study guide the respiratory system and disorders...able to manage major lung diseases (tbc, asthma,...

Study Guide Respiratory System and Disorders

Department of Medical Education - Faculty of Medicine - Universitas Udayana, 2017

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STUDY GUIDE THE RESPIRATORY SYSTEM AND DISORDERS

Planners

Prof. Dr.dr.Ida Bagus Ngurah Rai, Sp.P

Dr. dr. I Made Muliarta, M.Kes

Prof. dr.Wiryana, Sp.An KIC

Prof.dr I Gusti Made Aman, Sp.FK

dr. Winarti, Sp.PA

Dr. dr. Desak Wihandani, M.Kes

dr. Putu Gede Sudira, Sp.S

Contributors

Prof. Dr. dr. Ida Bagus Ngurah Rai, SpP

dr. IGN Sri Wiryawan, M.Repro

dr. Gede Wardana, M.Biomed

Dr. dr. Dsk Made Wihandani, M.Kes

Dr. dr. Ida Bagus Subanada, Sp.A

dr. Dewa Artika, Sp.P

dr. Ida Bagus Suta, Sp.P

dr. Made Bagiada, Sp.PD-KP

Prof. dr I Gst. Md. Aman, Sp.FK

Dr. dr. Muliarta, M.Kes

dr. IGN Bagus Artana, Sp.PD

Dr. dr. Ketut Putu Yasa, Sp.BTKV

Dr. dr. Elysanti Martadiani, Sp.Rad

dr. Putu Ekawati, M.Repro, Sp.PA

dr. Aryabiantara, Sp.An KIC

dr.Putu Siadi Purniti, Sp.A

dr. Ayu Setyorini, Sp.A

dr. DGA Eka Putra, Sp.THT

dr. Luh Made Ratnawati, Sp.THT(KL)

dr. Putu Andrika, Sp.PD-KIC

dr. Gede Ketut Sajinadiyasa, Sp.PD

Prof. Dr. dr. Suardana, Sp.THT

Editors

dr. Putu Gede Sudira, Sp.S

dr. IGA Sri Darmayani, Sp.OG

Layout

Anak Agung Istri Sarastriyani Dewi

First Edition February 2017

All rights reserved. No part of this publication mayy be reproduced, stored in a retrieval system,

or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or

otherwise without prior written permission of the publisher.

Published by Department of Medical Education Medicine Programme, Faculty of Medicine,

Universitas Udayana.



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CONTENTS

STUDY GUIDE THE RESPIRATORY SYSTEM AND DISORDERS ............................................... 2

CONTENTS........................................................................................................................................... 3

PREFACE ............................................................................................................................................. 5

GENERAL CURRICULUM RESPIRATORY SYSTEM AND DISORDERS .................................... 6

PLANNERS AND LECTURERS .......................................................................................................... 9

FACILITATORS .................................................................................................................................. 10

LEARNING ACTIVITY ........................................................................................................................ 11

IMPORTANT INFORMATIONS ......................................................................................................... 11

STUDENT PROJECT ......................................................................................................................... 12

ARTICLE REVIEW ASSESSMENT FORM ...................................................................................... 14

SELF ASSESSMENT ......................................................................................................................... 15

ASSESSMENT METHOD .................................................................................................................. 15

GENERAL TIME TABLE FOR A AND B CLASSES ........................................................................ 15

TIME TABLE OF CLASSES .............................................................................................................. 16

LEARNING PROGRAMS ................................................................................................................... 22

LECTURE 1......................................................................................................................................... 22

LECTURE 2......................................................................................................................................... 23

LECTURE 3......................................................................................................................................... 24

LECTURE 4......................................................................................................................................... 26

LECTURE 5......................................................................................................................................... 26

LECTURE 6......................................................................................................................................... 27

LECTURE 7......................................................................................................................................... 28

LECTURE 8......................................................................................................................................... 29

LECTURE 9......................................................................................................................................... 30

LECTURE 10 ...................................................................................................................................... 30

LECTURE 11 ...................................................................................................................................... 31

LECTURE 12 ...................................................................................................................................... 32

LECTURE 13 ...................................................................................................................................... 33

LECTURE 14 ...................................................................................................................................... 34



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LECTURE 15 ...................................................................................................................................... 35

LECTURE 16 ...................................................................................................................................... 38

LECTURE 17 ...................................................................................................................................... 40

LECTURE 18 ...................................................................................................................................... 42

LECTURE 19 ...................................................................................................................................... 44

LECTURE 20 ...................................................................................................................................... 44

BASIC CLINICAL SKILLS .................................................................................................................. 47

REFERENCES ................................................................................................................................... 50

CURRICULUM MAP........................................................................................................................... 51



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PREFACE

The medical curriculum has become increasingly vertically integrated, with stronger basic

concept and support by clinical examples and cases to help in the understanding of the

relevance of the underlying basic science. Basic science concepts may help in the

understanding of the pathophysiology and treatment of diseases. Respiratory system and

disorders block has been written to take account of this trend, and to integrate core aspects of

basic science, pathophysiology and treatment into a single, easy to use revision aid.

The respiratory system consists of a pair of lungs within the thoracic cage. Its main

function is gas exchange, but other roles include speech, filtration of microthrombin arriving from

systemic veins and metabolic activities such as conversion of angiotensin I to angiotensin II and

removal or deactivation of serotonin, bradykinin, norepinephrine, acetylcholine and drugs such

as propranolol and chlorpromazine. So this block will discuss about anatomy, histology,

symptom and signs of lung disease and its pathophysiology, major upper respiratory diseases,

major lung diseases, major pediatric lung disease, and basic principle concept to education,

prevention, treatment and rehabilitation in respiratory system disorder in patient, family and

community.

The learning process will be carried out for 4 weeks (20 working days) starts from 20th of

February 2017 as shown in the time table. The final examination will be conducted on 30th of

March 2017 in the form of MCQ. The learning situation include lecture, individual learning, small

group discussion, plenary session, practice, and clinical skills.

Most of the learning material should be learned independently and discuss in SGD by the

students with the help of facilitator. Lecture is given to emphasize the most important thing of

the material. In small group discussion, the students gave learning task to lead their discussion.

