KEGAWATDARURATAN PADA ANAK DAN BAYI

Kepaniteraan Klinik Emergensi RSUP Fatmawati JakartaFKIK UIN Syarif Hidayatullah

ASSESSMENT OFTHE CRITICALLY ILL PATIENT

Applying the PAT

Appearance Work of

breathing

Circulation Assessment

N N Respiratory distress

Abnormal N Abnormal Shock

Abnormal N N Primary CNS disfungtion/

Metabolic abnormality

Abnormal / Abnormal Cadiopulmonary failure

Framework for assessing the critically ill patient

PHASE IInitial contact-first minute

(primary survey)

“What is the main physiologi-

cal problem?”

PHASE IISubsequent reviews

(Secondary survey)

“What is the underlying

cause?”

History Main features of circums-

Tances and environment

• Witnesses, healthcare personel,

relatives

• Main symptoms: pain, dyspnea,

faintness

• Trauma?

• Operative or nonoperative?

• Medications/toxin

More detailed information

• Present complaint

• Past history, chronic diseases, operations

• Psychosocial & physical

Independence

• Medications & allergies

• Family history

• Ethical or legal issues

• System review

Examination Look; Listen; Feel• Airway

• Breathing & oxygenation

• Circulation

• Level of consciousness

Structured review of organ system

• Respiratory

• Cardiovascular

• Abdomen & GU tract

• CNS, musculoskeletal sys

• Endocrine, hematological

Chart review,

documentation

Essential physiology, vital signs

•Heart rate, rhythm

•Blood pressure

•Respiratory rate; pulse oxymetry

•Level of consciousness

Case records & note keeping

•Examine medical records if available

•Formulate specific diagnosis

•Document current events

Investigations •Blood gas analysis (use venous if arterias acces difficult)

•Blood glucose

•Laboratory blood test

•Radiology

•ECG

•Microbiology

Treatment Proceeds in parallel with the above

•Oxygen

•IV access + fluids

•Assess response to immediate resuscitation

•CALL FOR MORE EXPERIENCED ADVICE & ASSISTANCE

Refine treatment, assess responses, review trends

•Provide specific organ system support as required

•Choose most appropriate site for care

•Obtain specialist advice / assistance

Assessment of Airway & Breathing

Causes of obstructionblood, vomitus, foreign body, CNS depression, direct trauma,infections

LOOK forcyanosis, altered respiratory pattern & rate, use of accessorymuscles, tracheal tug, altered level of consciousness, protective airway reflect (cough, gag)

LISTEN fornoisy breathing (grunting, stridor, wheezing, gurgling)complete obstruction results in silence

FEEL fordecreased or absent air flow

AIR WAY

BREATHING

Cause of inadequate breathingDepressed respiratory drive: e.g CNS depressionDepressed respiratory effort: muscle weakness, nerve/spinal

cord damage, debilitation, chest wall abnormalities, painPulmonary disorders: pneumo/hemothorax, aspiration, chronic

obstructive pulmonary disease, asthma, pulmonary embolus, lung contusion, acute lung injury, ARDS,pulmonary edema

LOOK forcyanosis, altered respiratory pattern & rate, equality & depth ofrespiration, sweating, JVP, use of accessory muscles, tracheal tug, altered of consciousness, SaO2

FEEL forprecordial cardiac pulsation, pulses (central &peripheral) assessing rate, quality, regularity,symmetry

LISTEN for dyspnea, inability to talk, noisy breathing, percussion,

ausculatation

The Normal value of respiratory rate in children

Age Rate (breath per min)

Newborn 30 – 60

Infant 30 – 40

2 – 4 yr 20 – 30

4 – 7 yr 20 – 30

7 – 12 yr 16 – 20

> 13 yr 12 - 16

Tachypnea : respiratory rate > N

Signs of Pulmonary Disease

1. Change in mentation neurologic deterioration (blood gas abN)

2. Abnormality in respiratory rate tacypnea

3. Abnormal breathing pattern

4. Abnormality in the character of breathing- conspicuous ventilatory movements- diminished, barely chest - asymetry of movement between both sides of the chest or - asymetry of movement between chest and abdomen

5. Entirely thoracic breathing (normal) or entirely abdomen breathing (paralysis diaphragma)

6. Abnormality relative to phase of the respiratory cycle- labored inspiration : retraction suprasternal, supraclavicular, intercostal, substernal, nares flared- labored expiration: asthma, ARDS

