Lesson 12: Acute Respiratory Disease

=INTRODUCTION =

As you may recall in the last unit on Diarrhoea, we said that many acute infections in a child may present with diarrhoea. Some of these infections are otitis media, pharyngitis and pneumonia, which are some of the acute respiratory infections (ARI). In Kenya, acute respiratory infections are among the top three leading causes of childhood morbidity and mortality. This is why our government has put strong emphasis on the control of ARI, particularly pneumonia. In this unit you will learn the current standard case management of ARI as established by the Division of Child Health.

As you know, ARI lays a heavy burden on our outpatient clinics. It constitutes up to 40% of all the daily Outpatient Department (OPD) attendances especially for children under 5 years of age. Most children, especially those under 5 years of age, have about four to six episodes of acute respiratory infection each year.

12.1: WHAT ARE ACUTE RESPIRATORY INFECTIONS?
 Acute respiratory infections are infections of the respiratory tract that last less than 30 days, except acute ear infection that lasts less than 14 days. ARI include infections in any part of the respiratory tract such as:


 * Nose
 * Ear
 * Throat (Pharynx)
 * Voice box (Larynx)
 * Wind pipe (trachea)
 * Air passage (bronchi or bronchioles)
 * Lungs

This unit will not describe the diseases of the ear and throat because they will be discussed in Unit 13

12.2 CLASSIFICATION OF ACUTE RESPIRATORY INFECTIONS
The classification of ARIs can be done in several ways. A common method, which you are likely familiar with, is ARI by site of infection (Fig. 12.1). This method of classification distinguishes upper and lower acute respiratory tract infections.


 * 1) The Acute Upper Respiratory Tract Infection (AURI) which include:
 * 2) *Cold
 * 3) *Otitis media
 * 4) *Pharyngitis
 * 5) The Acute Lower Respiratory Infections (ALRI) which include:
 * 6) *Epiglottis
 * 7) *Laryngitis
 * 8) *Laryngotracheitis
 * 9) *Bronchitis
 * 10) *Bronchiolitis
 * 11) *Pneumonia

Currently the classification of ARIs is done using the Integrated Management of Childhood Illness approach. This approach classifys ARI on the basis of severity. One is expected to look for the presence or absence of fast breathing and low chest indrawing in order to determine the severity and category of an ARI in a child who presents with cough or difficult breathing. This approach helps you to separate children with serious illness (severe pneumonia or severe disease and pneumonia) from those with mild self-limiting conditions (no pneumonia: cough and cold). It also helps you to determine the proper treatment and the place of treatment as we shall learn later in this unit.



Figure 12.1: Diagram of the the respiratory tract

What are the Common ARIs in Kenya?

In Kenya, the most common Acute Respiratory Infections are:
 * Cough and cold
 * Pneumonia
 * Sore throat and Ear infections.

As mentioned earlier, sore throat and ear infections will be discussed in Unit 13 on common ENT conditions.

Before you read on do the following activity. It should take you 3 minutes to complete.

Confirm your answer as you read the following discussion.

It is very important that you are able to recognize pneumonia since it is one of the top 5 causes of death among children in Kenya.

Pneumonia is an infection of the lungs which involves not only the bronchi but also the alveoli. When a child develops pneumonia the lungs become stiff and they cannot absorb enough oxygen. One of the body's natural responses to stiff lungs and hypoxia (a condition in which too little oxygen reaches the organs of the body) is fast breathing. When pneumonia becomes more severe, the lungs become even stiffer and chest indrawing may develop. Fast breathing is a sign of pneumonia. Chest indrawing is a sign of severe pneumonia. Failure to identify pneumonia in a young child may lead to death or serious complications.

What are The Causes of Respiratory Tract Infections?

Both bacteria and viruses cause respiratory tract infections. However, bacteria are responsible for a lot of the pneumonia infections seen in developing countries. The most common bacteria are Streptococcus pneumoniae and Haemophilus influenzae. These enter the body through the respiratory tract. When a patient or a carrier of these bacteria talks, coughs, laughs, sneezes, or cries, he/she discharges infectious droplets of fluid into the air. When a healthy person breathes in air contaminated by the infectious droplets, he/she may develop an acute respiratory infection.

A child is more likely to get an ARI if he/she is:


 * Malnourished or poorly breastfed.
 * Vitamin A deficient.
 * Not fully immunized.
 * Living in overcrowded or poorly ventilated homes.
 * Young in age and low birth weight.
 * Exposed to air pollution such as tobacco smoke and environmental air pollution.

12.3 SIGNS AND SYMPTOMS OF ACUTE RESPIRATORY INFECTION
Before you read on do the following activity. It should take you 5 minutes to complete.

I hope your list contained the following signs and symptoms of acute respiratory infections:


 * Cough
 * Difficulty in breathing
 * Sore throat
 * Chest-indrawing
 * Running nose
 * Ear problems
 * Wheezing
 * Stridor
 * Fever
 * Fast breathing

In addition to any of the above signs or symptoms, the general danger signs may also be there. The process of finding out the presenting symptoms and signs is called assessment. The assessment starts with identification of the general danger signs in every sick child. The identification of the general danger signs is done before the assessment of the main presenting symptoms.

Identifying The General Danger Signs

What is a general danger sign?

A general danger sign is any problem or condition in a sick child that has immediate life threatening consequences. The danger signs include the following:


 * The child is not able to drink or breastfeed.
 * The child vomits everything.
 * The child is having convulsions.
 * The child is lethargic or unconscious.

To check for general danger signs, ask and look for the following:

1)	ASK: Is the child able to drink or breastfeed? A child has the sign "not able to drink or breastfeed" if the child is too weak to drink or is not able to suck or swallow when offered a drink or breastmilk.

When you ask the mother whether the child is able to drink, make sure that she understands the question. If the mother says that the child is not able to drink or breastfeed, ask her to describe what happens when she offers the child something to drink. For example, is the child able to take fluid into his mouth and swallow it?

