Presented by Stefen Andrianus 110100009 Mutia Fri Fahrunnisa 110100071BRONCHOPNEUMONIASUPERVISOR: dr. Nelly Rosdiana, Sp. A (K)

BACKGROUND

According to WHO,Acute respiratory illness remains a leading cause of childhood mortality, causing an estimated 1.62.2 million deaths globally in children < 5 years.In Indonesia, Pneumonia is the 2nd most common cause of death in children after diarrhea (15,5%). A 2007 study conducted by the Indonesia Ministry of Health shows that 30.470 children died from pneumonia that year, which is equal to 83 children in a day.

Pneumonia is defined as an inflammation of lung tissue due to an infectious agent. 2

2. Banaszak, I.W., Breborowicz, A. Pneumonia in Children. Department of Pulmonology, Pediatric Allergy and Clinnical Immunology, Poland: 2013.. Chapter 6: 54052

DEFINITION

The etiology of pneumonia based on Age 3

3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010ETIOLOGY

ETIOLOGY3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010

ETIOLOGY3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010

ETIOLOGY3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010

Clinical ManifestationCough FeverSign of Respiratory Distress- Tachypnoe- Shortness of breath- Chest retraction- Grunting

DIAGNOSIS

Tachypnoe defined according to WHO criteria2

2. Banaszak, I.W., Breborowicz, A. Pneumonia in Children. Department of Pulmonology, Pediatric Allergy and Clinnical Immunology, Poland: 2013.. Chapter 6: 54052

AgeRespiratory rate0-2 months>602-12 months>501-4 years>40>5 years>30

DIAGNOSIS2. Physical Examinationdullness on percussion of the chestdecreased breath soundsadditional breath sounds such as ronchi and wheeze

DIAGNOSISAdditional Tests2a. Complete blood testb. Chest X-rayChest x-ray may shows:Interstitial infiltrateAlveolar infiltrate, consolidation of the lungs (air bronchogram).Bronchopneumonia, infiltrate which is equally spread in both lungs. c. Determination of etiology microbiological investigations.d. C-Reactive Protein (CRP)

TREATMENT & MANGEMENTThe treatment of pneumonia in children consists of appropriate antibiotics for the offending organisms, supportive treatment such as oxygen, iv fluid and the correction of acid base disorder9.Outpatient settings:The first line antibiotic for outpatient settings is Amoxicillin 20 mg/kg or Cotrimoxazole (4mg/kg of Trimetoprim and 20 mg/kg of Sulfamethoxazole)Inpatient settingsThe first line antibiotics for inpatient settings is Beta Lactamase group or Chloramphenicol. Antibiotic is administered for 7-10 days. Antibiotic must be given as soon as possible in neonates. Broad spectrum antibiotics such as the Beta Lactamase group or third generation of cephalosporine are recommended. Upon stabilization, iv antibiotics can be switched to oral antibiotics and patients can be treated in the outpatient settings.

CASE REPORTH, a 5 months old girl with a body weight of 7000 g and a body length of 61 cm was admitted to the emergency room in Haji Adam Malik General Hospital Medan on 9th September 2015 at 06.00 pm with a complain of shortness of breath.

HISTORYThe patient is the youngest child in the family. The patients mother pregnancy and delivery history was unremarkable. She was born with a birth weight of 3000 g. The mother said that she had been noticing the shortness of breath for the past 11 days. Her child breathlessness was not associated with activites and weather changes.

Productive cough was notably present for the past 2 weeks. There was no history of hemoptysis. History of contact with others with similar symptoms was found, which was her older sister. Her older sister has been experiencing chronic cough for more than 3 weeks.

HISTORY (CONT)Intermittent fever was found, fever subsided with antipyretics and the highest recorded temperature was 39 degree Celcius.History of urination and defecation was unremarkable. Her mother was complaining about her child weight loss. She was losing approximately 2 kg of body weight for the past week. She was treated in another hospital for 8 days and was referred to RSUP HAM due to no improvement.

