Post on 18-Jan-2019
transcript
ACUTE ACUTE
RESPIRATORYRESPIRATORY
INFECTIONSINFECTIONS
PneumoniaPneumoniaBronkiolitisBronkiolitis
Bronkitis AkutBronkitis Akut
Acute Respiratory Infections (ARI)Acute Respiratory Infections (ARI)
Developed and developing countriesDeveloped and developing countries
High morbidityHigh morbidity
5 5 –– 8 episodes/year/child8 episodes/year/child
30 30 –– 50 % outpatient visit50 % outpatient visit30 30 –– 50 % outpatient visit50 % outpatient visit
10 10 –– 30 % hospitalization30 % hospitalization
Developing countriesDeveloping countries
High mortalityHigh mortality
30 30 –– 70 times higher than in developed countries70 times higher than in developed countries
1/4 1/4 -- 1/3 death in children under five year of age1/3 death in children under five year of age
ARIARI--ASSOCIATED DEATH RATE BY AGEASSOCIATED DEATH RATE BY AGE
TEKNAF, BANGLADESH, 1982TEKNAF, BANGLADESH, 1982--19851985
100
120
140
Deaths per 1000 children
0
20
40
60
80
1-5 6-11 12-23 24-35 36-50
Age i n Mont hs
Distribution of 12.2 million deaths among children less Distribution of 12.2 million deaths among children less than 5 years old in all developing countries, 1993than 5 years old in all developing countries, 1993
ARI (26.9%)
Malaria (6.2)
ARI/Malaria (1.6%)
Measles (2.4%)
Diarrhoea/measles
(1.9%)
Diarrhoea (22.8%)
Other (33.1%)
ARI/Measles (5.2%)
MalnutritionMalnutrition(29%)(29%)
RISK FACTORS FOR PNEUMONIARISK FACTORS FOR PNEUMONIAOR DEATH FROM ARIOR DEATH FROM ARI
Malnutrition, poorbreast feeding
practices
Vitamin A deficiency
Low birth weight
Lack of immunization
Young age
Increaserisk of
ARI
Cold weather
or chilling
Exposure to air pollution
• Tobacco smoke
• Biomass smoke
• Environmental air pollution
Crowding
High prevalence
of nasopharyngeal
carriage of
pathogenic bacteria
Magnitude of the ProblemMagnitude of the Problem
in Indonesiain IndonesiaPneumonia in children (< 5 years of age)Pneumonia in children (< 5 years of age)
Morbidity Rate 10Morbidity Rate 10--20 %20 %
Mortality Rate 6 / 1000Mortality Rate 6 / 1000
Pneumonias killPneumonias killPneumonias killPneumonias kill
�� 50.000 / a year50.000 / a year
�� 12.500 / a month12.500 / a month
�� 416 / a day = passengers of 1 jumbo jet plane416 / a day = passengers of 1 jumbo jet plane
�� 17 / an hour17 / an hour
�� 1 / four minutes1 / four minutes
Pneumonia is a no 1 killer for infants Pneumonia is a no 1 killer for infants
(Balita)(Balita)
PneumoniaPneumoniaClassificationsClassifications
Anatomical classificationAnatomical classification
�� Lobar pneumoniaLobar pneumonia
�� Lobular pneumoniaLobular pneumonia
�� Intertitial pneumoniaIntertitial pneumonia
BronchopneumoniaBronchopneumonia�� BronchopneumoniaBronchopneumonia
Etiological classificationEtiological classification
�� Bacterial pneumoniaBacterial pneumonia
�� Viral pneumoniaViral pneumonia
�� Mycoplasma pneumoniaMycoplasma pneumonia
�� Aspiration pneumoniaAspiration pneumonia
�� Mycotic pneumoniaMycotic pneumonia
Etiology of PneumoniaEtiology of Pneumonia
Predominantly : bacterial and viral Predominantly : bacterial and viral
In developing countries: In developing countries:
bacterial > viral bacterial > viral bacterial > viral bacterial > viral
(Shann,1986): In 7 developing(Shann,1986): In 7 developing countries, countries,
bacterial bacterial �� 60 %60 %
(Turner, 1987):(Turner, 1987): In developed countries,In developed countries,