This simple study guide need more revision in the future, so that the planners kindly invite

readers to give any comments and critics for its completion. Thank you.

Planners



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GENERAL CURRICULUM RESPIRATORY SYSTEM AND DISORDERS

Aims:

Comprehend the structure, physiologic, and pathologic of the respiratory system. Interpret the laboratory and imaging examination of the respiratory system disorders. Diagnose and treat the patient with common respiratory system disorders. Plan education, prevention, management and rehabilitation of respiratory system

disorders to patient, family and community.

Learning outcomes:

Concern about the size of problem and diversity of respiratory disease in the community.

Able to describe the structure and function of the respiratory system. Able to interpret the result of examination (physical, laboratory, function test, blood gas

analysis and chest imaging). Able to explore patients with respiratory problem (runny nose, cough, dyspnea, non

cardiac chest pain, hemoptysis). Able to manage major upper respiratory diseases (tonsillitis, rhinitis, sinusitis). Able to manage major lung diseases (TBC, asthma, COPD, lung cancer, pneumonia,

occupational lung disease, pleural disease) on patient, family and community. Able to manage major pediatric lung disease (bronchiolitis, TB, asthma). Able to implement DOTS program against TB. Able to implement the strategy of smoking cessation, especially in patient with

respiratory disease.

Curriculum contents:

Structural and function of the respiratory system. Physiology of lung in related with oxygen consumption and acid base balance. Symptoms and signs of lung disease. Pathophysiology of respiratory system disorders. Basic physical, laboratory and imaging examination. Interpretation of examination results. Drugs that commonly used in respiratory system disorders (decongestant, anti-asthma &

bronchodilators, antitussive, expectorant. Basic principle concept to education, prevention, treatment and rehabilitation in

respiratory system disorders in patient, family and community.

Curriculum structure:

Structure of curriculum mainly is derive from general competences of Indonesian general

practioner. Those competences in diagnosing diseases and doing clinical skills should be

mastered by all the general practioners here. Local values of our institutions are also considered

as added values in this curriculum.



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No Daftar Penyakit sesuai SKDI 2012 Tingkat Kemampuan 1 Influenza 4A 2 Pertusis 4A 3 Acute Respiratory distress syndrome (ARDS) 3B 4 SARS 3B 5 Flu burung 3B

Laring dan Faring 6 Faringitis 4A 7 Tonsilitis 4A 8 Laringitis 4A 9 Hipertrofi adenoid 2 10 Abses peritonsilar 3A 11 Pseudo-croop acute epiglotitis 3A 12 Difteria (THT) 3B 13 Karsinoma laring 2 14 Karsinoma nasofaring 2

Trakea 15 Trakeitis 2 16 Aspirasi 3B 17 Benda asing 2

ParuParu 18 Asma bronkial 4A 19 Status asmatikus (asma akut berat) 3B 20 Bronkitis akut 4A 21 Bronkiolitis akut 3B 22 Bronkiektasis 3A 23 Displasia bronkopulmonar 1 24 Karsinoma paru 2 25 Pneumonia, bronkopneumonia 4A 26 Pneumonia aspirasi 3B 27 Tuberkulosis paru tanpa komplikasi 4A 28 Tuberkulosis dengan HIV 3A 29 Multi Drug Resistance (MDR) TB 2 30 Pneumothorax ventil 3A 31 Pneumothorax 3A 32 Efusi pleura 2 33 Efusi pleura masif 3B 34 Emfisema paru 3A 35 Atelektasis 2 36 Penyakit Paru Obstruksi Kronik (PPOK) eksaserbasi akut 3B 37 Edema paru 3B 38 Infark paru 1 39 Abses paru 3A 40 Emboli paru 1 41 Kistik fibrosis 1 42 Haematothorax 3B 43 Tumor mediastinum 2 44 Pnemokoniasis 2 45 Penyakit paru intersisial 1 46 Obstructive Sleep Apnea (OSA) 1



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No Keterampilan Klinis sesuai SKDI 2012 Tingkat Keterampilan