HISTORY (CONT)History of medication: UnclearFamily History: Hs sister was suffering from chronic cough for more thatn 3 weeksHistory of parents medication: UnclearHistory of Pregnancy: The mothers age was 38 years old during pregnancy with a 36 weeks gestation.

HISTORY (CONT)History of Birth: Birth was assisted by a midwife. The patient was born pervaginal and cried immediately after birth. Body weight at birth was 3000 gram, body length at birth was unclear, and head circumference at birth was unclear.History of feeding: breast fed from birth until now (5 months)History of immunization: Incomplete immunization (polio 2 times).History of growth and development: The patients mother reported that H grew normally. H can now rolls from supine to prone.

PHYSICAL EXAMINATION

Present Status Level of consciousness: alert. Body temperature: 37,4C.BW: 7 kg, BH: 61 cm. L/A: -2

Localized statusHead:Eye: light reflex +/+, conjunctival pallor (-/-)Ear: unremarkableNose: O2 nasal canuleMouth: unremarkable

Neck:Jugular Vein Pressure: R+2 cm H2o

Localized Status (Cont)Thorax:Symmetric fusiform.Retractions (+) on the suprasternal and epigastric area.RR: 54x/I, regular, Ronchi (+,+) and stridor (+,+) in all lung fields.Dullness to percussion was found in all lung fields.HR 144 x/I, M1>M2, T1>T2, A2>A1, P2>P1, Continous murmur grade IV/IV.

Localized Status (Cont)Abdomen:Soft, normal peristaltic, liver and spleen were both unpalpable.Extremities:Pulse: 139x/i, regular, with adequate pressure and volume, warm, CRT < 3, blood pressure: 100/60 mmHg, SaO2 : 98%.

Chest X-RayResults: CTR of 56% , Aorta dilatation (-), Pulmonal artery dilatation (-), downward apex of the heart, Congestion (+), Infiltrate (+)

Conclusion : Cardiomegaly with congestion

LABORATORY FINDINGS

TestResultUnitReference RangeHemoglobin10.20g%10.7-17.1Erythrocyte4.14106/mm33.75-4.95Leukocyte18.25103/mm36.0-17.5Thrombocyte311103/mm3217-497Hematocrite29.40%38-52Eosinophil4.10%1-6Basophil0.500%0-1Neutrophil25.60%37-80Lymphocyte50.70%20-40Monocyte19.10%2-8

LABORATORY FINDINGS (CONT)

TestResultUnitReference RangeAbsolute Neutrophil count4.68103/L1.9-5.4Absoulute Lymphocyte count9.25103/L3.7-10.7Absolute Monocyte count3.48103/L0.3-0.8Absolute Basophil count0.09103/L0-0.1MCV71.00fL93-115MCH24.60pg29-35MCHC34.70g%28-34

Blood Gas Analysis

TestResultUnitReference RangepH7.4707.35-7.45PCO223.0mmHg38-42PO2201.0mmHg85-100Bicarbonate(HCO3)16.7mmol/L22-26Total CO217.4mmol/L19-25Base Excess-5.9mmol/L(-2)-(+2)O2 Saturation 100.0%95-100

Electrolyte

TestResultUnitReference RangeCalcium8.8mg/dL8.4-10.8Sodium138mEq/L135-155Potassium3.8mEq/L3.6-5.5Chloride100mEq/L96-106

Peripheral Blood Smear MorphologyErythorcyte: Microcytic hypochromic with anisocytosis.Leukocyte: Atypical Lymphocytes (+)Thrombocyte: Normal

Differential DiagnosisBronchopneumonia dd Bronchiolitis + Ventricel Septal Defect dd Patent Ductus Arteriosus.Bronchiolitis + Patent Ductus Arteriosus.