If you are not sure about the mother's answer, ask her to offer the child a drink of clean water or breastmilk. Look to see if the child is swallowing the water or breastmilk. A child who is breastfed may have difficulty in sucking when his nose is blocked. If the child's nose is blocked, clear it. If the child can breastfeed after his nose is cleared, the child does NOT have the danger sign, "not able to drink or breastfeed".

2)	ASK: Does the child vomit everything? A child who is not able to hold anything down at all has the sign "vomits everything". What goes down comes back up. A child who vomits everything will not be able to hold down food, fluids or oral drugs. A child who vomits several times but can hold down some fluids does not have the “vomiting everything” general danger sign.

When you ask the question, use words the mother understands. Give her time to answer. If the mother is not sure that the child is vomiting everything, help her to make her answer clear. For example, ask the mother how often the child vomits. Also, ask if the child vomits each time after swallowing food or fluids. If you are not sure of the mother's answers, ask her to offer the child a drink. See if the child vomits.

3)	ASK: Has the child had convulsions? During a convulsion, the child's arms and legs stiffen because the muscles are contracting. The child may lose consciousness or be unable to respond to spoken directions.

4)	LOOK: To see if the child is abnormally sleepy or unconscious: An abnormally sleepy child is not awake and alert when he should be. The child is drowsy and does not show interest in what is happening around him. Often, the abnormally sleepy child does not look at his  mother or watch your face when you talk. The child may stare blankly and appear not to notice what is going on around him. An unconscious child cannot be awakened. The child does not respond to touch, shaking, mother’s voice, clapping of hands or pain caused by rubbing the sternal region with the knuckles. Ask the mother whether the child is abnormally sleepy or whether she is unable to wake the child. The presence of any one general danger sign shows that a child has a serious problem and needs urgent attention. For example, a child who vomits everything could die very quickly from dehydration and electrolyte imbalances and cannot retain oral medication. If a child has any one of the above general danger signs, complete the rest of the assessment and any pre-referral treatment immediately so that referral to a hospital is not delayed.

Assessing a Child With Cough or Difficult Breathing.

Children with a cough or difficulty in breathing may have pneumonia and need careful assessment. You should assess such a child by:


 * 1) asking the mother several questions;
 * 2) looking at the child’s breathing
 * 3) listening to the child’s breathing.

1)	ASK: 	How old is the child? Does the child have cough or difficult breathing? For how long has the child had a cough or difficult breathing?

2) LOOK, LISTEN: (When the child is calm):


 * Count the breaths in one minute to determine whether there is fast breathing
 * Look for chest indrawing
 * Look and listen for stridor in a calm child
 * Look and listen for wheezing

If the child is sleeping and has a cough or difficult breathing, count the number of breaths first before you try to wake the child.

A child who has had a cough or difficulty breathing for more than 30 days has a chronic cough. This may be a sign of tuberculosis, asthma, whooping cough or another problem.

3)	LOOK for fast breathing:

You must count the breaths the child takes in one minute to decide whether the child has fast breathing. The child must be quiet and calm when you look and listen to his breathing. If the child is frightened, crying or angry, you will not be able to obtain an accurate count of the child's breaths.

You should always remember to tell the mother that you are going to count her child's breathing so that she can keep her child calm. If the child is sleeping do not wake the child.

To count the number of breaths in one minute:


 * 1) Use a watch with a second hand or a digital watch (if you do not have a watch, use the wall clock in the clinic, if available). Alternatively, you could ask another health worker to watch the second hand and tell you when 60 seconds have passed. Look at the child's chest and count the number of breaths. If you cannot find another health worker to help you, put the watch where you can see the second hand. Glance at the second hand as 'you count the breaths the child takes in one minute.
 * 2) Look for breathing movements anywhere on the child's chest or abdomen. Usually you can see breathing movements even on a child who is dressed. If you cannot see this easily, ask the mother to lift the child's shirt. If the child starts to cry, ask the mother to calm the child before you start counting.

If you are not sure about the number of breaths you counted (for example if the child was actively moving and it was difficult to watch the chest, or if the child was upset or crying), repeat the count.

As children get older, their breathing rate slows down. Table 12.1 below shows the number of breaths per minute for children whose age ranges from less than 2 months up to five years.

Table 12.1: Number of breaths per minute

Note that a child whose age is 12 months is not included in the second category of age 2 months up to 12 months. A 12 month-old child should be considered in the next group, that is, age 12 month up to 5 years. The same applies to the age group 12 months to 5 years of age. Children who are five years of age should not be considered here.

EVERY time you count 60 breaths per minute or more. This is important because the breathing rate of a young infant is erratic. The young infant will occasionally stop breathing for a few seconds, followed by a period of very rapid breathing. Therefore:


 * If you count less than 60 breaths per minute, the young infant does not have fast breathing.
 * If you count rate 60 breaths or more, wait and repeat again.
 * If the second count is also 60 or more breaths per minute, the young infant has fast breathing.
 * If the second count is less than 60 breaths per minute, the young infant does not have fast breathing.

4)	LOOK for chest indrawing: You should look for chest indrawing when the child BREATHES IN. If a child has chest indrawing, the lower chest wall (ribs included) goes in when the child breathes IN. Chest indrawing occurs when the effort that the child needs to BREATHE IN is much greater than normal.

How Can You Differentiate Between Normal Breathing And Chest Indrawing? Table 12.2 describes the difference between normal breathing and chest indrawing. Also see Fig. 12.2, which shows a picture of a child with chest indrawing and another without. Be especially careful when looking for chest indrawing in young infants. Mild chest indrawing is normal in young infants because their chest wall is soft. However, severe chest indrawing (very deep and easy to see) is a sign of severe pneumonia.

You should only diagnose chest indrawing when it is clearly visible and present all the time. If you only see chest indrawing when the child is crying or feeding, the child does not have chest indrawing.