PEMERIKSAAN FISIK

1 Inspeksi leher 4A

2 Palpasi kelenjar ludah (submandibular, parotid) 4A

3 Palpasi nodus limfatikus brakialis 4A

4 Palpasi kelenjar tiroid 4A

5 Rhinoskopi posterior 3

6 Laringoskopi, indirek 2

7 Laringoskopi, direk 2

8 Usap tenggorokan (throat swab) 4A

9 Oesophagoscopy 2

10 Penilaian respirasi 4A

11 Inspeksi dada 4A

12 Palpasi dada 4A

13 Perkusi dada 4A

14 Auskultasi dada 4A

PEMERIKSAAN DIAGNOSTIK

15 Persiapan, pemeriksaan sputum, dan interpretasinya

(Gram dan Ziehl Nielsen [BTA]) 4A

16 Pengambilan cairan pleura (pleural tap) 3

17 Uji fungsi paru/spirometri dasar 4A

18 Tes provokasi bronkial 2

19 Interpretasi Rontgen/foto toraks 4A

20 Ventilation Perfusion Lung Scanning 1

21 Bronkoskopi 2

22 ip)B superfisial 2

23 Trans thoracal needle aspiration (TINA) 2

TERAPEUTIK

24 Dekompresi jarum 4A

25 Pemasangan WSD 3

26 Ventilasi tekanan positif pada bayi baru lahir 3

27 Perawatan WSD 4A

28 Pungsi pleura 3

29 Terapi inhalasi/nebulisasi 4A

30 Terapi oksigen 4A

31 Edukasi berhenti merokok 4A



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PLANNERS AND LECTURERS

No Name Department Phone

1 Prof. Dr. dr. Ida Bagus Ngurah Rai, Sp.P

(Coordinator) Pulmonology 08123804579

2 Dr. dr. I Made Muliarta, M.Kes (Secretary) Physiology 081338505350

3 Prof. dr. Wiryana, Sp.An KIC (member) Anaesthesiology 0811392171

4 Prof. dr I Gst. Md. Aman, SpFK (member) Pharmacology 081338770650

5 dr.Winarti, Sp.PA (member) Pathology Anatomy 08123997328

6 Dr. dr. Desak Wihandani, M.Kes (member) Biochemistry 081338776244

7 dr. Putu Gede Sudira, Sp.S (member) DME 081805633997

8 dr. I GN Sri Wiryawan, M.Repro Histology 08123925104

9 dr. Gede Wardana, M.Biomed Anatomy 0361-7864957

10 Dr. dr. Ida Bagus Subanada, Sp.A Paediatric Dept. 0812399533

11 dr. Dewa Artika, Sp.P Pulmonology 08123875075

12 dr. Ida Bagus Suta, Sp.P Pulmonology 08123990362

13 dr. Made Bagiada, Sp.PD-KP Pulmonology 08123607874

14 dr. IGN Bagus Artana, Sp.PD Pulmonology 08123994203

15 Dr. dr. Ketut Putu Yasa, Sp.BTKV Thorax surgery 08123843260

16 Dr. dr. Elysanti Martadiani, Sp.Rad Radiology 08123807313

17 dr. Putu Ekawati, M.Repro, Sp.PA Pathology Anatomy 08123958158

18 dr. Aryabiantara, Sp.An KIC Anaesthesiology 08123822009

19 dr. Putu Siadi Purniti, Sp.A Paediatric 08123812106

20 dr. Ayu Setyorini, Sp.A Paediatric 081353286780

21 dr. DGA Eka Putra, Sp.THT Otorhinolaryngology 0813387826317

22 dr. Luh Made Ratnawati, Sp.THT(KL) Otorhinolaryngology 08123806108

23 dr. Putu Andrika, Sp.PD-KIC Pulmonology 08123989192

24 dr. Gede Ketut Sajinadiyasa, Sp.PD Pulmonology 085237068670

25 Prof. Dr. dr. Suardana, Sp.THT Otorhinolaryngology 0811385299



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FACILITATORS

Regular Class (Class A)

No Name Group Departement Phone Venue

(2ndfloor)

1 dr Muliani M.Biomed A1 Anatomy 085103043575 3rd floor: R.3.09

2 dr IA Dewi Wiryanthini M.Biomed

A2 Biochemistry 081239990399 3rd floor: R.3.10

3 dr Ni Putu Wardani M.Biomed Sp.An

A3 DME 08113992784 3rd floor: R.3.11

4 dr I Kadek Swastika M.Kes A4 Parasitology 08124649002 3rd floor: R.3.12

5 dr I Putu Adiartha Griadhi M.Fis

A5 Physiology 081999636899 3rd floor: R.3.13

6 dr Putu Aryani MPH A6 Public Health 082237285856 3rd floor: R.3.14

7 dr Ni Putu Ekawati M.Repro Sp.PA

A7 Pathology of Anatomy

08113803933 3rd floor: R.3.15

8 dr Ni Nyoman Metriani Nesa Sp.A M.Sc

A8 Pediatry 081337072141 3rd floor: R.3.16

9 dr Ni Made Ayu Surasmiati M.Biomed Sp.M

A9 Ophtalmology 081338341860 3rd floor: R.3.17

10 dr.IGAA.Dwi Karmila,SpKK A10 Dermatovenerology

08123978446 3rd floor: R.3.19

English Class (Class B)

No Name Group Departement Phone Venue

(2ndfloor)

1 dr Putu Gede Sudira Sp.S B1 DME 081805633997 3rd floor: R.3.09

2 Dr rer nat dr Ni Nyoman Ayu Dewi M.Kes

B2 Biochemistry 081337141506 3rd floor: R.3.10

3 dr IGA Dewi Ratnayanti M.Biomed

B3 Histology 085104550344 3rd floor: R.3.11

4 dr NN Dwi Fatmawati Sp.MK PhD

B4 Microbiology 087862200814 3rd floor: R.3.12

5 dr Agung Nova Mahendra M.Sc

B5 Pharmacology 087861030195 3rd floor: R.3.13

6 dr I Wayan Juli Sumadi Sp.PA

B6 Pathology of Anatomy

082237407778 3rd floor: R.3.14

7 Dr dr IBG Fajar Manuaba Sp.OG MARS

B7 Obsgyn 081558101719 3rd floor: R.3.15

8 dr Dewa Gede Mahiswara S Sp.Rad

B8 Radiology 08123846307 3rd floor: R.3.16

9 dr I Made Putra Swi Antara Sp.JP FIHA

B9 Cardiology 08123804782 3rd floor: R.3.17

10 dr Kumara Tini Sp.S FINS B10 Neurology 081238701081 3rd floor: R.3.19



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LEARNING ACTIVITY

There are several types of learning activity:

Lecture

Plenary session

Independent learning based on the lecture’s topic

Small group discussion to solve the learning task

Practicing

Student project

Clinical skill and demonstration

Self assessment at the end of every topic

Lecture will be held at room 3.01 (3rd floor), while discussion rooms available at 3rd floor

(room A309-A317, A319).

IMPORTANT INFORMATIONS

Meeting of the students’ representative

In the middle of block schedule, a meeting is designed among the student representatives

of every small group discussions, facilitators, and resource persons. The meeting will discuss

the ongoing teaching learning process, quality of lecturers and facilitators as a feedback to

improve the next process. The meeting will be taken based on schedule from Medical Education

Unit.



12

STUDENT PROJECT

Title of student project

Group discussion Topic

A1

A2

A3

A4

A5

A6

A7

A8

A9

A10

B1

B2

B3

B4

B5

B6

B7

B8

B9

B10

About Topic, Presentation’s place and schedules, Task rules, Assessment, and Evaluator will

be discussed at lecture of block introduction 20th February 2017.



13

TITLE

(subject/ topic: choose from compentency list)

Name

NIM

Faculty of Medicine, Udayana University

2017

______________

1. Introduction (Pendahuluan)

2. Content (Isi, sesuai topik yang dibahas)

3. Summary (Ringkasan)

4. Refferences: (Daftar Pustaka) Van Couver style

Example:

Journal

Sheetz MJ, King GL. Molecular understanding of hyperglycemia’s adverse effect for

diabetic complications. JAMA. 2002;288:2579-86.