DIAGNOSIS Bronchopneumonia dd Bronchiolitis + Ventricel Septal Defect dd Patent Ductus Arteriosus

TREATMENTO2 1 litre/iIVFD D5% NaCl 0.225% microdrips 10gtt/iAmoxicillin IV 350 mg q12hNebulized NaCl 0.9 % 2,5 cc q8hFurosemide 7 mg PO q12hCaptopril 3.125 mg PO q12hDigoxin 0.035 mg PO q12h

9th September 2015SOAPDypsneaSensorium: alert, T: 37,4 oC, Head: eye: light reflex +/+, conjuctival pallor: -/-, mouth/nose/ear: unremarkable.Thorax: symmetric fusiform, retraction (+) HR: 144x/i, continuous murmur(+), RR: 54x/i, Ronchi +/+, Stridor +/+

Abdomen: soft, normal peristaltic, non-tender, liver and spleen are both unpalpable.Extremities: Pulse: 144x/i, regular with adequate pressure and volume, warm, CRT < 3, pretibial edema (-)Physiological reflexes: APR(+), KPR (+)Pathological reflexes (-)Meningeal sign (-)Bronchopneumonia O2 1-2L/i through nasal cannulaCeftriaxone 350 mg IV bid Consult Cardiologist.

10th September 2015SOAPDypsneaSensorium : alert, T : 37,0 oC, BP: 100/60 mmHgHead: eye: light reflex +/+, conjunctival pallor: -/-, mouth/nose/ear: unremarkable.Thorax: symmetric fusiform, retraction (+) HR: 128x/i, continuous murmur (+), RR: 66x/i, Ronchi +/+, Stridor +/+

Abdomen: soft, normal peristaltic, non-tender, liver and spleen are both unpalpable.Extremities: Pulse: 128x/i, regular with adequate pressure and volume, warm, CRT < 3, pretibial edema (-)Physiological reflexes: APR(+), KPR (+)Pathological reflexes (-)Meningeal sign (-)Echochardiography result:Large VSDModerate PDAMild TRRecommendations: consult nutritionist and Endocrine & Metabolic Diseases DivisonBronchopneumoniaBronchiolitisDiapers rashLarge VSDModerate PDAMild TRO2 1-2L/i through nasal cannulaD5% NaCl 0,225% IV microdrips: 10gtt/iCeftriaxone 350 mg IV bid Mizol TP q8hNebule NaCl 0,9% 2,5cc tid

11th September 2015SOAPDyspnea(+)Fever (-)Sensorium : alert, T : 36,6 oC, BP: 100/70 mmHgHead: eye: light reflex+/+, conjunctival pallor: -/-, mouth/nose/ear: unremarkable.Thorax: symmetric fusiform, retraction (+) HR: 120x/i, continuous murmur(+), RR: 60x/i, Ronchi +/+, Stridor +/+Abdomen: soft, normal peristaltic, non-tender, liver and spleen are both unpalpable.Extremities: Pulse: 120x/i, regular with adequate pressure and volume, warm, CRT < 3, pretibial edema (-)Physiological reflexes: APR(+), KPR (+)Pathological reflexes (-)Meningeal sign (-)BronchopneumoniaBronchiolitisDiapers rashLarge VSDModerate PDAMild TRO2 1-2L/i through nasal cannulaD5% NaCl 0,225% IV microdrips: 10gtt/iCeftriaxone 350 mg IV bid Mizol TP q8hNebule NaCl 0,9% 2,5cc tidFurosemide 7mg PO q12hCaptopril 3,125mg PO q12hDigoxin 0,035 mg PO q12h