Table 12.2: Difference between normal breathing and chest indrawing



Figure 12.2: Child with chest indrawing and child without chest indrawing

5) LOOK AND LISTEN for Stridor

A stridor is a harsh sound which a child makes when breathing IN. A stridor is produced when there is narrowing of the larynx or trachea. The narrowing is caused by the swelling of the larynx, trachea or epiglottis (croup). The narrowing interferes with air entry into the lungs. The swelling can be life threatening when it blocks the airway. A child who has stridor when calm has a dangerous condition.

6) LOOK AND LISTEN for wheezing.

A child with wheezing makes a soft musical noise or shows a sign that indicates breathing OUT is difficult. Look when the child is breathing OUT and then listen for the wheeze by putting your ear near the child's mouth. Make sure that you are as close to the mouth as possible, as the noise may be difficult to hear.

A child with wheezing makes a soft musical noise or shows a sign that indicates breathing OUT is difficult. Look when the child is breathing OUT and then listen for the wheezing noise by putting your ear near the child’s mouth. Make sure that you are as close to the mouth as possible as the noise may be difficult to hear.

A narrowing of the air passages in the lungs causes wheezing. Usually when we think of asthma, we think of wheezing. But there are several other conditions besides asthma that can cause wheezing in children.

In children, parasitic disease, bronchitis and inhaled foreign bodies are all possible causes of wheezing. In infants, bronchiolitis is a common cause of wheezing. If the child is wheezing, ask the caretaker if her child has had a previous episode of wheezing within the last year. A child is said to have a "recurrent wheeze" if he/she has had more than one episode of wheezing in a 12-month period.

12.4: CLASSIFYING AND MANAGING A CHILD WITH ARI
For easy management, children are divided into three broad age groups:


 * Less than 2 months (young infant)
 * 2 months to 12 months and
 * 12 months to 5 years.

We shall start by discussing how to classify and manage children that falls within 2 months to 5 years and then discuss how to classify infants below 2 months of age.

There are three possible classifications of a child with cough or difficult breathing. They are:


 * Severe pneumonia or very severe disease
 * Pneumonia
 * No pneumonia: cough or cold

According to IMCI guidelines, if a child has a cough or difficult breathing with the following signs, then you should classify as shown in Table 12.3.

Table 12.3: Classification of Child with a Cough or Difficulty Breathing

Take note that pneumonia is the main disease to look for. This is because pneumonia is a killer disease, especially if it is not detected early.

Now, look at the following case studies so that you can learn how to classify children with cough or difficult breathing.

Did you refer to the classification table? Now compare your answer with mine.

Answer to Case Study 1: To classify Charles' cough or difficult breathing, you should use table 12.3. You start at the top of the signs column. You read down the column of the signs and decide whether the child has a sign or not. Since Charles does not have a general danger sign, such as chest indrawing or a stridor when he is calm, he does not have severe pneumonia or very severe disease. But since Charles has fast breathing, he is classified as having PNEUMONIA.

Next, look at the following Case Study 2 and then answer the following activity.

I hope you are getting better at classifying children with ARI. Now read the last case study and do the activity that follows.

Did you remember to use the classification table? Now compare your answer with the one given:

Classifying a Young Infant with Cough or Difficult Breathing

You have now learned how to check for general dangers signs, how to look for chest indrawing and fast breathing and how to look and listen for stridor and wheezing in children aged 2 months to 5 years. You also know how to classify children aged 2 months to 5 years when brought to your health facility with cough or difficult breathing. Now you will learn how to classify a young infant up to 2 months of age when brought for cough or difficult breathing.

Young infants have special characteristics that must be considered when classifying their illness:


 * They become sick and die very quickly from serious bacterial infections;
 * They are much less likely to cough with pneumonia and so cough is not a required sign for detecting cases of pneumonia;
 * They often have only non-specific signs such as poor feeding, fever, or low body temperature, abdominal distension and erratic breathing;
 * Mild chest indrawing is normal in young infants because their chest wall is soft. Therefore, the young infant must have severe chest indrawing for one to notice;
 * In young infants, signs of pneumonia may not be distinguishable from the signs of septicaemia or meningitis and these infections can co-exist.

As you can see in Table 12.4 there are only two classifications for the young infant. Identifying danger signs in a young infant is very important. Remember that a young infant who is classified as having severe pneumonia or very severe disease needs URGENT referral to a hospital. Table 12.4: Classifying a young infant with cough or difficult breathing.

Now go through the following case studies so that you can improve your ability to classify infants below 2 years of age.

I hope your classification tallies with mine.

Next let us look at yet another case study and then do the following activity.

12.5: MANAGEMENT AND TREATMENT OF ARIs
We shall now discuss the treatment that you should identify and give for each classification. Study the tables below which are adapted from the Kenya Ministry of Health IMCI guidelines.

Table 12.5: Treatment of ARI in Children Age 2 months to 5 years Table 12.6: Treatment of ARI in Young Infants <2 months

Now look at the tables on the following pages for the drugs we have discussed and doses you should give.


 * Antibiotics should not be used for coughs and colds.
 * Give first dose of antibiotic in clinic (help the mother give it to the child).
 * Instruct the mother on how to give the antibiotic for five days at home.
 * Instruct her to bring the child for review after 2 days or earlier if the child gets worse

Table 12.7: Treatment Instructions for Children with Pneumonia. Source: Kenya MOH IMCI Guidelines FIRST-LINE ANTIBIOTIC:      COTRIMOXAZOLE: SECOND-LINE ANTIBIOTIC: AMOXYCILLIN:


 * PROPHYLAXIS FOR SYMPTOMATIC HIV POSITIVE (+ve) OR HIV EXPOSED CHILD:COTRIMOXAZOLE:



Treatment of the Young Infant with Pneumonia:

Table 12.8: Treatment for a young infant with pneumonia
 * Explain to the Mother why the drug is being given.
 * Determine the dose appropriate for the infant’s weight (or age)
 * Use a sterile needle and sterile syringe to accurately measure the dose. Do not mix benzyl penicillin with Gentamicin.
 * Give the drug as intramuscular injection
 * If the infant cannot be referred, follow instructions provided in the section If Referral is not Possible in the table below.
 * Give First Dose of Intramuscular Antibiotics


 * Give first dose of both benzyl penicillin and gentamycin intramuscular



Referral is the best option for a young infant classified with VERY SEVERE DISEASE. If referral is not possible, give benzyl penicillin and gentamycin for at least 5 days then change to an appropriate oral antibiotic to complete 10 days. Give benzyl penicillin every 6 hours plus gentamycin once daily

12.6: TREATMENT OF FEVER
You will recall in Unit 3, we said that fever is a common presenting complaint in children. This is even more so among children suffering from acute respiratory infections. The methods of treating fever in a child aged 2 months to 5 years depend on whether the fever is high or low.