Textbook

Libby P. The Pathogenesis of atherosclerosis. In: Braunwald E, Fauci A, Kasper D,

Hoster S, Longo D, Jamason S (eds). Harrison’s principles of internal medicine. 15th ed.

New York: McGraw Hill; 2001. p. 1977-82.

Internet

WHO. Obesity: preventing and managing the global epidemic. Geneva: WHO 1998.

[cited 2005 July]. Available from:

http://www.who.int/dietphysicalactivity/publications/facts/ obesity/en.

6 – 10 pages, 1.5 space, Times new romance 12



14

ARTICLE REVIEW ASSESSMENT FORM

Faculty of Medicine, Udayana University

___________________________________________________________________________

Block : Respiratory System and Disorders

Name : ________________________________________

Student No. (NIM) : ________________________________________

Facilitator : ________________________________________

Title :

__________________________________________________

__________________________________________________

Time table of consultation

Point of discussion Week Date Tutor sign

1. Title 1

2. Refferences 1

3. Outline of paper 2

4. Content 3

5. Final discussion 4

Assessment

A. Paper structure : 7 8 9 10

B. Content : 7 8 9 10

C. Discussion : 7 8 9 10

Total point : ( A + B + C ) : 3 = _____________

Denpasar, ______________________

Facilitator,



15

SELF ASSESSMENT

Self assessment of each lecture will be given after each lecture session, and will be

marked. This mark can determine whether the student pass this block or not. Any final mark

between 62 - 64 will be reconsidered with self assessment’s mark to see the student’s status.

Any student with self assessment’s mark 65 or more will pass this block. And for the lower one

will have to attend the remedial examination. It is important to do this self assessment

cautiously, because this activity may be your ticket to pass this block just at first examination.

ASSESSMENT METHOD

Assessment in this theme consists of:

SGD : 5%

Final Exam : 80%

Student Project : 15%

Final mark 65 or more considered to pass this block. Certain conditions applied for those

with final mark between 62 – 64. These students will be analyzed using their self assessment’s

mark. Students with final mark 62 – 64 and self assessment’s mark equal or more than 65 will

also considered pass this block. The value of marking:

A ≥ 80

B+ >70-79

B 65-70

GENERAL TIME TABLE FOR A AND B CLASSES

CLASS A CLASS B

TIME ACTIVITIES TIME ACTIVITIES

08.00-09.00 Lecture 09.00-10.00 Lecture

09.00-10.30 Independent learning 10.00-11.30 Student project

10.30-12.00 SGD 11.30-12.00 Break

12.00-12.30 Break 12.00-13.30 Independent learning

12.30-14.00 Student project 13.30-15.00 SGD

14.00-15.00 Plenary session 15.00-16.00 Plenary session



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TIME TABLE OF CLASSES

DAY/DATE Class A Class B ACTIVITY VENUE PIC

1

Monday

Feb 20,

2017

08.00-08.30 09.00-09.30 Introduction Class room Prof.I.B. Rai

08.30-09.00 09.30-10.00

Lecture 1 Anatomy of

Respiratory System

Class room dr.Wardana

09.30-10.30 12.00-13.30 Independent learning

10.30-12.00 13.30-15.00 SGD Disc room Facilitator

12.00-12.30 11.30-12.00 Break

12.30-14.00 10.30-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr.Wardana

2

Tuesday

Feb 21,

2017

08.00-09.00 09.00-10.00

Lecture 2 Histology of

Respiratory System

Class room

dr. Sri

Wiryawan



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Sri

Wiryawan

3

Wednesda

y

Feb 22,

2017

08.00-09.00 09.00-10.00

Lecture 3 Physiology of

Respiratory System:

Ventilation

Class room dr. Muliarta



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Muliarta

4

Thursday

Feb 23,

2017

08.00-09.00 09.00-10.00

Lecture 4 Physiology of

Respiratory System:

Gas Exchange, diving,

altitude

Class room dr. Muliarta

09.00-15.00 10.00-16.00

Independent learning

Practice:

Anatomy, Histology

Anatomy: 1st

floor

dr. Wardana

Histology: 4th

floor

dr. Sri

Wiryawan



17

5

Friday

Feb 24,

2017

08.00-09.00 09.00-10.00

Lecture 5 Carriage of oxygen and

Carbon dioxide

Class room dr. Desak

Wihandani



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Desak

Wihandani

6

Monday

Feb 27,

2017

08.00-09.00 09.00-10.00

Lecture 6 Control of acid base

balance, Arterial Gas

Analysis (AGA)

Class room dr. Desak

Wihandani



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Desak

Wihandani

7

Tuesday

Feb 28,

2017

08.00-09.00 09.00-10.00

Lecture 7 Control of Respiratory

Function and Blood

Gas Analyzes

Class room dr. Arya

Biantara



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room Prof. Wiryana

8

Wednesda

y

March 1,

2017

08.00-09.00 09.00-10.00

Lecture 8 Pathology of

Respiratory Tract

Class room dr. Ekawati



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project Hospital Visit

14.00-15.00 15.00-16.00 Plenary session Class room dr. Ekawati

9

Thursday

March 2,

2017

08.00-09.00 09.00-10.00

Lecture 9 Lung Defense

Mechanism

Class room dr. Ekawati

09.00-15.00 10.00-16.00

Independent learning

Practice : Physiology,

Pathology Anatomy (PA)

Physiology:

2nd floor dr. Muliarta

PA: Joint Lab

(4th floor) dr. Ekawati



18

10

Friday

March 3,

2017

08.00-09.00 09.00-10.00

Lecture 10

Pharmacological and

non pharmacological

interventions

Class room Prof. Aman



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room Prof. Aman

11

Monday

March 6,

2017

08.00-09.00 09.00-10.00

Lecture 11

Pharmacological and

non pharmacological

interventions

Class room

Prof. Aman



12.00-12.30 11.30-12.00 Break


14.00-15.00 15.00-16.00 Plenary session Class room Prof. Aman

12

Tuesday

March 7,

2017

08.00-09.00 09.00-10.00 Lecture 12

Respiratory Imaging Class room dr. Elysanti



12.00-12.30 11.30-12.00 Break


14.00-15.00 15.00-16.00 Plenary session Class room dr. Elysanti

13

Wednesda

y

March 8,

2017

08.00-09.00

09.00-10.00

09.00-10.00

10.00-11.00

Lecture 13

Bronchiolitis, asthma in

children, Pneumonia,

Bronkopneumonia,

Class room

dr. IB

Subanada

dr. Ayu

Setyorini



13.00-13.30 11.30-12.00 Break

13.30-14.00 11.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. IB

Subanada

14

Thursday

March 9,

2017

08.00-09.00

09.00-10.00

09.00-10.00

10.00-11.00

Lecture 14 Aspiration Pneumonia,

Pertusis

TB in children, Difteri

Class room

dr. Ayu

Setyorini

dr. Siadi

Purniti



13.00-13.30 11.30-12.00 Break

13.30-14.00 11.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Siadi

Purniti



19

15

Friday

March 10,

2017

08.00-09.00

09.00-10.00

09.00-10.00

10.00-11.00

Lecture 15

Pulmonary TB and

Extrapulmonary TB,

TB in the

Immunocompromised

Host, Abses TB

Class room

dr. Sutha,

dr. Bagiada



13.00-13.30 11.30-12.00 Break


14.00-15.00 15.00-16.00 Plenary session Class room dr. Sutha,

dr. Bagiada

16

Monday

March 13,

2017

08.00-09.00 09.00-10.00

Lecture 16

Asthma,

COPD

Class room

Prof. IB Rai,

dr. Artana



12.00-12.30 11.30-12.00 Break

12.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room Prof. IB Rai,

dr. Artana

17

Tuesday

March 14,

2017

08.00-09.00

09.00-10.00

09.00-10.00

10.00-11.00

Lecture 17

Pleural effusion,

Emfisema, edema paru

Pneumothorax,

Hematothorax

Class room

dr. Andrika,

dr, Yasa



13.00-13.30 11.30-12.00 Break

13.30-14.00 11.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room dr. Andrika,

dr, Yasa

18

Wednesda

y

March 15,

2017

08.00-09.00

09.00-10.00

08.00-09.00

09.00-10.00

Lecture 18

Bronchitis and

Bronchiectasis,

Lung Ca and Education

of Smoking Cessation

Class room

dr.IB Suta,

dr. Saji



13.00-13.30 11.30-12.00 Break

13.30-14.00 10.00-11.30 Student project

14.00-15.00 15.00-16.00 Plenary session Class room

dr.IB Suta,

dr. Saji



20

19

Thursday

March 16,

2017

08.00-08.30

08.30-09.00

09.00-09.30

09.30-10.00

Lecture 19

Disorder of nose,

sinus, Nose foreign

Bodies

Class room

dr. Ratna,

Sp.THT



12.00-12.30 11.30-12.00 Break


14.00-15.00 15.00-16.00 Plenary session Class room dr. Ratna,

Sp.THT

20

Friday

March 17,

2017

08.00-09.00 08.00-09.00

Lecture 20

Disorder of larynx,

Disorder of Pharynx,

Throat foreign bodies

Class room

Prof.

Suardana, dr.

Dewa Artha

Eka Putra,

Sp.THT



12.00-12.30 12.00-12.30 Break


14.00-15.00 14.00-15.00 Plenary session Class room

Prof.

Suardana, dr.

Dewa Artha

Eka Putra,

Sp.THT

21

Monday

March 20,

2017

08.00-15.00 08.00-15.00

BCS: Physical diagnostic

examination of Thorax’s in

adult patients

BCS: Radio Imaging

BCS: Pemasangan dan

Perawatan WSD

(Pre-test, lecture, demo

Practice, discussion)

Physiology

Dept. (2nd

floor

Joint Lab

(4th Floor)

Anatomy (1st

floor)

Dr. Saji

dr. Elysanti

dr. Yasa

22

Tuesday

March 21,

2017

08.00-15.00 08.00-15.00

BCS: Spirometri

BCS: Pengambilan cairan

Pleura, Punksi, Dekompresi

jarum

BCS: Nebulisasi dan terapi

oksigen

(Pre-test, Lecture, practice,

demo)

Physiology

Dept. (2nd

floor

Joint Lab (4th

Floor)

Anatomy (1st

floor)

dr. Muliarta

dr. Yasa

dr. Arya

Biantara



21

23

Wednesda

y

March 22,

2017

08.00-15.00 08.00-16.00

BCS: Radio imaging



baby-children patients



adult patients

(Pre-test, lecture, practice,

demo)

Physiology

Dept. (2nd

floor

Joint Lab (4th

Floor)

Anatomy (1st

floor)

dr. Elysanti

dr. Ayu

Setyorini

dr. Saji

24

Thursday

March 23,

2017

08.00-15.00 08.00-16.00

BCS: Bronchoscopy,

Provocation test, Radio

Imaging

BCS: CPEP pada Bayi



adult patients

(Pre-test, lecture, demo)

Physiology

Dept. (2nd

floor

Joint Lab (4th

Floor)

Anatomy (1st

floor)

dr Artana

dr. Elysanti

dr. Arya

Biantara

dr. Saji

25

Friday

March 24,

2017

08.00-15.00 08.00-16.00



baby-children patients

BCS: Perawatan WSD,

Decompresi Jarum

BCS: Rhinoskopi Posterior

(Practice, post-test)

Physiology

Dept. (2nd

floor

Joint Lab (4th

Floor)

Anatomy (1st

floor)

dr. Ayu

Setyorini

dr. Yasa

THT staff

26

Thursday

March 30,

2017

Examination

27

Thursday

Jule 27,

2017

Remidial

Examination

Class Room : R. 3.01 (3rd Floor)



22

LEARNING PROGRAMS

LECTURE 1

ANATOMY OF RESPIRATORY TRACT

dr. I Nyoman Gede Wardana, M.Biomed

The respiratory system consists of conducting zone and respiratory zone. Conducting

zone, whose walls are too thick to permit exchange of gases between the air in the tube and the

blood stream. The nostrils (nares), nasal cavity, pharynx, larynx, trachea, bronchi, and terminal

bronchioles are included in this zone. Respiratory zone, whose walls are thin enough to permit

exchange of gases between tube and blood capillaries surrounding them. Air travels to the

lungs through that zone. The right lung divided into three lobes: superior, middle, and inferior.

