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PNEUMONIA PADA ANAK

Amiruddin L
Bagian Ilmu Kesehatan Anak
FK-UNHAS
Situasi Pneumonia Balita di
Indonesia
Situasi Pneumonia Balita
di Indonesia
Tujuan Instruksional

I. Tatalaksana Pneumonia
1) Tatalaksana komplikasi Pneumonia
2) Terapi Oksigen
3) Asuhan Perawatan Pneumonia
4) Tatalaksana Rujukan Pneumonia

II. Praktek /Study Kasus


PENDAHULUAN

Pneumonia (Pn) suatu peradangan parenkim


paru dapat disebabkan oleh bacteria, virus atau
organisme yg lain.
Pn
Gejala2 infeksi akut;batuk ,sesak, demam dll
Foto toraks : gbr infiltrat akut , konsolidasi
Auskultasi : ronki nyaring +/-
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
Besarnya masalah akibat pneumoni
di Indonesia
Pneumonia pada anak (< 5 tahun)
Morbidity Rate 10-20 %
Mortality Rate 6/1000 Populasi anak
Angka kematian Pneumonia
150.000 / a year
12.500 / a month
416 / a day = passengers of 1 jumbo jet plane
17 / an hour
1 / four minutes
Pneumonia is a number one killer of children
CLINICAL DIAGNOSIS

Suggestive signs and symptoms


CXR or other imaging technique
Microbiologic testing
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 %
Pneumonia
Classifications
Anatomical classification
Lobar pneumonia
Lobular pneumonia
Intertitial pneumonia
Bronchopneumonia
Etiological classification
Bacterial pneumonia
Viral pneumonia
Mycoplasma pneumonia
Aspiration pneumonia
Mycotic pneumonia
Bacterial etiology

Streptococcus pneumoniae
Hemophilus influenzae
Staphylococcus aureus
Streptococcus group A B
Klebsiella pneumoniae
Pseudomonas aeruginosa
Chlamydia spp
Mycoplasma pneumoniae
Pneumonia is a no 1 killer for
infants (Balita)
Clinical Presentation of Pneumonia

Purulent secretions
Densities on Chest
x-ray

Fever
Leukocytosis
(high wbc)
Pneumonia
Pernapasan cuping hidung
Dyspnea
Retraksi
Ronki Nyaring
Bronchopneumonia
Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the
alveolar spaces. The alveolar capillaries are distended and engorged.
SIGNS AND SYMPTOMS

Symptoms
Infants: non-specific manifestations
Fever, poor feeding, irritability, vomiting, diarrhea, URI Sx,
cough, respiratory distress
Older children: more specific
Fever, cough, chest pain, tachypnea, tachycardia, grunting,
nasal flaring, retracting. Cyanosis usually very late.
Signs/Physical exam
RR > 60 x/mnt
Hypoxia
Rales, wheezes, crackles, coarse breath sounds
CLINICAL MANIFESTATION

Non-respiratoric
fever, headache, fatigue, anorexia, lethargy,
vomiting and diarrhea
Respiratoric
cough, tachypnea , grunting, nasal flaring,
subcostal retraction, cyanosis, crackles and rales,
Sensitivity and specificity of symptoms for
identifying pneumonia

Symptom Sensitivity Specificity


Tachypnea 92 % 15 %
Cough 92 % 19 %

Toxic appearance 81 % 60 %

Crackles 44 % 80 %

Retractions 35 % 82 %

Flaring 35 % 82 %

Pallor 35 % 87 %

Grunting 19 % 94 %

Leventhal JM, 1982


Simple clinical signs of pneumonia (WHO)

Fast breathing (tachypnea)


Respiratory thresholds
Age Breaths/minute
< 2 months 60 x/mnt
2 - 12 months 50 x/mnt
1 - 5 years 40 x/mnt

Chest Indrawing (subcostal retraction)


Antibiotic consideration for pneumonia related to
age group

Newborn and very Infants and preschool


young infants age children School age children
(< 3 months) (3 months 5 years) ( > 5years)

Etiology: Etiology : Etiology :


Group B Streptococci S pneumoniae M pneumoniae
Gram negative H influenzae K pneumoniae
Enteric bacteriae S Pneumoniae
C trachomatis
S aureus
Antibiotic: Antibiotic:
Antibiotic: Beta-lactam Macrolide
ampicilin ampicilin erythromyin
amoxycilin amoxycilin, claritromycin
amoxycilin/ amoxycilin/clav acid azithromycin
clavulanic acid cephalosporin Tetracyclin and
+ gentamicin Co-trimoxazole) doxyciclin (> 8 years)
+ third generation Macrolide
cephalosporin Erythromycin,
Newer macrolide
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
TERAPI OKSIGEN
INDIKASI: Hipoksemia
Menentukan Hipoksemia:
- Pulse Oksimetri (SaO2 < 90%) Obyektif
- Tanda klinis (tidak terlalu akurat)
- Sianosis sentral
- Tidak bisa minum (ec gang respiratori)
- Tarikan dinding dada bagian bawah yg dalam
- Frekuensi napas 60x/menit
- Merintih (bayi muda)
- Anggukan kepala (head nodding)
TERAPI OKSIGEN

