Best Practice of Pneumonia

Management in Pandemic Era

Retno Asih Setyoningrum

Respirology Working Group

Faculty of Medicine Airlangga University- Dr Soetomo Hospital
 Outline
• Defining Pneumonia
• Fundamental of pneumonia management
(pandemic area)
 Defining Pneumonia
1. Pathological definitions
2. Clinical definitions
3. Radiological definitions
4. Source of infections

Kim Mulholland Pneumonia in Children 2016

Nelson Textbook of Pediatrics 2020
 Defining Pneumonia…pathological definitions

• Gold standard definitions

• As alveolar inflammation involving a protein-
rich exudate, with polymorphs and later
lymphocytes or macrophages
• It’s classically described
– Bronchopneumonia
– Lobar pneumonia
• Little use in clinical practice
Kim Mulholland Pneumonia in Children 2016
Nelson Textbook of Pediatrics 2020
 Defining pneumonia…clinical definitions

• Clinical features result from the inflammatory

response
• Symptom and signs of infection: fever, malaise
• Symptom and signs of respiratory problem:
cough, takipnea/ rapid breathing,

Kim Mulholland Pneumonia in Children 2016

Nelson Textbook of Pediatrics 2020
 WHO Definitions of Clinical Pneumonia

• Presumed pneumonia : cough + fast breathing

• A broad definition to catch most children with
pneumonia who need antibiotics.
• Around 80% of true pneumonia cases will be identified
• In 2013 WHO revised : lower chest indrawing as a key
physical sign for pneumonia management
• WHO defines severe pneumonia : Cough OR breathing
difficulty with
– signs of severe respiratory distress OR
– one of the danger signs listed by WHO

Kim Mulholland Pneumonia in Children 2016

Nelson Textbook of Pediatrics 2020
Tabel 1. WHO Definitions of Pneumonia

WHO Pneumonia Cough + fast breathing OR lower

chest indrawing
WHO Severe Cough + hypoxaemia OR severe
Pneumonia respiratory distress OR danger sign
WHO Radiological Significant alveolar consolidation
Pneumonia on X-ray
ALRI Acute Respiratory Infection + signs
of lower airways disease
WHO 2013
Kim Mulholland Pneumonia in Children 2016
Apakah anak menderita batuk dan atau sukar bernapas?
Jika YA,

TANYAKAN : LIHAT, DENGAR dan PERIKSA :

Berapa lama ? •Hitung napas dalam
1 menit*
•Lihat apakah ada tarikan ANAK Klasifikasikan
dinding dada ke dalam HARUS BATUK atau
•Lihat dan dengar adanya TENANG
SUKAR
wheezing BERNAPAS
•Periksa dengan pulse
oximeter (jika ada) untuk
menilasi saturasi oksigen

Umur anak : Napas cepat apabila :

2 bulan - < 12 bulan 50 kali atau lebih per menit
12 bulan - < 5 tahun 40 kali atau lebih per menit
* Hitung napas dengan menggunakan ARI sound timer atau
arloji yang mempunyai jarum detik
(Kemenkes RI, 2018)
 GEJALA KLASIFIKASI TINDAKAN/PENGOBATAN
• Tarikan • Beri Oksigen maksimal 2-3 liter/menit dengan
dinding dada menggunakan nasal prong
ke dalam • Beri dosis pertama antibiotik yang sesuai
ATAU PNEUMONIA BERAT • RUJUK SEGERA **
• Saturasi
Oksigen <90%
• Nafas cepat • Beri amoksisilin 2x sehari selama 3 hr atau 5 hr
***
• Beri pelega tenggorokan dan pereda batuk yang
aman
• Obati wheezing bila ada
PNEUMONIA • Apabila batuk >14 hari RUJUK untuk
pemeriksaan lanjutan
• Nasihati kapan kembali segera
• Kunjungan ulang 2 hari

• Tidak ada • Beri pelega tenggorokan dan Pereda batuk yang

tanda-tanda aman
Pneumonia • Obati wheezing bila ada
Berat • Apabila batuk >14 hari rujuk untuk pemeriksaan
maupun BATUK BUKAN PNEUMONIA TB dan sebab lain
Pneumonia • Nasihati kapan kembali segera
• Kunjungan ulang 2 hari jika tidak ada perbaikan

(Kemenkes RI, 2018)

 Sensitivity and specificity of clinical signs for diagnosing
pneumonia in children

Clinical sign Sensitivity (95% CI) Specificity (95%CI)

Tachypnea 74(60-88) 67(56-77)

Chest indrawing 71(56-86) 59(49-68)
Tachyp.& chest indrawing 68(52-83) 69(58-79)
Tachyp.& rales 46(29-62) 83(74-91)
Rales 46(29-62) 79(70-87)
Tachyp, chest indrawing &Rales 43(26-59) 84(71-88)
Chest indrawing & rale 42(25-58) 80(71-88)

(Palafox et al., Arch Dis Child 2000;82 :41-5)

 Why do not use auscultation?
Use auscultation to confirm pneumonia in a child

Location Sensitivity
1.Baltimore, Maryland 43%
2.New Haven, Connecticut 33%
3.Nairobi, Kenya 66%
4.Boston, Massachusetts 57%

Note: compared to pneumonia confirmed by chest x-ray.

