ACUTE RESPIRATORY INFECTIONS

(PEDIATRIC)

Dr. Fifi Sofiah, Sp.A

Blok 16 Sistem Respirasi FK UNSRI Tahun 2016

Sign & Symptom

Rinorrhea
Cough
Sneezing
Tachypnea, chest indrawing (important in IMCI)
Dyspnea, eq: nasal flaring, grunting, head bobbing,
retraction, cyanosis, etc

Severe sign/symptom:
Decreased conciousness, difficult to drink/eat, seizure

Physical Findings
Tachypnea
Normal RR
Age

Normal RR (IMCI/WHO)
Range

Av. Rate
during asleep

Age

RR

< 2 mo

< 60 x/m

2 mo-12mo

< 50x/m

Neonates

30 60

35

1 mo 1 y.o

30 60

30

1-5 y.o

< 40x/m

1 2 y.o

25 50

25

5-8 y.o

< 30 x/m

3 4 y.o

20 30

22

5 y.o 9 y.o

15 30

18

10 y.o

15 30

15

Physical Findings

Nasal flaring

Chest indrawing/retractions

Acute Respiratory Infections (ARI)/

Infeksi Saluran Pernapasan Akut (ISPA)
Acute Respiratory Infection (ARI): (Acute < 2 weeks)
1. Acute Upper Respiratory Infection (AURI):
- Common cold
- Otitis media
- Pharyngitis
- Tonsilitis
- Influenza
2. Acute Lower Respiratory Infection (ALRI):
- Croup
- Bronchitis
- Bronchiolitis
- Pneumonia

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

CROUP

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed

Croup

acute laryngotracheobronchitis
Causing respiratory tract obstruction
Self limiting, but occasionaly progress to severe or
even fatal

Definition

Disorders affecting larynx, infra/subglottis, trachea

and bronchi
Characterized by hoarseness, barking cough,
inspirational stridor, with/without respiratory distress

Classification

General classification:
Viral croup: characterized by prodromal respiratory
infection, respiratory obstruction lasts 3-5 days
Spasmodic croup: positive history of atopy, no
prodromal symptom

Classification severity

Mild: occasionaly barking cough, no stridor heard

while resting, mild retractions
Moderate: frequent barking cough, stidor easily
heard while resting, retractions, no respiratory
distress
Severe: frequent barking cough, stidor easily heard
while resting, retractions, respiratory distress
Impending respiratory distress: cough occasionaly
unclear, stridor, altered consciusness, lethargy

CROUP

Epidemiology

Occur mainly in children 6 mo-6 y.o

Etiology
Common etiology: Human Parainfluenza type 1 (HPIV-1)
HPIV 2,3 & 4
Adenovirus
Influenza A & B
RSV
Measles
Mycoplasma pneumonia (uncommon)

Pathogenesis

Nasopharyngeal infection spreading to trachea &

larynx epithelia diffuse inflammation, erythema &
oedema in trachea disturbance in vocal cord
mobility & irritation in subglottic area
hoarseness
Air turbulance upper respiratory tract stridor
followed by retractions
Disorders in chest and abdominal wall fatigue,
hypoxia, hypercapnea respiratory failure

Clinical Manifestations

Fever (12-72 hours)

Runny nose, sore throat, mild cough
Barking cough, hoarseness
Dyspnea, stridor, retractions, irritable

Differential diagnosis

Acute epiglotitis
Diptheria laryngitis
Acute angioneurotic oedema

Laboratory examination

Increased WBC count > 20,000/mm3 ,

predominantly PMN probably superinfection
coexist (ex: epiglotitis)

Radiologic examination

Neck X-Ray postero anterior position steeple sign

narrowing in subglotic column
CT scan shows more obvious etiology of obstrution in
severe clinical manifestation

Steeple sign

Management

Inhalation preferably cold mist moisten

respiratory tract, reduce inflammation, thins mucus,
Epinephrine nebulization:
Moderate-severe

symptoms & required intubation

No remissin after cold mist
Racemic epinephrine: 0.5 ml dissolve in 3 ml normal
saline nebulised for 20
L-epinephrine 1:1000 5 ml (5 ampoule)
Side effects: tachycardia, hypertension

Management
Steroids
Reduce laryngeal oedema
Reduce intubation rate, clinical course & length of
stay
Dexametasone
mg/BW orally or IM 1 dose can be repeated in
6-24 h