Sumber oksigen: sentral,silinder/tabung


oksigen, oksigen konsentrator
Metode pemberian:
- Nasal prong (rekomendasi)
- Kateter nasal
- Kateter nasofaring
Dosis pemberian:
- 1-2 l/menit (FiO2 30-35%)
- 0.5 l/menit (bayi muda)
TERAPI OKSIGEN
Pemantauan
- Tiap 3 jam perawat memonitor:
- Nilai SaO2 (pulse oksimetri)
- Kateter nasal/prongs bergeser
- Kebocoran sistem aliran oksigen
- Kecepatan aliran oksigen tdk tepat

Lama: diberikan sampai SaO2 > 90%,


-Tiap hari dicoba dilepas beberapa menit
(bila SaO2 > 90% oksigen dapat dihentikan)
-Pantau 30 mnt kemudian
-Tiap 3 jam selama 24 jam pertama
TERAPI CAIRAN
Prinsip pemberian terapi cairan:
- terapi pengganti (replacement)
- terapi rumatan (maintenance)

Menghitung cairan rumatan


- Rumus Darrow (rumatan 24 jam)
100 ml/kgBB untuk 10 kg pertama
50 ml/kgBB untuk 10 kg berikutnya
25 ml/kgBB untuk setiap tambahan kg BB berikutnya

- Jika terdapat demam dapat ditambahkan cairan 10%


setiap kenaikan suhu tubuh 1 derajat
DIAGNOSIS BANDING
DIAGNOSIS GEJALA TERAPI
Asma Riwayat wheezing Bronkodilator kerja cepat
berulang, kadang tidak (salbutamol, fenoterol,
berhubungan dg batuk dan terbutalin)
pilek Steroid (serangan sedang-
Hiperinflasi dinding dada berat)
Ekpirasi memanjang Penghindaran pencetus
Respon baik terhadap
bronkodilator
Bronkiolitis Episode wheezing pertama Sama dengan pneumoniae
pada anak umur < 2 tahun
Hiperinflasi dinding dada
Ekspirasi memanjang
Gejala pada pneumonia
juga dapat ditemukan
Respon kurang/tidak ada
respons dengan
bronkodilator
DIAGNOSIS BANDING
DIAGNOSIS GEJALA TERAPI

CROUP Demam Steroid


(Laringotrakeobronkitis) Suara serak Epinefrin inhalasi
Batuk menggongong
Stridor
Pertusis Batuk paroksismal dapat Antibiotik makrolide
diikuti whoop , muntah, Fasilitasi pengeluaran
sianosis atau apnu lendir saat batuk
Bisa tanpa demam Atasi hipoksia saat
Imunisasi DPT tidak serangan
ada/tdk lengkap
Klinis baik diantara batuk
DIAGNOSIS BANDING
DIAGNOSIS GEJALA TERAPI
Tuberkulosis Riwayat kontak positif dg pasien TB Biasa 3 OAT
TB dewasa TB Berat 4-5 OAT
Uji tuberkulin positif ( 10 mm, Diberikan tiap hari pada TB
pada keadaan imunosupresi 5 milier, efusi pleura,
mm) perikarditis dan meningitis
Pertumbuhan buruk/kurus atau TB ditambahkan steroid
berat badan menurun
Demam ( 2 minggu) tanpa
sebab yang jelas
Batuk kronik ( 3 minggu)
Pembengkakan KGB leher,
aksila,inguinal yg khas
Pembengkakan tulang/sendi
Difteri Demam, nyeri menelan, Stridor, Atasi obstruksi sal napas
Selaput putih mudah berdarah ADS
di saluran napas, Bull neck, Antibiotik (penisilin
miokarditis prokain)
Contoh : Diagnosis banding batuk atau kesulitan bernafas
TATA LAKSANA MERUJUK

Rujukan harus dilakukan pada keadaan


pasien stabil (tidak syok atau gagal napas)
Rujukan pada kasus berat :
- Atasi hipoksemia ( pasang O2)
- Pasang akses vena dan berikan cairan
- Pasien dirujuk dengan diantar petugas
medis, siapkan alat resusitasi saat proses
merujuk
TERIMA KASIH