anak broncho

Case report

BRONCHOPNEUMONIA

Presenters : Kiki Anggrita

Sari Mutiara Hutagalung

Day/Date : Thursday/December 23rd 2010

Supervisor : dr. Lily Irsa, Sp.A (K)

CHAPTER 1

1.1. INTRODUCTION

Pneumonia can be generally defined as inflammation of the lung

parenchyma, pneumonia is characterized by consolidation of the affected part and

a filling of the alveolar air spaces with exudate, inflammatory cells, and fibrin.

Most cases of pneumonia are due to infection by bacteria or viruses, although they

may also be due to the inhalation of chemicals, trauma to the chest wall, or other

infectious agents such as rickettsiae, fungi, and yeasts. 1

Bronchopneumonia is one of two types of bacterial pneumonia as

classified by gross anatomic distribution of consolidation (solidification), the

other being lobar pneumonia. Bronchopneumonia is an acute inflammation of the

walls of smaller bronchial tubes, with varying amount of pulmonary consolidation

due to spread of the inflammation into peribronchiolar alveoli and the alveolar

ducts.2.3

Although most cases of pneumonia are caused by microorganisms.

Pneumonia is an acute infection of one or both lungs that can be caused by a

bacterium, usually Streptococcus pneumoniae (also called pneumococcus; see

streptococcus streptococcus, any of a group of gram-positive bacteria, genus

Streptococcus, some of which cause disease, or by a virus, fungus, or other

organism. The causal organisms reach the lungs through the respiratory passages.

Usually an upper respiratory infection precedes the disease. Alcoholism, extreme

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youth or age, debility, immunosuppressive disorders and therapy, and

compromised consciousness are predisposing factors. 1.4

When one or more entire lobes of the lung are involved, the infection is

considered a lobar pneumonia. When the disease is confined to the air spaces

adjacent to the bronchi, it is known as bronchopneumonia. Aspiration pneumonia

is the pathological consequence of the abnormal entry of fluids, particulate matter,

or secretions in the lower airways. Noninfectious causes include aspiration of

food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances,

hypersensitivity reactions and drug or radiation induced pneumonitis.4

1.2. DEFINITION

Bronchopneumonia is a type of pneumonia that is characterized by an

inflammation of the lung generally associated with, and following about with

bronchiolitis. Bronchopneumonia or bronchial pneumonia or bronchogenic

pneumonia is an acute inflammation of the walls of the bronchioles. It is a type of

pneumonia characterized by multiple foci of isolated, acute consolidation,

affecting one or more pulmonary lobules. It is one of two types of bacterial

pneumonia as classified by gross anatomic distribution of consolidation

(solidification), the other being lobar pneumonia.2.3

1.3. ETIOLOGY

Pneumonia is most often caused by a bacterial infection (bacterial

pneumonia) or a viral infection (viral pneumonia). However, pneumonia can also

be caused by a fungal infection, yeast infection, trauma, or from inflammation of

the lungs due to exposure to toxic substances, such as poisonous gases.

Pathogens implicated in pneumonia vary with the age of the child, the

underlying patient-specific risk factors, immunization status, and seasonality.8

In the neonate, pathogens that may infect the infant via the maternal

genital tract include group B streptococci, Escherichia coli and other fecal

coliforms, and C trachomatis. Group B streptococci most often is transmitted to

the fetus in utero, usually as a result of colonization of the mother's vagina and

cervix by the organism. Affected infants commonly present within the first few

hours after birth, but if infection is acquired during the delivery, the presentation

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http://www.wrongdiagnosis.com/i/injury/intro.htm

http://www.wrongdiagnosis.com/c/candidiasis/intro.htm

http://www.wrongdiagnosis.com/f/fungal_infections/intro.htm

http://www.wrongdiagnosis.com/p/pneumonia/intro.htm

http://www.wrongdiagnosis.com/v/viral/intro.htm



http://www.wrongdiagnosis.com/b/bacterial_diseases/intro.htm

may be delayed. The usual presenting symptoms include tachypnea, hypoxemia,

and signs of respiratory distress. Physical examination may reveal diffuse fine

crackles, and the chest radiograph may demonstrate a ground-glass appearance

and air bronchograms.6

Newborns may be affected by the bacteria and viruses that cause

infections in older infants and children. Risk factors for infection include older

siblings, group daycare, and lack of immunization, particularly against pertussis.

