SELAMAT PAGI

1
TATA LAKSANA
PNEUMONIA PADA ANAK

Amiruddin L
Bagian Ilmu Kesehatan Anak
FK-UNHAS
SituasiPneum onia Balita di
Indonesia
 SituasiPneum onia Balita di
Indonesia
Pneumonia balita salah satu indikator
keberhasilan program pengendalian
penyakit dan penyehatan lingkungan
seperti tertuang dalam RENSTRA
Kemenkes RI 2010-2014.
Ditargetkan persentasi Penemuan dan
tatalaksana penderita pneumonia balita
thn 2014 adalah 100%
Epidem iologi
Pendahuluan
Infeksi respiratori akut (IRA) terpenting morbiditas

dan mortalitas pada anak, terutama << 5 tahun.

IRA infeksi respiratori atas(Cavum Nasi) dan

adneksanya hingga parenkim paru.

Pengertian akut infeksi berlangsung hingga 14

hari.
IRA (secara anatomi) : IRA atas dan IRA bawah

IRA atas : infeksi primer respiratori di atas laring,

IRA bawah: infeksi laring ke bawah(parenkim paru)

Wantania JM, Naning N, Wahani A. Infeksi Respiratori Akut. Dalam: Rahayu NN, Supriyatno B,
Setyanto DB, editors. Buku Ajar Respirologi Anak, Edisi Pertama. IDAI,Jakarta, 2012:268-365
Tujuan Instruksional

I. Tatalaksana Pneumonia
1) Tatalaksana komplikasi Pneumonia
2) Terapi Oksigen
3) Asuhan Perawatan Pneumonia
4) Tatalaksana Rujukan Pneumonia

II. Praktek /Study Kasus

 Pneumonia (Pn) suatu peradangan
parenkim paru dapat disebabkan oleh
bacteria, virus atau organisme yg lain.
Pn
Gejala2 infeksi akut;batuk ,sesak,
demam dll
Foto toraks : gbr infiltrat akut ,
konsolidasi
Auskultasi : ronki nyaring +/-
 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
 Besarnya masalah akibat pneumoni
di Indonesia
Pneumonia pada anak (< 5 tahun)
Morbidity Rate 10-20 %
Mortality Rate 6/1000 Populasi anak
Angka kematian Pneumonia
150.000 / a year
12.500 / a month
416 / a day = passengers of 1 jumbo jet
plane
17 / an hour
1 / four minutes
Pneumonia is a number one killer of
children
C LIN IC A L D IA G N O SIS

Suggestive signs and symptoms

CXR or other imaging technique
Microbiologic testing
Etiology ofPneum onia

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 %
Pneum onia
Classifi
cations
Anatomical classification
Lobar pneumonia
Lobular pneumonia
Intertitial pneumonia
Bronchopneumonia
Etiological classification
Bacterial pneumonia
Viral pneumonia
Mycoplasma pneumonia
Aspiration pneumonia
Mycotic pneumonia
Bacterialetiology

Streptococcus pneumoniae
Hemophilus influenzae
Staphylococcus aureus
Streptococcus group A B
Klebsiella pneumoniae
Pseudomonas aeruginosa
Chlamydia spp
Mycoplasma pneumoniae
Pneum onia is a no 1 killer for
infants (Balita)
ClinicalPresentation ofPneum onia

Purulentsecretions
DensitiesonChest
xray

Fever
Leukocytosis
(highwbc)
 Pneumoni
a
Pernapasan cuping hidung
Dyspnea
Retraksi
Ronki Nyaring
Bronchopneumonia
Early stages of acute bronchopneumonia. Abundant inflammatory
cells fill the alveolar spaces. The alveolar capillaries are distended
and engorged.
SIG N S AN D SYM PTO M S

Symptoms
Infants: non-specific manifestations
Fever, poor feeding, irritability, vomiting, diarrhea,
URI Sx, cough, respiratory distress
Older children: more specific
Fever, cough, chest pain, tachypnea, tachycardia,
grunting, nasal flaring, retracting. Cyanosis usually
very late.
Signs/Physical exam
RR > 60 x/mnt
Hypoxia
Rales, wheezes, crackles, coarse breath
sounds
CLINICAL MANIFESTATION

Non-respiratoric
fever, headache, fatigue, anorexia,
lethargy, vomiting and diarrhea
Respiratoric
cough, tachypnea , grunting, nasal
flaring, subcostal retraction, cyanosis,
crackles and rales,
Sensitivity and specificity of symptoms for
identifying pneumonia

Symptom Sensitivity Specificity

Tachypnea 92 % 15 %
Cough 92 % 19 %

Toxic appearance 81 % 60 %

Crackles 44 % 80 %

Retractions 35 % 82 %

Flaring 35 % 82 %

Pallor 35 % 87 %

Grunting 19 % 94 %

LeventhalJM,1982
Simple clinical signs of pneumonia (W H O )

Fast breathing (tachypnea)

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

ChestIndrawing(subcostal
retraction)
Antibiotic consideration for pneumonia related to
age group

