Asma bronkial + TB kasus anak

Embed Size (px)

Citation preview

  • 7/31/2019 Asma bronkial + TB kasus anak

    1/52

    Click to edit Master subtitle style

    7/5/12

    Case presentation

    Asthma and Tuberculosis

    By:Jessieca Liusen

    Lecturer:dr. Dahnul Elymbra,SpA

  • 7/31/2019 Asma bronkial + TB kasus anak

    2/52

    7/5/12

    TUBERCULOSIS

    Definition:

    Direct communicable disease caused byMycobacterium tuberculosis

    Epidemiology TB in Indonesia

    3rd highest score of the world 250.000 new

    case and 140.000 die because of it.

    1st killer among the communicable disease

    3rd killer among other disease after heart

    disease and acute respiratory distress

  • 7/31/2019 Asma bronkial + TB kasus anak

    3/52

    7/5/12

    Tuberculosis

    Risk factor:

    Contact with TB patients

    Young age

    Had HIV

    Severe malnutrition

  • 7/31/2019 Asma bronkial + TB kasus anak

    4/52

    7/5/12

    Pathophysiology

    Droplet nuclei inhalation alveolus

    TB phagocyted by macrofrag

    Replicated inside macrofag Form a colony Gohn complex

    Gohn complex would become:

    Restitution ad integrum

    Cure with a scar such as fibrotic

    Spread : perkontinuitatum, bronchogenic,

    hematogenic, and lymphogenic

  • 7/31/2019 Asma bronkial + TB kasus anak

    5/52

    7/5/12

    Pathophysiology

    Wallgren divided 3 type of TB inchildren:

    Limphohematogenic spread

    Endobronchial TB

    Chronic pulmonary TB

  • 7/31/2019 Asma bronkial + TB kasus anak

    6/52

    7/5/12

    AnamnesisPhysical

    Examination

    FurtherInvestigationDiagnosis

  • 7/31/2019 Asma bronkial + TB kasus anak

    7/527/5/12

    Ten Poin to suggest TBin children Contact to TB (+) BTA patients

    Tuberculin test positive > 10 mm

    Thorax rontgen suggestive for TB Eritema in 3-7 days after BCG

    immunization

    Cough > 3 weeks Prolong fever with unknown cause

    Body weight decreased without any

    clear cause or didnt get weight gain in 1

  • 7/31/2019 Asma bronkial + TB kasus anak

    8/527/5/12

    TBNot TB

    3 dari 1oitem

    Suggested TB

    Gave OAT for 2months and

    observed

    Improved Deteriorated/constant

    Drugresistant TB

    Reconciliate

    to hospital

  • 7/31/2019 Asma bronkial + TB kasus anak

    9/527/5/12

    Scoring to diagnosis of TB inchildrenParameter 0 1 2 3 skor

    Contact to TB patients - (+) contact tonegative or

    unknown BTA

    patients

    (+) contact topositive BTA

    patients

    Tuberculin test Negative Positive 10mm

    or 5mm in

    immunosupresivepatients

    Nutrition Mild malnutrition Severe

    malnutrition

    Fever with unknown cause 2 weeks

    Cough 3 weeks

    Limphadenopati coli,

    axilla, inguinal

    1cm, 1 lymph

    node, no pain

    Swelling on bone, coxae,

    phalangs

    +

    Thorax rontgen Normal Suggestive TB

  • 7/31/2019 Asma bronkial + TB kasus anak

    10/52

    7/5/12

    Diagnosis Tuberculosis

    Score 6 TB

    Score = 5 admitted to hospital tofurther investigate

    Tuberculin test positive:

    Natural TB infection

    Laten TB

    TB infected and suffered TB

    Cured TB

    BCG immunization

    M cobacterium ati ic infection

  • 7/31/2019 Asma bronkial + TB kasus anak

    11/52

    7/5/12

    Tuberculin Test Negative

    No infection for TB

    Incubation period of TB

    Anergy

  • 7/31/2019 Asma bronkial + TB kasus anak

    12/52

    7/5/12

    Score 6

    Gave OAT

    For 2 months and evaluate

    (+) response continued

    theraphy

    (-) response continued

    theraphy and searched for theexact cause

  • 7/31/2019 Asma bronkial + TB kasus anak

    13/52

    7/5/12

    Anti tuberculosis agent

    1st 2 months: intensive phase

    3 kinds of drugs

    Rifampicin

    Isoniazid

    Pyrazinamide

    2nd 4 months: next phase2 kinds of drugs

    Rifampicin

    Isoniazid

  • 7/31/2019 Asma bronkial + TB kasus anak

    14/52

    7/5/12

    Drug Dosage

    Name Dosage Maximal dosage

    Isoniazid 5-15 mg/kgBW/ day 300 mg/day

    Rifampicin 10-20 mg/kgBW/day 600 mg/day

    Pyrazinamid 15-30 mg/kgBW/day 2000 mg/day

    Etambuthol 15-20 mg/kgBW/day 1250 mg/day

    Streptomicin 15-40 mg/kgBW/day 1000 mg/day

  • 7/31/2019 Asma bronkial + TB kasus anak

    15/52

    7/5/12

    Follow Up

    After 2 months got drugs improveclinical, weight gain, no fever, decreasecough continued theraphy

  • 7/31/2019 Asma bronkial + TB kasus anak

    16/52

    7/5/12

    Asthma

    Definition:

    Chronic inflammation with reversiblerespiratory tracts constriction

    Epidemiology

    Prevalence of the world 7,2% (6% for adultand 10% for children)

  • 7/31/2019 Asma bronkial + TB kasus anak

    17/52

    7/5/12

    Risk factor

    Gender:

    Male: female ratio: 3:2 for 6-11 years old

    Male female ratio: 8:5 for 12-17 years old

    Age

    Young age persistent asthma

    Atopic Environment

    Race

    Smoke

  • 7/31/2019 Asma bronkial + TB kasus anak

    18/52

    7/5/12

    Pathophysiology

    Allergen respiratory tractsinflammation

    Released inflammation mediators

    Bronchoconstriction

    Hiperventilation + additional respiratorymuscles contraction

    Cough

    Cough +

  • 7/31/2019 Asma bronkial + TB kasus anak

    19/52

    7/5/12

    Cough +wheezingHistory

    Physical exTuberculin test

    Suggest asthma:EpisodicNocurnal/ morning drip

    After exerciseAtopic

    Imprecise asthma:Start at neonateFailure to thriveChronic infectionVomit/ chokingPulmonary focal disorderCardiovascular system disorder

    No facility, Check peak flowmeter or spirometer:

    Revercibility 15%Variability 15%

    Hiperreactivity 20%

    Consider:Thorax and sinus rontgenPulmonal physiology testBronchodilator response testBronchus provocation testSweat testCilia motility testEsofagogaster reflux evaluation

    Gave bronchodilator

    ASTHMA

    Grading and seacrhed forprecipitateIf episodic frequent/persistent: rontgen thorax

    Gave anti asthma drug:Unsuccefully reevaluatediagnosis and loyalty

    Didnt support other diagnosis Support other diagnosis

    Diagnosis and treatmentaccording to working diagnosis

    Consider asthma asparticipating disease NOT ASTHMA

    Al it S A

  • 7/31/2019 Asma bronkial + TB kasus anak

    20/52

    7/5/12

    Algoritme Serangan Asma

    Klinik / IGD

    Nilai Derajat Serangan

    Tata Laksana Awal Nebulisasi -agonis 3x, selang 20

    Nebulisasi ke-3 + antikolinergik

    Serangan Ringan(nebulisasi 1x,respons baik

    bertahan 1-2 jam,boleh pulang gejala timbul lagiserangan sedang

    Serangan sedang (nebulisasi 2-3x,

    repons parsial) berikan O2

    nilai ulang se-dang RuangRawat Sehari

    pasang infus

    Serangan berat(nebulisasi 3x,

    respons buruk)O2 sejak awal pasang infus nilai ulang berat,Ruang Rawat Inap

    foto Ro toraks

  • 7/31/2019 Asma bronkial + TB kasus anak

    21/52

    7/5/12

    Ruang RawatSehariOksigen teruskan Steroid oral Nebulisasi / 2 jam 8-12 jam klinisstabil boleh pulang 12 jam tetap belumbaik rawat inap