7. Stridor

8. Other signs:Cyanosis (central or peripheral), Subcutaneus emphysema, patient posture, pleural friction rub etc

Abnormal breathing patterns

1. Rapid with tidal volume sympathetic nervous stimulation, chest complience, airway resistance, pleuritic chest pain, trauma, elevated diaphragma

2. Rapid & deep (Kussmaul respirations)metabolic acidosis, hysterical hyperventilation, infarction of mid-brain or pons

3. Cheyne-Stokes respirationsbrain damage, cardiogenic shock, uremia, drug induced resp.depress

1. Biot’s respirations (irregular resp. with long periods of apnea) brainstem dysfunction

• Slow breathingdrug induced resp.depress, ICP, end-stege resp. muscle fatigue

• Apnea punctuated by erregular, gasping breaths (agonal)occurs just before death

Signs of Respiratory Distress and Potential Respiratory Failure

• Tachypnea, tachycardia• Retractions• Nasal flaring• Grunting• Stridor or wheezing• Mottled color• Change in responsiveness• Hypoxemia, hypercarbia, decreased Hgb saturations• LATE : poor air entry, weak cry apnea or gasping deterioration in systemic perfusion

bradycardia

PULSE OXIMETRY

that estimates functional oxyhemoglobin saturationNormal SpO2 96% - 99%

Poor signal detection:- poor prob positioning- motion- intense vasocontriction and/or shock states (weakens pulse)- sensor applied to tight

Factors that adversely SpO2

-neither a preinsertion nor an invivo calibration performed-Light intensity calibration not performed at the time insertion-Optics bent or broken-Catheter tip close to or facing the pulmonary artery wall-Increased carboxyhemoglobin or methemoglobin level-Poor perfusion-Anemia, hyperbilirubinemia, hypercapnia

CAPNOGRAPHY

To measure PaCO2 levelend tidal CO2 (ET-CO2) CO2 alveolar

Factors that adversely SpO2

-neither a preinsertion nor an invivo calibration performed-Light intensity calibration not performed at the time insertion-Optics bent or broken-Catheter tip close to or facing the pulmonary artery wall-Increased carboxyhemoglobin or methemoglobin level-Poor perfusion-Anemia, hyperbilirubinemia, hypercapnia

Circulation

Causes of circulatory inadequacy• primay-directly involving the heart

ischemia, conduction defects, valvular disorders,cardiomyopathy

• secondary-pathology originating elsewheredrugs, hypoxia, electrolyte disturbances, sepsis

LOOK for reduced perpheral perfusion (palor, ), hemorrhage(obvious concealed), altered level of conciousness,dyspnea, urine output

FEEL forprecordial cardiac pulsasion, pulses (central &peripheral) assessing rate, quality, regularity,symetry

LISTEN foradditional or altered heart sounds, carotid bruits

Assessment of circulation:

pulses rate, cardiac pulsasion, quality & regularity,skin temperature, & blood pressure

Heart Rate in Normal Children

Age (year) Rate/minut

< 1 110 – 160

1 – 2 100 – 150

2 – 5 95 – 140

5 – 12 80 – 120

> 12 60 - 100

Tachycardia: hypoxia, poor perfusion, febris, pain, emotional

Bradycardia: sign of preterminal hypoxia (decompensated stage), ischemia

Normal Blood Pressure in Children

Age (year) Sistolic (mmHg)

< 1 70 – 90

1 – 2 80 – 90

2 – 5 80 – 100

5 – 12 90 – 110

> 12 100 - 120

The lower limits of systolic blood pressure :

70 mmHg + (2 x age in year)

Signs of Poor Systemic Perfusion

• Tachycardia• Mottled color, pallor• Cool skin, prolonged capillary refill• Oliguria (urine volume < 1-2 ml/kg/hour)• Diminished intensity of peripheral pulses• Metabolic acidosis• Change in responsiveness • LATE : hypotension, bradycardia

Disability to assess signs of neurologic compromise precede lossof conscious

Decressing level of consciousness:

AVPU

• Awake• Responsive to voice• Responsive to pain• Unresponsive

Modified Glasgow Coma Scale for Infant

Score

Eye Opening: Spontaeous

To verbal stimuli

To pain only

No response

4

3

2

1

Verbal response: Coos and babbies

Irritable cries

Cries to pain

Moans to pain

No respons

5

4

3

2

1

Motor response: Moves spntaneously and purposefully

Withdraws to touch

Withdraws in response to pain

Decorticate posturing (abnormal flexion) in response to pain

Decerebrate posturing (abnormal extension) in response to pain

No rensponse

6

5

4

3

2

1

Modified Glasgow Coma Scale for Children

Score

Eye Opening: Spontaeous

To verbal stimuli

To pain only

No response

4

3

2

1

Verbal response: Orriented, appropriate

Confuse

Inappropriate words

Incomprehensible words or nonspecific sounds

No response

5

4

3

2

1

Motor response: Obeys commands

Localizes painful stimulus

Withdraws in response to pain

Flexion in response to pain

Extension in rensponse to pain

No rensponse

6

5

4

3

2

1

Signs of Increased Intracranial Pressure

• Decreased responsiveness (irritability, lethargy)• Inability to follow commands• Decreased spontaneous movement• Decreased response to painful stimulus• Pupil dilatation with decreased response to light• LATE : Hypertension Change in heart rate (bradycardia) Apne

Exposure

assessing the face, posture body & skinrush, hematoma, temperature, etc

Triage of all sick childrenEMERGENCY SIGNSIf any sign positive: give treatment(s), call for help, draw blood for emergency laboratory investigations(glucose, malaria smear, Hb)

1. ASSES:AIRWAY AND BREATHING

Obstructed breathing or Central cyanosis or Severe respiratory distress

IF FOREIGN BODY ASPIRATION Manage airway in choking childIF NO FOREIGN BODY ASPIRATION Manage airwayGive oxygenMake sure child is warm

Stop any bleeding Give oxygen Make sure child is warmIF NO SEVERE MALNUTRITION: Insert IV and begin giving fluids rapidly If no able to insert peripheral IV, insert an external jugular or intraosseous lineIF SEVERE MALNUTRITION:If lethargic or unconscious: Give IV glucose Insert UV line and give fluids

Col

Cold hands with: Capillary refill longer than 3 seconds, and Weak and fast pulse

2. ASSES:CIRCULATION

TREAT

ANY SIGNPOSITIVE

ANY SIGN POSITIVECheck for severemalnutrition

If not lethargic or unconscious: Give glucose orally or by NG tube Proceed immediately to full assessment and treatment

Manage airway If convulsing, give diazepam or paraldehyde rectally Position the unconscious child (if head or neck trauma is suspected, stabilize the neck first) Give IV glucose

Make sure child is warm

IF NO SEVERE MALNUTRITION: Insert IV line and begin giving fluids rapidly and diarrhoea treatment plan C in hospital

IF SEVERE MALNUTRITION: Do not insert IV Proceed immediately to full assessment and treatment

COMACONVULSING

Coma or Convulsing (now)

Diarrhoea plus any two of these Lethargy Sunken eyes Very slow skin pinch

SEVEREDEHYDRATION(only in child withDiarrhoea)

dI

IF COMA ORCONVULSING

DIARRHOEAPlus TWO SIGNSPOSITIVEChedk for severemalnutrition

PRIORITY SIGNS These children need prompt assessment and treatment

Visible severe wasting Oedema of both feetSevere plmar palor Any sick young infant (< 2 montha of age) Lethargy ontinually irritable and restless Major run Any respiratory distress or An urgent referral note from another facility

Note If a child has trauma or other surgical problems, get surgical help or follow surgical guidelines

NO- URGENTProceed with assessment and for treatment according to the child’s priority

Check for head/neck trauma before treating child-do not move neck if cervical spine injury possible

How to manage the airway in a choking child (foreignbody aspiration with increasing respiratory distress) Infants - Back slaps position: give 5 blows to the infant’s back with heel of hand - if obstruction persist, give 5 Chest thrust with 2 fingers, one finger breadth below nipple level in midline

- if obstruction persist, check infant’s mouth for any obstruction wich can be removed - if necessarry, repeat sequence with back slaps again

Children Slapping the back to clear airway obstruction Heimlich manoeuvre

if obstruction persist, check infant’s mouth for any obstruction wich can be removed

if necessarry, repeat sequence with back slaps again

How to manage the airway in a child with obstructedbreathing (or who has just stopped breathing) No neck trauma suspected Child conscious1. Inspect mouth and remove foreign body, if present (neutral

position)2. Clear secretions from throat3. Let child assume position of maximal comfort

Child unconscious

Look, listen and feel for breathing

Sniffing position to open the airway

1. Tilt the head as shown2. Inspect mouth and remove foreign body, if present3. Clear secretions from throat4. Check the airway by looking for chest movements,

listening for breath sounds and feeling for breath

Neck trauma suspected (possible cervical spine injury)

