Dr.

Abdul Rohman, SpP

K-4
BATASAN
Proses radang akut pada saluran napas bawah

UPPER RESP TRACT INFECTION
Acute Rhinitis
Acute Sinusitis
Acute Pharyngitis
Laryngotracheitis and Epiglottitis
Acute Ottitis Media


An inflamation of the tracheobronchial
tree, usually in assosiation with
generalized respiratory infection
LOWER RESP TRACT INFECTION
Acute Bronchitis
Community-Acquired Pneumonia
Hospital-Acquired Pneumonia
Pneumonia in the Compromised
Host
DEFENISI
Bronkitis akut adalah peradangan akut pada
saluran napas bawah (bronkus)
Bronkitis Akut - Cindy Thung FKUPH
Pada Bronkitis akut proses
peradangan baru saja terjadi
<3 minggu
An inflammation of the bronchial mucous membranes, usually in
association with generalized respiratory infection
Pada Bronkitis kronik,
proses peradangan sudah
berlangsung minimal 3 bulan
dan dalam 2 tahun berturut-
turut.
ESSENTIALS OF DIAGNOSIS
Acute inflammation of the tracheobrochial tree
Occur more often in adults than in children
Most often caused by viruses; occues most frequently in
winter
Cough and low-grade fever are prominent symptoms;
auscultation of lungs reveals ronchi and/or wheezes
Diagnosis is on clinical basis; laboratory investigations and
chest radiography are usually not helpful
Most patients require only symptomatic treatment; patients
with chronic cardiopulmonary disease may require
aggressive care including hospitalization, oxygen therapy,
and occasionally mechanical ventilation
Klasifikasi Batuk
Hati-hati awal
batuk kronik!!
Guideline for International Classification of Diseases, Ninth Revision [ICD-9]
Bronkitis Akut - Cindy Thung FKUPH
EPIDEMIOLOGI
ETIOLOGI
Most commonly respiratory viruses :
rhinovirus, coronavirus, influenza viruses, and
adenovirus
Also : Mycoplasma pn, Chlamydia
pn., Bordetella pertussis
May also - secondary invasion with :
Haemophillus influenza, streptococcus pn
S c a n s y s t e m n o w
Scan system now
KLASIFIKASI ETIOLOGI
Bronkitis Akut - Cindy Thung FKUPH
ETIOLOGI
Causes of Acute Bronchitis
Viral
Atypical
bacteria
Fungi & Yeast
Chemical agent
Bronkitis Akut - Cindy Thung FKUPH
Bronkitis Akut - Cindy Thung FKUPH
Etiology Agents of Acute Bronchitis
ETIOLOGI
Berdasarkan salah satu jurnal penelitian :
PETER A. WARK, PH.D., Bronchitis (Acute) Clinical Evidence
Concise Am Fam Physician. 2004 Aug 1; 70(3):557-558.
Etiologi bronkitis akut di Australia :
Virus 8 -23%,
Bakteri tipikal 45%
Bakteri atipikal 0-25%
Fungi & bahan iritan 0-5%

Bronkitis Akut - Cindy Thung FKUPH
Apakah bakteri tipikal adalah penyebab tersering bronkitis
akut di Indonesia ?? Data masih minim!
ETIOLOGY
Up to 90% - to be viral In fact : the number one cause of antibiotic abuse
- The usual viral : * Influenza A & B * Rhinovirus
* Parainfluenza * Respiratory syncycial virus
* Corona virus * Human metapneumovirus

There are also same bacterial :
* Mycoplasma pneumonia * Bordetella pertussis
*Chlamidophilia pneumonia * Bordetella parapertussis

Not commonly : - Streptococcus pneumonia
- Moraxella catarrhales acute exacerbation of CB
- Haemophilus influenzae

Repeated attacks of AB can result in CB
EPIDEMIOLOGY and PATHOGENESIS
Affects about 5% of adult annually

The ninth most common illness in outpatients in the US

Cough is the most common symptoms

The cause of cough multifactorial
- histologically : epithelial cell damage w/ release of
proinflamatory mediator, w/ lead to transient
bronchial hyperresponsiveness and airflow
obstructions.

