PNEUMONIA PADA ANAK : DIAGNOSIS DAN TATA LAKSANA. Ayu Setyorini M Mayangsari

(1)

PNEUMONIA PADA ANAK :

DIAGNOSIS DAN TATA LAKSANA

(2)

DEFINISI

• _Pneumonia

adalah inflammasi

parenkim paru yg

disebabkan oleh

respon terhadap

invasi

mikroorganisme

(3)

FAKTOR RISIKO

FAKTOR SOSIAL EKONOMI /

LINGKUNGAN

-  SOSIAL EKONOMI KURANG

-  PENDIDIKAN IBU KURANG

-  KESULITAN MENCAPAI FASKES

-  POLUSI UDARA DALAM RUMAH

-  MALNUTRISI

-  TIDAK MENDAPAT ASI

-  PAPARAN ASAP ROKOK

-  PADA REMAJA : PENGGUNAAN

ALKOHOL, OBAT DAN ROKOK

FAKTOR PENYAKIT DASAR

-  PENYAKIT JANTUNG BAWAAN

-  PENYAKIT NEUROMUSKULAR (TERUTAMA

BILA DISERTAI KESADARAN MENURUN &

KETERLAMBATAN PERKEMBANGAN)

-  DEFISIENSI UMUM PRIMER ATAU DIDAPAT

-  GANGGUAN GIT (GER, TEF)

-  ASMA

-  BRONCHOPULMONARY DYSPLASIA

-  DIABETES MELLITUS

-  CYSTIC FIBROSIS

-  ANEMIA SICKLE CELL

(4)

ETIOLOGI MIKROORGANISME

• _{Dipengaruhi oleh faktor usia}

Table 25.1

Most Common Agents Causing Community-Acquired Pneumonia

According to Age Group

Table 25.1

Most Common Agents Causing Community-Acquired Pneumonia

According to Age Group

Table 25.1

Most Common Agents Causing Community-Acquired Pneumonia

According to Age Group

Table 25.1

Most Common Agents Causing Community-Acquired Pneumonia

According to Age Group

Table 25.1

Most Common Agents Causing Community-Acquired Pneumonia

According to Age Group

(5)

KLASIFIKASI PNEUMONIA BERDASARKAN ASAL

MIKROORGANISME

• PNEUMONIA KOMUNITAS

– 

Pneumonia pada anak tanpa riwayat MRS dalam 2

minggu terakhir, atau

– 

Pada anak yang MRS <48 jam

• PNEUMONIA RUMAH SAKIT

– 

Pneumonia pada anak dengan riwayat MRS dalam 2

minggu terakhir, atau

– 

Pada anak yang MRS >48 jam dimana saat MRS tidak ada

gejala respirasi

(6)

PATOGENESIS

MIKROORGANISME

Aspirasi

Inhalasi isi

cavum oral atau

gaster

Inhalasi

melalui udara

Hematogenous

FAKTOR HOST

Sistem immunitas

paru menurun

FAKTOR LINGKUNGAN

Kepadatan

Usia

Sosial

ekonomi

KOLONISASI

MIKROORGANISME

INFEKSIUS DALAM SALURAN

NAPAS BAWAH

(7)

pathogenesis cont’d

KOLONISASI MIKROORGANISME PATOGEN DALAM SALURAN NAPAS

BAWAH

VIRUS

Akumulasi sel

mononuklear di

submukosa dan

perivaskular

Obstruksi jalan napas

partial/komplit

BAKTERI

1. Kongesti

2. Hepatisasi merah

3. Hepatisasi kelabu

4. Resolusi

1-2 hari

2-4 hari

4-7 hari

• Kongesti kapiler diserta penggantian

udara dlm alveoli diganti oleh eksudat

selular (neutrofil, limfosit) & bakteri

• Eritrosit >>, neutrofil, deskuamasi sel

epitel, dan fibrin dalam alveoli

• Kapiler alveolar terisi darah (engorged)

è

konsistensi paru seperti hepar

• Eritrosit mengalami disintegrasi/lisis &

dominasi eksudat fibrinopurulen

• Makrofag mulai bermigrasi ke dalam

alveolus

• Paru tampak abu-abu kekuningan

• Resorpsi dan perbaikan struktur paru

• Fagositosis sel asing oleh makrofag

alveolar

1-2 hari

3 minggu

(8)

