REHABILITASI MEDIK

PADA KASUS GANGGUAN PERNAPASAN

AKIBAT BENCANA
Dr. dr. Nury Nusdwinuringtyas, Sp KFR-K, M.Epid
dr. Peggy, Sp KFR
 Dr. dr. Nury Nusdwinuringtyas, SpKFR-K,
MEpid
Organisation :
• PERDOSRI
• IDI
• Club Jantung Sehat
• RESPINA
• IKLASI (Ikatan Kedokteran Laser
Indonesia)
Email : nury_nus@yahoo.com
Fanpage :
• Catatan Nury
• Nury’s Keynotes
Weblogs :
• http://nury-nus.blogspot.com
• http://rehab-med.blogspot.com
• http://rehab-med-research.blogspot.com
• http://tanpa-pita-suara.blogspot.com
Link Youtube:
• http://laryngectomees.blogspot.com
• https://www.youtube.com/channel/UCwQTZz-AgpWKq2s0bXZU9MQ
Pendahuluan
Data Badan Nasional Penanggulangan Bencana (BNPB)
Kejadian bencana
• Tahun 2015 : 1.694 Jenis bencana:
1. Bencana hidrometeorologi
• Tahun 2016 : 2.306 2. gempa bumi
3. kebakaran hutan dan lahan
• Tahun 2017 : 2.866 4. kekeringan
• Tahun 2018 : 3.397
• Tahun 2019 : 3.622
• Tahun 2020 : 2.818
http://gis.bnpb.go.id/
Pendahuluan
 Mechanics of Inspiration and forced expiration

Neumann, D. A. (2010). Kinesiology of the musculoskeletal system: Foundations for rehabilitation. St. Louis, Mo: Mosby/Elsevier.
 Integrated Spinal Stabilizing System
• The integrated spinal stabilizing system (ISSS) is
comprised of balanced co-activation between
the deep cervical flexors and spinal extensors
in the cervical and upper thoracic region, as well
as the diaphragm, pelvic floor, all sections of
the abdominals and spinal extensors in the
lower thoracic and lumbar region.
• The diaphragm, pelvic floor and transversus
abdominis regulate intra abdominal pressure
and provide anterior lumbopelvic postural
stabilityà provide dynamic stability of the
spine (“deep core”)
Frank C, Kobesova A, Kolar P. Dynamic neuromuscular stabilization & sports rehabilitation. Int J Sports Phys Ther. 2013;8(1):62-73.
Pendahuluan

https://med.libretexts.org/
TRAUMA INHALASI
ASPIRASI AIR
TRAUMA DINDING DADA
Trauma Inhalasi
• Pasca bencana asap
• Kebakaran Gedung
• Pencemaran kimia/radioaktif
 Trauma inhalasi
• Paparan berbagai macam bentuk • Angka mortalitas
zat kimia terhadap organ paru àakibat trauma inhalasi :11 %.
àasap, àakibat kerusakan paru :
àgas, 30-90%
àuap air panas, atau àé menjadi 60% apabila terjadi
àuap hasil pembakaran. komplikasi pernapasan

1. Shubert J, Sharma S. Inhalation Injury. 2020 Nov 21. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan
2. Kubo T, Osuka A, Kabata D, et al. Chest physical therapy reduces pneumonia following inhalation injury. Burns : Journal of the International Society for Burn Injuries. 2020 Jul.
Gangguan Fungsi Pernapasan Akibat Trauma
Inhalasi

• Katarzyna Reczyńska, Priyanka Tharkar, Sally Yunsun Kim, Yiwei Wang, Elżbieta Pamuła, Hak-Kim Chan, Wojciech Chrzanowski. Animal models of smoke inhalation injury and related
acute and chronic lung diseases. Advanced Drug Delivery Reviews. Vol 123. 2018. 107-134.
• Otterness, Karalynn & Ahn, Christine & Nusbaum, Jeffrey & Gupta, Nachi. (2018). Emergency Department Management of Smoke Inhalation Injury in Adults [digest]. Emergency
medicine practice. 20. 1-2.
• Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J Trauma Resusc Emerg Med. 2013 Apr 19;21:31.
 Gangguan Fungsi Pernapasan Akibat Trauma
Inhalasi

