INFEKSI SALURAN PERNAFASAN AKUT (ISPA) Dr. Fifi Sofiah, SpA

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 is a no 1 killer for infants (Balita)

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

Complications

¨  Pleural effusion (empyema)

¨  Piopneumothorax

¨  Pneumothorax

¨  Pneumomediastinum

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