ACUTE
RESPIRATORY
INFECTIONS
Pneumonia
Bronkiolitis
Bronkitis Akut
Acute Respiratory Infections (ARI)
Developed and developing countries
High morbidity
5 – 8 episodes/year/child
30 – 50 % outpatient visit
10 – 30 % hospitalization
Developing countries
High mortality
30 – 70 times higher than in developed countries
1/4 - 1/3 death in children under five year of age
ARI-ASSOCIATED DEATH RATE BY AGE
TEKNAF, BANGLADESH, 1982-1985
Deaths per 1000 children
140
120
100
80
60
40
20
0
1-5 6-11 12-23 24-35 36-50
Ag e i n M on t h s
Distribution of 12.2 million deaths among children less
than 5 years old in all developing countries, 1993
ARI/Malaria (1.6%)
Malaria (6.2)
ARI (26.9%)
Malnutrition
(29%)
Other (33.1%)
ARI/Measles (5.2%)
Measles (2.4%)
Diarrhoea/measles
(1.9%)
Diarrhoea (22.8%)
RISK FACTORS FOR PNEUMONIA
OR DEATH FROM ARI
Malnutrition, poor
breast feeding
practices
Lack of immunization Vitamin A deficiency
Young age Low birth weight
Increase
risk of
ARI
Cold weather
Crowding or chilling
High prevalence Exposure to air pollution
of nasopharyngeal • Tobacco smoke
carriage of • Biomass smoke
pathogenic bacteria • Environmental air pollution
Magnitude of the Problem
in Indonesia
Pneumonia in children (< 5 years of age)
Morbidity Rate 10-20 %
Mortality Rate 6 / 1000
Pneumonias kill
50.000 / a year
12.500 / a month
416 / a day = passengers of 1 jumbo jet plane
17 / an hour
1 / four minutes
Pneumonia is a no 1 killer for infants
(Balita)
Pneumonia
Classifications
Anatomical classification
Lobar pneumonia
Lobular pneumonia
Intertitial pneumonia
Bronchopneumonia
Etiological classification
Bacterial pneumonia
Viral pneumonia
Mycoplasma pneumonia
Aspiration pneumonia
Mycotic pneumonia
Etiology of Pneumonia
Predominantly : bacterial and viral
In developing countries:
bacterial > viral
(Shann,1986): In 7 developing countries,
bacterial 60 %
(Turner, 1987): In developed countries,
bacterial 19 % ; viral 39 %
Bacterial etiology
Streptococcus pneumoniae
Hemophilus influenzae
Staphylococcus aureus
Streptococcus group A – B
Klebsiella pneumoniae
Pseudomonas aeruginosa
Chlamydia spp
Mycoplasma pneumoniae
BACTERIA ISOLATED FROM LUNG ASPIRATES
IN 370 UNTREATED CHILDREN WITH PNEUMONIA
%
50
40
30
20
10
0
S Pneumoniae H Influenzae S Aureus
Characteristic features
S pneumoniae
mucosal inflammation lesion
alveolar exudates
frequently lobar pneumonia)
H influenzae, S viridans, Virus
invasion and destruction of mucous membrane
Staphylococcus, Klebsiella
destruction of tissues multiple abscesses
Simple Clinical Signs of Pneumonia
(WHO)
Fast breathing (tachypnea)
Respiratory thresholds
Age Breaths/minute
< 2 months 60
2 - 12 months 50
1 - 5 years 40
Chest Indrawing
(subcostal retraction)
Pathology and Pathogenesis
Bacteriae peripheral lung tissues
tissues reaction oedematous
Red Hepatization Stadium
alveoli consist of : leucocyte, fibrine,erythrocyte,
bacteria
Grey Hepatization Stadium
fibrine deposition, phagocytosis
Resolution Stadium
neutrophil degeneration, loose of fibrine,
bacterial 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
1. Diffuse alveolar and interstitial
pneumonia (perivascular and
interalveolar changes)
2. Bronchopneumonia
(inflammation of airways and
parenchyma)
3. Lobar pneumonia
(consolidation in a whole lobe)
4. Nodular, cavity or abscess lesions
(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 and
human herpes virus, leucocytois 17000, ESR 8 mm/ h l, CRP 22 mg/l
Blood Gas Analysis & Acid Base Balance
Hypoxemia (PaO2 < 80 mm Hg)
with O2 3 L/min 52,4 %
without O2 100 %
Ventilatory insufficiency
(PaCO2 < 35 mmHg) 87,5 %
Ventilatory failure
(PaCO2 > 45 mmHg ) 4.8 %