    Ruang Rawat InapOksigen teruskan Atasi dehidrasi &

    asidosis jika ada Steroid IV tiap

    6-8 jam Nebulisasi/1-2 jam Aminofilin IV awal,

    lanjutkan rumatan Nebulisasi 4-6x

    baik, interval 4-6 j 24 jam stabil boleh pulang Dengan steroid &

    aminofilin IV tetaptidak baik ICU

    Boleh PulangBekali -agonis(hirupan / oral)

    Jika ada obat pengendali,teruskan Inf.virus (+),steroid oral

    24-48 jam kontrolproevaluasi

    Catatan:Jika menurut penilaian serangannya berat, nebulisasi 1x,

    langsung -agonis + antikolinergik Bila belum ada alatnya, nebulisasi awal dapat diganti dgnadrenalin sk. 0,01 ml/kgBB/kali, maksimal 0,3 ml/kali.

    Untuk serangan sedang dan terutama berat, O2 2-4L/mntdiberikan sejak awal, termasuk saat nebulisasi

  • 7/31/2019 Asma bronkial + TB kasus anak

    22/52

    7/5/12

    Obat pereda: -agonis atau teofilin (hirupanatau oral) bila perlu

    Tambahkan obat pengendali:

    steroid hirupan dosis rendah

    Pertimbangkan alternatif penambahansalah satu obat:- -agonis kerja panjang (LABA)- Teofilin lepas lambat- AntileukotrienAtau dosis steroid hirupan ditingkatkan(medium)

    Steroid dosis medium ditambahkan salah

    satu obat:- -agonis kerja panjang- Teofilin lepas lambat- Antileukotrien- Atau dosis steroid hirupan ditingkatkan

    (tinggi)

    Obat diganti steroid oral

    Asma Episodik Jarang

    4 6 minggu > 3x dosis/minggu

    3x dosis/minggu

    6-8 minggu, respons :

    Asma Episodik Sering

    (-) (+)

    (-) (+)

    (-) (+)

    6-8 minggu, respons :

    6-8 minggu, respons :

    Asma Persisten

    PE

    NGHINDARAN

  • 7/31/2019 Asma bronkial + TB kasus anak

    23/52

    7/5/12

    Case

  • 7/31/2019 Asma bronkial + TB kasus anak

    24/52

    7/5/12

    Patient Identity

    Name : Chd. D

    Age : 1 year 9 months old

    Parent : Sudadi/ Rina Tribe : Javanese

    Address : Perawang

    Admitted: 24 August 2011

  • 7/31/2019 Asma bronkial + TB kasus anak

    25/52

    7/5/12

    Anamnesis

    Chief complain

    Dispnea that became deteriorate since 2months before admittion

  • 7/31/2019 Asma bronkial + TB kasus anak

    26/52

    7/5/12

    Present Illness History

    Since 2 months before admittion

    Dispnea on the effort, if he took rest, itbecame well

    Productive cough happened at the same timewith dispnea

    Fever with unknown cause, not too high, andusually became higher at night.

    Patient got drugs from pediatric policlinicat RSUD AA

  • 7/31/2019 Asma bronkial + TB kasus anak

    27/52

    7/5/12

    Present Illness History

    He can drank mothers milk

    No history of vomitting, choking

    As long as dispnea happened, his skinnever became blue.

    No weight loss since last 2 months

  • 7/31/2019 Asma bronkial + TB kasus anak

    28/52

    7/5/12

    Anamnesis

    Past Illness History

    Family Illness History

    Parent Illness History Gestation history

    Diet history

    Immunization Physical growth

    Mental growth

    House and environment

  • 7/31/2019 Asma bronkial + TB kasus anak

    29/52

    7/5/12

    Physical Examination

    General condition: moderate illness

    Consciousness: composmentis

    Vital signBP: 100/60 mmHg

    Temp : 36,80C

    HR : 122x/minutes

    RR : 46x/minutes

  • 7/31/2019 Asma bronkial + TB kasus anak

    30/52

    7/5/12

    Physical Examination

    Nutrition: 92% normal

    Body height: 78 cm

    Body weight: 10 kg

    Upper arm circumference: 15 cm

    Head circumference: 47 cm(normocephali)

