Aspirasi Pneumonia Cetak R

7/23/2019 Aspirasi Pneumonia Cetak R

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Pneumonia AspirasiPneumonia Aspirasi

pada Anakpada Anak

Divisi Respirologi AnakDivisi Respirologi Anak

Ilmu Kesehatan Anak FK Unand-RS Dr. M.Ilmu Kesehatan Anak FK Unand-RS Dr. M.

DjamilDjamil

SejarahSejarah

400 thn SM : Hippocrates400 thn SM : Hippocrates bahayabahaya

aspirasiaspirasi

Mendelson th 1946 :Mendelson th 1946 : aspiration lungaspiration lung

injury injury

Sampai 50 thn terakhir masih menjadiSampai 50 thn terakhir masih menjadi

tantangan pada anak dan dewasatantangan pada anak dan dewasa

DefinisiDefinisi

ne!monia aspirasi : istilah !m!mne!monia aspirasi : istilah !m!m!nt!k beberapa sindrom klinik!nt!k beberapa sindrom klinik

"ejala klinik tergant!ng material"ejala klinik tergant!ng materialyang teraspirasiyang teraspirasi

#ipikal : berisi makanan $ cairan#ipikal : berisi makanan $ cairanberasal dari lamb!ngberasal dari lamb!ng

%isa j!ga &at lain seperti minyak%isa j!ga &at lain seperti minyaktanah' benda asingtanah' benda asing

(omplikasi : in)eksi(omplikasi : in)eksi

KlasifikasiKlasifikasi

Men!r!t wakt! kejadian :Men!r!t wakt! kejadian :

* ak!t* ak!t

* silent* silent Men!r!t j!mlah materi :Men!r!t j!mlah materi :

* sedikit* sedikit

* masi) * masi)

Men!r!t jenis material :Men!r!t jenis material :padatpadatcairancairan

KlasifikasiKlasifikasi

Acute,

large-volume aspiration

Recurrent, small-volume

aspiration and GER

oreign !odies

"ear dro#ning

$%drocar!on &kerosene'

(onditions Predisposing to(onditions Predisposing to

aspiration )ung *njur%aspiration )ung *njur%+natomic and+natomic and

mechanicalmechanical,e!rom!sc!lar,e!rom!sc!lar Miscellane!sMiscellane!s

,asogastric,asogastric

t!bet!be-aryngeal cle)t-aryngeal cle)t remat!rityremat!rity oor or oraloor or oral

hygienehygiene

tracheostomytracheostomy .le)t palate.le)t palate .erebral palsy.erebral palsy

/##/## "/"/ Hydrocephal!sHydrocephal!s

MicrognathiaMicrognathia M!sc!larM!sc!lardistrophydistrophy

MacroglosiaMacroglosia

+ Pneumonia Aspirasi akutmasiv+ Pneumonia Aspirasi akutmasiv

#ipikal : mengand!ng makanan#ipikal : mengand!ng makanan $cairan dari lamb!ng $cairan dari lamb!ng

Mengakibatkan per!bahan patologiMengakibatkan per!bahan patologi

dan )isiologi' tgtg pH dan j!mlahdan )isiologi' tgtg pH dan j!mlahmaterialmaterial

http://slidepdf.com/reader/full/aspirasi-pneumonia-cetak-r 8/51PatofisiologiPatofisiologi

)argesmall particle

Acidneutral li.uid Aspiration

Refle/ air#a%

clossure

Air#a% o!struction

Severe h%poventilation

Pulmonar% edema

$emorrhagic pneumonitis

Destruction and

dilution of surfactant

AtelectasisHypoxemia

Patholog%cal changesPatholog%cal changes

#ime a)ter aspiration e2ent3#ime a)ter aspiration e2ent3 athologic changesathologic changes

+ )ew min!tes acid asp3+ )ew min!tes acid asp3 +telectasis local+telectasis local

%e)ore 4 ho!rs%e)ore 4 ho!rs /pithelial degeneration o) bronch!s'/pithelial degeneration o) bronch!s'

