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

Deaths per 1000 children

140 120 100 80 60 40 20 0 1-5 6-11 12-23 Age in Months 24-35 36-50

Distribution of 12.2 million deaths among children less than 5 years old in all developing countries, 1993

ARI/Malaria (1.6%) Malaria (6.2) ARI (26.9%)

Other (33.1%)

Malnutrition (29%)

ARI/Measles (5.2%) Measles (2.4%) Diarrhoea/measle s (1.9%) Diarrhoea (22.8%)

RISK FACTORS FOR PNEUMONIA OR DEATH FROM ARI

Malnutrition, poor breast feeding practices Lack of immunization Young age Vitamin A deficiency Low birth weight

Increase risk of ARI

Crowding High prevalence of nasopharyngeal carriage of pathogenic bacteria Cold weather or chilling Exposure to air pollution Tobacco smoke Biomass smoke Environmental air pollution

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): In 7 developing countries: bacterial 60 % (Turner, 1987): 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

BACTERIA ISOLATED FROM LUNG ASPIRATES IN 370 UNTREATED CHILDREN WITH PNEUMONIA
%
50 40 30 20 10 0

S Pneumoniae

H Influenzae

S Aureus

Characteristic features

S pneumoniae
mucosal

inflammation lesion alveolar exudates frequently lobar pneumonia

H influenzae, S viridans, Virus

invasion

and destruction of mucous membrane of tissues multiple abscesses

Staphylococcus, Klebsiella
destruction

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 Severe Pneumonia

Sign/Symptom Tachypnea (+) Chest indrawing (+) Tachypnea (+) Chest indrawing (-) Tachypnea (-) Chest indrawing (-)

Management Refer

Pneumonia

Antibiotic

Cough Not Pneumonia

No antibiotic

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

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

Ventilatory insufficiency Ventilatory failure Metabolic Acidosis

poor (PaCO2 (PaCO2

O2 3 L/min without O2

52,4 % 100 %

< 35 mmHg) 87,5 % > 45 mmHg ) 4.8 %

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 Clinical

inflammation

syndromes: fast breathing, retractions, wheezing < 2 years of age (2 6 months)

Predominantly

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