ACUTE ACUTE

RESPIRATORYRESPIRATORY

INFECTIONSINFECTIONS

PneumoniaPneumoniaBronkiolitisBronkiolitis

Bronkitis AkutBronkitis Akut

Acute Respiratory Infections (ARI)Acute Respiratory Infections (ARI)

Developed and developing countriesDeveloped and developing countries

High morbidityHigh morbidity

5 5 –– 8 episodes/year/child8 episodes/year/child

30 30 –– 50 % outpatient visit50 % outpatient visit30 30 –– 50 % outpatient visit50 % outpatient visit

10 10 –– 30 % hospitalization30 % hospitalization

Developing countriesDeveloping countries

High mortalityHigh mortality

30 30 –– 70 times higher than in developed countries70 times higher than in developed countries

1/4 1/4 -- 1/3 death in children under five year of age1/3 death in children under five year of age

ARIARI--ASSOCIATED DEATH RATE BY AGEASSOCIATED DEATH RATE BY AGE

TEKNAF, BANGLADESH, 1982TEKNAF, BANGLADESH, 1982--19851985

100

120

140

Deaths per 1000 children

0

20

40

60

80

1-5 6-11 12-23 24-35 36-50

Age i n Mont hs

Distribution of 12.2 million deaths among children less Distribution of 12.2 million deaths among children less than 5 years old in all developing countries, 1993than 5 years old in all developing countries, 1993

ARI (26.9%)

Malaria (6.2)

ARI/Malaria (1.6%)

Measles (2.4%)

Diarrhoea/measles

(1.9%)

Diarrhoea (22.8%)

Other (33.1%)

ARI/Measles (5.2%)

MalnutritionMalnutrition(29%)(29%)

RISK FACTORS FOR PNEUMONIARISK FACTORS FOR PNEUMONIAOR DEATH FROM ARIOR DEATH FROM ARI

Malnutrition, poorbreast feeding

practices

Vitamin A deficiency

Low birth weight

Lack of immunization

Young age

Increaserisk of

ARI

Cold weather

or chilling

Exposure to air pollution

• Tobacco smoke

• Biomass smoke

• Environmental air pollution

Crowding

High prevalence

of nasopharyngeal

carriage of

pathogenic bacteria

Magnitude of the ProblemMagnitude of the Problem

in Indonesiain IndonesiaPneumonia in children (< 5 years of age)Pneumonia in children (< 5 years of age)

Morbidity Rate 10Morbidity Rate 10--20 %20 %

Mortality Rate 6 / 1000Mortality Rate 6 / 1000

Pneumonias killPneumonias killPneumonias killPneumonias kill

�� 50.000 / a year50.000 / a year

�� 12.500 / a month12.500 / a month

�� 416 / a day = passengers of 1 jumbo jet plane416 / a day = passengers of 1 jumbo jet plane

�� 17 / an hour17 / an hour

�� 1 / four minutes1 / four minutes

Pneumonia is a no 1 killer for infants Pneumonia is a no 1 killer for infants

(Balita)(Balita)

PneumoniaPneumoniaClassificationsClassifications

Anatomical classificationAnatomical classification

�� Lobar pneumoniaLobar pneumonia

�� Lobular pneumoniaLobular pneumonia

�� Intertitial pneumoniaIntertitial pneumonia

BronchopneumoniaBronchopneumonia�� BronchopneumoniaBronchopneumonia

Etiological classificationEtiological classification

�� Bacterial pneumoniaBacterial pneumonia

�� Viral pneumoniaViral pneumonia

�� Mycoplasma pneumoniaMycoplasma pneumonia

�� Aspiration pneumoniaAspiration pneumonia

�� Mycotic pneumoniaMycotic pneumonia

Etiology of PneumoniaEtiology of Pneumonia

Predominantly : bacterial and viral Predominantly : bacterial and viral

In developing countries: In developing countries:

