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CLOSE THIS BOOKClinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)
Chapter 2 - Respiratory diseases
VIEW THE DOCUMENTStrategy for the control of acute respiratory infections in developing countries
VIEW THE DOCUMENTCommon cold
VIEW THE DOCUMENTPharyngitis and Tonsillitis
VIEW THE DOCUMENTAcute otitis
VIEW THE DOCUMENTChronic otitis
VIEW THE DOCUMENTAcute laryngitis
VIEW THE DOCUMENTSinusitis
VIEW THE DOCUMENTBronchitis
VIEW THE DOCUMENTPneumonia and Bronchopneumonia
VIEW THE DOCUMENTStaphylococcal pneumonia
VIEW THE DOCUMENTBronchiolitis
VIEW THE DOCUMENTAsthma
VIEW THE DOCUMENTTuberculosis

Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.)

Chapter 2 - Respiratory diseases

Strategy for the control of acute respiratory infections in developing countries

In developing countries, lower respiratory tract infections are one of the main causes of mortality in children under 5 years of age. A large proportion of these infections are bacterial. Prompt treatment with an appropriate antibiotic will therefore assist in decreasing child mortality. At the peripheral dispensary 1evel, simple, reliable clinical criteria are needed to allow health workers to decide whether:

- to give antibiotics for moderate cases;

- to refer severe cases to a doctor or hospital.

This chapter is based upon the WHO (38) strategy which aims to define these criteria. This chapter only deals with lower respiratory tract infections.

Management of the child with a cough

Cough is always present in upper or lower respiratory tract infections (rare exceptions). Diagnosis and treatment are based on cough.

WHEN DOES A CHILD WITH A COUGH NEED ANTIBIOTIC TREATMENT?

Most of coughing children do not need antibiotics. But association of cough and some other signs indicates that A.R.I. should be treated with antibiotics.

- Positive criteria
If one or several of those following criteria exist, antibiotic treatment:

· Tachypnea > 50 respirations/minute
· Alar flare (dilatation of the nostrils with each inspiration)
· Chest indrawing (sternal or intercostal recession)
· Cyanosis
· Child unable to drink
· Child malnourished (< 70% weight-for-height or kwashiorkor)
· Post-measles

- Criteria that are not useful at a dispensary level

· Fever (since viral infections also cause fever)
· Yellow sputum (difficult symptom to assess in a young child)
· Chest auscultation (needs a doctor, difficult in tiny children)

WHEN SHOULD A CHILD BE REFERRED TO HOSPITAL?

Although tachypnea is the best predictor of the presence of pneumonia, the severity is best judged by chest indrawing.

- Chest indrawing (sternal or intercostal recession), except if child is less than 1 month of age or child has asthma, as in these two conditions chest indrawing can be present even with mild disease. In these cases, use tachypnea as the main criterion.

- Tachypnea > 60 respirations/minute.

- Cyanosis.

- Child unable to drink.

- Respiratory fatigue or apnoeic periods.

- Clouded consciousness.

- Stridor

- Convulsions

WHICH ANTIBIOTIC SHOULD BE CHOSEN TO TREAT PNEUMONIA IN A CHILD UNDER 5 YEARS OF AGE?

Account should be taken of bacterial activity, effectiveness, ease of availibility (price, supplies...) and side effects.

Dispensary: according to the situation and to availability, the choice should be made from the following four antibiotics:

1. cotrimoxazole per os x 5 days
2. amoxcillin per os x 5 days
3. ampicillin per os x 5 days
4. PPFIM (or procain penicillin)

5. chloramphenicol per os

: 40 mg/kg/d of SMX divided in 2 doses
: 50 mg/kg/d divided in 3 doses
: 100 mg/kg/d divided in 3 doses
: 50,000 to 100,000 IU/kg once daily avoid
in children less than 1 year of age
: 50 to 75 mg/kg/d divided in 3 doses

X 5 days

Choice is determined by the national recommendations of the country.

Hospital: the same antibiotics as above. Two special situations:

- Serious cases, or need for parenteral administration

ampicillin (IM - IV)

: 100 mg/kg/d divided in 3 injections / 24 hours

chloramphenicol(IM - IV)

: 50 to 75 mg/kg/d divided in 3 injections / 24 hours

Treat for 7 days. If possible, switch to oral forms after 72 hours.

