PNEUMONIA

PNEUMONIA

Dr. Abdul Rohman, SpPK-3B

1DEFINITION2Red hepatization : 2 4 daysGray hepatization : 4 8 daysResolution : > 8 10 days PATOGENESISMikroorganismeLingkunganHostDEFENSEPhysical, Humoral & CellularCARA

I NOKULASI langsungINHALASIHEMATOGENKOLONISASI (terbanyak)FAKTOR RISIKO

AlkoholMerokokPeny. kronik: -Jantung & ParuObstruksi bronkusImmunosupressiDrug abuse34STADIUMPATOLOGI ANATOMIKLINIK

Prodromal(Minggu 01)

Alveolus terisi sekrit yang terinfeksi

Tanda-tanda prodromalinfeksi akut

Hepatisasi(Minggu 1-3)

Sebukan sel-sel PMN alveolus padat, infeksi akut Restriksi + demam

Restriksi Fungsi pernafasan Demam Radang menyebar ke pleura viscerlis Nyeri dada (tidur miring kesisi yang sehat) Ekspansi paru terhambat sesak nafas. Batuk /Batuk darah +/-Obstruksi bronkus Wheezing Toraks yang sakit (pernafasan tertinggal, fremitus suara nafas bronkeal, ronki basah kasar) Dehidrasi +/-Resolusi(Minggu 3-)

Alveolus melunak berubah menjadi dahak

Demam , Batuk produktif, Ronki basah halus +/-

5Jenis pneumonia Pneumonia komuniti (PK/CAP) : bakteri Gram positifPneumonia nosokomial : bakteri Gram negatifPneumonia aspirasi : bakteri anaerobCara penularan Droplet Steptococcus pneumoniae Slang infus Staphylococcus aureusVentilator P. aerugenusa dan Enterobacter

ETIOLOGY6Pejamu Faktor Modifikasi Lingkungan :luar or dalam RS, ICU atau non ICU ETIOLOGI78Klinis dan EpidemiologisPneumonia komuniti (community-acquired pneumonia)Pneumonia nosokomial (nosocomial pneumonia) : - HAPPneumonia aspirasi - VAPPneumonia pada penderita immunocompromised. - HCAP

Bakteri PenyebabPneumonia bakterial/ tipikalPneumonia atipikal penyebab: Mycoplasma, Legionella dan ChlamydiaPneumonia virus Pneumonia jamur infeksi sekunder pd pend immunocompromisedKLASIFIKASI93.Berdasarkan predileksi infeksiPneumonia lobarisSering pada pneumonia bakterialJarang pada bayi dan orang tua aspirasi benda asingTerjadi pada satu lobus/ segmen : sekunder obstruksi bronkusBronkopneumonia : keganasan - Dapat oleh bakteri maupun virus - Sering pada bayi dan orang tua - Pada lapangan paru & jarang dihub dgn obstruksi bronkusc. Pneumonia interstisial

10DIAGNOSISShould not be made on history & physical finding alone, a chest X-ray should be taken(In situations where chest x-ray is not possible, clinical prediction rules (eg history, physical exam, presence of fever, tachypnea, etc) may be usedPulmonary TB needs to be considered & rule out esp in elderly patientsPatients w/ HIV may present w/ PCP or pulmonary TB11Gambaran KlinisAnamnesisDemam, menggigil, suhu s/d > 40CBatuk : kering mukoid purulen kadang disertai darah (rusty in color and frankly bloody)Nyeri dada pleuritik, sesak napasPemeriksaan fisis tergantung luas lesi di paruInspeksi : tertinggal waktu napasPalpasi : fremitus suara mengerasPerkusi : redupAuskultasi : bronkovesikuler bronkial ronki basah halus kasar pd stad resolusi

DIAGNOSIS12

These crackles and bronchial breathing were recorded posteriorly over the consolidated left lower lung of a 16 year old boy with tuberculosis.The respirosonogram provides a visual representation of the content of the respiratory sound recording. Time is shown on the horizontal and frequency on the vertical axis. Sound intensity is indicated on a color scale, ranging from red (loud) over yellow and light green (medium) to dark green and gray (low). Calibrated air flow is displayed at the top (I = inspiration, above zero; E = expiration, below zero).

These late inspiratory fine crackles were recorded over the right posterior lower lung of a 55 year old woman with rheumatoid lung disease.The respirosonogram provides a visual representation of the content of the respiratory sound recording. Time is shown on the horizontal and frequency on the vertical axis. Sound intensity is indicated on a color scale, ranging from red (loud) over yellow and light green (medium) to dark green and gray (low). Calibrated air flow is displayed at the top (I = inspiration, above zero; E = expiration, below zero).

These crackles were recorded over the right posterior lower chest of a 9 year old boy with pneumonia.

