PLENO PAKAR

25 NOVEMBER 2013
A3
2012/2013

ANATOMY OF THE RESPIRATORY

SYSTEM

HISTOLOGY OF THE RESPIRATORY

SYSTEM

 Nasal cavity

Vestibule lined with keratinized stratified squamous epithelium. Hairs and sebaceous glands are
also present
Transition from vestibule to respiratory region (respiratory epithelium) stratified squamous ==
pseudostratified columnar == ciliated. Goblet cells also present in this epithelium.
Conchae bony projection increase surface area of the nasal cavity and create turbulence in the
stream of passing air facilitates conditioning of the air.
Lamina propria supplements the secretion of goblet cells. Veins in the lamina propria form thinwalled cavernous bodies.
Olfactory region tissue on the superior conchae and nasal septum. Cilia in the epithelium of
olfactory region arise from olfactory cells no dynein arms deny motility.
Cell membrane covering the surface of the cilia respond to odorants. The axons of the olfactory cells
collect into bundles in the lamina propria. Supporting cells also present.
Basal cells == olfactory cells or supporting cells

 Pharnyx
Respiratory epithelium (nasopharynx or epipharynx)
Stratified squamous epithelium (oropharynx or meso- and hypo-phraynx)
Lymphocytes usually accumulate beneath the epithelium of the pharynx tonsils

Larynx
Vocal folds lined by stratified squamous epithelium.
Contains the muscle (striated, skeletal) and ligaments needed to control the vocal folds.

 Trachea
Lined by respiratory epithelium.
Physical or chemical irritation increase goblet cell number. Prolonged intense
irritation transformation to stratified squamous epithelium.
Also contains brush cells, endocrine cells, surfactant-producing cells, serous
cells.
Mucosa epithelium and lamina propria
Submucosa elastic membrane (lamina propria) borders mucosa and
connective tissue belows it. Submucosa glands supplement the secretion of
the cells in the epithelium.
Tracheal cartilage dorsal ends : trachealis muscle and connective tissue
fibres.
Annular ligaments connect individual cartilages.

 Bronchi
Similar to those of the trachea and the main bronchi
Surrounded by a layer of smooth muscle, located between the cartilage and
epithelium

Bronchioles
Ciliated columnar epithelium
Glands and cartilage are absent
Smooth muscle layer relatively thicker

Alveoli
Wall formed by a thin sheet of tissue separating neighbouring alveoli
epithelial cells and intervening connective tissue.
Between the connective tissue, we find dense, anastomosing network of
pulmonary capilaries.
Alveolar pores connect neighbouring alveoli to each other.
o Alveolar type I cells extremely flattened
o Alveolar type II cells irregularly (sometimes cuboidal) shaped. Contain
cytosomes consisting of precursors to pulmonary surfactant.
Alveolar macrophages remove particular matters inspired into the alveoli

COUGHING

FISIOLOGI BATUK
Pada dasarnya mekanisme batuk dapat dibagi
menjadi empat fase yaitu :
I.
II.
III.
IV.

FASE IRITASI
FASE INSPIRASI
FASE KOMPRESI
FASE EKSPIRASI

 Cough reflex
The bronchi and trachea are so sensitive to light touch that very slight
amounts of foreign matter or other causes of irritation initiate the cough
reflex. The larynx and carina (the point where the trachea divides into the
bronchi) are especially sensitive, and the terminal bronchioles and even the
alveoli are sensitive to corrosive chemical stimuli such as sulfur dioxide gas or
chlorine gas. Afferent nerve impulses pass from the respiratory passages
mainly through the vagus nerves to the medulla of the brain. There, an
automatic sequence of events is triggered by the neuronal circuits of the
medulla, causing the following effect.
o First, up to 2.5 liters of air are rapidly inspired.
o Second, the epiglottis closes, and the vocal cords shut tightly to entrap the air
within the lungs.
o Third, the abdominal muscles contract forcefully, pushing against the
diaphragm while other expiratory muscles, such as the internal intercostals,
also contract forcefully. Consequently, the pressure in the lungs rises rapidly to
as much as 100 mm Hg or more.
o Fourth, the vocal cords and the epiglottis suddenly open widely, so that air
under this high pressure in the lungs explodes outward.