Some pathologic changes occur symptoms and physical
effects resolve completely in 3-6 weeks
Faktor Predisposisi
Bronkitis Akut - Cindy Thung FKUPH
Faktor Presipitasi
Bronkitis Akut - Cindy Thung FKUPH
MANIFESTASI KLINIS
- Self-limiting disease
- Perjalanan peny : 1-2 minggu, terkadang > 1 bln
- Pendekatan Dx. dengan menyingkirkan
:pneumonia dan infeksi influenza A

- Batuk : kering mukoid purulen
- Demam (low grade))
Trakeobronkitis : burning substernal pain
very painful substernal sensation w/
cough
- keringat malam
sampai sesak napas

- sal
napas atas lain : sore
throat
THE PHYSICAL EXAMINATION
Usually negative other than cough
- crackles or egophony + fever + pos X-ray rule out
pneumonia
- fever + cough + negative chest x-ray - influenza
- pertussis
- 90% of AB viral
only one virus : influenza causes fever
Influenza high morbidity and mortality
- cough 90% - mialgia 94%
- weakness 93% - fever 68%
Influenza season (primary winter)
sudden onset of fever and cough suggests influenza

URTI often : coronavirus, rhinovirus and adenovirus
nasal congestion, rhinorrhea and pharyngitis
as well as cough
CLINICAL PRESENTATION
A sudden onset of cough
in the absence of fever, tachycardia, and tachypnea
Should not have : asthma, common cold or other URTI
- Uncomplicated AB = an exacerbation of CB
- Simple URTI (rhinitis, laryngitis, pharyngitis, and sinusitis)
> be caused by = bacteria
= viruses
> lack of inflamation of LRTI (trachea, bronchi, and bronchioles)
+
cough is rarely present in simple URTI
- Some patient
soreness in the chest or primary symptoms : a cough w/o
mild shortness of breath | sputum production
+
cough lasting > 5 days
10-20 days unusual
4 5 weeks occasional
- 50 % : purulent sputum


The presentation of bronchitis and pneumonia
are similar
Cough maybe productive or nonproductive sputum.
Associated : fever, chest discomfort, and fatigue.
Pleurisy or dyspnea ~ more extensive involvement :
pneumonia.

Classic CAP : a sudden chill follow by fever, pleuritic pain
and productive cough.
The atypical pneumonia syndrome (Mycoplasma or
Clamydophila)
often begin with a sore throat and headache.
Bronkitis Akut - Cindy Thung FKUPH
both
Physical examination
Misleading, especially w/ underlying lung disease
consolidation (bronchial breath sounds, egophony)
pneumonia

Bronkitis Akut - Cindy Thung FKUPH
Chest x-ray

- Acute bronchitis : usually no infiltrate or sign of
consolidation
In contrast to pneumonia
- Misleading because changes of CLD can simulate
new infiltrate in same patients with bronchitis
whereas dehydration can minimize radiographic
abnormalities in patients with pneumonia


GEJALA KLINIS
Acute Phase
Protracted phase
GEJALA KLINIS
Bronkitis Akut - Cindy Thung FKUPH

Bronkitis Akut - Cindy Thung FKUPH
The symptoms of acute bronchitis can include:

Sore throat
Fever
A cough that may bring up yellow or green mucus
Chest congestion
Shortness of breath
Wheezing
Chills
Body aches


PENUNJANG KLINIK

Lab rutin darah
- Lekosit mungkin meningkat
- Hitung jenis dominasi sel lekosit PMN
Sputum atas indikasi
- berguna untuk deteksi dini
pneumonia
Manula + komorbid
(CHF, DM)
Foto dada tidak spesifik, untuk exclude
pneumonia
Diagnosis

Diagnosis of acute bronchitis

should be made

after appropriate evaluation and exclusion of other
causes of cough
DIAGNOSIS BANDING
DIFFERENTIAL DIAGNOSIS
Cough : - Pneumonia or pneumonitis - GER
- Asthma - CB + acute exacerbation
- PNDS - Medication reaction
Acute cough : - Peumonia
- Acute exacerbation of CB
Cough + fever : - Influenza
- Pertussis
- SARS morbidity & mortality |
quickly develops pneumonia
Subacute cough ( 3-6 weeks ) :
- PNDS - Pertussis
- Asthma - Pneumonia
- GERD - AECB

PNDS=Post Nasal Drip Syndrome (Upper airway cough syndrome)
often airway congestion & sensation of adrip in the posterior oropharynx & has often been present
for longer than 6 weeks