bacterial bacterial ��19 % ; viral 19 % ; viral ��39 % 39 %
Bacterial etiologyBacterial etiology
Streptococcus pneumoniaeStreptococcus pneumoniae
Hemophilus influenzaeHemophilus influenzae
Staphylococcus aureusStaphylococcus aureus
Streptococcus group A Streptococcus group A –– BB
Klebsiella pneumoniaeKlebsiella pneumoniae
Pseudomonas aeruginosaPseudomonas aeruginosa
Chlamydia sppChlamydia spp
Mycoplasma pneumoniaeMycoplasma pneumoniae
30
40
50
BACTERIA ISOLATED FROM LUNG ASPIRATESBACTERIA ISOLATED FROM LUNG ASPIRATES
IN 370 UNTREATED CHILDREN WITH PNEUMONIAIN 370 UNTREATED CHILDREN WITH PNEUMONIA
%%
0
10
20
30
S Pneumoniae H Influenzae S Aureus
Characteristic featuresCharacteristic features
S pneumoniaeS pneumoniae
�� mucosal inflammation lesionmucosal inflammation lesion
�� alveolar exudatesalveolar exudates
�� frequently frequently ��lobar pneumonia)lobar pneumonia)
H influenzae, S viridans, VirusH influenzae, S viridans, Virus
�� invasion and destruction of mucous membraneinvasion and destruction of mucous membrane
Staphylococcus, KlebsiellaStaphylococcus, Klebsiella
�� destruction of tissues destruction of tissues �� multiple abscessesmultiple abscesses
Simple Clinical Signs of Pneumonia Simple Clinical Signs of Pneumonia
(WHO)(WHO)
Fast breathing (tachypnea)Fast breathing (tachypnea)
Respiratory thresholds Respiratory thresholds
AgeAge Breaths/minuteBreaths/minute
< 2 months< 2 months 6060< 2 months< 2 months 6060
2 2 -- 12 months12 months 5050
1 1 -- 5 years5 years 4040
Chest IndrawingChest Indrawing(subcostal retraction)(subcostal retraction)
Pathology and PathogenesisPathology and Pathogenesis
Bacteriae Bacteriae ��peripheral lung tissues peripheral lung tissues
�� tissues reaction tissues reaction �� oedematousoedematous
Red Hepatization StadiumRed Hepatization Stadium
alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte,
bacteriabacteria
Grey Hepatization Stadium Grey Hepatization Stadium
fibrine deposition, phagocytosisfibrine deposition, phagocytosis
Resolution Stadium Resolution Stadium
neutrophil degeneration, loose of fibrine,neutrophil degeneration, loose of fibrine,
bacterial phagocytosisbacterial phagocytosis
Bronchopneumonia Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the alveolar spaces. The alveolar capillaries are distended and engorged.
Bronchopneumonia Acute bronchopneumonia. The alveolar spaces contain abundant PMNs and an inflammatory infiltrate rich in fibrin.
Acute Bronchopneumonia Acute bronchopneumonia; the alveolar spaces are full and distended with PMNs and a proteinaceous exudate. Only the alveolar septa allow identification of the tissue as lung.
Radiographic patterns Radiographic patterns
1.1. Diffuse alveolar and interstitial Diffuse alveolar and interstitial pneumoniapneumonia (perivascular and (perivascular and interalveolar changes)interalveolar changes)
2.2. BronchopneumoniaBronchopneumonia2.2. BronchopneumoniaBronchopneumonia(inflammation of airways and (inflammation of airways and parenchyma)parenchyma)
3.3. Lobar pneumoniaLobar pneumonia(consolidation in a whole lobe)(consolidation in a whole lobe)
4.4. Nodular, cavity or abscess lesionsNodular, cavity or abscess lesions(esp.in immunocompromised patients)(esp.in immunocompromised patients)
Female girl, 6,5 y cxr interstitial infiltrates, ec S pneumoniae: IgG pneumolysin increased Leucocytosis 29800, ESR 35 mm/h I, CRP 9 mg/l.