Enkhbaatar P, Pruitt BA Jr, Suman O, et al. Pathophysiology, research challenges, and clinical
management of smoke inhalation injury. Lancet (London, England). 2016 Oct;388(10052):1437-1446.
Aspirasi Air
• Bencana Banjir
• Tsunami
Aspirasi Air
• Aspirasi air

1. Tenggelam (drowning) adalah mati lemas karena saluran napas atas terendam media cair
(biasanya berupa air)

2. Hampir tenggelam (near drowning) adalah kondisi mampu bertahan hidup minimal untuk
sementara setelah cairan teraspirasi ke dalam organ paru.

• Komplikasi paru (pneumonia aspirasi, acute respiratory distress syndorome) : akibat aspirasi air

1. F. St C. Golden, M. J. Tipton And R. C. Scott. Immersion, Near-drowning And Drowning. Br. J. Anaesth. 1997; 79: 214.225
2. Pierro MM, Bollea L, Di Rosa G, Gisondi A, Cassarino P, Giannarelli P, Gentile M, Morocutti A, Ossella MT, Talone L, Stortini M. Anoxic brain injury following near-drowning in children.
Rehabilitation outcome: three case reports. Brain Inj. 2005 Dec;19(13):1147-55.
 Gangguan Fungsi Pernapasan Akibat Aspirasi
Air

1
Gangguan fungsi organ paru
berupa:
2 1. Pulmonary thoracic
compliance
2. Intra-lung shunt
3 3. Alveolar decruitment
4

Cerland L, Mégarbane B, Kallel H, Brouste Y, Mehdaoui H, Resiere D. Incidence and Consequences of Near-Drowning–Related Pneumonia—A Descriptive Series from
Martinique, French West Indies. International Journal of Environmental Research and Public Health. 2017; 14(11):1402.
Trauma Dinding Dada
• Bencana Gempa
• Likuifaksi
• Longsor
• Angin puting beliung
Trauma Dinding Dada
• Trauma dinding dada dibedakan menjadi dua tipe:
1. Cedera penetrasi (tembus): cedera yang merusak
integritas kulit dan jaringan lunak rongga dada

2. Cedera tumpul : cedera yang menyebabkan

kerusakan organ dan struktur di bawah jaringan

• Bekir Nihat Dogrul , Ibrahim Kiliccalan, Ekrem Samet Asci, Selim Can Peker. Blunt trauma related chest wall and pulmonary injuries: An overview. Chinese Journal of Traumatology
*

23 (2020) 125e138
• van Aswegen, Helena. "Physiotherapy management of patients with trunk trauma: A state-of-the-art review." South African Journal of
Physiotherapy.2020;76.1
Gangguan Fungsi Pernapasan Akibat Trauma
Dinding Dada

van Aswegen, Helena. "Physiotherapy management of patients with trunk trauma: A state-of-the-art review." South African Journal of
Physiotherapy.2020;76.1
Gangguan Fungsi Muskuloskeletal Akibat
Trauma Dinding Dada
Impairments Causes of impairment
Limited in active shoulder joint and trunk range of pain from rib fractures, presence of ICD tubing and
motion (ROM) distention of the abdomen
temporary weakness of the arm on the affected side compression of ICD tubing on the first thoracic nerve
of the thorax of which the superior part joins the brachial plexus or
compression on the third to sixth intercostal nerves
which affects serratus posterior muscle action
rotective side-flexed trunk posture towards the pain from rib fractures, ICD or postoperative
affected side of the thorax
protective flexed trunk posture postoperative abdominal pain
generalised muscle wasting and weakness and poor Major trauma
cardiorespiratory exercise endurance

van Aswegen, Helena. "Physiotherapy management of patients with trunk trauma: A state-of-the-art review." South African Journal of Physiotherapy.
2020;76.1
PR0GRAM
 Asesment Rehabilitasi Paru

