acute respiratory diseases in the tropics: diagnosis and treatment protocols for resource poor areas...

Acute Respiratory Diseases in the Tropics: diagnosis and treatment protocols for

resource poor areas of sub-Saharan Africa

Taste of Tropical MedicineBill Stauffer

University of Minnesota

Departments of Medicine and Pediatrics,

Infectious Diseases

Introduction

Acute respiratory illness is the leading cause of mortality of children worldwide.

Resources will vary, these protocols will be most useful in resource limited settings and must be adapted to each new clinical setting depending on: Disease epidemiology (i.e. malaria endemic) Diagnostics available Medications available

Unwell child or infant older than 2

months

Exclude malaria

Take a full history and perform an examination using unwell child and infant history and examination form

What is the child’s main complaint/symptom?

Diarrhoea

Gastroenteritis Treatment Protocol

Fever(not malaria)

Septic Child Protocol

Difficulty in breathing and

cough

Acute Respiratory DistressProtocol

Irritability, neck stiffness or bulging

fontanelle

Meningitis Treatment Protocol

Acute Respiratory

Distress Protocol

Count respiratory rate over 1 minute>50 breaths and child 2 – 11 months

>40 breaths and child 1-5 yearsGo to septic child protocol

No

Yes

Take oxygen saturationsIf < 90% start oxygen

Does the child have any of the following?

Gallop rhythmHeart murmurEnlarged palpable liver

Possible Cardiac Failure frequently

aneamic Consider

furosemide 1mg/kgBlood transfusion if tachycardia and hgb

less then 5**Call the doctor

Sudden onset of symptoms

Consider Foreign Body

Aspiration(inspiratory/

expiratory chest x-ray, in babies left

and right lateral x-rays)

Barking coughStridor

Hoarse voice

Upper Airway ObstructionGo to Stridor

Treatment Protocol

On auscultation of the chest

the predominant

feature is wheeze?

Child > 2- 3 years previous wheeze or diagnosis of asthma: follow Acute Asthma

Protocol

If no to all of the above move to the Pneumonia Protocol

If the child is less than 2 years and has wet sounding crepitations on auscultation and no increase in RR consider Bronchioloitis as a diagnosis

Bronchiolitis Protocol*

*if severe, may attempt 5ml 1:1000 adrenaline (epinephrine) nebulized.**discuss with physician if signs of heart failure but aneamia with a Hgb. more than 5.

Does the infant have indrawing of the chest wall?

Does the infant have any of the following?Central cyanosis off oxygenSevere respiratory distressInability to drink

PneumoniaSevere PneumoniaVery Severe Pneumonia

No

NoYes

Yes

Pneumonia Protocol: Infants and Children > 2 months

Amoxicillin orAmpicillin

Ampicillin plusChloramphenicol

Ceftriaxone

Worsens or fails to respond in 48-72 hours

Very Severe Pneumonia PneumoniaSevere Pneumonia

Ceftriaxone (50-100 mg/kg IV divided Bid (may give IM if no IV access)

Monitor and ensure oxygen saturations >90%

Give paracetamol (15mg/kg as needed up to 4 times a day) for fever

Ensure that the child is receiving adequate fluidEncourage breastfeeding and oral fluidsIf child cannot drink:For Severe Pneumonia: pass a nasogastric tube and give maintenance fluid in one hourly amounts, or,For Very Severe Pneumonia give IV flush* if dehydrated and start on D5NS maintenance, the doctor and all medics on duty must be aware of this child, especially overnight

Weight Fluid ml/hour

2kg 8

4kg 16

6kg 25

8kg 33

10kg 42

12kg 46

14kg 50

16kg 54

18kg 58

20kg 63

22kg 65

24kg 67

26kg 69

The child MUST be discussed with

a doctor and reviewed as soon

as possible

Obtain a chest x-ray

Give ampicillin (100 mg/kg IV/IM every 6

hours) and chloramphenical (50

mg/kg every 8 hours) for at least 48 hours

Child should be checked by a nurse every 6 hours and by a doctor or medic every day

Give oral amoxicillin (or IV ampicillin)Give the first dose in the clinic

**Maintenance fluid (D5NS)


*IV flush10-20 mls/kg of NS

Improvement after 48 hours?