 * If fever is high (axillary temperature 38.50C), lower the fever by giving the child paracetamol. Tell the mother to give the child paracetamol every six hours in the appropriate dosage for a period of 24 hours;
 * If fever is lower than 38.50C, advise the mother to give more fluids. Paracetamol is not needed;
 * Tell the mother to keep the child with any fever higher than 37.5o C lightly clothed. She should not over-wrap the child or overdress him. It is uncomfortable and may make the fever worse;
 * Children age 2 months up to 5 years should NOT be given antibiotics if they have fever alone. However, fever is a danger sign in young infants, so you should give a young infant with fever a first dose of antibiotic and refer to hospital. You should NOT give paracetamol for fever to this child.

To classify the fever and treat it appropriately, it is necessary to take the child’s temperature. So the first thing you should do is to determine whether the temperature indicates a high fever, a fever that is not high, or a low body temperature. This is indicated by the following temperatures:


 * 38.5 C or more means a HIGH FEVER
 * 37.5 C to 38.5 C means FEVER NOT HIGH
 * 36 C means LOW BODY TEMPERATURE

The following table will guide you how to treat fever.

Table 12.9: Treating a fever

12.7 TREATMENT OF WHEEZING
The following Tables summarizes the treatment of wheezing and dosage of salbutamol.

'''Table 12.10: Treatment of Wheezing. Source: Kenya MOH IMCI Guidelines'''







Dosage of Oral Salbutamol and Rapid Acting Brochondilator

Well, I hope you now well understand and are able to assess, classify and treat common ARIs using the IMCI approach. Next we shall discuss the diagnosis and management of other ARIs that are common in our health facilities, such as tonsillitis, pharyngitis, laryngitis and

12.8. Management of Other ARIs
There are a number of other ARIs which are important and common in our health facilities. These are:
 * Acute and chronic tonsillitis;
 * Acute laryngo-tracheo-bronchitis;
 * Acute Spasmodic Laryngitis;
 * Acute Bronchitis;
 * Acute bronchiolitis.

We shall look at each in turn and discuss its causes, signs and symptoms and treatment.

ACUTE TONSILLITIS

What is Acute Tonsilitis?

Acute tonsillitis is inflammation of the tonsils, which are small glands located at the back of our throat. Acute tonsillitis usually lasts 3 to 4 days, but may last up to 14 days.

Cause and Epidemiology

The causes of acute tonsillitis include:


 * Viruses: measles, Epstein-Barr virus, rhinoviruses, parainfluenza virus, influenza virus, respiratory syncytial virus, adenovirus, coxsackie virus, echo virus, herpes simplex and rhinovirus.


 * Bacteria: Group A beta haemolytic streptococcus, group C beta haemolytic streptococcus, Group G beta haemolytic streptococcus, Arcanobacterium haemolyticum, Corynebacterium diphtheriae, Francissella tularensis, mycoplasma pneumoniae, and Neisseria gonorrhoeae. Group A beta haemolytic streptococcus is the most common cause of bacterial infection.


 * Fungi: Candida albicans is common in immunosuppressed children. Most cases of tonsillitis are caused by viruses.

Bacterial tonsillitis and bacterial pharyngitis are rare in children before 2-3 years of age. The peak of bacterial tonsillitis and pharyngitis occurs between 5 and 15 years of age. The streptococci are spread from a carrier or sick person to the other by inhalation of infectious droplets or are transmitted by food, milk and water. Overcrowding in homes, schools and other institutions facilitates the acquisition of streptococci. That is why you find that there is a high incidence of bacterial tonsillitis and pharyngitis once a child starts schooling.

Outside the newborn period, oral candidiasis and pharyngeal candidiasis mainly occur in immunosuppressed children or in children who have been given antibiotics for a long time.

All the causative organisms are spread by inhalation of infected droplets or ingestion of contaminated food, milk or water.

Clinical Manifestations:

Acute tonsillitis presents with the following:


 * fever;
 * malaise;
 * sore throat;
 * refusal to feed;
 * pain during swallowing;
 * enlarged and painful cervical lymph nodes.

The signs of tonsillitis are dry tongue, enlarged red tonsils, tonsillar and pharyngeal yellow exudate (surface coating), red throat, and enlarged and tender cervical lymph nodes (see Figure 12.3). Airway obstruction may cause the child to breath through the mouth.

 Figure 21.1 Tonsilitis and Peritonsillar Abscess

Treatment

Treatment of viral tonsillitis.

There is no specific treatment for viral tonsillitis. A child with viral tonsillitis needs: paracetamol to relieve pain,warm drinks, soft foods, throat lozenges in those old to cooperate do help in relieving the sore throat, plenty of fluids to prevent dehydration.

Treatment of bacterial tonsillitis

In addition to the above treatment for soothing of the throat, a child with Group A beta haemolytic streptococcal tonsillitis is also treated with oral penicillin for 10 days. The dosage of oral penicillin is 250 mg 8 hourly in children and 250-500 mg 8 hourly in adolescents and adults. If the patient is sensitive to penicillin, he or she is given erythromycin, 30 to 50 mg/kg/24 hours divided in three doses for 10 days. Cotrimoxazole is a suitable alternative antibiotic.

Tonsillectomy (surgical removal of the tonsils) is recommended if there are three or more treated episodes of tonsillitis in a year. The child is given

Complications An abscess may form underneath a tonsil. This is called a peritonsillar abscess and  swallowing becomes extremely painful. Other complications include the following


 * Poststreptococcal acute glomerulonephritis;
 * Acute rheumatic fever.