DeLisa Physical Medical and Rehabilitation. Fifth edition Vol 1

 Asesmen ICF

Bui KL, Nyberg A, Maltais F, Saey D. Functional Tests in Chronic Obstructive Pulmonary Disease, Part 1: Clinical Relevance and Links to the International Classification of Functioning, Disability, and
Health. Ann Am Thorac Soc. 2017 May;14(5):778-784.
 Uji Fungsional

Bui KL, Nyberg A, Maltais F, Saey D. Functional Tests in Chronic Obstructive Pulmonary Disease, Part 1: Clinical Relevance and Links to the International Classification of Functioning, Disability, and
Health. Ann Am Thorac Soc. 2017 May;14(5):778-784.
Trauma Inhalasi
 Asesmen Fungsi Paru
The Effect of a Pulmonary Rehabilitation on Lung Function and Exercise Capacity in Patients with
Burn: A Prospective Randomized Single-Blind Study

Won YH, Cho YS, Joo SY, Seo CH. The Effect of a Pulmonary Rehabilitation on Lung Function and Exercise Capacity in Patients with Burn: A Prospective Randomized Single-Blind Study. J Clin Med. 2020 Jul 15;9(7):2250. PMC7409013.
 Diagram for subject
enrollment, allocation
and follow up

Won YH, Cho YS, Joo SY, Seo CH. The Effect of a Pulmonary Rehabilitation on Lung Function and Exercise Capacity in Patients with Burn: A Prospective Randomized Single-Blind Study. J Clin Med. 2020 Jul 15;9(7):2250. PMC7409013.
Tatalaksana Rehabilitasi Medik Akibat Trauma Inhalasi
Fase Akut
• Terapi Fisik Dada
1. Manual expiratory rib cage compression
2. Postural drainage
3. Cough exercise
• Terapi Latihan
1. Latihan pernapasan
2. Latihan lingkup gerak sendi
3. Latihan penguatan dan ketahanan otot
4. Latihan mobilisasi dan ambulasi
Kubo T, Osuka A, Kabata D, et al. Chest physical therapy reduces pneumonia following inhalation injury. Burns : Journal of the International Society for Burn
Injuries. 2020 Jul.
Tatalaksana Rehabilitasi Medik Akibat Trauma Inhalasi
Post Akut
• Terapi Latihan (Circuit Training)
1. Latihan pernapasan dengan atau
tanpa alat
2. Latihan kebugaran kardiorespirasi
3. Latihan penguatan dan ketahanan
otot

Kubo T, Osuka A, Kabata D, et al. Chest physical therapy reduces pneumonia following inhalation injury. Burns : Journal of the International Society for Burn
Injuries. 2020 Jul.
 Tatalaksana Rehabilitasi Medik Akibat Trauma Inhalasi
No. Nama Peneliti Judul Penelitian Subjek Penelitian Intervensi Hasil

