PROBLEM BASED LEARNING

SISTEM RESPIRASI
MODUL 2

SESAK NAPAS

Oleh : Kelompok A4
Adi
Ahmad Rizal
Chwee
Fani
Fitri
Hikma
Ika B.
Junaid
Lina
Mira
Otto
Rezki
Rizki
Wahyu
Zainal

SKENARIO 1
A boy

aged one year one month admitted to the

hospital with the complains of dyspnoea. Before
he went to the hospital, he suffered cough with
sputum and fever. This patient was born with a
weight of 3kg , spontaneus delivery and aterm.He
had no history of dyspnoea.

KEY WORDS
Boy

age 1 year 1 month

Dyspneu since 3 days before
Cough with mucus
Fever
Born normal with weight 3 kg
No historic of dyspneu before

IMPORTANT QUESTIONS
Differential

diagnosis

Etiology
Patomechanism

of DD and symptoms
Clinical manifestation
Treatment
Prevention
Complication
Prognosis

DD
Bronchiolitis
Bronchopneumonia
Bronchitis
Croup
TB

acute

BRONCHIOLITIS

DEFINITION
Acute

respiratory infection (confined

to infants under the age of 12 months).

ETIOLOGY
Usually

respiratory synctial virus.

Rare cases of parainfluenza and
adenoviruses.

PATHOLOGY
Bronchioles

acute epithelial damage &

lymphocytic infiltration of the walls.
Lumens filled w/ mucus plugs which
cause distal alveolar air trapping.
Cases caused by adenoviruses tend to have
greater degree of necrosis & higher
mortality rate.

CLINICAL MANIFESTATIONS
Cold
Dyspnea
Cough
Wheeze

INVESTIGATIONS
Anamneses:
PE:

I tachypnea, chest hyperinflated &

IC retraction is usually obvious.
A fine crackles, prolongation of the
expiratory phase & variable
wheeze, which is indicative of
lower airway obstruction.

 X-ray:

In

air trapping, peribronchial trapping

& areas of segmental collapse.

severe cases as the diseases progresses:

dyspnea increases, cyanosis occurs.
blood gas shows falling PO2 & rise of
PCO2.
some infants needs assisted
ventilation.

MANAGEMENT
Management

of hypoxia adequate O2 (to

relieve restlessness & prevent cyanosis).
Prevention of dehydration adequate
fluids. (IV therapy b/c most infants are
often unable to take fluids orally)
Antiviral agents ribavirin.

Bronchopneumonia
(Diffuse pneumonia)

Introduction
Diffuse

pneumonia is very common

It is differentiated from severe bronchitis by
signs of bronchial breathing or patchy
shadows on the chest X-ray.
Widespread diffuse pneumonia is a common
terminal event, resulting from an inability
of patient dying from other conditions (e.g
cancer

Definition
implies

a patchy distribution of
inflammation that generally involves more
than one lobe

Characteristics

This pattern usually results from an initial infection of the

bronchi and bronchioles with extension into the adjacent
alveoli
Focus either on bronchioles or bronchus
Usually in infant or
Secondary to the predisposing infection
In certain cases, it contains fibrosis circulation and abscess
Predisposition occurs is due to the clearness failure of the
production secretion in the respiratory tract
Staphylococcus aureus, Streptococcus pneumoniae ,
Haemophilus influenzae, fungus.

Clinical features symptoms

Fever
Rigor
Malaise
Anorexia
Dyspnoea
Cough
Purulent sputum
Haemophysis
Pleuritic chest pain

Clinical features signs

Fever
Cyanosis
Confusion
Tachypnoea
Tachycardia
Hypotension
Signs

of consolidation
Pleural rub

PATHOPHYSIOLOGY
Fever with chills and rigors
Infection by bacteria
Productive cough
Rusty sputum
Cough reflex
In alveoli
Lung consolidation
Vocal fremitus
Dullness on percussion

PNEUMONIA
Acute Pulmonary congestion
Fibrous blood/Neutrophils exudate
In pleural

Togs of fibrin on pleural

and lung surface

Pleural effusion
Getting severe

Rough pleural surfaces

rub together as lung expand
and contract

Deviation of trachea
Bronchial breath sound over
The consolidated site

Pleural rub
Crackles while auscultate
Pleuritic chest pain

Therapeutic Approach

For Staphylococcus- Cannot give penicillin because

staphylococcus generally produces penicillase.
A penicillase resistant antibiotic is used- oxacillin or
nafcillin.
When Staphylococcus is resistant to these derivativesVancomycin is given.

Therapeutic approach
Frequently used antibiotics for common pneumonias:
1.
2.
3.
4.
5.
6.
7.
8.