- Neonatal pneumonia

ampicillin IV:

100 mg/kg/d divided in 3 injections x 7 days

Depending on gravity, combine this with:

gentamicin IM:

< 10 days: 4 mg/kg/d divided in 2 injections x 7 days


10 days to 1 year: 6 mg/kg/d divided in 2-3 injections x 7 days

Note: in situations where the patient will only be seen once (such as mobile clinics, or with nomads), one can use a slow-release depot preparation, oil chloramphenicol: 100 mg/kg in 1 IM injection, repeated after 48 hours if possible.


Table 2

SUPPORTIVE THERAPY

Oxygen

· Expensive, difficult to procure, questionable effectiveness.
· Reserve for cyanosed asthmatic children or those with RR > 70.
· Administer by intranasal catheter, flow rate 1 litre/min.

Food and fluids

· Imperative to continue breast feeding.
· Encourage oral fluids; use nasogastric tube if necessary.
· Encourage child to eat.

Keep nose clear

· Lavage with syringe and normal saline (Nacl 0.9 % or ringer lactate) in hospital.

· Show mother how to use a clean piece of cloth at home.

Temperature

· Treat any fever above 38°C.
· Treat for malaria in an endemic zone.

Humidify air: If possible: wet sheet across top of cot...

Do not give antitussive medicines: expensive and sometimes dangerous.

MANAGEMENT BY A HEALTH AUXILIARY OF UNDER-FIVES WITH LOWER RESPIRATORY TRACT INFECTIONS

(the health auxiliary should have received at least 6 months training)

When an antibiotic is needed it should be given as early in the illness as possible.

The auxiliary must be able to decide properly when to refer to hospital. (See table B).


Table

Some upper respiratory tract infections require antibiotic treatment:

- Acute laryngitis: because of the severe dyspnea, this condition will be classified as a serious case and will receive antibiotics.

- Tonsillitis et otitis media: cough is often associated for antibiotic indication.

MEASURES FOR PRESENTING LOWER RESPIRATORY TRACT INFECTIONS IN THE UNDERFIVES

- Improve environment (better housing, less crowding).

- Bedding, blankets, clothing.

- Better nutrition.

- Immunization against measles, pertussis and diphtheria: Expanded Program of Immunization (EPI).

Common cold

Viral infection of the nasopharyngeal mucosa which are frequent and seasonal. Person to person transmission is usually airborne.

Clinical features

- Runny nose, often with fever and cough.

- May be the prodrome of influenza or measles.

- Sometimes accompanied by conjunctivitis.

Treatment (dispensary)

- Nasopharyngeal lavage using a syringe filled with normal saline (or clean water with ORSadded, 1 sachet/litre), 4 to 6 times a day.

- Treat fever.

- Treat or take preventive steps against conjunctivitis.

- If allergic component (morning sneezing fits):
promethazine (PO)

Adult: 75 mg/d divided in 3 doses x 3-5 days
Child: 1 mg/kg/d divided in 3 doses x 3-5 days
or
chlorphenamine: 12 mg/d divided in 3 doses x 3-5 days

Follow-up

Risk of secondary infection and acute otitis media in infants. Always check the tympanic membranes of an infant with a cold.

Pharyngitis and Tonsillitis

Infection and inflammation of the pharynx and tonsils accompanied by fever, dysphagia and adenopathy.

Treatment

The two main objectives of therapy are to recognise and treat the tonsillitis of diphtheria and to reduce the complications of streptococcal throat infections (acute rheumatic fever and cardiac lesions).


Table 3

- Always treat the fever and keep well hydrated (dysphagia).

- Patients with infectious mononucleosis will almost always present with an allergy to ampicillin. Stop the treatment.

- Follow-up to exclude acute rheumatic fever (polyarthritis, cardiac signs) and glomerulonephritis (edema, proteinuria, hypertension, hematuria).

- In case of diphteria, procede a survey in the patient neighbourhood. Contacts should be systematically treated with penicillin or erythromycin.

Note

Test the sensitivity to the equine antitoxin (SC 0.1 ml), wait 20 minutes to check an adverse reaction before complete treatment.

Acute otitis

Otitis externa

Infection of extemal auditory meatus (sometimes due to a foreign body).

Clinical features

- Pain, elicited especially by traction upon the pinna.

- Redness of meatus + abscess.

- May be an exudate.

- Drum normal.

Treatment (dispensary)

- Analgesia: acetylsalicylic acid or paracetamol.

- Local: if exudate ravage with normal saline. Apply gentian violet with a cotton bud for 3-5 days.