Male boy, 1,9 y, cxr alveolar infiltrates in right lobe ec. S pneumoniae: IgG pneumolysin increased, leucocytosi 13.800, ESR 125/h I, CRP 332 mg/l.
Female girl, 2,8 y, cxr alveolar infiltrates in lower left lobe ec. rhinovirus: leucocytosis 17700, ESR 64 mm/h I, CRP 128 mg/l.
Female infant, 0,3 y, cxr. alveolar infiltrates in upper right lobe ec parainfluenza andhuman herpes virus, leucocytois 17000, ESR 8 mm/ h l, CRP 22 mg/l
Blood Gas Analysis & Acid Base BalanceBlood Gas Analysis & Acid Base Balance
Hypoxemia Hypoxemia (P(PaaOO22 < 80 mm Hg)< 80 mm Hg)
�� with Owith O22 3 L/min 3 L/min 52,4 %52,4 %
�� without Owithout O22 100 %100 %
Ventilatory insufficiencyVentilatory insufficiencyVentilatory insufficiencyVentilatory insufficiency�� (P(PaaCOCO22 < 35 mmHg)< 35 mmHg) 87,5 %87,5 %
Ventilatory failureVentilatory failure�� (P(PaaCOCO22 > 45 mmHg )> 45 mmHg ) 4.8 %4.8 %
Metabolic Acidosis Metabolic Acidosis �� poor intake and/or hypoxemiapoor intake and/or hypoxemia 44,4 % 44,4 %
(Mardjanis Said, et al. 1980)(Mardjanis Said, et al. 1980)
ManagementManagement
Severe PneumoniaSevere Pneumonia
HospitalizationHospitalization
Antibiotic administrationAntibiotic administration
�� Procain Pennicilline, ChloramphenicolProcain Pennicilline, Chloramphenicol�� Procain Pennicilline, ChloramphenicolProcain Pennicilline, Chloramphenicol
�� Amoxycillin + Clavulanic AcidAmoxycillin + Clavulanic Acid
Intra Venous Fluid DripIntra Venous Fluid Drip
OxygenOxygen
Detection and management of Detection and management of complicationscomplications
WHO recommendations for treatment of infants less 2 WHO recommendations for treatment of infants less 2 months who have cough or difficulty breathingmonths who have cough or difficulty breathing
No pneumonia : No tachypnea, no severe chest indrawingDo not administer an antibiotic
Severe pneumonia : Tachypnea or severe chest indrawingAdmit, administer benzylpenicillin + gentamycin, and oxygen
WHO recommendations for treatment of children aged 2 WHO recommendations for treatment of children aged 2 months months
to 4 years who have cough or difficulty breathingto 4 years who have cough or difficulty breathing
No pneumonia : No tachypnea, no chest indrawingDo not administer an antibiotic
Pneumonia : Tachypnea, no chest indrawingHome treatment with cotrimoxazole,amoxicillin or procaine penicillinamoxicillin or procaine penicillin
Severe pneumonia : Chest indrawing, no cyanosis,
and able to feed. Admit; administer
benzylpenicillin i.m. every 6 h
Very severe pneumonia :Chest indrawing with cyanosis and
not able to feed Admit; administer
chloramphenicol i.m. every 6 h
and oxygen
Initial empirical treatment based Initial empirical treatment based on age and severity of pneumoniaon age and severity of pneumonia
Age
3 - 6 mos
6 mos to
Outpatients(Mild to Moderate)
Inpatients (Moderate) Inpatients (Severe)
Amoxicillin with or without clavulanateErythromycin
Ceftriaxone or cefotaximCeftriaxone or cefotaxime
+ vancomycin
Amoxicillin with orwithout clavulanate
Ceftriaxone, cefotaxime, or
Ceftriaxone or cefotaxime+ macrolide + vancomycin
to 5 yrs
5 – 18 yrs
without clavulanateErythromycin
orCefuroxime + macrolide
