Gawat Darurat Paru

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Oea Khairsyaf Gawat Darurat Paru

Transcript of Gawat Darurat Paru

Gawat Darurat Paru

123Asma serangan akut

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7Gejala danBerat Serangan AkutKeadaanTandaRinganSedangBeratMengancam jiwaSesak napasBerjalanBerbicaraIstirahatPosisiDapat tidur terlentangDudukDuduk membungkuk Cara berbicara Satu kalimat Beberapa kataKata demi kataKesadaranMungkin gelisahGelisahGelisahMengantuk, gelisah, kesadaran menurunFrekuensi napas 30/menitNadi< 100100 120> 120BradikardiaPulsus paradoksus-10 mmHg+ / - 10 20 mmHg+> 25 mmHg-Kelelahan ototOtot Bantu Napas dan retraksi suprasternal-++Torakoabdominal paradoksalMengiAkhir ekspirasi paksaAkhir ekspirasiInspirasi dan ekspirasiSilent ChestAPE> 80%60 80%< 60%PaO2> 80 mHg 80-60 mmHg< 60 mmHgPaCO2< 45 mmHg< 45 mmHg> 45 mmHgSaO2> 95%91 95%< 90%9

Ventilasi-perfusi tidak padu padanHiperinflasi paruVentilasi tak seragamObstruksi jalan napasHipoventilasi alveolusb.konstriksi, edema, hipersekresiGangguan compliancePaO2 PaCO2v.konstriksi pulmonalAsidosisSurfaktanAtelektasisKerja napasPatofisiologi Serangan AsmaBronkokonstriksiEdemaHipersekresiPaCO2 AsidosisPaO2 Tujuan tatalaksana serangan asmaMenghilangkan gejala secara cepat dan tepat Fungsi paru kembali normalPasca serangan: evaluasi ulangMengurangi Hipoksia

PENATALAKSANAAN SERANGAN ASMA DI RUMAH SAKIT

15Penilaian Ulang setelah 1 jam Pem.fisis, saturasi O2 dan pemeriksaan lain atas indikasi16

Serangan AsmaNebulisasi 1-2 xBaikPulangBronkodilatorRespons sebagianOne Day CareOksigenNebulisasiSteroid Oral IVFDBaikTidak responsPulangRawat InapOksigenNebulisasiIVFD: rehidrasiSteroid sistemik Aminofilin-Agonis Ideal 2 agonistRapid onsetLong duration of actionFull AgonistMinimal doseMinimal side effect-Agonis +Ipr bromida-Agonis +Ipr bromidaSerangan SedangRespons baik: PulangRespons parsial terhadap terapi Rawat ODCOksigenSteroid oral IVFDNebulisasi ulang: agonis + ipratropium bromidaRespons buruk: Rawat OksigenMengurangi hipoksia Nebulisasi-agonis + Ipratropium brMengurangi perawatanKerja obat lebih lama

IVFDHidrasiObat parenteralSteroidSistemikMengurangi inflamasi AminofilinInisial: 6-8 mg/kgBB bolus 20 mntMaintenans: 0,5-1 mg/kgBB/jamS E RANGANB E RA T

1. Ward M. J. et al. Br. J. Dis. (1985) 79, 374 - 373. SUPERIOR BRONCHODILATIONSalbutamol + Ipratropium Parasympathetic PathwayAtrovent Theophylline Beta agonistsBeta 2 receptorsCholinergicreceptorsSympatheticPathway Atrovent+ It therefore appears that in acute severe asthma it is beneficial to use drugs which act in different ways: salbutamol stimulating beta-adrenoceptors and Ipratropium bromide blocking parasympathetic receptorsIDEALCOMBINATIONIDEALCOMBINATIONIDEALCOMBINATIONPenggunaan ipratropium bromida saja: inferior dibanding beta-2 agonis mula kerja lambatPenggunaan bersama 2 agonis : menguntungkanmempercepat mula kerja memperpanjang efek bronkodilator Kombinasi salbutamol - ipratropium brSchuh, 1995Penggunaan IPR + agonis 3x vs agonis 2x, IPR yg ke 3, pada asma beratIPR + agonis bersamaan sejak awal perbaikan klinis & fungsi paru lebih baikQureshi, 1998 ; Zorc, 1999Pada serangan asma berat dan sedang pemberian IPR pada dosis ke 2 dan 3 dari inhalasi salbutamol (Qureshi) & 3 dosis (Zorc)----Terjadi perbaikan faal paru, penurunan skor asma, penurunan perawatan rumah sakit bermakna vs monoterapi salbutamolManfaat kombinasi salbutamol + ipratropium

Naspitz CK., Journal of Asthma 1992, 29(4),253-258

Reisman J et.al. J Allergy Clin. Immunol 81,16-20 (1988)

ODriscoll BR Nebulized Salbutamol with & without Ipratropium Bromide, Lancet June 24, 1418-1420 (1989)

Combinasi salbutamol-antikolinergik lebih superior meningkatkan FEV1 dibanding salbutamol sajaGarrett JE, J. Allergy Clin Immunol 1997;100:165-7028KEY POINTS:Spirometry is the best tool for the early identification of COPD in high risk patients.Full function tests [PFTs] are not requiredSpirometry allows the physician to:define the patients condition as obstructive or restrictive [or a combination of the two]define the severity of the conditiondetermine degree of reversibility to bronchodilators