Asthma
often intermittent or chronic w/ acute spells of worsening shortness of breath or chest pain,
associated w/ wheezing
and exacerbated by change in season, temperature, or climate

Pneumonia
Batuk, demam, nyeri dada, pemeriksaan fisik: tanda konsolidasi, rontgen: infiltrat lober

GERD
most often presents as a chronic cough, w/ a history of heartburn or a cough that
exacerbates at night-time or with meals

AECB
chronic cough and smoking history, acute change in the baseline cough w/ increased
sputum production or change in color

Pertussis
- a cause of cough w/ fever but it is often associated w/ a more prolonged cough, lasting as long
as 10 t0 12 weeks and
coughing paroxysm.
- In adult : often have milder illness, don't always have characteristic whoop and have post-
tussive emesis up to 40%
- often presents with cough and fever
- typical physical exam. finding : tachycardia, lung crackles or egophony
- In contrast : only 30% of elderly aged 75 ys or older w/ CAP presented w/ fever, and only
37% had tachycardia


Differential Diagnosis

New onset of cough caused by pneumonia, presence of a
foreign body, toxic-fume injury, drug side effects such as
angiotensin-converting enzyme inhibitors, endobronchial
malignancy, or congestive heart failure may be mistaken
initially for acute bronchitis.

TB excluded in case with chronic cough, particullary in
patients with high risk profile.
Common Cold Influenza Acute bronchitis Pneumonia
Acute rhinorrhea, sneezing, sore
throat, burning eyes, cough,
malaise, headache, anosmia
Acute onset of fever, chills, myalgia,
headache, sore throat,
nonproductive cough, and severe
malaise
Cough and low-grade fever are
prominent symptoms
Productive or non-productive
cough, fever, dyspnea, pleuritic
chest pain
Usually there is no or low-grade
fever in adults higher fever in
infants and children
Winter or epidemic setting Occure more often in adults than in
children. Most often caused by
viruses; occurs most frequently in
winter
Affects any age group
Examination may demonstrate
serous nasal discharge,
conjungtival and/or pharyngeal
congestion, and rhonchi
Lungs are usually clear, although
scattered rhonchi and crackles can
be heard in as many as a quarter of
patients. Variable white blood cell
counts
Auscultation of lungs reveals
rhonchi and/or wheezes.
On examination, patient may have
hyper or hypothermia, tachypnea,
crepitations, rhonchi, and evidence
of consolidation; some patients
present with signs of septic shock
Diagnosis is made clinically, can
be confirmed by serology or
nasopharyngeal viral cultures in
selected cases
Nasopharyngeal specimen ideally
collected within 2-3 days of illness;
placed into viral transport media;
virus usually isolated within 2-6
days of inoculation into tissue
culture
Diagnosis is on clinical basis;
laboratory investigations and chest
radiography are usually not helpful
Laboratory findings usually
included leukocytosis with an
increase in neutrophilic response;
hypoxemia, azotemia, and acidosis
occur in severe cases; when
positive, blood cultures are
diagnostic of a specific
microbiologic etiology; Gram stain
of a good sputum specimen can be
helpful diagnostically
Imaging is helpful if bacterial
superinfective complications
suspected (ie. Sinusitis)
Directed antigen assay (+) on
nasopharyngeal specimens for
Influenza A
Most patients require only
symptomatic treatment; patients
with chronic cardiopulmonary
disease may require aggressive
care including hospitalization,
oxygen therapy, and occasionally
mechanical ventilation.
Chest radiography demonstrates
patchy, segmental lobar or
multilobar consolidation or other
patterns; false-negative chest
radiographs can occur
Increased school absenteeism or
emergency room visits signal
outbreak
ACUTE BRONCHITIS Suspected

History
Physical examination
Recent upper respiratory tract
infections or no known lung disease
Known history of chronic bronchitis
Acute exacerbation
of chronic bronchitis
Patient afebrile
Normal physical examination
Rales or fever 101F
Infiltrate Negative
Assess likehood of influenzae A
Pneumonias
High likelihood Low likelihood
Consider:
Amantadine
Tamiflu
Chest x-ray examination
(B)
(A)
Recent upper respiratory tract
infections or no known lung disease
Known history of chronic bronchitis
Acute exacerbation
of chronic bronchitis
Patient afebrile
Normal physical examination
Rales or fever 101F
Infiltrate Negative

Low likelihood
Insignificant
or nonpurulent
sputum
Significant
or purulent
sputum
(D)
Patient otherwise
healthy
Elderly patient or
Patient with comorbidities
< 5 polymorphonuclear leukocytes > 5 polymorphonuclear leukocytes
Consider:
Antibiotics
(E)
Symptomatic
treatment

Insignificant
or nonpurulent
sputum
PRPR
Treatment Plan
PRIMARY CARE VISIT
Patient presents w/ cough &
symptoms of acute bronchitis


COMPLICATIONS
Is bronchitis
Uncomplicated ?