 Defining pneumonia…radiological definitions

• In clinical practice it is usually not necessary to

perform an X-ray to make a diagnosis of pneumonia
• Clinical definitions are preferred
• The X-ray is needed: more severe cases to identify
complications or abnormal features
• Peribronchial tickening or minor degree of interstitial
consolidation: common in children with minor illness
or no illness at all
• Many cases of severe pneumonia: minor X-ray
changes or none at all
Kim Mulholland Pneumonia in Children 2016
Nelson Textbook of Pediatrics 2020
 Radiological definition established by WHO

• Alveolar consolidation
• Less severe changes or
no changes at all will be
missed
• That are enrinched for
bacterial cases

WHO 2013
Kim Mulholland Pneumonia in Children 2016
Tabel 2. Radiological assesment of children diagnosed with non-severe
pneumonia on the basis of fast breathing alone by the three radiologists.
Values are number (%)

Radiologist Radiologist Radiologist

Radiological 1 2 3
classification (n = 1848) (n = 1848) (n = 371)
Normal 1496 (81) 1366 (74) 270 (73)
Pneumonia 259 (14) 416 (23) 87 (23)
Bronchiolitis 93 (5) 66 (4) 14 (4)

82% of non severe pneumonia patients: normal

results on chest X-rays

Hazir T, et al. BMJ 2006:1-4.

 CXR: is it enough with the AP photos?

• Lateral CXR is not routinely performed in

patients with pneumonia
• AP position
• Sensitivity 85%
• Specificity: 98%
 Laboratory Examination
• Platelet count can be considered as a significant indicator
of disease severity and outcome on evaluation of
hemogram values (CBC) rather than the commonly used
leukocyte count.
• Regarding CRP, the available data are conflicting to
differentiate bacterial and viral pneumonia. and
frequently difficult to interpret.
• Procalsitonin: the most effective both in selection of
bacterial cases and in evaluation of severity. However, a
precise cut-off level able to separate bacterial from viral
cases and mild from severe cases has not been defined.
Egyptian Journal of Chest Diseases and Tuberculosis (2015) 64, 617-623
Int. J. Mol. Sci. 2017
Tabel 3. Platelet and leukocyte ciunts in relation to in hospital mortality of 95
CAP patients.
Survival Non-survival P-value
(n = 75) (n = 20)
No. % No %
Platelet count 0.006*
Thrombocytopenia 2 2.7 3 15
Normal 56 74.7 8 40
Thrombocytosis 17 22.6 9 45
Leukocyte count 0.858
Normal 21 28 5 25
Leukocytosis 53 70.6 14 70
Leukopenia 1 1.3 1 5
*significant P-value

Both thrombocytopenia and thrombocytosis were significantly increased in

non survival (p <0.006), while there was no significant difference for the
number of leukocytes.
Fundamental of pneumonia
management
• The management of pneumonia: appropriate
antibiotics and supportive therapy
• The initial treatment is undertaken without
knowledge of the causing organism
• Most cases of pneumonia are caused by virus (RSV,
RV, InflV, Parainfl V, coronavirus àSARS CoV 2!!)
• Viral infection might predispose a child to bacterial
pneumonia
• Even when a viral cause has been identified : it is not
possible to rule out bacterial superinfection à
antibiotics still be used in most cases
 Pneumonia, etiology
§ Virus
§ Bacteria
§ Fungi
ØDepends on age
§ Atypical pathogen

Neonates 1-2 months 3-12 months 1-5 years >5 years

Streptococcus Chlamydia Viruses Viruses S pneumoniae
group B trachomatis
Enteric gram Ureaplasma Streptococcus S pneumoniae M
negative urealyticum pneumoniae pneumoniae

Viruses H influenzae Mycoplasma C pneumoniae

pneumoniae
Bordetella Staphylococcu Chlamydia
pertussis s aureus pneumoniae
Moraxella
catharrhalis
Disorders of resp tract in children, Kendig’s, 2012
Januari 2020 17 Februari 2020

