croup kuliah 2006
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SINDROMA “CROUP”
B.RUDYANTOB.RUDYANTO
Divisi Respirologi Bagian Ilmu Kesehatan AnakDivisi Respirologi Bagian Ilmu Kesehatan Anak
FK UHT/RSAL DR. RAMELANFK UHT/RSAL DR. RAMELAN
SurabayaSurabaya
DefiniDefinisi Sindroma CROUPsi Sindroma CROUP
Kelompok penyakit pada laring, Kelompok penyakit pada laring, trakea dan bronkustrakea dan bronkus
Terutama disebabkan virusTerutama disebabkan virus CCiri khas : iri khas : batuk, suara parau, batuk, suara parau,
stridor inspiratoirstridor inspiratoir
ISPA ATAS•Common cold
•Faringitis
•Sinusitis
•Otitis media
•CROUP
ISPA BAWAH
•Bronkitis
•Bronkiolitis
•Pneumonia
Epidemiologi Sindroma CROUP
•Usia terbanyak : 3 bulan- 4 tahun•Gejala klinis berat dibawah usia 3 tahun•Anak laki-laki lebih sering•Lama sakit : 5 – 6 hari•Puncak : musim dingin/ hujan
Croup: Epidemiologi
PATOFISIOLOGI SINDROMA CROUP
INFEKSIINFEKSI
MEKANISMEKANIS
ALERGIALERGI
SPASME + SEMBAB LARINGSPASME + SEMBAB LARING
OBSTRUKSI SALURAN NAPASOBSTRUKSI SALURAN NAPAS
ATASATAS
PatogenesisPatogenesis Sindroma CROUP Sindroma CROUP
Penyempitan subglotis karena Penyempitan subglotis karena inflamasi.inflamasi.
““Cricoid ring” menyebabkan Cricoid ring” menyebabkan penyempitan.penyempitan.
Pembengkakan 1mm Pembengkakan 1mm menyebabkan obstruksi 65% pada menyebabkan obstruksi 65% pada bayi.bayi.
PatogenesisPatogenesis Sindroma CROUP Sindroma CROUP
Atelektasis/mucus pluggingAtelektasis/mucus plugging Ventilation/perfusion mismatchVentilation/perfusion mismatch Tekanan negatif intrapleura Tekanan negatif intrapleura
menyebabkan edema paru.menyebabkan edema paru. Hipoksia/hiperkarbiaHipoksia/hiperkarbia
PENYEBAB SINDROMA CROUP
INFEKSI : terbanyak infeksi virusINFEKSI : terbanyak infeksi virus
Bakteri : H. influenza , C.diphteriBakteri : H. influenza , C.diphteri
Virus: P. influenza 1,2,3, Infuenza,Virus: P. influenza 1,2,3, Infuenza,
Adeno, Entero, RSV, morbilli Adeno, Entero, RSV, morbilli
. MEKANIK: Benda asing. MEKANIK: Benda asing
Pasca pembedahanPasca pembedahan
Penekanan masa ekstrinsikPenekanan masa ekstrinsik . ALERGI : Sembab angioneurotik. ALERGI : Sembab angioneurotik
Penyebab CROUP: Infeksi.....