Newborn and very Infants and preschool

young infants age children School age children
(< 3 months) (3 months 5 years) ( > 5years)

Etiology: Etiology : Etiology :

Group B Streptococci S pneumoniae M pneumoniae
Gram negative H influenzae K pneumoniae
Enteric bacteriae S Pneumoniae
C trachomatis
S aureus
Antibiotic: Antibiotic:
Antibiotic: Beta-lactam Macrolide
ampicilin ampicilin erythromyin
amoxycilin amoxycilin, claritromycin
amoxycilin/ amoxycilin/clav acid azithromycin
clavulanic acid cephalosporin Tetracyclin and
+ gentamicin Co-trimoxazole) doxyciclin (> 8 years)
+ third generation Macrolide
cephalosporin Erythromycin,
Newer macrolide
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
TERAPIO KSIG EN
 TERAPIO KSIG EN
INDIKASI : Hipoksemia
Menentukan Hipoksemia:
- Pulse Oksimetri (SaO2 < 90%) Obyektif
- Tanda klinis (tidak terlalu akurat)
- Sianosis sentral
- Tidak bisa minum (ec gang respiratori)
- Tarikan dinding dada bagian bawah yg dalam
- Frekuensi napas 60x/menit
- Merintih (bayi muda)
- Anggukan kepala (head nodding)
TERAPIO KSIG EN

Sumber oksigen: sentral,silinder/tabung

oksigen, oksigen konsentrator
Metode pemberian:
- Nasal prong (rekomendasi)
- Kateter nasal
- Kateter nasofaring
Dosis pemberian:
- 1-2 l/menit (FiO2 30-35%)
- 0.5 l/menit (bayi muda)
TERAPIO KSIG EN
Pemantauan
- Tiap 3 jam perawat memonitor:
- Nilai SaO2 (pulse oksimetri)
- Kateter nasal/prongs bergeser
- Kebocoran sistem aliran oksigen
- Kecepatan aliran oksigen tdk tepat

Lama: diberikan sampai SaO2 > 90%,

-Tiap hari dicoba dilepas beberapa menit
(bila SaO2 > 90% oksigen dapat dihentikan)
-Pantau 30 mnt kemudian
-Tiap 3 jam selama 24 jam pertama
TERAPICAIRAN
Prinsip pemberian terapi cairan:
- terapi pengganti (replacement)
- terapi rumatan (maintenance)

Menghitung cairan rumatan

- Rumus Darrow (rumatan 24 jam)
100 ml/kgBB untuk 10 kg pertama
50 ml/kgBB untuk 10 kg berikutnya
25 ml/kgBB untuk setiap tambahan kg BB berikutnya

- Jika terdapat demam dapat ditambahkan cairan 10%

setiap kenaikan suhu tubuh 1 derajat
 P EN YEB A B K EM ATIA N
PA D A P N EU M O N IA
HIPOKSIA

- SIANOSIS SENTRAL
- SATURASI OKSIGEN
< 90 %
PNEUM ONI A

- SESAK NAPAS
BERAT (MERINTIH,
TARIKAN DINDING
DADA YANG
Lower chest wall
indrawing: with
out in
DALAM)
inspiration, the lower
chest wall moves in. br eathing

Avoid unnecessar y har m f ul m edicat ions such as r em edies cont aining

atropine, codeine derivatives or alcohol.
P EM ER IK SA A N

Lakukan
pemeriksaan
saturasi
oksigen pada Lakukan Foto
semua pasien Toraks jika
yang dicurigai memungkinka
pneumonia n
 Sources
Ox ygen should be available at all tim es. The t wo m ain sources of oxygen
are cylinders and oxygen concentrators. It is im por tant that all equipm ent is
checked for com patibilit y.

TER A P I O K SIG EN
Oxygencylinders andconcentrators
See list of recom m ended equipm ent for use with oxygen cylinders and con-
centrators and instructions for their use in the WHO m anuals on clinical use
of oxygen therapy and on oxygen system s.

10. SUPPORTIVE CARE

Oxygen delivery
Nasal prongs are the preferred
m et ho d o f deliver y in m ost
Berikan oksigen pada anak
cir cum st an ces, as t h ey ar e
s af e, n o n - in vasi ve, r eliabOXYGEN
le
dengan SatO2 < 90%
and do not obstruct the nasal
THERAPY

air way. Nasal or nasophar yn- tape on the cheeks near the nose (see gure). Care should be taken to keep the
geal catheters m ay be used as nostrils clear of m ucus, w hich could block the ow of oxygen.
an alternative only when nasal
ATAU
prongs are not available. The
Set a ow r ate of 12 litres/m in (0.5 litre/m in for young infants) to deliver an
inspired oxygen concentr ation of up to 40% . Hum idi cation is not required
use of headboxes is not rec-
with nasal prongs.
om m ended. Face m asks w ith
Tanda : a reser voir at tached to deliver Nasal catheter: a 6 or 8 French gauge catheter that is passed to the back of
100% oxygen m ay be used for the nasal cavity. Inser t the catheter at a distance equal to that from the side of
Sianosis sentral resuscitation. the nostril to the inner m argin of t he eyebrow.