In the young infant, aged 1-3 months, continued concern about perinatally

acquired pathogens mentioned above as well as the unusual Listeria

monocytogenes remains. However, most pneumonia in this age group is

community acquired and involves Streptococcus pneumoniae, Staphylococcus

aureus, and non-typeable Haemophilus influenzae. Streptococcus pneumoniae is

by far the most common bacterial pathogen in this age group. Infection with

Staphylococcus aureus may be complicated by lung abscess, parapneumonic

effusions, and empyema. 6

Young children, viruses are a common cause of pneumonia among

toddlers and preschoolers. The usual culprits are those previously discussed.

Tsolia et al identified a viral infection among 65% of hospitalized children with

community-acquired pneumonia. Streptococcus pneumoniae is by far the most

common bacterial cause of pneumonia. Among hospitalized children,

Streptococcus pneumoniae accounts for 21-44% of disease. In a recent study to

evaluate the effectiveness of heptavalent pneumococcal conjugate vaccine in

prevention of pneumonia in children younger than 5 years, Black et al showed a

32.2% reduction in the first year of life and a 23.4% reduction between 1-2 years,

but only a 9.1% reduction in children older than 2 years.Children in this age group

are also at risk for infection by M pneumoniae.6

Older children and adolescents, M. pneumoniae is a frequent cause of

pneumonia among older children and adolescents. Mycoplasma accounts for 14-

35% of pneumonia hospitalizations in this age group. C pneumoniae can cause

pneumonia in this age group.

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Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumoniae

both are the common bacterium which causes bronchopneumonia in the adults

and children.1.6

1.4. EPIDEMIOLOGY

The WHO Child Health Epidemiology Reference Group estimated the

median global incidence of clinical pneumonia to be 0.28 episodes per child-

year.1 This equates to an annual incidence of 150.7 million new cases, of which

11-20 million (7-13%) are severe enough to require hospital admission. Ninety-

five percent of all episodes of clinical pneumonia in young children worldwide

occur in developing countries.7

The insiden of pneumonia is 10 times higher in developing than in

developed countries, with as many as 5 million deaths occurring yearly in children

younger than 5 years. Such variable as nutritional status, age, and the presence of

an underlying condition influence morbidity and mortality rafes due to community

acquired pneumonia.8

In the United State, In a randomized double-blind trial, the heptavalent

pneumococcal vaccine reduced the incidence of clinically diagnosed and

radiographically diagnosed pneumonia among children younger than 5 years by

4% and 20%, respectively.7

1.5. PATHOPHYSIOLOGY

Pneumonia results from inflammation of the alveolar space and may

compromise air exchange. While often complicating other lower respiratory

infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also

occur via hematogenous spread or aspiration. Most commonly, this inflammation

is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of

chemical injury or may follow direct lung injury.7

Four stages of lobar pneumonia have been described. In the first stage,

occurring within 24 hours of infection, the lung is characterized microscopically

by vascular congestion and alveolar edema. Many bacteria and few neutrophils

are present. The stage of red hepatization (2-3 d), so called because of its

similarity to the consistency of liver, is characterized by the presence of many

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http://emedicine.medscape.com/article/967822-overview

erythrocytes, neutrophils, desquamated epithelial cells, and fibrin within the

alveoli. In the stage of gray hepatization (2-3 d), the lung is gray-brown to yellow

because of fibrin purulent exudates, disintegration of red cells, and hemosiderin.

The final stage of resolution is characterized by resorption and restoration of the

pulmonary architecture. Fibrinous inflammation may extend into the pleural

space, causing a rub heard by auscultation, and it may lead to resolution or to

organization and pleural adhesions.7

Bronchopneumonia, a patchy consolidation involving one or more lobes,

usually involves the dependent lung zones, a pattern attributable to aspiration of

oropharyngeal contents. The neutrophilic exudates are centered in bronchi and

bronchioles, with centrifugal spread to the adjacent alveoli. 7 In a person suffering

from bronchopneumonia, bacteria invade the lungs, which results to an

inflammatory immune response. This reaction of the lungs leads to the filling of

the alveolar sacs with exudates. As a result, consolidation takes place a condition

where in the air space in the lungs is replaced with fluids.