+ macrolide + vancomycin
Macrolide Ceftriaxone or cefotaxime
+ macrolide
Ceftriaxone or cefotaxime+ macrolide + vancomycin
Hsiao G et al, 2001
ComplicationsComplications
Pleural effusion (empyema)Pleural effusion (empyema)
PiopneumothoraxPiopneumothorax
PneumothoraxPneumothorax
PneumomediastinumPneumomediastinum
BronchiolitisBronchiolitis
�� Bronchioles inflammationBronchioles inflammation
�� Clinical syndromes: Clinical syndromes: fast breathing, retractions, wheezingfast breathing, retractions, wheezingfast breathing, retractions, wheezingfast breathing, retractions, wheezing
�� Predominantly < 2 years of age Predominantly < 2 years of age (2 (2 –– 6 months)6 months)
�� Difficult to differentiate with pneumoniaDifficult to differentiate with pneumonia
PathologyPathology�� Necrosis of the resp. epithelium Necrosis of the resp. epithelium
�� Destruction of ciliated epithelial cellsDestruction of ciliated epithelial cells
�� Peribronchial infiltration with lymphocites & neutrophilsPeribronchial infiltration with lymphocites & neutrophils
�� Sub mucosal edematousSub mucosal edematous
…Bronchiolitis…Bronchiolitis
�� Sub mucosal edematousSub mucosal edematous
�� No destruction of collagen, muscle, or elastic tissueNo destruction of collagen, muscle, or elastic tissue
PathophysiologyPathophysiologyEdema + accumulation of mucous & cellular debris Edema + accumulation of mucous & cellular debris ��
narrow of peripheral airway narrow of peripheral airway �� partially / totally partially / totally
occluded occluded �� over distention / atelectasisover distention / atelectasis
EtiologyEtiology�� Predominantly RSV (Respiratory Syncytial Predominantly RSV (Respiratory Syncytial
Virus)Virus)
�� Other viruses : rhinovirus, adenovirus, Other viruses : rhinovirus, adenovirus, influenza virus, parainfluenza virus, entero influenza virus, parainfluenza virus, entero
…Bronchiolitis…Bronchiolitis
influenza virus, parainfluenza virus, entero influenza virus, parainfluenza virus, entero virus, etc.virus, etc.
Severity Severity �� PrematurityPrematurity OR 1.84OR 1.84
�� Underlying medical condition OR 2.84Underlying medical condition OR 2.84
�� Group A RSV strain Group A RSV strain OR 3.26OR 3.26
�� Age < 3 mo Age < 3 mo OR 4.39OR 4.39
…Bronchiolitis…Bronchiolitis
DiagnosisDiagnosis
�� Etiological diagnosisEtiological diagnosis
Microbiologic examination Microbiologic examination
�� Clinical diagnosisClinical diagnosis
Signs and symptomsSigns and symptomsSigns and symptomsSigns and symptoms
AgeAge
Resource of infection Resource of infection �� epidemic of RSVepidemic of RSV
�� Laboratory findingLaboratory finding
�� Radiological examinationRadiological examination
Clinical Manifestations : mild rhinorrhea, Clinical Manifestations : mild rhinorrhea, cough, cold, lowcough, cold, low--grade fevergrade fever
11--2 d 2 d �� fast breathing, chest retraction, fast breathing, chest retraction, wheezing, irritable, vomitus, poor intakewheezing, irritable, vomitus, poor intake
…Bronchiolitis…Bronchiolitis
wheezing, irritable, vomitus, poor intakewheezing, irritable, vomitus, poor intake
