ACUTE ACUTE RESPIRATORYRESPIRATORYINFECTIONSINFECTIONS

Dr. Dwi Wastoro, SpAKDr. Dwi Wastoro, SpAK

PneumoniaPneumoniaBronchiolitisBronchiolitis

Acute Respiratory Infections (ARI)Acute Respiratory Infections (ARI)

Developed and developing countriesDeveloped and developing countries

High morbidityHigh morbidity

5 – 8 episodes/year/child5 – 8 episodes/year/child

30 – 50 % outpatient visit30 – 50 % outpatient visit

10 – 30 % hospitalization10 – 30 % hospitalization

Developing countriesDeveloping countries

High mortalityHigh mortality

30 – 70 times higher than in developed countries30 – 70 times higher than in developed countries

1/4 - 1/3 death in children under five year of age1/4 - 1/3 death in children under five year of age

ARI-ASSOCIATED DEATH RATE BY AGEARI-ASSOCIATED DEATH RATE BY AGETEKNAF, BANGLADESH, 1982-1985TEKNAF, BANGLADESH, 1982-1985

0

20

40

60

80

100

120

140

1-5 6-11 12-23 24-35 36-50

Age in Months

Deaths per 1000 children

Distribution of 12.2 million deaths among Distribution of 12.2 million deaths among children less than 5 years old in all developing children less than 5 years old in all developing

countries, 1993countries, 1993

ARI (26.9%)

Measles (2.4%)

Diarrhoea/measles (1.9%)

Diarrhoea (22.8%)

Other (33.1%)

Malaria (6.2)

ARI/Malaria (1.6%)

ARI/Measles (5.2%)

MalnutritionMalnutrition(29%)(29%)

RISK FACTORS FOR PNEUMONIARISK FACTORS FOR PNEUMONIAOR DEATH FROM ARIOR DEATH FROM ARI

Increaserisk of

ARI

Malnutrition, poorbreast feeding

practices

Vitamin A deficiency

Low birth weight

Cold weatheror chilling

Exposure to air pollution• Tobacco smoke• Biomass smoke• Environmental air pollution

Lack of immunization

Young age

Crowding

High prevalenceof nasopharyngealcarriage ofpathogenic bacteria

Magnitude of the ProblemMagnitude of the Problemin Indonesiain Indonesia

Pneumonia in children (< 5 years of age)Pneumonia in children (< 5 years of age)

Morbidity Rate 10-20 %Morbidity Rate 10-20 %

Mortality Rate 6 / 1000Mortality Rate 6 / 1000

Pneumonias killPneumonias kill 50.000 / a year50.000 / a year 12.500 / a month12.500 / a month 416 / a day = passengers of 1 jumbo jet plane416 / a day = passengers of 1 jumbo jet plane 17 / an hour17 / an hour 1 / four minutes1 / four minutes

Pneumonia is a no 1 killer for infants Pneumonia is a no 1 killer for infants (Balita)(Balita)

PneumoniaPneumoniaClassificationsClassifications

Anatomical classificationAnatomical classification Lobar pneumoniaLobar pneumonia Lobular pneumoniaLobular pneumonia Intertitial pneumoniaIntertitial pneumonia BronchopneumoniaBronchopneumonia

Etiological classificationEtiological classification Bacterial pneumoniaBacterial pneumonia Viral pneumoniaViral pneumonia Mycoplasma pneumoniaMycoplasma pneumonia Aspiration pneumoniaAspiration pneumonia Mycotic pneumoniaMycotic pneumonia

Etiology of PneumoniaEtiology of Pneumonia

Predominantly : bacterial and viral Predominantly : bacterial and viral

In developing countries: In developing countries:

bacterial > viral bacterial > viral

(Shann,1986): In 7 developing(Shann,1986): In 7 developing countries, countries,

bacterial bacterial 60 % 60 %

(Turner, 1987):(Turner, 1987): In developed countries,In developed countries, bacterial bacterial 19 % ; viral 19 % ; viral 39 % 39 %