- If present, remove the foreign body.

Otitis media

Acute infection of the middle ear. Usually bacterial, tracking up from the nasopharynx: streptococcal, pneumococcal, Hemophilus influenzae in children under 5 years.

Clinical features

- Fever, severe pain, crying, agitation, vomiting, diarrhea.

- Ear drum: becomes progressively congested, inflamed, bulging, and finally perforates with release of pus.

Treatment (dispensary)

- Treat for fever and pain.

- If upper respiratory tract infection: nasopharyngeal ravage (ringer lactate).

- Rehydration if necessary.

-Antibiotherapy:

Over 5 years

Adult:

penicillin v(PO): 2 MIU/d divided in 3 doses x 10 days

Child:

penicillin V(PO): 100,000 IU /kg/d divided in 3 doses x 10 days


or


PPF (ou procain penicillin): 100,000 IU/kg/d IM x 3 days, then peni V per


os: same dose divided in 3 doses/day (total treatment: 10 days)

If allergic to penicillin:
erithromicin (PO):

Adult:

1.5-2 g/d divided in 3 doses x 10 days

Child:

50 mg/kg/d divided in 3 doses x 10 days

Under 5 years

ampicillin (PO): 100 mg/kg/d divided in 3 doses x 10 days
or
cotrimoxazole (PO): 60 mg/kg/d SMX divided in 2 doses x 10 days

- Paracentesis: is indicated if the ear drum is bulging but not yet perforated. Should be done in the infero-posterior quadrant.

Aspirate the pus and prescribe an antibiotic as above.

Prognosis

If neglected, acute otitis media may become chronic. There is also a risk of mastoiditis.

Chronic otitis

Chronic infection of the middle ear with perforation of the tympanic membrane.

Clinical features

-Chronic discharge (otorrhea)

-Occasional acute re-infection: fever + pain, usually associated with an obstruction to drainage through the perforated drum with secondary infection by streptococci, pneumococci or gram negative organisms.

Treatment (dispensary)

-Do not prescribe antibiotics.

-Only if acute re-infection occurs give:

ampicllin
or
cotrimaxozole

in the same doses as for acute otitis media.
Lavage with normal saline and aspirate with a syringe.

-Always put a little dry cotton wool or small wick in the ear to absorb the discharge; change 3-4 times/day til dried up.

Prognosis

-Risk of deafness in affected ear.

-Risk of mastoiditis and meningitis during acute re-infections.

Acute laryngitis

Acute infections of the laryngeal mucosa often associated with viral infections (e.g. colds, measles...).

Prognosis

The prognosis is good. However, patients sometimes develop partial respiratory obstruction, and it is important to identify these "high risk' situations and to take the necessary precautions.

ADULT

- Usually associated with a "hoarse" voice and a cold. The etiology is viral. Symptomatic treatment: A A.S. or paracetamol(PO).

- Rarely, epiglottitis from H. influenzae, diphtheria or retropharyngeal abscess. In these cases, use the same methods as for treating children.

- Tuberculous laryngitis.

CHILD

There is a risk of respiratory obstruction.

Signs of distress

Inspiratory stridor, with or without intercostal recession, pallor, with or without cyanosis with cough and "croupy" voice.

There are 2 distinct clinical features.

1. Progressive dyspnea (1 or more days)

In a child < 3 years, if other causes have been eliminated (e.g. diphtheria, retropharyngeal abscess, foreign body), the dyspnea is probably due to mild subglottic obstruction from a viral infection (laryngo-tracheobronchitis).

It is important to watch the child carefully, to keep him calm and to provide humidified air.

Antibiotics are unnecessary except for secondary infections (use PO ampicillin or cotrimoxazole). Steroids are not useful.

If the dyspnea worsens, intubation or tracheostomy may be necessary.

2. Rapid onset dyspnea (several hours)

Carefully examine the patient in a sitting position. Do not lie them down.

-Foreign body: if the dyspnea becomes labored, remove foreign body rapidly, in surgical surroundings.

-Acute epiglottitis from Haemophilus influenzae

· Child of 3 - 8 years: sudden onset dyspnea, high fever, stridor, dysphagia (drools saliva), breathes through mouth, cervical lymphadenopathy.

· Do not lie the patient down and avoid examining the larynx as these actions may precipitate respiratory obstruction.

