acute respiratory infection.ppt
TRANSCRIPT
ACUTE ACUTE RESPIRATORYRESPIRATORYINFECTIONSINFECTIONS
Dr. Dwi Wastoro, SpAKDr. Dwi Wastoro, SpAK
PneumoniaPneumoniaBronchiolitisBronchiolitis
Acute Respiratory Infections (ARI)Acute Respiratory Infections (ARI)
Developed and developing countriesDeveloped and developing countries
High morbidityHigh morbidity
5 – 8 episodes/year/child5 – 8 episodes/year/child
30 – 50 % outpatient visit30 – 50 % outpatient visit
10 – 30 % hospitalization10 – 30 % hospitalization
Developing countriesDeveloping countries
High mortalityHigh mortality
30 – 70 times higher than in developed countries30 – 70 times higher than in developed countries
1/4 - 1/3 death in children under five year of age1/4 - 1/3 death in children under five year of age
ARI-ASSOCIATED DEATH RATE BY AGEARI-ASSOCIATED DEATH RATE BY AGETEKNAF, BANGLADESH, 1982-1985TEKNAF, BANGLADESH, 1982-1985
0
20
40
60
80
100
120
140
1-5 6-11 12-23 24-35 36-50
Age in Months
Deaths per 1000 children
Distribution of 12.2 million deaths among Distribution of 12.2 million deaths among children less than 5 years old in all developing children less than 5 years old in all developing
countries, 1993countries, 1993
ARI (26.9%)
Measles (2.4%)
Diarrhoea/measles (1.9%)
Diarrhoea (22.8%)
Other (33.1%)
Malaria (6.2)
ARI/Malaria (1.6%)
ARI/Measles (5.2%)
MalnutritionMalnutrition(29%)(29%)
RISK FACTORS FOR PNEUMONIARISK FACTORS FOR PNEUMONIAOR DEATH FROM ARIOR DEATH FROM ARI
Increaserisk of
ARI
Malnutrition, poorbreast feeding
practices
Vitamin A deficiency
Low birth weight
Cold weatheror chilling
Exposure to air pollution• Tobacco smoke• Biomass smoke• Environmental air pollution
Lack of immunization
Young age
Crowding
High prevalenceof nasopharyngealcarriage ofpathogenic bacteria
Magnitude of the ProblemMagnitude of the Problemin Indonesiain Indonesia
Pneumonia in children (< 5 years of age)Pneumonia in children (< 5 years of age)
Morbidity Rate 10-20 %Morbidity Rate 10-20 %
Mortality Rate 6 / 1000Mortality Rate 6 / 1000
Pneumonias killPneumonias kill 50.000 / a year50.000 / a year 12.500 / a month12.500 / a month 416 / a day = passengers of 1 jumbo jet plane416 / a day = passengers of 1 jumbo jet plane 17 / an hour17 / an hour 1 / four minutes1 / four minutes
PneumoniaPneumoniaClassificationsClassifications
Anatomical classificationAnatomical classification Lobar pneumoniaLobar pneumonia Lobular pneumoniaLobular pneumonia Intertitial pneumoniaIntertitial pneumonia BronchopneumoniaBronchopneumonia
Etiological classificationEtiological classification Bacterial pneumoniaBacterial pneumonia Viral pneumoniaViral pneumonia Mycoplasma pneumoniaMycoplasma pneumonia Aspiration pneumoniaAspiration pneumonia Mycotic pneumoniaMycotic pneumonia
Etiology of PneumoniaEtiology of Pneumonia
Predominantly : bacterial and viral Predominantly : bacterial and viral
In developing countries: In developing countries:
bacterial > viral bacterial > viral
(Shann,1986): In 7 developing(Shann,1986): In 7 developing countries, countries,
bacterial bacterial 60 % 60 %
(Turner, 1987):(Turner, 1987): In developed countries,In developed countries, bacterial bacterial 19 % ; viral 19 % ; viral 39 % 39 %
Bacterial etiologyBacterial etiology
Streptococcus pneumoniaeStreptococcus pneumoniae
Hemophilus influenzaeHemophilus influenzae
Staphylococcus aureusStaphylococcus aureus
Streptococcus group A – BStreptococcus group A – B
Klebsiella pneumoniaeKlebsiella pneumoniae
Pseudomonas aeruginosaPseudomonas aeruginosa
Chlamydia sppChlamydia spp
Mycoplasma pneumoniaeMycoplasma pneumoniae
0
10
20
30
40
50
S Pneumoniae H Influenzae S Aureus
BACTERIA ISOLATED FROM LUNG ASPIRATESBACTERIA ISOLATED FROM LUNG ASPIRATESIN 370 UNTREATED CHILDREN WITH PNEUMONIAIN 370 UNTREATED CHILDREN WITH PNEUMONIA
%%
Characteristic featuresCharacteristic features
S pneumoniaeS pneumoniae mucosal inflammation lesionmucosal inflammation lesion alveolar exudatesalveolar exudates frequently frequently lobar pneumonia)lobar pneumonia)
H influenzae, S viridans, VirusH influenzae, S viridans, Virus invasion and destruction of mucous membraneinvasion and destruction of mucous membrane
Staphylococcus, KlebsiellaStaphylococcus, Klebsiella destruction of tissues destruction of tissues multiple abscesses multiple abscesses
Simple Clinical Signs of Simple Clinical Signs of Pneumonia (WHO)Pneumonia (WHO)
Fast breathing (tachypnea)Fast breathing (tachypnea)
Respiratory thresholds Respiratory thresholds
AgeAge Breaths/minuteBreaths/minute
< 2 months< 2 months 6060
2 - 12 months2 - 12 months 5050
1 - 5 years1 - 5 years 4040
Chest IndrawingChest Indrawing(subcostal retraction)(subcostal retraction)
Pathology and PathogenesisPathology and Pathogenesis
Bacteriae Bacteriae peripheral lung tissues peripheral lung tissues
tissues reaction tissues reaction oedematous oedematous
Red Hepatization StadiumRed Hepatization Stadium
alveoli consist of : leucocyte, fibrine,erythrocyte, alveoli consist of : leucocyte, fibrine,erythrocyte, bacteriabacteria
Grey Hepatization Stadium Grey Hepatization Stadium
fibrine deposition, phagocytosisfibrine deposition, phagocytosis
Resolution Stadium Resolution Stadium
neutrophil degeneration, loose of fibrine,neutrophil degeneration, loose of fibrine,
bacterial phagocytosisbacterial phagocytosis
Bronchopneumonia Early stages of acute bronchopneumonia. Abundant inflammatory cells fill the alveolar spaces. The alveolar capillaries are distended and engorged.
Bronchopneumonia Acute bronchopneumonia. The alveolar spaces contain abundant PMNs and an inflammatory infiltrate rich in fibrin.
Acute Bronchopneumonia Acute bronchopneumonia; the alveolar spaces are full and distended with PMNs and a proteinaceous exudate. Only the alveolar septa allow identification of the tissue as lung.