!lmonary edema' hemorrhagic with!lmonary edema' hemorrhagic with

necrosis type 1 al2eolar cells'necrosis type 1 al2eolar cells'

in)iltrations and )ibrins in al2eolarin)iltrations and )ibrins in al2eolar

spacesspaces

,et 4*76 ho!rs,et 4*76 ho!rs +l2eolar consolidation' m!cosal+l2eolar consolidation' m!cosal

slo!ghingslo!ghing

+)ter 48 jam+)ter 48 jam Hyaline membran may be seenHyaline membran may be seen

%y ho!rs%y ho!rs egeneration o) bronchial epitheli!m'egeneration o) bronchial epitheli!m'

proli)eration o) )ibroblast' decreaseproli)eration o) )ibroblast' decrease

ac!t in)lammationac!t in)lammation

+)ter *7 weeks+)ter *7 weeks arenchymal scarring' bronchiolitisarenchymal scarring' bronchiolitis

obliteransobliterans

(linical 0anifestations(linical 0anifestations

n2ol2ed witnessed inhalation o)n2ol2ed witnessed inhalation o)

2omit or tracheal s!ctioning o)2omit or tracheal s!ctioning o)

gastric contentsgastric contents

Ha2e se2eral risk )or aspirationHa2e se2eral risk )or aspiration

Mild or se2ere respiratory distressMild or se2ere respiratory distress

.lassic Mendelson syndrome :.lassic Mendelson syndrome :asthma like reactionasthma like reaction whee&ing'whee&ing'

hypoemia' hypercapniahypoemia' hypercapnia

(linical manifestations(linical manifestations

;e2er' co!ghing and whee&ing;e2er' co!ghing and whee&ing

-ab )inding : le!kocytosis-ab )inding : le!kocytosisin)ection <3in)ection <3

adiological : in)iltrates' esp rightadiological : in)iltrates' esp right

!pper lobes!pper lobes

0anagement0anagement

S!pporti2e : oygen therapy' mechanicalS!pporti2e : oygen therapy' mechanical2entilation with //2entilation with //

%ronchoscopy and la2age )or large particle%ronchoscopy and la2age )or large particle

,o 2al!e to la2age )or ne!trali&ed acid,o 2al!e to la2age )or ne!trali&ed acidaspiratedaspirated

Maintained intra2asc!lar 2ol!meMaintained intra2asc!lar 2ol!me .orticosteroid : still contro2ersial' !se)!ll.orticosteroid : still contro2ersial' !se)!ll

when gi2ed close to the time o) massi2ewhen gi2ed close to the time o) massi2easpiration' =aspiration' =

1utcomes1utcomes

Mortality : 40 > 80 ?Mortality : 40 > 80 ?

n)ectio!s complications : 50?n)ectio!s complications : 50?

+ntibiotic )or initial therapy :+ntibiotic )or initial therapy :penicillin' ampicillin' clindamycinpenicillin' ampicillin' clindamycin

.hest perc!ssi2e therapy.hest perc!ssi2e therapy

(onditions Predisposing to infectious(onditions Predisposing to infectious

complications of Aspirationcomplications of Aspiration

"ingi2itis"ingi2itis

@ecayed teeth@ecayed teeth

"astric o!tlet or intestinal obstr!ction"astric o!tlet or intestinal obstr!ction /nteral t!be )eeding/nteral t!be )eeding

rolonged hospitali&ationrolonged hospitali&ation

/nditracheal int!bation/nditracheal int!bation Ase o) antacid$H blockersAse o) antacid$H blockers

2 Recurrent, small-volume2 Recurrent, small-volume

aspiration and GERaspiration and GER

Microaspiration or silent aspirationMicroaspiration or silent aspiration

Small aspiration into the l!ngSmall aspiration into the l!ng

"/ : "astro /osophagal e)l!"/ : "astro /osophagal e)l! #here is a relationship among#here is a relationship among

rec!rrent aspiration' "/ andrec!rrent aspiration' "/ and

respiratory diseaserespiratory disease

Mechanisms or the association oMechanisms or the association o

!"R and Respirator# disease!"R and Respirator# disease

!"R$ causing respirator# disease!"R$ causing respirator# disease

AspirationAspiration

Direct eect % &ronchitis$ tracheitis$ pneumonia$ atelectasisDirect eect % &ronchitis$ tracheitis$ pneumonia$ atelectasis

Rele' rom irritation o trachea or upper air(a#$Rele' rom irritation o trachea or upper air(a#$

lar#ngospasm$ &ronchospasmlar#ngospasm$ &ronchospasm

Indirect eect % inlammator# or another alterationIndirect eect % inlammator# or another alteration

predisposising to air(a# h#perreactivit#predisposising to air(a# h#perreactivit#

"sophageal % air(a# rele' (iout aspiration"sophageal % air(a# rele' (iout aspiration