Consider cloxacillin

(50mg/kg IV QID)

After 5 days if the child has responded well

change to oral amoxicillin and oral chloramphenical

for a further 5 days

If the child improves on cloxacillin continue cloxacillin orally 4 times a day for a total course of 3 weeks

Very Severe Pneumonia Severe Pneumonia

Look for complications

Improvement after 48 hours?

Change to ceftriaxone 50-100mg/kg BID for 10

days

YesNoNoYes

Oral amoxicillin for 5 days

Look for complications likeEffusion/empysema

Antibiotic treatment can be changed by a doctor when blood culture results are available

Treat complications if found

Complications include:

Empyaema*

Pleural effusion*

Lung abscess*

*May need surgical intervention


Asthma Treatment Protocol

Assess Severity

Mild / ModerateNo respiratory distressRR normalNo / minimal chest indrawingPeak flow >70% predictedSaturations >92% in air

SevereUnable to talk in sentencesFast respiratory rateChest indrawingNasal flaringPeak flow 33-50% predictedSaturations <92% in air

Life ThreateningPale or cyanosisPoor respiratory effortExhaustedConfusionSilent chestPeak flow <33%

5-10 puffs salbutamol via spacer (infants with facemask)

DischargeAsk to return if becomes

worseEnsure good inhaler

technique and adequate drug supply

Nebulized salbutamol 5mg every 20 minutes for 1 hourPrednisolone 1mg/kg (max 40mg)Oxygen to keep O2 Saturations >92%

Reassess after one hour

Improvement

Yes

No

Improvement

Admit1 hourly observations until improvement maintainedSalbutamol nebulizer every 2-4 hoursPrednisolone for 3 days

Start IV aminophylline 5mg/kg (max 500mg) over 1 hour every 6 hoursSTOP if the child starts to vomit, PR> 180, develops a headache or has a convulsionChest X-ray (rule out pneumothorax)

Close observationSalbutamol nebulizer every hourPrednisolone for 3 days

Call the Doctor

Consider Antibiotics (as per ARI protocol) only if the child

has a fever

NoYes

Nebulized salbutamol 5mg every 20 minutes for 1 hourPrednisolone 1mg/kg (max 40mg) or IV hydrocortisone (see emergency drug chart for dose)Oxygen to keep O2 Saturations >92%

Peak flow if child older than 7 years

Bronchiolitis Treatment Protocol

Common coldRunny nose

Blocked noseWet sounding

coughBilateral

crepitationsWheeze

MildInfant feeding wellNo signs of respiratory distress

ModerateFeeding for shorter timeMild chest indrawingNo cyanosisRR not increased

SevereNot feeding wellRR increasedSigns of respiratory distress

Treat using the Pneumonia

Protocol

Feeding compromised < 3 monthsBorn prematureOther medical conditionsMother not coping

Admit for observation of feeding (child might need NGT fluids)

and respiratory rate

If wheeze is present give 5 puffs of salbutamol via a spacer, if

there is an improvement in the child’s condition give 5 puffs via

a spacer QID

Discharge homeSymptomatic

treatmentAsk the mother to return if the baby develops respiratory distress or cannot feed

Yes

No

Nebulized salbutamol 5mg every 20 minutes for 1 hour, ifImprovement every 1 hour prn. IfNo improvement can d/c.

if severe, may attempt 5ml 1:1000 adrenaline (epinephrine) nebulized.