S.pneumoniae - penicillin, macrolide , selected quinolones

Staphylococcus oxacillin, nafcillin , vancomycin
H.influenzae cephalosporins, trimethoprim-sulfamethoxasole
Gram(-) rods aminoglycosides, cephalosporins
Anaerobes penicillin, clindamycin
Mycoplasma organisms macrolide, quinolone
Legionella macrolide , quinolones
Chlamydia pneumoniae tetracycline . macrolide

Complications of Pneumonia

Lung Abscess

Represents localized collection of pus . Abscesses generally result from tissue

destruction complicating a pneumonia.
When antibiotics have been administered , organisms may no longer be obtainable
from the abscess cavity.

Empyema

When pneumonia extends to pleural surface , inflammatory process may eventually

lead to empyema.
Empyema represents thick, creamy or yellow fluid within the pleural space
containing leukocytes , PMNs and bacterial organisms.
As a result of empyema , drainage of fluid from the pleural space is required .

CROUP

Laringotrakeobronkitis acute

definition
Croup is an acute viral infection
characterized by a barking
cough,hoarseness, inspiratory stridor, and
varyings degrees of respiratory distress.
usually lasts 5 to 6 days. Symptoms may be
worse at night and symptoms most
commonly occur in children 1 to 3 years
old.

ethiology
parainfluenza

virus type I 60% of cases

Parainfluenza virus type II
RSV
Rhinovirus
Measles corynebacterium diphteri
Staph. aureus

Pathophysiology
The causative virus is transmitted via the respiratory
route. The initial port of entry is the nose and
nasopharynx. Viral replication occurs, which
clinically produces coryza. As infection spreads
distally, the walls of the larynx and trachea become
erythematous and edematous. A fibrinous exudate
partially occludes the lumen of the trachea. In
addition to luminal narrowing, edema of the vocal
cords and subglottic larynx leads to stridor,
hoarseness, and the characteristic barklike cough.

The edema formation in young children

and infants can lead to significant airway
compromise due to an already narrowed
diameter of the airway, especially at the
level of the cricoid cartilage. Hypoxemia
may occur secondary to the luminal
narrowing and impaired alveolar
ventilation and ventilation-perfusion
mismatch.

physical
mild

expiratory wheezing
minimal distress to severe respiratory failure due to
airway obstruction.
primarily inspiratory stridor at rest with nasal flaring
suprasternal and intercostal retractions
Lethargy or agitation may be a result of hypoxemia.
Tachypnea, tachycardia, fever, pallor, and
hypotonia, cyanosis,

Lab studies

The WBC count generally is within reference range; however,

lymphocytosis or leukopenia may occur.
In mild cases, transcutaneous oximetry usually is within
reference range, but hypoxemia is observed with severe
disease.
Arterial blood gases (ABGs) are unnecessary and show
neither hypoxia nor hypercarbia unless respiratory fatigue
ensues.
If bacterial superinfection is suspected, direct laryngoscopy
can be performed. Viral and bacterial cultures can be obtained
if the presentation is atypical or the course is unusually
severe.

radiographs
In typical cases, radiographs are unnecessary unless the

diagnosis is in question.
Radiographs of the lateral soft tissue of the neck may
show subglottic narrowing from soft tissue edema in
severe disease; however, most of these radiographs are
normal or show overdistention (ballooning) of the
hypopharynx during inspiration.
The anteroposterior view of the neck will show
narrowing of the laryngeal air column 5-10 mm below
the level of the vocal cord (steeple sign) in 50-60% of
cases.

procedures
Direct

laryngoscopy in a stable child can be used

to exclude other entities, such as peritonsillar
abscess.
Fiberoptic laryngoscopy usually reveals a pale and
boggy laryngeal mucosa. In bacterial tracheitis
there is abundant purulent exudate and
pseudomembranes. In spasmodic croup, the
mucosa is inflamed, erythematous and with a
velvety appearance.

histologic
Histologic

evaluation reveals mucosal

edema with infiltration of the lamina
propria, submucosa, and adventitia with
lymphocytes, histiocytes and
polymorphonuclear leukocytes.

action
non farmaco
keeping in good health ownself.
drinking many water and fruity juices.
farmaco
Humidified oxygen -- Provides water droplets that
penetrate the area of inflammation. Provides moisture
to the mucosa. Increased humidity decreases the
viscosity of the secretions and facilitates clearance.
Titrate to maintain oxygen saturation above 94%

Epinephrine, racemic (Vaponefrin, Racepinephrine) 2.25%

-- Mixture of the D- and L- isomers of epinephrine. Causes
adrenergic stimulation, which constricts precapillary
arterioles, thereby decreasing capillary hydrostatic
pressure. 0.25-1 mL of a 2.25% solution in 3 mL of saline
via a nebulizer; dose can be gauged by the weight of the
patient:
<20 kg: 0.25 mL
20-40 kg: 0.5 mL
>40 kg: 0.75 mL