The left lung divided into two lobes: superior and inferior. Each lung cover by a membrane that

called pleura. Both lungs are inside the thoracic cage. The thoracic cage is formed by the

vertebral column behind, the ribs, and intercostal spaces on other side and the sternum and

costal cartilages in front. Below it separated from the abdominal cavity by diaphragm

Learning Task

Vignette 1:

Kesawa, 32 years old, was seen in the clinic ten days ago, was diagnosed with rhinitis and sent

home with instructions for increased fluids, decongestants, and rest. Kesawa presents today

with worsened symptoms of malaise, low-grade temperature, nasal discharge, night time

coughing, mouth breathing, early morning pain over sinuses, and congestion. The doctor

diagnose he is suffering sinusitis.

1. Describe the boundaries of the nasal cavity and its blood supply! 2. Describe the paranasal sinuses and its opening at nasal cavity!

Vignette 2: Gotawa, a singer-18 years old came to clinic with complain a hoarse voice for 3 days. She also suffers sore throat, nose block, and fever. She was diagnosed laryngitis

1. Describe the structure of larynx and location of vocal cord! 2. Describe the intrinsic and extrinsic muscle of larynx!

Vignette 3: Mande, 30 years old male came to clinic with chief complaint difficulty to breath start from this morning. He also suffers cough, runny nose and fever. He has history bronchial asthma when he was 2 years old. The doctor diagnose he is suffering bronchial asthma.

1. Describe the structure of trachea! 2. Describe the different between right and left main bronchus! 3. Describe the principal different between trachea, bronchi, and bronchioles!

Vignette 4:

A 57-year-old male is admitted to the hospital with a chief complaint of shortness of breath for 2

weeks. The radiology examination shows a large left-side pleural effusion.

1. Describe the different between right lung and left lung! 2. Describe the structure of pleura! 3. Describe the structure of thoracic wall!



23

LECTURE 2

HISTOLOGY OF RESPIRATORY TRACT

dr. Sri Wiryawan, M.Repro

The lower respiratory tract consists of: the lower part of the trachea, the two main

bronchi, lobar, segmental, and smaller bronchi, bronchioles and terminal bronchioles, and last

but not least is the end respiratory unit. These structure make up the tracheobronchial tree. As

for the structure distal to the main bronchi along with a tissue known as the lung parenchyma.

There are several structure we should also understand, when talking about lower

respiratory tract. Several structures such as thorax, mediastinum, pleurae and pleural cavity,

and lung. Thorax especially thoracic cavity and thoracic wall protect our lung and mediastinum

and also play an important role in respiratory process. The mediastinum, which has a role in

protecting our heart , located between the two lungs, and contains the heart and great vessels,

trachea and esophagus, phrenic and vagus nerves, and lymph nodes.

The pleurae covers the external surface of the lung, and is then reflected to cover the

inner surface of thoracic cavity. Pleurae divided into the visceral (lines the surface of the lung)

and parietal (lines the thoracic wall and diaphragm) one. The space between these two pleurae

called as pleural cavity which contains a thin film fluid to allow the pleurae to slip over each

other during breathing.

The lungs are placed within the thoracic cavity. The lungs contain airways structure,

vessels, lymphatic and lymph nodes, nerves, and supportive connective tissue. The trachea

divides and form the left and right primary bronchi, which in turn divide to form lobar bronchi.

Each lobar bronchi divide again to give segmental bronchi to supply air to bronchopulmonary

segments. The tracheobronchial tree can also be classified into two functional zones: the

conducting zone (proximal to the respiratory bronchioles) which involved in air movement, and

the respiratory zone (distal to the terminal bronchioles) which involved in gaseous exchange.

The other term to show functional structure of the lower respiratory tract is the acinus.

The acinus defined as the part of the airway that is involved in gaseous exchange. The acinus

consist of respiratory bronchioles, alveolar ducts, and alveoli as the smallest functional structure

of the lung. The areas of lung containing groups of between three to five acini surrounded by

parenchimal tissue are called lung lobules.

The alveolus is an blind-ending terminal sac of respiratory tract. Most gaseous exchange

occurs in the alveoli. The alveoli are lined with type I (structural) and type II (produce surfactant)

of pneumocytes cell. The understanding about histological pattern of these functional structures

of the lung is important in pathophysiology of lung problems.

Learning Tasks

A. Structure of The Upper Respiratory tract Krishna, a man, 25 years old came to doctor Arjuna clinic with fever, sore throat, sneezing,

runny nose and sometimes blocked nose. He also cannot smell well. The doctor diagnoses

Krishna with acut Rhinopharingitis.

1. Describe the histological structure of the upper respiratory tracts are involved?

2. Describe the histological structure and function of epiglottis!

3. Compare the histological structure and function between vestibular fold and vocal fold!



24

B. Structure of The Lower Respiratory tract

Radha, a 17 years old beautiful girl, came to doctor Laksmi clinic with shortness of breath,

wheezing and cough with phlegm. The doctor diagnoses Radha with Asthma.

1. Describe the histological structure of the lower respiratory tracts are involved?

2. Compare the histological structure and function between terminal bronchioles and

respiratory bronchioles!

3. Describe the histological structure of the interalveolar septum!

4. Describe the histological structure of blood-air barrier?

5. Describe about the pulmonary surfactant?

LECTURE 3 PHYSIOLOGY OF RESPIRATORY SYSTEM: VENTILATION

dr. I Made Muliarta, MKes

In living cells aerobic metabolism consumes oxygen and produces carbon dioxide. Gas

exchange requires a large , thin, moist exchange surface, a pump to move air circulatory

system to transport gases to cells. The primary function system are:

Exchange the gases between atmosphere and the blood.