The respirosonogram provides a visual representation of the content of the respiratory sound recording. Time is shown on the horizontal and frequency on the vertical axis. Sound intensity is indicated on a color scale, ranging from red (loud) over yellow and light green (medium) to dark green and gray (low). Calibrated air flow is displayed at the top (I = inspiration, above zero; E = expiration, below zero).

TYPICAL SYMPTOMS OF CAPFever New cough w/ or w/o sputum production Change in color of sputum in patients w/ chronic coughPleutitic chest painShortness of breath

file:///E:/Recordings.htmfile:///E:/Recordings.htm16If you suspect pneumonia, ask about alcohol intake and comorbidities (especially chronic heart and lung disease and diabetes mellitus); foreign travel(risk of legionella); and upper respiratory tract infection are so common that positive answers are unlikely to narrow down the list of possible organisms.

Typical clinical features of bacterial pneumoniaClinical featuresIncidence (%)Respiratory features cough sputumdyspneachest painupper respiratory tract symptomshemoptysis907070653313Nonrespiratory vomiting confusion diarrhea rash abdominal pain20151555 17Typical clinical features of bacterial pneumoniaClinical featuresIncidence (%)Signs fever tachypnea tachycardia abnormal chest signs hypotension confusion herpes labialis80 9080 9080 9080 90201510

18DIAGNOSIS2.Pemeriksaan PenunjangGambaran radiologisFoto toraks (PA / lateral) penunjang utama diagnosis : infiltrat konsolidasi dg air bronchogram, interstisial serta gambaran kaviti.Foto toraks petunjuk kearah diagnosis etiologi :Pneumonia lobaris Streptokokus pneumoniaeInfiltrat bilateral/bronkopneumonia Pseudomonas aeruginosa

Pemeriksaan laboratoriumLeukosit > 10.000 - 30.000Hitung jenis leukosit pergeseran ke kiri dan peningkatan LEDDiagnosis etiologi : dahak, kultur darah, dan serologiKultur darah positif : 20 -25 % penderita tidak terobatiAnalisa gas darah hipoksemia dan hipokarbiaStadium lanjut asidosis respiratorik19PNEUMONIA KOMUNITI(DIDAPAT DI MASYARAKAT)ETIOLOGI

- Kepustakaan : Gram pos. & bakteri atipik- Indonesia : Gram negatip (beberapa kota) - Klebsiella pneumoniae 45,18 % - Pseudomonas aerugenosa 8, 56 %- Streptococcus pneumoniae 14,04 % - Streptococcus hemolyticus 7,89 %- Streptococcus viridans 9,21 % - Enterobacter 5, 26 % -Staphylococcus aureus 9, 00% - Pseudomonas spp 0, 90 % - -

20DIAGNOSIS PASTI

Foto R : infiltrat baru atau infiltrat progresif + 2 atau lebih gejala dibawah :

Batuk-batuk bertambah Perubahan karakteristik dahak/purulenSuhu 38 C (aksila)/ riwayat demamFisik : tanda konsolidasi, bronkial & ronkiLeukosit 10.000 atau < 4.500 21Faktor modifikasi meningkatkan risiko infeksi mikroorganisme patogen spesifik

Pneumokokus resisten terhadap penisilinUmur > 65 tahunMemakai obat-obatan gol laktam selama 3 bulan terakhirPecandu alkoholPenyakit gangguan kekebalanPenyakit penyerta yang multipel

222. Bakteri enterik Gram negatif

Penghuni rumah jompoMempunyai penyakit dasar kelainan jantung paruMempunyai kelainan penyakit yang multipelRiwayat pengobatan antibiotik233. Pseudomonas aeruginosa

Kelainan Struktural : Bronkiektasis Pengobatan kortikosteroid > 10 mg/hari Pengobatan antibiotik spektrum luas > 7 hari pada bulan terakhir Gizi kurang ( malnutrisi )24MODIFYING FACTORS THAT INCREASE THE RISK OF INFECTION W/ SPESIFIC PATHOGENSPatogen Penincillin & Drug-Resistant PneumococclEnteric Gram-ve OrganismPseudomonas aeruginosaFactors Age > 65 year-lactam use within the last 3 monthAlcoholismImmunosuppresionMultiple medical comorbiditiesExposure to child in daycare centerCardiopulmonaryNursing home residentMultiple medical comorbiditiesRecent antibiotic therapyStructural lung disease (bronchiectasis)Prolonged corticosteroid therapy (> 10 mg prednisolone/day)Broad-spectrum antibiotic therapy > 7 days in the past monthMalnutrition25 Pasien PK Usia 50 Th ..ya..