· Keep the child sitting in a humid atmosphere. Give:
ampicillin (IV): 200 mg/kg/24 hours divided in 3-4 injections, reverting to oral treatment as soon as possible; total duration: 7 days
or
chloramphenicol(IV): 100 mg/kg/d divided in 3-4 injections, reverting to oral treatment as soon as possible; total duration: 7 days

· Severe distress or obstruction: tracheostomy.

-Recurrent laryngitis

· Child of 2-4 years with a cold or measles.
· Nocturnal dyspnea with no fever.
· Place the infant in humidified atmosphere.
· Eventually, give: promethazine(PO): 75 mg/kg/d divided in 3 doses x 5 days
or
chlorphenamine (PO): 12 mg/d divided in 3 doses x 5 days

-Diphtheria: false membrane in the throat

· Unvaccinated children.
· Sometimes the false membrane is extensive an adherent.
· Poor general condition.
· Treatment:

diphtheria antitoxin
penicillin G or PPF IM

· Tracheostomy if necessary.

Sinusitis

Infection of the sinus mucosae with purulent nasal discharge. May originate from:

- the nose: rhinitis, allergic rhinitis, nasal obstruction (e.g. mal-formation, trauma);

- the teeth: caries with arthritis and /or osteitis.

Clinical features

Associated with pain and a purulent nasal discharge.

ADULT

- Pain

· Periorbital: frontal sinusitis.
· Facial: maxillary or ethmoidal sinusitis.

- Purulent unilateral nasal discharge on the affected side with nasal obstruction and a moderate fever.

- Examination:

· Exquisite tenderness can be elicited over these points.
· Rhinoscopy: inflamed mucosa with purulent exudate.

Bacteria responsible are Haemophilus influenzae in persons < 5 years and pneumococcus in older persons.

INFANTS

Acute ethmoiditis: high fever, edema of lower eyelids and the bridge of the nose with purulent rhinorrhea.

Danger of spread to bone or orbit. Treat vigorously.

Bacteria responsible are Haemophilus, pneumococcus and staphylococcus.

Treatment (dispensary)

- Nasopharyngeal lavage with removal of foreign body (if found).

- A.A.S. or paracetamol for fever and pain.

- If dental focus of infection, extract tooth under antibiotic cover.

- Antibiotic:

cotrimoxazole (PO): 60 mg of SMX/kg/d divided in 2 doses x 10 days
or
ampicillin (PO): 100 mg/kg/d divided in 3 doses x 10 days

- Ethmoiditis

ampicillin (IV): 200 mg/kg/d divided in 3 or 4 injections stat until cured. Change to PO as soon as possible.
or
chloramphenico/(IV or IM): 100 mg/kg/d divided in 3 or 4 injections, then change to PO as soon as possible.

Prognosis

Acute sinusitis may become chronic, so always exclude other pathology (e.g. foreign body, allergy, dental caries...).

Bronchitis

Acute bronchitis

Acute infection of the bronchial mucosa

Clinical features

- Often preceded by an upper respiratory tract infection.

- Cough, dry at first, then productive.

- Low grade fever.

- No marked dyspnea.

- Scattered rhonchi.

Treatmert (dispensary)

-In basically healthy patient following rhino-pharyngitis or flu.

· Keep well hydrated, treat fever, humidified air if possible.

· Nasopharyngeal lavage with isotonic solution(normal saline or ringer lactate).

· No antibiotics (mostly viral).

-In patient with poor basic health (malnutrition, measles, rickets, anaemia, chronic bronchitis, cardiac disease, elderly...) or dyspnea > 50 mn or other serious signs.

In these cases, superinfection is probable (haemophilus, gram - bacilli, pneumococcus). Treat with:
cotrimoxazole (PO)

Adult: 1,600 mg/ d of SMX divided in 2 doses x 5-7 days
Child: 60 mg/kg/ d of SMX divided in 2 doses x 5-7 days
or
ampicillin (PO): 100 mg/kg/d divided in 3 doses x 5-7 days
or
chloramphenicol (PO): 50 mg/kg/d divided in 3 doses x 5-7 days

- Where wheezing occurs, treat as asthma.

Chroniques

Chronic inflammation of the bronchial mucosa of irritant (tobacco) or allergic (asthma) origin, progressing towards chronic respiratory failure.

Part of the syndrome of chronic obstructive airways disease (COAD).

Clinical features

- Morning cough, clear sputum, bronchial rales.

- If secondary infection: fever and purulent sputum.

- Always exclude TB: sputum smear for AFB.

