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TOPIC 1.
INTRODUCTION
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CONTENTS
Introduction
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CLASSIFICATION
ANATOMICALLY :
(ARNOLD,1996)
INDONESIAN :
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AURI (IRA-A) :
COMMON COLD (RHINITIS, RHINOPHARYNGITIS)
PHARYNGITIS - TONSILOPHARYNGITIS
RHINO-SINUSITIS
OTITIS MEDIA
ALRI (IRA-B) :
EPIGLOTITIS
LARYNGO-TRACHEOBRONCHITIS
BRONCHITIS
BRONCHIOLITIS
PNEUMONIA
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MORBIDITY
50% OF ALL ILLNESS DISEASE IN CHILDREN
UNDER 5 YEARS; 30% IN CHILDREN 5 -12 YEARS
MOST INFECTIONS ARE LIMITED TO UR TRACT, ABOUT
5% LR TRACT
EPISODE IN URBAN 5-8, RURAL 3-5/YEAR
PNEUMONIA IN DEVELOPING COUNTRY IS MORE THAN
IN DEVELOPED COUNTRY
IN INDONESIA
MORBIDITY
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ETIOLOGY
AURI : >> VIRUS ( 90%)
COMMON VIRUSES
AURI (IRA -A) : Rhinovirus, Corona virus,
Adenovirus, Entero virus
ALRI (IRA -B) : RSV, Para influenza 1,2,3;
Corona virus,
Adeno virus, Enterovirus
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Common cold
COMMON COLD
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...COMMON COLD
...COMMON COLD
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...COMMON COLD
Rhinoviruses
30-50
Coronaviruses
10-15
Influenza viruses
5-15
Parainfluenza viruses
Adenoviruses
<5
Enteroviruses
<5
Metapneumovirus
Unknown
Unknown
20-30
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...COMMON COLD
...COMMON COLD
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Recruitment of PMNs to
nasal epithelium (IL-8)
Pappas DE, Hendley JO. Epidemiology, clinical manifestations, and pathogenesis of rhinovirus infections.
Up to date. Last updated February 2008
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...COMMON COLD
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...COMMON COLD
TREATMENT
Supportive therapy is the only recommended
treatment
Antihistamines, decongestants, antitussives, and
expectorants, singly and in combinations, are all
marketed for symptomatic relief in children.
few clinical trials of these products in infants
and children and none that demonstrate benefit
for treatment of the symptoms
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...COMMON COLD
Symptomatic therapy
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...COMMON COLD
Antipyretics
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...COMMON COLD
Saline irrigation
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...COMMON COLD
Antihistamines
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...COMMON COLD
Antitussives
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14
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...COMMON COLD
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...COMMON COLD
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Decongestants
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...COMMON COLD
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...COMMON COLD
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...COMMON COLDv
Zinc
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...COMMON COLD
Other treatments
Echinacea
Vitamin C
Honey
Antibiotics
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...COMMON COLD
Antibiotic therapy
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...COMMON COLD
PREVENTION
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Laryngotracheobronchitis
DEFINITION
Primarily pediatric viral respiratory tract illness
that affect larynx, trachea, and bronchi
Characteristic : hoarseness, a seal-like barking
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EPIDEMIOLOGY
Accounting for approximately 15% of clinic and emergency
department visits for pediatric respiratory tract infections
ETIOLOGY
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PATHOPHYSIOLOGY
Start at nasopharynx and spread to the epitel
of trachea and larynx
Diffuse inflamation, redness, and oedema of
trachea wall irritate the mobility of vocal
cords and subglottis
areahoarsenessturbulence air
flowstridorretractionhypoxia and
hypercapnerespiratory failure
CLASSIFICATION
1. Viral croup: prodromal symptoms respiratory
tract infection, obstruction (3-5 days)
laryngotracheobronchitis
2. Spasmodic croup: atopic factor, without
prodromal symptoms, suddenly occur
obstruction especially at night for a
moment back to normal
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CLASSIFICATION
Based on the level of emergency:
1. Mild: sometimes barking cough, no stridor, mild
retraction
2. Moderate: often barking cough, stridor, mild
retraction, no respiratory distress
3. Severe: often barking cough, inspiratory stridor
when take a rest, sometimes expiratory stridor,
retraction, respiratory distress
4. Threatening life respiratory failure: cough, stridor,
decrease of conciousness, letragy
CLASSIFICATION
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CLINICAL MANIFESTATION
Nonspecific respiratory symptoms rhinorrhea, sore
throat, and cough
Fever is generally low grade (38-39C) but can exceed
40C
Within 1-2 days, the characteristic signs of hoarseness,
barking cough, and inspiratory stridor develop, often
suddenly, along with a variable degree of respiratory
distress
Symptoms worsening at night, with most ED visits
occurring between 10 pm and 4 am resolve within 3-7
days but can last as long as 2 weeks
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DIAGNOSIS
Diagnostic clues based on presenting history
and physical examination findings