Stridor Treatment Protocol

Definition: harsh breathing noise (DURING INSPIRATION) produced by obstruction to breathing in the larynx or trachea.It is one of the common features of upper airway obstruction with hoarseness and barking cough

Leave the child in a comfortable positionDO NOT distress the child

Stridor

Croup Epiglottitis Foreign body inhalation Anaphylaxis

SymptomsCoryzal onsetNo droolingBarking coughAble to drinkHarsh stridorHoarse voice

SymptomsRapid onsetToxic appearanceDroolingTemp >38.5°c

SymptomsSkin rash (urticaria)ItchingOedema

SymptomsChokingSudden onset

TreatmentModerate respiratory distress – prednisolone 2mg/kg (max 40mg)Severe respiratory distress – Prednisolone and 5ml 1:1000 adrenaline (epinephrine) nebulized

TreatmentContact Surgery

Prednisolone 2mg/kg (max 40mg)5ml 1:1000 adrenaline nebulizedCeftriaxone 50mg/kg IM

TreatmentChoking Child Protocol

TreatmentIM adrenaline/epinephrine:0.05ml <6months0.012ml 6 mths – 5 years0.25ml 6 years – 11 years0.5ml 12 years+Hydrocortisone25mg TID <1year50mg TID 1yr – 5 years100mg TID 6 years – 11 years250mg TID 12 years+If wheeze 5mg nebulized salbutamolChlorpheniramine2.5mg QID <1year5mg QID 1yr – 5 years10mg QID 6 years – 11 years20mg QID 12 years+

Case 1

4 year old with cc of cough, shortness of breath two days

No fevers Examination

RR 72, O2 sats 88%, chest in-drawing Bilateral wheezes throughout Able to talk only in 1 and 2 word sentences

What do you want to do?


months

Exclude malaria



Diarrhoea


Fever(not malaria)



cough



fontanelle


Acute Respiratory

Distress Protocol



No

Yes





aneamic Consider

furosemide 1mg/kgBlood transfusion if tachycardia and hgb








Hoarse voice


Treatment Protocol


the predominant

feature is wheeze?


Protocol






Assess Severity





Improvement



has a fever

Yes


Case 2

22 month old, health, sudden onset of cough 10 days ago, fever 5 days ago, on antibiotics for 4 days, still fever.Temp 38.8C, RR 72, O2 sats 91%General: tachypnic, mild chest in-drawingResp: reduced air entry on L hemithorax,

no other abnormalities


months

Exclude malaria



Diarrhoea


Fever(not malaria)



cough



fontanelle


Acute Respiratory

Distress Protocol



No

Yes





aneamic Consider

furosemide 1mg/kgBlood transfusion if tachycardic and hgb








Hoarse voice


Treatment Protocol


the predominant

feature is wheeze?


Protocol





Case 3

13 month old with cough, runny nose, wet cough for 2 days. Not eating or drinking well.

Examination T 38.1 C, RR 87, O2 sats 83%, weight 12 Kg. General: lethargic HEENT: coryza Resp: nasal flaring, super-clavicular and chest in-

drawing, abdominal breathing, bilateral wheeze/rhonchi throughout with some scattered crepitations.


months

Exclude malaria



Diarrhoea


Fever(not malaria)



cough



fontanelle


Acute Respiratory

Distress Protocol



No

Yes





aneamic Consider









Hoarse voice


Treatment Protocol


the predominant

feature is wheeze?


Protocol








coughBilateral

crepitationsWheeze





Protocol


if severe, may attempt 5ml 1:1000 adrenaline (epinephrine) nebulized.

Does the infant have indrawing of the chest wall?

Does the infant have any of the following?Central cyanosis off oxygenSevere respiratory distressInability to drink

PneumoniaSevere PneumoniaVery Severe Pneumonia

No

NoYes

Yes


Amoxicillin orAmpicillin

Ampicillin plusChloramphenicol

Ceftriaxone

Worsens or fails to respond in 48-72 hours







2kg 8

4kg 16

6kg 25

8kg 33

10kg 42

12kg 46

14kg 50

16kg 54

18kg 58

20kg 63

22kg 65

24kg 67

26kg 69



as possible










Case 3

You give three salbutamol nebs over one hour, no improvement.