Homeostatic regulation of body pH .

Protection from inhaled pathogens and irritation substance

Vocalization.

In addition to serving these function, the respiratory system also source of significant losses

of water and heat from the lung.

A single respiratory cycle consists of an inspiration and expiration. Relation with ventilation

had to know about compliance, surfactant, lung volume and capacities

Respiratory control resides in a central pattern generator, a net work of neurons in the pons

and medulla oblongata.



25

Learning Task

1. What is the sequence of event during quiet inspiration (muscle involvement, pressure

changes (intrapulmonary and intrapleura), volume changes)!

2. What is pulmonary ventilation and alveolar ventilation means?

3. Andi, male, 30 years old, has a puncture wound due to car accident in his right chest and

penetrate his pleural cavity. The patient has complained shortness of breathing and doctor

determine that his lung is collapsed.

a. What is this condition called?

b. Describe the mechanism of the lung collapse!

c. What kind respiratory system compensation to anticipate this condition (lung collapse)?

d. How can he still be alive in this condition?

4. Describe the Boyle’s Law!



26

LECTURE 4 PHYSIOLOGY OF RESPIRATORY SYSTEM: GAS EXCHANGE, DIVING, ALTITUDE

dr. I Made Muliarta, Mkes

Gas exchange during external respiration occurs in respiratory membrane. Several factors

may influence gas exchange. Dalton’s law and Henry’s law may apply during gas exchange.

Some physiologic responses on respiratory system at high altitude and during diving.

Some illnesses/injuries related pressure change may occurs at high altitude and during diving.

Learning Task

1. Describe the Dalton’s Law!

2. Describe the factors that influence oxygen diffusion from alveoli into the blood!

3. Predict the response of the pulmonary arterioles and bronchioles when PO2 increase and

PCO2 decrease!

4. Describe some illnesses/ injuries due to high altitude!

5. Describe some illnesses/ injuries due to diving!

LECTURE 5 CARRIAGE OF OXYGEN AND CARBON DIOXIDE

dr. Desak Wihandani

The supply of oxygen to the tissues is our most immediate physical need. We take in

about 250 ml of oxygen gas per minute and this is our most pressing physical need. If our

oxygen supply is interrupted for more than a few minutes, irreversible damage is done to some

tissues, notably the brain. Oxygen is abundantly available in the air around us but cannot diffuse

into our tissues at sufficient rate to meet our needs. It must be transported from the lung, the

specialized organ for gas exchange, by the blood to all the other tissue.

While oxygen has to be transported from lungs to tissues, carbon dioxide must be

transported from the tissues for excretion by the lungs. Carbon dioxide has physicochemical

properties that make its transport less difficult then transport of oxygen. Carbon dioxide can be

transported in the blood in three ways: in simple solution, by reversible conversion to

bicarbonate and by reversible combination with haemoglobin to form carbamino haemoglobin.

Learning Task:

1. Describe the structure and function of hemoglobin!

2. Describe the mechanism of oxygen binding to hemoglobin!

3. Describe the differences between hemoglobin and myoglobin!

4. Describe the mechanism of oxygen binding to myoglobin!

5. Describe conformational differences between deoxygenated and oxygenated Hb!

6. Summarize the processes by which carbondioxide is transported from peripheral tissues

to the lungs!



27

LECTURE 6 CONTROL OF ACID BASE BALANCE, ARTERIAL GAS ANALYSIS (AGA)

dr. Desak Wihandani

Acid-Base Balance

There is large daily flux of oxygen, carbon dioxide and hydrogen ion through the human body.

Carbon dioxide generated in tissues dissolves in H2O to form carbonic acid, which in turn

dissociates releasing hydrogen ion. The blood concentration of hydrogen ion is constant, it

remains between 36 and 46 nmol/L (pH 7,36-7,46). Changes in pH will affect the activity of

many enzyme and tissue oxygenation. Problems with gas exchange and acid-base balance

underlie many diseases of respiratory system.

Blood Gases

Blood gas measurement is an important first-line investigation performed whenever there is a

suspicion of respiratory failure or acid-base disorders. In respiratory failure, the results of such

measurements are also an essential guide to oxygen therapy and assisted ventilation. The key

clinically used parameters are pH, pCO2 and pO2, the bicarbonate concentration is calculated

from pH and pCO2 values.

Learning Task:

1. Describe organs in our body involved in acid-base balance, and how they work!

2. Describe acid-base balance disorders! What is mean by :

a. Respiratory alkalosis,

b. metabolic alkalosis,

c. respiratory acidosis, and

d. metabolic acidosis?

3. In which condition respiratory acidosis and respiratory alkalosis occurs?

4. What is the importance of blood gas measurement. To perform measurement where are

the blood sample taken from? What kind of measurements are done?



28

LECTURE 7 CONTROL OF RESPIRATORY FUNCTION

Prof. Dr. dr. Wiryana, SpAn

When considering contol of breathing, the main control variable is PaCO2 (we try to

control this value near to 40 mmHg). This can be carried out by adjusting the respiratory rate,

the tidal volume, or both. By controlling PaCO2 we are effectively controlling alveolar ventilation

(see Ch.3) and thus PACO2. Although PaCO2 is the main control variable, PaO2 is also

controlled, but normally to a much lesser extent than PaCO2. However, the PaO2 control system

can take over and become the main controlling system when the PaO2 drops below 50 mmHg.

Control can seem to be brought about by:

1. Metabolic demands of the body (metabolic control)-tissue oxygen demand and acid-

base balance.

2. Behavioural demands of the body (behavioral control) – singing, coughing, laughing

(i.e.control is voluntary).

These are essentially feedback and feed-forward control systems, respectively. The

behavioural control of breathing overalys the metabolic control. Its control is derived from higher

centres of the brain. The axons of neurons whose cell bodies are situated in the cerebral cortex

bypass the respiratory centres in the brainstem and synapse directly with lower motor neurons

that control respiratory muscles. This system will not be dealt with in this next;we shall deal only

with the the metabolic control of respiration.