1. Kubo T, Osuka A, Chest 139 pasien Kelompok intervensi diberikan program Angka kejadian pneumonia lebih
Kabata D, Kimura M, physical therapy may trauma inhalasi di terapi fisik dada dan terapi latihan rendah dan lama rawat lebih
Tabira K, Ogura H reduce pneumonia unit perawatan konvensional (20-40 menit setiap hari pendek pada kelompok
following inhalation injury intensif hingga pasien keluar dari rumah sakit) intervensi dibandingkan kontrol
(2020) Kelompok kontrol hanya diberikan terapi
latihan konvensional (20 menit setiap hari
hingga pasien keluar dari rumah sakit)
2. Yu Hui Won , Yoon Soo The Effect of a Pulmonary 120 pasien Kelompok intervensi diberikan program Terdapat perbaikan bermakna
Cho , So Young Joo, Rehabilitation on Lung trauma inhalasi rehabilitasi respirasi. (latihan sirkuit: latihan pada peak cough flow, maximal
Cheong Hoon Seo Function and Exercise setelah fase akut aerobik, latihan penguatan, dan latihan inspiratory pressure,
Capacity in Patients with (rawat jalan) pernapasan) diaphragmatic mobility, dan
Burn: A Prospective Kelompok kontrol diberikan rehabilitasi diffusing capacity for carbon
Randomized Single-Blind konvensional (latihan aerobik). monoxide pada kelompok
Study ( Intervensi 5 hari /minggu selama 12 minggu. intervensi dibandingkan kontrol
3. Amal. M. Abd El Baky, Efficacy of 12-week 30 pasien anak Kelompok intervensi diberikan program Terdapat perbaikan bermakna
Sahar. M. Adel Pulmonary Rehabilitation dengan trauma rehabilitasi respirasi. (latihan aerobic VO2 max dan treadmill time
Program on Exercise inhalasi (1 bulan menggunakan treadmill, latihan diafragma, pada kelompok intervensi
Capacity of Burned setelah keluar latihan peregangan, latihan penguatan otot)
Children: A Randomized dari rumah sakit) Kelompok kontrol diberikan rehabilitasi
Control Study (2013) konvensional (latihan diafragma, latihan
peregangan, latihan penguatan otot).
Intervensi 3 hari /minggu selama 12 minggu.

1. Kubo T, Osuka A, Kabata D, et al. Chest physical therapy reduces pneumonia following inhalation injury. Burns : Journal of the International Society for Burn Injuries. 2020 Jul.
2. Won YH, Cho YS, Joo SY, Seo CH. The Effect of a Pulmonary Rehabilitation on Lung Function and Exercise Capacity in Patients with Burn: A Prospective Randomized Single-Blind Study. J Clin Med. 2020 Jul 15;9(7):2250.
3. Abd El Baky, Amal & Adel, Sahar. (2013). Efficacy of 12-week Pulmonary Rehabilitation Program on Exercise Capacity of Burned Children: A Randomized Control Study.
Aspirasi Air
 Tatalaksana Rehabilitasi Medik Akibat Aspirasi
Air
Tujuan:
1. Pemulihan fungsi sistem respirasi (mempercepat proses weaning
ventilator, mencegah fibrosis paru, meningkatkan fungsi oksigenasi
dan ventilasi, serta meningkatkan ekspansi dinding dada)
2. Meningkatkan kapasitas latihan à kapasitas fungsional
3. Meningkatkan kualitas hidup

Hsieh MJ, Lee WC, Cho HY, Wu MF, Hu HC, Kao KC, Chen NH, Tsai YH, Huang CC. Recovery of pulmonary functions, exercise capacity, and quality of life after pulmonary
rehabilitation in survivors of ARDS due to severe influenza A (H1N1) pneumonitis. Influenza Other Respir Viruses. 2018 Sep;12(5):643-648.
 Tatalaksana Rehabilitasi Medik Akibat Aspirasi
Air
Program rehabilitasi respirasi terdiri dari:
• Positioning
• Latihan Kontrol Pernapasan dan Latihan Pernapasan
• Latihan Mobilisasi Dada
• Latihan ketahanan kardiorespirasi dan otot
• Latihan Mobilisasi dan Ambulasi
• Program rehabilitasi neuromuscular sesuai dengan komplikasi
neurologis pasien