DD BATUK

Pneumonia : akut dan kronik

TBC Paru
Ca paru lokal
Cystic Fibrosis
Abcess Paru
Bronchiektasis

IMMUNIZATION

NORMAL GROWTH AND

DEVELOPMENT OF A 7-YEAR-OLD
CHILD

 Motor Development
hand-eye coordination is well developed
has good balance
can execute simple gymnastic movements, such as somersaults

Language and Thinking Development

uses a vocabulary of several thousand words

demonstrates a longer attention span
uses serious, logical thinking; is thoughtful and reflective
able to understand reasoning and make the right decisions
can tell time; knows the days, months, and seasons
can describe points of similarity between two objects
begins to grasp that letters represent the sounds that form
words
able to solve more complex problems
individual learning style becomes more clear-cut

 Social and Emotional Development

desires to be perfect and is quite self-critical
worries more; may have low self-confidence
tends to complain; has strong emotional reactions
understands the difference between right and
wrong
takes direction well; needs punishment only rarely
avoids and withdraws from adults
is a better loser and less likely to place blame
waits for her turn in activities
starts to feel guilt and shame

PERTUSSIS
ETIOLOGY AND PATHOGENESIS

 Humans are the sole reservoir for B. pertussis and B. parapertussis. B.

pertussis, a gram-negative pleomorphic bacillus, is the main causative
organism for pertussis.
B. pertussis spreads by aerosolised droplets produced by the cough of
infected individuals, attaching to and damaging ciliated respiratory
epithelium. B. pertussis also multiplies in the respiratory epithelium,
starting in the nasopharynx and ending primarily in the bronchi.
Pertussis is highly contagious, developing in approx. 80-90% of susceptible
individuals who are exposed to it.
A mucupurulosanguineous exudate froms in the respiratory tract. This
exudate compromises the small airways (esp. those of infants) and
predisposes the affected individual to atelectasis, cough, cyanosis, and
pneumonia. The lung parenchyma and bloodstream are not invaded,
therefore, blood culture results are negative.

 Transmission of pertussis can occur through direct face-to-face contact,

through sharing of a confined space, or through contact with oral, nasal,
or respiratory secretions from an infected source.
Young infants, esp. those born prematurely, and patients with underlying
cardiac, pulmonary, neuromuscular, or neurologic disease are at high risk
for contracting the disease and for complications.
Risk factors :

Non-vaccination in children
Contact with an infected person
Epidemic exposure
Pregnancy

Transmission by contact with contaminated articles is rare. Patients are

usually not infectious after the third week of paroxysmal phase.

PERTUSSIS
DIAGNOSIS

 The criterion standard for diagnosis of pertussis is isolation of B.

pertussis in culture. However, laboratory confirmation of pertussis is
difficult and delayed. Therefore, clinicians need to make the diagnosis of
pertussis presumptively in patients with a history of intense paroxysmal
coughing, with or without whooping, color changes, posttussive vomiting,
incomplete or absent pertussis vaccination, and a finding of lymphocytosis
on a laboratory examination.

 A clinical case of pertussis is defined as one of the following :

An acute coughing illness that lasts at least 14 days in a person with at least
one characteristic pertussis symptoms ( i.e. paroxysmal cough, posttussive
vomiting, or inspiratory whoop)
A cough that lasts at least 14 days in an outbreak setting.

A confirmed case is defined as one of the following :

Any cough illness in which B. pertussis is isolated and cultured
A case consistent with the clinical case definition confirmed by PCR assay
findings or epidemiologic linkage to a laboratory confirmed case

 Leukocytosis ( 15.000 50.000 /microlitre ) with absolute lymphocytosis

occurs during the late catarrhal and paroxysmal phases. It is a non-specific
finding but correlates with the severity of the disease.
Culture specimen should be obtained by using deep nasopharyngeal
aspiration or by holding a flexible swab (Dacron or calcium alginate) in the
patients posterior nasopharynx for 15-30 seconds or until a cough is
produced.
The media preferred include Bordet-Gengou agar and modified StainerScholler media and should be promptly inoculated. B. pertussis usually
grows after 3-4 days. However, negative results can only be considered
until after 10 days.

PERTUSSIS
CLINICAL FEATURES

 The incubation period averages 7-14 days (maximum of 3 weeks). B. pertussis

invades respiratory mucosa, increasing the secretion of mucus, which is initially
thin and later viscid and tenacious.
Uncomplicated disease lasts about 6-10 weeks and consists of :
- Catarrhal phase
- Paroxysmal phase
- Convalescent phase

 The catarrhal stage begins insidiously, generally with sneezing,

lacrimation, or other signs of coryza; anorexia; listlessness; and a
troublesome, hacking nocturnal cough that gradually becomes diurnal.
Hoarseness may occur. Fever is rare.
Usually lasts for ca. 1 2 weeks.

 The paroxysmal phase begins with an increase in the severity and

frequency of the cough. Repeated bouts of 5 or more rapidly consecutive
forceful coughs occur during a single expiration and are followed by a
whoop a hurried, deep inspiration.
Copious viscid mucus may be expelled or bubble from the nares during or
after the paroxysms. Posttussive vomitting is characteristic.
In infants, choking spells (with or without cyanosis) may be more common
than whoops.
Usually lasts for 1-6 weeks, but may persists for up to 10 weeks.

