DRAFT SOOCA PROXIMA

#6 RSP
Bronchopneumonia
Created by : Tim Draft SOOCA-PROX
BHP : PHOP :
1. (Beneficence) Penggunaan flue vaccine yang dilakukan 1. Primary level, pada negara berkembang - MTBS ( Management Terpadu Balita Sakit)
secara regular, apakah wajar atau tidak? 2. National level, untuk mengurangi mortalitas dan morbiditas Pneumonia
3. International level, untuk mengurangi mortalitas dan morbiditas Pneumonia

CRP : Pneumonia is a common disease. The overall attack rate is

about 12 cases per 1000 persons per year.

SakinaPS, AzizahNH, EvelineY, YasminAR, AdindaSN, FadhalMA, HasnaH, DeviA, DeaD Halo dr Proxima, semangat di tahun 3nya ya :D Semoga bisa sama-sama menjadi dr yang baik 
Learning that we should know

• Explain the anatomy of upper and lower respiratory tract (Department of Anatomy).review • COPD
• Explain the histology of the respiratory tract wall and lung parenchyma (Department of Histology).REVIEW
• COPD
• Explain the growth and development of the respiratory tract (department of Biomedic).
• COPD
• Explain the gas exchange of the lung (Department of Physiology).
• Explain the physiology of respiration, pathophysiology of dyspnea and coughing (Department of • Coughing = Croup
Physiology).review
• Explain the acid-base balance of the blood and acidosis/alkalosis (Department of Biochemistry).review • COPD
• Explain the laboratory findings of pneumonia (Department of Clinical Pathology).
• Explain the microbiology findings of pneumonia (Department of Microbiology).
• Describe the anatomical pathology of pneumonia (Department of Anatomical Pathology).
• Describe the radiological findings of pneumonia (Department of Radiology).
• Explain the host defenses mechanisms of the respiratory tract (Department of Pediatric).
• Explain the clinical manifestation of pneumonia in children and adults (Department of Pediatric and Internal
Medicine).
• Explain the WHO guidelines for the management of cough or difficult breathing in under-5 child (Department
of Pediatric).
• Explain the epidemiology of pneumonia in children and adults (Department of Pediatric and Internal
Medicine).
• Explain the epidemiology of bacterial etiology of pneumonia in children and adults (Department of Pediatric
and Internal Medicine).
 Learning that we should know

• Explain about influenza disease

• Explain the pathogenesis of pneumonia (Department of Pediatric and Internal Medicine).
• Explain the diagnosis of pneumonia in children and adults (Department of Pediatric and Internal
Medicine).
• Explain the risk factors of pneumonia in children (Department of Pediatric).
• Explain the management and antibiotics therapy of bacterial pneumonia in children and adults
(Department of Pediatric and Internal Medicine).
• Explain the complication of pneumonia (Department of Pediatric and Internal Medicine).
• Explain the prevention program of pneumonia in children and adults (Department of Pediatric and
Internal Medicine).
• Understand the recent situation of Under-Five-Children Pneumonia in Indonesia (epidemiology,
prevalence, incidence)
• Describe the international and national framework for Pneumonia Control (including prevention of
Pneumonia in children)
• Explain how to do early detection of Pneumonia at home or primary health care i.e Integrated
Management of Children Illness or ‘ManajementerpaduBalitaSakit (MTBS)’ in Eradication of Acute
Respiratory Infection Program (Program Pemberantasan ISPA)
• Explain ethical issue of flu Vaccine
• Formulate research problems of the case. (How to build a good research background)
Case Review
Identitas Dugie, 10 month old boy
Keluhan utama : Difficulty of breathing since the last 3 days
HT : PE : LE :
• fever since the last 2 days • Body weight 8 kg, Height 67 cm. • Hb 11.3 g/dl, Hematocrit 37%, WBC 21.700/mm3,
• common cold since 4 days Fully alert, dyspnea, severely ill. Thrombocyte 210.000/mm3
ago Blood pressure 90/60 mmHg, Heart • Differential count -/2/4/68/25/1.
• The difficulty of breathing rate 136 bpm. Respiratory rate 60 • Blood smear shows toxic granule in neutrophil.
didn’t accompany with x/min, Temperature 38.9C • Chest X-Ray showed bilateral infiltrate.
noisy breathing such as • Looked dyspnea with nasal flaring, • Blood sample was taken for culture and susceptibility
wheeze or snoring, retraction of suprasternal, test
cyanotic at finger or intercostal and epigastric without
around his mouth, and perioral cyanosis. Diagnosis : BRONCHOPNEUMONIA
also seizure • The inspection of the chest showed
• no history of choking, retraction of the intercostal space, Management : Intravenous Ampicillin 4 x 400 mg
vomiting, and swelling in symmetrical movement, the
extremities palpation and percussion didn’t Epilogue :
• Dugie’s father suffered show abnormality and in the Three days afterward the dyspnea and other symptoms was
from cough and fever, but auscultation found crackles in the disappeared. Dugie was discharged from the hospital and
had been recovered whole of bilateral hemithorax gets Amoxicillin syrup 125 mg, three times daily.
• His immunization was Culture result : Streptococcus pneumoniae with good
complete for his age sensitivity to penicillin antibiotic group.

