Sign & Symptom
¨ Rinorrhea ¨ Cough ¨ Sneezing ¨ Tachypnea, chest indrawing (important in IMCI) ¨ Dyspnea, eq: nasal flaring, grunting, head bobbing,
retraction, cyanosis, etc
Severe sign/symptom: Decreased conciousness, difficult to drink/eat, seizure
Infeksi Saluran Pernafasan Akut (ISPA) (Akut < 2 minggu) Acute Respiratory Infection (ARI): ¨ 1. Acute Upper Respiratory Infection (AURI):
- Common cold - Otitis media - Pharyngitis - Tonsilitis - Influenza
¨ 2. Acute Lower Respiratory Infection (ALRI): - Croup - Bronchitis - Bronchiolitis - Pneumonia
Acute Respiratory Infections (ARI)
Developed and developing countries ¨ High morbidity ¨ 5 – 8 episodes/year/child ¨ 30 – 50 % outpatient visit ¨ 10 – 30 % hospitalization Developing countries ¨ High mortality ¨ 30 – 70 times higher than in developed countries ¨ 1/4 - 1/3 death in children under five year of age
ARI-ASSOCIATED DEATH RATE BY AGE TEKNAF, BANGLADESH, 1982-1985
0
20
40
60
80
100
120
140
1-5 6-11 12-23 24-35 36-50Age in Months
Deaths per 1000 children
Distribution of 12.2 million deaths among children less than 5 years old in all developing countries, 1993
ARI (26.9%)
Measles (2.4%)
Diarrhoea/measles (1.9%)
Diarrhoea (22.8%)
Other (33.1%)
Malaria (6.2)
ARI/Malaria (1.6%)
ARI/Measles (5.2%)
Malnutrition (29%)
RISK FACTORS FOR PNEUMONIA OR DEATH FROM ARI
Increase risk of ARI
Malnutrition, poor breast feeding
practices
Vitamin A deficiency
Low birth weight
Cold weather or chilling
Exposure to air pollution • Tobacco smoke • Biomass smoke • Environmental air pollution
Lack of immunization
Young age
Crowding
High prevalence of nasopharyngeal carriage of pathogenic bacteria
Magnitude of the Problem in Indonesia
Pneumonia in children (< 5 years of age) ¨ Morbidity Rate 10-20 % ¨ Mortality Rate 6 / 1000 ¨ Pneumonias kill
¤ 50.000 / a year ¤ 12.500 / a month ¤ 416 / a day = passengers of 1 jumbo jet plane ¤ 17 / an hour ¤ 1 / four minutes
Pneumonia Classifications
¨ Anatomical classification ¤ Lobar pneumonia ¤ Lobular pneumonia ¤ Intertitial pneumonia ¤ Bronchopneumonia
¨ Etiological classification ¤ Bacterial pneumonia ¤ Viral pneumonia ¤ Mycoplasma pneumonia ¤ Aspiration pneumonia ¤ Mycotic pneumonia
Etiology of Pneumonia
¨ Predominantly : bacterial and viral ¨ In developing countries:
bacterial > viral (Shann,1986):
à In 7 developing countries: bacterial 60 %
(Turner, 1987):
à In developed countries: bacterial 19 %, viral 39 %
Bacterial etiology
¨ Streptococcus pneumoniae ¨ Hemophilus influenzae ¨ Staphylococcus aureus ¨ Streptococcus group A – B ¨ Klebsiella pneumoniae ¨ Pseudomonas aeruginosa ¨ Chlamydia spp ¨ Mycoplasma pneumoniae
0
10
20
30
40
50
S Pneumoniae H Influenzae S Aureus
BACTERIA ISOLATED FROM LUNG ASPIRATES IN 370 UNTREATED CHILDREN WITH PNEUMONIA
%
Characteristic features
¨ S pneumoniae ¤ mucosal inflammation lesion ¤ alveolar exudates ¤ frequently àlobar pneumonia
¨ H influenzae, S viridans, Virus ¤ invasion and destruction of mucous membrane
¨ Staphylococcus, Klebsiella ¤ destruction of tissues à multiple abscesses
Simple Clinical Signs of Pneumonia (WHO)
Fast breathing (tachypnea)
Respiratory thresholds Age Breaths/minute < 2 months 60 2 - 12 months 50 1 - 5 years 40
Chest Indrawing (subcostal retraction)
Integrated Management Childhood Illness (IMCI)
Classification Sign/Symptom Management
Severe Pneumonia Tachypnea (+) Chest indrawing (+)
Refer
Pneumonia Tachypnea (+) Chest indrawing (-)
Antibiotic
Cough Not Pneumonia Tachypnea (-) Chest indrawing (-)
No antibiotic
Pathology and Pathogenesis
Bacteriae àperipheral lung tissues à tissues reaction à oedematous ¨ Red Hepatization Stadium
alveoli consist of : leucocyte, fibrine, erythrocyte, bacteria
¨ Grey Hepatization Stadium
fibrine deposition, phagocytosis
¨ Resolution Stadium
neutrophil degeneration, loose of fibrine, bacterial phagocytosis
Bronchopneumonia Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the alveolar spaces. The alveolar capillaries are distended and engorged.
