PNEUMONIA PADA ANAK : DIAGNOSIS DAN TATA LAKSANA

PNEUMONIAPADAANAK:DIAGNOSISDANTATALAKSANA

AyuSetyoriniMMayangsari

DEFINISI•  Pneumoniaadalahinflammasiparenkimparuygdisebabkanolehresponterhadapinvasimikroorganisme

FAKTORRISIKOFAKTORSOSIALEKONOMI/

LINGKUNGAN

-  SOSIALEKONOMIKURANG-  PENDIDIKANIBUKURANG

-  KESULITANMENCAPAIFASKES-  POLUSIUDARADALAMRUMAH

-  MALNUTRISI-  TIDAKMENDAPATASI-  PAPARANASAPROKOK

-  PADAREMAJA:PENGGUNAANALKOHOL,OBATDANROKOK

FAKTORPENYAKITDASAR

-  PENYAKITJANTUNGBAWAAN-  PENYAKITNEUROMUSKULAR(TERUTAMA

BILADISERTAIKESADARANMENURUN&KETERLAMBATANPERKEMBANGAN)

-  DEFISIENSIUMUMPRIMERATAUDIDAPAT-  GANGGUANGIT(GER,TEF)

-  ASMA-  BRONCHOPULMONARYDYSPLASIA

-  DIABETESMELLITUS-  CYSTICFIBROSIS

-  ANEMIASICKLECELL

ETIOLOGIMIKROORGANISME

•  Dipengaruhiolehfaktorusia

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Table 25.1Most Common Agents Causing Community-Acquired PneumoniaAccording to Age Group

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KLASIFIKASIPNEUMONIABERDASARKANASALMIKROORGANISME

•  PNEUMONIAKOMUNITAS–  PneumoniapadaanaktanpariwayatMRSdalam2mingguterakhir,atau

–  PadaanakyangMRS<48jam

•  PNEUMONIARUMAHSAKIT–  PneumoniapadaanakdenganriwayatMRSdalam2mingguterakhir,atau

–  PadaanakyangMRS>48jamdimanasaatMRStidakadagejalarespirasi

PATOGENESISMIKROORGANISME

AspirasiInhalasiisi

cavumoralataugaster

Inhalasimelaluiudara

Hematogenous

FAKTORHOST

Sistemimmunitasparumenurun

FAKTORLINGKUNGAN

Kepadatan

Usia

Sosialekonomi

KOLONISASIMIKROORGANISME

INFEKSIUSDALAMSALURANNAPASBAWAH

pathogenesiscont’d

KOLONISASIMIKROORGANISMEPATOGENDALAMSALURANNAPASBAWAH

VIRUS

Akumulasiselmononukleardisubmukosadanperivaskular

Obstruksijalannapaspartial/komplit

BAKTERI

1.Kongesti

2.Hepatisasimerah

3.Hepatisasikelabu

4.Resolusi

1-2hari

2-4hari

4-7hari

•  Kongestikapilerdisertapenggantianudaradlmalveolidigantioleheksudatselular(neutrofil,limfosit)&bakteri

•  Eritrosit>>,neutrofil,deskuamasiselepitel,danfibrindalamalveoli

•  Kapileralveolarterisidarah(engorged)èkonsistensiparusepertihepar

•  Eritrositmengalamidisintegrasi/lisis&dominasieksudatfibrinopurulen

•  Makrofagmulaibermigrasikedalamalveolus

•  Parutampakabu-abukekuningan

•  Resorpsidanperbaikanstrukturparu•  Fagositosisselasingolehmakrofag

alveolar

1-2hari

3minggu

PATOFISIOLOGI

Fine

path,cont’dEfusipleura

Aliranudaraê

Ventilasiparutdkadekuat

MANIFESTASIKLINIS

GEJALAUMUM GEJALARESPIRASI

•  Irritable•  Nafsumakan/minummenurun•  Malaise•  Keluhansalurancerna•  Bilaberat:dehidrasi,kejang,kesadaranmenurun

manifestasicont’d

•  BatukDISERTAIdemamdandistressnapas•  Distressnapas:–  TakipneèBatasannormallajunapas:

•  <60x/mnt:<2bulan•  <50x/mnt:2sd12bulan•  <40x/mnt:1sd5tahun

–  Retraksidindingdada:subkostae,interkostae,suprasternal

–  Napascupinghidung–  Headnodding(kepalamengangguk-angguk),grunting

•  Auskultasi:crackle/rhalesbasahhalusdapatdisertaiwheezing

GEJALARESPIRASI

KLASIFIKASIDERAJATPNEUMONIAWHO

BUKANPNEUMONIA

PNEUMONIA:Batuk,demam,takipne,crackle

PNEUMONIABERAT:GejalaPNEUMONIAdisertaisalahsatudari-Retraksidindingdada-Napascupinghidung-Headnodding-Grunting-Sianosis-Dehidrasi-Lethargi-Kejang

RawatjalanRawatinap

PEMERIKSAANPENUNJANG

•  Saturasioksigen•  Darahlengkap•  RontgendadaPA/AP:– Konsolidasilobaris– Bercakinfiltrattersebarpadalapanganparu(bronkopneumonia)

–  Interstitial•  Biakansputumdan/ataudarah

RONTGENDADA

•  Indikasirontgendada:–  Gejalapneumoniaberat–  Gambaranklinismeragukan– Menyingkirkankemungkinanpenyebabdistressnapaslain(bendaasing,penyakitkardiopulmonallain)

–  Padasetiapanakdengandemamberkepanjangandanleukositosistanpasebabyangjelaswalaupuntelahdiberiantibiotikaempirikadekuat

•  Rodadatidakrutindilakukanpadaanakdenganpneumoniayangdapatdilakukanrawatjalan

RONTGENDADA

Konsolidasilobar

Retikularinterstitial

Posisi:bilaberumur>4thndansudahbisa

berdiri:PAPadaanaklbhmuda:

APLateraldekubitusbilaadakecurigaanefusi

pleura

Bronkopneumonia Pneumatocele

Normal

Airbron-cho-gram

KONSOLIDASILOBAR

Bercak2opasitasmultipelyang

konfluen

Tampakairbroncho-gram

Opasitastersebarsampaikeperifer,bilateral,dantidaksimetris

BRONKOPNEUMONIA

BERCAKBERBENTUK

SEPERTIBENANG(LINEAR,

RETIKULAR)YANGTERSEBAR

SAMPAIKEPERIFER

AERASIMASIHTERLIHAT

INTERSTITIAL

Massakistikberdin-dingtipisberisiudara

berbagaiukuran

PENATALAKSANAAN

•  Oksigenasi•  Hidrasi•  Antibiotika•  Bilawheezing:inhalasisalbutamol•  Terapisupportif:antipiretika,mukolitik

OKSIGENASI

•  Semuagejalapneumoniaberat•  Saturasioksigen<90%•  Konjungtivapucat(anemiaberat)

INDIKASI

CARAPEMBERIAN:-Nasalkanul,masker,CPAP,ventilator

LAJUALIRANMAKSIMUMMELALUINASALKANUL-  ½L/mnt:0-2bln-1L/mnt:2-12bln-  2L/mnt:1–5tahun-max4L/mnt

oksigenasicont’d

ANTIBIOTIKA

– Rawatjalan:Antibiotikaselama3-5hari•  Amoksisilin80-100mg/kgBB/haridibagi2dosis

atau•  Eritromisin40-60mg/kgBB/haridibagi3-4dosis

– Rawatinap:•  Linipertama:ampisilin50mg/[email protected]/kgBB@24jamselama5hari•  Linikedua:ceftriaxone25-50mg/kgBB@12jamselama5hari•  BilaadakecurigaaninfeksiolehS.aureus:Kloksasilin50mg/kgBB/6jam