bacterial > viral bacterial > viral bacterial > viral bacterial > viral

(Shann,1986): In 7 developing(Shann,1986): In 7 developing countries, countries,

bacterial bacterial �� 60 %60 %

(Turner, 1987):(Turner, 1987): In developed countries,In developed countries,

bacterial bacterial ��19 % ; viral 19 % ; viral ��39 % 39 %

Bacterial etiologyBacterial etiology

Streptococcus pneumoniaeStreptococcus pneumoniae

Hemophilus influenzaeHemophilus influenzae

Staphylococcus aureusStaphylococcus aureus

Streptococcus group A Streptococcus group A –– BB

Klebsiella pneumoniaeKlebsiella pneumoniae

Pseudomonas aeruginosaPseudomonas aeruginosa

Chlamydia sppChlamydia spp

Mycoplasma pneumoniaeMycoplasma pneumoniae

30

40

50

BACTERIA ISOLATED FROM LUNG ASPIRATESBACTERIA ISOLATED FROM LUNG ASPIRATES

IN 370 UNTREATED CHILDREN WITH PNEUMONIAIN 370 UNTREATED CHILDREN WITH PNEUMONIA

%%

0

10

20

30

S Pneumoniae H Influenzae S Aureus

Characteristic featuresCharacteristic features

S pneumoniaeS pneumoniae

�� mucosal inflammation lesionmucosal inflammation lesion

�� alveolar exudatesalveolar exudates

�� frequently frequently ��lobar pneumonia)lobar pneumonia)

H influenzae, S viridans, VirusH influenzae, S viridans, Virus

�� invasion and destruction of mucous membraneinvasion and destruction of mucous membrane

Staphylococcus, KlebsiellaStaphylococcus, Klebsiella

�� destruction of tissues destruction of tissues �� multiple abscessesmultiple abscesses

Simple Clinical Signs of Pneumonia Simple Clinical Signs of Pneumonia

(WHO)(WHO)

Fast breathing (tachypnea)Fast breathing (tachypnea)

Respiratory thresholds Respiratory thresholds

AgeAge Breaths/minuteBreaths/minute

< 2 months< 2 months 6060< 2 months< 2 months 6060

2 2 -- 12 months12 months 5050

1 1 -- 5 years5 years 4040

Chest IndrawingChest Indrawing(subcostal retraction)(subcostal retraction)

Pathology and PathogenesisPathology and Pathogenesis

Bacteriae Bacteriae ��peripheral lung tissues peripheral lung tissues

�� tissues reaction tissues reaction �� oedematousoedematous

Red Hepatization StadiumRed Hepatization Stadium

alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte,

bacteriabacteria

Grey Hepatization Stadium Grey Hepatization Stadium

fibrine deposition, phagocytosisfibrine deposition, phagocytosis

Resolution Stadium Resolution Stadium

neutrophil degeneration, loose of fibrine,neutrophil degeneration, loose of fibrine,

bacterial phagocytosisbacterial 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 Radiographic patterns

1.1. Diffuse alveolar and interstitial Diffuse alveolar and interstitial pneumoniapneumonia (perivascular and (perivascular and interalveolar changes)interalveolar changes)

2.2. BronchopneumoniaBronchopneumonia2.2. BronchopneumoniaBronchopneumonia(inflammation of airways and (inflammation of airways and parenchyma)parenchyma)

3.3. Lobar pneumoniaLobar pneumonia(consolidation in a whole lobe)(consolidation in a whole lobe)

4.4. Nodular, cavity or abscess lesionsNodular, cavity or abscess lesions(esp.in immunocompromised patients)(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 andhuman herpes virus, leucocytois 17000, ESR 8 mm/ h l, CRP 22 mg/l

Blood Gas Analysis & Acid Base BalanceBlood Gas Analysis & Acid Base Balance

Hypoxemia Hypoxemia (P(PaaOO22 < 80 mm Hg)< 80 mm Hg)

�� with Owith O22 3 L/min 3 L/min 52,4 %52,4 %

�� without Owithout O22 100 %100 %

Ventilatory insufficiencyVentilatory insufficiencyVentilatory insufficiencyVentilatory insufficiency�� (P(PaaCOCO22 < 35 mmHg)< 35 mmHg) 87,5 %87,5 %

Ventilatory failureVentilatory failure�� (P(PaaCOCO22 > 45 mmHg )> 45 mmHg ) 4.8 %4.8 %

Metabolic Acidosis Metabolic Acidosis �� poor intake and/or hypoxemiapoor intake and/or hypoxemia 44,4 % 44,4 %

(Mardjanis Said, et al. 1980)(Mardjanis Said, et al. 1980)

ManagementManagement

Severe PneumoniaSevere Pneumonia

HospitalizationHospitalization

Antibiotic administrationAntibiotic administration

�� Procain Pennicilline, ChloramphenicolProcain Pennicilline, Chloramphenicol�� Procain Pennicilline, ChloramphenicolProcain Pennicilline, Chloramphenicol