Treatment (dispensary)

- Discourage cigarette smoking.

- No antibiotics unless secondary infection. In this case, see acute bronchitis.

Pneumonia and Bronchopneumonia

Infection of pulmonary alveoli and bronchial mucosa.

Cause:

- viral
- bacterial: pneumococcus, Haemophilus influenzae, mycoplasma pneumonia
- parasitic: pneumocystis carinii (AIDS)

Clinical features

- High fever (> 39°), cough, respiratory distress, chest pain and tachypnea (> 50/min).

- Examination: dullness to percussion, diminished vesicular breath sounds, crepitations and sometimes bronchial breath sounds.

Treatment

Depends on age and presence of respiratory distress tachypnea (> 60/mn in infants less than 2 months, > 50/mn from 2 to 12 months, > 40/mn from 1 to 5 years), intercostal recession, alar flare, stridor, cyanosis, respiratory pauses, xyphi-sternal recession.

Other serious extrapulmonary signs can be present.

ABSENCE OF SERIOUS SIGNS

- Classical pneumonia in adults and children < 5 years

Localised crepitation, sometimes bronchial breathing or localised dullness to percussion = pneumococcus. By far the most common germ after 5 years of age.

Treatment (dispensary)

penicillin V(PO):
Adult: 2,4-3,6 MIU/d divided in 3 doses (tab 250 mg = 0.4 M1U: 2-3 tab x 3/d) x 5 days
Child: 50 000 IU/kg/divided in3 doses x 5 days
or
cotrimoxazole (PO):
Adult: 1600 mg of SMX/divided in2 doses x 5 days
Child: 50 mg of SMX/kg/divided in 2 doses x 5 days

- Pneumonia in child of 2 months to 5 years
H. Influenzae common at this age. Therefore, first line of treatment:

cotrimaxazole(PO): 50 mg of SMX/kg/d divided in 2-3 doses x 5 days
or
ampicillin(PO):100 mg/kg/d divided in 3-4 doses x 5 days
or
amoxycillin (PO): 50 mg/kg/d divided in 3 doses x 5 days, depending on availability

- Pneumonia in infant < 2 months

Hospitalize (risk of rapid decompensation).
ampicillin PO if possible (if not IM): 100 mg/kg/d divided in 3-4 doses x 7 days

Always treat fever and ensure adequate hydration and nourishment. Always review the patient 2 days later.

PNEUMONIA WITH RESPIRATORY DISTRESS: HOSPITALIZE

- Adult and child > 5 years

· If clinical evidence favours pneumococcus (one or several systematic foci with crepitation and/or decreased vesicular breath sounds, sometimes bronchial breathing or dullness to percussion):
PPF IM:

Adult:

3-4 MIU/d in 1 injection x 2-3 days


then commence oral therapy with peni V: 3-4 MIU/d divided in 3-4


doses to complete 7 days

Child:

50.000 UI/kg/d in 1 dose x 2-3 days


then commence oral therapy with peni V: 50.000 IU/kg/d divided in 3-4


doses to complete 7 days

or
chloramphenicol IV-IM:

Adult:

3-4 g/d divided in 3-4 doses over several days, then commence orally


(same dosage) to complete 7 days

Child:

100 mg/kg/d divided in 3-4 doses over several days, then commence


orally (same dosage) to complete 7 days

· In all other cases:
chloramphenicol IV or IM:

Adult:

3-4 g/d divided in 3-4 doses over 2-3 days

Child:

100 mg/kg/d divided in 3-4 doses over 2-3 days, then in both cases


change to oral treatment with the same dosage to complete 7 days

or
ampicillin IV or IM:

Adult:

3-4 g/d divided in 3-4 doses over 2-3 days

Child:

100 mg/kg/d divided in 3-4 doses over 2-3 days, then in both cases


change to oral treatment with the same dosage to complete 7 days

Where no improvement with ampicillin after 2 days, combine with
gentamicin IM:

Adult:

160 mg/d divided in 2 doses

Child:

3-6 mg/kg/d divided in 2 doses x 7 days

- Child of 2 months to 5 years

chloramphenicol IV or IM: 100 mg/kg/d divided in 3-4 doses; change to oral treatment as soon as possible in the same dosage to complete 7-10 days
or
ampicillin IV or IM: 100 mg/kg/d divided in 3-4 doses; change to oral treatment as soon as possible in the same dosage to complete 7-10 days

When possible, combine with gentamicin IM: 6 mg/kg/d divided in 2 doses during 7-10 days

In the absence of improvement or when deterioration occurs at the end of properly conducted treatment, think about staphylococcal pneumonia.