Bronchopneumonia Acute bronchopneumonia. The alveolar spaces contain abundant PMNs and an inflammatory infiltrate rich in fibrin.
Acute Bronchopneumonia Acute bronchopneumonia; the alveolar spaces are full and distended with PMNs and a proteinaceous exudate. Only the alveolar septa allow identification of the tissue as lung.
Radiographic patterns
1. Diffuse alveolar and interstitial pneumonia (perivascular and interalveolar changes)
2. Bronchopneumonia (inflammation of airways and parenchyma)
3. Lobar pneumonia (consolidation in a whole lobe)
4. Nodular, cavity or abscess lesions (esp.in immunocompromised patients)
Blood Gas Analysis & Acid Base Balance
¨ Hypoxemia (PaO2 < 80 mm Hg) ¤ with O2 3 L/min 52,4 % ¤ without O2 100 %
¨ Ventilatory insufficiency ¤ (PaCO2 < 35 mmHg) 87,5 %
¨ Ventilatory failure ¤ (PaCO2 > 45 mmHg ) 4.8 %
¨ Metabolic Acidosis ¤ poor intake and/or hypoxemia 44,4 %
(Mardjanis Said, et al. 1980)
Management
Severe Pneumonia ¨ Hospitalization ¨ Antibiotic administration
¤ Amphycillin ¤ Chloramphenicol or Gentamycin
¨ Intra Venous Fluid Drip ¨ Oxygen ¨ Detection and management of complications
Bronchiolitis
¤ Bronchioles inflammation
¤ Clinical syndromes: fast breathing, retractions, wheezing
¤ Predominantly < 2 years of age (2 – 6 months)
¤ Difficult to differentiate with pneumonia
Bronchiolitis
¨ Etiology Predominantly RSV (Respiratory Syncytial Virus), adenovirus etc.
¨ Diagnosis Etiological diagnosis ¤ Microbiologic examination Clinical diagnosis ¤ Signs and symptoms ¤ Age ¤ Resource of infection
Bronchiolitis
¨ Clinical Manifestations cough, cold, fever, fast breathing, retraction, wheezing, irritable, vomitus, poor intake
¨ Physical Examinations tachypnea, tachycardia, retraction, expiration >, wheezing, fever, pharyngitis, conjunctivitis, otitis media.
Bronchiolitis
¨ Radiologic examination diffuse hyperinflation ¤ flat diaphragm, ¤ subcostal > ¤ retrosternal space >
peribronchial infiltrates pleural effusion (rare)
Bronchiolitis
¨ Management ¤ Supportive ¤ Severe disease
hospitalization intra venous fluid drip oxygen (antibiotics)
¤ Bronchodilator: controversial ¤ Corticosteroid: controversial
Bronchiolitis
¨ Natural history & complications ¤ Improved clinical findings : in 3-4 days ¤ Improved radiological features: in 9 days
¨ Persistent respiratory obstruction : 20% ¨ Respiratory failure : 25 % ¨ Lung collaps (rare)
Bronchiolitis
¨ Correlation with Asthma ¤ 30 % - 50 % becomes asthmatic patients ¤ Similarity in : - pathogenic mechanisms
- pathologic disorders
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