ACUTE RESPIRATORY INFECTIONS Pneumonia Bronkiolitis Bronkitis Akut
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 ARITEKNAF, BANGLADESH, 19821982-1985 Deaths per 1000 children
140 120 100 80 60 40 20 0 1-5
6-11
12-23 Ag e i n M on t h s
24-35
36-50
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%)
Other (33.1%)
Malnutrition (29%)
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 Young age
Vitamin A deficiency Low birth weight
Increase risk of ARI Crowding High prevalence of nasopharyngeal carriage of pathogenic bacteria
Cold weather or chilling Exposure to air pollution • Tobacco smoke • Biomass smoke • Environmental air pollution
Magnitude of the Problem in Indonesia Pneumonia in children (< 5 years of age) Morbidity Rate 1010-20 % 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.
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)
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 and human herpes virus, leucocytois 17000, ESR 8 mm/ h l, CRP 22 mg/l
Blood Gas Analysis & Acid Base Balance Hypoxemia (PaO2 < 80 mm Hg)
with O2 3 L/min without O2
52,4 % 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)
Management Severe Pneumonia Hospitalization Antibiotic administration
Procain Pennicilline, Chloramphenicol Amoxycillin + Clavulanic Acid
Intra Venous Fluid Drip Oxygen Detection and management of complications
WHO recommendations for treatment of infants less 2 months who have cough or difficulty breathing
No pneumonia
:
No tachypnea, no severe chest indrawing Do not administer an antibiotic
Severe pneumonia : Tachypnea or severe chest indrawing Admit, administer benzylpenicillin + gentamycin, and oxygen
WHO recommendations for treatment of children aged 2 months to 4 years who have cough or difficulty breathing No pneumonia
: No tachypnea, no chest indrawing Do not administer an antibiotic
Pneumonia
: Tachypnea, no chest indrawing Home treatment with cotrimoxazole, amoxicillin 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 on age and severity of pneumonia Outpatients (Mild to Moderate)
Inpatients (Moderate)
Inpatients (Severe)
3 - 6 mos
Amoxicillin with or without clavulanate Erythromycin
Ceftriaxone or cefotaxim
Ceftriaxone or cefotaxime + vancomycin
6 mos to 5 yrs
Amoxicillin with or without clavulanate Erythromycin
Ceftriaxone, cefotaxime, Ceftriaxone or cefotaxime or + macrolide + vancomycin Cefuroxime + macrolide
Age
5 – 18 yrs
Macrolide
Ceftriaxone or cefotaxime Ceftriaxone or cefotaxime + macrolide + vancomycin + macrolide
Hsiao G et al, 2001
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
Pathology
Necrosis of the resp. epithelium Destruction of ciliated epithelial cells Peribronchial infiltration with lymphocites & neutrophils Sub mucosal edematous No destruction of collagen, muscle, or elastic tissue
Pathophysiology Edema + accumulation of mucous & cellular debris narrow of peripheral airway partially / totally occluded over distention / atelectasis
…Bronchiolitis
Etiology
Predominantly RSV (Respiratory Syncytial Virus) Other viruses : rhinovirus, adenovirus, influenza virus, parainfluenza virus, entero virus, etc.
Severity
Prematurity OR 1.84 Underlying medical condition OR 2.84 Group A RSV strain OR 3.26 Age < 3 mo OR 4.39
…Bronchiolitis
Diagnosis
Etiological diagnosis Microbiologic examination
Clinical diagnosis Signs and symptoms Age Resource of infection epidemic of RSV
Laboratory finding Radiological examination
…Bronchiolitis
Clinical Manifestations : mild rhinorrhea, cough, cold, lowlow-grade fever 1-2 d fast breathing, chest retraction, wheezing, irritable, vomitus, poor intake Physical Examinations tachypnea, tachycardia, retraction, prolonged expiration, wheezing, fever,pharyngitis, conjunctivitis, otitis media, dehydration
…Bronchiolitis
Radiologic examination diffuse hyperinflation
flat diaphragm, Intercostal space > retrosternal space >
peribronchial infiltrates / thickening patchy atelectasis segmental collapse pleural effusion (rare) Laboratory finding
Respiratory rate : Arterial saturation pCO2
…Bronchiolitis
Laboratory finding
Microbiologic examination WBC : 5000 – 24.000 cells/mm3, predominantly PMN & bands Blood Gas Analysis Arterial saturation pCO2 Mild respiratory alkalosis Metabolic acidosis Acute respiratory acidosis
…Bronchiolitis
Management
Mild treated at home Moderate / severe disease hospitalization support : oxygen intra venous fluid drip (antibiotics) detect & treat possible complication prevent the spread of inf. Controversial : bronchodilator corticosteroid antiviral antibiotic
…Bronchiolitis
Natural history & complications
Regeneration of bronchiolar epithelium after 3 or 4 d Cilia after 3 or 4 d Improved clinical findings : in 33-4 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
Bronkitis akut radang bronkus akut umumnya disertai radang akut saluran napas bawah lainnya Tidak pernah berdiri sendiri Trakeobronkitis akut = Bronkitis
Istilah yang membingungkan Bronkitis kapiler (Capillary Bronchitis) Bronkitis Pneumonia interstitial Bronkitis asmatika Salah satu bentuk asma
Etiologi Bronkitis akut Umum : virus Spesifik
Influenza Pertusis Campak (morbilli) Salmonella Difteria Scarlet fever
Predisposisi dan faktor yang berpengaruh Asap rokok Alergi Cuaca Keadaan umum yang jelek (Poor health) Infeksi kronik alat napas atas
Pemeriksaan fisis Panas : ((-) (+) Mukosa : - nasofaringitis - konjungtivitis - rhinits virus Suara napas kasar Ronki basah kasar halus Mengi (Wheezing)
(-)
SPUTUM
: Jernih
beberapa hari
keruh
5-10 hari
Batuk hilang
jernih
Gejala dan tanda lain bronkitis akut
Rasa tidak enak di bawah tulang dada : Seperti terbakar sakit Suara napas berbunyi seperti siulan Sesak Muntah
Penanggulangan bronkitis akut Simptomatis Pengeluaran lendir/sputum :
Posisi tidur diubahdiubah-ubah Jaga kelembaban udara Sering minum
Kodein : hatihati-hati ! (sangat jarang diperlukan) Antihistamin : HatiHati-hati Atropin like effect
Bronkitis akut Ekspektoran : tidak perlu Antibiotika : Tidak ada gunanya Indikasi Bronkitis akut berulang Ada komplikasi
Komplikasi bronkitis akut Otitis Sinusitis Pneumonia Terutama kalau gizi buruk
Batuk kronik berulang pada anak: bronkitis kronik tidak ada
dasar : - penyakit paru - penyakit sistemik DD/
D/
Komponen refleks batuk Reseptor
Aferen
Laring
Cabang nervus vagus
Pusat batuk
Eferen
Otot,
Laring, trakea dan bronkus
Trakea Bronkus
Efektor
Nervus vagus
Telinga Lambung Hidung Sinus paranasalis
Nervus trigeminus
Faring
Nervus glosofaringus
Perikardium diafragma
Nervus frenikus
Tersebar merata di medula dekat Pusat pernapasan : di bawah kontrol Pusat yang Diafragma, otot-otot Nervus Frenikus, Interkostal, lebih tinggi Interkostal & lumbaris
abdominal & otot lumbal
Saraf-saraf Otot saluran napas Trigeminus, Fasialis dan otot bantu napas Hipoglosus,dll