0.6

Other option prednisone/methyl prednisolone: 1-2

mg/BW

Management
Steroids
Budesonide:
Nebulized

2-4 mg (2 ml) budesonide can be

repeated in first 12-48 h

Endotracheal intubation
For

severe patient un responsive to other therapy

Indications:
Hypercarbia,

impending respiratory failure

Increased stridor, RR, HR, severe retractions
Cyanosis, lethargy, altered consciousness

Management
Antibiotics
Unecessary except laryngotracheobronchitis &
laryngotracheopneumonitis + bacterial infection
Initial therapy: 2nd or 3rd generation cephalosporine

Complications

Otitis media
Dehydration
Pneumonia (rare)
Heart failure & respiratory failure inadequate
treatment

ACUTE BRONCHITIS

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed

Bronchitis

Inflammation process on trachea & brochi

Self limiting disease usually resolve in 2 weeks
May coexsist with other respiratory tract conditions

Etiology

Virus:
Most common etiology
Rhinovirus, RSV, Influenza virus, Parainfluenza virus, Adenovirus,
Robeola, Paramyxovirus

Bacteria:
Less common etiology
Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus
influenzae, Mycoplasma pneumoniae, Chlamydia sp.
Unimunized children: Bordetella pertussis, Corynebacterium
diptheriae.

Clinical Manifestations

Preceeded by non spesific upper respiratory

infection rhinitis & pharyngitis
Cough
3-4 days following rhinitis
Dry, hacking cough productive cough purulent
sputum (due to leucocyte migration, not necessaarily
bacterial infection) gradually thins

Vomiting
Chest pain older children

Management

Viral supportive :
Rest
Sufficient

fluid intake
Acetaminophen (if necessary)

Antibiotics only for bacterial etiology

Chlamydia erythromycin, tetracyclin (>9 years
old)

BRONCHIOLITIS

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed

Bronchiolitis
Bronchioles

inflammation

Clinical

syndromes:
fast breathing, retractions, wheezing

Predominantly

< 2 years of age

(2 6 months)
Difficult

to differentiate with pneumonia

Pathophysiology
Infection on cilliary epithelia on bronchioli
inflammationoedema, mucus secretion, deposit of
cell debris peribronchial lympocyte infiltration &
sub mucosal oedema bronchioli obstruction

Etiology

Etiology
Predominantly RSV (Respiratory Syncytial Virus),
adenovirus etc.
Diagnosis
Etiological diagnosis
Microbiologic examination
Clinical diagnosis
Signs and symptoms
Age
Resource of infection

Bronchiolitis

Anamnesis
Cough, runny nose
Low grade fever
Vomiting (usually after cough)
Dyspnea
Irritability
Anorexic
Cyanosis

Bronchiolitis

Physical exam
Fever,

tacypnea, tachycardia,
Nasal flaring, retractions/chest indrawaing,
prolonged expiration time, wheezing
Severe symptoms cyanosis, apnea

Bronchiolitis

Laboratory exam
Routine

blood exam & electrolyte WBC

count usually within normal

Bronchiolitis

Radiologic examination
diffuse hyperinflation
flat

diaphragm,
subcostal >
retrosternal space >

peribronchial infiltrates
pleural effusion (rare)

Bronchiolitis

Management
Supportive
Severe

disease
hospitalization
intra venous fluid drip
oxygen
(antibiotics)
Bronchodilator: controversial
Corticosteroid: controversial

Bronchiolitis
Management (ex: Ped dept RSMH)
Prophylaxis antibiotic administration:

Chloramphenicol (div in 3-4 doses, IV if dyspnea ):

< 6 mo : 25-50 mg/BW/day
> 6 mo : 50-75 mg/BW/day OR

Gentamycin 3 5 mg/BW/day(in 2 doses),

If dyspnea resolved iv antibiotics can be switche to oral
chlorampehicol,or erythromycin 30-50 mg/ BW/day div in 2-3
doses

Supportive :
Corticosteroid aimed to reduce respiratory tract inflammation.
Dexametasone 0.5 mg/BW/day div in 3 doses for 3 days
IVFD D5% + NaCl (adjusted to age and BW)
Oxygenation

Bronchiolitis

Natural history & complications

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

PNEUMONIA

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed

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

Upaya Pengendalian Pneumonia

Promotif

Preventif

Diagnostik

Kuratif

PROMOTIF

Faktor risiko mortalitas pneumonia di

negara berkembang

Umur
Berat badan lahir
Imunisasi yang tidak
lengkap
Tidak mendapatkan
ASI yang adekuat
Status gizi kurang
Defisiensi vitamin A