Metabolic Acidosis
poor intake and/or hypoxemia 44,4 %
(Mardjanis Said, et al. 1980)
Management
Severe Pneumonia
Hospitalization
Antibiotic administration
Procain Pennicilline, Chloramphenicol
Amoxycillin + Clavulanic Acid
Intra Venous Fluid Drip
Oxygen
Detection and management of
complications
WHO recommendations for treatment of infants less 2
months who have cough or difficulty breathing
No pneumonia : No tachypnea, no severe chest
indrawing
Do not administer an antibiotic
Severe pneumonia : Tachypnea or severe chest
indrawing
Admit, administer benzylpenicillin
+ gentamycin, and oxygen
WHO recommendations for treatment of children aged 2
months
to 4 years who have cough or difficulty breathing
No pneumonia : No tachypnea, no chest indrawing
Do not administer an antibiotic
Pneumonia : Tachypnea, no chest indrawing
Home treatment with cotrimoxazole,
amoxicillin 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
on age and severity of pneumonia
Outpatients
Age Inpatients (Moderate) Inpatients (Severe)
(Mild to Moderate)
Amoxicillin with or
Ceftriaxone or cefotaxime
3 - 6 mos without clavulanate Ceftriaxone or cefotaxim
+ vancomycin
Erythromycin
6 mos Amoxicillin with or Ceftriaxone, cefotaxime,
Ceftriaxone or cefotaxime
to without clavulanate or
+ macrolide + vancomycin
5 yrs Erythromycin Cefuroxime + macrolide
5 – 18 yrs Macrolide Ceftriaxone or cefotaxime Ceftriaxone or cefotaxime
+ macrolide + macrolide + vancomycin
Hsiao G et al, 2001
Complications
Pleural effusion (empyema)
Piopneumothorax
Pneumothorax
Pneumomediastinum
Bronchiolitis
Bronchioles inflammation
Clinical syndromes:
fast breathing, retractions, wheezing
Predominantly < 2 years of age
(2 – 6 months)
Difficult to differentiate with pneumonia
…Bronchiolitis
Pathology
Necrosis of the resp. epithelium
Destruction of ciliated epithelial cells
Peribronchial infiltration with lymphocites & neutrophils
Sub mucosal edematous
No destruction of collagen, muscle, or elastic tissue
Pathophysiology
Edema + accumulation of mucous & cellular debris
narrow of peripheral airway partially / totally
occluded over distention / atelectasis
…Bronchiolitis
Etiology
Predominantly RSV (Respiratory Syncytial
Virus)
Other viruses : rhinovirus, adenovirus,
influenza virus, parainfluenza virus, entero
virus, etc.
Severity
Prematurity OR 1.84
Underlying medical condition OR 2.84
Group A RSV strain OR 3.26
Age < 3 mo OR 4.39
…Bronchiolitis
Diagnosis
Etiological diagnosis
Microbiologic examination
Clinical diagnosis
Signs and symptoms
Age
Resource of infection epidemic of RSV
Laboratory finding
Radiological examination
…Bronchiolitis
Clinical Manifestations : mild rhinorrhea,
cough, cold, low-grade fever
1-2 d fast breathing, chest retraction,
wheezing, irritable, vomitus, poor intake
Physical Examinations
tachypnea, tachycardia, retraction,
prolonged expiration, wheezing,
fever,pharyngitis, conjunctivitis, otitis media,
dehydration
…Bronchiolitis
Radiologic examination
diffuse hyperinflation
flat diaphragm,
Intercostal space >
retrosternal space >
peribronchial infiltrates / thickening
patchy atelectasis segmental collapse
pleural effusion (rare)
Laboratory finding
Respiratory rate : Arterial saturation
pCO2
…Bronchiolitis
Laboratory finding
Microbiologic examination
WBC : 5000 – 24.000 cells/mm3, predominantly
PMN & bands
Blood Gas Analysis
Arterial saturation
pCO2
Mild respiratory alkalosis
Metabolic acidosis
Acute respiratory acidosis
…Bronchiolitis
Management
Mild treated at home
Moderate / severe disease hospitalization
support : oxygen
intra venous fluid drip
(antibiotics)
detect & treat possible complication
prevent the spread of inf.
