infeksi saluran pernafasan akut (ispa) fifi spa
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INFEKSI SALURAN PERNAFASAN AKUT (ISPA)
Dr. Fifi Sofiah, SpA
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Infeksi Saluran Pernafasan Akut (ISPA)
Acute Respiratory Infection (ARI): 1. Acute Upper Respiratory Infection (AURI):
- Cold - Otitis media- Pharyngitis
2. Acute Lower Respiratory Infection (ALRI):- Croup- Bronchitis- Bronchiolitis- Pneumonia
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Acute Respiratory Infections (ARI)
Developed and developing countries High morbidity 5 – 8 episodes/year/child 30 – 50 % outpatient visit 10 – 30 % hospitalizationDeveloping countries High mortality 30 – 70 times higher than in developed countries 1/4 - 1/3 death in children under five year of age
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ARI-ASSOCIATED DEATH RATE BY AGETEKNAF, BANGLADESH, 1982-1985
0
20
40
60
80
100
120
140
1-5 6-11 12-23 24-35 36-50
Age in Months
Deaths per 1000 children
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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%)
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RISK FACTORS FOR PNEUMONIAOR DEATH FROM ARI
Increaserisk of
ARI
Malnutrition, poorbreast feeding
practices
Vitamin A deficiency
Low birth weight
Cold weatheror chilling
Exposure to air pollution• Tobacco smoke• Biomass smoke• Environmental air pollution
Lack of immunization
Young age
Crowding
High prevalenceof nasopharyngealcarriage ofpathogenic bacteria
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Magnitude of the Problemin 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
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Pneumonia is a no 1 killer for infants (Balita)
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PneumoniaClassifications
Anatomical classification Lobar pneumonia Lobular pneumonia Intertitial pneumonia Bronchopneumonia
Etiological classification Bacterial pneumonia Viral pneumonia Mycoplasma pneumonia Aspiration pneumonia Mycotic pneumonia
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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 %
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Bacterial etiology
Streptococcus pneumoniae Hemophilus influenzae Staphylococcus aureus Streptococcus group A – B Klebsiella pneumoniae Pseudomonas aeruginosa Chlamydia spp Mycoplasma pneumoniae
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0
10
20
30
40
50
S Pneumoniae H Influenzae S Aureus
BACTERIA ISOLATED FROM LUNG ASPIRATESIN 370 UNTREATED CHILDREN WITH PNEUMONIA
%
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Characteristic features
S pneumoniae mucosal inflammation lesion alveolar exudates frequently lobar pneumonia
H influenzae, S viridans, Virus invasion and destruction of mucous
membrane Staphylococcus, Klebsiella
destruction of tissues multiple abscesses
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Simple Clinical Signs of Pneumonia (WHO)
Fast breathing (tachypnea)
Respiratory thresholds Age
Breaths/minute< 2 months
602 - 12 months 501 - 5 years 40
Chest Indrawing(subcostal retraction)
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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
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Pathology and Pathogenesis
Bacteriae peripheral lung tissues tissues reaction
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
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Bronchopneumonia Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the alveolar spaces. The alveolar capillaries are distended and engorged.
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Bronchopneumonia Acute bronchopneumonia. The alveolar spaces contain abundant PMNs and an inflammatory infiltrate rich in fibrin.
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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.
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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)
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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)
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Management
Severe Pneumonia Hospitalization Antibiotic administration
Amphycillin Chloramphenicol or Gentamycin
Intra Venous Fluid Drip Oxygen Detection and management of
complications
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Complications
Pleural effusion (empyema) Piopneumothorax Pneumothorax Pneumomediastinum
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Bronchiolitis
Bronchioles inflammation Clinical syndromes:
fast breathing, retractions, wheezing Predominantly < 2 years of age
(2 – 6 months) Difficult to differentiate with
pneumonia
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Bronchiolitis
EtiologyPredominantly RSV (Respiratory Syncytial Virus), adenovirus etc.
DiagnosisEtiological diagnosis Microbiologic examination Clinical diagnosis Signs and symptoms Age Resource of infection
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Bronchiolitis
Clinical Manifestationscough, cold, fever, fast breathing, retraction, wheezing, irritable, vomitus, poor intake
Physical Examinations tachypnea, tachycardia, retraction, expiration >, wheezing, fever, pharyngitis, conjunctivitis, otitis media.
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Bronchiolitis
Radiologic examinationdiffuse hyperinflation flat diaphragm, subcostal > retrosternal space >
peribronchial infiltratespleural effusion (rare)
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Bronchiolitis
Management Supportive Severe disease
hospitalizationintra venous fluid dripoxygen(antibiotics)
Bronchodilator: controversial Corticosteroid: controversial
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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)
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Bronchiolitis
Correlation with Asthma 30 % - 50 % becomes asthmatic patients Similarity in : - pathogenic mechanisms
- pathologic disorders
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Thank you