Tidak

Adakah R/ ko-morbid - Neoplasma Pasien masuk dalam kelas - Gagal jantung kongestif Ya. resiko II-IV sesuai langkah - Peny. Serebrovaskuler ke 2/ sistim skor rumus - Peny. Ginjal prediksi - Peny. Hati

Tidak

Adakah kelainan pd pemeriks fisik .. ya - Perub. Status mental - Nadi 125x/mnt Kelas - Pernapasan 30/mnt - Tek. Sistolik 90 mmHg.............. Tidak Resiko I - Suhu 35C atau 40C

SKEMA LANGKAH PERTAMA RUMUS PREDIKSI PNEUMONIA :MENDETEKSI PASIEN DENGAN KELAS RESIKO IKarakteristik penderitaJumlah poin Langkah 2 rumus prediksi pneumoni Sistem skor u/ deteksi pend dgn kelas resiko II-IV Faktor demografiUsia : laki-laki perempuanPerawatan di rumahPenyakit penyertaKeganasanPenyakit hatiGagal jantung kongestifPeny. serebrovaskulerPenyakit ginjalPemeriksaan fisisPerub. status mentalPernapasan 30 kali/menitTekanan darah sitolik 90mmHgSuhu tubuh < 35C atau 40 CNadi 125 kali/menitHasil laboratorium / RadiologiAnalisis gas darah arteri : pH 7,35BUN > 30 mg/dLNatrium < 130 mEq/literGlukosa > 250 mg/dLHematokrit < 30%PO2 60 mmHgEfusi pleuraUmur (tahun)Umur (tahun) 10+ 10

+ 30+ 20+ 10+ 10+ 10

+ 20+ 20+ 20+ 15+ 10

+ 30+ 20+ 20+ 10+ 10+ 10+ 1027 Pasien PK

Usia 50 tahun .ya..

Tidak

Adakah riwayat komorbid- Neoplasma Pasien dimasukkan dalam - Gagal jantung kongestif kelas risiko II-V- Peny. Serebrovaskuler .ya. Sesuai sistim skor rumus- Penyakit ginjal prediksi- Penyakit hati

Tidak

Adakah kelainan pd pemeriks. fisik- Perubahan status mental- Nadi 125x/menit- Pernapasan 30x/menit ..ya- Tekanan drh sistolik 90 mmHg- Suhu 35C atau 40C

Tidak

Pasien dimasukkan dalam Kelas resiko I

An algorithm for triage in patient with community acquired pneumonia Sistem skor pada pneumonia komuniti berdasarkan PORT Karakteristik penderitaJumlah poinFaktor demografiUsia : laki-laki perempuanPerawatan di rumahPenyakit penyertaKeganasanPenyakit hatiGagal jantung kongestifPeny. serebrovaskulerPenyakit ginjalPemeriksaan fisisPerub. status mentalPernapasan 30 kali/menitTekanan darah sitolik 90mmHgSuhu tubuh < 35C atau 40 CNadi 125 kali/menitHasil laboratorium / RadiologiAnalisis gas darah arteri : pH 7,35BUN > 30 mg/dLNatrium < 130 mEq/literGlukosa > 250 mg/dLHematokrit < 30%PO2 60 mmHgEfusi pleuraUmur (tahun)Umur (tahun) 10+ 10

+ 30+ 20+ 10+ 10+ 10

+ 20+ 20+ 20+ 15+ 10

+ 30+ 20+ 20+ 10+ 10+ 10+ 1029SKOR MENURUT SISTEM PORT

Risk Risk class Based on Algorithm

I Low II 70 total points III 71-90Moderate IV 91-130High V 130Stratification of Risk ScoreStratification of Risk ScoreRisk Risk class Based on Algorithm

I Low II 70 total points III 71-90Moderate IV 91-130High V 130Kriteria indikasi rawat inap PK berdasarkan kesepakatan PDPI:Skor PORT > 70 (Pneumonia Patient Outcome Research Team)Skor PORT 70 tetap dirawat inap jika ada satu dari kriteria:Frekuensi napas > 30/menitPaO2/FiO2 kurang dari 250 mmHgFoto toraks paru menunjukkan kelainan bilateralFoto toraks paru melibatkan > 2 lobusTekanan sistolik < 90 mmHgTekanan diastolik < 60 mmHg3.Pneumonia pada pengguna NAPZA33Another prognostic tool has been used to avoid overlooking a serious ill patients. This rule named CURB-85, defines a patient as being ill (i.e. having at least a 10 % risk of death) and probably needing hospitalisation if at least two of five criteria are present ConfusionBlood Urea > 7 mmol/L (ie blood urea nitrogen (BUN) of 19,6 mg/dL)Respiratory rate > 30 breaths/minBlood pressure of 7 mmol/L (20 mg/dL) 1Respiratory rate: > 30 breaths/minute1Blood pressure: systolic < 90 mm Hg or diastolic < 60 mmHg1Age 65 years1 Penatalaksanaan berdasarkan CURB-65 ScoreGroupTreatment Options0 or 1Group 1 : mortality low (14,5%) Low risk, consider home treatment 2Group 2 : mortality intermediate (40%) Consider hospital-supervised treatment 3Group 3 : mortality high (52%) Manage in hospital as severe pneumonia consider admission to intensive care unit, especially with CURB score of 4 or 5.KRITERIA PERAWATAN INTENSIF