In pathology, we can found macroscopically multiple foci of consolidation

are present in the basal lobes of the human lung, often bilateral. These lesions are

2-4 cm in diameter, grey-yellow, dry, often centered on a bronchiole, are poorly

delimited and have the tendency to confluence, especially in children,

microscopically, A focus of inflammatory condensation is centered on a

bronchiole with acute bronchiolitis (suppurative exudates - pus - in the lumen and

parietal inflammation). Alveolar lumens surrounding the bronchiole are filled with

neutrophils ("leukocytic alveolitis"). Massive congestion is present. Inflammatory

foci are separated by normal, aerated parenchyma.1

1.6. CLINICAL FEATURES ( Signs & Symptoms )

Fever and difficulty in breathing are commonest presenting symtoms,

usually preceded by an upper respiratory tract infection. Other symptoms include

cough, lethargy, poor feeding, an “unwell child”. Localized chest, abdominal, or

neck pain is feature of pleuralirritationand suggest bacterial infection.10 The signs

and symptoms of pneumonia are often nonspecific and widely vary based on the

patient’s age and the infectious organisms involved.

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Newborns, newborns with pneumonia rarely cough; they more commonly

present with tachypnea, retractions, grunting, and hypoxemia. Grunting in a

newborn is due to vocal cord approximation as they try to provide increased

positive end-expiratory pressure (PEEP) and keep their lower airways open.

Grunting suggests a lower respiratory tract disease. Retractions result from the

effort to increase intrathoracic pressure to compensate for decreased compliance.

Older infants, grunting may be less common; however, tachypnea,

retractions, and hypoxemia are common and may be accompanied by a persistent

cough, congestion, fever, irritability, and decreased feeding.

Toddlers and preschoolers, these children most often present with fever,

cough (productive or nonproductive), tachypnea, and congestion. They may have

some posttussive emesis.

Older children and adolescents, this group may also present with fever,

cough (productive or nonproductive), congestion, chest pain, dehydration, and

lethargy.

Extra pulmonary signs and symptoms include (1) abdominal pain or an

ileuses accompanied by emesis in patients with lower lobe pneumonia, (2) nuchal

rigidity in patients with right upper lobe pneumonia, or (3) a rub caused by

pericardial effusion in patients with lower lobe pneumonia due to Haemophilus

influenzae infection.

All children, many children present with nasal flaring, which increases

airflow to respiratory surfaces.7

Auscultation of the lung fields may yield rales, wheezing, diminished

breath sounds, tubular breath sounds, or pleural friction rub. The affected lung

field may be dull to percussion. Decreased tactile and vocal fremitus, as well as

egophony, may be appreciated over the area of pneumonia.10

1.7. LABORATORY STUDY

Identifying the causative infectious agent is the most valuable step in

managing a complicated case of pneumonia. Unfortunately, an etiologic agent can

be difficult to identify. Therefore, in most patients with community-acquired

pneumonia who are treated on an outpatient basis, treatment is empiric and based

primarily on patient age and clinical presentation.

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a. CBC count

Testing should include a CBC count with differential and evaluation of

acute-phase reactants (ESR, CRP, or both) and sedimentation rate. The total WBC

and differential may aid in determining if an infection is bacterial or viral, and,

together with clinical symptoms chest radiography and ESR can be useful in

monitoring the course of pneumonia. In viral pneumonia, the WBC count may be

normal or elevated . Bacterial pneumonia is often associated with an elevated

WBC count in the range of 15,000–40,000/mm3 and a predominance of

granulocytes.1.3

b. Sputum culture

Sputum is rarely produced in children younger than 10 years, and samples

are always contaminated by oral flora. An adequate sputum culture should contain

more than 25 polymorphonuclear (PMN) cells per field and fewer than 10

squamous cells per field.