Radiographic patterns Radiographic patterns
1.1. Diffuse alveolar and interstitial Diffuse alveolar and interstitial pneumoniapneumonia (perivascular and (perivascular and interalveolar changes)interalveolar changes)
2. Bronchopneumonia2. Bronchopneumonia(inflammation of airways and (inflammation of airways and parenchyma)parenchyma)
3. 3. Lobar pneumoniaLobar pneumonia(consolidation in a whole lobe)(consolidation in a whole lobe)
4. 4. Nodular, cavity or abscess lesionsNodular, cavity or abscess lesions(esp.in immunocompromised patients)(esp.in immunocompromised patients)
Blood Gas Analysis & Acid Base BalanceBlood Gas Analysis & Acid Base Balance
Hypoxemia Hypoxemia (P(PaaOO22 < 80 mm Hg) < 80 mm Hg) with Owith O22 3 L/min 3 L/min 52,4 %52,4 % without Owithout O22 100 %100 %
Ventilatory insufficiencyVentilatory insufficiency (P(PaaCOCO22 < 35 mmHg) < 35 mmHg) 87,5 %87,5 %
Ventilatory failureVentilatory failure (P(PaaCOCO22 > 45 mmHg ) > 45 mmHg ) 4.8 %4.8 %
Metabolic Acidosis Metabolic Acidosis poor intake and/or hypoxemiapoor intake and/or hypoxemia 44,4 % 44,4 %
(Mardjanis Said, et al. 1980)(Mardjanis Said, et al. 1980)
ManagementManagement
Severe PneumoniaSevere Pneumonia
HospitalizationHospitalization
Antibiotic administrationAntibiotic administration Procain Pennicilline, ChloramphenicolProcain Pennicilline, Chloramphenicol Amoxycillin + Clavulanic AcidAmoxycillin + Clavulanic Acid
Intra Venous Fluid DripIntra Venous Fluid Drip
OxygenOxygen
Detection and management of Detection and management of complicationscomplications
ComplicationsComplications
Pleural effusion (empyema)Pleural effusion (empyema)
PiopneumothoraxPiopneumothorax
PneumothoraxPneumothorax
PneumomediastinumPneumomediastinum
BronchiolitisBronchiolitis
Bronchioles inflammationBronchioles inflammation
Clinical syndromes: Clinical syndromes: fast breathing, retractions, wheezingfast breathing, retractions, wheezing
Predominantly < 2 years of age Predominantly < 2 years of age (2 – 6 months)(2 – 6 months)
Difficult to differentiate with pneumoniaDifficult to differentiate with pneumonia
BronchiolitisBronchiolitis
EtiologyEtiologyPredominantly RSV (Respiratory Syncytial Predominantly RSV (Respiratory Syncytial Virus), adenovirus etc.Virus), adenovirus etc.DiagnosisDiagnosis
Etiological diagnosisEtiological diagnosis Microbiologic examination Microbiologic examination
Clinical diagnosisClinical diagnosis Signs and symptomsSigns and symptoms AgeAge Resource of infectionResource of infection
BronchiolitisBronchiolitis
Clinical ManifestationsClinical Manifestationscough, cold, fever,fast breathing, retraction, cough, cold, fever,fast breathing, retraction, wheezing, irritable, vomitus, poor intakewheezing, irritable, vomitus, poor intake
Physical Examinations Physical Examinations tachypnea, tachycardia, retraction, tachypnea, tachycardia, retraction, expiration >, wheezing, fever,pharyngitis, expiration >, wheezing, fever,pharyngitis, conjunctivitis, otitis media.conjunctivitis, otitis media.
BronchiolitisBronchiolitis
Radiologic examinationRadiologic examinationdiffuse hyperinflationdiffuse hyperinflation flat diaphragm, flat diaphragm, subcostal >subcostal > retrosternal space >retrosternal space >
peribronchial infiltratesperibronchial infiltrates
pleural effusion (rare)pleural effusion (rare)
BronchiolitisBronchiolitis
ManagementManagement SupportiveSupportive Severe disease Severe disease
hospitalizationhospitalization
intra venous fluid dripintra venous fluid drip
oxygenoxygen
(antibiotics)(antibiotics) Bronchodilator: controversialBronchodilator: controversial Corticosteroid: controversialCorticosteroid: controversial
BronchiolitisBronchiolitis
Natural history & complicationsNatural history & complications Improved clinical findings : in 3-4 daysImproved clinical findings : in 3-4 days Improved radiological features: in 9 daysImproved radiological features: in 9 days
Persistent respiratory obstruction : 20%Persistent respiratory obstruction : 20%
Respiratory failure : 25 %Respiratory failure : 25 %
Lung collaps (rare)Lung collaps (rare)