Minimal 1 dari 2 gejala mayor tertentu 1. Butuh ventilasi mekanik2. Butuh vasopresor 4 jam (syok septik)ATAU 2 dari 3 gejala minor tertentu 1. PaO/FiO < 250 mmHg2. Foto dada : kelainan bilateral3. Tekanan sistolik < 90 mmHg37ALUR TATALAKSANA PNEUMONIA KOMUNITIAnamnesis, pemeriksaan fisis, foto toraksInfiltrat + gejala klinis yg menyokong diagnosis pneumoniaTidak ada infiltratDi tatalaksana sbg diagnosis lainEvaluasi untuk kriteria rawat jalan/ rawat inapRawat jalanRawat inapTerapi empirisPemerikasaan bakteriologisMembaikMemburukR. Rawat biasaR. Rawat intensifTerapi empirisMembaikMemburukTerapi empiris dilanjutkanTerapiKausatif 38

PENGOBATAN

Antibiotika

Berdasarkan data mikroorganisme dan hasil uji pekaanTerapi empiris dengan syarat - Penyakit berat dapat mengancam jiwa - Bakteri patogen hasil isolasi belum tentu penyebab pneumonia - Hasil biakan bakteri perlu waktuSegera diberikan tanpa menunggu hasil kultur Epidemiologis : > 4 jam angka morbiditas & mortalitas

39TERAPI EMPIRIK PKSehat : Gram (Kota besar : ada Gram )Komorbid : Gram ditambah Gram Faktor modifikasi :a. Pneumokokus resisten terhadap penisilinb. Bakteri enterik Gram c. Pseudomonas aerogenosa

Kesemuanya dapat ditambahkan makrolid baru (kecurigaan adanya bakteri atipik)Petunjuk terapi empiris menurut PDPI Rawat

jalan

Tanpa faktor modifikasi:Golongan laktam / laktam + anti laktamaseDengan faktor modifikasi: Gol laktam + anti laktamase atauFluorokuinolon respir (levofloksasin, moksifloksasin, gatifloksasin)Bila dicurigai pneumonia atipik: makrolid baru (roksitromisin, klaritromisin, azitromisin)41PDPI (PerhimpunanDokterParuIndon) Terapi empiris Pneumonia (CAP/PK)Rawat JalanPRT (Pulmonary Resp Therapy)No CardioPulmDis & No Modifying FactAdvanced macrolide (Azithromycin) or DoxycyclineCardioPulmoDis & Modifying Factor- -lactam (oral cefpodoxim,cefuroxim, high dose amoxil,amox/clav, or parenteral ceftriaxon followed oral cefpodoxim) macrolide or doxycyclineAntipneumococ fluoroquinolone (levofloxacin,moxi-fl,gati-fl,gemi-fl) aloneA ketolide monoTx-no enteric Gram (-)Tanpa faktor modifikasi:Golongan laktam / laktam + anti laktamaseDengan faktor modifikasi: Gol laktam + anti laktamase atauFluorokuinolon respir (levofloksasin, moksifloksasin, gatifloksasin)Bila dicurigai pneumonia atipik: makrolid baru (roksitromisin, klaritromisin, azitromisin)42Rawat

inap

Tanpa faktor modifikasi:-Golongan laktam / laktam + anti laktamase iv, atauSefalosporin G2, G3 iv, atauFlurokuinolon respirasi ivDengan faktor modifikasi:Sefalosporin G2, G3 ivFluorokuinolon respirasi ivBila dicurigai ada infeksi bakteri atipik ditambah makrolid baruPDPIRawat Inap Nonintensif

PRTNo CardioPulm Dis & Modifying Factor- IV azithromycin aloneIf allergic/intolerant Doxycycline and -lactam - Antipneumococcal fluoroquinoloneCardioPulm Dis & Modifying Factor- iv -lactam (cefotaxim,ceftriaxon, ampi/sulbac or high dose ampic) iv or oral macrolide or doxycycline- iv antipneumococcal fluoroqquinolone alone (gatifloxacine,levofloxacine, or moxifloxacine) Tanpa faktor modifikasi:- Gol laktam / laktam + anti laktamase iv, atauSefalosporin G2, G3 iv, atauFlurokuinolon respirasi ivDengan faktor modifikasi:Sefalosporin G2, G3 ivFluorokuinolon respirasi ivBila dicurigai ada infeksi bakteri atipik ditambah makrolid baru44Rawat