�� Amoxycillin + Clavulanic AcidAmoxycillin + Clavulanic Acid

Intra Venous Fluid DripIntra Venous Fluid Drip

OxygenOxygen

Detection and management of Detection and management of complicationscomplications

WHO recommendations for treatment of infants less 2 WHO recommendations for treatment of infants less 2 months who have cough or difficulty breathingmonths who have cough or difficulty breathing

No pneumonia : No tachypnea, no severe chest indrawingDo not administer an antibiotic

Severe pneumonia : Tachypnea or severe chest indrawingAdmit, administer benzylpenicillin + gentamycin, and oxygen

WHO recommendations for treatment of children aged 2 WHO recommendations for treatment of children aged 2 months months

to 4 years who have cough or difficulty breathingto 4 years who have cough or difficulty breathing

No pneumonia : No tachypnea, no chest indrawingDo not administer an antibiotic

Pneumonia : Tachypnea, no chest indrawingHome treatment with cotrimoxazole,amoxicillin or procaine penicillinamoxicillin 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 Initial empirical treatment based on age and severity of pneumoniaon age and severity of pneumonia

Age

3 - 6 mos

6 mos to

Outpatients(Mild to Moderate)

Inpatients (Moderate) Inpatients (Severe)

Amoxicillin with or without clavulanateErythromycin

Ceftriaxone or cefotaximCeftriaxone or cefotaxime

+ vancomycin

Amoxicillin with orwithout clavulanate

Ceftriaxone, cefotaxime, or

Ceftriaxone or cefotaxime+ macrolide + vancomycin

to 5 yrs

5 – 18 yrs

without clavulanateErythromycin

orCefuroxime + macrolide

+ macrolide + vancomycin

Macrolide Ceftriaxone or cefotaxime

+ macrolide

Ceftriaxone or cefotaxime+ macrolide + vancomycin

Hsiao G et al, 2001

ComplicationsComplications

Pleural effusion (empyema)Pleural effusion (empyema)

PiopneumothoraxPiopneumothorax

PneumothoraxPneumothorax

PneumomediastinumPneumomediastinum

BronchiolitisBronchiolitis

�� Bronchioles inflammationBronchioles inflammation

�� Clinical syndromes: Clinical syndromes: fast breathing, retractions, wheezingfast breathing, retractions, wheezingfast breathing, retractions, wheezingfast breathing, retractions, wheezing

�� Predominantly < 2 years of age Predominantly < 2 years of age (2 (2 –– 6 months)6 months)

�� Difficult to differentiate with pneumoniaDifficult to differentiate with pneumonia

PathologyPathology�� Necrosis of the resp. epithelium Necrosis of the resp. epithelium

�� Destruction of ciliated epithelial cellsDestruction of ciliated epithelial cells

�� Peribronchial infiltration with lymphocites & neutrophilsPeribronchial infiltration with lymphocites & neutrophils

�� Sub mucosal edematousSub mucosal edematous

…Bronchiolitis…Bronchiolitis

�� Sub mucosal edematousSub mucosal edematous

�� No destruction of collagen, muscle, or elastic tissueNo destruction of collagen, muscle, or elastic tissue

PathophysiologyPathophysiologyEdema + accumulation of mucous & cellular debris Edema + accumulation of mucous & cellular debris ��

narrow of peripheral airway narrow of peripheral airway �� partially / totally partially / totally

occluded occluded �� over distention / atelectasisover distention / atelectasis

EtiologyEtiology�� Predominantly RSV (Respiratory Syncytial Predominantly RSV (Respiratory Syncytial

Virus)Virus)

�� Other viruses : rhinovirus, adenovirus, Other viruses : rhinovirus, adenovirus, influenza virus, parainfluenza virus, entero influenza virus, parainfluenza virus, entero

…Bronchiolitis…Bronchiolitis

influenza virus, parainfluenza virus, entero influenza virus, parainfluenza virus, entero virus, etc.virus, etc.

