PNEUMONIA

Patologik

Radang parenkim paru, asinus terisi cairan

radang dengan atau tanpa infiltrasi sel
radang

Risk factors

Obstruction
When part of the airway (bronchi) leading to
the alveoli is obstructed, the lung is not able
to clear fluid when it accumulates. This can
lead to infection of the fluid resulting in
CAP.

Risk factors

Lung disease
People with underlying lung disease are
more likely to develop CAP.

Immune problems
People who have immune system problems
are more likely to get CAP.

Etiology
Most cases of CAP are caused by a few
common respiratory pathogens, including:
o Streptococcus pneumoniae
Accounts for ~50% of all cases of CAP requiring
hospital admission
o Haemophilus influenzae
o Staphylococcus aureus
o Mycoplasma pneumoniae
o Chlamydia pneumoniae

o Moraxella catarrhalis
o Legionella spp.
o Aerobic gram-negative bacteria
o Influenza viruses
o Adenoviruses
o Respiratory syncytial virus

History
o Most typical
signs/symptoms
Fever
Cough (nonproductive
or productive of purulent
sputum)
Pleuritic chest pain
Chills and/or rigors
Dyspnea

o Frequent
signs/symptoms
Headache
Nausea
Vomiting
Diarrhea
Fatigue
Arthralgia/myalgia
Falls and new-onset
or worsening confusion
(in elderly patients)

Physical
o

findings

Fever
o Tachypnea
In two studies, patients with
a respiratory rate of >25/min
had a pneumonia likelihood
ratio of 1.53.4.
o Tachycardia
Patients with a heart rate of
100/min, a temperature of
37.8C, and a respiratory rate
of 20/min were 5 times more
likely to have pneumonia than
patients without these findings
in one study.

o Chest examination
Dullness to percussion
Increased tactile and
vocal fremitus
Whispering pectoriloquy
Crackles
Pleural friction rub

CLASIFICATION

Patients are stratified into 5 severity

classes by means of a 2step process.
Class I indicates an age <50 years, with
none of 5 comorbid conditions (neoplastic
disease, liver disease, congestive heart
failure, cerebrovascular disease, or renal
disease), normal or only mildly deranged
vital signs, and normal mental status.

CLASIFICATION

classes IIV on the basis of points assigned

for 3 demographic variables (age, sex, and
nursing home residency), 5 comorbid
conditions (summarized above), 5 physical
examination findings, and 7 laboratory
and/or radiographic findings.

ADJUNCT

Lab darah lengkap

Gram's Stain and Culture of Sputum
Blood Cultures
Antigen Tests
Polymerase Chain Reaction
Serology

LOW RISK CAP

MODERATE RISK CAP

HIGH RISK CAP

Stable vital signs

RR < 30
breaths/min
PR < 125
beats/min
SBP > 90 mmHg
DBP > 60 mmHg
No or stable
comorbid conditions
No evidence of
extrapulmonary
sepsis
No evidence of
aspiration
Chest X-ray:
localized infiltrates
no evidence of
pleural effusion nor
abscess
not progressive
within 24 hrs

Unstable vital signs:

RR > 30 breaths/min
PR > 125 beats/min
Temp > 40oC or <35oC
Unstable comorbid
condition
(i.e. uncontrolled
diabetes mellitus,
congestive
heart failure (CHF) Class
II-IV,
unstable coronary artery
disease,)
Evidence of
extrapulmonary sepsis
(hepatic, hematologic,
gastrointestinal,
endocrine)
Suspected aspiration
Chest X-ray:
multilobar infiltrates
pleural effusion or
abscess
progression of findings
to > 50% in

Any of the clinical

feature of
moderate risk
CAP plus any of
the following:
1. Shock or signs of
hypoperfusion
hypotension
altered mental
state
urine output <
30 ml/hr
2. Hypoxia (PaO2 <
60 mmHg) or
Acute hypercapnea
(PaCO2 > 50 mmHg)
Chest X-ray:
as in moderate
risk CAP
cap.pmd

LOW RISK CAP

PTENTIAL PATHOGEN

EMPIRIC THERAPY

Streptococcus
pneumoniae
Haemophilus influenzae
Chlamydophilia
pneumoniae
Mycoplasma
pneumoniae
Moraxella catarrhalis
Enteric Gram-negative
bacilli
(among those with comorbid
illness)

Previously healthy:
amoxicillin
OR
extended macrolides
Alternative:
cotrimoxazole
With stable comorbid
illness:
co-amoxiclav OR
sultamicillin
OR
2nd generation
cephalosporins
OR
extended macrolide

MODERATE RISK CAP

POTENTIAL
PATHOGEN

EMPIRIC THERAPY

Streptococcus
pneumoniae
Haemophilus influenzae
Chlamydophilia
pneumoniae
Mycoplasma
pneumoniae
Moraxella catarrhalis
Enteric Gram-negative
bacilli
Legionella pneumophila
Anaerobes (among those
with
risk of aspiration)

IV nonpseudomonal blactam
with or without blactamase
inhibitor + macrolide
OR
antipneumococcal
fluoroquinolones (FQ)

HIGH RISK CAP

POTENTIAL
PATHOGEN

EMPIRIC THERAPY

Streptococcus
pneumoniae
Haemophilus influenzae
Chlamydophilia
pneumoniae
Mycoplasma
pneumoniae
Moraxella catarrhalis
Enteric Gram-negative
bacilli
Legionella pneumophila
Anaerobes (among those
with
risk of aspiration)
Staphylococcus aureus
Pseudomonas
aeruginosa

No risk for P.
aeruginosa:
a. IV nonpseudomonal
blactam
with or without
blactamase
inhibitor +
IV macrolide
b. IV antipneumococcal
FQ
With risk for P.
aeruginosa:
IV pseudomonal blactam with
or without b-lactamase
inhibitor
+
IV macrolide or
IV antipneumococcal FQ
+/aminoglycoside or

Indikasi Rawat

C confusion
U Blood Urea >7mmol/l (jadi BUN
19,6mg/dl)
R Respiratory Rate > 30x/mnt
B Blood Pressure S<90; D<60
65 Age > 65 years
Bila 2 kriteria rawat
> 3 kriteria rawat ICU

Diagnosa(1)

Anamnesa : demam, batuk-batuk, sesak,

nyeri dada
Pemeriksaan fisik tergantung luas lesi
bagian yang sakit tertinggal, vokal fremitus
mengeras, perkusi: redup, bising nafas
bronkhovaskuler sampai bronkhial, ronki
basah halus sampai kasar

Diagnosa (2)

Foto thorax: PA & Lateral infiltrat sampai

konsolidasi dengan air bronchogram
Lab : lekositosis, shift to the left, LED meningkat
Kultur: darah dan sputum
Kimia darah: adakah tanda-tanda renal failure?
AGD: PO2 , PCO2 , sampai Asidosis
Respiratorik
Pungsi pleura diagnostik: cairan exudat?