The common agents that cause pneumonia may be normal oral flora. For

these reasons, sputum cultures are not useful in most children with pneumonia,

although a Gram stain may help. An example of a positive Gram stain for S

pneumoniae is shown in the image below.3.8

(A) Gram stain demonstrating gram-positive cocci in pairs and chains and

(B) culture positive for Streptococcus pneumoniae.

c. Blood culture

Although blood cultures are technically easy to obtain and relatively

noninvasive and non traumatic, the results are rarely positive in the presence of

pneumonia and even less so in cases of pretreated pneumonia.

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In a study of 168 patients with known pneumonia, Wubbel et al found only

sterile blood cultures. In general, blood culture results are positive in 10-15% of

patients with streptococcal pneumonia. The numbers are even less in patients with

Staphylococcus infection. A blood culture is still recommended in complicated

cases of pneumonia.3

d. Skin tests

Tuberculosis should always be considered as possible diagnose, especially

in endemic areas.8

These tests are used in diagnosing TB. Mantoux skin test (intradermal

inoculation of 5 TU of purified protein derivative) results should be read 48-72

hours after placement. In children older than 4 years without any risk factors, test

results are positive if the indurations (not the area of erythematic, which may be

larger) is 15 mm or larger. Among children younger than 4 years, those who have

an increased environmental exposure to TB or other medical risk factors (eg,

lymphoma, diabetes mellitus, malnutrition, renal failure), results are positive if the

indurations is 10 mm or larger. In immunosuppressed children or those in close

contact with others who have known or suspected cases of TB, test results are

positive if the indurations is 5 mm or larger.

Even if the child has received the Bacillus Calmette-Guérin (BCG)

vaccine, Mantoux test results should be interpreted using the criteria outlined

above.3

e. Bronchoscopy

Flexible fiberoptic bronchoscopy is occasionally useful to obtain lower

airway secretions for culture or cytology. This procedure is most useful in

immunocompromised patients who are believed to be infected with unusual

organisms (Pneumocystis, other fungi) or in patients who are severely ill.3

1.8. IMAGING STUDY

Radiography, this is the primary imaging study used to confirm the

diagnosis of pneumonia. Radiography is often performed when diagnosing

pneumonia, however, it is not always necessary or useful in determining the

etiology of the infection.3 In general, chest radiographs are standart practice with

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hospitalized children whom a diagnose pneumonia being considered. The

sensitivity of the test to diagnose is approximately 75%.8

Viral pneumonias are associated with a patchy perihilar infiltrate,

hyperinflation, and atelectasis on chest radiography.In patients with bacterial

pneumonia, typical findings include a lobar consolidation with air bronchograms

occasionally accompanied by a pleural effusion (see the images below).Photo

thorax there bronkopeumoni patches infiltrates in one or several lobes, if the

pneumonia lobaris seen a consolidation in one or several lobes. Pneumatoceles

and abscesses are less commonly found but may indicate an S aureus, gram-

negative, or complicated pneumococcal pneumonia.3

A small propotion of pneumonias are associated with a parapneumonic

effusion, where they may be blunting of the costophrenic angle on the chest X-

ray. Some of this effusion develop into empyema.8

1.9. MANAGEMENT AND TREATMENT

Infant and children with mild and moderste low respiratory tract infection

can be safely cared for at home. In this situation, the child usually should be

reexamined within 48 hours of beginning treatment. According to the British

Thoracic Society guideline, an SaO2 of 92% or less, cyanosis, respiratory rate

greater than 70 breaths per minute, difficulty of breathing, intermittent apnea,

grunting, inability to feed, and family incapable of providing appropriate

observation or supervision are indicators for hospital admission among infant.8

General supportive care should include antipyretics, oxygen to keep

saturation > 92. Fluids should be given if necessary, ensuring that an excessive

volume is not given because of potensial inappropiate ADH secretion.10

Treatment decisions in children with pneumonia are dictated based on the

likely etiology of the infectious organism and the age and clinical status of the

patient. Antibiotic administration must be targeted to the likely organism, bearing

in mind the age of the patient, the history of exposure, the possibility of resistance

(which may vary, depending on local resistance patterns), and other pertinent

history. The initial outpatient treatment of children with pneumonia depends upon

the clinical findings and the patient's age.3

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A position paper by the U.S Center for Disease and Control and

Prevention was recently published supporting the findings that intermediate

susceptible strain of pneumococcus respond well to high doses of beta-lactam.