Prognosis : Ad vitam ad bonam ; Ad functionam Ad bonam

Growth and development of the respiratory tract (department of Host defenses mechanisms of the respiratory tract
Biomedic)
Pada kasus dibahas tentang host defense mechanism, karna pneumonia merupakan secondary
Pada kasus dibahas tentang perkembangan embriologi, karna berhubungan dengan factor infection yang predisposisinya adalah kemungkinan viral (karna ada common cold) oleh karena itu,
resiko yaitu jalur nafas yang masih sempit akibat perkembangan yang belum sempurna seharusnya pertahanan tubuh dapat menangkal terjadinya ke dua infeksi tsb dengan cara :

1. Physical barrier
 Deposition: upper airway filtering system
GROWTH AND DEVELOPMENT  CoughBatuk merupakan mekanisme normal untuk airway clearance. Batuk
OF RESPIRATORY TRACT dikarakteristikkan oleh 4 fase spesifik, yaitu:
Def: Merupakan perkembangan 1. Batuk dimulai dengan usaha yang cepat dan dalam dari respirasi (inspiratory phase)
dari respiratory tract (dan juga 2. Cepat dan dalamnya inspirasi dengan segera diikuti kompresi (compression phase)
organ) yang dimulai sejak minggu 3. Bukaan spontan dari glottis, high expiratory airflow, explosive sound. Collapse of the central
ke 4 di dalam kandungan. Bukan airways can occur (expressive phase)
hanya perkembangan paru-paru, 4. Relaksasi otot dan tekanan reversal (relaxation phase)
tapi juga perkembangan dari  Mucocilliary escalator: trapping at mucus, moved by cilia
conducting pathways (trachea-  Respiratory epithelium: punya fungsi physical barrier, antimicrobial function (mucus, Ig,
bronnchioles) lysozyme, lactoferrin, mucus proteinase inhibitor), regulatory function (neuropeptide
degrading enzymes, endothelin, NO, TGF-b), dan pro-inflammatory function (arachidonic acid
metabolites, inflammatory cytokines)
 Secreted substances: ;ysozyme, surfactant-associated proteins, lactoferrin, fibronectin,
1. Prenatal Lung Growth 2. The Lung at Birth
antiproteases
1. Embryonic (days 26-52): Terjadi perubahan yang krusial pada
2. Pseudoglandular (days 52-week 16) fase ini. Epitel paru-paru berubah dari
2. Cellular-alveolar Mechanism
3. Canalicular (week 16-28) liquid secretion menjadi fluid
 Phagocytosis by alveolar macrophage
4. Saccular (week 28-36) absorption. Aliran darah meningkat 20x
lipat. Cairan yang ada di dalam paru Identifyinitiation  transmission from receptor  efector  collecting
5. Alveolar (week 36-term) pseudopodia  pseupodia phagocyte  fusion
akan diresorpsi oleh darah dan limfatik
Peningkatan pada phagocytosis, makrofag sekresi H2O2, kills bacteria
3. Postnatal Lung Growth  Immunologic reactions
1. diameter trakea melebar sekitar kali lipat (triple) Macrophage initiate humoral and cellular immune system, B and T lymphocyte 
2. jumlah alveolar meningkat sekitar 10 kali lipat antibody and cell mediated
3. massa tubuh meningkat sekitar 20 kali lipat.  Immunoglobulins
4. hubungan anatomi lainnya dari paru-paru bayi dan anak adalah sama dengan Ig are present in the secretion of the upper and lower airways. In the upper
those in the adult’s lung. airways IgA accounts for 10% of the protein content. IgG is minimal (1%), and IgE is
5. Jumlah alveoli meningkat pesat dari 20 million sampai 200 million pada tahun found in trace amounts unless allergic rhinitis or autopsy presents. IgA seems to be
ketiga kehidupan, tetapi kemudian alveolar multiplication slows. most important for host defense, it is not clear how it functions.
6. Pada mature adult lung, , jumlah alveoli bervariasi 200-600 million, dan
individual diameter alveolus is 250-350 μm.
Common Cold
Definition : Management :
Common cold adalah penyakit yang disebabkan akibat infeksi - Istirahat
virus yang menyebabkan adanya runny nose, sore throat, - Mucolytic untuk mengurangi batuk
sneezing, dan coughing. - NO antibiotic