CHRONIC TONSILLITIS

What is Chronic Tonsillitis Chronic tonsillitis is persistent inflammation of the tonsils for more than 3 months. Chronic tonsillitis is often associated with chronic infection of the adenoids, the collection of lymphoid tissue between the back of the nose and the pharynx.

Causes The bacteria which cause chronic tonsillitis include:
 * Streptococci;
 * Haemophilus influenzae;
 * Anaerobic species (Peptostreptococcus, Prevotella, and Fusobacterium).

Clinical Manifestations

Children with chronic tonsillitis present with chronic sore throats, bad mouth smell, and expulsion of foul-tasting and smelly cheese like lumps from the mouth. Chronically inflammed tonsils are large and contain large amounts of debris in the crypts (pits). The cervical lymph nodes are large and tender.

Complications The greatly enlarged tonsils and the adenoids cause upper airway obstruction. The upper airway obstruction manifests with chronic mouth breathing, snoring, and breathing pauses and restlessness during sleep with or without awakening. The child may sleep in unusual positions such as sleeping with the neck extended excessively or sleeping in a prone position with the buttocks up. There may also be excessive sleepiness during the day. If neglected, upper airway obstruction is complicated with heart failure.

Management A child with airway obstruction needs both tonsillectomy and adenoidectomy (surgical removal of adenoids. Therefore, a child with persistent mouth breathing must be referred to an ENT surgeon for further evaluation and treatment.

ACUTE LARYNGO-TRACHEO-BRONCHITIS (LTB)

What is Acute Laryngo-tracheo-bronchitis?

Acute laryngo-tracheo-bronchitis is the inflammation of the larynx, trachea and the bronchi resulting in narrowing of the airways which may easily lead to obstruction.

Causes and epidemiology

The majority of cases of laryngo-tracheo-brochitis are due to viruses ( adenoviruses, measles, parainfluenza, influenza, respiratory syscytial virus). Bacteria may be present as either primary or secondary invaders.

Laryngo-tracheo-bronchitis affects more males than females. Most patients are aged 3 months to 5 years with the peak being during the second year of life. Recurrences are common between 3 and 6 years of age. Thereafter the frequency of laryngo-tracheo-bronchitis decreases with the growth of the airways.

Now compare your answer with the information given in the following discussion.

Clinical Manifestations

Following a simple rhinitis, mild  laryngotracheobronchitis manifests with:
 * Mild to moderate fever with little or no prostration,
 * a hoarse voice;
 * barking cough, and
 * inspiratory stridor.

Severe laryngo-tracheo-bronchitis manifests with:
 * noisy inspiration and expiration (stridor);
 * retraction of intercostal and supraclavicular spaces during inspiration;
 * the child is irritable, restless and fights for air.

The symptoms and signs worsen with agitation or crying at night. The end result of the respiratory distress may be exhaustion. With exhaustion, the stridor may disappear. This is a sign of worsening for it is associated with the manifestations of hypoxia and the child may be almost unconscious.

Exhaustion, hypoxia, bronchopneumonia or septicaemia or a combination of these conditions may cause death. In children with stridor, the examination is limited to the mouth inspection. This is because examining the pharynx and the larynx may precipitate complete obstruction of the airway.

Complications The complications of laryngo-tracheo-bronchitis include heart failure, severe pneumonia, atelectasis, emphysema and hyperpyrexia. The complication of pneumonia occurs because of immunosupression by the measles virus, malnutrition or iron deficiency anaemia.

Differential Diagnosis

The other conditions which may resemble laryngo-tracheo-bronchitis are foreign bodies (aspirated foods, peanut etc), epiglottitis, retropharyngeal abscess, peritonsillar abscess and paratracheal lymph node enlargement.

Treatment

A patient with laryngo-tracheo-bronchitis must be hospitalized immediately.

Treatment of children with mild mild tracheobronchitis. On admission, treatment of children with mild laryngotracheobronchitis involves:
 * Placing the patient in an atmosphere of high humidity and oxygen concentration achieved by nebulization of plain water into an oxygen tent.
 * Giving paracetamol to reduce oxygen consumption;
 * Administration of oral or intramuscular dexamethasone 0.15 mg/kg or nebulized budesonide;
 * Administration of nebulized epinephrine (5ml of 1:1000 epinephrine) every 20 minutes;
 * Giving adequate amounts of fluid, either orally or intravenously in order to minimize the drying of the secretions.

A child with mild laryngo-tracheo-bronchitis may be discharged after 2- 3 hours of observation and treatment provided that they have no stridor at rest, have a normal air entry and have a normal level of consciousness.

Treatment of children with moderate to severe laryngo-tracheo-bronchitis. The treatment of children with moderate to severe laryngo-tracheo-bronchits involves: Giving the above treatment of children with moderate to severe LTB Nasotracheal intubation with continuation of administration of oxygen in high humidity in children with hypoxia, cyanosis, pallor or impaired consciousness on admission or in children with signs of an impeding respiratory failure (a pulse rate greater than 150 beats per minute and rising and a high PC02 ). One must not wait for cyanosis before intubating. Remember that while intubation may be life saving, it requires a skilled paediatric anaesthetist and so it should only be done in hospital.

A child with intubation must be carefully monitored. Crusting may occur at the end of the tube. This crusting may cause obstruction of the breathing.

Extubation is usually possible after a period of 7-14 days. Granulation tissue in the larynx may make extubation difficult and this tissue may have to be surgically removed.

Sedation should be avoided as it may depress the respiration. Also expectorants are not effective while Atropine dries the secretions which are already too dry.

Prognosis. The mortality rate of those requiring intubation is 6-20%.

ACUTE SPASMODIC LARYNGITIS

What is Acute Spasmodic Laryngitis? Acute spasmodic croup is a condition characterized by recurrent laryngeal obstruction.