High doses of penicillin, ampicillin, and amoxicillin have been

recommended whenever intermediate susceptible strain are considered. Some

expert suggest an option with third generation cephalosporins such as ceftriaxon

or cefotaxime.8

Children in whom pneumococcal disease is suspected initially should be

treated with amoxicillin or penicillin. A macrolide antibiotic alone, or in

combination with sulfisoxazole or an oral cephalosporin is an alternative.7

The choice antibiotic is determinaned by child’s age, newborn require

broad-spectrum intrvenous antibiotics. Most older infant can be manage with oral

amoxicillin, with broader spectrum antibiotics. For children >5 years of age either

amoxicillin or an oral macrolide such as erytrhomycin is the treatment of choice.10

1.10. COMPLICATION

Fortunately, most children with pneumonia recover without complications.

Persistent effusions and empyemas are the most common serious complications of

bacterial pneumonia, others include the following:7

Pulmonary abscess

Respiratory distress

Sepsis

1.11. PROGNOSIS

Patients who were placed on a protocol-driven pneumonia clinical

pathway are more likely to have favorable outcomes. The prognosis for most

forms of pneumonia is excellent. Most cases of viral pneumonia resolve without

treatment, common bacterial pathogens and atypical organisms respond to

antimicrobial therapy.7

The prognosis for varicella pneumonia is somewhat more guarded.

Staphylococcal pneumonia, although rare, can be very serious despite treatment.

Immunocompromised children, those with underlying lung disease, and neonates

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are at high risk for severe sequelae. Some forms of viral pneumonia, particularly

adenoviral disease, may cause necrotizing bronchiolitis or bronchiolitis

obliterans.7

CHAPTER 2

2.1. OBJECTIVE

The aim of doing this paper is to report a case of bronchopneumonia of an

1-year-old girl that was admitted at the Infection Unit of Haji Adam Malik

General Hospital.

2.2. CASE

N, a 2-year-old girl, 9.5 kg, 82 cm, was admitted to the Infection Unit of

Haji Adam Malik General Hospital on September 16th, 2010 at 21.00 pm with

chief complaint was shortness of breath. The shortness of breath occurred since 2

days ago and getting worst in 1 day before she admitted to the hospital. The

shortness of breath was not related to activity and weather. Cyanosis was not

found. Productive cough occurred since 3 day ago. History of contact with TB

patient was not found.

Fever was found since 1 week ago with a characteristic of high fever

which relieved with fever relieving medication. Shivers and seizures were not

found. History of diarrhea was found since 5 days ago with frequency 5 times a

day and the volume was 20cc/diarrhea. Currently the patient is having watery

stool. Micturition is in normal range. History of birth, the patient was delivered

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through caesarian operation and cried instantly. She had a history of complete

immunizations.

History of previous illness: This patient was referred from pediatrician

History of drugs usage : -

PHYSICAL EXAMINATION

Generalized Status:

Body weight (BW) : 9.5 kg Body length (BL) : 82 cm

BW/ BL : 84% (mild malnutrition)

Sensorium : Compos Mentis Body Temperature : 40.5 ۫CAnemic (-), icteric (-), cyanosis (-), edema (-), dyspnea (+)

Localized Status:

Head : Eye: light reflexes (+/+), isochoric pupil (right=left), pale inferior

conjunctival palpebra (-/-), palpebra edema (-/-)

Mouth/Ears: Within normal limit, Nose: Nasal Flaring (+)

Neck : Lymph node enlargement (-), JVP: R-2cmH₂O

Chest : Symmetrical fusiformic, retraction (+)

HR: 180 bpm, regular, murmur (-)

RR: 20 rpm, regular, ronchi (+)

Abdominal : Soepel, peristaltic (+) normal, Liver/Spleen: within normal limits

Extremities : Pulse: 180 bpm, regular, pressure/volume = sufficient

BP: 90/60 mmHg, warm extremity

Urogenital : Female, within normal limit

Laboratory Findings (September 16th 2010) from Private Lab

Test Result Normal Value

Complete Blood Count

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Hemoglobin (HGB)

Erythrocytes (RBC)

Leucocytes (WBC)