Bacterial etiologyBacterial etiology

Streptococcus pneumoniaeStreptococcus pneumoniae

Hemophilus influenzaeHemophilus influenzae

Staphylococcus aureusStaphylococcus aureus

Streptococcus group A – BStreptococcus group A – B

Klebsiella pneumoniaeKlebsiella pneumoniae

Pseudomonas aeruginosaPseudomonas aeruginosa

Chlamydia sppChlamydia spp

Mycoplasma pneumoniaeMycoplasma pneumoniae

0

10

20

30

40

50

S Pneumoniae H Influenzae S Aureus

BACTERIA ISOLATED FROM LUNG ASPIRATESBACTERIA ISOLATED FROM LUNG ASPIRATESIN 370 UNTREATED CHILDREN WITH PNEUMONIAIN 370 UNTREATED CHILDREN WITH PNEUMONIA

%%

Characteristic featuresCharacteristic features

S pneumoniaeS pneumoniae mucosal inflammation lesionmucosal inflammation lesion alveolar exudatesalveolar exudates frequently frequently lobar pneumonia)lobar pneumonia)

H influenzae, S viridans, VirusH influenzae, S viridans, Virus invasion and destruction of mucous membraneinvasion and destruction of mucous membrane

Staphylococcus, KlebsiellaStaphylococcus, Klebsiella destruction of tissues destruction of tissues multiple abscesses multiple abscesses

Simple Clinical Signs of Simple Clinical Signs of Pneumonia (WHO)Pneumonia (WHO)

Fast breathing (tachypnea)Fast breathing (tachypnea)

Respiratory thresholds Respiratory thresholds

AgeAge Breaths/minuteBreaths/minute

< 2 months< 2 months 6060

2 - 12 months2 - 12 months 5050

1 - 5 years1 - 5 years 4040

Chest IndrawingChest Indrawing(subcostal retraction)(subcostal retraction)

Pathology and PathogenesisPathology and Pathogenesis

Bacteriae Bacteriae peripheral lung tissues peripheral lung tissues

tissues reaction tissues reaction oedematous oedematous

Red Hepatization StadiumRed Hepatization Stadium

alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte, bacteriabacteria

Grey Hepatization Stadium Grey Hepatization Stadium

fibrine deposition, phagocytosisfibrine deposition, phagocytosis

Resolution Stadium Resolution Stadium

neutrophil degeneration, loose of fibrine,neutrophil degeneration, loose of fibrine,

bacterial phagocytosisbacterial phagocytosis

Bronchopneumonia                       Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the alveolar spaces. The alveolar capillaries are distended and engorged.

Bronchopneumonia                         Acute bronchopneumonia. The alveolar spaces contain abundant PMNs and an inflammatory infiltrate rich in fibrin.

Acute Bronchopneumonia                                        Acute bronchopneumonia; the alveolar spaces are full and distended with PMNs and a proteinaceous exudate. Only the alveolar septa allow identification of the tissue as lung.

Radiographic patterns Radiographic patterns

1.1. Diffuse alveolar and interstitial Diffuse alveolar and interstitial pneumoniapneumonia (perivascular and (perivascular and interalveolar changes)interalveolar changes)

2.  Bronchopneumonia2.  Bronchopneumonia(inflammation of airways and (inflammation of airways and parenchyma)parenchyma)

3. 3. Lobar pneumoniaLobar pneumonia(consolidation in a whole lobe)(consolidation in a whole lobe)

4. 4. Nodular, cavity or abscess lesionsNodular, cavity or abscess lesions(esp.in immunocompromised patients)(esp.in immunocompromised patients)

Blood Gas Analysis & Acid Base BalanceBlood Gas Analysis & Acid Base Balance

Hypoxemia Hypoxemia (P(PaaOO22 < 80 mm Hg) < 80 mm Hg) with Owith O22 3 L/min 3 L/min 52,4 %52,4 % without Owithout O22 100 %100 %

Ventilatory insufficiencyVentilatory insufficiency (P(PaaCOCO22 < 35 mmHg) < 35 mmHg) 87,5 %87,5 %