Respirator# disease causing !"R Respirator# disease causing !"R

diaphragma lattening and changes o intraa&dominal pressurediaphragma lattening and changes o intraa&dominal pressure

gradientgradient

"ect o medication causing decreased lo(er esophageal sphincter"ect o medication causing decreased lo(er esophageal sphincter

pressurepressure

Disorders associated #ith GERDisorders associated #ith GER

+sthma+sthma %ronchiolitis%ronchiolitis

obliteransobliterans

.hronic co!gh or.hronic co!gh or

whee&ingwhee&ing

+pnea' bradycardia+pnea' bradycardia

+telectases+telectases +c!te li)e threating+c!te li)e threating

e2entse2ents

%ronchiectasis%ronchiectasis StridorStridor!lmonary )ibrosis!lmonary )ibrosis HoarsnessHoarsness

ne!monia'ne!monia'

bronchitisbronchitis

-aryngomalacia-aryngomalacia

3 oreign !od% aspiration3 oreign !od% aspiration

Brganic or anorganic materialBrganic or anorganic material

nitially placing objects in the mo!thnitially placing objects in the mo!th

#here is three distinct clinical phase#here is three distinct clinical phase

* period immediately a)ter the aspiration:* period immediately a)ter the aspiration: co!ghing' gagging' chokin' stridor' whee&ing'co!ghing' gagging' chokin' stridor' whee&ing'

cyanoticcyanotic

* min!tes to month : asymtomatic phase* min!tes to month : asymtomatic phase

* renewed symtomatic period : o!gh' sp!t!m* renewed symtomatic period : o!gh' sp!t!mprod!ction' )e2er' whee&ing' hemoptysisprod!ction' )e2er' whee&ing' hemoptysis

Supporting 0anagementSupporting 0anagement

o chest + and -ateralo chest + and -ateral

May be radiol!scentMay be radiol!scent

o epiration and inspirationso epiration and inspirations %ronchoscopy ' %ronchography%ronchoscopy ' %ronchography

+c!te aspiration : Heimlich+c!te aspiration : Heimlich

mane!2ermane!2er %lind )inger sweeping is%lind )inger sweeping is

contraindicated in in)antcontraindicated in in)ant

(omplications after air#a% foreign(omplications after air#a% foreign

!ad% removal!ad% removal+c!te airway+c!te airway

obstr!ctionobstr!ction-aringeal laceration-aringeal laceration

ne!momediastin!mne!momediastin!m %ronchial stenosis%ronchial stenosis

ne!mothorane!mothora #racheoseophageal#racheoseophageal

)ist!la)ist!la

Massi2e hempotysisMassi2e hempotysis @istal bronchiectasis@istal bronchiectasis

-aringeal edema-aringeal edema

4 "ear dro#ning4 "ear dro#ning

Most likely in children !nder 5 yearsMost likely in children !nder 5 years -!ng inj!ry ind!ced hypoia to the l!ng-!ng inj!ry ind!ced hypoia to the l!ng

parenchyma as well as aspiration o) water'parenchyma as well as aspiration o) water'

debris' gastric contents' or bacteriadebris' gastric contents' or bacteria n )resh water aspiration : p!lmonaryn )resh water aspiration : p!lmonary

s!r)actant is washed o!t and dil!teds!r)actant is washed o!t and dil!ted atelectasisatelectasis

n saltwater aspiration : osmotic shi)t o)n saltwater aspiration : osmotic shi)t o)protein*rich )l!id )rom the capillary intoprotein*rich )l!id )rom the capillary intothe al2eolithe al2eoli p!lmonary edemap!lmonary edema

5 $%drocar!on aspiration5 $%drocar!on aspiration

isk )actor : preschool age' mental retardation'isk )actor : preschool age' mental retardation'

etcetc

(erosene : most commonly(erosene : most commonly

Sign and symptom : choking' co!ghing' gaggingSign and symptom : choking' co!ghing' gagging ;e2er' cyanosis' se2ere respiratory distress;e2er' cyanosis' se2ere respiratory distress

o changes : appear a)ter 70 min!tes a)ter ingesto changes : appear a)ter 70 min!tes a)ter ingest

hydrocarbon' most commonly in 1 ho!rshydrocarbon' most commonly in 1 ho!rs

@econtamination like : ind!ction o) 2omiting'@econtamination like : ind!ction o) 2omiting'nasogastric la2age' are contraindicatednasogastric la2age' are contraindicated

OSASOSAS::(Obstructive sleep(Obstructive sleep

apnea syndrome)apnea syndrome)

aaconsequenceconsequence

of childhoodof childhood

obesitobesit

*ntroduction*ntroduction

ObstructiveObstructive sleep apnea syndromesleep apnea syndrome

(OSAS)(OSAS)

is ais a disorder of breathingdisorder of breathing during sleepduring sleepthat disrupts normal ventilation as wellthat disrupts normal ventilation as well

as sleep pattern and associated withas sleep pattern and associated with

symptoms including habitualsymptoms including habitual snoring,snoring,sleep diculties, and/or daytimesleep diculties, and/or daytime

neurobehavioral problemsneurobehavioral problems

Pediatrics !!"#!$#%!Pediatrics !!"#!$#%!