Cause The causes include
 * Viruses
 * Allegy
 * Psychologic factors
 * Gastrooesophageal reflux (backflow of gastric acid into the oesophagus)
 * Familial predisposition

Clinical features

Following mild to moderate coryza and hoarseness and most frequently in the evening or night time, the child suddenly awakens with barking cough, inspiratory stridor, respiratory distress, anxiety and a frightened look. The child has also slow and laboured breathing, rapid pulse cool and moist skin but has no fever. Excitement worsens the difficulty in breathing. Intermittent episodes of cyanosis are rare. Within several hours, the symptoms disappear leaving only slight hoarseness and cough in the following day. For another night or two similar attacks without respiratory distress may occur.

Treatment Steam inhalation often ends the attack. Any underlying gastrooesophageal reflux should be treated. Use of warm or cool humidification near the child’s bed for the 2-3 days may prevent the return of the attack. Expectorants, bronchodilators and antihistamines are not helpful.

ACUTE BRONCHITIS

What is Acute Bronchitis?

Acute bronchitis is inflammation of the large breathing tubes (airways) called brochi with cough as the predominant clinical feature.

Causes

Bronchitis is caused by
 * Viruses (rhinovirus, respiratory syncytial virus, influenza virus, parainfluenza virus, adenovirus and coxsackie;
 * Bacteria: Bordetella pertussis, Corynebacterium diphtheriae and mycoplasma pneumoniae;
 * Allergy;
 * Air with smoke, dust or irritating vapour.

Acute bronchitis commonly follows an upper respiratory tract infection and is a component of laryngo-tracheo-bronchitis.

Complications

Pneumonia is a common complication of acute bronchitis especially if there are heart or lung problems.

Clinical Features

Bronchitis first presents with non specific upper respiratory tract infection symptoms of running nose, malaise (overall body discomfort and not feeling well), fever, back and muscle pain and sore throat. In 3-4 days, the patient develops cough. In young infants, vomiting or gag may occur after a bout of cough. In older children, there may be chest pain which is worsened by cough. An episode usually takes 7-14 to resolve but the cough may last several weeks.

The signs of brochitis include rhinitis, conjuctivitis, nasopharyngitis, rales and wheezes. A chest x-ray shows normal or increased bronchial markings.

Treatment

There is no specific treatment. Advice the mother to increase the child’s fluid intake and steaming. Frequent changes in position may facilitate postural drainage. Antibiotics may be considered if the cough persists more than 14 days. However, cough suppressants, expectorants and antihistamines should not be given. All these drugs have no beneficial effect.

ACUTE BRONCHIOLITIS

What is Acute Bronchiolitis?

Acute bronchiolitis is inflammation of the bronchioles caused by infection. The bronchioles are partially or completely blocked by the inflammatory changes.

Cause and Epidemiology. Bronchiolitis affects infants and children with a peak incidence in infants 1- 3 months of age. Bronchiolitis is rare after 2 years of age. It affects males more frequently than the females. Bronchiolitis also more frequently affects those infants who are not exclusively breastfed than those who are exclusively breastfed. Brochiolitis is particularly common in conditions of overcrowding.

The majority of bronchiolitis are caused by respiratory syncytial virus, a virus which may also cause rhinitis, laryngitis, bronchitis or pneumonia. Other viruses which may cause bronchiolitis are adenovirus and parainfluenza virus. Other causes of brochiolitis include mycoplasma pneumoniae and inhalation of hot air.

Clinical Manifestations. Following a common cold for 1-2 days, the infant develops difficulty in breathing, rapid shallow breathing and a cough that may resemble that of whooping cough. Vomiting may follow the bouts of cough. There is little or no fever. There may be cyanosis, restlessness, and refusal to feed as the child tries to concentrate on breathing,

The signs of bronchiolitis include:


 * Signs of mild upper respiratory infection;
 * Overinflated (barrel) chest;
 * Shallow rapid breathing;
 * Suprasternal and substernal retractions;
 * Decreased breath sounds;
 * Wheezes and rales;
 * Palpable liver and spleen;
 * Difficulty in palpating the apex beat and in hearing the heart sounds because of emphysema.

White cell count is either normal or shows leukocytosis. The chest x-ray shows generalized emphysema.

Diagnosis

The diagnosis of bronchiolitis is clinical.

Differential Diagnosis.

It is possible to differentiate bronchiolitis from asthma which occasionally occurs in infants. How? If after administering a bronchodilator the child has relief, then the child has asthma. If no relief is attained after administering the bronchodilator, then it is bronchiolitis.

Treatment.

The treatment of a child with bronchiolitis involves:
 * Placing the patient in an atmosphere of high humidity to prevent dehydration and oxygen (40- 60%)
 * Administration of adequate amounts of fluid by nasogastric tube if tolerated or intravenously in order to prevent dehydration.
 * A therapeutic trial of a bronchodilator such as salbutamol by nebulization. e need for nebulization may last longer than the need of oxygen administration.  A gradual shift from nebulization and oxygen to nebulization alone is made.
 * Digoxin is administered if there is heart failure

Complications

The complications of bronchiolitis are bronchopneumonia and bronchiolitis obliterans.

Having looked at the management and treatment of common acute respiratory infections, let us now discuss how to prevent them. You will agree with me that prevention is better than cure!

12.9: PREVENTION OF ARI
Good! I believe your answers included the following preventive measures.

ARIs are serious, but they can sometimes be prevented. The following measures would help to prevent their occurrence:


 * Protecting children from cold and wetness by adjusting their clothing to suite different changes in temperature and weather. During the cold season the children should be dressed warmly.


 * Better housing with less overcrowding. The frequency of respiratory infections is related to the problem of overcrowding;


 * Smoke, from fireplace or cigarettes, is often a serious problem. Parents should ensure that the baby or child is as far from the source of the smoke as possible and smokers should not smoke near a child;


 * Better nutrition especially exclusive breastfeeding in the first 6 months of life will improve a child’s natural resistance to ARIs;


 * Immunization. Advice parents to bring their  children for Immunization against  measles, whooping cough, diphtheria, tuberculosis, hepatitis B and Haemophilus influenzae b. By preventing these diseases it will help a child avoid ARIs.