Prevalens kolonisasi
bakteri patogen di
nasofaring
Immunocompromised
Pajanan terhadap
polusi udara
Kepadatan hunian
Ventilasi udara rumah
yang tidak baik

The United Nations Childrens Fund (UNICEF), World Health Organization (WHO). Pneumonia the forgotten killer of children. 2006

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
Crowding
High prevalence
of nasopharyngeal
carriage of
pathogenic bacteria

Cold weather
or chilling
Exposure to air pollution
Tobacco smoke
Biomass smoke
Environmental air pollution

Anak yang terpapar rokok, 4 kali lebih

tinggi memerlukan rawat inap karena
masalah pernapasan dan 2-3 kali lebih
tinggi dalam hal kunjungan ke gawat
darurat karena masalah pernapasan

Pencegahan

Vaccine-preventable deaths WHO 2012

Pneumococcal disease is the leading cause of vaccine-preventable death
in children aged <5 year worlwide 1,2

WHO recommends including PCV in childhood immunization programs 3

1. World Health Organization. Initiative for Vaccine Research. Acute respiratory infections (update September 2009).
http://www.who.int/vaccine_research/diseases/ari/en/index1.html. Accessed October 16, 2013. 2. World Health Organization. Global
immunization data (2012 data). July 2013. http://www.who.int/immunization_monitoring/Global_Immunization_Data_v2.pdf. Accessed
October 16, 2013. 3. World Health Organization. Pneumococcal vaccines. WHO position paper2012. Wkly Epidemiol Rec.
2012;87(14):129-144.

KENALI KELOMPOK RISIKO TINGGI !

Risk group

Condition

Immunocompetent
children

Chronic heart disease (Particularly cyanotic congenital heart disease and

cardiac failure)
Chronic lung disease(Including asthma if treated with high-dose oral
corticosteroid )
Diabetes mellitus
Cerebrospinal fluid leaks
Cochlear implant

PJB, Asma, DM, HIV,

Thalassemia,
Keganasan, CKD

Children with functional

or anatomic asplenia

Sickle cell disease and other hemoglobinopathies

Congenital or acquired asplenia, or splenic dysfunction
HIV infection
Chronic renal failure and nephrotic syndrome

Children with
immunocompromising
conditions

Diseases associated with treatment with immunosuppressive drugs or

radiation therapy, including malignant neoplasms, leukemias, lymphomas
and Hodgkin disease; or solid organ transplantation
Congenital immunodeficiency Includes B- (humoral) or T-lymphocyte
deficiency; complement deficiencies, particularly C1, C2, C3, and C4
deficiency; and phagocytic disorders (excluding chronic granulomatous
disease).
Advisory Committee on Immunization Practices, 2010.

Etiology
Age
Birth to 20 days

Common causes
Bacteria
Escherichia coli
Group B streptococci
Listeria monocytogenes

Less common causes

Bacteria
Anaerobic organisms
Group D streptococci
Haemophilus influenzae
Streptococcus pneumoniae
Ureaplasma urealyticum
Viruses
Cytomegalovirus
Herpes simplex virus

3 weeks to 3
months

Bacteria
Chlamydia trachomatis
S. pneumoniae

Bacteria
Bordetella pertussis
H. influenzae type B and
nontypeable
Moraxella catarrhalis
Staphylococcus aureus
U. urealyticum

Viruses
Adenovirus
Influenza virus
Parainfluenza virus 1, 2, and 3
Respiratory syncytial virus

Virus
Cytomegalovirus

Etiology
4 months to 5 years

Bacteria
Chlamydia pneumoniae
Mycoplasma pneumoniae
S. pneumoniae

Viruses
Adenovirus
Influenza virus
Parainfluenza virus
Rhinovirus
Respiratory syncytial virus
5 years to adolescence Bacteria
C. pneumoniae
M. pneumoniae
S. pneumoniae

Bacteria
H. influenzae type B
M. catarrhalis
Mycobacterium
tuberculosis
Neisseria meningitis
S. aureus
Virus
Varicella-zoster virus

Bacteria
H. influenzae
Legionella species
M. tuberculosis
S. aureus
Viruses
Adenovirus
Epstein-Barr virus
Influenza virus
Parainfluenza virus
Rhinovirus
Respiratory syncytial
virus
Varicella-zoster virus