JULI 2020
16 Maret 2020 27 Maret 2020
23
ORANG DALAM PEMANTAUAN
#1 DAN
Tidak ada penyebab lain
berdasarkan gambaran
klinis yang meyakinkan

SAKIT TENGGOROKAN
Demam/

PILEK
Riwayat
BATUK

demam ATAU ATAU ATAU

DAN
≥38oC
Pada 14 hari terakhir sebelum timbul
gejala memiliki riwayat perjalanan
atau tinggal di negara/wilayah yang
melaporkan transmisi
lokal*.
ORANG DALAM PEMANTAUAN
#2
GEJALA GANGGUAN
SISTEM PERNAPASAN

DAN
SAKIT TENGGOROKAN

Pada 14 hari terakhir sebelum timbul

PILEK

BATUK

ATAU ATAU gejala memiliki riwayat kontak

dengan kasus konfirmasi COVID-19
PASIEN DALAM PENGAWASAN (SUSPEK)
DAN
#1
Tidak ada penyebab lain

PNEUMONIA RINGAN -BERAT

SAKIT TENGGOROKAN
berdasarkan gambaran klinis

SESAK NAPAS
Demam/ yang meyakinkan
Riwayat

PILEK
ISP demam BATUK
DA DAN
A ≥38oC
N Pada 14 hari terakhir sebelum
timbul gejala memiliki riwayat
perjalanan atau tinggal di
negara/wilayah yang
melaporkan transmisi lokal*

Demam (≥38oC) atau riwayat demam atau ISPA DAN pada 14 hari terakhir sebelum timbul gejala
#2 memiliki riwayat kontak dengan kasus konfirmasi COVID-19.

Orang dengan ISPA berat/pneumonia berat** yang membutuhkan perawatan di rumah sakit DAN
#3 tidak ada penyebab lain berdasarkan gambaran klinis yang meyakinkan.
 ALAT PELINDUNG DIRI

Paket Paket Paket Paket Paket Paket Paket

1 2A 2B 3A 3B 4 5
LEVEL LEVEL 2 LEVEL
3 1
CDC
Preferred

28
Should the child be admitted to hospital?
• Many cases of pneumonia can be treated at
home
• The main reasons for admitting a child to hospital
are
– The need for parenteral antibiotics
– The possibility that child might deteriorate
– The need for intensive monitoring
– The need for oxygen
– Feeding support and/or intravenous fluids
– The need for invasive procedures
– WHO: presence of danger signs
 Management of outpatient pneumonia

• The management algorithm : IMCI

• WHO treatment recommendations
– Amoxicillin (40 mg/kg 2 times a day) for 5 days
with a high HIV infections rate
– Amoxicillin (40 mg/kg 2 times a day) for 3 days
with a low HIV infections prevalence
• Kemenkes 2018 : MTBS à Amoksisilin
• Assesment of treatment success : important
 PENGOBATAN DALAM BAGAN PENILAIAN DAN KLASIFIKASI
Untuk Pneumonia :
Beri Antibiotik Amoksisilin Oral
AMOKSISILIN 45mg/kgBB/kali
2x sehari selama 3 hari untuk Pneumonia
BERAT BADAN 2x sehari selama 5 hari untuk Pneumonia dengan klasifikasi HIV
SIRUP
Tablet (500mg)
125 mg/5mL 250 mg/5mL
4 - < 6kg 1/2 10 mL 5 mL
6 - < 10kg 3/4 15 mL 7,5 mL
10 - <16kg 1 1/4 25 mL 10 mL
16 - < 19kg 1 1/2 30 mL 12,5 mL
• Amoksisilin adalah obat pilihan yang dianjurkan karena efikasinya dan tingginya
resistensi terhadap kotrimoksasol
• Jika tidak respon dengan Amoksisilin, berikan Eritromisin 50mg/kgBB dalam 3 dosis
pemberian
(Kemenkes RI, 2018)
 Case Management in Hospital