- Infant < 2 months
ampicillin IV or IM: 100 mg/kg/d divided in 3-4 doses; change to oral treatment as soon as possible in the same dosage to complete 7-10 days
plus gentamicin IM: 6 mg/kg/d divided in 2-3 doses x 7-10 days (for neonates < 10 days old: 4 mg/kg/d in 2 doses))

When no improvement occurs or there is deterioration after 4 days of correct treatment, think about a staphylococcal pneumonia (see "staphylococcal pneumonia").

In all cases, treat the temperature, ensure adequate nutrition and hydration (gastric tube if necessary). If oxygen available, use by means of nasal tube at the rate of 1 litre per minute when there is respiratory distress.

REFRACTORY PNEUMONIA IN ADULTS OR OLDER CHILDREN

Consider atypical pneumonia (mycoplasma) or tuberculosis. Alternative therapies to try: tetracycline

Adult: 1.5-2 g/ d divided in 3-4 doses x 7-10 days
Child > 8 years: 50 mg/ kg/ d divided in 3-4 doses x 7-10 days
or
erythromycin: same dosages as for tetracycline
or
cotrimoxazole
Adult: 1600 mg of SMX/d divided in 2 doses x 7-10 days
Child: 50 mg of SMX/kg/d divided in 2 doses x 7-10 days

If at the end of 3 courses of therapy the signs persist, consider tuberculosis (see "Tuberculosis").

Staphylococcal pneumonia

Staphylococcal pneumonia often occurs in an infant that is otherwise unwell (malnutrition, skin sepsis...).

Clinical features

- Fever, pallor, fatigue.

- Signs similar to those of severe bronchiolitis, with vomiting, diarrhea, abdominal distension, often skin abscesses.

- Auscultation: asymmetrical chest signs + pleural effusion.

- Neutrophilia.

- Chest X-ray: bullae, pleural effusion.

Treatment (hospital)

- Antibiotics, if available:

cloxacillin (IV): 100 mg/kg/ d divided in 4 injections x 10 days
and
gentamicin (IM): 3-6 mg/kg/d divided in 2 injections x 10 days

Otherwise:

chloramphenicol(IV): 100 mg/kg/d divided in 3 injections x 10 days

- Hydration: oral or IV.

- If there is a significant effusion, a pleural tap may be necessary or, if severe, an intercostal catheter with underwater drain.

Prognosis

Danger of complications of suppurative pleurisy, pneumothorax and pyo-pneumothorax.

In a pediatric ward where staphylococcal pneumonia are expected to be managed, health workers should be trained to perform urgent pleural tap. Adequat equipment should always be available.

Bronchiolitis

- Acute viral infection of the bronchioles occurring in infants under 10 months of age which can lead to fatal acute respiratory failure.

- Tends to occur in epidemics during the cold season.

Clinical features

- Onset often follows a cold.

- Low grade fever, cough, variable degree of respiratory distress with tachypnea, alar flare and chest indrawing (stemal and intercostal recession).

Cyanosis if severe.

- Hyperinflated chest, hyper-resonant to percussion.

- Auscultation can be normal or reveal rhonchi (wheezes) and crepitations.

Treatment (hospital)

- Close monitoring: very important.

- Sitting position (propped up or held by mother).

- Keep well hydrated but avoid fluid overload.

Humidified air.

- Bronchodilators: try salbutamol as a therapeutic test if available. The least dangerous is the spray (see "Asthma", see 67). Make two attempts at 15 minutes intervals, then wait. If there is improvement, continue; if not, do not persist.

- Corticosteroids not effective.

- Antibiotics to prevent secondary bacterial infection:

cotrimaxazole (PO): 40 mg of SMX/kg/day in 2 divided doses x 5 days
or
ampicillin (PO or IM): 100 mg/kg/d divided in 3 doses x 5 days

- If cardiac decompensation (gallop rhythm, rate > 160): digoxin (IV): 0.01 mg/kg stat every 6-8 hours for the first 24 hours thence same dose once daily as maintenance. furosemide(IV):1 mg/kg

- Respiratory fatigue: if possible, intubation and manual ventilation.

Prognosis

- May have high mortality rate.

- Possibility of recurrence.

Asthma

Paroxysmal reversible airways obstruction due to a combination of bronchospasm, peribronchial edema and hypersecretion. Often allergic in origin.