……IntroductionIntroduction

Prevalence of OSAS in &S$ #%#!'Prevalence of OSAS in &S$ #%#!' he most common symptom of OSAS he most common symptom of OSAS

in children isin children is snoringsnoring is* factors$is* factors$

+ adenotonsillar hypertrophyadenotonsillar hypertrophy+ obesityobesity

+ craniofacial anomaliescraniofacial anomalies+ neuromuscular disorderneuromuscular disorder

Am am Physician !!-".$##-0%1-Am am Physician !!-".$##-0%1-

Pediatrics !!"#!$0!-%#Pediatrics !!"#!$0!-%#

onsilloadenoidectomy onsilloadenoidectomy (A) is the(A) is the2rst line therapy2rst line therapy

3linical s4uealae$3linical s4uealae$

+neurobehavioral problemsneurobehavioral problems

+cardiovascular problemscardiovascular problems

+failure to thrivefailure to thrive

+mortalitymortality

Sleep 5edicine eview !!6"0$.#%7!Sleep 5edicine eview !!6"0$.#%7!

Am am Physician !!-".$##-0%1-Am am Physician !!-".$##-0%1-

……IntroductionIntroduction

DefinitionDefinition

1SAS is during 6 hours of nocturnal sleep,1SAS is during 6 hours of nocturnal sleep,

at least 37 apneic episodesat least 37 apneic episodes

Apnea #as defined as cessation of Apnea #as defined as cessation of

respirator% flo# for at least +7 secondsrespirator% flo# for at least +7 seconds

A$* A$*8 the ratio of the total num!er of8 the ratio of the total num!er of

apneas and h%popneas o!served to theapneas and h%popneas o!served to the

total sleep time in hourtotal sleep time in hourPediatrics 1976; 58:23-31.

8e2nition8e2nition

8isorder of breathing during sleep8isorder of breathing during sleep

Prolonged partial upper airwayProlonged partial upper airway

obstruction 9/ intermittent completeobstruction 9/ intermittent complete

obstructionobstruction

8isrupt normal ventilation during sleep8isrupt normal ventilation during sleep

9 normal sleep pattern9 normal sleep pattern

Symptoms$ snoring, sleep diculties, 9/Symptoms$ snoring, sleep diculties, 9/

daytime neurobehavioral problemsdaytime neurobehavioral problems

Pediatrics !!"#!$#%!Pediatrics !!"#!$#%!

is! factorsis! factors

Enlarge tonsils and or adenoidsEnlarge tonsils and or adenoids Craniofacial abnormalitiesCraniofacial abnormalities

AgeAge Sex: Adult Male>>>Sex: Adult Male>>> ObesityObesity

)"RS Monograph *++,%-/01)"RS Monograph *++,%-/01

3linical manifestation3linical manifestation

SnoringSnoring

Sleep disorder breathingSleep disorder breathing

Apnea episodesApnea episodes

5outh breathing5outh breathing

re4uent awa*eningre4uent awa*ening

8iaphoresis8iaphoresis

:;cessive daytime somnolent:;cessive daytime somnolent :nuresis:nuresis

e;tboo* of pediatrics< #0 e;tboo* of pediatrics< #0thth edision< !!-$#60%7.edision< !!-$#60%7.

Am am Phisician !-".$##-0%1-Am am Phisician !-".$##-0%1-

3linical manifestation3linical manifestation

8uring wa*efulness are often normal8uring wa*efulness are often normal

Adenotonsillar hypertrophy$ mouthAdenotonsillar hypertrophy$ mouth

breathing, nasal obstruction duringbreathing, nasal obstruction during

wa*efulness, adenoidal facies 9 hyponasalwa*efulness, adenoidal facies 9 hyponasal

speechspeech

3omplications$ systemic hypertension,3omplications$ systemic hypertension,

pulmonary hypertension 9 poor growthpulmonary hypertension 9 poor growth

Pediatrics !!"#!$0!-%#Pediatrics !!"#!$0!-%#

Am am Phisician !-".$##-0%1-Am am Phisician !-".$##-0%1-

"#A#"#A#

"#A#"#A#Ad$%t &'i%dren

Snoring With pauses ContinuousGender M:!"#$%:$ M:!$:$

Enlarged &#A 'ncommon Most common

Obesity Major MinorComplications cardiopulmona

Gro(th)

beha*ior)

de*elopmentalSurgical minority Most cases

C+A+ Most common Selected

Pat'op'ysio%o(yPat'op'ysio%o(y

,ncreased,ncreased fat depositionfat deposition in thein thepharyngeal (allspharyngeal (alls