• Must be determined to decide whether to

admit a child to the general ward or intensive
care unit
• Treatment:
– Antibiotics
– Supportive care
• Monitoring
 Antibiotics
• First line :
– Ampicillin 50mg/kg every 6 hours AND
– Gentamicin
• Second line : Ceftriaxon (80mg/kg im or iv once
daily) in case of failure of the first line treatment
• Second and third generation cephalosporins :
coverage against, haemophyllus influenzae and
other gram negative organisms
• Pandemi era : Ceftriaxon
 Supportive Therapy
• Organization of care in the ward
Pandemic area
– isolation room
– cohorting
• Food and nutrition
• Oxygen therapy
• Symptomatic treatment
• Nebulization
• Bronchodilators should not be routinely used.
• Bacterial lower respiratory tract infections rarely trigger asthma
attacks
• The wheezing that is sometimes heard in patients with
pneumonia is usually caused by airway inflammation, mucus
plugging, or both and does not respond to bronchodilator.
• Children with reactive airway disease or asthma may react to a
viral infection with bronchospasm, which responds to
bronchodilators.
• Medicated aerosol should be absolutely limited to true indication,
including short-acting bronchodilator for patients with reactive
airways or chronic airway obstruction. Pneumonia or hypoxemia
alone is NOT an indication.
• Aerosol nebulization is considered to be a high risk for
transmission
• Requires gown, gloves, N95 respirator, and eye protection and a
negative airflow room is preferred (if available)
• Patients who are not in negative pressure room should receive
priority for MDI’s
• Disposing of used equipment after each use
• Maintaining at least 6 feet or greater distance from the patient
should be considered.
2019
 REKOMENDASI TERAPI INHALASI PADA ASMA

Rekomendasi 2
• Pemberian obat pereda inhalasi menggunakan
pMDI+spacer sama efektifnya dengan pemberian
melalui nebuliser
• Kortikosteroid ampul harus diberikan dengan
nebuliser jet, tidak boleh dengan nebuliser
ultrasonik
• Cara inhalasi dengan DPI tidak sebaik nebuliser atau
pMDI+spacer
Asma dengan ancaman henti napas
Rekomendasi 4
• Pasien anak asma yang mengalami serangan asma
berat dengan ancaman henti napas, lakukan inhalasi
kombinasi SABA dan antikolinergik ditambah dengan
kortikosteroid sistemik intravena dan kortikosteroid
inhalasi dosis tinggi yang keduanya diberikan sebagai
obat pereda
Rekomendasi 5
• Terapi inhalasi pada asma serangan berat dan
ancaman henti napas diberikan dengan
menggunakan nebuliser

Rekomendasi 6
• Antikolinergik tidak digunakan sebagai terapi
tunggal dalam tatalaksana serangan asma
 REKOMENDASI TERAPI INHALASI UNTUK
KASUS NON-ASMA

Rekomendasi 15
• Pada kasus bronkiolitis
– Pada bronkiolitis ringan dan infeksi virus saluran
respiratori lainnya, pemberian inhalasi
kortikosteroid dan bronkodilator tidak terbukti
memberikan perbaikan klinis
– Pada bronkiolitis berat dalam perawatan, bisa
diberikan inhalasi cairan NaCl 3% 2,5-4 ml, dapat
diulang setiap 6-8 jam
Rekomendasi 16
• Pada kasus laringotrakeobronkitis atau croup
– Pada croup ringan tidak perlu diberikan terapi
inhalasi
– Pada croup sedang sampai berat dapat diberikan
adrenalin inhalasi 1:1000 sebanyak 0,5 ml/kg
sampai maksimal 5 ml atau budesonid inhalasi 2
mg (4 ml)
– Pada kasus IRA atas (common cold) tidak perlu
diberikan terapi inhalasi
 Monitoring
• Empirical treatment : monitoring
• The child should be regularly re assess
• There are a number of possibilities
– The child responds to treatment
– The child is slow to respond or worsens
– The child responds but later represent with new
episode of pneumonia
à Unsatisfactory response to treatment
 If children have unsatisfactory response to
treatment
1. Possible other cause (differential diagnosis)
– Causative agent (Tuberculosis, Staphylococcus,
Mycoplasma)
– Differential Diagnosis (CHD, Foreign body)
2. Underlying conditions
– Pulmonary factors
– Cardiac factors
– Neurological factors
– Immunological factors
3. Complications of pneumonia
 Take home messages
• Pneumonia is a disease characterized by
inflammation of the lung tissue due to infection
• Defining pneumonia : clinically
• Treatment of pneumonia depends on effective
antibiotics treatment and supportive therapy
• Pandemic situation :
– PPE
– Minimally contact with patients
– Antibiotics once daily
– Be carefull with aerosol procedure
 Stay safe…...
Stay health…..
• Nama : Dr. Retno Asih Setyoningrum,dr.,SpA(K)
• Tempat/tanggal lahir: Tulungagung, 26 Maret 1971
• Alamat : Mojo Kidul Blok I no 25 Surabaya

Pendidikan
• Dokter Umum : 8 Desember 1997 (Universitas Airlangga)
• Spesialis Anak : 28 Februari 2005 (Universitas Airlangga)
• Konsultan Respirologi Anak : 6 Juli 2011
• Doktor : November 2017