 * Keeping kerosene bottles out of the reach of children. Advice mothers to ensure that they do not leave kerosene in bottles within reach of toddlers or young children. The fumes can be dangerous;


 * Seeking early and appropriate treatment of ARIs. This  will avert deaths and  prevent infections from becoming chronic or recurrent.



12.10. EFFECTIVE COMMUNICATION IN ARI.
Why is it important?

For the effective management of ARIs, mothers need to follow the instructions carefully and correctly. As a health worker you therefore play a very important role in making sure that the mother understands these instructions and is able to carry them out. You should talk to the mother and teach her effectively, so that she can be able to give the appropriate home care and administer an antibiotic correctly. You therefore need to develop good communication skills. The ability to communicate well with a mother can make the difference between an effective health worker and an ineffective one.

We shall look at some specific communication techniques a case study. These are:


 * giving information, demonstration and practice;
 * asking checking questions;
 * using a home care card;
 * giving support.

The Need for Good Communication

Nura’s one-year-old daughter had a cough. She became concerned and brought the child to the doctor.

Write your answers to the questions below to record your impressions of this case study. Then continue reading.

Let us look at what was going on in Nura’s mind. Actually, it is hard to know what was in her mind. Did she tell the truth to the doctor? If not, why might she have lied? Was she confused? Was she misunderstood? Imagine, for a moment, that you are Nura and listen to her thoughts as she answers several of the doctor’s key questions. Her thoughts are enclosed in italics below.

Now we have a much different picture of what really happened. If we were to follow Nura home, we would find that she tried to give ½ a tablet each morning and evening. The baby struggled, choked and spit it out. She gave no special attention to what the baby ate or drank, assuming she must be less hungry when she is sick. Nura gave up trying to give the tablets after 2 days. The baby was not much better but she did not take the baby back to the health worker because she did not want more tablets.

All this could have been avoided if the health worker had applied the following good communication techniques.

a) Teaching with Information, Examples and Practice

How can you teach a mother effectively? Think about how you learned to write, or to cook, or to swim, or to do any other task. You were probably first given some instructions. Perhaps you then watched someone else do the task. Finally you tried doing it yourself. Therefore, you learnt by these 3 basic ways:

With each of these, you became more actively involved in learning and better able to do the task.
 * by receiving information
 * by seeing demonstration
 * by practising

When you teach mothers or other family members how to give antibiotic to a child at home or how to give home care, you should also give information, a demonstration and a chance for them to practice. The following are examples of ways to do this.

Give Information - Tell the mother how to do it.


 * Give instructions in writing or in pictures so the mother can remember them later.
 * Write down the instructions or draw simple pictures to show the mother how much of antibiotic to give and when to give it. See Figure 12.3.



Figure 12.3 Grinding tablet or opening a capsule Source: Where There Is No Doctor, David Werner, 1977

Show by Example	

Show the mother how to give an antibiotic. For example, demonstrate crushing and mixing an antibiotic tablet with food and then feeding it to the child with a spoon.


 * Show the mother the number of tablets to give each morning and night.


 * Show pictures, such as pictures of suitable foods to feed a child with ARI.


 * Be specific (instead of just giving a general rule). For example, tell the mother to give the child warm fluids to soothe the throat instead of just telling her to give a cough remedy.



Figure 12.4: Mixing tablet

Tell a story, for example, a story of a sick child whose mother stopped giving the antibiotic as soon as the child seemed better and who then became much sicker.

Let the mother Practice

Have the mother do the task herself. For example, have her divide and crush a tablet, mix it with food, and feed it to the child with a spoon.

Have the mother describe what she is going to do at home. This enables her to recalla the steps of the task at hand. For example, ask her to tell you the signs that she will look for at home, in order to tell that the child’s condition is worse and the child should be brought back to the hospital.

If a mother does a task in front of you, you will know what is difficult for her and you can help her learn it better. Also, she is more likely to remember something she has done than something she has just heard about. If a task is impractical to do in front of you, you may ask a mother to describe how she would do it a home. This would give her practice recalling the steps of the task and will give you some assurance that she knows what to do.

Always give supportive feedback on practice. Praise the mother for what she did well, or recalled correctly. Then correct any errors or omissions. Allow more practice if necessary.

When giving information, a demonstration and a chance for practising to family members, always:


 * Use what the parents know and do about treating ART. Remember the community’s ways of treating it. Reinforce or recommend helpful current practices and warn against commonly used harmful practices. For example, you may encourage the custom of giving weak tea with honey for cough and warn against breathing smoke of burned herbs or removing the uvula.


 * Use locally appropriate terms and words that family members will understand. For example, if there is a local word for convulsions, use it instead of “convulsions” when getting history or advising a mother.


 * Be careful not to teach too much at once. Emphasize the messages that are most important for the child’s care at that time. For example, if a mother is continuing to give fluids and food to a child with ARI, you may praise her for that but not review all the details on the home care card about feeding.

Other home care activities include:
 * Feeding the child during the illness;
 * Increasing the feeds after the illness by giving an extra feed per day;
 * Giving more fluids by offering an extra drink;
 * Soothing the throat with and relieving cough with tea with sugar or honey;
 * Returning in 2 days or sooner if the child gets worse.

Ask if there are any questions and try to answer them.

b) Asking Checking Questions

You have learned about teaching mothers by providing information, giving examples, demonstration and a chance to practise. There is a communication technique that you can then use to check whether mothers understand and remember what you have taught them.

The technique is to ask “checking questions”. These are questions intended to find out what a mother has learned, so that you can provide more information, demonstration or practice if necessary.

For example, after you have explained the last rule of home care, you might ask the following “checking question”:

“Tell me the signs that show you that you need to bring your child back to me.”

When you ask a mother checking questions, it is helpful to phrase the questions in such as way that it requires her to say much more than “yes” or “no”. For example, you should avoid questions such as

“Do you understand the signs that show you that you should bring your child back to me?”

The mother may answer “yes” whether she understood or not. She might be reluctant to say she does not remember and possibly seem stupid.