GEJALA KLINIS SINDROMA CROUP
MULAI SUARA SERAK,MULAI SUARA SERAK, BATUK MENGGONGGONGBATUK MENGGONGGONG STRIDOR INSPIRATOIRSTRIDOR INSPIRATOIRBILA OBSTRUKSI > STRIDOR >>BILA OBSTRUKSI > STRIDOR >>JIKA PAYAH : STRIDOR MELEMAHJIKA PAYAH : STRIDOR MELEMAH
RETRAKSI SUPRAKLAVIKULAR,SUPRASTERNAL,RETRAKSI SUPRAKLAVIKULAR,SUPRASTERNAL, INTERKOSTAL,EPIGASTRIALINTERKOSTAL,EPIGASTRIAL
HIPOKSIA GELISAH, JIKA PAYAH : DIAMHIPOKSIA GELISAH, JIKA PAYAH : DIAMBERTAMBAH BERAT : GAGAL NAPASBERTAMBAH BERAT : GAGAL NAPAS
Anatomi & Etiologi Stridor
ExtratExtratorakalorakal• SupraglotSupraglotisis
–Epiglotitis, Epiglotitis, abses abses retroretroffararinging, di, diffteriateria
• GlotiGlotiss & Subgloti & Subglotiss–Croup, larCroup, lariingomalangomalassia, traia, trakkeomalaeomalassia, ia,
paralysisparalysis pita suara pita suara IntratoraIntratorakalkal
–Vascular rings/webs, Vascular rings/webs, Benda asingBenda asing, , penekanan karena tumor/ kelenjar getah penekanan karena tumor/ kelenjar getah beningbening
Grading of Stridor
Grade 1Grade 1 Inspiratory obstruction only. A dry Inspiratory obstruction only. A dry barking barking cough, but the cry is not affectedcough, but the cry is not affected
Grade 2Grade 2 Inspiratory and mild expiratory Inspiratory and mild expiratory obstruction obstruction (i.e. expiratory stridor and/or (i.e. expiratory stridor and/or prolonged prolonged expiration)expiration)
Grade 3Grade 3 Inspiratory and active expiratory Inspiratory and active expiratory obstruction (i.e. visible or palpable contraction of the obstruction (i.e. visible or palpable contraction of the abdominal muscles), or pulsus paradoxicus abdominal muscles), or pulsus paradoxicus (pulse (pulse at wrist becomes softer on inspiration)at wrist becomes softer on inspiration)
Grade 4Grade 4 Marked retractions, apathy, cyanosisMarked retractions, apathy, cyanosis
Continued...
Grading of Stridor (Contd…)
Croup of Grade 2 or greater Croup of Grade 2 or greater requires treatment in hospital. requires treatment in hospital. Remember that this grading Remember that this grading assesses degree of obstruction assesses degree of obstruction to breathing and not the stridor. to breathing and not the stridor. Stridor may become softer as Stridor may become softer as the obstruction increases.the obstruction increases.
5 PENYAKIT CROUP OLEH KARENA INFEKSI
LARINGITIS DIFTERIALARINGITIS DIFTERIA EPIGLOTITIS AKUTAEPIGLOTITIS AKUTA LARINGITIS AKUTALARINGITIS AKUTA LARINGOTRAKEOBRONKITIS LARINGOTRAKEOBRONKITIS
AKUTAAKUTA LARINGITIS SPASMODIKLARINGITIS SPASMODIK
EPIGLOTITIS AKUT
• DEFINISI : KERADANGAN AKUT EPIGLOTIS,• BIASA DISEBABKAN OLEH INFEKSI
BAKTERI
= BACTERIAL CROUP
= SUPRAGLOTTIC CROUP• ETIOLOGI :TERBANYAK H. INFLUENZA B• UMUR : 3 – 7 TAHUN• MERUPAKAN KEADAAN GAWAT DARURAT,
DIAGNOSIS HARUS SECEPAT MUNGKIN• TERAPI YANG CEPAT DAN TEPAT, DAPAT
MENURUNKAN KEMATIAN
EpiglotitisEpiglotitis
Etiologi:
Haemophilus influenza
GEJALA KLINIS EPIGLOTITIS :
- MENDADAK PANAS TINGGI
- STRIDOR INSPIRATOIR + RETRAKSI
CEPAT TIMBUL
- NYERI EPIGLOTIS : SUARA KECIL (PELAN), NYERI TELAN
- “TOKSIS”, SAKIT KERAS, TAKUT , “NGILER “,
GELISAH, SIANOSIS
- EPIGLOTIS BENGKAK DAN MERAH SEPERTI
