Lower Respiratory Infections

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These conditions include Pneumonia and Bronchitis.

Pneumonia

This is an inflammation of the lungs usually caused by Streptococcus pneumoniae, Mycoplasma pneumoniae and Staphylococcus aureus Haemophilus Influenzae type B and atypical organisms such as Jiroveci pneumonia.

Clinical features These are usually of sudden onset.

Symptoms

  • Fever
  • Dry or productive cough
  • Chest pain
  • Chills
  • Breathlessness
  • Children may be unable to drink or breastfeed

Signs

  • Bronchial breathing
  • Drowsiness
  • Increased respiration rate
  • Cyanosis may be present
  • Flaring of nostrils
  • Chest indrawing
  • Increased pulse rate
  • Crepitations
  • Breath sounds may be reduced
  • Sputum may be "rusty".

Complications

  • Septicaemia
  • Lung abscess
  • Emphysema
  • Heart failure
  • Meningitis

Diagnosis
This is based on clinical findings but may be supported by radiological examinations which show lobar and bronchial pneumonia.

Treatment
Some patients will need admission particularly if there is cyanosis or complications.

  • Benzylpenicillin 1-2MU intravenously 6 hourly for 5 days adults, children 25,000-50,000 units/kg intravenously/intramuscularly in 4 divided doses for 7 days (as soon as the symptoms and respiratory rates are controlled change to oral medication i.e. Amoxycillin 250mg for adults and 125 mg/5ml in children) or
  • Ceftriaxone 1g - 2g daily adults, children 20 50mg/kg daily intravenously/intramuscularly for 7 days. if allergic to penicillin or
  • Erythromycin 500mg adults, orally 6 hourly for 7 days, children 20-30mg/kg in 4 divided doses for 7 days
  • Oxygen is indicated if respiratory distress or cyanosis is present

Non-opiate analgesics; Paracetamol 500mg - 1g orally 3 - 4 times daily adults, children 10-20mg/kg orally 3 - 4 times daily.
Refer early to a specialist if the patient is not rapidly improving with antibiotic treatment.

Pneumonia in Children

If a child has a cough or difficulty in breathing, then he/ she may have a respiratory tract infection.

Clinical features
May include:

  • Fast breathing
  • Chest in drawing
  • Stridor in a calm child
  • Wheezing

It is important to count the respiratory rate of the child.

If the child is: Fast breathing is:
2 months up to 12 months 50 breaths per minute or more
12 months up to 5 years 40 breaths per minute or more

Classification

  • No pneumonia cough or cold: a child is classified as having no pneumonia cough or cold if there are no signs of pneumonia
  • Pneumonia: a child is classified as having pneumonia if there is fast breathing accompanying wheeze or cough Severe pneumonia: a child is classified as having severe pneumonia if there is chest in-drawing or stridor in a calm child.

Treatment
No pneumonia cough or cold:

  • If coughing for more than 21 days, refer for assessment,
  • If wheezing give oral Salbutamol
  • Follow up in 5 days if not improving.

 

PNEUMONIA
Give an Appropriate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION OR VERY SEVERE DISEASE:
AMOXYCILLIN
Give three times daily for 5 days Amoxicillin

ERYTHROMYCIN
Give four times daily for 5 days 2nd-LINE ANTIBIOTIC - Erythromycin
AGE or WEIGHT TABLET SYRUP AGE or WEIGHT TABLET SYRUP
250 mg 125 mg per 5 ml 250 mg 250 mg 125/5 ml
2 months up to 12 months (4-<10 kg) ½ 5ml 2 months up to 4 months 4-<6kg) ¼ 2.5 ml
12 months up to 5 years (10-19kg) 1 10ml 4 months up to 12 months (6-<6kg) ½ 5 ml
      12 months up to 5 years (10-19kg) 1 10 ml

 