Hsieh MJ, Lee WC, Cho HY, Wu MF, Hu HC, Kao KC, Chen NH, Tsai YH, Huang CC. Recovery of pulmonary functions, exercise capacity, and quality of life after pulmonary
rehabilitation in survivors of ARDS due to severe influenza A (H1N1) pneumonitis. Influenza Other Respir Viruses. 2018 Sep;12(5):643-648.
Trauma Dinding Dada
Tatalaksana Rehabilitasi Medik Akibat Trauma
Dinding Dada
• Mengoptimalkan fungsi sistem respirasi
1. Edukasi
2. Teknik relaksasi
3. Teknik splinting
4. Positioning
5. Latihan pernapasan (latihan diafragma, latihan pernapasan terlokalisasi di sisi
yang cedera, latihan pernapasan costal bilateral lateral, incentive spirometry)
6. Latihan batuk, ACBT, dan teknik ekspirasi paksa à disesuaikan dengan kondisi
pasien (??)
7. Latihan mobilisasi thoraks, bahu, dan ekstremitas atas
8. Mobilisasi di sekitar bed, berjalan, dan naik turun tangga
9. Terapi modalitas TENS
van Aswegen, Helena. "Physiotherapy management of patients with trunk trauma: A state-of-the-art review." South African Journal of Physiotherapy.
2020;76.1
Tatalaksana Rehabilitasi Medik Akibat Trauma
Dinding Dada
• Mengoptimalkan fungsi sistem musculoskeletal
1. Latihan lingkup gerak sendi thoraks dan ekstremitas
2. Latihan Aktivitas Kehidupan Sehari-hari mandiri
3. Latihan penguatan dan ketahanan otot
4. Latihan ketahanan kardiorespirasi
5. Latihan mobilisasi bertahap

van Aswegen, Helena. "Physiotherapy management of patients with trunk trauma: A state-of-the-art review." South African Journal of Physiotherapy.
2020;76.1
Data
Data Kebakaran Hutan Riau Oktober 2019
(Perdosri Cabang Sumatera 2)
UMUR KELUHAN BORG SKALA PFR PCF SO2 ETCO2 RR/HR
22 tahun - 9/0/2 320 / 330 / 350 330 / 340 / 360 97% 11 24 / 70
36 tahun - 9 / 0,5 / 0 380 / 400 / 430 410 / 440 / 430 98% 24 24 / 93
25 tahun - 11 / 0,5 / 0 520 /690 / 690 370 / 440 / 370 97% 30 26 / 87
30 tahum flu 7/2/2 400 / 380 / 420 330 / 320 / 370 99% 27 19 / 79
29 tahun - 7 / 0 / 0,5 510 / 520 / 590 520/ 420 / 420 97% 21 24 / 70
39 tahun merasakan bau 13 / 4 / 5 180 / 200 / 270 380 / 360 / 390 97% 13 27 / 72
asap
26 tahun demam, batuk, flu 9 / 0 / 0,5 300 / 310 / 370 270 / 270 / 330 96% 18 24 / 90
26 tahun - 0/0/0 330 / 330 / 320 270 / 310 / 310 99% 17 20 / 86
24 tahun sakit tenggorokan - 430 / 360 / 450 290 / 270 / 270 98% 18 24 / 72