Asking checking questions requires patience. When you ask a mother a question, you must be quiet and give her a chance to think and then answer. If the mother is silent, your impulse may be to answer the question yourself or to quickly ask a different question.

Realize that the mother may know the answer but be slow to respond for several reasons:


 * She may be surprised that your really expect her to answer;
 * She may fear her answer may be wrong;
 * She may hesitate to speak to an authority figure.

So wait for her to answer and give her encouragement.

Sometimes, you may get an incomplete answer to a checking question. Then, you will need to ask more checking questions to find out whether the mother really understands the instructions.

For example: After an explanation of how to care for a child with ARI, you can ask the mother the following checking question:

“What signs will you look out for in order to know that you need to return to the clinic quickly?

The mother may answer, “Strange breathing”.

Since it is not clear that the mother knows exactly what signs to watch for (and since it is so important that she does), you could follow-up with a question like:

“What sort of strange breathing?” and then, ”What other signs will you watch for?”

If the mother answers or says she does not remember, be careful not to make her feel uncomfortable. Teach her again by giving more information, a demonstration and a chance to practise. Then ask a checking question again.

c) Using a Home Care Card

A home care card can be given to each mother to help her remember how to care for a child with ARJ at home. It should have words and pictures that illustrate the main things that mothers should do to care for the child. An example of a home care card is shown in Annex 1. Some home care cards have photographs rather than drawings.

There are many reasons why a home care card can be useful:
 * It will remind you or your staff of the main points to cover when teaching mothers how to care for the child with ART at home;
 * It will remind the mother what to do when she gets home;
 * If you or your staff are in a hurry and mistakenly leave out important messages when talking with the mother, she will still get those messages when she refers to the card at home;
 * Because the mother keeps the card, the next time her child has an ARI, she can refer to the card and remember what to do;
 * The mother will appreciate being given something during her visit;
 * The card can help you teach other health staff the messages to tell mothers

If there are not enough home care cards to give one to each mother, health staff should keep one to show to mothers when talking with them. If there is no home care card, make a poster for the health centre that tells how to care for a child at home.

d) Giving Support

The instructions that you give the mothers may not help the child unless the mothers carry them out correctly. And even though they know how to carry out your instructions correctly, some mothers still may not do so. They may lack the resources (such as time, materials, or money) which are needed to follow your instructions, or they, or other family members, may not want to follow your instructions for some reason.

Giving support to mothers involves:


 * Helping them obtain the resources they need;
 * Convincing them (or helping them to convince other family members) that following your instruction is best for the child;
 * Giving them confidence and encouragement.

To find out if the mother has the necessary resources to follow your instructions, you will need to ask her questions like:


 * Do you have ingredients to make this cough mixture at home?
 * Do you have time to prepare and give the antibiotic as I have shown you twice each day?
 * Is there anyone who can stay with the child when you are working to watch for the danger signs I have just discussed with you?

If the mother lacks the necessary resources, help her figure out how she can obtain them, or suggest a substitute.

If you are referring a child to a hospital, giving support would include explaining the urgency and helping the mother to plan how she will get the child there. Perhaps you can arrange for her to be picked up by hospital transport. Also, you should praise the mother for coming today for treatment and point out how important that was.

When a mother does not want to follow your instructions, it may be for any number of reasons. Before you proceed do the following activity. It should take you less than 5 minutes.

I believe your answers included some of the following reasons:


 * She may feel that some other method would be better. For example, her primary concern may have been to get a drug for her child’s cold. When you do not give a drug, but advise her about home care, she may be disappointed and not believe home care will help.


 * Your suggestions may be demanding. For example, crushing an antibiotic tablet, mixing it with food, and feeding it to a small child can be time-consuming. Giving a child an extra meal each day may also require much effort.


 * Your instructions may seem so complicated that the mother feels she cannot follow them correctly.

When you are talking with the mothers, you must try to prevent or overcome these feelings or beliefs.

There are several ways to do this:


 * Find out about other methods the mother has used or may be using currently, for example, commercial cough and cold remedies or traditional healing methods. Praise her for any actions which are good for the child, such as continuing to feed him and giving him warm drinks to soothe his throat. If any of the treatments are harmful, explain why. Tell her why home care (and antibiotic, if it is needed) is better than hospital admission. Remember not to make the mother feel guilty or incompetent; concentrate on what she has done right or will do right in the future.


 * If the instructions are demanding, acknowledge it. Describe the reasons for and the benefits of following the instructions. Suggest ways in which other family members may be able to help.


 * Build the mother’s confidence while you are teaching her how to care for her child. When she practices a task or answers a question correctly, praise her and tell her you feel sure she can care for her child well at home. This will build her confidence and increase the likelihood that she will remember and repeat the action. Of course, you will need to correct any mistakes, but focus more on the successes.

Once you have discussed with the mother what she will be able to do, you will be confident that she is convinced and finds it worthwhile to do it. Also, once she has thought about and told you herself what she will do, she is more likely to do it. For example, you could ask her,

“What food and drinks do you give to your child at home?”

When she answers, you can confirm that these foods and fluids will be good for her child and discuss how she will persuade her child to eat if he is not hungry. Your interest in her situation will help her to be committed to carrying out the recommendations.

It will be helpful to have in mind some explanations for the important messages that you will teach parents. Following are some ideas that may help you deal with issues that.parents often raise. You may modify these or think of additional explanations.

Table 12.11: Possible Explanations For Common Questions Parents May Ask

=SUMMARY=

You have now come to the end of this unit on Acute Respiratory Infections. In this unit we discussed the most common acute respiratory tract infections in children. These were cough, cold and pneumonia. We also described the clinical signs of acute respiratory tract infections, specific treatment needed in treatment of ARI and how to communicate effectively with a caretaker of the child on how to give the antibiotic and home care.

It is important that you know how to recognize danger signs in a child with ARI and manage them appropriately before you refer the child. I hope you found this unit useful. Take a break and then complete the Tutor Marked Assignment before you go on to the next unit.