inap intensif

Tidak ada faktor risiko infeksi pseudomonas:Sefalosporin G3 iv non pseudomonas + makrolid baru atau fluorokuinolon respirasi ivAda faktor risiko infeksi pseudomonas:Sefalosporin anti pseudomonas iv atau karbapenem iv + fluorokuinolon anti pseudomonas (siprofloksasin) iv atau aminoglikosida ivBila curiga disertai infeksi bakteri atipik : sefalosporin anti pseudomonas iv atu carbapenem iv + aminoglikosida iv + makrolid baru atau flurokuinolon respirasi iv45Rawat Inap IntensifPDPIPRTNo risks for Pseudomonas aeroginasaiv -lactam (cefotaxim,ceftriaxon) either iv macrolide or iv fluoroquinoloneRisks for Pseudomonas aeroginosaCombined therapy required- Selected iv antipseudomonal -lactam (cefepim,imipenem,meropenem, or piperacilin /tazobactam) iv antipseudomonal quinolone (i.e., ciprofloxacin)- Selected iv antipseudomonal -lactam aminoglycoside either iv macrolide or iv nonpseudomonal fluroquinolone

Tak ada faktor risiko infeks pseudomonas:Sefalosporin G3 iv non pseudomonas + makrolid baru atau fluorokuinolon respirasi ivAda faktor risiko infeksi pseudomonas:-Sefalosporin anti pseudomonas iv atau karbapenem iv + fluorokuinolon anti pseudomonas (siprofloksasin) iv atau aminoglikosida ivBila curiga disertai infeksi bakteri atipik : sefalosporin anti pseudomonas iv atu carbapenem iv + aminoglikosida iv + makrolid baru atau flurokuinolon respir iv46KEY POINTS : PRINCIPLES OF INPATIENTS THERAPY

Give the first dose antibiotics within 4 hours of arrival to the hospitalNo beta-lactam monotherapy as emperical therapyLimit macrolide monotherapy to patients without risks for drug-resistant pneumococcus or enteric gram negative organismsNo quinolone monotherapy for ICU-admitted patientsFor non-ICU patients, quinolone monotherapy is equivalent to a beta-lactam/macrolide combination47TERAPI SULIH (SWITCH THERAPY)Perubahan obat : suntik oral obat jalanMasa perawatan dipersingkatBiaya perawatan kurangMencegah infeksi nosokomialKetersediaan obat iv obat oral & efektifitas imbang Streamline obat disesuaikan hasil kulturSekuensial (obat sama, potensi sama) : levofloksasin, moksifloksn, gatifloksasin Switch over (obat berbeda, potensi sama: seftasidim iv ke siprofloksasin Step down ( obat sama/beda, potensi rendah: amoksilin, sefuroksim, sefotaksim iv ke sefiksim oralObat suntik 2-3 hari hari 4 obat oral & penderita berobat jalan

48Kriteria Terapi Sulih Tidak ada indikasi untuk pemberian iv lagiTidak ada kelainan pada penyerapan sal cernaPenderita sudah tidak panas 8 jamGejala klinis membaik : frek. napas, batukLekosit menuju normal atau normal 49Suportif 1. O PaO 80-100 mmHg atau SaO 95-96 %2. Nebulisasi : - humidifikasi pengencer dahak - bronkodilator3. Fisioterapi dada : - batuk dan napas dalam pengeluaran dahak - fish mouth breathing lancarkan ekspirasi pengeluaran CO 4. Pengaturan cairan5. Kortikosteroid sepsis berat50B. Suportif

6. Inotropik : gguan sirkulasi /gagal ginjal prerenal7. Ventilasi mekanik : - hipoksemia persisten - gagal napas - retensi sputum sulit8. Drainase empiema9. Nutrisi kalori : gagal napas diberi lemak CO

51Criteria for clinically stable:Temperature 37,8 CHeart rate 100 beats/minRespiratory rate 24 times/minSystolic blood pressure 90 mmHgArterial saturation oxygen 90 % or 60 mmHg on room airAbility to maintain intakeNormal mental status

Evaluasi Pengobatan(tidak ada perbaikan selama 24 -72 jam)

Faktor obat Faktor bakteriPenderita tidak respons dengan pengobatan empiris yang telah diberikanSalah diagnosisDiagnosis sudah benarFaktor penderitaGagal jantungEmboliKeganasanSarkoidosisReaksi obatPerdarahan Respons pend tidak adekuatKelainan lokal (sumbatan benda asing) Komplikasi - super infeksi - empiemaSalah pilih obatSalah dosis/cara beri obatKomplikasi Reaksi obatKuman-resisten thd obatBakteri patogen lainMikobakteria atau nonkardiaNonbakterial (jamur atau virus)Ektrapulmoner infeksius (pneumonia pneumokokus = bakteriemia) : meningitis, arthritis, endokarditis, perikarditis, peritonitis dan empiema.Ektrapulmoner non infektious (memperlambat gambaran radiologis paru): gagal ginjal, gagal jantung, emboli atau infark paru dan IMA.ARDS, gagal organ jamak dan pneumonia nosokomialKOMPLIKASI1. Vaksinasi influenza dan pneumokokus pada :- orang dengan resiko tinggi- orang dengan gangguan imunologis- penghuni rumah jompo- penghuni rumah penampungan peny. Kronik- usia diatas 65 tahun2. Pola hidup sehat : tidak merokok & alkoholPencegahan(pneumonia komuniti)Ditujukan pada upaya program pengawasan & pengontrolan infeksi termasuk : - pendidikan staf pelaksana- pelaksanaan tehnik isolasi- praktek pengontrolan infeksiTerapi pencegahan pada :- gagal organ ganda- skor APACHE yang tinggi- penyakit dasar yg dpt berakibat fatalBeberapa faktor dapat dikoreksi - pembatasan pemakaian slang nasogastrik atau endotrakeal - pembatasan pemakaian obat sitoprotektif sbgi pengganti antagonis H dan antasid