PATOFISIOLOGI

(9)

path,cont’d

Efusi

pleura

udara ê

Aliran

Ventilasi

paru tdk

adekuat

(10)

MANIFESTASI KLINIS

GEJALA UMUM

GEJALA RESPIRASI

• _Irritable

• _{Nafsu makan/minum menurun}

• _Malaise

• _{Keluhan saluran cerna}

• _{Bila berat : dehidrasi, kejang, kesadaran}

menurun

(11)

manifestasi cont’d

• Batuk DISERTAI demam dan distress napas

• Distress napas :

– 

Takipne è Batasan normal laju napas:

• < 60 x/mnt : < 2 bulan

• < 50 x/mnt : 2 sd 12 bulan

• < 40 x/mnt : 1 sd 5 tahun

– 

Retraksi dinding dada : subkostae, interkostae,

suprasternal

– 

Napas cuping hidung

– 

Head nodding (kepala mengangguk-angguk), grunting

• Auskultasi : crackle/rhales basah halus dapat disertai

wheezing

GEJALA RESPIRASI

(12)

KLASIFIKASI DERAJAT PNEUMONIA WHO

BUKAN PNEUMONIA

PNEUMONIA : Batuk, demam, takipne, crackle

PNEUMONIA BERAT :

Gejala PNEUMONIA disertai salah satu dari

- Retraksi dinding dada - Napas cuping hidung

- Head nodding - Grunting - Sianosis

- Dehidrasi - Lethargi - Kejang

Rawat jalan

Rawat inap

(13)

PEMERIKSAAN PENUNJANG

• _{Saturasi oksigen}

• _{Darah lengkap}

• _{Rontgen dada PA/AP :}

– 

Konsolidasi lobaris

– 

Bercak infiltrat tersebar pada lapangan paru

(bronkopneumonia)

– 

Interstitial

• _{Biakan sputum dan/atau darah}

(14)

RONTGEN DADA

• Indikasi rontgen dada :

– 

Gejala pneumonia berat

– 

Gambaran klinis meragukan

– 

Menyingkirkan kemungkinan penyebab distress napas

lain (benda asing, penyakit kardiopulmonal lain)

– 

Pada setiap anak dengan demam berkepanjangan dan

leukositosis tanpa sebab yang jelas walaupun telah diberi

antibiotika empirik adekuat

• Ro dada tidak rutin dilakukan pada anak dengan

pneumonia yang dapat dilakukan rawat jalan

(15)

RONTGEN DADA

Konsolidasi lobar

Retikular interstitial

Posisi : bila berumur >

4 thn dan sudah bisa

berdiri : PA

Pada anak lbh muda :

AP

Lateral dekubitus bila

ada kecurigaan efusi

pleura

Bronkopneumonia

Pneumatocele

Normal

(16)

Air

bron-

cho-gram

(17)

Bercak2

opasitas

multipel

yang

konfluen

Tampak air

broncho-

gram

Opasitas

tersebar

sampai ke

perifer,

bilateral,

dan tidak

simetris

BRONKOPNEUMONIA

(18)

BERCAK

BERBENTUK

SEPERTI BENANG

(LINEAR,

RETIKULAR)

YANG TERSEBAR

SAMPAI KE

PERIFER

AERASI MASIH

TERLIHAT

INTERSTITIAL

(19)

Massa

kistik

berdin-ding tipis

berisi

udara

berbagai

ukuran

(20)

PENATALAKSANAAN

• _Oksigenasi

• _Hidrasi

• _Antibiotika

• _{Bila wheezing : inhalasi salbutamol}

• _{Terapi supportif: antipiretika, mukolitik}

(21)

OKSIGENASI

• _{Semua gejala pneumonia berat}

• _{Saturasi oksigen <90%}

• _{Konjungtiva pucat (anemia berat)}

INDIKASI

CARA PEMBERIAN:

- Nasal kanul, masker, CPAP, ventilator

LAJU ALIRAN MAKSIMUM MELALUI NASAL

KANUL

-  ½ L/mnt : 0-2 bln - 1 L/mnt : 2-12 bln

-  2 L /mnt : 1 – 5 tahun -max 4 L/mnt

(22)

