INFEKSI SALURAN PERNAFASAN AKUT (ISPA)

Dr. Fifi Sofiah, SpA

Infeksi Saluran Pernafasan Akut (ISPA)

Acute Respiratory Infection (ARI): 1. Acute Upper Respiratory Infection (AURI):

- Cold - Otitis media- Pharyngitis

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 % hospitalizationDeveloping 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 AGETEKNAF, BANGLADESH, 1982-1985

0

20

40

60

80

100

120

140

1-5 6-11 12-23 24-35 36-50

Age in Months

Deaths per 1000 children

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

ARI (26.9%)

Measles (2.4%)

Diarrhoea/measles (1.9%)

Diarrhoea (22.8%)

Other (33.1%)

Malaria (6.2)

ARI/Malaria (1.6%)

ARI/Measles (5.2%)

Malnutrition(29%)

RISK FACTORS FOR PNEUMONIAOR DEATH FROM ARI

Increaserisk of

ARI

Malnutrition, poorbreast feeding

practices

Vitamin A deficiency

Low birth weight

Cold weatheror chilling

Exposure to air pollution• Tobacco smoke• Biomass smoke• Environmental air pollution

Lack of immunization

Young age

Crowding

High prevalenceof nasopharyngealcarriage ofpathogenic bacteria

Magnitude of the Problemin 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)

PneumoniaClassifications

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

0

10

20

30

40

50

S Pneumoniae H Influenzae S Aureus

BACTERIA ISOLATED FROM LUNG ASPIRATESIN 370 UNTREATED CHILDREN WITH PNEUMONIA

%

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

602 - 12 months 501 - 5 years 40

Chest Indrawing(subcostal retraction)

Integrated Management Childhood Illness (IMCI)

Classification Sign/Symptom Management

Severe Pneumonia Tachypnea (+)Chest indrawing (+)

Refer

Pneumonia Tachypnea (+)Chest indrawing (-)

Antibiotic

Cough Not Pneumonia

Tachypnea (-)Chest indrawing (-)

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 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

Amphycillin Chloramphenicol or Gentamycin

Intra Venous Fluid Drip Oxygen Detection and management of

complications

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

EtiologyPredominantly RSV (Respiratory Syncytial Virus), adenovirus etc.

DiagnosisEtiological diagnosis Microbiologic examination Clinical diagnosis Signs and symptoms Age Resource of infection

Bronchiolitis

Clinical Manifestationscough, cold, fever, fast breathing, retraction, wheezing, irritable, vomitus, poor intake

Physical Examinations tachypnea, tachycardia, retraction, expiration >, wheezing, fever, pharyngitis, conjunctivitis, otitis media.

Bronchiolitis

Radiologic examinationdiffuse hyperinflation flat diaphragm, subcostal > retrosternal space >

peribronchial infiltratespleural effusion (rare)

Bronchiolitis

Management Supportive Severe disease

hospitalizationintra venous fluid dripoxygen(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

Thank you