INDIKASIPULANG

•  Distresnapasteratasi•  Tidakadahipoksia(saturasioksigen>90%)padasuhuruang

•  Dapatmakandenganbaik•  Dapatminumobatoralatautelahmenyelesaikanterapiantibiotikparenteral

•  Orangtuamemahamigejalapneumonia,faktorrisikodankapanharuskembali

KOMPLIKASI

•  Gagalnapas•  Effusipleura•  Empiema•  Pneumotorak,pneumomediastinum•  Absesparu•  Sepsis

61Journal of the Scientific Society, Vol 41 / Issue 1 / January-April 2014

Management of spontaneous pneumothorax in a newborn: A rare clinical entitySir,The sudden unexpected development of spontaneous pneumothorax in a full-term, apparently healthy infant is rarely seen, though it is a well-known complication of the respiratory distress syndrome and its therapy.[1] Spontaneous pneumothorax that occurs during this period is mostly associated with assisted ventilation, birth trauma, meconium aspiration or prematurity.[2] We report the occurrence of spontaneous pneumothorax in a 3.5 kg healthy neonate born by spontaneous vaginal delivery at 38 weeks gestation in the absence of any known predisposing factors. The prenatal course was unremarkable with no evidence of chorioamnionitis, oligohydramnios or any systemic infection. Amniotic fluid did not show any staining with meconium and Apgar scores were eight and nine at 1 and 5 min, respectively. After delivery, the baby was active and showed no sign of respiratory distress, but the baby suddenly became lethargic and pale without any preceding clinical event 6 h after birth.

On admission to neonatal emergency unit, the neonate was lethargic, pale and had a respiratory rate of 72 breath/min, heart rate 172 beats/min, CFT <3 s, but peripheral pulses were palpable. On examination, the anterior fontanelle was normal, SpO2 was 75% on room air and decreased breath sounds on the right side of the chest. The chest X-ray revealed pneumothorax on the right side with the shift to the left [Figure 1] while brain and abdominal sonograms were normal. The initial sepsis screen was negative, blood sugar and electrolytes were normal. The chest tube was inserted immediately on the right side and the baby had sudden improvement with SpO2 >92% and respiratory rate <60 breaths/min and patient started accepting breast feeds. The repeat chest X-ray revealed normal findings and the child was discharged after 5 days [Figure 2]. The occurrence of spontaneous pneumothorax in a healthy newborn is a rare entity.[3] Most neonatal pneumothorax, pneumomediastinum and surgical emphysema in the neck occurs as a result of birth injury, shoulder dystonia, prematurity, pneumonia, meconium aspiration syndrome or assisted ventilation.[3-5] However, during normal delivery, when the term baby passes through the vagina, there are potential chances of his thoracic cage being over-compressed during the delivery. Under such circumstances, the pressure gradient between the alveolar and perivascular space can increase abnormally for a transient period that may possibly lead to the rupture of the alveoli. However, this condition may manifest several hours after birth and respiratory distress may develop, which is considered to be the most important presenting sign, as has been noted in the present case. Though renal anomalies are commonly associated in neonates with

Figure 1: Chest X-ray revealing pneumothorax on the right side with the shift to the left

Figure 2: Chest X-ray revealing normal bilateral lung fields without any shift of the heart

lEttEr to Editor

[Downloaded free from http://www.jscisociety.com on Sunday, August 12, 2018, IP: 182.1.81.25]

Efusipleura Pneumothorak

Pneumomediatinum Absesparu

PENCEGAHAN

•  Carabatuk/bersindanmembuangdahakyangbenar

•  Mencucitangan•  DorongibumemberikanASIekslusif•  Nutrisicukup•  Imunisasisesuaijadwal

PNEUMONIA PADA ANAK : DIAGNOSIS DAN TATA LAKSANA

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