BUAH CHERRY
- DAPAT CEPAT TERJADI : GAGAL NAPAS
Epiglotitis
GbrGbr kiri: Obstruksi total saluran napas ataskiri: Obstruksi total saluran napas atas
Gbr kanan: Saluran napas terbuka setelahGbr kanan: Saluran napas terbuka setelah
dilakukan intubasidilakukan intubasi
Do Do notnot look in throat look in throatDo Do notnot use obstructed airway maneuver use obstructed airway maneuver
DIAGNOSIS EPIGLOTITIS:
- GEJALA KLINIS - PEMERIKSAAN FISIK - FOTO LEHER LATERAL: OBSTRUKSI SUPRAGLOTIS KARENA PEMBENGKAKAN EPIGLOTIS (THUMB SIGN)
LABORATORIUM: LEKOSIT MENINGKAT,
PERGESERAN KE KIRI
HAPUSAN TENGGOROKAN +
BIAKAN DARAH :
H. INFLUENZAE TIPE B
Comparison of the Features of Epiglottitis and
Croup CharacteristicCharacteristic EpiglottitisEpiglottitis CroupCroup
AgeAge Any ageAny age 6months-12yrs6months-12yrs
OnsetOnset SuddenSudden GradualGradual
LocationLocation SupraglotticSupraglottic SubglotticSubglottic
TemperatureTemperature High feverHigh fever Low-grade feverLow-grade fever
DysphagiaDysphagia SevereSevere Mild or absentMild or absent
DyspneaDyspnea PresentPresent PresentPresent
DroolingDrooling PresentPresent PresentPresent
CoughCough UncommonUncommon Characteristic coughCharacteristic cough
PositionPosition Leaning forward, Leaning forward, mouth openmouth open
comfortablecomfortable
X-RayX-Ray Thumb signThumb sign Steeple signSteeple sign
Foto Leher AP dan lateral
Thumb Sign
Can be found in normal childrenOnly seen in 50% with epiglottitis
Can be seen in all children during inspirationSeen in less than 50% of Croup cases
Steeple Sign
TATALAKSANA EPIGLOTITIS AKUT :
MRS DI ICU
-CAIRAN I.V. + O2 + UAP + STEROID
-ANTIBIOTIKA: AMPISILIN 100 MG/KG/24 JAM IV, 4 X SEHARI
ATAU KLORAMFENIKOL : 50 MG/KG/24JAM IV,
4 X SEHARI
ATAU SEFALOSPORIN GEN 3 (CEFOTAKSIM ATAU
CEFTRIAKSON )
-ANTIPIRETIK
-SERING : MEMERLUKAN TRAKEOSTOMI
LARINGITIS AKUT / LARINGO-TRAKEO-LARINGITIS AKUT / LARINGO-TRAKEO-BRONKITIS AKUTABRONKITIS AKUTA
DEFINISI: Keradangan pada laring/ laring-trakea-DEFINISI: Keradangan pada laring/ laring-trakea-
bronkusbronkus
ETIOLOGI: penyebab >>> virus,ETIOLOGI: penyebab >>> virus,
70% V. Para influenza, V ,Influenza, 70% V. Para influenza, V ,Influenza,
adenovirus , RSV, V. morbilliadenovirus , RSV, V. morbilli
UMUR : 3 bulan – 5 tahunUMUR : 3 bulan – 5 tahun
PADA LTB : dapat terjadi infeksi sekunder karenaPADA LTB : dapat terjadi infeksi sekunder karena
bakteribakteri
GEJALA KLINIS LARINGITIS AKUTA
SERING PADA ANAK, BIASANYA RINGANSERING PADA ANAK, BIASANYA RINGAN SELALU DIDAHULUI ISPA ATASSELALU DIDAHULUI ISPA ATAS GEJALA KLINIS : PANAS, PILEK,BATUK 2 – 3 GEJALA KLINIS : PANAS, PILEK,BATUK 2 – 3
HARI, MENDADAK SUARA PARAU, BATUKHARI, MENDADAK SUARA PARAU, BATUK
MENGGONGGONG, STRIDOR INSPIRATOIRMENGGONGGONG, STRIDOR INSPIRATOIR KESUKARAN NAPAS : TIDAK BERATKESUKARAN NAPAS : TIDAK BERAT FARING : HIPERAEMIFARING : HIPERAEMI
GEJALA KLINIS LARINGO-TRAKEO-BRONKITIS AKUT
PENYAKIT MENJALAR KE BRONKUSPENYAKIT MENJALAR KE BRONKUS
KESUKARAN BERNAPAS >>>KESUKARAN BERNAPAS >>>
PANAS PANAS
FISIS : TANDA-TANDA BRONKITISFISIS : TANDA-TANDA BRONKITIS
DIAGNOSIS LA/LTBA
BERDASARKAN GEJALA KLINISBERDASARKAN GEJALA KLINIS