Etiology :
Viral Infection
- Rhinovirus (40%)
- Coronavirus (20%)
- RSV (20%)
- Parainfluenza

Risk Factor :
- Age (bayi 4-6 minggu memiliki risiko tertinggi)
- Orang sekitar yang sedang terinfeksi

Sign & Symptoms :

- Sore throat
- Sneezing
- Coughing
- Runny Nose
- Headache
- Fever (rarely)

Prevention :
ASI (untuk bayi), PHBS, dan tidur yang cukup
 Microbial aspect of Streptococcus pneumonia Clinical Science of Pneumonia
• NORMAL FLORA PADA URT Rute Infeksi:
• Merupakan gram positif diplococci - Microaspiration dari sekresi oropharyngeal yang
• Berbentuk rantai, dilindungi oleh kapsul Def: Inflamasi akut pada terdapat koloni mikroorganisme
polisakarida. parenchym paru yang - Gross aspiration (biasanya pada CNS disorder)
• Di dalam solid media, sensitif terhadap menyebabkan adanya - Aerosolization
optochin test. infiltrasi sel-sel inflammatory - Hematogenous route
• Alfa-hemolitik. pada alveoli. - Contiguous spread
• Grows well on sheep blood agar.
Mempunyai pneumolysin : melisiskan Epidemiology
red blood cell pada kondisi anaerob (alfa- o Pneumonia is a common disease. The overall attack rate is about 12 cases per 1000 persons
hemolisis) per year.
o Pneumonia merupakan pembunuh utama anak dibawah usia lima tahun (Balita) di duniaDi
Virulence factor :
Indonesia berdasarkan hasil Riset Kesehatan Dasar (Riskesdas) tahun 2007, menunjukkan;
1. Polysaccharide capsule : melindungi dari phagocytosis, prevalensi nasional ISPA: 25,5% (16 provinsi di atas angka nasional), angka kesakitan
menghambat complement pathway (morbiditas) pneumonia pada Bayi: 2.2 %, Balita: 3%, angka kematian (mortalitas) pada bayi
2. Cell wall polysaccharide : inflammatory effect (enhance 23,8%, dan Balita 15,5%
vascular permeability, mast cell degranulation, etc)
3. Pneumolysin : cytotoxin. Menyebabkan cell lysis
Pathogenesis :
Pneumococci masuk via inhalasi, menempel pada epitel saluran pernafasan atas dengan
sebelumnya terkena infeksi virus (biasanya). Epithelial damage, disebabkan oleh infeksi
sebelumnya oleh virus di pernafasan atas, memudahkan pneumococci untuk menempel dan
berkolonisasi di epitel. Kegagalan dari mekanisme pertahanan tubuh spesifik (secretory IgA)
dan nonspesifik (cough, mucosal secretion, dan cilia transport) dapat memfasilitasi bakteri
untuk pindah menuju lower respi (bronchi and lung). Epithelial damage juga memungkinkan
pneumococci untuk menembus bloodstream. Dari darah mengalir menuju meningen dan
menyebabkan meningitis. Bisa juga secara langsung lewat nasopharynx.

