu kali dosis antibiotik sebelum anak dirujuk (bila
memungkinkan).
• Anjurkan ibunya untuk tetap memberikan ASI .
• Penting untuk menjaga agar bayi tetap hangat.
 RAWAT JALAN
• Edukasi pemberian asupan cairan yang cukup, perhitungkan juga jika
ada demam, small frequent feeding jika ada muntah
• ANTIBIOTIK :
- Berikan dosis pertama di fasyankes
- Oral :
a. High HIV infection rate: amoksisilin 40-50 mg/kg (80-100m/kg/hari)
per kali; 2x/hari (5hari)
b. Low HIV infection rate: amoksisilin 40-50 mg/kg
per kali; 2x/hari (3hari)
• Hindari pemberian obat yang tidak diperlukan seperti golongan
atropin, obat yang mengandung alkohol, ataupun kodein
• Alergi amoksisilin:
– Eritromisin 40-60mg/ kg/hari terbagi 3-4 dosis
 ANTIBIOTIK (NON HIV )
- Ampisilin 50 mg/kg atau benzilpenicillin 50.000 U/kg IM atau IV/6
jam (min 5 hari)
- Dan Gentamisin 7.5 mg/kg IM atau IV sekali sehari (min 5 hari)

- Jika dalam 48 jam tidak membaik  gentamisin + kloksasilin (50

mg/kg IM/IV tiap 6 jam

- AB Lini kedua : Seftriakson (80 mg/kg IM /IV sekali sehari)

- Bila dibawah 2 bulan

Ampisilin 100 mg/kg IV/12 jam (min 5 hari)
Dan Gentamisin 5 mg/kg IM atau IV dua kali sehari (min 5 hari)
PENYEBAB KEMATIAN PADA
PNEUMONIA
• HIPOKSIA

- SIANOSIS SENTRAL

- SATURASI OKSIGEN < 90 %

- SESAK NAPAS BERAT

(MERINTIH, TARIKAN DINDING
DADA YANG DALAM)
 PEMANTAUAN DAN PENYAPIHAN
TERAPI OKSIGEN
• Setiap 3 jam perawat • Setiap hari oksigen dititrasi
menilai apakah: secara bertahap
• Dapat dihentikan jika:
- Klinis membaik
- Kondisi anak stabil - Saturasi oksigen >90 % pada
- Nasal prong terletak pada udara ruang
tempatnya • Pastikan saturasi > 90% (dalam
15 menit saat penghentian) ;
- Tidak ada plak mukus
pantau 30 menit berikutnya ;
- Koneksi ke sumber oksigen selanjutnya tiap 3 jam pada
tetap terjaga (flow rate) hari pertama
- Saturasi oksigen baik • Jika stabil oksigen dapat
dihentikan
 KOMPLIKASI
Jika dalam 48 – 72 jam klinis tidak membaik/bahkan
memburuk pikirkan komplikasi :
Lakukan pemeriksaan foto toraks
• Pneumatocele
• Parapneumonic effusion (termasuk empiema)
• Pneumotoraks / Pneumomediastinum
• Abses Paru
• Sepsis (Septic shock, penyebaran infeksi ke organ lain
seperti meningitis, peritonitis dll)
 KAPAN PASIEN DAPAT PULANG

• Sesak berkurang atau menghilang

• Tidak ada hipoksemia (saturasi oksigen > 90%)
• Asupan makan baik
• Dapat minum obat secara oral atau telah
menyelesaikan pemberian obat antibiotik parenteral
• Orangtua mengerti gejala dan tanda pneumonia,
faktor risiko dan kapan harus datang kontrol
 PENCEGAHAN

• IMUNISASI • Asupan gizi seimbang

DPT- HIB
• Pemberian ASI eksklusif
Pneumokok (PCV)
Campak
• Hindari paparan asap
MR rokok dan polusi udara
Influenza
• Atasi komorbiditas
 Bronchiolitis Acute
• A viral disease, mostly cause by RSV
• The other viruses: para influenza, adeno, human
bocavirus, human metapneumovirus, mycoplasma
• More common in boys
• Risk factors:
– Have not breast fed
– Live in crowded condition
– Mother who smoked during pregnancy
Clinical manifestation
• Usually preceded by exposure to an older contact with a
minor respiratory syndrome within the previous week
• Initially a mild URI, accompanied by diminished appetite and
fever
• Gradually respiratory distress ensues
Physical examination
• dominated by wheezing
• Nasal flaring and retractions
• Auscultation: fine crackles or overt wheezes with prolongation
of the respiratory phase
• Permit palpation of liver and spleen
Diagnostic evaluation
• Chest Rǒ : hyperinflation
• WBC and differential count normal
• Viral testing
Treatment
• Hospitalized who have respiratory distress
• The mainstay treatment is supportive
• Bronchodilators
• Ribavirin?
• Prevention
• Palivizumad
• Hand hygiene