Controversial : bronchodilator
corticosteroid
antiviral
antibiotic
…Bronchiolitis
Natural history & complications
Regeneration of bronchiolar epithelium after 3
or 4 d
Cilia after 3 or 4 d
Improved clinical findings : in 3-4 days
Improved radiological features: in 9 days
Persistent respiratory obstruction : 20%
Respiratory failure : 25 %
Lung collaps (rare)
…Bronchiolitis
Correlation with Asthma
30 % - 50 % becomes asthmatic patients
Similarity in : - pathogenic mechanisms
- pathologic disorders
Bronkitis akut
radang bronkus akut
umumnya disertai radang akut saluran
napas bawah lainnya
Tidak pernah berdiri sendiri
Trakeobronkitis akut = Bronkitis
Istilah yang membingungkan
Bronkitis kapiler (Capillary Bronchitis)
Bronkitis
Pneumonia interstitial
Bronkitis asmatika
Salah satu bentuk asma
Etiologi Bronkitis akut
Umum : virus
Spesifik
Influenza
Pertusis
Campak (morbilli)
Salmonella
Difteria
Scarlet fever
Predisposisi dan faktor yang
berpengaruh
Asap rokok
Alergi
Cuaca
Keadaan umum yang jelek (Poor health)
Infeksi kronik alat napas atas
Pemeriksaan fisis
Panas : (-) (+) (-)
Mukosa : - nasofaringitis
- konjungtivitis
- rhinits virus
Suara napas kasar
Ronki basah kasar halus
Mengi (Wheezing)
SPUTUM : Jernih beberapa hari keruh
5-10 hari
Batuk hilang jernih
Gejala dan tanda lain bronkitis akut
Rasa tidak enak di bawah tulang dada :
Seperti terbakar sakit
Suara napas berbunyi seperti siulan
Sesak
Muntah
Penanggulangan bronkitis akut
Simptomatis
Pengeluaran lendir/sputum :
Posisi tidur diubah-ubah
Jaga kelembaban udara
Sering minum
Kodein : hati-hati ! (sangat jarang
diperlukan)
Antihistamin : Hati-hati Atropin like effect
Bronkitis akut
Ekspektoran : tidak perlu
Antibiotika :
Tidak ada gunanya
Indikasi
Bronkitis akut berulang
Ada komplikasi
Komplikasi bronkitis akut
Otitis
Sinusitis
Pneumonia
Terutama kalau gizi buruk
Batuk kronik berulang
pada anak: bronkitis kronik tidak ada
dasar : - penyakit paru
- penyakit sistemik
DD/ D/
Komponen refleks batuk
Reseptor Aferen Pusat batuk Eferen Efektor
Laring Cabang nervus
vagus Otot,
Laring, trakea
Trakea
dan bronkus
Bronkus Nervus vagus
Tersebar merata
Telinga
di medula dekat
Pusat pernapasan :
Lambung
di bawah kontrol
Pusat yang Diafragma, otot-otot
Nervus Frenikus,
Hidung Nervus lebih tinggi Interkostal &
Interkostal,
Sinus paranasalis trigeminus abdominal
lumbaris
& otot lumbal
Saraf-saraf
Nervus Otot saluran napas
Faring Trigeminus, Fasialis
dan otot bantu napas
glosofaringus Hipoglosus,dll
Perikardium
Nervus frenikus
diafragma