12th September 2015 14th September 2015SOAPImprovement in SOB Fever (-)Sensorium : alert, T : 36,8 oC, BP: 100/60 mmHgHead: eye: light reflex +/+, conjunctival pallor: -/-, mouth/nose/ear: unremarkable.Thorax: symmetric fusiform, retraction (-) HR: 108x/i, continuous murmur(+), RR: 32x/i, Ronchi -/-, Stridor -/-Abdomen: soft, normal peristaltic, non-tender, liver and spleen are both unpalpable.Extremities: Pulse: 108x/i, regular with adequate pressure and volume, warm, CRT < 3, pretibial edema (-)Physiological reflexes: APR(+), KPR (+)Pathological reflexes (-)Meningeal sign (-)BronchopneumoniaBronchiolitisDiapers rashLarge VSDModerate PDAMild TRAmoxicillin 3,5cc IV q8hFurosemide 7mg PO q12hCaptopril 3,125mg PO q12hDigoxin 0,035 mg PO q12hNebule NaCl 0,9% 2,5cc tidMizol TP q8h

15th September 2015SOAPSOB (-) Fever (-)Sensorium : alert, T : 36,5 oC, BP: 110/700 mmHgHead: eye: light reflex +/+, conjunctival pallor: -/-, mouth/nose/ear: unremarkable.Thorax: symmetric fusiform, retraction (-) HR: 106x/i, continuous murmur(+), RR: 30x/i, Ronchi -/-, Stridor -/-Abdomen: Seopel, Normal peristaltic, non-tender, liver and spleen are both unpalpable.Extremities: Pulse: 108x/i, regular with adequate pressure and volume, warm, CRT < 3, pretibial edema (-)Physiological reflexes: APR(+), KPR (+)Pathological reflexes (-)Meningeal sign (-)BronchopneumoniaBronchiolitisDiapers rashLarge VSDModerate PDAMild TRAmoxicillin 3,5cc IV q8hFurosemide 7mg PO q12hCaptopril 3,125mg PO q12hDigoxin 0,035 mg PO q12hNebule NaCl 0,9% 2,5cc tidMizol TP q8h

16th September 2015Patient was discharged from the hospital

DISCUSSION

TheoryCasesThe incidence of pneumonia is highest in children under 5 years of age.Our patient is a 5 months old baby. The diagnosis of pneumonia is made by the presence of respiratory distress, such as tachypnoe, history of breathlessness or difficulty in breathing chest retractions, nasal flaring, grunting, use of accessory muscles of respiration. Tachypnoe is a very sensitive marker of pneumonia. Between 50-80% of children with WHO-defined tachypnoe had radiological signs of pneumonia.

Chest x-ray may shows: interstitial infiltrate, alveolar infiltrate, consolidation of the lungs (air bronchogram), Bronchopneumonia, infiltrate which is equally spread in both lungs. Our patients presenting complaint was shortness of breath. Chest retractions, grunting, and tachypnoe was found on physical examinations.

Her chest X-ray revealed infiltrate which was equally spread in both lungs. This finding suggests the diagnosis of Bronchopneumonia.

The treatment of pneumonia in children consists of appropriate antibiotics for the offending organisms, supportive treatment such as oxygen, iv fluid and the correction of acid base disorder.

First-line recommended therapy in previously healthy children regardless of age is Amoxicillin, as it provides sufficient coverage against the most common invasive bacterial pathogen, namely Streptococcus pneumoniae. The treatments for this patient include oxygen 1 litre/i given through nasal canule, IVFD D5% NaCl 0.225% microdrips 10 gtt/i, and Amoxicillin IV 350mg q12h.

SUMMARYH, A 5 months old baby girl, was admitted to the emergency department due to breathlessness and was diagnosed with bronchopneumonia and ventricular septal defect. The diagnosis was made based on her history, physical examinations ,lab studies, chest X-ray and echocardiography. The patients treatments consist of:O2 1 litre/iIVFD D5% NaCl 0.225% microdrips 10gtt/iAmoxicillin IV 350 mg q12hNebulized NaCl 0.9 % 2,5 cc q8hFurosemide 7 mg PO q12hCaptopril 3.125 mg PO q12hDigoxin 0.035 mg PO q12h

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