Hematocrit

Thrombocytes (PLT)

MCV

MCH

MCHC

RDW

10,40 g%

4,15 x 106/mm3

10,79 x 103/ mm3

31,50 %

225 x 103/ mm3

75,9 fL

25,1 pg

33 g%

13,8 %

11,3-14,1

4,40-4,48

6,0-17,5

37-41

217-497

81-95

25-29

29-31

11,6-14,8

Cell Count

Neutrophil

Lymphocyte

Monocyte

Eosinophil

Basophil

75,40 %

13,60 %

10,90 %

0%

0,10 %

37-80

20-40

2-8

1-6

0-1

Arterial Blood Gases

pH

pCO2

pO2

Bicarbonate (HCO3)

Total CO2

BE

O2 Saturation

7,515

23,9 mmHg

135,2 mmHg

18,9 mmol/L

19,6 mmol/L

-3,0 mmol/L

99,2 %

7,35-7,45

38-42

85-100

22-26

19-25

(-2) – (+2)

95-100

Serum Electrolyte

Natrium

Kalium

Chloride

130 mEq/dL

3,0 mEq/dL

99 mEq/dL

135- 155

3.6- 5.5

96- 106

Chest X-Ray (September 16th 2010)

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Chest X-Ray showed infiltrated on right lower lung ( right pericardial), specific

process, with differential diagnosis Bronchopneumonia.

Differential diagnosis : 1. Bronchopneumonia + GE without Dehydration

2. Bronkiolitis

3. Pulmonary Tuberculosis

Working diagnosis : Bronchopneumonia + GE without Dehydration

Management :

O2 1 L/i Nasal Canal

Nebule NaCl 0,9% 2,5cc/8 hours

IVFD D5% NaCl 0,225% 40 gtt/i

Injection Ampicillin 250mg/6 hours/iv skin test

Injection Gentamycin 80mg/24 hours/iv skin test

Paracetamol 3x100mg, if needed

Fasting as the temporary diet

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Investigation Plan: - Chest X-Ray (AP)

- Mantoux Test

Follow Up

Follow Up November 17th 2010 6:00 am

S Shortness of breath (+), Cough (+), Fever (-), Diarrhea (+)

O Sens: Compos Mentis T: 37.4 ۫C BW: 9.5 kg BL: 82 cm

BW/BL: 84% (mild malnutrition)

Head : Eyes: Light reflexes (+/+), isochoric pupil, pale inferior

palpebral conjunctiva (-/-), Nose: Nasal Flaring (+)

Mouth/Ears: Within normal limits

Neck : Lymph nodes enlargement (-), JVP: R-2cmH₂O

Chest : Symmetrical fusiformic, retraction (+),

HR : 132 bpm, regular, murmur (-)

RR : 48 rpm, regular, ronchi (+)

Abdomen : Soepel, normal peristaltic,

Liver/Spleen: Within normal limits

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Extremities : Pols 132 bpm, regular, Pressure/Volume: sufficient,

BP : 90/60 mmHg, warm extremity

A Bronchopneumonia + GE without Dehydration

P O2 1 L/I Nasal Canal



Injection Ampicillin 250mg/6 hours/iv (D-2)

Injection Gentamycin 80mg/24 hours/iv (D-2)

Paracetamol 3x100 mg, if needed

Zinc Kid 1x20mg

Lacto B 2x1 sachet

Diet M II 900 kkal with 35 grams of protein

Investigation plan : -


S Shortness of breath (+), Cough (+), Fever (-), Diarrhea (-)







Chest : Symmetrical fusiformic, retraction (+),







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Zinc Kid 1x20mg

Lacto B 2x1 sachet


Investigation plan : - Consultation to Respirology Department

Respirology Consult : Normal


S Shortness of breath (+), Cough (+), Fever (-), Diarrhea (-)







Chest : Symmetrical fusiformic, retraction (-),








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Ambroxol 5mg + Salbutamol 1mg : 3 x pulv I


Zinc Kid 1x20mg

Lacto B 2x1 sachet


Investigation plan : - Mantoux Test

- Chest Physiotherapy (20/12/2010)

- Check for ABG and Electrolyte


S Shortness of breath (+), Cough (+), Fever (+), Diarrhea (-)