Uncomplicated Complicated



DIAGNOSIS TREATMENT
Acute bronchitis ? Therapy based upon patients
Yes Rule out other causes : comorbid conditions
- (Acute Bronchitis) - Pneumonia ?
- - Previous undiagnosed asthma ?
- - GERD ?
No
(Other causes)
CONSIDERATIONS :
Common pathogens
- Influenza A & B - Rhinivirus See Treatment Plans
- Parainfluenza - Bordetella pertussis Pneumonia or asthma
- Resp syncytial virus - Mycoplasma pneumonia
- Adenovirus - Chlamydia pneumonia

See next page for Uncomplicated < 60 yo, no history of COPD, CHF or immunosuppression Or
treat GERD
treatment
appropriately
Treatment Plan (Contd)
TREATMENT PHARMACOTHERAPY
Routine antibiotics are not recommended regardless of duration of cough unless pertussis is suspected
Symptomatic Pharmacotherapy Suspected Pertussis
Inhaled or oral bronchodilators - Perform diagnostic testing
- Individualize therapy to patients w/ - Administer antibiotic therapy
hyperresponsive airways - Macrolide
( wheezing or bothersome cough) - Co-trimoxasole
Antitussives
- May have moderate effect on duration &
severity of cough


TREATMENT NON PHARMACOLOGICAL & PATIENT COUNSELING
Methods of Non-Pharmacological Treatment
Elimination of cough triggers ( eg dust & dander)
I ncrease fluid intake
Increase humidity w/ vaporized air treatments in low humidity environtment

Patient satisfaction should not depend on receiving antibiotic therapy but on quality of physician visit
Quality of patient physician visit may be increased by :
Explaining that the duration of cough may last 10 14 days after primary care visit
Reviewing risk of unnecessary antibiotic use :
- Infection w/ antibiotic-resistent bacteria
- GI symptoms
- Chance of allergic reactions eg anaphylaxis, rash

PENATALAKSANAAN
Self
Limitin
g
Disease
PENATALAKSANAAN
2.Non-Medikamentosa
Eliminasi pencetus batuk (dust & dunder)
Hidrasi (terapi cairan)
Humiditi dengan uap air
Istirahat
Oksigen
Me kualitas patient-physician visit :
- resiko pe + antibiotik yang tidak perlu : resiten, alergi, gangguan lambung
- durasi batuk lama 10-14 hari, dll

prognosis

Excellent

Mortality and morbidity |
in patients with an underlying comorbid condition



Prevention
Hand washing is an important measure in preventing
the acquisition of viruses that cause viral LRTI
Care must also be taken in handling fomites from a
person who is ill
Annual administration of influenza A/B vaccine is
important for the presentation of influenza virus
infection

AVOIDING TREATMENT ERROR
Major treatment error is the use of antimicrobia Tx for AB rising
microbial resistance are encouraged to use only symptomatic Tx
unless specific microbial are identified or suspected
FUTURE DIRECTION
AB is highly prevalent in primare care practice
The carefull history and physical examination most helpful diagnostic
tools
Procalcitonin test to discriminate between pneumonia and bronchitis
The chest physical examination remains the most useful tools
The use of antibiotics is not recommended - however up to 70% of
patient who seek care receive antibiotics
Limiting the overprescibing of antibiotic should decrease the cost of
health
care and reduce the emergence of resistant pathogen
PENYULIT
Pneumonia
Abses paru
Empiema
Septikemia
COMPLICATIONS
Most episodes resolve
spontaneously
W/ underlying chronic cardiopulm dis.
: COPD, CHF, severe
immunosuppression respir.
compromise hospitalization
in severe cases mechanical
ventilation
Cough in otherwise healthy person
may persist 6-8 weeks because of
increase airway reactivity
THANK YOU FOR YOUR
ATTENTION
ABOUT BRONKITIS
AKUT
Makacih Yaaa. ^^
Acute bronchitis presents with acute onset of
cough, frequently productive of clear or
purulent sputum.
There are no specific radiographic findings in
patients with acute bronchitis. The primary
purpose of the chest x-ray examination is to
exclude pneumonia in patients with fever and
pulmonary findings on physical examination.
Influenza A virus epidemic is generally
confined to winter months. During the
epidemic season for influenza A, amantadine
therapy should be considered for patients with
acute bronchitis, especially elderly patients
who are at increased risk for morbidity.