1. Stabilize the neck, use jaw thrust without head tilt 2. Inspect mouth and remove foreign body if present 3. Clear secretions from throat 4. Check the airway by looking, listen and feel for breathing

If the child is still not breathing with carrying out the above, ventilate with bag & mask

How to give oxygen• Give oxygen through nasal prongs or a nasal catheter• Start oxygen flow at 1-2 litres/minute

NASAL PRONGSPlace the prongs just inside

the nostrils and secure with tape

NASAL CATHETERUse an 8F size tube

Measure the distance from the side of the nostril to the inner eyebrow margin

with the catheterInsert the catheter to this depth

Secure with tape

Start oxygen flow at 1-2 at 1-2 litres/minute

How to position the unconscious child

If neck trauma is not suspected: - turn the child on the side to reduce risk of aspiration - keep the neck slightly extended and stabilize by placing cheek on one hand - bend one leg to stabilize the body position

If neck trauma is suspected: - stabilize the child’s neck an keep the child lying on the back - prevent the neck from moving by supporting the child’s head - of vomiting, turn on the side, keeping the head in ling with the body

SYOK ADALAH SUATU SINDROMA AKUT KARENA DISFUNGSI KARDIOVASKULAR DAN KETIDAKMAMPUAN SISTEM SIRKULASI MEMBERIKAN OKSIGEN DAN NUTRIEN UNTUK MEMENUHI KEBUTUHAN ORGAN VITAL

SYOK HIPOVOLEMIK: DEHIDRASI PERDARAHAN

SYOK DISTRIBUTIF: SEPSIS, DSS, ANAFILAKSIS

SYOK KARDIOGENIK: CHD, KARDIOMIOPATI

SYOK OBSTRUKTIF: TAMPONADE JANTUNG, TENSION PNEUMOTHORAKS

TAKHIKARDITAKHIPNEUPENGISIAN KAPILER>> IRITABILITAS RINGANTEKANAN NADI MENYEMPIT

KULIT DINGIN, LEMBAB, PUCAT, SIANOSIS

PENGISIAN KAPILER >4 DETIKHIPOTENSI (SANGAT KASIP)OLIGURIADISTENSI ABDOMEN, BISING USUS AGITASI, KONFUSI, HALUSINASI,

KOMA

1. TENTUKAN STATUS KARDIOVASKULAR

2. TENTUKAN GANGGUAN SIRKULASI TERHADAP PERNAPASAN, TINGKAT KESADARAN, PERFUSI, SUHU DAN PRODUKSI URIN

3. ESTIMASI BB, DAN BESARNYA KEHILANGAN VOLUME:

BB (Kg) = 2 x ( umur dlm th + 4)Estimasi volume darah = 80 mL/KgBB

1. BERIKAN 02 (FiO2 100%), BILA PERLU VENTILATOR

2. CEPAT PASANG AKSES VASKULAR, BERIKAN BOLUS 20mL/BB KRISTALOID SECEPAT MUNGKIN DAPAT DIULANG 2-3 X HINGGA NADI TERABA

3. NILAI RESPON APAKAH STATUS KARDIOVASKULAR DAN PERFUSI MEMBAIK, UKUR PRODUKSI URIN/JAM

4. BILA NADI BELUM TERABA PASANG KATETER VENA SENTRAL (CVP) BERIKAN CAIRAN SESUAI NILAI CVP

5. BILA HB<5 GR/Dl koreksi dg prc 10 cc/KGBB. USAHAKAN HB>10gr/Dl atau Ht 40%

6. BILA HB<5 GR/Dl koreksi dg prc 10 cc/KGBB. USAHAKAN HB>10gr/Dl atau Ht 40%

7. SETELAH KLINIS MEMBAIK PERIKSA KEMUNGKINAN DISFUNGSI ORAGAN:

UREUM, KREATININ THORAKS FOTO IRAMA JANTUNG? PTT, aPTT, FDP, TROMBOSIT, D-DIMER GANGGUAN SSP?