A Bronchopneumonia


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Laboratory Findings:

ABG : pH/pCO2/pO2/HCO3 = 7.42/40.6/84.7/26.1

Total CO2/BE/SaO2 = 27.3/1.6/96.5%

Electrolyte : Na/K/Cl = 132/27/94

Follow Up November 21st 2010 6:00 am

S Shortness of breath (+), Cough (-), Fever (-)














A Bronchopneumonia



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Follow Up November 22nd 2010 6:00 am

S Shortness of breath (+) ↓, Cough (+) ↓, Fever (-)







Chest : Symmetrical fusiformic, retraction (-), stridor (+)


RR : 32 rpm, regular, ronchi (+), Prolonged expiration (+)





Bronchopneumonia

P O2 1 L/I Nasal Canal, if needed

Nebule Ventolin 2,5 cc + NaCl 0,9% 2,5cc/8 hours


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Chest Physiotherapy


Follow Up November 23rd 2010 6:00 am

S Shortness of breath (+)↓, Cough (+) ↓, Fever (-)







Chest : Symmetrical fusiformic, retraction (-), stridor (-)


RR : 36 rpm, regular, ronchi (+), prolonged expiration (+)





A Bronchopneumonia

P O2 1 L/I , if needed

Nebule Ventolin 2,5 cc + NaCl 0,9% 2,5cc/8 hours



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Chest Physiotherapy

Investigation plan : - Discharge (24/12/2010)

CHAPTER 3

3.1. DISCUSSION

N, a 2-years-old girl, 9.5 kg, 82 cm, was admitted to the Infection Unit of

Haji Adam Malik General Hospital with chief complaint of shortness of breath.

The shortness of breath occurred since 2 days ago and getting worst in 1 day

before she admitted to the hospital. The shortness of breath was not related to

activity and weather. Cyanosis was not found. Productive cough occurred since 3

day ago. Fever was found since 1 week ago with a characteristic of high fever

which relieved with fever relieving medication. Shivers and seizures were not

found. History of diarrhea was found since 5 days ago with frequency 5 times a

day and the volume was 20cc/diarrhea. Currently the patient is having watery

stool. This patient was referred to Haji Adam Malik Hospital by pediatrician with

bronchopneumonia and gastroenteritis without dehydration.

Bronchopneumonia is a type of pneumonia that is characterized by an

inflammation of the lung generally associated with, and following about with

bronchiolitis. Bronchopneumonia or bronchial pneumonia or bronchogenic

pneumonia is an acute inflammation of the walls of the bronchioles. Pneumonia is

most often caused by a bacterial infection (bacterial pneumonia) or a viral

infection (viral pneumonia). The insiden of pneumonia is 10 times higher in

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http://www.wrongdiagnosis.com/b/bacterial_diseases/intro.htm

developing than in developed countries, with as many as 5 million deaths

occurring yearly in children younger than 5 years. In this case patient is a girl 2

years old.

In clinical feature, fever and difficulty in breathing are commonest

presenting symtoms, usually preceded by an upper respiratory tract infection. In

this case patient was admitted with chief complaint shortness of breath, fever was

found since 1 week ago and her temperature 40,50C, productive cough occurred

since 3 day ago.

Pneumonia results from inflammation of the alveolar space and may

compromise air exchange. While often complicating other lower respiratory

infections such as bronchiolitis or laryngotracheobronchitis, pneumonia may also

occur via hematogenous spread or aspiration. Most commonly, this inflammation

is the result of invasion by bacteria, viruses, or fungi, but it can occur as a result of

chemical injury or may follow direct lung injury. In the young infant, aged 1-3

months most pneumonia in this age group is community acquired and involves

Streptococcus pneumoniae, Staphylococcus aureus, and non-typeable

Haemophilus influenzae. Streptococcus pneumoniae is by far the most common

bacterial pathogen in this age group.

Usually preceded by upper respiratory tract infection. This disease usually

arises suddenly, the temperature increased 39-40 0C with chills, shortness of

breath and rapid, coughing productive "breath sounds" when percussion dim lung

examination, breath sounds during auscultation ronchi smooth wet and loud. The

laboratory found leukocytosis 15000-40000 / mm3. Photo thorax there

bronkopeumoni patches infiltrates in one or several lobes, if the pneumonia

lobaris seen a consolidation in one or several lobes.