Severity Severity �� PrematurityPrematurity OR 1.84OR 1.84

�� Underlying medical condition OR 2.84Underlying medical condition OR 2.84

�� Group A RSV strain Group A RSV strain OR 3.26OR 3.26

�� Age < 3 mo Age < 3 mo OR 4.39OR 4.39

…Bronchiolitis…Bronchiolitis

DiagnosisDiagnosis

�� Etiological diagnosisEtiological diagnosis

Microbiologic examination Microbiologic examination

�� Clinical diagnosisClinical diagnosis

Signs and symptomsSigns and symptomsSigns and symptomsSigns and symptoms

AgeAge

Resource of infection Resource of infection �� epidemic of RSVepidemic of RSV

�� Laboratory findingLaboratory finding

�� Radiological examinationRadiological examination

Clinical Manifestations : mild rhinorrhea, Clinical Manifestations : mild rhinorrhea, cough, cold, lowcough, cold, low--grade fevergrade fever

11--2 d 2 d �� fast breathing, chest retraction, fast breathing, chest retraction, wheezing, irritable, vomitus, poor intakewheezing, irritable, vomitus, poor intake

…Bronchiolitis…Bronchiolitis

wheezing, irritable, vomitus, poor intakewheezing, irritable, vomitus, poor intake

Physical Examinations Physical Examinations tachypnea, tachycardia, retraction, tachypnea, tachycardia, retraction, prolonged expiration, wheezing, prolonged expiration, wheezing, fever,pharyngitis, conjunctivitis, otitis media, fever,pharyngitis, conjunctivitis, otitis media, dehydrationdehydration

Radiologic examinationRadiologic examinationdiffuse hyperinflationdiffuse hyperinflation�� flat diaphragm, flat diaphragm,

�� Intercostal space >Intercostal space >

�� retrosternal space >retrosternal space >

peribronchial infiltrates / thickeningperibronchial infiltrates / thickening

…Bronchiolitis…Bronchiolitis

peribronchial infiltrates / thickeningperibronchial infiltrates / thickening

patchy atelectasis patchy atelectasis �� segmental collapsesegmental collapse

pleural effusion (rare)pleural effusion (rare)

Laboratory finding Laboratory finding �� Respiratory rate Respiratory rate �� : Arterial saturation : Arterial saturation ��

pCO2 pCO2 ��

Laboratory finding Laboratory finding

�� Microbiologic examination Microbiologic examination

�� WBC : 5000 WBC : 5000 –– 24.000 cells/mm24.000 cells/mm33, predominantly , predominantly

PMN & bandsPMN & bands

…Bronchiolitis…Bronchiolitis

�� Blood Gas Analysis Blood Gas Analysis

Arterial saturation �

pCO2 �

Mild respiratory alkalosis

Metabolic acidosis

Acute respiratory acidosis

ManagementManagement

�� Mild Mild �� treated at hometreated at home

�� Moderate / severe disease Moderate / severe disease �� hospitalizationhospitalization

support : support : oxygen oxygen

intra venous fluid dripintra venous fluid drip

(antibiotics)(antibiotics)

…Bronchiolitis…Bronchiolitis

(antibiotics)(antibiotics)

detect & treat possible complicationdetect & treat possible complication

prevent the spread of inf.prevent the spread of inf.

�� Controversial : Controversial : bronchodilator bronchodilator

corticosteroidcorticosteroid

antiviralantiviral

antibioticantibiotic

Natural history & complicationsNatural history & complications

�� Regeneration of bronchiolar epithelium after 3 Regeneration of bronchiolar epithelium after 3

or 4 dor 4 d

�� Cilia after 3 or 4 dCilia after 3 or 4 d

…Bronchiolitis…Bronchiolitis

�� Cilia after 3 or 4 dCilia after 3 or 4 d

�� Improved clinical findings : in 3Improved clinical findings : in 3--4 days4 days

�� Improved radiological features: in 9 daysImproved radiological features: in 9 days

Persistent respiratory obstruction : 20%Persistent respiratory obstruction : 20%

Respiratory failure : 25 %Respiratory failure : 25 %

Lung collaps (rare)Lung collaps (rare)

Correlation with AsthmaCorrelation with Asthma

�� 30 % 30 % -- 50 % becomes asthmatic patients50 % becomes asthmatic patients

�� Similarity in : Similarity in : -- pathogenic mechanismspathogenic mechanisms

…Bronchiolitis…Bronchiolitis

�� Similarity in : Similarity in : -- pathogenic mechanismspathogenic mechanisms

-- pathologic disorderspathologic disorders

Bronkitis akut

radang bronkus akutradang bronkus akut

umumnya disertai radang akut saluran umumnya disertai radang akut saluran napas bawah lainnyanapas bawah lainnyanapas bawah lainnyanapas bawah lainnya

