ACUTE

RESPIRATORY
INFECTIONS
Pneumonia
Bronkiolitis
Bronkitis Akut
 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 24-35 36-50
Ag e i n M on t h s
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%)

Malnutrition
(29%)
Other (33.1%)

ARI/Measles (5.2%)
Measles (2.4%)
Diarrhoea/measles
(1.9%)

Diarrhoea (22.8%)
 RISK FACTORS FOR PNEUMONIA
OR DEATH FROM ARI
Malnutrition, poor
breast feeding
practices
Lack of immunization Vitamin A deficiency

Young age Low birth weight

Increase
risk of
ARI
Cold weather
Crowding or chilling

High prevalence Exposure to air pollution

of nasopharyngeal • Tobacco smoke
carriage of • Biomass smoke
pathogenic bacteria • 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
Staphylococcus, Klebsiella
 destruction of tissues  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)
 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)
Female girl, 6,5 y cxr interstitial infiltrates, ec S pneumoniae: IgG
pneumolysin increased Leucocytosis 29800, ESR 35 mm/h I, CRP 9 mg/l.
Male boy, 1,9 y, cxr alveolar infiltrates in right lobe ec. S pneumoniae: IgG
pneumolysin increased, leucocytosi 13.800, ESR 125/h I, CRP 332 mg/l.
Female girl, 2,8 y, cxr alveolar infiltrates in lower left lobe ec. rhinovirus:
leucocytosis 17700, ESR 64 mm/h I, CRP 128 mg/l.
Female infant, 0,3 y, cxr. alveolar infiltrates in upper right lobe ec parainfluenza and
human herpes virus, leucocytois 17000, ESR 8 mm/ h l, CRP 22 mg/l
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
 Procain Pennicilline, Chloramphenicol
 Amoxycillin + Clavulanic Acid
Intra Venous Fluid Drip
Oxygen
Detection and management of
complications
 WHO recommendations for treatment of infants less 2
months who have cough or difficulty breathing

No pneumonia : No tachypnea, no severe chest

indrawing
Do not administer an antibiotic

Severe pneumonia : Tachypnea or severe chest

indrawing
Admit, administer benzylpenicillin
+ gentamycin, and oxygen
WHO recommendations for treatment of children aged 2
months
to 4 years who have cough or difficulty breathing

No pneumonia : No tachypnea, no chest indrawing

Do not administer an antibiotic

Pneumonia : Tachypnea, no chest indrawing

Home treatment with cotrimoxazole,
amoxicillin or procaine penicillin

Severe pneumonia : Chest indrawing, no cyanosis,

and able to feed. Admit; administer
benzylpenicillin i.m. every 6 h

Very severe pneumonia :Chest indrawing with cyanosis and

not able to feed Admit; administer
chloramphenicol i.m. every 6 h
and oxygen
 Initial empirical treatment based
on age and severity of pneumonia

Outpatients
Age Inpatients (Moderate) Inpatients (Severe)
(Mild to Moderate)

Amoxicillin with or
Ceftriaxone or cefotaxime
3 - 6 mos without clavulanate Ceftriaxone or cefotaxim
+ vancomycin
Erythromycin

6 mos Amoxicillin with or Ceftriaxone, cefotaxime,

Ceftriaxone or cefotaxime
to without clavulanate or
+ macrolide + vancomycin
5 yrs Erythromycin Cefuroxime + macrolide

5 – 18 yrs Macrolide Ceftriaxone or cefotaxime Ceftriaxone or cefotaxime

+ macrolide + macrolide + vancomycin

Hsiao G et al, 2001

 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

Pathology
 Necrosis of the resp. epithelium
 Destruction of ciliated epithelial cells
 Peribronchial infiltration with lymphocites & neutrophils
 Sub mucosal edematous
 No destruction of collagen, muscle, or elastic tissue

Pathophysiology
Edema + accumulation of mucous & cellular debris 
narrow of peripheral airway  partially / totally
occluded  over distention / atelectasis
 …Bronchiolitis

Etiology
 Predominantly RSV (Respiratory Syncytial
Virus)
 Other viruses : rhinovirus, adenovirus,
influenza virus, parainfluenza virus, entero
virus, etc.
Severity
 Prematurity OR 1.84
 Underlying medical condition OR 2.84
 Group A RSV strain OR 3.26
 Age < 3 mo OR 4.39
 …Bronchiolitis