  • 7/31/2019 Asma bronkial + TB kasus anak

    31/52

    7/5/12

    Physical Examination

    Skin: normally

    Head: normocephali, anterior fontanelalready closed

    Hair: black, not easy to put off

    Eye:

    Conjunctiva: normally

    Sclera: normally

    Pupils: isochor, 2 mm

    Pupil reflex : +/+

  • 7/31/2019 Asma bronkial + TB kasus anak

    32/52

    7/5/12

    Physical Examination

    Ears: normally

    Nose: normally

    Lips: moist Mucosa : moist, red

    Palatum: normally

    Tongue: normally Teeth: normally

    Neck: lymph node (-), stiffness (-)

  • 7/31/2019 Asma bronkial + TB kasus anak

    33/52

    7/5/12

    Physical Examination

    Thorax

    Inspection: simetrical movement of thoraxwall

    Palpation: fremitus right and left same

    Percussion: resonance, head alignmentnormally

    Auscultation: wheezing

  • 7/31/2019 Asma bronkial + TB kasus anak

    34/52

    7/5/12

    Physical Examination

    Abdomen

    Inspection: flat

    Palpation: flexible, no tenderness,

    hepatosplenomegaly (-)

    Percussion: tymphani

    Auscultation: bowel sound (+) at normal rate

  • 7/31/2019 Asma bronkial + TB kasus anak

    35/52

    7/5/12

    Physical Examination

    Genitalia: male

    Extremity: warm, red, CRT < 2 seconds

  • 7/31/2019 Asma bronkial + TB kasus anak

    36/52

    7/5/12

    Laboratory

    Hb : 9,9 g/dL

    Ht : 30,2 %

    Leukosit: 12600/uL Platelet : 594000/uL

    LED : 50mm/jam

    Diff count:Neutrophil: 37%

    Lymphocite: 53%

    Monocyte: 9,1%

  • 7/31/2019 Asma bronkial + TB kasus anak

    37/52

    7/5/12

  • 7/31/2019 Asma bronkial + TB kasus anak

    38/52

    7/5/12

    Working Diagnosis

    Asthma and pulmonary TB

  • 7/31/2019 Asma bronkial + TB kasus anak

    39/52

    7/5/12

    Treatment

    IVFD KAEN1B 20 gtt

    Kalmetason injection 1/3 amp

    1st 2 months:

    Rifampicin 150 mg 1x1

    Pyrazinamid 200 mg 1x1Isoniazid 200 mg 1x1

    Vitamin B6 5 mg 1x1

    High calory and protein diet

  • 7/31/2019 Asma bronkial + TB kasus anak

    40/52

    7/5/12

    PROGNOSIS

    Quo ad vitam : bonam

    Quo ad fungsionam : bonam

  • 7/31/2019 Asma bronkial + TB kasus anak

    41/52

    7/5/12

    Tanggal Subjektif Objektif Assestment Terapi

    24/8/11 Sesak napas (+),

    batuk (+)

    T: 36,90C

    N: 124x/menit

    R: 50x/menit

    Asma dan Susp

    TB paru

    IVFD KAEN1B 20 tpm

    Inj kalmetason 1/3 amp

    Foto thorax AP

    25/8/11 Sesak napas (-),

    batuk (+)