Tidak pernah berdiri sendiri Tidak pernah berdiri sendiri

Trakeobronkitis akut = BronkitisTrakeobronkitis akut = Bronkitis

Istilah yang membingungkan

Bronkitis kapiler Bronkitis kapiler (Capillary Bronchitis)(Capillary Bronchitis)

�� BronkitisBronkitis

�� Pneumonia interstitialPneumonia interstitial�� Pneumonia interstitialPneumonia interstitial

Bronkitis asmatikaBronkitis asmatika

�� Salah satu bentuk asmaSalah satu bentuk asma

Etiologi Bronkitis akut

UmumUmum : virus: virus

Spesifik Spesifik

�� InfluenzaInfluenza

�� PertusisPertusis�� PertusisPertusis

�� Campak (morbilli)Campak (morbilli)

�� SalmonellaSalmonella

�� DifteriaDifteria

�� Scarlet feverScarlet fever

Predisposisi dan faktor yang berpengaruh

Asap rokokAsap rokok

AlergiAlergi

CuacaCuaca

Keadaan umum yang jelek Keadaan umum yang jelek (Poor health)(Poor health)

Infeksi kronik alat napas atasInfeksi kronik alat napas atas

Pemeriksaan fisis

PanasPanas : (: (--)) (+)(+) ((--))

MukosaMukosa : : -- nasofaringitisnasofaringitis

-- konjungtivitiskonjungtivitis

-- rhinits virusrhinits virus-- rhinits virusrhinits virus

Suara napas kasarSuara napas kasar

Ronki basah kasarRonki basah kasar halushalus

Mengi (Wheezing)Mengi (Wheezing)

SPUTUMSPUTUM : Jernih : Jernih beberapa hari beberapa hari keruhkeruh

55--10 hari10 hari55--10 hari10 hari

Batuk hilangBatuk hilang jernihjernih

Gejala dan tanda lain bronkitis akut

Rasa tidak enak di bawah tulang dada : Rasa tidak enak di bawah tulang dada : Seperti terbakar Seperti terbakar sakitsakit

Suara napas berbunyi seperti siulanSuara napas berbunyi seperti siulanSuara napas berbunyi seperti siulanSuara napas berbunyi seperti siulan

SesakSesak

MuntahMuntah

Penanggulangan bronkitis akutPenanggulangan bronkitis akut

SimptomatisSimptomatis

Pengeluaran lendir/sputum :Pengeluaran lendir/sputum :

�� Posisi tidur diubahPosisi tidur diubah--ubahubah

�� Jaga kelembaban udaraJaga kelembaban udara�� Jaga kelembaban udaraJaga kelembaban udara

�� Sering minumSering minum

Kodein : hatiKodein : hati--hati ! (sangat jarang hati ! (sangat jarang diperlukan)diperlukan)

Antihistamin : HatiAntihistamin : Hati--hati hati Atropin like effectAtropin like effect

Bronkitis akut

Ekspektoran : tidak perluEkspektoran : tidak perlu

Antibiotika :Antibiotika :

�� Tidak ada gunanyaTidak ada gunanya�� Tidak ada gunanyaTidak ada gunanya

�� IndikasiIndikasi

Bronkitis akut berulang

Ada komplikasi

Komplikasi bronkitis akut

OtitisOtitis

SinusitisSinusitis

PneumoniaPneumoniaPneumoniaPneumonia

Terutama kalau gizi burukTerutama kalau gizi buruk

Batuk kronik berulang

pada anak: bronkitis kronik tidak adapada anak: bronkitis kronik tidak ada

dasar : dasar : -- penyakit parupenyakit paru

-- penyakit sistemikpenyakit sistemik

DD/DD/ D/ D/

Komponen refleks batukKomponen refleks batuk

Reseptor Aferen Pusat batuk Eferen Efektor

Cabang nervus

vagus

Nervus vagus

Otot,

Laring, trakea

dan bronkus

Laring

Trakea

Bronkus

Tersebar merataTelinga

Lambung

Tersebar merata

di medula dekat

Pusat pernapasan :

di bawah kontrol

Pusat yang

lebih tinggiHidung

Sinus paranasalis

Nervus

trigeminus

Nervus Frenikus,

Interkostal &

lumbaris

Diafragma, otot-otot

Interkostal,

abdominal

& otot lumbal

FaringNervus

glosofaringus

Saraf-saraf

Trigeminus, Fasialis

Hipoglosus,dll

Otot saluran napasdan otot bantu napas

Perikardium

diafragmaNervus frenikus