PBL- MODULE 2

Breathlessness
By A3

Scenario 1

A year and a month old boy was

brought
to
the
hospital
with
breathlessness which started 3 days
prior to admission as a chief
complain.
He
also
experienced
productive cough and fever. He was
born weighing 3 kg, spontaneously
and aterm. There is no history of
breathlessness.

Keywords

A boy, aged a year and a month.

Breathlessness, 3 days
(dyspnoea)
Productive Cough
Fever
Born normal
No history of breathlessness

Questions

Disease in children with dyspnoea as

a clinical manifestation?
Differential Diagnosis
Pathomechanism of dyspnoea
The differences between cardiac
caused dyspnoea and respiratory
caused dyspnoea
Pathomechanism of productive
cough`

Disease that shows dyspnoea as a

clinical manifestation in children

Bronchial Asthma
Bronchiolitis
Pneumonia
Acute Bronchitis
Pneumothorax and
pneumomediastinum
Atelectasis
Emphysema pulmonum
Pleural Effusion

Differential
Diagnosis

Bronchiolitis
Acute Bronchitis
Pneumonia
Bronchial Asthma

Dyspnoea
Mucous Production, mucosal edema,
bronchoconstriction

Limited air flow into lungs

Reduced airway
diameter

Reduced ventilation

Acute in expiratory
flow resistance
Insufficient time for expiration before
another inspiratory phase is initiated

PO2, PCO2 in blood

Air trapping in lungs

Stimulation of carotid and aortic bodies

and respiratory centre

Hyper inflated lungs

Lung compliance reduced (due to
increased functional residual capacity)

Reflex tachypnoea
Increased depth of breath

Increased effort to breath

Awareness of difficulty
in breathing

Dyspnoea

Chest Tightness

Productive Cough
Inflammation of the airway

Excessive mucous production,

Epithelial damage
Stimulation of the receptor
Of the airways

Efferent
(n. Glossopharyngeal)

Medulla Oblongata
(Cough Centre)

Stimulation of laryngeal, intercostals muscle,

diaphragm

Increased intrathoracic pressure

Sudden glottis opening

Afferent (n. Vagus)

Deep inspiration and closure

Of glottis

Pushes diaphragm

Expulsion of mucous and other

desquamated cell

Contraction of abdominal muscle

PRODUCTIVE COUGH

BRONCHIOLITI
S

Bronchiolitis
Definition

Disease of the airway because of

bronchioles obstruction
Epidemiology
- Children aged 6months to 2 years old
(frequent)
- Boys > Girls
- Mother who smokes

 Etiology

RSV ( Respiratory Syncytial Virus)50%

- Parainfluenza Viruses
- Mycoplasm pneumoniae (Eaton
Agent)
- Adenovirus and other viruses
-

Clinical Manifestation
Rhinitis

and Pertussis Cough

Anorexia
Fever (38.5oC 39oC)
Dyspnoea (progressive)
Tachypnoea
Cyanosis
Restlessness

Pathophysiology
RSV particles

Antigen-antibody complex

Bronchioles mucous damaged

Damaged PMN

Lysozyme enzyme

Obstruction

Partial

Emphysema

Total

Atelectasis

Examinations
Physical

Examination
Chest X-Ray
Laboratory Tests

Treatment
O2

therapy
Fluid intake
Antibiotics
Corticosteroid

ACUTE BRONCHITIS

Acute Bronchitis
Definition

Sudden inflammation of the

tracheobronchial tree, which
comprises the trachea and the
bronchi. Usually associated with viral
(most common) and bacteria
(Mycoplasm pneumoniae, Bordetella
pertusis) infection

 Epidemiology

Children under 2 years old (most

potential)
Predisposition Factors
Allergy
Weather
Air Pollution
Upper airways infection (no clear
mechanism found)

Etiology
Viruses
Respiratory
Syncytial Virus
(RSV)
Adenovirus
Rhinovirus
Parainfluenza Virus
Enterovirus

Bacteria
Mycoplasm
pneumoniae
Streptococcus
pneumoniae
Chlamydia
pneumoniae
Bordetella pertusis
Haemophilus
influenzae

Clinical Manifestations
Persistent

dry cough that turns to

productive cough a few days later.
Usually associated with upper
respiratory infection and rhinitis
Low grade fever
Progressive dyspnoea
Retrosternal chest pain (in elderly
child)

Pathophysiology
Infection Agent

Damaging airways epithelial

layer spontaneously

Mild dyspnoea in
infants

Mucosal membrane and

Non productive
Tracheobronchial epithelia cough
inflammation

Increased in secrete
production (mucoid & clear)

Pro-inflammation
Cytokines released

Decreased in
Mucociliary clearance

Secrete retention
(thick & mucopurulent)

Progressive
dyspnoea

Secondary infection by bacteria

Accumulation of purulent and
thick secrete
Severe dyspnoea
(wheezing and rhonchi)

Cough frequency and sputum volume

Examinations
Physical

Examination
Chest X -Ray
Laboratory Tests

Treatment
Viral Usually resolves without treatment.
- Increase fluid intake (for fever)
Bacteria Antibiotics
Tetracycline
Erythromycin
Amoxicillin (children)
+ Chloramphenicol
Avoiding inhalation of toxic particles, such
as cigarette smokes and polluted air

PNEUMONIA

PNEUMONIA
Pneumonia is defined as an infection of
peripheral lung parenchyma. Clinically,
pneumonia is an acute illness in which
there are signs of consolidation in the
chest.

Aetiolgy & epidemiology

Organisms

Types

1) Bacteria

Diplococcus pneumoniae, pneumococcus streptococcus

hemolyticus, streptococcus aureus, staphylacoccus auries,
hemophilus influenza.

