INFEKSI RESPIRASI AKUT

Bronkhopneumonia
 Pendahuluan

Hasil survey Kesehatan Rumah Tangga

Nasional th 1980 :
ISPA ---> 19,9 % † seluruh penduduk
----> urutan teratas dlm penyebab †
---> 22,9 % kematian bayi 0 -1 th
---> 28,2 % kematian anak 1 – 5 th
 UPF IKA Dr. Soetomo 1983 – 1984
Ispa ----> pengunjung terbanyak di poli Anak
( 40 % )
----> urutan ke- 2 setl GEA dari pend
rawat inap ( 27 % )
----> pend ringan & sedang dirawat
jalan
Perlu perawatan bila :
* berat
* radang paru2 + sesak ?
* bronkhiolitis
* morbili
Angka mortalitas ---> ↑
 Acute Respiratory Infections (ARI)

Developed and developing countries

High morbidity
5 – 8 episodes/year/child
30 – 50 % outpatient visit
10 – 30 % hospitalization
Developing countries
High mortality
30 – 70 times higher than in developed countries
1/4 - 1/3 death in children under five year of age
 ARI-ASSOCIATED DEATH RATE BY AGE
TEKNAF, BANGLADESH, 1982-1985
Deaths per 1000 children
140

120

100

80

60

40

20

0
1-5 6-11 12-23 24-35 36-50
Ag e i n M on t h s
Distribution of 12.2 million deaths among children less
than 5 years old in all developing countries, 1993

ARI/Malaria (1.6%)
Malaria (6.2)

ARI (26.9%)

Malnutrition
(29%)
Other (33.1%)

ARI/Measles (5.2%)
Measles (2.4%)
Diarrhoea/measles
(1.9%)

Diarrhoea (22.8%)
 RISK FACTORS FOR PNEUMONIA
OR DEATH FROM ARI
Malnutrition, poor
breast feeding
practices
Lack of immunization Vitamin A deficiency

Young age Low birth weight

Increase
risk of
ARI
Cold weather
Crowding or chilling

High prevalence Exposure to air pollution

of nasopharyngeal • Tobacco smoke
carriage of • Biomass smoke
pathogenic bacteria • Environmental air pollution
 Magnitude of the Problem
in Indonesia
Pneumonia in children (< 5 years of age)
Morbidity Rate 10-20 %
Mortality Rate 6 / 1000
Pneumonias kill
 50.000 / a year
 12.500 / a month

 416 / a day = passengers of 1 jumbo jet plane

 17 / an hour

 1 / four minutes
Pneumonia is a no 1 killer for infants
(Balita)
 Pneumonia
Classifications
Anatomical classification
 Lobar pneumonia
 Lobular pneumonia
 Intertitial pneumonia
 Bronchopneumonia
Etiological classification
 Bacterial pneumonia
 Viral pneumonia
 Mycoplasma pneumonia
 Aspiration pneumonia
 Mycotic pneumonia
Etiology of Pneumonia

Predominantly : bacterial and viral

In developing countries:
bacterial > viral
(Shann,1986): In 7 developing countries,
bacterial  60 %
(Turner, 1987): In developed countries,
bacterial 19 % ; viral 39 %
 Bacterial etiology

Streptococcus pneumoniae
Hemophilus influenzae
Staphylococcus aureus
Streptococcus group A – B
Klebsiella pneumoniae
Pseudomonas aeruginosa
Chlamydia spp
Mycoplasma pneumoniae
 BACTERIA ISOLATED FROM LUNG ASPIRATES
IN 370 UNTREATED CHILDREN WITH PNEUMONIA
%
50

40

30

20

10

0
S Pneumoniae H Influenzae S Aureus
 Characteristic features

S pneumoniae
 mucosal inflammation lesion
 alveolar exudates
 frequently lobar pneumonia)
H influenzae, S viridans, Virus
 invasion and destruction of mucous membrane
Staphylococcus, Klebsiella
 destruction of tissues  multiple abscesses
Simple Clinical Signs of Pneumonia
(WHO)

Fast breathing (tachypnea)

Respiratory thresholds
Age Breaths/minute
< 2 months 60
2 - 12 months 50
1 - 5 years 40

Chest Indrawing
(subcostal retraction)
 Pathology and Pathogenesis
Bacteriae peripheral lung tissues
 tissues reaction  oedematous
Red Hepatization Stadium
alveoli consist of : leucocyte, fibrine,erythrocyte,
bacteria
Grey Hepatization Stadium
fibrine deposition, phagocytosis
Resolution Stadium
neutrophil degeneration, loose of fibrine,
bacterial 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.
Blood Gas Analysis & Acid Base Balance

Hypoxemia (PaO2 < 80 mm Hg)

 with O2 3 L/min 52,4 %
 without O2 100 %
Ventilatory insufficiency
 (PaCO2 < 35 mmHg) 87,5 %
Ventilatory failure
 (PaCO2 > 45 mmHg ) 4.8 %
Metabolic Acidosis
 poor intake and/or hypoxemia 44,4 %
(Mardjanis Said, et al. 1980)
 Radiographic patterns
1. Diffuse alveolar and interstitial
pneumonia (perivascular and
interalveolar changes)
2. Bronchopneumonia
(inflammation of airways and
parenchyma)
3. Lobar pneumonia
(consolidation in a whole lobe)
4. Nodular, cavity or abscess lesions
(esp.in immunocompromised patients)
 Management
Severe Pneumonia
Hospitalization
Antibiotic administration
 Procain Pennicilline, Chloramphenicol
 Amoxycillin + Clavulanic Acid
Intra Venous Fluid Drip
Oxygen
Detection and management of
complications
 Complications

Pleural effusion (empyema)

Piopneumothorax
Pneumothorax
Pneumomediastinum
 Bronchiolitis

 Bronchioles inflammation
 Clinical syndromes:
fast breathing, retractions, wheezing
 Predominantly < 2 years of age
(2 – 6 months)
 Difficult to differentiate with pneumonia
 Bronchiolitis
Etiology
Predominantly RSV (Respiratory Syncytial
Virus), adenovirus etc.
Diagnosis
Etiological diagnosis
 Microbiologic examination
Clinical diagnosis
 Signs and symptoms
 Age
 Resource of infection
 Bronchiolitis

Clinical Manifestations
cough, cold, fever,fast breathing, retraction,
wheezing, irritable, vomitus, poor intake
Physical Examinations
tachypnea, tachycardia, retraction,
expiration >, wheezing, fever,pharyngitis,
conjunctivitis, otitis media.
 Bronchiolitis

Radiologic examination
diffuse hyperinflation
 flat diaphragm,
 subcostal >
 retrosternal space >
peribronchial infiltrates
pleural effusion (rare)
 Bronchiolitis
Management
 Supportive
 Severe disease
hospitalization
intra venous fluid drip
oxygen
(antibiotics)
 Bronchodilator: controversial
 Corticosteroid: controversial
 Bronchiolitis

Natural history & complications

 Improved clinical findings : in 3-4 days
 Improved radiological features: in 9 days
Persistent respiratory obstruction : 20%
Respiratory failure : 25 %
Lung collaps (rare)
 Bronchiolitis

Correlation with Asthma

 30 % - 50 % becomes asthmatic patients
 Similarity in : - pathogenic mechanisms
- pathologic disorders