How is acute bronchitis treated?

Most cases of acute bronchitis will go away on their own after a few days or a week.
It's a good idea to get plenty of rest, drink lots of noncaffeinated fluids (for example, water and fruit
juices) and increase the humidity in your environment.
You can also take an over-the-counter pain reliever (such as ibuprofen or acetaminophen) to ease
pain and lower fever.
It is okay to take an over-the-counter cough suppressant if your cough is dry (not producing any
mucus). It's best not to suppress a cough that brings up mucus because this type of cough helps
clear the mucus from your bronchial tree faster. Cough medicine is not recommended for children,
especially those under 2 years of age.

Because acute bronchitis is usually caused by viruses, antibiotics usually do not help. Even if you
cough up mucus that is colored or thick, antibiotics probably wont help you get better any faster.

If you smoke, you should quit. This will help your bronchial tree heal faster.

Some people who have acute bronchitis need medicines that are usually used to treat asthma. If you
hear yourself wheezing, this indicates you may need asthma medicines. These medicines can help
open the bronchial tubes and clear out mucus. They are usually given with an inhaler. An inhaler
sprays the medicine right into the bronchial tree. Your doctor will decide if this treatment is right for
you.





TREATMENT NON-PHARMACOLOGICAL & PATIENT
COUNSELING

Methods of Non-Pharmacological Treatment
Elimination of cough triggers (eg dust and dander)
Increase fluid intake
Increase humidity w/ vaporized air treatments in low humidity
environments

Patient satisfication should not depend on receiving antibiotic
therapy but on quality of physician visit
Quality of patient-physician visit may be increased by :
Explaining that the duration of cough may last 10 -14 days after
primary care visit
Reviewing risk of unnecessary antibiotic use:
Infection w/ antibiotic-resistant bacteria
GI symptoms
Chance of allergic reactions eg anaphylaxis, rash
How do people get acute bronchitis?

The viruses that cause acute bronchitis are sprayed into
the air or onto peoples hands when they cough. You can
get acute bronchitis if you breathe in these viruses. You
can also get it if you touch a hand that is coated with the
viruses.

If you smoke or are around damaging fumes (such as
those in certain kinds of factories), you are more likely
to get acute bronchitis and to have it longer. This is
because your bronchial tree is already damaged.

How long will the cough from acute bronchitis last?


Sometimes the cough from acute bronchitis lasts for
several weeks or months.

Usually this happens because the bronchial tree is taking a
long time to heal.

However, a cough that doesnt go away may be a sign of
another problem, such as asthma or pneumonia.

How can I keep from getting acute bronchitis again?

One of the best ways to keep from getting acute
bronchitis is to wash your hands often to get rid of any
viruses.

If you smoke, the best defense against acute bronchitis is
to quit. Smoking damages your bronchial tree and makes
it easier for viruses to cause infection. Smoking also slows
down the healing process, so it takes longer for you to get
well.


PN
EU
MO
NIA
ATI
PIK


Tanda dan Gejala Pneumonia Atipik Pneumonia Tipik
Onset Gradual Akut
Suhu Kurang tinggi Tinggi, menggigil
Batuk Non produktif Produktif
Dahak Mukoid Purulen
Gejala lain Nyeri kepala,
mialgia, sakit
tenggorokan, suara
parau, nyeri telinga
Jarang
Gejala luar paru sering lebih jarang
Pewarnaan Gram Flora normal /
spesifik
Kokus Gram (+) or ()
Radiologis patchy atau normal
Konsolidasi lobar
Laboratorium Lekosit N kadang
rendah
Lebih tinggi
Gguan fungsi hati Sering jarang