PENCEGAHAN(PNEUMONIA NOSOKOMIAL)

Rekomendasi Dalam Pengelolaan Faktor Resiko yang Dapat DiubahFaktor Inang - Nutrisi adekuat, makananenteral dengan nasogastrik - Reduksi/penghentian terapi imunosupresif - Cegah ekstubasiyang tidak direncanakan (tangan diikat, beri sedasi - Tempat tidur yang kinetik - Spirometer incentif, napas dalam, kontrol rasa nyeri - Menghindari penghambat histamin tipe 2 dan antasidaFaktor alat - Kurangi obat sedatif dan paralitik - Hindari overdistensi lambung - Pencabutan slang endotrakeal & nasogastrik yang terencana - Hindari intubasi dan reintubasi - Posisi duduk ( 30 40 derajat ) - Jaga saluran ventilator bebas dari kondensasi - Tekanan ujung slang endotrakeal 20 cmH O (menjaga kebocoran patogen ke saluran napas bawah) - Aspirasi sekresi epiglottis yang kontinyuFaktor lingkungan - Pendidikan- Menjaga prosedur pengontrol infeksi oleh staf - Program pengontrolan infeksi- Mencuci tangan, desinfektasi peralatanPROGNOSISPneumonia KomunitiAngka kematian ok pneumokokus = 5 %, meningkat pada orang tua dengan kondisi buruk.Pneumonia dgn influensa = 59 %.Pneumonia dgn usia lanjut = 89 %.PK dirawat di ICU = 20 % (terkait faktor perubah)

Pneumonia Nosokomial- Angka kematian = 33 50 % jadi 70 % terkait penyakit dasar. Penyebab kematian biasanya ok bakteriemia - Ps. Aerugenosa - Acinobacter spp.PROGNOSISUmumnya : baik. penderitabakteri penyebabantibiotikKOMPLIKASIEfusi pleura Empiema Abses paru Pneumotoraks

Gagal napas

Sepsis60PNEUMONIA ATIPIKEtiologi - Sering : Mycoplasma pneumonia, Chlamydia pneumonia, Legionella spp, - Lain : Chlamydia psittasi, Coxiella burnetti, virus Influenza tipe A & B, Adenovirus and RSVDIAGNOSISGejala : - Saluran napas : batuk non produktif - Sistemik : demam, nyeri kepala dan mialgia2. Fisik : rales basah tersebar, konsolidasi jarang terjadi3. Radiologi : Infiltrat interstisial4. Laboratorium : - Lekositosis ringan - Gram, biakan dahak/darah : bakteri negatif 5. Terapi : - Makrolid baru azitromisin, klaritromisin, roksitromisin - Fluorokuinolon, atau Doksisiklin

61

THANK YOU FOR YOUR ATTENTION ABOUT PNEUMONIA62

Terimakasih63PNEUMONIA ATIPIK

Tanda dan GejalaPneumonia AtipikPneumonia Tipik Onset Gradual Akut Suhu Kurang tinggi Tinggi, menggigil Batuk Non produktifProduktif 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 jarang64CAPHAPTerjadiMasyarakatRumah sakitKejadian2 days before2 days afterEtiologiGram positifGram negatifFaktor predisposisiAlcohol excessCigarette smokingChronic heart & lung diseaseBronchial obstructionImmunosuppressionDrug abuseIntubationSuppressed cough leading to aspiration (postoperatively)Reduced host defensesLong stay in hospitalClinical featuressimilarsimilarLaboratory testsimilarsimilarManagement Out, hospitalized & ICU - patientsGood Gram negative coverageFaktor modifikasiYesNone65Pneumonia LobarisBronko-pneumoniaPneumonia interstitialLokasiMencakup 1 lobusTersebar di dekat bronkusInflamasi pada jaringan interstitisl paruInsidensusia dewasa

sering pada bayi dan orang tua-Etiologi

Gram negatifStreptococcus Virus Staph

Virus

Gambaran radiologisAir bronchogram (+)Air bronchogram (-) corakan bronkovaskuler hiperaerasi Bercak infiltrat