Physical Examinations Physical Examinations tachypnea, tachycardia, retraction, tachypnea, tachycardia, retraction, prolonged expiration, wheezing, prolonged expiration, wheezing, fever,pharyngitis, conjunctivitis, otitis media, fever,pharyngitis, conjunctivitis, otitis media, dehydrationdehydration
Radiologic examinationRadiologic examinationdiffuse hyperinflationdiffuse hyperinflation�� flat diaphragm, flat diaphragm,
�� Intercostal space >Intercostal space >
�� retrosternal space >retrosternal space >
peribronchial infiltrates / thickeningperibronchial infiltrates / thickening
…Bronchiolitis…Bronchiolitis
peribronchial infiltrates / thickeningperibronchial infiltrates / thickening
patchy atelectasis patchy atelectasis �� segmental collapsesegmental collapse
pleural effusion (rare)pleural effusion (rare)
Laboratory finding Laboratory finding �� Respiratory rate Respiratory rate �� : Arterial saturation : Arterial saturation ��
pCO2 pCO2 ��
Laboratory finding Laboratory finding
�� Microbiologic examination Microbiologic examination
�� WBC : 5000 WBC : 5000 –– 24.000 cells/mm24.000 cells/mm33, predominantly , predominantly
PMN & bandsPMN & bands
…Bronchiolitis…Bronchiolitis
�� Blood Gas Analysis Blood Gas Analysis
Arterial saturation �
pCO2 �
Mild respiratory alkalosis
Metabolic acidosis
Acute respiratory acidosis
ManagementManagement
�� Mild Mild �� treated at hometreated at home
�� Moderate / severe disease Moderate / severe disease �� hospitalizationhospitalization
support : support : oxygen oxygen
intra venous fluid dripintra venous fluid drip
(antibiotics)(antibiotics)
…Bronchiolitis…Bronchiolitis
(antibiotics)(antibiotics)
detect & treat possible complicationdetect & treat possible complication
prevent the spread of inf.prevent the spread of inf.
�� Controversial : Controversial : bronchodilator bronchodilator
corticosteroidcorticosteroid
antiviralantiviral
antibioticantibiotic
Natural history & complicationsNatural history & complications
�� Regeneration of bronchiolar epithelium after 3 Regeneration of bronchiolar epithelium after 3
or 4 dor 4 d
�� Cilia after 3 or 4 dCilia after 3 or 4 d
…Bronchiolitis…Bronchiolitis
�� Cilia after 3 or 4 dCilia after 3 or 4 d
�� Improved clinical findings : in 3Improved clinical findings : in 3--4 days4 days
�� Improved radiological features: in 9 daysImproved radiological features: in 9 days
Persistent respiratory obstruction : 20%Persistent respiratory obstruction : 20%
Respiratory failure : 25 %Respiratory failure : 25 %
Lung collaps (rare)Lung collaps (rare)
Correlation with AsthmaCorrelation with Asthma
�� 30 % 30 % -- 50 % becomes asthmatic patients50 % becomes asthmatic patients
�� Similarity in : Similarity in : -- pathogenic mechanismspathogenic mechanisms
…Bronchiolitis…Bronchiolitis
�� Similarity in : Similarity in : -- pathogenic mechanismspathogenic mechanisms
-- pathologic disorderspathologic disorders
Bronkitis akut
radang bronkus akutradang bronkus akut
umumnya disertai radang akut saluran umumnya disertai radang akut saluran napas bawah lainnyanapas bawah lainnyanapas bawah lainnyanapas bawah lainnya
Tidak pernah berdiri sendiri Tidak pernah berdiri sendiri
Trakeobronkitis akut = BronkitisTrakeobronkitis akut = Bronkitis
Istilah yang membingungkan