(23)

(24)

ANTIBIOTIKA

– 

Rawat jalan : Antibiotika selama 3-5 hari

• Amoksisilin 80-100 mg/kgBB/hari dibagi 2 dosis

atau

• Eritromisin 40-60 mg/kgBB/hari dibagi 3-4 dosis

– 

Rawat inap :

• Lini pertama: ampisilin 50 mg/kgBB @6 jam dan

gentamisin 7.5 mg/kgBB @ 24 jam selama 5 hari

• Lini kedua: ceftriaxone 25-50 mg/kgBB @ 12 jam

selama 5 hari

• Bila ada kecurigaan infeksi oleh S. aureus : Kloksasilin

50 mg/kgBB/6 jam

(25)

INDIKASI PULANG

• _{Distres napas teratasi}

• _{Tidak ada hipoksia (saturasi oksigen >90%)}

pada suhu ruang

• _{Dapat makan dengan baik}

• _{Dapat minum obat oral atau telah}

menyelesaikan terapi antibiotik parenteral

• _{Orang tua memahami gejala pneumonia,}

faktor risiko dan kapan harus kembali

(26)

KOMPLIKASI

• _Gagal napas

• _{Effusi pleura}

• _Empiema

• _{Pneumotorak, pneumomediastinum}

• _Abses paru

• _Sepsis

(27)

61 Journal of the Scientific Society, Vol 41 / Issue 1 / January-April 2014

Management

of spontaneous

pneumothorax in

a newborn: A rare

clinical entity

Sir,

The sudden unexpected development of spontaneous pneumothorax in a full-term, apparently healthy infant is rarely seen, though it is a well-known complication of the respiratory distress syndrome and its therapy.[1]_{Spontaneous pneumothorax that}

occurs during this period is mostly associated with assisted ventilation, birth trauma, meconium aspiration or prematurity.[2]_{We report the occurrence}

of spontaneous pneumothorax in a 3.5 kg healthy neonate born by spontaneous vaginal delivery at 38 weeks gestation in the absence of any known predisposing factors. The prenatal course was unremarkable with no evidence of chorioamnionitis, oligohydramnios or any systemic infection. Amniotic fluid did not show any staining with meconium and Apgar scores were eight and nine at 1 and 5 min, respectively. After delivery, the baby was active and showed no sign of respiratory distress, but the baby suddenly became lethargic and pale without any preceding clinical event 6 h after birth.

On admission to neonatal emergency unit, the neonate was lethargic, pale and had a respiratory rate of 72 breath/min, heart rate 172 beats/min, CFT <3 s, but peripheral pulses were palpable. On examination, the anterior fontanelle was normal, SpO₂ was 75% on room air and decreased breath sounds on the right side of the chest. The chest X-ray revealed pneumothorax on the right side with the shift to the left [Figure 1] while brain and abdominal sonograms were normal. The initial sepsis screen was negative, blood sugar and electrolytes were normal. The chest tube was inserted immediately on the right side and the baby had sudden improvement with SpO₂ >92% and respiratory rate <60 breaths/min and patient started accepting breast feeds. The repeat chest X-ray revealed normal findings and the child was discharged after 5 days [Figure 2]. The occurrence of spontaneous pneumothorax in a healthy newborn is a rare entity.[3]_{Most neonatal}

pneumothorax, pneumomediastinum and surgical emphysema in the neck occurs as a result of birth injury, shoulder dystonia, prematurity, pneumonia, meconium aspiration syndrome or assisted ventilation.[3-5]

However, during normal delivery, when the term baby passes through the vagina, there are potential chances of his thoracic cage being over-compressed during the delivery. Under such circumstances, the pressure gradient between the alveolar and perivascular space can increase abnormally for a transient period that may possibly lead to the rupture of the alveoli. However, this condition may manifest several hours after birth and respiratory distress may develop, which is considered to be the most important presenting sign, as has been noted in the present case. Though renal anomalies are commonly associated in neonates with

Figure 1: Chest X-ray revealing pneumothorax on the right side with the shift to the left

Figure 2: Chest X-ray revealing normal bilateral lung fields without any shift of the heart

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PNEUMONIA PADA ANAK : DIAGNOSIS DAN TATA LAKSANA. Ayu Setyorini M Mayangsari