    T: 37,10C

    N: 121x/menit

    R: 46x/menit

    Asma dan TB

    paru

    IVFD KAEN1B dan

    Inj kalmetason off

    Foto thorax AP: KP duplex

    Rawat jalan

    Rifampisin 150 mg

    Pirazinamid 200 mg

    Isoniazid 200 mg

    Vit B6 5 mg

  • 7/31/2019 Asma bronkial + TB kasus anak

    42/52

    7/5/12

    Case Analysis

    Dispnea became worst since 2 monthsbefore admittion

    Asthma

    Pneumonia

    Bronchiolitis

    Congenital heard disease

    Corpus alienum aspiration

    Pulmonary TB

  • 7/31/2019 Asma bronkial + TB kasus anak

    43/52

    7/5/12

    Case Analysis

    Precipitation factor: activity

    Happened at same time with cough

    Fever since 2 months

    Asthma

    Pneumonia Bronchiolitis

    TB pulmonary

  • 7/31/2019 Asma bronkial + TB kasus anak

    44/52

    7/5/12

    Patient ate and drank as usual

    No blue history when dispnea occurred

    It wasnt congenital heard disease orpneumonia

  • 7/31/2019 Asma bronkial + TB kasus anak

    45/52

    7/5/12

    No weight loss since last 2 months didnt mean that it wasnt TB

    Positive family history for asthma uncle

    Complete history of immunization mantoux test became false positive

  • 7/31/2019 Asma bronkial + TB kasus anak

    46/52

    7/5/12

    Scoring to diagnosis of TB inchildrenParameter 0 1 2 3 skor

    Contact to TB patients - (+) contact to

    negative or

    unknown BTA

    patients

    (+) contact to

    positive BTA

    patients

    2

    Tuberculin test Negative Positive 10mm

    or 5mm in

    immunosupresive

    patients

    0

    Nutrition Mild malnutrition Severe

    malnutrition

    0

    Fever with unknown cause 2 weeks 1

    Cough 3 weeks 1

    Limphadenopati coli,

    axilla, inguinal

    1cm, 1 lymph

    node, no pain

    0

    Swelling on bone, coxae,

    phalangs

    + 0

    Thorax rontgen Normal Suggestive TB 1

    Ten Poin to s ggest TB

  • 7/31/2019 Asma bronkial + TB kasus anak

    47/52

    7/5/12

    Ten Poin to suggest TBin children Contact to TB (+) BTA patients

    Tuberculin test positive > 10 mm

    Thorax rontgen suggestive for TB

    Eritema in 3-7 days after BCGimmunization

    Cough > 3 weeks Prolong fever with unknown cause

    Body weight decreased without any

    clear cause or didnt get weight gain in 1

  • 7/31/2019 Asma bronkial + TB kasus anak

    48/52

    7/5/12

    Analysis

    More than 3 poins suggest TB gave antituberculosis agent

    Cough +wheezing

  • 7/31/2019 Asma bronkial + TB kasus anak

    49/52

    7/5/12

    HistoryPhysical ex

    Tuberculin test

    Suggest asthma:EpisodicNocurnal/ morning dripAfter exerciseAtopic

    Imprecise asthma:Start at neonateFailure to thriveChronic infectionVomit/ chokingPulmonary focal disorderCardiovascular system disorder

    No facility, Check peak flowmeter or spirometer:

    Revercibility 15%Variability 15%

    Hiperreactivity 20%

    Consider:Thorax and sinus rontgenPulmonal physiology testBronchodilator response testBronchus provocation testSweat testCilia motility testEsofagogaster reflux evaluation

    Gave bronchodilator

    ASTHMA

    Grading and seacrhed forprecipitateIf episodic frequent/persistent: rontgen thorax

    Gave anti asthma drug:Unsuccefully reevaluatediagnosis and loyalty

    Didnt support other diagnosis Support other diagnosis

    Diagnosis and treatmentaccording to working diagnosis

    Consider asthma asparticipating disease NOT ASTHMA

    Asthma Treatment for

  • 7/31/2019 Asma bronkial + TB kasus anak

    50/52

    7/5/12

    Asthma Treatment forthe patient Kalmetason/ dexametason intravena 1/3

    amp = 1,3 mg a day

    Steroid bolus dosage : 0,5-1

    mg/kgBW/day.

  • 7/31/2019 Asma bronkial + TB kasus anak

    51/52

    7/5/12

    Antituberculosis Agent

    Rifampicin 150 mg 1x1, dosage 15mg/kgBW/day

    Pyrazinamid 200 mg 1x1, dosage 20

    mg/kgBW/day Isoniazid 200 mg 1x1, dosage 20

    mg/kgBW/day

    Vitamin B6 5 mg 1x1

  • 7/31/2019 Asma bronkial + TB kasus anak

    52/52

    Thank You