Bronkitis kapiler Bronkitis kapiler (Capillary Bronchitis)(Capillary Bronchitis)
�� BronkitisBronkitis
�� Pneumonia interstitialPneumonia interstitial�� Pneumonia interstitialPneumonia interstitial
Bronkitis asmatikaBronkitis asmatika
�� Salah satu bentuk asmaSalah satu bentuk asma
Etiologi Bronkitis akut
UmumUmum : virus: virus
Spesifik Spesifik
�� InfluenzaInfluenza
�� PertusisPertusis�� PertusisPertusis
�� Campak (morbilli)Campak (morbilli)
�� SalmonellaSalmonella
�� DifteriaDifteria
�� Scarlet feverScarlet fever
Predisposisi dan faktor yang berpengaruh
Asap rokokAsap rokok
AlergiAlergi
CuacaCuaca
Keadaan umum yang jelek Keadaan umum yang jelek (Poor health)(Poor health)
Infeksi kronik alat napas atasInfeksi kronik alat napas atas
Pemeriksaan fisis
PanasPanas : (: (--)) (+)(+) ((--))
MukosaMukosa : : -- nasofaringitisnasofaringitis
-- konjungtivitiskonjungtivitis
-- rhinits virusrhinits virus-- rhinits virusrhinits virus
Suara napas kasarSuara napas kasar
Ronki basah kasarRonki basah kasar halushalus
Mengi (Wheezing)Mengi (Wheezing)
SPUTUMSPUTUM : Jernih : Jernih beberapa hari beberapa hari keruhkeruh
55--10 hari10 hari55--10 hari10 hari
Batuk hilangBatuk hilang jernihjernih
Gejala dan tanda lain bronkitis akut
Rasa tidak enak di bawah tulang dada : Rasa tidak enak di bawah tulang dada : Seperti terbakar Seperti terbakar sakitsakit
Suara napas berbunyi seperti siulanSuara napas berbunyi seperti siulanSuara napas berbunyi seperti siulanSuara napas berbunyi seperti siulan
SesakSesak
MuntahMuntah
Penanggulangan bronkitis akutPenanggulangan bronkitis akut
SimptomatisSimptomatis
Pengeluaran lendir/sputum :Pengeluaran lendir/sputum :
�� Posisi tidur diubahPosisi tidur diubah--ubahubah
�� Jaga kelembaban udaraJaga kelembaban udara�� Jaga kelembaban udaraJaga kelembaban udara
�� Sering minumSering minum
Kodein : hatiKodein : hati--hati ! (sangat jarang hati ! (sangat jarang diperlukan)diperlukan)
Antihistamin : HatiAntihistamin : Hati--hati hati Atropin like effectAtropin like effect
Bronkitis akut
Ekspektoran : tidak perluEkspektoran : tidak perlu
Antibiotika :Antibiotika :
�� Tidak ada gunanyaTidak ada gunanya�� Tidak ada gunanyaTidak ada gunanya
�� IndikasiIndikasi
Bronkitis akut berulang
Ada komplikasi
Komplikasi bronkitis akut
OtitisOtitis
SinusitisSinusitis
PneumoniaPneumoniaPneumoniaPneumonia
Terutama kalau gizi burukTerutama kalau gizi buruk
Batuk kronik berulang
pada anak: bronkitis kronik tidak adapada anak: bronkitis kronik tidak ada
dasar : dasar : -- penyakit parupenyakit paru
-- penyakit sistemikpenyakit sistemik
DD/DD/ D/ D/
Komponen refleks batukKomponen refleks batuk
Reseptor Aferen Pusat batuk Eferen Efektor
Cabang nervus
vagus
Nervus vagus
Otot,
Laring, trakea
dan bronkus
Laring
Trakea
Bronkus
Tersebar merataTelinga
Lambung
Tersebar merata
di medula dekat
Pusat pernapasan :
di bawah kontrol
Pusat yang
lebih tinggiHidung
Sinus paranasalis
Nervus
trigeminus
Nervus Frenikus,
Interkostal &
lumbaris
Diafragma, otot-otot
Interkostal,
abdominal
& otot lumbal
FaringNervus
glosofaringus
Saraf-saraf
Trigeminus, Fasialis
Hipoglosus,dll
Otot saluran napasdan otot bantu napas
Perikardium
diafragmaNervus frenikus