Ventilatory failureVentilatory failure (P(PaaCOCO22 > 45 mmHg ) > 45 mmHg ) 4.8 %4.8 %

Metabolic Acidosis Metabolic Acidosis poor intake and/or hypoxemiapoor intake and/or hypoxemia 44,4 % 44,4 %

(Mardjanis Said, et al. 1980)(Mardjanis Said, et al. 1980)

ManagementManagement

Severe PneumoniaSevere Pneumonia

HospitalizationHospitalization

Antibiotic administrationAntibiotic administration Procain Pennicilline, ChloramphenicolProcain Pennicilline, Chloramphenicol Amoxycillin + Clavulanic AcidAmoxycillin + Clavulanic Acid

Intra Venous Fluid DripIntra Venous Fluid Drip

OxygenOxygen

Detection and management of Detection and management of complicationscomplications

ComplicationsComplications

Pleural effusion (empyema)Pleural effusion (empyema)

PiopneumothoraxPiopneumothorax

PneumothoraxPneumothorax

PneumomediastinumPneumomediastinum

BronchiolitisBronchiolitis

Bronchioles inflammationBronchioles inflammation

Clinical syndromes: Clinical syndromes: fast breathing, retractions, wheezingfast breathing, retractions, wheezing

Predominantly < 2 years of age Predominantly < 2 years of age (2 – 6 months)(2 – 6 months)

Difficult to differentiate with pneumoniaDifficult to differentiate with pneumonia

BronchiolitisBronchiolitis

EtiologyEtiologyPredominantly RSV (Respiratory Syncytial Predominantly RSV (Respiratory Syncytial Virus), adenovirus etc.Virus), adenovirus etc.DiagnosisDiagnosis

Etiological diagnosisEtiological diagnosis Microbiologic examination Microbiologic examination

Clinical diagnosisClinical diagnosis Signs and symptomsSigns and symptoms AgeAge Resource of infectionResource of infection

BronchiolitisBronchiolitis

Clinical ManifestationsClinical Manifestationscough, cold, fever,fast breathing, retraction, cough, cold, fever,fast breathing, retraction, wheezing, irritable, vomitus, poor intakewheezing, irritable, vomitus, poor intake

Physical Examinations Physical Examinations tachypnea, tachycardia, retraction, tachypnea, tachycardia, retraction, expiration >, wheezing, fever,pharyngitis, expiration >, wheezing, fever,pharyngitis, conjunctivitis, otitis media.conjunctivitis, otitis media.

BronchiolitisBronchiolitis

Radiologic examinationRadiologic examinationdiffuse hyperinflationdiffuse hyperinflation flat diaphragm, flat diaphragm, subcostal >subcostal > retrosternal space >retrosternal space >

peribronchial infiltratesperibronchial infiltrates

pleural effusion (rare)pleural effusion (rare)

BronchiolitisBronchiolitis

ManagementManagement SupportiveSupportive Severe disease Severe disease

hospitalizationhospitalization

intra venous fluid dripintra venous fluid drip

oxygenoxygen

(antibiotics)(antibiotics) Bronchodilator: controversialBronchodilator: controversial Corticosteroid: controversialCorticosteroid: controversial

BronchiolitisBronchiolitis

Natural history & complicationsNatural history & complications Improved clinical findings : in 3-4 daysImproved clinical findings : in 3-4 days Improved radiological features: in 9 daysImproved radiological features: in 9 days

Persistent respiratory obstruction : 20%Persistent respiratory obstruction : 20%

Respiratory failure : 25 %Respiratory failure : 25 %

Lung collaps (rare)Lung collaps (rare)

BronchiolitisBronchiolitis

Correlation with AsthmaCorrelation with Asthma 30 % - 50 % becomes asthmatic patients30 % - 50 % becomes asthmatic patients Similarity in : Similarity in : - pathogenic - pathogenic

mechanismsmechanisms

- - pathologic disorderspathologic disorders