PATOFISIOLOGI
STADIUM I: HIPEREMIA/ KONGESTI
Inokulasi mikroorganismerespon peradanganakumukasi sel MN pada
submukosa dan ruang perivaskuler obstruksi parsial pada jalan nafas.
Penyakit bertambah berat jika sel alveolar tipe II kehilangan integritas strukutralnya
produksi surfaktan berkurang, sehingga terjadi edema

STADIUM II: HEPATISASI MERAH

RBC, fibrin, PMNs fills the alveoli

STADIUM III: HEPATISASI KELABU

Leucocytes and fibrin consolidated in infected alveoli

STADIUM IV: RESOLUTION

Exudate absorbed by macrophage

Diagnosis Pneumonia

MTBS (manajemen
terpadu balita sakit)
best practice

Dokter dan Dr Sp Anak

Mempertajam klinis
dan penunjang selain
MTBS

Clinical Manifestation
General symptoms
Fever
Headache
Irritable
Anorexia
GIT symptoms: nausea, vomiting or diarrhoea

Clinical Manifestation
Respiratory symptoms
Cough
Dyspnea: nasal flaring, chest indrawing, grunting
Tacypnea
Cyanosis
Crackel/Rales/Ronchi

PEMERIKSAAN PENUNJANG

Lakukan pemeriksaan
saturasi oksigen pada
semua pasien yang
dicurigai pneumonia

Lakukan Foto
Toraks jika
memungkinkan

Radiological exam

Not a routine procedure indicated for:

Severe

clinical symptom
Poor response to therapy
Deterioration in clinical symptoms

Radiological exam

Interstitial infiltrate increased

bronchovasculature, peribronchial cuffing,
hyperaerated
Alveolar infiltrate consolidation with air
bronchogram
Consolidation

in one lobe lobar pneumonia

Bronchopneumonia infiltrate spreading to

peripheral area, increased peribronchial
vasculature

Radiological exam
Consolidation in lower right lobe

Consolidation in upper right lobe

Laboratory Findings

Peripheral WBC (White Blood Cells):

In viral pneumonianormal or elevated usually not
higher than 20,000/mm3, with a lymphocyte
predominance.
Bacterial pneumonia (occasionally, adenovirus
pneumonia) is often associated with an elevated WBC
count in the range of 15,000-40,000/mm3 and a
predominance of granulocytes
Low WBC count/ leucopenia poor prognosis

Laboratory Findings
CRP ( C-reactive protein)
lower in viral infection
No conclusive evident to distinguish viral or
bacterial infection

Management

Management
Causative
Proper and rapid antibiotic administration key to
succesful management
Empirical antibiotic therapy no rapid
microbiology test early identification of
causative microorganism not possible
Mild symptoms treat in outpatient
care, oral antibiotic

Management
ANTIBIOTICS:
Best predictor of etiology : AGE
Empirical vs microorganism found
Pneumonia nature

Community acquired pneumonia gram positive

Hospital acquired pneumonia gram negative

Spesific radiology findings (lobar pneumonia,

pneumatocele)

Antibiotic consideration for pneumonia related to age group

Newborn and very
Infants and preschool
young infants
age children
(< 3 months)
(3 months 5 years)
Etiology:
Etiology :
Group B Streptococci S pneumoniae
Gram negative
H influenzae
Enteric bacteriae S aureus
Antibiotic:
C trachomatis
Beta-lactam
S aureus
ampicilin
Antibiotic:
ampicilin
amoxycilin,
amoxycilin
amoxycilin/clav acid
amoxycilin/
cephalosporin
clavulanic acid
Co-trimoxazole)
+ gentamicin
Macrolide
+ third generation Erythromycin,
cephalosporin Newer macrolide

School age children

( > 5years)
Etiology :
M pneumoniae
K pneumoniae
S Pneumoniae
Antibiotic:
Macrolide
erythromyin
claritromycin
azithromycin
Tetracyclin and
doxyciclin (> 8 years)

Antibiotic recommendations for community acquired pneumonia (AAFP)

Patient Outpatient
age
Birth to Admit
20 days

Inpatient

Critically ill

Ampicillin IV or IM:
Age <7 days:
Weight <2 kg (4.4 lb): 50 to 100 mg per kg per day in divided
doses every 12 hours
Weight >=2 kg: 75 to 150 mg per kg per day in divided doses every
8 hours
Age >=7 days:
Weight <1.2 kg (2.6 lb): 50 to 100 mg per kg per day divided every
12 hours
Weight 1.2 to 2 kg: 75 to 150 mg per kg per day in divided doses
every 8 hours
Weight >2 kg: 100 to 200 mg per kg per day in divided doses every
6 hours
plus
Gentamicin IV or IM:
>=37 weeks of gestation
and
Age zero to 7 days: 2.5 mg per kg every 12 hours
Age >7 days: 2.5 mg per kg every 8 hours
with or without
Cefotaxime (Claforan) IV:
Age <=7 days:
100 mg per kg per day in divided doses every 12 hours
Age >7 days:
150 mg per kg per day in divided doses every 8 hours

