PENYAKIT SISTEM RESPIRASI ANAK

(EMERGING DAN REEMERGING DISEASE)

dr. MS Anam, MSi.Med, Sp.A

Divisi Respirologi Departemen Ilmu Kesehatan Anak

FK Undip/RSUP dr. Kariadi Semarang
2015

SASARAN BELAJAR
Pada akhir perkuliahan mahasiswa mampu
menjelaskan definisi, etiologi, patogenesis dan
patofisiologi, diagnosis dan tatalaksana penyakit berikut :
Pneumonia
Bronchiolitis
Bronchitis Akut
Pertusis
Bronkiektasis
Asma Bronchial

PNEUMONI
A
Terminologi
Pneumonia,
Bronchopneumonia,
Acute Respiratory Tract Infection (Ispa)
Lung Infection
etc

DEFINITION
Inflamasi parenkim paru
Penyebab
Infeksi
Non Infeksi
Inflamasi parenkim paru yang disebabkan
oleh aspirasi benda asing disebut
PNEUMONIA ASPIRASI

ETIOLOGY
INFEKSI
BAKTERI : >> SERING
VIRUS : segera diikuti infeksi sekunder bakteri
JAMUR : Aspergilus, Candida
PARASIT : jarang (Loeffler Disease)

NON INFEKSI
INHALAN Pneumokoniosis
ASPIRASI BENDA ASING isi lambung, zat luar
POSITIONING Orthostatik Pneumonia

ETIOLOGI
.

TERSERI
NG

CLASSIFICATION
Community Acquired Pneumonia
Pneumonia yang terjadi di komunitas
Kuman paling sering Streptococcus
pneumonia, Haemopylus Influenza
Hospital Acquired Pneumonia
Pneumonia yang terjadi setelah
minimal 2 hari perawatan di RS
Kuman tergantung dari pola kuman RS
setempat

Other
Classification..
Anatomical
Lobar Pneumonia
BRONCHOPNEUMONIA (Lobaris Duplex)

Lobularis/Segmental Pneumonia
Interstitial Pneumonia

Etyological
Viral, Bacterial, Fungal, Paracytic

Causes
Infection and Non Infection

LOBARIS PNEUMONIA
Affect one lobus of the lung

BRONCHOPNEUMONIA
Affect more than one lobus of
the lung, usually duplex

PATHOGENESIS &
PATHOPHYSIOLOGY
INFECTION DETERMINED BY
1.integrity of pulmonary host defenses
2.microbial pathogenicity and
3.external environmental exposures

PULMONARY DEFENSE IN UPPER AND LOWER

RESPIRATORY TRACT

PULMONARY DEFENSE IN LOWER

RESPIRATORY TRACT

PATHOGENESIS

Bacterial entry into the host

Pulmonary pathogens may reach the lung
parenchyma by the following routes:
Direct inhalation of bacterial-laden aerosols
Aspiration of oropharyngeal or gastric
contents
Direct spread of infection from the upper
respiratory system to the lower parts along
mucosal surfaces
Haematogenous spread to the lungs from
an adjacent infected organ

MOST
COMMON
ROUTE

Microbial virulence factors

IMMUNE DEFENSES AND INFLAMMATORY

RESPONSE
In bacterial pneumonia, injury to the lung parenchyma usually
results from activation of the immune system in response to
bacterial infection

MORPHOPATHOLOGICAL FINDINGS
4 STAGES
1.
2.
3.
4.

CONGESTION
RED HEPATIZATION
GREY HEPATIZATION
RESOLUTION

STAGES OF PNEUMONIA
CONGESTION
vascular congestion
intra-alveolar proteinaceous fluid
small numbers of scattered
neutrophils, and
numerous bacteria within the alveoli.
the infected lobes are grossly heavy,
hyperaemic, dark-red and boggy

RED HEPATIZATION

Few days later

Eritrocyte in alveolar
Neutrofil , and
Fibrin
Cause by persisting vascular congestion with red cell
extravasation
Lung appearance like liver, solid and consolidated

GREY HEPATIZATION

One or two days

Eritrocyte lysis
Fibrinosuppurative exudate
Large Mononuclear cell
Lung still looks consolidated but is paler, gray, dry, firm
and non crepitant

