CASE MANAGEMENT OF ARI AT

PHC LEVEL
Definition:
ARI is an acute infection of less than 30 days
duration of any part of the respiratory tract and
related structures (from nose to alveoli). For middle
ear infection - duration of acute infection is taken as 14
days or less
 Classification Of ARI

Acute upper respiratory tract infection (AURI)

include the common cold, pharyngitis and otitis
media.

Acute lower respiratory tract infection (ALRI)

include epiglottitis, laryngitis, bronchitis,
bronchiolitis and pneumonia.
Respiratory system
 PROBLEM STATEMENT
ARI is responsible for about 30 - 50% of visit to
health facility and for about 20 - 40% of hospital
admission
On an average children below 5 yr of age suffer
about 5 episodes of ARI per year
ARI is one of the major cause of death in under five
children
- 13% of inpatient death in Paediatric ward
- 90% of ARI death are due to Pneumonia
Burden of disease in terms of Daly's lost - is 25.5
million in which 24.8 million is due to ALRI, 2.74
lakh - AURI, 4.75 lakh - Otitis media
 CLINICAL ASSESSMENT
History:
How old is the child?
Is the child coughing ? for how long?
Is the child eating/drinking well since the onset of
present illness?
Is the child excessively drowsy or difficult to wake?
Did the child have convulsion?
Did the mother notice irregular breathing?
Any antecedent illness such as measles?
Any other complaints?
 PHYSICAL EXAMINATION

Count the breath in one minute

# Child must be calm
# Expose the chest and abdomen
# Count RR for 1 full minute
# Repeat counting if RR is high or when in doubt
# Fast breathing is present when the RR is :
60 0r more in a child < 2 months
50 or more in a child 2 - 12 months
40 or more in a child 12 months - 5 yrs
 CHEST INDRAWING

Definite inward motion of lower chest wall while

breathing in
Child should be observed lying flat in the bed or
mother’s lap
Intercostals and supraclavicular retraction in
which only soft tissue goes in is not chest in
drawing
Child under 2 yrs may have mild chest in drawing
Because of soft chest wall
Look and listen for stridor:
Harsh noise when breathing in (due to
narrowing of larynx, trachea, or epiglottis)

Look for wheeze:

A child with wheeze makes soft whistling
noise or shows signs that breathing out is difficult.

See if the child is abnormally sleepy or difficult to

wake
Feel for fever or hypothermia
Check for severe malnutrition
Cyanosis
CLASSIFICATION OF ILLNESS

A: child aged 2 months up to 5 years

1. Very severe disease
2. Severe pneumonia
3. Pneumonia
4. No pneumonia
 VERE SEVERE DISEASE
Signs: not able to drink
Convulsion
Abnormally sleepy
Stridor in calm child
Severe malnutrition

Treatment: refer urgently to hospital

Give first dose of antibiotics
Treat fever / wheezing if present
If cerebral malaria is possible, give an anti -
malarial.
 SEVERE PNEUMONIA

Signs: Chest indrawing

Fast breathing + /-
Nasal flaring
Grunting
Cyanosis

Treatment : Refer urgently to hospital

Give first dose of antibiotic
Treat fever / wheeze if (+)
 PNEUMONIA
Signs : fast breathing and no chest in drawing

Treatment :
Advice mother to give home care
Give an antibiotic
Treat fever / wheeze if (+)
Advice mother to review in 2 days or earlier if the
child worsens
During review :
Worse - refer to hospital
Same - change antibiotic or refer
Improving - finish 5 days of antibiotic
 NO PNEUMONIA

No chest in drawing & no fast breathing

Treatment :
- If coughing > 30 days refer for assessment

- Assess & treat ear problem or sore throat if (+)

- Advice mother to give home care

- Treat fever / wheezing (+)

 B.CLASSIFYING THE ILLNESS OF
INFANT
VERY SEVERE DISEASE
- Stopped feeding well
- Convulsions
- Abnormally sleepy
- Stridor, wheeze
- Fever / hypothermia
TREATMENT:
- Refer urgently to hospital
- Keep infant warm
- Give 1ST Dose of antibiotic
2. SEVERE PNEUMONIA
- Severe chest in drawing or fast breathing
TREATMENT:
- Refer urgently to hospital
- Keep infant warm
- Give 1st dose of antibiotic