Combinasi memberikan respons lebih nyata vs salbutamol sajaGarrett JE, J. Allergy Clin Immunol 1997;100:165-7029KEY POINTS:Spirometry is the best tool for the early identification of COPD in high risk patients.Full function tests [PFTs] are not requiredSpirometry allows the physician to:define the patients condition as obstructive or restrictive [or a combination of the two]define the severity of the conditiondetermine degree of reversibility to bronchodilators

Nakanishi AK, et al. Chest 2003;124:790-4.Perry TT, et al. Pediatrics 2004;114:543-4; Yung M, et al. Arch Dis Child 1998;79:405-10; Ream RS, et al. Chest 2001;119:1480-8.Keuntungan Bentuk MDI aerosol Turbohaler dry powder Handihaler dry powder Nebulisasi nebules (jet/ultrasonik) Bekerja langsung pada saluran napas Mula kerja cepat Dosis obat yang dipakai kecil Efek samping obat minimal

TERAPI INHALASI :33There is much that can be done to accurately diagnose and care for people suffering from COPD, but physicians need to be aware of the risk factors and symptoms, use spirometry when COPD is suspected, and explore treatment options, both pharmacologic and non-pharmacologic. The Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease can be a useful support tool for clinical decisions when caring for these individuals. Alat ini mengubah obat yang berbentuk larutan menjadi aerosol secara terus menerus atau berselang dengan tenaga yang berasal dari udara yang dihisap penderita melalui mouthpiece atau masker

Efektivitas obat dengan nebulizer masuk sampai ke paru: 20-30%

Alat nebulizer NEBULISASI:

34KEY POINTS:Spirometry is the best tool for the early identification of COPD in high risk patients.Full function tests [PFTs] are not requiredSpirometry allows the physician to:define the patients condition as obstructive or restrictive [or a combination of the two]define the severity of the conditiondetermine degree of reversibility to bronchodilators

SALBUTAMOLIPRATROPIUM BROMIDA2,5 MG0,5 MGDalam 1 UDV( Unit Dose Vial )35There is much that can be done to accurately diagnose and care for people suffering from COPD, but physicians need to be aware of the risk factors and symptoms, use spirometry when COPD is suspected, and explore treatment options, both pharmacologic and non-pharmacologic. The Guidelines for the Treatment of Chronic Obstructive Pulmonary Disease can be a useful support tool for clinical decisions when caring for these individuals. Edema paru363945ParameterEdema paru kardiogenik

Edema paru non kardiogenikRiwayat penyakitKardiak akut++ / -Pemeriksaan fisikCardiac outputS3 GallopJugular vena distensiRonkiPenyakit dasar non cardiac yang mendasarinya, Co ; sepsisLow flow(perifer dingin)++Basah-High flow(perifer hangat)--Kering+Pemeriksaan penunjangEKGRO thoraxEnzim cardicTekanan kapiler paruIskemi/infark/LVHPerihilar distribusiMungkin meningkat 18 mmHgBiasanya normalPeripheral distribusiBiasanya normal< 18 mmHg58Gagal Napas65Keterlibatan parenkim difusEdema paru kardiogenikARDSSindrom emboli lemakEdema paru neurogenikTenggelam ( near drowning)Pneumonia bilateral yang disebabkan olehBateri ( S. aureus, P. aeroginosa, legiolela, H influenza, MycoplasmaVirus: influenza, CMV, Varicella, adeno virus, RSV, parainfluenzaParasit : Pneumocystis cariniiInfiltratifFibrosis paruInfiltrative tumorReaksi sitotoksik obatLain-lain: reaksi taransfusi, aspirasi isi lambung, trauma inhalasi dan salisilatKeterlibatan parenkim :efusi pleura, atelektasis, pneumonia, trauma paruTanpa keterlibatan parenkim: pneumotoraks, emboli paru, pirau intrakardial, asma, penyakit paru obstruktif kronik ( PPOK)Peningkatan kebutuhan metabolisme : sepsis, syok , excessive feeding68Kerusana pengaturan sentralStruktur al:StrokePerdarahan intra cranialInfiltrasi tumorKeracunan obat: obat-obat paralitik, aminoglikosida, racun organofosfatInfeksi: botulisme, tetanus, poliomyelitisPenyakit neuromuscular:Sidroma Gullian- Barre, miatenia gravis, sclerosis amiotropik lateral, distrofi muscularKelelahan otot respiraasiKelumpuhan saraf frenikus: bedah torak, infiltrasi tumor mediastinumGanggua metabolismMalnutisi, hipofosfatemia, hipokalemia, hiponagesemia, hipokalsemiaDeformitas dinding dada: kifoskoliosis, pectus exccava, flail chest, sidrom hipoventilasi, kegemukanDistensi abdomen massif; asites, obesitasObstruksi jalan napas :Tumor endobronkial Paralisi pita suaraObstructive sleep apnea70Gagal napas dapat disebabkan oleh ARDS, hipertensi, tromboemboli, emboli air ketuban., asma akut berat

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