PADA BAYI DAN ANAK MENGAKIBATKAN GANGGUAN HEMODINAMIK, DEPRESI MIOKARDIUM DAN AKTIVASI KASKADE KOAGULASI

PADA AWALNYA TERJADI HIPERPIREKSIA, HIPERVENTILASI, TAKIKARDI, GANGGUAN KESADARAN, DAN AKRAL YANG HANGAT

KOMPENSASI CURAH JANTUNG DAN TAHANAN VASKULAR SISTEMIK

STADIUM DEKOMPENSASI (COLD SHOCK)JIKA TERAPI AWAL GAGAL DAN TUBUH

GAGAL MENGKOMPENSASI, TERJADI HIPOTENSI, HIPOKSIA DAN METABOLISME ANAEROB

1. RESUSITASI CAIRAN, BILA TIDAK BERHASIL BERIKAN INOTROPIK ATAU VASOPRESOR, JIKA TERDAPAT PENURUNAN TAHANAN VASKULAR SISTEMIK PIKIRKAN VASODILATOR PERIFER.

2. KOREKSI KETIDAKSEIMBANGAN ASAM BASA, ELEKTROLIT.

3. ANTIBIOTIKA

SYOK TERJADI KARENA VASODILATASI DAN KEHILANGAN CAIRAN KARENA GANGGUAN PERMEABILITAS KAPILAR

1. HENTIKAN ALERGEN, BERIKAN ADRENALIN 2. PERTAHANKAN JALAN NAFAS DAN PERNAPASAN

ADEKUAT, BERIKAN NEBULASI ADRENALIN. BILA PERLU INTUBASI, ATAU SURGICAL AIRWAY JIKA TERJADI SUMBATAN JALAN NAFAS

3. BILA MASIH MENGI NEBULASI SALBUTAMOL BILA PERLU HIDROKORTISON 4mg/BB IV ATAU DRIP AMINOFILIN

4. BILA SYOK LAKUKAN RESUSITASI CAIRAN KRISTALOID ATAU KOLOID DILANJUTKAN OBAT INOTROPIK.

5. BILA HENTI JANTUNG, LAKUKAN RJP

PRINSIP PENATALAKSANAAN TERAPI CAIRAN

1. TERAPI RUMATAN (MAINTENANCE)2. PENGGANTIAN DEFISIT (DEFISIT)3. ONGOING LOSSES

How to give IV fluids rapidly for shock(child not severely malnourished)

• insert an IV line (and draw blood for emergency laboratory investigations)• infusion RL or normal saline 20 ml/kg as rapidly as possible

Age/weight Volume of RL or normal saline

(20 ml/kg)

2 month (<4 kg) 75 ml

2-<4month (4-<6 kg) 100 ml

4-12 month (6-<10 kg) 150 ml

1-<3years (10-14 kg) 250 ml

3-<5 years (14-19 kg) 350 ml

Reasses child after appropriate volume has run in

0 min5 min Recognize decrease mental status and perfusion. Maintain airway and

establish access according to PALS gidelines

Push 20 cc/kg isootonic saline or colloid boluses up to and over 60 cc/kg. Correct hypoglicemia, dan hypocalsemia

Titrate epinefrin for cold shock, norepinefrine for warm shock to normal MAP-CVP and SVC O2saturation >70%

Establish central venmous access, begin dopamine therapy and arterial monitoring

Cathecholamine-resistant shock At risk of adrenal insufficiency? Not at risk? Give hydrocortis Do not Give hydrocortisone

15 min Fluid refractory shock

Fluid Responsive

Observase in PICU

Fluid refractory dopamine resistant shock

PERSISTENT CATHECHOLAMINE-RESISTANT SHOCK

60 menit

Add vasodilatororType III PDE inhibitor with volume loading

Titrate volume And Epinephrine

Titrate volume and norepinephrineVasopresin orangiotensin

Low Blood PressureCold ShockSVC O2 Saturation <70%

Low Blood Pressurewarm Shock

Normal Blood Pressure Cold ShockSVC O2 Saturation <70%

Recommnendation for stpewise management of hemodynamic support with goals of normal perfusion and perfusion pressure (MAP-CVP) in infants and children

Refractory shockPlace pulmonary artery catheter and direct fluid, inotrope, vasopressor, vasolidator, and hormonal,

Therapies to attain normal MAP-CVP andCI>3.3 and <6.0 L/mnt/m2

ECMO

How to give IV fluids for shock in a child withsevere malnutrition

Give this treatment only if the child has signs of shock and is lethargic or has lost consciousness:• insert an IV line (& draw blood for emergency laboratory investigations)

& weight the child• IV fluid 15 ml/kg over 1 hour: - RL with 5% glucose (dextrose) or