 Symptoms diminish as the convalescent phase begins recovery is

gradual.
The cough becomes less paroxysmal and disappears in 2-3 weeks.
However, paroxysms often recur with subsequent respiratory infections
for many months after the onset of pertussis.

PERTUSSIS
TREATMENT

 Supportive care
Erythromycin or azithromycin

 Hospitalization with respiratory isolation is recommended for seriously ill

infants. Isolation is continued until antibiotics have been given for 5 days.
In infants, suction to remove excess mucus from the throat may be
lifesaving. O2 and tracheostomy or nasotracheal intubation is occasionally
needed. Expectorants, cough suppressants, and mild sedation are of little
value. Because any disturbance can precipitate serious paroxysmal
coughing with anoxia, seriously ill infants should be kept in a darkened,
quiet room and disturbed as little as possible. Patients treated at home
should be quarantined, particularly from susceptible infants, for at least 4
wk from disease onset and until symptoms have subsided.
Antibiotics given during the catarrhal stage may ameliorate the disease.
After paroxysms are established, antibiotics usually have no clinical
effect but are recommended to limit spread. Preferred drugs are
erythromycin 10 to 12.5 mg/kg po q 6 h (maximum 2 g/day) for 14 days or
azithromycin 10 to 12 mg/kg po once/day for 5 days. Antibiotics should
also be used for bacterial complications (eg, bronchopneumonia, otitis
media).

PERTUSSIS
PREVENTION

 Active immunization is part of standard childhood vaccination. Five doses

of vaccine are given (usually combined with diphtheria and tetanus [DTP
or DTaP]) at age 2, 4, and 6 mo; boosters are given at 15 to 18 mo and 4 to
6 yr. Significant adverse effects from the pertussis component of the
vaccine include encephalopathy within 7 days; seizure, with or without
fever, within 3 days; persistent, severe, inconsolable screaming or crying
for 3 h; collapse or shock within 48 h; fever 40.5 C within 48 h; and
immediate severe or anaphylactic reaction. These reactions
contraindicate further use of pertussis vaccine; combined diphtheria and
tetanus vaccine is available without the pertussis component. The
acellular vaccine (DTaP) is better tolerated.
Immunity after natural infection lasts about 20 yr. Passive immunization is
unreliable and is not recommended.
Close contacts < 7 yr who have had < 4 doses of vaccine should be
vaccinated. Contacts of all ages, whether vaccinated or not, should receive
a 10-day course of erythromycin 500 mg po qid or 10 to 12.5 mg/kg po
qid.

CEREBRAL PALSY
PATHOGENESIS

 Cerebral Palsy (CP) ?

A group of disorders of the development of movement and posture
causing activity limitations that are attributed to non-progressive
disturbances that occurred in the developing fetal or infant brain.
The motor disorders of cerebral palsy are often accompanied by
disturbances of sensation, cognition, communication, perception, and/or
behaviour, and/or a seizure disorder.

 Major events in human brains development and their peak times of

occurrence include the following :

Primary neurulation weeks 3-4 of gestaion

Prosencephalic development months 2-3 of gestation
Neuronal proliferation months 3-4 of gestation
Neuronal migration months 3-5 of gestation
Organisation month 5 of gestation to years postnatal
Myelination birth to years postnatal

CEREBRAL PALSY
APPROACH CONSIDERATIONS

 The management of patients with CP must be individualized based on

the childs clinical presentation and requires a multidisciplinary
approach. Rehabilitation is a comprehensive intervention strategy
designed to facilitate adaptation to and participation in an increasing
number and variety of settings in a particular society and cultures.
Neurologists and rehabilitation medicine specialists (physicitrists) play
significant roles in the management of antispasticity medications. The
physicians responsibility is to closely supervise and manage the multiple
medical complications associated with CP.
In addition, seizure disorders are common in persons with CP. Thus, the
clinician should be comfortable with the management of anticonvulsant
medications.

TB MENINGITIS
COMPLICATIONS

 TBRM (Tuberculous radiculomyelitis) is a complication of TBM that has

been reported only rarely in the modern medical literature. It develops at
various intervals after TBM, even in adequately treated patients after
strerilization of the CSF.
The most common symptoms are subacute paraparesis, radicular pain,
bladder disturbance, and subsequent paralysis.

TB MENINGITIS
PREVENTION

 BCG vaccination offers a protective effect (approx. 64%) against TBM.

Improvement in weight for age was associated with a decreased risk of the
disease. However, further studies are needed to evaluate the association,
if any, between nutritional status and vaccine efficiency.