Laboratory test results confirming this
diagnosis complete blood cell (CBC) count is
usually nonspecific, although the white blood
cell (WBC) count and differential may suggest
a viral cause with lymphocytosis
PROCEDURES
Direct laryngoscopy if the child in not in acute
distress
Fiberoptic laryngoscopy
Bronchoscopy (for cases of recurrent croup to
rule out airway disorders)
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RADIOGRAPHY
Steeple or pencil sign
of the proximal
trachea (50%)
THERAPY
To overcome the obstruction or respiratory
tract
Most of croup didnt need to be hospitazed
1. Inhalation therapynebulized epinephrin
a. Racemic epinephrin
b. L-epinephrin 1:1000 5 ml
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THERAPY
2. Corticosteroid to reduce oedema mucosa of
the larynx
a. Dexamethason 0,6mg/kgbw/x
b. Budesonid nebulized 2-4mg (2ml)
3. Endotracheal intubationsevere croup
4. Antibioticno need to be used except
laryngotracheobronchitis,
laryngotracheopneumonitis
PROGNOSIS
Excellent, and recovery is usually complete
self limited disease
Hospitalization rates vary widely among
communities, ranging from 1.5-30% and
typically averaging 2-5%
< 2% of hospitalized children require
intubation
10-year study found a mortality rate of less
than 0.5% in intubated patients
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COMPLICATIONS
A secondary bacterial infection may result in
pneumonia or bacterial tracheitis
Pulmonary edema
Pneumothorax
Lymphadenitis
Otitis media
Dehydration
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EPIDEMIOLOGY
85% children have acute otitis media 1 x in 1st year
of life
50% children have acute otitis media > 2 x
1st year of life having acute otitis media increase
the risk of having chronic or recurrent otitis media
The incidence decrease at age 6 years
United State all children experience otitis media
at age 2 years and 3 episodes or more of acute otitis
media
Peak incidence 3-18 months
PATHOPHYSIOLOGY
Intrinsic mechanical obstruction caused by
infection and allergy
Extrinsic obstruction caused by adenoid and
nasopharynx cancer
Functional obstruction caused by the amount
and stiffness of cartilage of the tube, most
common in children
Eustachian tube obstruction pressure of
middle ear negative if still persist, middle ear
transudat effusion
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ETIOLOGY
Viral Pathogen : Respiratory Synctitial Virus
Bacterial Pathogen :
1. Streptococcus pneumoniae (50%)
2. Haemophillus influenzae (20%)
3. Moraxella catarrhalis (10%)
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RISK FACTORS
Prematurity and low birth
weight
Young age
Early onset
Family history
Race - Native American, Inuit,
Australian aborigine
Altered immunity
Craniofacial abnormalities
Neuromuscular disease
Allergy
Day care
Crowded living conditions
Low socioeconomic status
Tobacco and pollutant
exposure
Use of pacifier
Prone sleeping position
Fall or winter season
Absence of breastfeeding,
prolonged bottle use
CLINICAL MANIFESTATION
Preceeding by upper respiratory tract infection
with fever, otalgia and hearing impairment
Baby : irritability, diarrhea, poor feeding, often
cry
Children : pain and uncomfortable in the ear
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PHYSICAL EXAMINATION
Pneumatic otoscopy: the tympanic
membrane signs of inflammation :
reddening of the mucosa
progressing to the formation of
purulent middle ear effusion
poor tympanic mobility
The tympanic membrane may bulge
in the posterior quadrants
the superficial epithelial layer may
exhibit a scalded appearance
PHYSICAL EXAMINATION
Perforation of the tympanic membrane is not unusual in
posterior or inferior quadrants. Before or instead of a single
perforation, an opaque serumlike exudate is sometimes seen
oozing through the entire tympanic membrane.
The discharge initially is purulent, though it may be thin and
watery or bloody; pulsation of the otorrhea is common.
Otorrhea from acute perforation normally lasts 1-2 days
before spontaneous healing occurs.
The bullae or blebs may contain serous or hemorrhagic fluid
CT scan or MRI if there is complication
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DIFFERENTIAL DIAGNOSIS
External otitis
Dental pain
Temporomandibular joint pain
Acute viral pharyngitis
Trauma to the ear
TREATMENT
Depend on culture and sensitivity of the
specimen
1st line : Amoxycillin 40 mg/kgBW/24hours,
3x/day,10 days
2nd line : Erytromicin 50mg/kgBW/24hours with
sulfonamid (100mg/kgBW/24hours trisulfa or
150mg/kgBW/24hours sulfisoksazol) 4x/day,
sefaclor 40mg/kgBW/24hours 3xday, amoxycillinclavulanat 40mgkgBW/24hours 3x/day, cefixim
8mg/kgBW/24hours 1-2x/day
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TREATMENT
Acute otitis media without complication
antibiotic in 5 days
Supportive theray: analgesic, antipyretic,
decongestant
TYMPANOCENTESIS
Neonates who are younger than 6 weeks (and
therefore are more likely to have an unusual or
more invasive pathogen)
Patients who are immunosuppressed or
immunocompromised
Patients in whom adequate antimicrobial
treatment has failed and who continue to show
signs of local or systemic sepsis
Patients who have a complication that requires a
culture for adequate therapy
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PROGNOSIS
Death rare
Chilren with < 3 episodes of acute otitis media
single course of antibiotic
Middle ear effusion and conductive hearing
loss persist well beyond the duration of the
therapy : 70% effusion after 14 days, 50% at 1
month, 20% after 2 months, 10% after 3
months
THANK
YOU...
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