3. NO PNEUMONIA
- No chest in drawing or fast breathing
TREATMENT :
- Advice mother to give home care
 MEDICAL TREATMENT
Treatment for children (2 months- 5 yrs) pneumonia

Age / weight Paediatric tablet: Syrup (5ml)

Sulphamethoxazole Sulphamethoxazole
100 mg & 200mg &
Trimethoprim Trimethoprim 40mg
20mg
< 2months 1 tab bd ½ Spoon bd
2 - 12 months 2 tab bd 1 spoon bd
1- 5 yrs 3 tab bd 1 ½ spoon bd
 SEVERE PNEUMONIA
A. First 48hrs
- Benzyl penicillin 50,000iu/kg/dose 6 hourly IM
- Or Ampicillin 50mg/kg/dose or Chloramphenicol
25mg /kg/dose 6 hourly IM

B. If condition improves, then for next 3 days

- Give procaine penicillin 50,000 iu/kg OD IM
- Or Ampicillin 50mg/kg/dose or Chloramphenicol
25mg/kg/dose orally 6 hourly

If no improvement then for next 48hrs

- Change antibiotic
Cont.

C. Provide symptomatic treatment for fever &

wheezing if required
D. Monitor fluid & food intake
E. Advice mother on home management on discharge
 VERY SEVERE DISEASE

- Should be treated in health facility with provision

for Oxygen
O therapy & intensive monitoring
- Chloramphenicol IM is the drug of choice.
Treat for 48hrs
- If condition improves start orally.
- If worsens switch to Cloxacillin & Gentamycin.
 PNEUMONIA IN YOUNG INFANTS
ANTIBIOTIC DOSE FREQUENCY
AGE
< 7 Days 7 days -
2
Months
Inj. Benzyl 50,000 IU/KG 12 Hrly 6 Hrly
Penicillin or
Inj. Ampicillin & 50 mg / kg / 12 Hrly 8 Hrly

Inj.Gentamycin 2.5 mg / kg 12 Hrly 8 Hrly

 HOME CARE
Advice mother
- Feed the child during illness
- Increase feeding after illness
- Clear the nose if it interferes with feeding
- Increase the fluid intake of the child
- Advice to continue breast feeding
- Soothe the throat and relieve the cough
with safe remedy
- Watch for signs of pneumonia
 TREATMENT OF FEVER
If fever is high > 39 c
- Give paracetamol 6 hourly till temp drops < 39 c

If fever is low
- Advice mother to give more fluids
- Keep the child lightly clothed

In areas with falciparum Malaria

- Start anti-malarials
 TREATMENT OF WHEEZING
1st episode
- Look for signs of respiratory distress

If present If Not present

Give rapidly acting Give oral
bronchodilators bronchodilators

Recurrent episode
- Give rapidly acting bronchodilator
 EAR PROBLEM
Signs Tender Pus from ear Pus from
swelling < 2wk ear > 2wk
behind the Ear pain
ear Red ear
drum
Classify as Mastoiditis Acute Chronic
infection infection

Treatment Referal Antibiotic Dry the ear

Antibiotic Dry the ear
treat fever & by wicking
pain
Measures To Reduce Complication Of ARI
- Improve the nutrition of the child
- Reduction of air pollution
- Immunisation
- Early diagnosis & treatment
- Teaching the mother about the signs of pneumonia
- Promote breast feeding
- Training of health workers to identify the signs of
pneumonia
- Referral at the appropriate time
 ARI CONTROL PROGRAMME
- Was taken up as a pilot project in the country in
the yr 1990
- Since 1992-1993 it is implemented as a part of
CSSM programme
Aim of the programme
- Improving treatment practices in hospitals&
health centres to reduce mortality rates due to
pneumonia
- To reduce the unnecessary use of antibiotics
 REFERENCE

National CSSM programme-integrated clinical

skills course for physicians
The management of ARI in children - practical
guidelines for outpatient care
Park’s textbook of preventive and social medicine
THANK YOU