GIVE THESE TREATMENTS IN CLINIC ONLY
• Explain to the caretaker why the drug is given
• Determine the dose appropriate for the child’s weight (or age)
• Use a sterile needle and syringe. Measure the dose accurately
Give an Intramuscular Antibiotic
• For severe pneumonia or severe disease or very severe febrile illness
FOR CHILDREN REFERRED URGENTLY WHO CANNOT TAKE AN • Give first dose intra-muscular Chloramphenicol and refer child urgently to hospital
• If chloramphenicol is not available, give the first dose of Benzylpenicillin IM and refer urgently
IF REFERRAL IS NOT POSSIBLE • Repeat the Chloramphenicol injection every 12 hours for 5 days
• Then change to an appropriate oral antibiotic to complete 10 days of treatment
• Do not attempt to treat with Benzylpenicillin alone.
AGE or WEIGHT CHLORAMPHENICOL  Dose: 40 mg per kg Add 5.0 ml sterile water to vial containing 1000 mg=5.6 ml at 180 mg/ml BENZYLPENICILLIN To a vial of 600 mg (1,000,000 units):
Add 2.1 ml of sterile water=2.5 ml at 400,000
2 months up to 4 months (4-<6kg) 1.0 ml = 180 mg 0.8 ml
4 months up to 9 months (6-<8kg) 1.5 ml = 270 mg 1.0 ml
9 months up to 12 months (8-<10kg) 2.0 ml = 360 mg 1.2 ml
12 months up to 12 months(10-<14kg) 2.5 ml = 450 mg 1.5 ml
3 years up to 5 years (14-19kg) 3.5 ml = 630 mg 2.0 ml

 

Aspiration Pneumonia

More common in new-born babies especially in premature, respiratory distress, chronically ill, chronic aspirators, post vascular operations

Treatment• Gentamycin, 5mg/kg twice a day or I.M 10 mg once daily
• Ciprofloxacin, 10mg/Kg body weight 3 times daily, the benefit must outweigh the risk but may be used for 5 to 17-year-olds.

Atypical Pneumonia

Signs and symptoms of pneumonia plus extra-pulmonary signs such as arthritis, splenomegaly caused by Mycoplasma, Chlamydia, PCP.

Treatment

  • Erythromycin 500mg orally QID for 14 days for Chlamydia
  • Co-trimoxazole 960mg every 12 hours for 21 days in combination with a steroid i.e. Prednisolone for PCP starting with 40mg per day and reducing by 5mg every 3 days for adults
  • For children above 4 weeks to adults 120mg/Kg body weight in 2 to 4 divided doses for 21 days

Obstructive Airway Disease

Obstructive Airway Disease can be upper or lower.

Upper airway obstruction

The condition is caused by a viral infection or inhaled foreign body. The main symptom is stridor.
When it is caused by viral infection the condition is called Croup. Croup is fairly common and is frightening to parents. Usually, admission is advisable. If the infection has caused epiglottitis, the obstruction may be so severe as to necessitate tracheal incubation and antibiotics may be required.

Treatment

  • Chloramphenicol 50 - 100mg/kg intravenously in 4 divided doses daily for 5 days
  • Humidified oxygen (30 - 40% concentration)
  • Dexamethasone 0.3mg/kg intramuscularly stat, Repeat after 6 hours
  • Naso-tracheal intubation or tracheostomy if an obstruction is severe

Stridor due to Diphtheria In stridor due to diphtheria, an examination of the throat will reveal a white membrane. Diphtheria infection is uncommon nowadays.

Treatment
• Benzyl Penicillin IM/IV 25,000 - 50,000 units/kg intravenously in 4 divided doses for 5 days

Prevention
• Diphtheria can be effectively prevented by active immunisation in childhood

Stridor due to an inhaled foreign body is usually preceded by sudden chock whilst eating a meal or playing with small objects.

Treatment
• Remove foreign body

Stridor due to inhaled Paraffin

Symptoms

  • Smell of paraffin
  • Cyanosis
  • High respiratory rate
  • Tachycardia
  • Tachypnoea

Treatment
DO NOT INDUCE VOMITING!

  • Give milk
  • Hydrate
  • Give Oxygen
  • Antibiotic prophylaxis with Amoxycillin 125mg/5ml taken 3 times a day.

Advice to patients

  • Do not put paraffin in soft drink containers
  • Clearly label paraffin containers