Clinical features

- Wheeze (prolonged expiratory phase).

- Cough, dyspnea.

- Auscultation: expiratory rhonchi (wheezes) in both lung fields.

- 3 forms:

· simple attack,
· unstable asthma: repeated attacks,
· status asthmaticus: prolonged, severe attack.

Treatment

Certain intestinal parasites during their invasive phase can cause allergic phenomena such as urticaria or asthma. Always think of this and treat in an endemic area: hookworm, strongyloides, ascaris, schistosomes, filaria.

SIMPLE ATTACK (dispensary)

- Half-sitting position, reassurance, hydration, oxygen if available.

- Aminophylline (PO): 5 mg/kg every 6 hours as necessary
(contra-indicated in children under 2 years).

- Child < 2 years: commence with salbutamol if available (the spray is the least dangerous), if not adrenaline (epinephrine) (see "alternative treatments"). Aminophylline should only be used as a last recours at this age.

SEVERE CASES = STATUS ASTHMATICUS (hospital)

- Aminophylline (IV): 5 mg/kg diluted in 100 ml of 5% glucose, injected over 20 to 30 minutes, then 5 mg/kg over 6-8 hours depending on the clinical result.

- Never inject aminophylline undiluted (risk of convulsions and cardiac arrest).

- Combine with:

· Infusions (alternative glucose end ringer lactate)
· salbutamol spray if avaiblable.

dexamethasone (IV):

Adult: 16-24 mg/d divided in 4-6 injections
Child: 0.1-0.5 mg/kg/d divided in 4-6 injections

Adjust the dosage to clinical state and decrease progressively.

- Antibiotics:

Adult: peni V PO or PPF IM: 3-4 MIU/d x 5 days
Child < 5 years: chloramphenicol IVor PO: 100 mg/kg/d divided in 3-4 doses x 5 days
or
ampicillin IV or PO: 100 mg/kg/d divided in 3-4 doses x 5 days

- After 2-3 hours aminophyllin infusion, when no improvement, return if possible to salbutamol or adrenaline.

UNSTABLE CASES

- Attacks which stop and recur despite treatment.

- Institute the following
aminophylline (PO)

Adult and child: 8-12 mg/kg/d divided in 3 doses, reduce dose progressively over several days

Duration depends on clinical state; decrease must be very gradual every 4-5 days.

Or better, but rarely available:

salbutamol(PO)

Adult: 12-16 mg/d divided in 3-4 doses x 5 days
Child: 0.2 mg/kg/d divided in 3-4 doses x 5 days, then decrease very gradually (every 4-5 days)

- In case of failure, consider short term, corticosteroid therapy.
If used, it is essential to exclude underlying pulmonary infection
(if in doubt: peni Vor cotrimoxazole).
Give prednisone (or prednisolone) per os
Adult: 30 mg/d in a single dose x 3-4 days
Child: 1 mg/kg/d in a single dose x 3-4 days.
Then decrease very gradually every 3-4 days depending on the clinical state.

ALTERNATIVE TREATMENTS

- salbutamol spray: a double puff if an attack occurs, without exceeding 3-4 doses per day.

- salbutamol IV: difficult to control (tachycardia +++). Begin with 0.1 mg/10 kg in 100 ml 5 % glucose, over 20 minutes. Watch pulse, blood pressure. Continue with 1 mg/hour (0.25-1.5 mg/h) for adult; in child, 0.3-0.6 mg/10 kg/ hour. Change to oral treatment after 24 hours. Reserve for refractory cases in children or status asthmaticus.

- epinephrine (adrenaline) SC: use 0.1 % (1 mg/ml) solution.

Adult: 0.5 ml SC, repeat if necessary 30 minutes later; do not exceed 4 injectionsper day.
Child: 0.01 ml/kg SC without exceeding 0.5 ml/injection, repeat after 30 minutes if still necessary; do not exceed 4 injections per day; exercise extreme caution (+++) in infants less than 1 year old.

Watch pulse, blood pressure (tachycardia +++).

Adrenaline can be utilised in case of simple attack.

Tuberculosis

Disease of variable manifestations caused by Mycobacterium tuberculosis. It is important to understand the distinction between:

- Tuberculous infection: presence of M. tuberculosis in the organism, manifested by a positive skin test. Is very often asymptomatic.