RESOLUTION
Uncomplicated cases
Alveolar exudate
enzymatically digested
producing a semifluid granular
debris that is resorbed, cleared by macrophages,
expectorated or undergoes organization
Alveolar epithelium soon regenerates and is becomes
normal again within 8-14 days
Macroscopically, the consolidated lung softens and liquefies
and returns to its normal red colour

PATHOPHYSIOLOGY
Inflammatory Response

Fever
Inadequate Gas Exchange

Respiratory syptoms; cough,

tachypnea, dyspnea, retraction,
hypoxia, sianosis; Obstruction
symptoms; abnormal physical
finding (ronkhi)

2 BULAN 5 TAHUN

GEJALA KLINIS

Demam tinggi Desaturasi

Sesak napas
Retraksi
Batuk
(suprasternal,
intercostal,
Napas cepat
subcostal)
Sianosis
Suara napas
Malas minum/makan
menurun
Penurunan
Rhonki basah halus
kesadaran

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)

DIAGNOSIS PNEUMONIA

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

Complications
Pleural effusion (empyema)
Piopneumothorax
Pneumothorax
Pneumomediastinum

Management
Severe Pneumonia
Hospitalization
Antibiotic administration
Amoxycilline
Ampicilline + Gentamicyne
Ceftriaxone

Intra Venous Fluid Drip

Oxygen
Detection and management of

ANTIBIOTIC

ANTIBIOTIC
Community setting
Amoxycilline ORAL
25 50 mg/kg/day 3x
80 mg/kg/day 2x (high dose)

Hospital
Injectable antibiotic
Combination
Ampicilline (50-100 mg/kg/day 3-4x) +
Gentamycine
Ceftriaxone

NO
2

DIAGNOSIS
Pneumonia
usia < 2 bulan

Pneumonia
usia 2 bln - 5 thn

Pneumonia
Usia > 5 Tahun

KUMAN
PENYEBAB
-Streptokokus atau
kombinasi kuman gram
positif dan gram
negative

Streptococcus
pneumonia,
Hemophylius influenza,
staphylococcus
aureus
Streptokokus
pneumonia dan
-Streptokokus,
Mycoplasma,
pneumonia,
chlamidia

REKOMENDASI
ANTIBIOTIK
Lini pertama
Ampicilin
DAN (+)
Gentamicin
Lini kedua
Ceftriakson
Lini pertama
Ampicilin
DAN (+)
Gentamicin
Lini kedua
Ceftriakson
Lini pertama
Ampicilin
DAN (+)
Gentamicin
Lini kedua
Ceftriakson
Eritromisin

DOSIS

FREK

LAMA

CARA

50-100 mg/kg/hari

3-4 x

7-10 hari

i.v

7,5 mg/kg/hari

1-2 x

7-10 hari

i.v

50-100 mg/kg/hari

1-2 x

7-10 hari

i.v

50-100 mg/kg/hari

3-4 x

7-10 hari

i.v

7,5 mg/kg/hari

12 x

7-10 hari

i.v

50-100 mg/kg/hari

1-2 x

7-10 hari

i.v

50-100 mg/kg/hari

3-4 x

7-10 hari

i.v

7,5 mg/kg/hari

1-2 x

7-10 hari

i.v

50-100 mg/kg/hari
50 mg/kg/hari

1-2 x
3-4 x

7-10 hari
7-10 hari

i.v
p.o/i.v

BRONCHIOLI
TIS

DEFINITION
Inflammation of the BRONCHIOLUS
Bronchiolus the end
of conducting respiratory
tract zone

ETIOLOGY
Typically caused by VIRAL
The MOST common
Respiratory Syncytial Virus (RSV)
Others viruses : influenza,
parainfluenza, adenovirus,
coronavirus, rhinovirus
Myc. Pneumonia very rare
thought isolated not recognized as
etiologic agent

PATHOGENESIS &
PATHOPHYSIOLOGY

Obstructed Bronchiolus cause respiratory

symptoms difficult breathing, tachypnea,
dyspnea, sianosis, hypoxemia, nasal flaring, etc.
Inflammation cause low grade fever, rhinorrea,
cough, etc

Physical finding; tachypnea,

low grade fever, retraction of
the chest wall, raised work of
breathing, sianosis,
Lung auscultation wheezing,
abnormal bronchovesicular
sound, late experium