Nasal prongs. These are shor t Set a ow rate of 12 litres/m in. Humidi cation is not required.
Kesulitan minum akibat sesak
tubes inser ted into the nostrils. Nasoph Oaryng
xygenealtherap y: Nasal
catheter. Ap6rongs
or 8 correctly
positioned and secured
Place them just inside the nos- Fr ench gauge catheter is passed to
Merintih setiap kali bernapas
trils, and secure with a piece the of phar ynx just below the level of
the uvula. Inser t the catheter at a
Tarikan dinding dada yang distance equal to that from the side 313
of the nostril to the front of the ear
berat (see gur e). If it is placed too far
dow n, gagging and vom iting and,
Penurunan kesadaran rarely, gastric distension can o ccur.
Set a ow r ate of 12 litres/m in to
Frekuensi Napas > 70 x/mnt
PB2_ch10.indd 313 avoid gastric distension. Hum idi- 5/06/13 10:09 AM
10. SUPPORTIVE CARE

cation is r equired.

Monitoring
Tr ain nur ses to p lace and secur e
th e nasal prongs cor rectly. Check
regularly that the equipm ent is wor king properly, and rem ove and clean the
prongs at least t w ice a d ay.
M onitor the child at least ever y 3 h to identify and corr ect any problem s,
including:
SU M B ER O K SIG EN

Tabung
silinder
Oksigen
konsentrator
Oksigen
sentral
P EM A N TA U A N D A N
P EN YA PIH A N TER A P I O K SIG EN
Setiap hari oksigen dititrasi
Setiap 3 jam perawat secara bertahap
menilai apakah: Dapat dihentikan jika:
Kondisi anak stabil - Klinis membaik
Nasal prong terletak Saturasi oksigen >90 %
pada tempatnya pada udara ruang
Tidak ada plak mukus Pastikan saturasi > 90%
Koneksi ke sumber (dalam 15 menit saat
penghentian) ; pantau 30
oksigen tetap terjaga
(flow rate) menit berikutnya ;
selanjutnya tiap 3 jam pada
Saturasi oksigen baik
hari pertama
Jika stabil oksigen dapat
dihentikan
 D IAG N O SIS BAN D IN G
DIAGNOSIS GEJALA TERAPI
Asma Riwayat wheezing Bronkodilator kerja
berulang, kadang cepat (salbutamol,
tidak berhubungan dg fenoterol, terbutalin)
batuk dan pilek Steroid (serangan
Hiperinflasi dinding sedang-berat)
dada Penghindaran
Ekpirasi memanjang pencetus
Respon baik terhadap
bronkodilator
Bronkiolitis Episode wheezing Sama dengan
pertama pada anak pneumoniae
umur < 2 tahun
Hiperinflasi dinding
dada
Ekspirasi memanjang
Gejala pada
pneumonia juga
dapat ditemukan
Respon kurang/tidak
 D IAG N O SIS BAN D IN G
DIAGNOSIS GEJALA TERAPI

CROUP Demam Steroid

(Laringotrakeobronkitis Suara serak Epinefrin inhalasi
) Batuk menggongong
Stridor
Pertusis Batuk paroksismal Antibiotik makrolide
dapat diikuti whoop , Fasilitasi pengeluaran
muntah, sianosis atau lendir saat batuk
apnu Atasi hipoksia saat
Bisa tanpa demam serangan
Imunisasi DPT tidak
ada/tdk lengkap
Klinis baik diantara
batuk
 D IAG N O SIS BAN D IN G
DIAGNOSIS GEJALA TERAPI
Tuberkulosis Riwayat kontak positif dg TB Biasa 3 OAT
pasien TB dewasa TB Berat 4-5 OAT
Uji tuberkulin positif ( 10 Diberikan tiap hari
mm, pada keadaan pada TB milier, efusi
imunosupresi 5 mm) pleura, perikarditis
Pertumbuhan buruk/kurus dan meningitis TB
atau berat badan ditambahkan steroid
menurun
Demam ( 2 minggu)
tanpa sebab yang jelas
Batuk kronik ( 3 minggu)
Pembengkakan KGB leher,
aksila,inguinal yg khas
Pembengkakan
tulang/sendi
Difteri Demam, nyeri menelan, Atasi obstruksi sal
Stridor, Selaput putih napas
mudah berdarah di ADS
saluran napas, Bull neck, Antibiotik (penisilin
Contoh : Diagnosis banding batuk atau kesulitan bernafas
TATA LAKSAN A M ERU JU K

Rujukan harus dilakukan pada keadaan

pasien stabil (tidak syok atau gagal napas)
Rujukan pada kasus berat :
- Atasi hipoksemia ( pasang O2)
- Pasang akses vena dan berikan cairan
- Pasien dirujuk dengan diantar petugas
medis, siapkan alat resusitasi saat proses
merujuk
TER IM A K A S IH