Etiology
The effects of pneumolysin on ciliary beating of epithelial cells and the effects of the IgA1
protease secreted by pneumococci (see the section on virulence factors, above) might
impair these defense mechanisms.
Clinical Science of Pneumonia
Keterangan

Risk Factor
The type of agent (typical or atypical) causing the
infection,
• Typical pneumonias result from infection by bacteria
that multiply
extracellularly in the alveoli and cause inflammation and
exudation of fluid into the air-filled spaces of tthe alveoli
Clinical manifestation

Most children with pneumonia present with cough or difficulty breathing, • Aypical pneumonias are caused by viral and
but only the minority of children with these symptoms have pneumonia. mycoplasma infections that involve the alveolar
Bacterial pneumonia should be considered in children <3 years of age who septum and the interstitium of the lung. They produce
present with fever > 38.5, chest recession and increased respiratory rate less striking symptoms and physical findings than
>50 breaths/minute. If chest indrawing, nasal flaring, grunting or bacterial pneumonia; there is a lack of alveolar
crepitations are also present then the probability of pneumonia is increased infiltration and purulent sputum, leukocytosis, and lobar
further consolidation on the radiograph

Distribution of the infection

• lobar pneumonia refers to consolidation of
a part or all of a lung lobe
• bronchopneumonia signifies a patchy
consolidation involving more than one lobe
Setting
Klasifikasi community-acquired pneumonia,
- Berdasarkan lokasi - Berdasarkan tipe - Berdasarkan asal infeksi Def : Pneumonia yang didapatkan dari kontak sosial.
1. Lobarpneumonia agent 1. Community Acquired RF; Cerebrovascular disease, tobacco smoking, COPD, HIV.
Etiology: S. Pneumonia, H. Influenzae, S. Aureus, M. Pneumoniae, Influenza virus, adenovirus,
2. Bronchopneumonia 1. Typical Pneumonia Pnemonia (CAP)
RSV.
3. Interstitial 2. Atypical Pneumonia 2. Hospital Acquired Pneimonia
Treatment: Pemberian anti microbial agent penyebab (berdasarkan pemeriksaan lab) selama 20-
Pneumonia (HAP) 24 hari.
- Berdasarkan - Berdasarkan tingkat - Berdasarkan durasi
Etioloogi keparahan 1. Kronik >2w hospital-acquired (nosocomial) pneumonia,
1. Viral 1. Very severe 2. Akut <2w Def : Pneumonia yang terjadi paling tidak 48 jam setelah hospital admission dan tidak inkubasi
2. Bacterial 2. Severe 3. Persisten pada waktu admission.
3. Mycoplasma 3. Non severe Transmisinya lewat intubasi nasogatric dan endotracheal.
Etiology: S. Aureus, P. Aureginosa
4. Fungal
Treatment: Tetap di rumah sakit. Jika semakin parah, masuk ke ICU.
 Clinical Science of Pneumonia

Sign & Symptom : Diagnosis:

- Onset insidious - Chest X-Ray: Dilihat opacity. Akan
nampak ada infiltrasi Complications of pneumonia
- Demam
- Blood culture SOURCE :
- Tachypneu, shortness of breath
http://www.nhs.uk/Conditions/Pneumonia/Pages/Introduction.aspx
- Batuk (bisa berdahal bisa tidak) - Sputum stain and culture
Complications of pneumonia are more common in young children, the elderly and
- Pleuritic chest pain - Blood Test: : WBC jika bakteri 15.000-
those with pre-existing health conditions, such as diabetes.
- Chills, rigors, headache, nause, 40.000
Possible complications of pneumonia include:
vomitiing - Deteksi antigen pathogen di urine  pleurisy / pleuritis – where the thin linings between your lungs and ribcage
- Crackles saat auskultasi, dullness saat - Serology (pleura) become inflamed, which can lead to respiratory failure
perkusi - PCR
 a lung abscess – a rare complication that's mostly seen in people with a
Classification of the severity of pneumonia (WHO 2005) serious pre-existing illness or a history of severe alcohol misuse
Sign and symptoms Classification  blood poisoning (septicaemia) – also a rare but serious complication
- Central cyanosis Very severe pneumonia
- Severe respiratory distress (e.g. head nodding) Preventing pneumonia
SOURCE :
- Not able to drink
http://www.nhs.uk/Conditions/Pneumonia/Pages/Introduction.aspx
- Chest indrawing Severe pneumonia
Although most cases of pneumonia are bacterial and aren't passed on from one
- Fast breathing Pneumonia
person to another, ensuring good standards of hygiene will help prevent germs
≥ 60 breaths/minute in a child aged < 2 months spreading.
≥ 50 breaths/minute in a child aged < 2-11 months For example, you should:
≥ 40 breaths/minute in a child aged 1-5 years  cover your mouth and nose with a handkerchief or tissue when you cough or
- Definite crackles on auscultation sneeze
- No sign of pneumonia, or severe, or very severe No pneumonia cough or cold
pneumonia  throw away used tissues immediately – germs can live for several hours after
they leave your nose or mouth
Management of Pneumonia
Manajemen Pneumonia adalah tipe causative management yang diarahakan  wash your hands regularly to avoid transferring germs to other people or
secara langsung terhadap apa yang menjadi penyebab dari pneumonia tersebut. objects
Jika penyebabnya adalah bakteri, maka antibiotik adalah pilihan utama untuk
A healthy lifestyle can also help prevent pneumonia. For example, you should avoid
terapinya.Untuk manajemen lainnya, diberikan berdasarkan clinical manifestations smoking as it damages your lungs and increases the chance of infection.
yang muncul. Dan ada beberapa supportive care yang biasanya diberikan, seperti Find out how to stop smoking.
1. Terapi oksigen jika muncul tanda hypoxia Excessive and prolonged alcohol misuse also weakens your lungs' natural defences
2. Antipyretic, jika demam lebih atau sama dengan 39 derajat celcius against infections, making you more vulnerable to pneumonia.
3. Suction of any thick secretion of the throat
4. Fluid hydration. Tapi pastikan hidrasi yang diberikan sesuai dengan usia anak.
5. Makan yang cukup sesuai waktunya.
 RECOMMENDATION FOR PNEUMONIAE - Source : WHO

Recommendation 1 Recommendation 2 Recommendation 3

 Children with fast breathing pneumonia with  Children age 2–59  Children aged 2–59 months with severe pneumonia1
no chest indrawing or general danger sign months with chest should be treated with parenteral ampicillin
should be treated with oral amoxicillin: at indrawing (or penicillin) and gentamicin as a first-line
least 40 mg/kg/dose twice daily pneumonia4 treatment.
(80mg/kg/day) for five days. should be treated — Ampicillin: 50 mg/kg, or benzyl penicillin: 50 000
 In areas with low HIV prevalence, give with oral units per kg IM/IV every six hours for at
amoxicillin for three days. amoxicillin: at least five days
 Children with fast-breathing pneumonia who least — Gentamicin: 7.5 mg/kg IM/IV once a day for at
fail on first-line treatment with amoxicillin 40mg/kg/dose least five days
should twice daily Ceftriaxone should be used as a second-line
have the option of referral to a facility where (80mg/kg/day) for treatment in children with severe pneumonia having
there is appropriate second-line treatment five days. failed on the first-line treatment.

Recommendation 4 Recommendation 5

 Ampicillin (or penicillin when ampicillin is not available) plus  Empiric cotrimoxazole treatment for suspected Pneumocystis
gentamicin or ceftriaxone are recommended as a first-line jirovecii (previously Pneumocystis carinii) pneumonia (PCP) is
antibiotic regimen for HIV-infected and -exposed infants and recommended as an additional treatment for HIV-infected and -
for children under 5 years of age with chest indrawing exposed infants aged from 2 months up to 1 year with severe or
pneumonia or severe pneumonia. very severe pneumonia.
 For HIV-infected and -exposed infants and for children with  Empirical cotrimoxazole treatment for Pneumocystis jirovecii
chest indrawing pneumonia or severe pneumonia (PCP) is not recommended for HIV-infected and -
pneumonia, who do not respond to treatment with ampicillin exposed children over 1 year of age with chest indrawing or severe
or penicillin plus gentamicin, ceftriaxone alone is pneumonia.
recommended for use as second-line treatment
Management of Children Illness or ‘ManajementerpaduBalitaSakit (MTBS)’ in Eradication of Acute Respiratory Infection Program
(Program Pemberantasan ISPA)