Ampicillin IV or IM, in same dosages

as for inpatients
plus
Gentamicin IV or IM, with or without
cefotaxime IV, in same dosages as
for inpatients

Antibiotic recommendations for community acquired pneumonia (AAFP)

3 weeks If patient is afebrile:
to 3
Azithromycin (Zithromax), 10 mg per
months kg orally on day 1, then 5 mg per kg
per day on days 2 through 5
or
Erythromycin, 30 to 40 mg per kg per
day orally in divided doses every 6
hours for 10 days
Admit if patient is febrile or hypoxic.

Erythromycin, 40 mg per kg per

day IV in divided doses every 6
hours*
If patient is febrile, add one of
these agents:
Cefotaxime, 200 mg per kg per
day IV in divided doses every 8
hours*
or
Cefuroxime (Ceftin), 150 mg per
kg per day IV in divided doses
every 8 hours*

Cefotaxime, 200 mg per kg per day IV in

divided doses every 8 hours plus cloxacillin
(Tegopen), 150 to 200 mg per kg per day IV
in divided doses every 6 hours*
or
Cefuroxime alone, 150 mg per kg per day IV
in divided doses every 8 hours*

4 months Amoxicillin, 90 mg per kg per day

to 5
orally in divided doses every 8 hours
years
for 7 to 10 days
Consider initial dose of ceftriaxone
(Rocephin), 50 mg per kg per day IM,
up to 1 g per day. Follow with oral
therapy for full course.
Alternatives: amoxicillin-clavulanic
acid (Augmentin), azithromycin,
cefaclor (Ceclor), clarithromycin
(Biaxin), erythromycin

Cefotaxime, 150 mg per kg per

day IV in divided doses every 6
hours*
or
Cefuroxime, 150 mg per kg per
day IV in divided doses every 8
hours*
If the patient has pneumococcal
infection:
Ampicillin alone, 200 mg per kg
per day IV in divided doses every
8 hours*

Cefuroxime, 150 mg per kg per day IV in

divided doses every 8 hours, plus
erythromycin, 40 mg per kg per day IV or
orally in divided doses every 6 hours for 10
to 14 days*
or
Cefotaxime, 200 mg per kg per day IV in
divided doses every 8 hours, plus cloxacillin,
150 to 200 mg per kg per day IV in divided
doses every 6 hours for 10 to 14 days

Antibiotic recommendations for community acquired pneumonia (AAFP)

5 years
Azithromycin, 10 mg per kg
and older (maximum of 500 mg) orally on
day 1, followed by 5 mg per kg per
day on days 2 through 5
or
Clarithromycin, 15 mg per kg per
day orally in divided doses every
12 hours for 7 to 10 days
or
Erythromycin, 40 mg per kg per
day orally in divided doses every 6
hours for 7 to 10 days
If the patient has pneumococcal
infection:
Amoxicillin alone, 90 mg per kg per
day orally in divided doses every 8
hours

Cefuroxime, 150 mg per kg per day IV in

divided doses every 8 hours
plus
Erythromycin, 40 mg per kg per day IV or
orally in divided doses every 6 hours for 10 to
14 days
If pneumococcal infection is confirmed:
Ampicillin alone, 200 mg per kg per day IV in
divided doses every 8 hours

Cefuroxime, 150 mg per kg per

day IV in divided doses every 8
hours
plus
Erythromycin, 40 mg per kg per
day IV or orally in divided doses
every 6 hours for 10 to 14 days

Management
Causative inpatient
Broad spectrum antibiotic (Example in Moh. Hoesin
Hospital):
Ampicillin 100 mg/BW/day div. in 3-4 doses +
Chloramphenicol (div in 3-4 doses):
< 6 mo : 25-50 mg/BW/day
> 6 mo : 50-75 mg/BW/day OR

Gentamycin 3 5 mg/BW/day(in 2 doses),

Severe clinical symptoms or laboratory finding
suggesting sepsis ceftazidime 50-100 mg/BW/day
(div 2-3 doses)