Diagnosis
 Etiological diagnosis
Microbiologic examination
 Clinical diagnosis
Signs and symptoms
Age
Resource of infection  epidemic of RSV
 Laboratory finding
 Radiological examination
 …Bronchiolitis

Clinical Manifestations : mild rhinorrhea,

cough, cold, low-grade fever
1-2 d  fast breathing, chest retraction,
wheezing, irritable, vomitus, poor intake
Physical Examinations
tachypnea, tachycardia, retraction,
prolonged expiration, wheezing,
fever,pharyngitis, conjunctivitis, otitis media,
dehydration
 …Bronchiolitis
Radiologic examination
diffuse hyperinflation
 flat diaphragm,
 Intercostal space >
 retrosternal space >
peribronchial infiltrates / thickening
patchy atelectasis  segmental collapse
pleural effusion (rare)
Laboratory finding
 Respiratory rate  : Arterial saturation 
pCO2 
 …Bronchiolitis

Laboratory finding
 Microbiologic examination
 WBC : 5000 – 24.000 cells/mm3, predominantly
PMN & bands
 Blood Gas Analysis
Arterial saturation 
pCO2 
Mild respiratory alkalosis
Metabolic acidosis
Acute respiratory acidosis
 …Bronchiolitis
Management
 Mild  treated at home
 Moderate / severe disease  hospitalization
support : oxygen
intra venous fluid drip
(antibiotics)
detect & treat possible complication
prevent the spread of inf.
 Controversial : bronchodilator
corticosteroid
antiviral
antibiotic
 …Bronchiolitis

Natural history & complications

 Regeneration of bronchiolar epithelium after 3
or 4 d
 Cilia after 3 or 4 d
 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
 Bronkitis akut

radang bronkus akut

umumnya disertai radang akut saluran
napas bawah lainnya
Tidak pernah berdiri sendiri
Trakeobronkitis akut = Bronkitis
 Istilah yang membingungkan

Bronkitis kapiler (Capillary Bronchitis)

 Bronkitis

 Pneumonia interstitial

Bronkitis asmatika
 Salah satu bentuk asma
 Etiologi Bronkitis akut
Umum : virus
Spesifik
 Influenza
 Pertusis
 Campak (morbilli)
 Salmonella
 Difteria
 Scarlet fever
 Predisposisi dan faktor yang
berpengaruh

Asap rokok
Alergi
Cuaca
Keadaan umum yang jelek (Poor health)
Infeksi kronik alat napas atas
 Pemeriksaan fisis
Panas : (-) (+) (-)
Mukosa : - nasofaringitis
- konjungtivitis
- rhinits virus
Suara napas kasar
Ronki basah kasar halus
Mengi (Wheezing)
SPUTUM : Jernih beberapa hari keruh

5-10 hari

Batuk hilang jernih

 Gejala dan tanda lain bronkitis akut

Rasa tidak enak di bawah tulang dada :

Seperti terbakar sakit
Suara napas berbunyi seperti siulan
Sesak
Muntah
 Penanggulangan bronkitis akut
Simptomatis
Pengeluaran lendir/sputum :
 Posisi tidur diubah-ubah
 Jaga kelembaban udara
 Sering minum
Kodein : hati-hati ! (sangat jarang
diperlukan)
Antihistamin : Hati-hati Atropin like effect
 Bronkitis akut
Ekspektoran : tidak perlu
Antibiotika :
 Tidak ada gunanya

 Indikasi

Bronkitis akut berulang

Ada komplikasi
 Komplikasi bronkitis akut
Otitis
Sinusitis
Pneumonia
Terutama kalau gizi buruk
 Batuk kronik berulang
pada anak: bronkitis kronik tidak ada

dasar : - penyakit paru

- penyakit sistemik

DD/ D/
 Komponen refleks batuk
Reseptor Aferen Pusat batuk Eferen Efektor

Laring Cabang nervus

vagus Otot,
Laring, trakea
Trakea
dan bronkus
Bronkus Nervus vagus
Tersebar merata
Telinga
di medula dekat
Pusat pernapasan :
Lambung
di bawah kontrol
Pusat yang Diafragma, otot-otot
Nervus Frenikus,
Hidung Nervus lebih tinggi Interkostal &
Interkostal,
Sinus paranasalis trigeminus abdominal
lumbaris
& otot lumbal
Saraf-saraf
Nervus Otot saluran napas
Faring Trigeminus, Fasialis
dan otot bantu napas
glosofaringus Hipoglosus,dll
Perikardium
Nervus frenikus
diafragma