PENGOBATANPenisilin resisten Streptococcus pneumoniae (PRSP) Betalaktam oral dosis tinggi (u/ rawat jauh) Sefotaksim, Seftriakson dosis tinggi Makrolid baru dosis tinggi Fluorokuinolon respirasi

Penisilin sensitif Streptococcus pneumoniae (PSSP) Golongan Penisilin TMP-SMZ Makrolid

673. Pseudomonas aeruginosaAminoglikosidSeftazidim, Sefoperason, SefepimTikarsilin, PiperasilinKarbapenem : Meropenem, ImipenemSiprofloksasin, Levofloksasin

4. Methicillin resistent Staphylococcus aureus (MRSA)VankomisinTeikoplaninLinezolid 68PENGOBATANHemophilus influenzae TMP-SMZ Azitromisin Sefalosporin gen. 2 atau 3 Fluorokuinolon respirasi

6. Mycoplasma pneumoniae Doksisiklin Makrolid Fluorokuinolon8. Chlamydia pneumoniae Doksisiklin Makrolid Fluorokuinolon7. Legionella Chlamydia pneumoniae Doksisiklin Makrolid Fluorokuinolon Makrolid Flurokuinolon Rifampisin 69Community-acquired pneumonia PathogenesisOrgansim enter the lungs usually having been inhaled from the environment or nasopharynx. These organism may be eliminate by the lungs defense mechanism (physical, humoral, and cellular defense) or they may survive and multiply.Factors that undermine the lungs defense, therefore, increase the risk of pneumonia :Alcohol excessCigarette smokingChronic heart and lung diseasesBronchial obstructionImmunosuppression Drug abuse

The pathogen stimulates host defenses and alveolar airspaces become filled with eosinophilic edematous fluid containing neutrophil polymorphs. The edema transport, organisms through the pores of Kohn into the alveoli.in days 2 4; a red hepatization occurs; there is accumulation in alveolar spaces of polymorps, lymphocytes, and macrophages. The alveolar exudate contains a fine network of fibrin and large numbers of extravasated red cells. The lung is red, solid, and airless. Red hepatization corresponds to an area of edema and hemorrhage.In days 4 8; a gray hepatization occur. Fibrinous pleurisy is present. Alveolar spaces are microscopically distended and filled by a dense network of fibrin-containing neutrophil polymorphs. Gray hepatization represents a zone of advanced consolidation with destruction of red and white blood cells. The lung is gray or brown and solid.Resolution occurs after 8 10 days in untreated cases. When bacteria has been eliminated, macrophages enter and replace granulocytes. The exudate is liquefied by fibrinolytic enzymes and coughed up or absorped. 70ETIOLOGYS. Pneumoniae is the causative organism in 55 75% of cases.

Causes and features of community acquired pneumiaOrganismFeatures of pneumonia% casesStreptococcus pneumoniaeGram-positive alpha-hemolytic; polysaccharide capsule determines virulence and is detectable serologically; responsible for a high mortality (esp. in the setting bacteremia) unless treated appropriately; vaccine available55 - 75Mycoplasma pneumoniaeEpidemics every 3-4 years usually in young patients, 50% have cold agglutinins; associated with many extrapulmonary manifestations; penicillin ineffective as no bacterial cell wall5 18influenzo

Epidemics common; affects patients with underlying lung disease; can be severe; S. aureus, S. pneumoniae, H. influenzae occur secondarily; a vaccine is available8Legionella pneumophilaGram-negative; found in cooling towers and air-conditioning; causes very severe pneumonia with high mortality and is frequently associated with extrapulmonary features; antigen may help in diagnosis2 5Chlamydia pneumoniaeHeadache very common; usually serological diagnosis2 5Haemophilus influenzaeGram-negative rod; more commonly associated with exacerbations of COPD4 5Viruses other than influenzae2 8Staphylococcus aureusgram-positive coccus; often follow flu; alcoholics and patient with mitral valve disease are susceptible; often causes severe; often cavitating pneumonia; commonly fatal1 5Klebsiella pneumoniaeGram-negative; seen in alcoholics; severe and often cavitates171ComplicationsThe key of complications are:Respiratory failureParapneumonic effusionsEmpyemaLung abscessPulmonary fibrosis, after resolution

Laboratory testsSputum-culture and Gram stainBlood-full blood count, blood culture (low sensitivity, high specificity)Pleural fluid-culture and Gram stainChest radiographyBronchoscopy with BAL if diagnosis uncertainAssessment of oxygenationOther specific tests Mycoplasma, Legionella, and Chlamydia antibodies; pneumococcal antigen testing by counter-immunoelectrophoresis (CIE) of the sputum, urine, and serum.ManagementAntibiotic treatment should be started immediately, without waiting for microbiology results.Empirical treatment with macrolide, doxycycline, or fluoroquinolone (outpatients)Fluoroquinolone or an extended-spectrum cephalosporin in combination with a macrolide (hospitalized patients)Ceftriaxone, cefotaxime, ampicillin-sulbactam, or piperacillin-tazobactam combined with a fluoroquinolone or macrolide (ICU patients)Pathogen-spesific therapy when the pathogen is identified

In addition, pleuritic pain should be relieved with simple analgesia and oxygen therapy administered if appropriate.