Obstruction of the bronchiolus hyperinfaltion lung,

air trapped, emphysematous

Hyperinfaltion
Lung

Air Trapped

emphysematous

Differentiation with pneumonia

Affect young infant (2 month 24 month, usually 11 month)
penumonia under 5 years
Etiology Virus pneumonia (mostly bacterial)
Located in bronchiolus (pneumonia reached alveolus)
Low grade fever (pneumonia high grade)
Pathological dominancy obstruction of the airway
Lung auscultation wheezing pneumonia rhonki
Chest X-Ray hyperinflation, air trapped, emphysematous
pneumonia consolidation, infiltrate, etc

Clinical Manifestation
History
o early rhinorrhea, cough, low-grade fever
o later tachypnea, wheezing, retractions,
fussiness, poor feeding, lethargy, apnea
Physical Examination
o tachypnea, retractions, fever, tachycardia
o fever may suggest more severe infection,
longer hospital stay and worse lung disease
o Skin: sianosis concurrent conjunctivitis, otitis
media or pharyngitis, auscultation wheezing,
prolonged expiratory phase

DIAGNOSIS
Based on history and physical exam,
and should not routinely order
laboratory and radiologic studies for
diagnosis
Typical bronchiolitis presents as
seasonal respiratory illness in children
< 2 years old with

fever
tachypnea
wheezing
increased respiratory effort (grunting, nasal

TREATMENT
Assess hydration and ability to take
fluids orally (SR)
Temperature regulation (SR)
Oxygen
o Insufficient evidence to determine when to
use oxygen therapy in children with lower
respiratory tract infections
o American Academy of Pediatrics
recommendations
o if oxyhemoglobin saturation (SpO2) persistently
below 90%, adequate supplemental oxygen
should be used to maintain SpO2 90% (AAP
Option D)
o oxygen may be discontinued if SpO2 90% and
infant is feeding well and has minimal
respiratory distress (AAP Option D)

Mumet
bro?
Seh ONO
Meneh
looo.
Lanjut yaa

ACUTE
BRONCHITIS

DEFINITION
Inflammation of the mucous membrane within the Bronchial Tube

Bronchus
conducting respiratory
tract zone from trachea
to bronchiolus

ACUTE
Less than 6 weeks

CHRONIC
Reoccuring frequently for more
than 2 years

ETIOLOGY
Usually caused by VIRAL often caused by the same
viruses that cause the flu and the common cold
< 1 year RSV, parainfluenza, and corona
1 10 years parainfluenza, enterovirus, RSV, rhinovirus
> 10 years influenza virus, RSV, adenovirus
Risks factors for acute bronchitis include:
o Dust or other air pollution
o Fumes or vapors
o Tobacco smoke, including second hand smoke
o Comorbid lung disease
o Elderly, children and infants

Etiology.

PATHOGENESIS &
PATHOPHYSIOLOGY

Inflammation edema, mucous secretion, partial

obstruction, damaged cillia cell

 Inflammation
Low grade fever
Malaise
Obstruction
Stimulate cough receptor
cough
Respiratory sign : tachypnea,
prolonged expiration,
wheezing, abnormal
bronchovesicular sound,

DIAGNOSIS
Sign & Symptoms
Cough, Sputum production, Wheezing,
Dyspnea, Chest pain, Fever, Hoarseness,
Malaise

Physical Examination & Diagnostic

Studies
Fever, tachypnea, wheezing, rhonki, and
prolonged expiration
NO Consolidation on chest x-ray

TREATMENT
Protussives and antitussives
Protussives (hypertonic saline, guaifenesin)
Antitussives (hydrocodon, codein,
dextrometorphan, carbetapentane,
benzonatate)

Bronchodilators
Beta agonis

Antibiotics
Wide spectrum antibiotics

Mesti do
bingung!!
wkwkkw

.Lanjut

PERTUSIS

ETIOLOGY
Bordetella Pertussis pleiomorfic
Bacillus gram (-)
> 40% Cases < 5 Years
Incubation periods 7-10 days (range 421 days)

ANTIGENITAS

Transmission
Very Contagious
Transmission occurs via respiratory
droplets

http://www.universityscience.ie/imgs/scientists/whoopingcough.gif

http://www.ratbags.com/rsoles/history/2000/12december.htm

pathogenesis
Non invasive infection of respiratory mucosa
Ciliated epithelium of bronchi , trachea

Human is the only natural host

IP : 1 2 weeks
Tracheal cytotoxin ( TC )
Pertussis toxin (PT)
Lymphocytosis

Filamentous haemagglutnin (FHA)