Started on oxygen and Ceftriaxone.

Chest x-ray pending

You need to give fluids, what are you going to give?







2kg 8

4kg 16

6kg 25

8kg 33

10kg 42

12kg 46

14kg 50

16kg 54

18kg 58

20kg 63

22kg 65

24kg 67

26kg 69



as possible











2kg 8

4kg 16

6kg 25

8kg 33

10kg 42

12kg 46

14kg 50

16kg 54

18kg 58

20kg 63

22kg 65

24kg 67

26kg 69


*IV flush10-20 mls/kg of NSWeight was 12 Kilograms:

Flush: 12 X 20 ml/kg = 240 mls. NS

Maintenance:

12 Kg. = 46 D5NS

Case 3

Respiratory rate increases to 90 over the next 12 hours despite previous therapy. Oxygen sats, originally over 92% on oxygen now 78%. Child has increased nasal flaring, chest in-drawing, and poor capillary refill.

What do you want to do?




coughBilateral

crepitationsWheeze





Protocol


if severe, may attempt 5ml1:1000 adrenaline (epinephrine) nebulized.

Case 4

4 y.o. with cc of fever and cough for two daysWorse at night

ExaminationT 39 C, rr 25, o2 sats 95%General: Barky coughResp: CTA B except upper airways sounds.


months

Exclude malaria--POSITIVE



Diarrhoea


Fever(not malaria)



cough



fontanelle


Acute Respiratory

Distress Protocol



No

Yes





aneamic Consider









Hoarse voice


Treatment Protocol


the predominant

feature is wheeze?


Protocol








Stridor



SymptomsRapid onsetToxic appearanceDroolingTemp >38.5°c

SymptomsSkin rash (urticaria)ItchingOedema

SymptomsChokingSudden onset


TreatmentContact Surgery

Prednisolone 2mg/kg (max 40mg)5ml 1:1000 adrenaline nebulizedCeftriaxone 50mg/kg IM

TreatmentChoking Child Protocol

TreatmentIM adrenaline/epinephrine:0.05ml <6months0.012ml 6 mths – 5 years0.25ml 6 years – 11 years0.5ml 12 years+Hydrocortisone25mg TID <1year50mg TID 1yr – 5 years100mg TID 6 years – 11 years250mg TID 12 years+If wheeze 5mg nebulized salbutamolChlorpheniramine2.5mg QID <1year5mg QID 1yr – 5 years10mg QID 6 years – 11 years20mg QID 12 years+




Stridor




Case 5

8 year old with known asthma, with cough for 3 days now acutely short of breath. Examination

T 38 C, rr 48, 02 sats 91% Gen: tachypnic, unable to speak in full sentences Skin: crepitations in neck and supra-clavicular Resp: Bilateral wheezes throughout


months

Exclude malaria



Diarrhoea


Fever(not malaria)



cough



fontanelle


Acute Respiratory

Distress Protocol



No

Yes





aneamic Consider









Hoarse voice


Treatment Protocol


the predominant

feature is wheeze?


Protocol






Assess Severity





Improvement



has a fever

Yes


Case 5

No improvement with therapy, now what?

Case 6

3 year old with cough for three days, drooling. No other symptoms.

Examination:T 37.8 C, rr 21, O2 sats 98%General NADRespiratory: CTA B

...with a vision for the children of the world: that every one of them - without exception - lives a full and healthy life, with rights secured and protected, freed from poverty, violence and discrimination --UNICEF State of the World’s Children, 2000

acute respiratory diseases in the tropics: diagnosis and treatment protocols for resource poor areas...

Documents

overnightthe child

oral fluidsif child

treatment protocols

acute respiratory diseases

infant history

chest wall

iv accessmonitor

iv flush