26 tahun - - 520 / 530 / 540 540 / 440 / 520 97% 24 20 / 65

24 tahun - 0/0/0 400 / 390 / 410 450 / 480 / 460 99% 24 29 / 82
28 tahun - 1/1/1 360 / 370 / 400 300 / 340 / 350 98% 21 20 / 93
23 tahun - 2/2/2 380 / 350 / 390 400 / 350 / 360 99% 32 20. / 78
29 tahun - 0/0/0 370 / 350 / 380 230 / 250 /250 99% 22 20. / 67
 Data Kebakaran Hutan Riau Oktober 2019
(Perdosri Cabang Sumatera 2)
49 tahun - 0/0/0 390 / 430 / 430 230 / 350 /450 98% 24 11 / 79
29 tahun - 0/0/0 450 / 470 / 510 500 / 510 / 470 98% 26 22 / 91
67 tahun terasa oyong dan cepat 2 / 2 / 2 250 / 270 / 300 110 / 160 / 220 98% 23 18 / 84
lelah
27 tahun - 0/0/0 300 / 310 / 360 270 / 210 / 250 99% 24 20 / 75
23 tahun batuk sedikit 2/2/2 310 / 310 / 330 300 / 250 / 250 99% 25 18 /75
45 tahun flu 0,5 / 0,5 / 0,5 400 / 410 / 430 359 / 350 / 380 98% 27 16 / 98
30 tahum batuk dan flu 0,5 / 0,5 / 0,5 430 / 550 / 560 580 / 600 /600 98% 33 20 / 93
26 tahun sesak nafas 0,5 / 0,5 / 0,5 370 / 380 / 380 400 / 400 / 420 99% 25 15 /89
29 tahun sesak nafas 3/3/3 400 / 330 / 370 400 / 420 /420 99% 28 18 / 105
35 tahun flu 0,5 / 0,5 / 0,5 390 / 500 / 470 440 / 450 / 360 99% 36 18 /70
23 tahun batuk 0/0/0 440 / 500 / 500 450 / 500 / 500 99% 17 24 /84
27 tahun kepala pusing, 0,5 / 0,5 / 0,5 530 /400 /450 400 / 440 / 430 99% 24 18 / 73
tenggorokan gatal
49 tahun sulit menelan dan sesak 5 / 5 / 5 220 /210 /220 240 / 310 / 270 88,97% 22 28 /105
nafas
17 tahun sesak nafas 0,5 / 0,5 / 0,5 280 / 350 / 350 97% 21 16 / 88
19 tahun pusing 0,5 / 0,5 / 0,5 300 / 310 / 290 310 / 330 /330 98% 27 18 / 77
35 tahun pusing 0,5 / 0,5 / 0,5 450 / 380 / 390 390 / 380 / 400 97% 29 18 / 71
38 tahun mata perih dan pusing 1 / 1 / 1 450 / 480 / 510 450 / 430 / 450 99% 21 19 / 91
32 tahun sesak nafas kepala 2 / 2 / 2 310 / 340 / 400 400 / 400 / 350 99% 27 -
pusing
10 tahun pusing, mual 0,5 / 0,5 / 0,5 200 / 240 / 240 250 / 290 / 290 18 -
Kebakaran Hutan Riau Oktober 2019
(Perdosri Cabang Sumatera 2)

• Dr Tengku Lia SpKFR

• Dr Putri Alfaridi SpKFR

Two minute step test
Two Minute Step Test
Film
Penelitian Rikli, Jones
Range of scores between the 25% and 75% percentiles
Age Number of steps – Women Number of steps – Men
60 - 64 75-107 87-115
65 - 79 73-107 86-116
70 - 74 68-101 80-110
75 - 79 68-100 73-109
80 - 84 60-90 71-103
85 - 90 55-85 59-91
90 - 95 44-72 52-86

Scores less than 65 were associated with lower levels of functional ability
 Data Poli Rawat Jalan two minute step test
No Tgl Pemeriksaan Usia Jenis Kelamin 2 minute step test Assesment
Sat HR
Sat Pre HR pre Post Post
1 12/12/20 19 thn Laki-laki 99 110 99 115 Para parese endurance berkurang
2 12/12/20 61 thn Laki-laki 98 70 98 91 Endurance membaik untuk anggota gerak bawah
02/01/21 98 71 98 97 Anggota gerak atas. overhead saturasi menurun
3 18/12/20 73 thn Laki-laki 96 92 98 105Pro CABG
4 21/12/20 51 thn Laki-laki 98 91 97 120 Post CABG dengan endurance membaik
Endurance perbaikan rencana peg board and ring
02/01/21 97 78 98 104 test
5 29/12/20 51 thn Perempuan 97 82 93 107Deconditioning
05/01/21 91 77 80 105 Endurance dan keseimbangan kurang
Penurunan saturasi setelah di uji .
6 12/01/21 67 thn Laki-laki 99 91 99 125Post CABG dengan endurance menurun