- half normal saline with 5% glucose (dextrose) or - half-strength Darrow’s solution with 5% glucose (dextrose)

or if these are unavailable- RL

• measure the pulse & breathing rate at the start and every 5-10 minute

If there are signs of improvement (pulse & breathing rates fall):• give repeat IV 15 ml/kg over 15 hour; then• switch to oral or NGT rehydration with ReSoMal 10 ml/kg/h up to 10 hours• initiate refeeding with starter F-75

If the child fails to improve after the first 15 ml/kg iv,assume the child has septic shock:• give maintenance iv fluid (4 ml/kg/h) while waiting for blood• when blood is available, transfuse FWB 10 ml/kg slowly over 3 hours• initiate refeeding with starter F-75

How to give diazepam rectally for convulsions

Give diazepam rectally

Draw up the dose from an ampoule of diazepam into a tuberculin (1 ml) syringe, base the dose

on the weight of the child, where possible, then remove the needle

Insert the syringe into the rectum 4-5 cm and inject the diazepam solution Hold buttock together for a few minutes

Diazepam 0,3-0,5 mg/BW iv or

Diazepam rectally Body weight < 10 : O,5 mg/BW > 10 : 0,3 mg/BW

orDiazepam rectally BW < 10 mg ; 5 mg

BW > 10 ; 10 mg

Seizures

Seizures

Yes

5-10 min

No

STOPDiazepam 0,3-0,5 mg/BW iv orDiazepam rectally 0,2-0,5 mg/BWHypoglycemia : D25% 2 ml/BW

Seizures

Yes

5-10 minprolonged seizure

No

STOP

Airway-breathing-circulation sign : trauma, infection, paresis Vein access Laboratorium : Blood :Glucose, electrolyte

Fenitoin 15-20 mg/BW iv bolus1mg/BW/min

Seizures

Yes No

12 hours laterfenitoin 5-7 mg/BW iv

Fenobarbital 10-20 nmg/BW im

Status of Convulsions

Seizures

Yes No

12 hours laterfenitoin 5-7 mg/BW iv+ fenitoin 5-7 mg/kg

PICU, Intubation

Midazolam 0,03 mg/BW bolus,and maintenance,

if needed : ventilator

How to treat severe dehydration in an emergency setting

RAPID IV FLUID REPLACEMENT IN severe dehydration.BABY (< 1YRS)

70 ML/KB/1 HR30 ML/KB/5 HR

CHILDREN70 ML/KG/0.5 HR30 ML/KG/2.5 HR

SLOWER IN DKA AND MENINGITIS, MUCH SLOWER IN HYPERNATREMIA STATE (REHYDRATED OVER 48 HOURS, SERUM SODIUM SHOULD NOT FALL BY > 1 MMOL/L/HR

PENANGANAN EKSASERBASI AKUT

ASMA PADA BAYI DAN ANAK

BERVARIASI INTER-/INTRA INDIVIDUDALAM HAL:GEJALA DAN TANDADERAJAT BERATNYALAMA SERANGANKOMPLIKASIRESPON TERHADAP OBATPENANGANAN KASUS PER

KASUSDISESU-AIKAN DENGAN KLASIFIKASI DAN

RESPON

PATHOPHYSIOLOGYChemical mediators

Bronchoconstriction, mucosal edema, exes.secret

Airway obstruction

Nonuniformventilation

Atelectasis Hyperinflation

Mismatching V/P Decreased compliance

Increased work of breathing

AlveolarHypoventilation

PaCO2PaO2

Acidosis

Hyperinflation

Pulmonary vasoconstriction

PARAMETER YANG DIJADIKAN DASAR:

I. KLINIS: AKTIFITAS, KEMAMPUAN BICARA, POSISI, KESADARAN, SIANOSIS, WHEEZING, SESAK, OTOT BANTU, RETRAKSI, FREKUENSI NAPAS, NADI DAN PULSUS PARADOKSUS

II. HASIL SPIROMETRIK (FEV1) DAN FLOWMETER (PEFR)

III. GAS DARAH: SATURASI O2; Pa O2; Pa CO2

KLASIFIKASI EKSASERBASI

RINGAN SEDANG BERATANCAMAN

HENTI NAPAS

LANJUTAN

LANJUTAN

1. MEREDAKAN OBSTRUKSI2. MENGURANGI HIPOKSEMIA3. MENORMALKAN FAAL PARU4. MERENCANAKAN

PENANGANAN JANGKA PANJANG SESUAI KLASIFIKASI PENYAKIT

LANJUTAN

LANJUTAN

LANJUTAN