Treatment decisions in children with pneumonia are dictated based on the

likely etiology of the infectious organism and the age and clinical status of the

patient. Antibiotic administration must be targeted to the likely organism, bearing

in mind the age of the patient, the history of exposure, the possibility of resistance

(which may vary, depending on local resistance patterns), and other pertinent

history. Children in whom pneumococcal disease is suspected initially should be

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treated with amoxicillin or penicillin. A macrolide antibiotic alone, or in

combination with sulfisoxazole or an oral cephalosporin is an alternative.

Fortunately, most children with pneumonia recover without complications.

Persistent effusions and empyemas are the most common serious complications of

bacterial pneumonia

Patients who were placed on a protocol-driven pneumonia clinical

pathway are more likely to have favorable outcomes. The prognosis for most

forms of pneumonia is excellent. Most cases of viral pneumonia resolve without

treatment, common bacterial pathogens and atypical organisms respond to

antimicrobial therapy.

This patient N, a 2-years-old girl had shortness of breath, productive

cough, high fever, and history of diarrhea was found. Physical examination found

nasal flaring, chest symmetrical fusiformic, retraction, ronchi on both left and

right lower lungs. From chest X-ray showed infiltrated on right lower lung

(pericardial). Thus, the patient was diagnosed as bronchopneumonia.

3.2. SUMMARY

It has been reported a case of a 2-years-old girl with Bronchopneumonia.

The diagnosis was established based on history taking, clinical manifestation, and

laboratory findings. Treatment for this patient was only supportive and

symptomatic. This patient was discharged after free from any complaint such as

shortness of breath, fever, and diarrhea.

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REFERENCES

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Respiratory Tract in Children Seventh Edition. USA: Saunders Elsevier.

Page: 441-451.

2. Lissauer, T., Clayden, G., 2007. Illustrated Textbook of Paediatrics Third

Edition. London: Mosby Elsevier. Page: 268-270.

3. Mansjoer, A., Supriohata, Wardhani, W.I., 2000. Kapita Selekta Kedokteran

Edisi Ketiga Jilid Kedua. Jakarta: Media Aesculapius. Page: 465-468.

4. Mark I Neuman, MD, MPH, 2010. Pediatrics Pneumonia. Emedicine.

Available from: http://emedicine.medscape.com/ . [Accessed December 6th

2010]

5. Nicholas John Bennett, MB, BCh\ 2010. Pneumonia. Emedicine. Available

from: http://emedicine.medscape.com/ . [Accessed December 6th 2010]

6. Wahyuni, N., 2009. Bronkopneumonia. Medpaper. Available from:

http://ningrumwahyuni.wordpress.com/2009/08/03/bronkopneumonia/

[Accessed December 7th 2010]

7. Nader Kamangar, MD, 2010. Bacterial Pneumonia. Emedicine. Available

from: http://emedicine.medscape.com/ . [Accessed December 6th 2010]

8. Perhimpunan Dokter Paru Indonesia. 2003. Pedoman Diagnosis dan

Penatalaksanaan di Indonesia: Perhimpunan Dokter Paru Indonesia.

9. Price, S.A., Wilson, L.M., 2006. Patofisiologi Konsep Klinis Proses-Proses

Penyakit Volume 2 Edisi 6. Jakarta: EGC. Page: 804-810.

10. Rahajoe, N.N., Supriyatno, B., Setyanto, D.B., 2008. Buku Ajar Respirologi

Anak Edisi Pertama. Jakarta: Badan Penerbit IDAI. Page: 333-365.

11. Theodore C. Sectish, Charles G. Prober. Pneumonia. In: Behrman, Richard

E., Kliegman, Robert M., Jenson, Hal B. (eds). Nelson Textbook of

Pediatrics 17th ed. USA: Saunders. 2004; Page: 1433-1435.

12. Wickham, H., 2010. Pathophysiology. Creative Commons. Page: 15-19.

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http://emedicine.medscape.com/

http://ningrumwahyuni.wordpress.com/2009/08/03/bronkopneumonia/



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