External compressionExternal compression

by superficiallyby superficially

located fat masseslocated fat masses ,ncreased,ncreased neck circumferenceneck circumference

Deegan PC et al. ERS Monograph 1998: 28-62

8iagnosis8iagnosis

=old standard$ polysomnography (PS=)=old standard$ polysomnography (PS=)

Pediatrics !!6"##$70!%0Pediatrics !!6"##$70!%0

>ead and nec* surgery%otolaryngology" #7< h< 0!0%>ead and nec* surgery%otolaryngology" #7< h< 0!0%

8? SaO

5ild 1%! @71

5oderate #%-! .1%7-

Severe @-! .1

able #< 3lassi2cation of OSAS

Severity

Screening testScreening test

3linical score3linical score

Pulse o;ymetryPulse o;ymetry BideotapingBideotaping

3linical score3linical score

hree 4uestions hree 4uestions

+ >ow often would you say your child has>ow often would you say your child has

diculty breathing when he or she isdiculty breathing when he or she is

sleepingCsleepingC(!Dnever, #Doccasionaly, Dfre4uently, 6Dconstantly)(!Dnever, #Doccasionaly, Dfre4uently, 6Dconstantly)

+ 8oes your child stop breathing when he8oes your child stop breathing when he

or she is asleepCor she is asleepC

(!Dno, #Dyes)(!Dno, #Dyes)

+ >ow often would you say your child>ow often would you say your child

snoresCsnoresC (!Dnever, #Doccasinaly,Dfre4uently,(!Dnever, #Doccasinaly,Dfre4uently,

6Dconstantly)6Dconstantly)

OSAS scoreDOSAS scoreD

#,-(a) E #,-#(b) E !,0#(c) % 6,06#,-(a) E #,-#(b) E !,0#(c) % 6,06

Frouillette classi2cation$Frouillette classi2cation$

+%#D OSAS (%)%#D OSAS (%)

+ %# G 6,1D doubtfull%# G 6,1D doubtfull

+@6,1D OSAS (E)@6,1D OSAS (E)

HH3linical score3linical score

5anagement5anagement

Surgical$Surgical$

+ onsilloadenoidectomy onsilloadenoidectomy

+&vulopalatoplasty&vulopalatoplasty

+3raniofacial correction3raniofacial correction

+ racheostomy racheostomy

Am am Phisician !!-".$##-0%1-Am am Phisician !!-".$##-0%1-

Sleep 5edicine eview !!6"0$.#%7!Peditrics !!"#!$0!-%#Sleep 5edicine eview !!6"0$.#%7!Peditrics !!"#!$0!-%#

HH5anagement5anagement

Ion surgicalIon surgical

+educing body weighteducing body weight

+3ontinuous positive airway3ontinuous positive airwaypressurepressure (3PAP)(3PAP)

+3anule o;ygen3anule o;ygen

+3orticosteroid3orticosteroid Am am Phisician !!-".$##-0%1-Am am Phisician !!-".$##-0%1-

Sleep 5edicine eview !!6"0$.#%7!Sleep 5edicine eview !!6"0$.#%7!

Peditrics !!"#!$0!-%#Peditrics !!"#!$0!-%#

Other testsOther tests Polysomnography (PS=)$ severe OSASPolysomnography (PS=)$ severe OSAS

")ese - "#A#")ese - "#A#

Obese children (ith breathingObese children (ith breathingdifficulties: -. / 012 OSASdifficulties: -. / 012 OSAS

Obese children (ith 3asymptomatic4:Obese children (ith 3asymptomatic4:$.)"2 OSAS$.)"2 OSAS

Obese ,5WObese ,5W >> $"%2 OSAS more$"%2 OSAS morepre*alencepre*alence

")esity")esity

#he pre2alence o) obesity: increase#he pre2alence o) obesity: increase)Am 2 3lin 4utr 5667//%5+-1)Am 2 3lin 4utr 5667//%5+-1

Anderdiagnose .linical diagnosis CsAnderdiagnose .linical diagnosis Cs

%M3%M3D hysician: 46?hysician: 46?