- Tuberculous disease: affects about 10% of the infected population. Clinical disease can take very diverse forms:

· meningitis,

· pulmonary TB: the commonest form and the main source of transmission ("open" cases coughing up large numbers of AFB),

· lymphadenitis,

· osteo-articular, Pott's disease,

· intestinal, renal, peritoneal, cutaneous

- Transmission and maintenance of endemicity depend upon:

· the number and sources of infection: open pulmonary cases can be easily identified by 3 consecutive daily sputum examinations
(direct smear for AFB);

· living conditions: crowding, hygiene,

· susceptibility of the population (e.g. malnutrition).

- Individuals with low immune defences (e.g. malnourished, infants, elderly, AIDS patients) are more susceptible to the very severe forms (TB meningitis, miliary TB).

Note: not all cases of hemoptysis are necessarily TB. It is important not to forget other causes, especially if sputum smears are negative: paragonimiasis and meliodosis in Southeast Asia; systemic mycoses; histoplasmosis; and bronchogenic carcinoma.

- An active pulmonary TB is considered as an opportunistic among AIDS or HIV infected patients. thus TB can be the initial step of AIDS.
Control of tuberculosis

ENVIRONMENT

Improvement of living conditions in a community lessens the risk of contagion (e.g. ventilation, light, no crowding...).

BCG AND CHEMOTHERAPY

- The BCG vaccination confers limited individual protection, and is mainly effective against infantile TB meningitis. It does not protect against most other forms of TB and does not confer herd immunity upon the population.

- The chemotherapy of TB is a complex issue. Certain fundamental rules must always be followed:

- Chemotherapy is only effective if rigorously organized and controlled. On an epidemiological level, a poorly organized program may be worse than no program at all. Poor treatment compliance leads to chronic, refractory cases and encourages the emergence of drug resistance.

- The success of a program depends less upon the intrinsic quality of the chosen treatment regimen than upon rigorous supervision and follow-up of patients during the entire duration of therapy.

· The program should be designed specifically for the local social, cultural and economic conditions.

· TB control is almost always co-ordinated at a national level.
Foreign medical beams must adhere strictly to the national guidelines.

Practical organization

- The objective is to reduce transmission. The way to achieve this is to find and to treat sputum-positive cases.

- Clues to the identification of infectious patients are:

· cough of more than 3 weeks duration,
· hemoptysis, chest pain,
· weight loss,
· night sweats?

- Chest X-ray is not a pafficularly useful criterion for deciding upon treatment; only sputum-positive and extrapulmonary cases should be commenced on therapy.

- The laboratory must be capable of carrying out direct smears for
AFB, otherwise a control program cannot be envisaged. Active case detection is important, but only if a mechanism for effective treatment and follow-up exists.

- The main issue is to establish the mechanisms (infrastructure, trained personnel, transport, supplies) that will ensure good treatment compliance and follow-up, whatever the particular regimen. Without this, the program will fail. The availability of sophisticated drugs (such as rifampicin) is an issue of much lesser importance.

Three examples of treatment regimens

Low COST

Cost of full course < $US 20; 12 months duration.

- isoniazid(5mg/kg/d) + thioacetazone(2.5mg/kg/d) combination= INH+ TB1

Adult: tab 300 mg INH + tab 150 mg TB1
Child (< 6 years): tab 100 mg INH + tab 50 mg TB1 each day by mouth for 12 months with an initial supplement of 2 months of streptomycin (IM): 20 mg/kg

HIGH COST

Cost of full course > $US 175; 6 months duration.

- isoniazid:

Adult: 5mgtkg/d
Child: 10 to 20 mg/kg/d
+ rifampicin: 10 mg/kg/d
+ pyrazinamide: 25 mg/kg/d for first 2 months only
+ ethambutol: 20 mg/kg/d for first 2 months only.
INTERMEDIATE COST

Cost of full course approx. $US 85; 8 months duration.

- First 2 months: isonazid: 5 mg/kg/d
+ rifampicin: 10 mg/kg/d
+ pyrazinamide: 25mg/kg/d
+ streptomycin(IM): 20 mg/kg/d

- Next 6 months: isoniazid + thioacetazone: 5 mg/kg/d of INH.

Note

- Consult other documents on tuberculosis control programs, especially concerning case detection and short-course regimens
(40).

- Hemoptysis is not always caused by tuberculosis. Other causes if
AFB -; paragonimosis and melioidosis in South East Asia; deep mycosis: histoplasmosis; bronchopulmonary cancer.

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