PrognosisIt is important to assess the severity of CAP as this impacts on prognosis and therefore treatment planning. Prognosis may range from full recovery to death.The key adverse prognostic features are:New mental confusionUrea > 7 mmol/LRespiratory rate 30/minSystolic blood pressure < 90 mmHg / diastolic 60 mmHgPatient with two or more of these features are at high risk of mortality and should be managed aggressively. 72INDIKASI VENTILATOR MEKANIK PADA PNEUMONIA

Hipoksemia persisten dengan O 100 % pakai maskerGagal napas (asidosis resp). Henti napas, retensi sputum sulit 73Hospital-acquired PneumoniaOr Nosocomial Pneumonia refers to a new lower respiratory tract infection at least two days after hospital admissionIt occurs in 1 5 % of admissions and is a serious cause of morbidity and mortality.

EtiologyFactors predisposing to hospital-acquired infections are:IntubationSuppressed cough leading to aspiration (e.g., postoperatively)Reduced host defensesLong stay in hospital, with associated exposure to pathogens

Pathogens Gram-negative bacteria (Escheruchia, Klebsiella, and Pseudomonas spp.) are the cause of hospital-acquired pneumonia in many cases, although Staphylococcus aureus (particularly drug-resistant strains) is also common

Clinical features & laboratory tests similar to those described above under CAP.

Management

Good Gram-negative coverage is achieved with an aminoglycoside plus anti pseudomonal penicillin or a third-generation cephalosporin. Most hospital-acquired pneumonia is serious, and these drugs are frequently given intravenously.741.Pneumocystis carinii pneumonia (PCP)Is a fungal infection that is largely confined to the lung. It is the most common opportunistic infection in the immunocompromised.Infection occurs by inhalation of the organism. The patient presents with an insidious or abrupt onset of dry cough, fever, and dyspnea. Pleural effusions rare.

Pathology There is an interstitial infiltrate of mononuclear cells and alveolar airspaces are filled with foamy eosinophilic material.

DiagnosisBilateral pneumonia in an immunocompromised patient should raise suspicion of PCP.Diagnosis in 90% of cases is by staining using Giemsa, methanamine-silver, Papanicocoau, or Gram-Weigert stains with monoclonal antibodies.Chest radiography shows diffuse bilateral alveolar and interstitial shadowing, beginning in peripheral regions and spreading in a butterfly pattern.

TreatmentTrimethoprim-sulfamethoxazole is given, intravenously at first. Prophylaxis is recommended in patients with low CD4 counts or where previous infection has occurred. Mortality of untreated patients is 100%; in treated patients, mortality is 20 50%Pneumonia in the immunocompromised patient75Pneumonia in the immunocompromised patientCytomegalovirus (CMV)Is a DNA virus in the herpes group. Of patient with AIDS, 90% are infected with CMV. CMV also occurs in recipients of bone marrow and solid organ transplants. Only occasionally does CMV cause pneumonia.Usual symptoms are a nonproductive cough, dyspnea, and fever. Disseminated infection occurs, causing encephalitis, pneumonitis, retinitis, and diffuse involvement of the gastrointestinal tract.

PathologyInterstitial inflammatory infiltrate of mononuclear cellsScattered alveolar hyaline membranesProtein-rich fluid in alveoliIntranuclear inclusion bodies found in alveolar epithelial cells.

DiagnosisCMV infection can be diagnosed by the identification of characteristic intranuclear owls eye inclusions in tissue and by direct immunofluorescence.

Treatment by intravenous or oral ganciclovir.AspergillusCryptococcusVaricella zosterKaposis sarcoma76

Pneumococcal pneumonia. Gross section of lung showing gray hepatization of the upper lobe in right lower lobe consolidation

Pneumonia. Chest radiograph of left lower lobe pneumonia

Pneumonia. Chest radiograph of right upper lobe pneumonia

PCP pneumonia. Chest radiograph of patient with pneumocystis carinii pneumonia

PNEUMOCYSTIS PNEUMONIA

Pneumococcal pneumonia. Gross section of lung showing gray hepatization of the upper lobe in right lower lobe consolidation86

Pneumonia. Chest radiograph of right upper lobe pneumonia87

Pneumonia. Chest radiograph of left lower lobe pneumonia88

PCP pneumonia. Chest radiograph of patient with pneumocystis carinii pneumonia89

PNEUMOCYSTIS PNEUMONIA90Eksudasi dan Infiltrasi sel-sel polimorphonuclear dan makrophagProses :

Eksudasi dan Infiltrasi sel-sel polimorphonuclear dan makrophagProses :

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