PEMERIKSAAN FISISPEMERIKSAAN FISIS X FOTO LEHER : PEMBENGKAKAN JARINGAN X FOTO LEHER : PEMBENGKAKAN JARINGAN
SUBGLOTISSUBGLOTIS LABORATORIUM: DARAH : NORMALLABORATORIUM: DARAH : NORMAL
JIKA INF. SEKUNDER BAKTERIJIKA INF. SEKUNDER BAKTERI
LEKOSITLEKOSIT
DIAGNOSIS LA/LTBA
Foto leher AP:
“steeple sign”
Tatalaksana LA / LTBTatalaksana LA / LTB
UAPUAP• NaCl fisiologisNaCl fisiologis
Nebulisasi Recemic EpinephrineNebulisasi Recemic Epinephrine• Gd II + stridorGd II + stridor
DEDEKSKSAMETASONAMETASON• IV / IIV / IM M / PO / PO – 0.6 mg/kg– 0.6 mg/kg• NEBNEBULISASI BUDESONIDEULISASI BUDESONIDE / FLUTIKASON/ FLUTIKASON• PREDNISOLONPREDNISOLON
TATALAKSANA LA/LTBA
UMUMNYA TIDAK PERLU MRSUMUMNYA TIDAK PERLU MRS LA: TIDAK PERLU ANTIBIOTIKALA: TIDAK PERLU ANTIBIOTIKA LTBA: DAPAT DIBERI PENISILIN +/ KLORAMF.LTBA: DAPAT DIBERI PENISILIN +/ KLORAMF. UAP/NEBULASI:BILA ADA RACEMIC EPINEFRINUAP/NEBULASI:BILA ADA RACEMIC EPINEFRIN ANTIPIRETIK : BILA PERLUANTIPIRETIK : BILA PERLU SAKIT BERAT: MRS : O2 +UAP, CAIRAN IVSAKIT BERAT: MRS : O2 +UAP, CAIRAN IV AMPISILIN IVAMPISILIN IV STEROID: DEKSAMETASON IVSTEROID: DEKSAMETASON IV 0,5 mg/kg/24 jam, 3 X/hari 1-2 hari0,5 mg/kg/24 jam, 3 X/hari 1-2 hariJARANG : TRAKEOSTOMIJARANG : TRAKEOSTOMI
SPASMODIC LARYNGITIS(ALLERGIC CROUP, PSEUDO CROUP )
ETIOLOGI : VIRUSETIOLOGI : VIRUS
ALERGIALERGI
FAKTOR PSIKOLOGISFAKTOR PSIKOLOGIS UMUR : 1 - 3 TAHUNUMUR : 1 - 3 TAHUN KLINIS: Bisa pilek/serak atau tanpa pilek/serakKLINIS: Bisa pilek/serak atau tanpa pilek/serak
malam batuk menggonggong,stridor insp, malam batuk menggonggong,stridor insp,
gelisah, tanpa panasgelisah, tanpa panas
gejala : pagi berkurang, malam menghebatgejala : pagi berkurang, malam menghebat
berulang-ulang, ada predisposisi keluargaberulang-ulang, ada predisposisi keluarga
SPASMODIC LARYNGITIS
DIAGNOSIS: KLINIS DAN PEMERIKSAAN DIAGNOSIS: KLINIS DAN PEMERIKSAAN FISIS, LABORATORIUM : NORMALFISIS, LABORATORIUM : NORMAL
PENGOBATANPENGOBATAN
Tidak perlu rawat inap, tidak perlu Tidak perlu rawat inap, tidak perlu
antibiotikaantibiotika
Yang penting : pemberian uapYang penting : pemberian uap
SSeringkalieringkali setelah muntah, laringospasmussetelah muntah, laringospasmus
hilanghilang
CaseCase
An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation
The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier
CaseCase
An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation. No resp. Distress.
The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier
Mild disease, doesn’t need admission
Case
An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation
The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier
Mild disease, doesn’t need admission
Bronchodialators not indicated in Croup
CaseCase
An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation
The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier
Mild disease, doesn’t need admission
Bronchodialators not indicated in Croup
antibiotics if there is an indication
Case
An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation
The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier
Treatment of choice for mild croup despite lack of
supporting evidence
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