Management
Supportive
Mild symptoms
Inpatient :
IVFD
Oxygen
Analgetic/

antipyretic

TERAPI SUPORTIF LAIN

Pastikan patensi
jalan napas

Antipiretik jika
demam tinggi

Status hidrasi :
- Atasi dehidrasi atau jika perlu
Jika mengi dapat diberikan koreksi suhu
- Asupan ASI/oral jika
bronkodilator
memungkinkan
- Jika tidak bisa oral berikan / NGT
Koreksi gangguan elektrolit, asam basa

Oxygen Therapy

Berikan oksigen pada anak

dengan SatO2 < 90%
ATAU

Tanda :
Sianosis sentral
Kesulitan minum akibat sesak
Merintih setiap kali bernapas
Tarikan dinding dada yang berat
Penurunan kesadaran
Frekuensi Napas > 70 x/mnt

SUMBER OKSIGEN

Tabung silinder
Oksigen
konsentrator
Oksigen sentral

PEMANTAUAN DAN PENYAPIHAN TERAPI OKSIGEN

Setiap 3 jam perawat

menilai apakah:

Kondisi anak stabil

Nasal prong terletak
pada tempatnya
Tidak ada plak mukus
Koneksi ke sumber
oksigen tetap terjaga
(flow rate)
Saturasi oksigen baik

Setiap hari oksigen dititrasi

secara bertahap

Dapat dihentikan jika:

- Klinis membaik
Saturasi oksigen >90 % pada
udara ruang

Pastikan saturasi > 90% (dalam

15 menit saat penghentian) ;
pantau 30 menit berikutnya ;
selanjutnya tiap 3 jam pada
hari pertama

Jika stabil oksigen dapat

dihentikan

KOMPLIKASI
Jika dalam 48 72 jam klinis tidak
membaik/bahkan memburuk pikirkan komplikasi :
Lakukan pemeriksaan foto toraks
O Pneumatocele
O Parapneumonic effusion (termasuk empiema)
O Pneumotoraks / Pneumomediastinum
O Abses Paru
O Sepsis (Septic shock, penyebaran infeksi ke organ
lain seperti meningitis, peritonitis dll)

KOMPLIKASI
Abses Paru

Pneumomediastinum

TATA LAKSANA KOMPLIKASI

O

Efusi pleura / Empiema

Drainase analisis cairan

pleura, pulasan gram dan kultur
kuman
Ampisilin atau kloksasilin (50
mg/kg IM/IV tiap 6 jam) +
Gentamisin jika anak telah
membaik (min 7 hari AB)
lanjutkan dengan kloksasilin oral
selama 3 minggu

Jika gejala menetap dengan

terapi yang adekuat
eksplorasi ke arah HIV dan TB

Abses paru

Ampisilin atau kloksasilin (50

mg/kg IM/IV tiap 6 jam) +
Gentamisin jika anak telah
membaik (min 7 hari AB)
lanjutkan dengan kloksasilin
oral selama 3 minggu

Terapi bedah Abses paru

yang berukuran besar atau
dengan hemoptisis dan
perburukan gejala walaupun
sudah diberikan AB

TATA LAKSANA KOMPLIKASI

Pneumotoraks
Biasanya sekunder
akibat penumpukan
udara dalam rongga
pleura akibat
pecahnya alveoli atau
mikroorganisme
penghasil gas
Pemasangan chest tube
drainage (WSD)
O

Other Complications

Pericarditis
Hematologic spread
Meningitis
Osteomyelitis
Suppurative

arthritis

IMCI (Integrated Management of Childhood Illness)/MTBS

(Managemen Terpadu Balita Sakit)

Aimed for:
Young

infant aged 1 day-2 months

Children aged 2 months-5 years

To be practiced by:
Paramedic

and medical practitioner in primary health

care (puskesmas & pustu):
Paramedic

(midwives & nurses)

Physician in primary healthcare (Puskesmas)

Not for inpatient care / ward

Derajat penyakit berdasarkan MTBS

1. Bukan Pneumonia
2. Pneumonia (tidak berat):
Batuk atau sesak napas dan napas cepat.
Napas cepat: Usia < 2 bl
: 60 x/mnt
Usia 2 12 bl
: 50 x/mnt
Usia 1 5 th
: 40 x/mnt
Auskultasi:
Crackles/Rales/Ronchi
Suara napas bronkial

Derajat penyakit berdasarkan MTBS

3. Pneumonia Berat
Batuk/sesak napas disertai salah satu di bawah ini:
Retraksi dinding dada
Napas cuping hidung
Grunting (merintih)

Derajat penyakit berdasarkan MTBS