2) Virus

Respiratory syncytial virus, virus influenza, adenovirus

3)

Histoplasma capsulatum, cryptococcus neoformans,

blastomyces dermatitides, aspergillus species, candida
albicans.

4) Aspirasi : makanan, kerosen, cairan amnion, benda asing.

5) Pneumonia hipostik
6) Sindrom Loeffler
Epidemiology : children > 3 years old (Pneumonia lobaris)
baby (Bronchopneumonia)

 In pediatric, pneumonia can be classified

on the basis of anatomy :
PNEUMONIA LOBARIS

BRONCHOPNEUMONIA

Clinical Features
Cough (productive cough)
character : rusty sputum
high fever
rigors
chills
dyspnoe
vomit and diare

Rusty Sputum
Acute congestion
of lung

Infection of bacteria

Acute inflammation

Complement activation

Active dilation of
alveolar capillaries
( permeability)

Plasma protein, blood,

neutrophyls leak into
Interstitial space and
into alveolar

RUSTY SPUTUM

Normal alveolar defense

have been overcome

Sputum production
consist of bacteria,
exudates, blood&neutrophils

Alveolar macrophages
Secret mediators

Exudation into
alveolar

Cough reflex

Fever with chills + rigors

Infection by bacteria
in pneumonia

FEVER

IL-1 released by variety of

cells involved in self defence

temperature set point

Sensation of cold response to the

thermoregulatory set points call for
more heat

RIGORS

chattering of the teeth

and severe shivering

Hypothalamic
regulotary center

PGE2 synthesis

CHILLS

Physical examination
Physical examination

Sign observed

Inspection

abnormal ventilation rate

Palpation

tractile vocal fremitus

Percussion

dullness

Auscultation

bronchial breath sound

ronki

(> 40 x/m)
sianosis
abnormal patterns of
breathing (using nose)
(increased resonance)

Physical examination
PNEUMONIA
Acute pulmonary congestion

ronki in one lobe

Fibrous blood neutrophils exudate

In alveoly
Lung consolidation

vocal fremitus
& resonance

dullness on percussion

Auscultation while breathing:

Bronchiol breath sound
over the consolidated area

Chest x-ray examination

Consolidation is seen
as an area of white
lung and represents
fluid or cellular matter
where there would
normally air.
Air broncogram sign
Enlargement of hilar.

Lab test
Clinical phatology
Microscopic test
- leukositosis 15.000-40.000
Sputum test
early sputum : small volume, sometimes
with blood.
resolution : large volume, < viscous

Complication
Empiema
Lung abscess
Bronchiectasis
Atelactasis
Acute otitis media

Treatment
Penicillin : 50000 U/kgbb/hari
Cloramfenicol : 50-75 mg/kgbb/hari
Dyspnoe : intravena fluid and oxygen
Intravena fluid contain:
glucose 5%, NaCl 0,9% + KCl 10
mEq/500ml

BRONCHIAL ASTHMA

BRONCHIAL ASTHMA

Asthma is a chronic inflammatory

disorder of the lung characterized by
variability in symptoms and lung
function.

Epidemiology

4 11% in children
Male > female, > 2 years old
Have history in family (genetic)

Aetiology

Allergy (atopic)
Infection
Animal (cat)
Cold / dry air
Physical activity

Patomechanism of asthma
Inhalled allergen/ antigen

IgE production by plasma cell & lymphoid tisue

IgE binds mast cell

Secretion of mediators in mast cell

(histamin, leukotriens, chemotacting factors)

- capillary permeability
- mucus production
- bronchconstriction

Bronchial inflamation

Mucosal oedema&hyperemia
Infiltration with inflamatory cells
Release cytokines from
mast cell

Accumulation of eosinophils
Produce leukotriens C4&PAF

Regulate adhesion molecules

on vascular endothelium&on
Inflammatory cell

Activate mast cell

release mediators

Ephitelial cell damage

Loss of epithelial integrity

Inflammatory respons
can be sustained
Antigen enter
the mucosal

Release additional
mediators

Clinical features

Productive cough / dry cough

character : viscous or dificult to
cough up
worse at night & intermittent
Dyspnoe
Chest tightness
Wheezing

Dyspnoea&wheezing+coug
Dyspnoe&wheezing
Prolonged expirationn
h
Airflow limitation

Airway obstruction

Prolonged bronchoconstriction

BRONCHIAL ASTHMA

Via afferent vagus nerve

to the brain
Medulla oblongata
(cough center)
Cough with
sputum

Blast of air
Leaves lung

Stimulate cough
receptor
Impuls to efferent
nerves
Glottis open
suddenly

Difficult to expel air

mucus secretion

Iritation of the
mucosal

Sharp inspiration

intrapulmonary
pressure

Investigation & lab test

Investigation
Lung function test
Skin prick test
Bronchiol provocation test
Spidometer (children > 7 years old)
Lab test
Eosinophil increased
Ig E total increased

Treatment
Non pharmacology
Avoid extrinsic factors
Pharmacology
Relievers (bronchodilators)
- short-acting 2 agonist
- anticholinergic
- long-acting 2 agonist
- xanthines
Preventers ( corticosteroid, leukotriene
receptor antagonists, sodium cromogylycate)

Complication

Pneumonia
Atelactasis
Emphysema
Pneumotoraks
Bronchiectasis
Heart failure

A3

Chica
Wirya
Sri
Fadlyah
Nazihah
Hidayah
Yusuf
Taufik
Irwan
Maaruf

Muhriani
Rahmah
Nina
Ovi
Juliastuti