D ,!rse: 77?,!rse: 77?

D esident: 1 ?esident: 1 ? )2 Am 8oard Fam 9ract 5667*%*0-5*1)2 Am 8oard Fam 9ract 5667*%*0-5*1

*ana(ement*ana(ement

6epair craniofacial abnormalities6epair craniofacial abnormalities &onsiloadenoidectomy&onsiloadenoidectomy

C+A+C+A+ &opical steroid&opical steroid 7iet7iet

epair craniofacia%epair craniofacia%

n yo!ng childrenn yo!ng children

@epend on anatomical abnormalities@epend on anatomical abnormalities

D ,asal s!rgery,asal s!rgery

D etroling!al operationsetroling!al operations

D Maillo)acial s!rgeryMaillo)acial s!rgery

Levy P et al. ERS Monograph 1998;205-26

+onsi%oadenoidectomy+onsi%oadenoidectomy

/))ecti2ity : 5*100?/))ecti2ity : 5*100? (Schechter MS. Pediatrics(Schechter MS. Pediatrics

2002; 109:1-20)2002; 109:1-20)

+ssociated with: increased gain in+ssociated with: increased gain in

height' weight' %Mheight' weight' %M (Arch Pediatr Adolesc Med(Arch Pediatr Adolesc Med

1999;153:33-7)1999;153:33-7)

mpro2e a)ter tonsiloadenoidectomy'mpro2e a)ter tonsiloadenoidectomy'

b!t se2ere @ o)ten had manyb!t se2ere @ o)ten had manyrespiratory problemsrespiratory problems (Arch Otolaryngol Head Neck(Arch Otolaryngol Head Neck

Surg 1995; 121:525!"#Surg 1995; 121:525!"#

&PAP&PAP

*ndication8 e/cessive da%time sleepiness*ndication8 e/cessive da%time sleepiness *mprovement in*mprovement in

9 SleepinessSleepiness

9 (ognitive function score(ognitive function score

9 :lood pressure:lood pressure

9 ,,$a%ity of %ife$a%ity of %ife

Enle!an "M. A! # res$ir %rit %are Med 2002;&5:7'3-'Enle!an "M. A! # res$ir %rit %are Med 2002;&5:7'3-'

+opica% steroid+opica% steroid

%eclomethasone 4 weeks3 can%eclomethasone 4 weeks3 can

red!ce adenoid hypertrophy andred!ce adenoid hypertrophy and

nasal airway obstr!ctionnasal airway obstr!ction

.ontro2ersial.ontro2ersial

Deman !" et al.Pe#atr$% 1995&95&'55-6(

ei('t %ossei('t %oss

%eha2io!r modi)ication%eha2io!r modi)icationD +nalysis o) eating+nalysis o) eatingD ;ood related beha2io!r;ood related beha2io!r

@iet therapy@iet therapyD /d!cation/d!cationD oor adherenceoor adherence

/ercise/erciseD eg!larlyeg!larly

"astric s!rgery"astric s!rgeryD "astric 2ol!me limited"astric 2ol!me limited

Mont%errat !M et al. ERS Monograph1998&1((-)8..

&omp%ications&omp%ications

8eurobeha*ioral changes8eurobeha*ioral changes ailure to thri*eailure to thri*e

EnuresisEnuresis

6espiratory tract diseases6espiratory tract diseases +oor Academic performances+oor Academic performances

9 Mathematics O6 -;<= $;-#$%;$) science O6 ?;-= $;-#Mathematics O6 -;<= $;-#$%;$) science O6 ?;-= $;-#

$?;<) spelling O6 -;0= $;-#$%;-$?;<) spelling O6 -;0= $;-#$%;- Cardio*asculer abnormalities: corpulmonaleCardio*asculer abnormalities: corpulmonale

*r%$ht+ MS et al. ,m ! Re%pr rt are Me# 200';168&(6(-8

&onc%$sions&onc%$sions

BS+S: disease on 1BS+S: disease on 1stst cent!rycent!ry

Bbese is a risk )actors o) BS+SBbese is a risk )actors o) BS+S

Eeight red!ction is key managementEeight red!ction is key managemento) BS+S with obese childhoodo) BS+S with obese childhood

beside tonsiloadenoidectomybeside tonsiloadenoidectomy

Aspirasi Pneumonia Cetak R

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