 Dexamethasone

(Decadron) Corticosteroids exert

beneficial effect by means of anti-inflammatory
action whereby laryngeal mucosal edema is
decreased. 0.15-0.6 mg/kg PO/IM as a single dose
Prednisone (Deltasone, Sterapred) 1-2 mg/kg/d PO
for 5 d; not to exceed 60-80 mg/d
Budesonide (Pulmicort Respules) 2 mg inhaled via
nebulizer qd prn

complication

The most common complication is worsening airway obstruction,

which is observed most frequently in infants or young children and
may require endotracheal intubation. Pneumothorax and
pneumomediastinum also may occur as complications of
endotracheal intubation. The inflammation may extend into the
lower airway causing wheezing and tachypnea.
Bacterial superinfection may cause bacterial tracheitis. Pneumonia
is uncommon and usually associated with bacterial tracheitis.
Other complications include lymphadermatitis and otitis media.
Inability to maintain adequate oral intake may lead to dehydration.
Subglottic stenosis has been described in intubated patients.
Toxic shock syndrome has been seen with bacterial tracheitis due
to staphylococcus aureus.

prognosis
Croup

is a self-limited disease with

excellent prognosis for good recovery
without sequelae.

ACUTE
BRONCHITIS

AETIOLOGY
Infections

: virus, bacteria, fungi

Chemical substance
Alergy

CLASSIFICATION
VIRAL BRONCHITIS

acute
BACTERIAL BRONCHITIS
secondary infections
FUNGAL BRONCHITIS

CLINICAL FEATURES
VB

: rhinitis, dry cough, chest pain, fever,

ronchi, prolonged bronchial expiration
BB : = VB, fever more, tachycardia,
purulent sputum

CLINICAL DIAGNOSE
Anamnesa
Physical

diagnose
Laboratory : leukosit

TREATMENT
Symptomatic

Ex : Antitusive

COMPLICATION
Pneumonia
Emphysema
Bronchiectasis
Atelectasis
Cor

pulmonale

TUBERCULOSIS

DEFINITION
Tuberculous

infection-Defined by a positive
tuberculin skin test but no evidence of active
disease
Tuberculous disease(active tuberculosis)defined by presence of clinically active
disease in one or more organ system, ideally
with confirmation of the diagnosis by
isolation of the organism M.tuberculosis

Etiology
Mycobacterium

tuberculose
Mycobacterium bovis rare

Patomechanism
To be

continued

Mycobacterium Tuberkulosis (air-borne droplets)

Mycobacterium Bovis (unpasteurized milk) rare
Into the lung
Non-specific acute inflammatory
response
Tubercle bacilli multiply in alveolar and alveoli duct
Most killed some survived in non-activated macrophages
Bacilli ingested by macrophages transported to regional lymph
nodes
If not contained, dissemination through blood stream occur
Type IV hypersensitivity cell mediated response
developed
Granuloma formed
Caseous necrosis and encapsulation

Monocytes change to macrophages and enter the infection area

Healing with calcification of the granuloma
Calcified peripheral lung lesions and calcified hilary
lymph node
GHON COMPLEX

Infection with MTBC

Non immune host
(usually child)

Partially immune
Hypersensitized host
(usually adult)

Primary Tuberculosis
Primary complex
Hilar nodes
Ghon focus

Heals by fibrosis
Immunity n
hypersensitivity
Tuberculin
positive

reinfection
Secondary TB
Fibrocaseous
Cavity lesion

Progressive lung
disease

Severe
bacteremia
Miliary TB

Death (rare)
death

Preallergic
Lymphatic or
Hematogenous
dissemination
Dormant tubercle
bacilli in several
organs
Reactivation
in adult life

Extrapulmonary TB
Meningitis
TB of brain

Vertebral
TB (Potts
disease)

TB
lymphadenitis

Renal TB

Intestinal TB

Reactivation TB
of the lung

SIGNS AND SYMPTOMS

1.
2.
3.
4.
5.
6.
7.

hemoptysis
dispneu
chest pain
fever
cough
anorexia
malaise

PHYSICAL EXAMINATION
Conjunctiva
Subfebril
Weight

loss

Radiology examination
Lymphadenophaty
Calcifications
Fibrosis
Halter

lines

Lab studies

Obtain sputum for acid-fast bacilli stain.

AFB (+) ~ 65,2 % contact to MT (+)
AFB (-) MT culture (+) ~ 26,8 % contact to MT (+)
AFB (-), MT culture (-) ~ 17,6 % contact to MT (+)

Tuberculin test
MAntoux methode
Interpretation :
Indurations 0-5 mm : mantoux (+)
Indurations 6-9 mm : mantoux (+)
Indurations 10 mm : mantoux (+)

Antibody detection
Specific to Mycobacterium is Lipoarabinomanan (LAM)

Patology anatomy examination

In the tissue biopsy there are tubercle appearance

Treatment
OAT
Isoniazid
Rifampisin
Etambutol
Pirazinamid
Streptomysin

complication
Pleural

effusion
Millier TB
Abdomen TB
Pneumonia
Meningitis TB

Prevention
Nutritional

and environment correction.

BCG vaccine
Early diagnose and adequate treatment to elder
TB suspect
Primary INH prophylaxis to the child with
negative tuberculin test but near to elder TB
suspect.
Secondary INH prophylaxis to the infected child.