Whooping Cough
Also known as Pertussis
Outbreaks first described in the 16th
Century
Major cause of childhood fatality
prior to vaccination

paaap.org/immunize/ course/slide27.html

Clinical Manifestation
Paroxysm Cough inspiratory
whoop and/or post-tussive vomiting
Stage :
1.Catarrhal ( 1-2 weeks) URTI
(intermitten non-productive cough)
2.Paroxysmal (2-6 weeks)
paroxysmal cough, whooping
3.Convalescens (6 12 weeks)

COMPLICATION
Pneumonia
Nutritional problem frequent
vomiting
Neurological problem due to Hipoxia
seizures, enchepalophaty
Pressure effect rib fracture,
pneumothorax, atelectasis, epistaxis,
subdural hematoms, hernia, and rectal
prolaps

Diagnosis

Based
Basedon
onsymptoms
symptoms

Culture
Cultureon
onBordet-Gengou
Bordet-Gengou(potato-glycerol-blood
(potato-glycerol-blood
agar)
agar)medium
medium

Isolation by culture
PCR
Direct fluorescent antibody
Serological testing
http://medinfo.ufl.edu/year2/mmid/bms5300/images/d7053.jpg

Laboratory Diagnosis

Specimens

Post / per nasal swab (no cotton

swab) / cough plate

Microscopy

Gram negative coccobacilli

Fluorescent antibody stain

Culture

Bordet Gengou Medium

mercury drop pearl appearance
colonies

Identification

Microscopy & slide agglutination

Antibiotic

Erythromycin / Co-trimoxazole

Treatment
Antibiotic therapy
Erythromycin
Azithromycin and clarithromycin

http://www.aboutthatbug.com/AboutThatBug/files/CCLIBRARYFILES/
FILENAME/0000000032/033_lg.jpg

http://www.vet.purdue.edu/bms/courses/lcme510/chmrx/macrohd.htm

Pertussis Vaccine
1st Pertussis vaccine- whole cell
Acellular vaccine now used
Combination vaccines

http://www.tdh.state.tx.us/immunize/providers.htm
http://www.nfid.org/publications/clinicalupdates/pediatric/pertussis.html

Vaccine problems
Complications/Safety
Multiple administration
Waning adolescent and adult
immunity
Strain Variability

http://www.healthcareforhoosiers.com/Member/vaccineschedule.html

BRONCHIECT
ASIS

DEFINITION
1819 Rene-Theophile-Hyacinthe Laennec
Abnormal irreversibly dilated and often thick walled bronchi, resulting
from a variety of pathological process that cause destruction of the
bronchial wall and its surrounding supporting tissues

TREATMENT
GENERAL GOALS
1. To limit the cycle of infection and inflammation
2. To limit the progression of the airway damage
3. To reduce the symptoms
4. To reduce the number of exacerbations, AND
5. To improve the quality of life

1. General Supportive Therapy

Good nutrition
Avoid smoking and exposure
Regular exercise
Exposure to fresh air
Multi team health care professionals
Physicians
Physiotherapist
Nurses
Occupational therapist
Phsycologist

2. Treatment of the Underlying Causative

Conditions

3. Prevention of Secondary Infection

with Vaccination
Influenza vaccine
Pneumococcal vaccine

4. Mobilization of Airway Secretions

Chest physiotherapy
Postural drainage
Active Cycles of Breathing Technique (ABCT)
Positive Expiratory Pressure (PEP)
Oscillatory PEP device
High frequency chest wall percussion
Exercise
Inspiratory muscle training

4. Mobilization of Airway Secretions cont

Mucolytic and inhaled hiperosmolar agent s
Bromhexine (combination with antibiotics)
Erdostein
Recombinant human DNA-ase (harm for non CFB)
Inhaled mannitol
Inhaled hypertonic saline (NaCl 3-5-7 %)

5. Bronchodilator Therapy

Short acting beta agonist

Long acting beta agonist
Anti cholinergic
Methylxanthine
Leucotrien antagonist

6. Antibiotics Therapy
Acute infective exacerbation
Broad spectrum antibiotics (P aurug, Staph Aureus,
Haemophyl Inf)
Treating pneumonia

Maintenance
Macrolide longterm treatment

7. Antiinflammatory agents
Corticosteroids
High dose inhaled
CS
Oral CS (no study)

Macrolide

Question ??