Learning Tasks

1. Discuss the central control of breathing with reference to the pontine respiratory group

and the dorsal-ventral respiratory groups of medulla spinalis!

2. List the different types of receptors involved in controlling the respiratory system!

3. Describe factors that stimulate central and peripheral chemoreceptor!

4. Outline the response of the respiratory system to change in carbon dioxide

concentration, oxygen concentration and pH!

5. Discuss the mechanism thought to influence the control of ventilation in exercise!

6. Discuss the changes that occur in response to high altitude!



29

LECTURE 8 PATHOLOGY OF UPPER AND LOWER URINARY TRACT

dr. Ni Wayan Winarti, SpPA

The term “upper airways” is used here to include the nose, pharynx, and larynx and their related parts. Disorders of these structures are among the most common afflictions of humans, but fortunately the overwhelming majority are more nuisances than threats. Inflammatory diseases are the most common disorders of the upper respiratory tract, i.e. rhinitis, sinusitis, pharyngitis, tonsillitis and laryngitis. It may occur as the sole manifestation of allergic, viral, bacterial or chemical insult. Although most infections are self-limited, they may at times be serious, especially laryngitis in infancy or childhood, when mucosal congestion, exudation, or edema may cause laryngeal obstruction. Tumors in these locations are infrequent but include the entire category of mesenchymal and epithelial neoplasms. Some distinctive types are nasopharyngeal angiofibroma, Sinonasal (Schneiderian) Papilloma, Olfactory Neuroblastoma and Nasopharyngeal Carcinoma.

Classification of lower respiratory tract (lung) diseases can be made based on the result of lung function test, although some authors prefer etiology and pathogenesis background. Some important diseases are obstructive lung disease (asthma, COPD, bronchiectasis) and restrictive lung disease (ARDS), and also infections, diseases of vascular origin and tumors. Pleura as protective structure of the lungs, are sometimes involved as secondary complication of some underlying disease, but in rare case, can be primary.

Because of the complexity of respiratory disease, it is important to understand their pathogenesis, supported by recognizing their morphologic changes. LEARNING TASK

Case 1

A male patient, 16 year old, came to a doctor with chief complaint difficulties in breathing. It has

occurred since 1 month ago. This patient suffers from rhinitis alergica since he was 3 year old.

On physical examination, a pedunculated nodule in right nasal cavity was found. It was whitish

in color, 1.5 cm in diameter occluding the nasal cavity.

1. Based on clinical finding, what is the most possible diagnosis? 2. What are the DDs? 3. Describe the morphological appearance (macroscopy and microscopy) that supposed to

be found to confirm your diagnosis! 4. Explain the pathogenesis of this diasease!

Case 2

A male patient, 65 year old, has suffered from dyspnea and productive cough since 1 year ago.

Lung function test showed increased of FEV1 with normal FVC (confirm an obstructive lung

disease). He is a heavy smoker since he was 25 year old. No history of atopy. No evidence of

cardiac disorders.

1. Mention 4 diseases including in the spectrum of obstructive lung disease! 2. Explain their pathogenesis! 3. Distinguish their morphology!

Case 3

A female patient, 50 year old, has suffered from tumor of right lung with pleural effusion. As the

first step to confirm the diagnosis, doctor asked the patient to do cytology test.

1. Mention some cytology test can be choose for this patient! 2. Among the test mention above (A), which one is the most simple and non-invasive? 3. And, discuss how to collect the specimen!



30

LECTURE 9 LUNG DEFENCE MECHANISM

dr. Ni Wayan Winarti, SpPA

Respiratory tract is an organ that constantly exposed by contaminated air. It is there fore a

small miracle that the normal lung parenchyma remains sterile. Fortunately, a plethora of

immune and non immune defense mechanisms exist in the respiratory system, extending from

the nasopharynx all the way into alveolar airspaces.

The major categories of defense mechanisms to be discussed include : (1) physical or

anatomic factors related to deposition and clearance of inhaled materials, (2) antimicrobial

peptides, (3) phagocytic and inflammatory cells that interact with inhaled materials, (4) adaptive

immune response, which depends on prior exposure to recognize the foreign materials. Each

components appears to have a distinct role, but a tremendous degree of redundancy and

interaction exists among different components.

Any condition breaks down the lung defense mechanism may result in lung injury and

respiratory tract infections

Learning Tasks

1. Defense mechanism of the lung and respiratory tract ca be divided into four major categories. Mention them, their components and explain how each of them acts against foreign materials!

2. Explain about diseases or conditions that break the lung defense mechanism down which result in increase susceptibility to respiratory tract infections!

LECTURE 10 PHARMACOLOGICAL AND NON PHARMACOLOGICAL INTERVENSION I

Prof. dr. GM Aman

Drugs for cough, rhinitis, asthma bronchiale

Cough is a protective reflex mechanism that removes foreign material and secretions from

the bronchi and bronchioles. It can be inappropriately stimulated by inflammation in the

respiratory system or by neoplasia. In these cases, antitussive (cough suppressant) drugs are

sometimes used. It should be understood that these drugs merely suppress the symptom

without influencing the underlying condition. In cough associated with bronchiectasis or chronic

bronchitis, antitussive drugs can cause harmful sputum thickening and retention. They should

not be for the cough associated with asthma.

Most drugs used in rhinitis are effectively relief the symptom of rhinitis, not affect the

underlying disease. No drug can relief symptom completely. Drugs are more effective for

allergic rhinitis than non allergic rhinitis, and acute form of allergy respond more favorable than

chronic form of allergy. The most common drugs used for rhinitis are antihistamine, nasal

disodium cromoglycate, nasal decongestant, anticholinergic, intranasal corticosteroid.

Bronchial Asthma is a disease characterized by airway inflammation, edema and

reversible bronchospasm. Bronchodilator and anti-inflammatory are the most useful drugs used

in asthma. B2 selective agonists, muscarinic antagonists, aminophylline and leucotriene



31

receptor blockers are the most effective bronchodilator. Anti-inflamatory drugs such as

corticosteroid, mast cell stabilizers, leucotriene antagonists, and an anti IgE antibody are widely

used. Short acting B2 agonist are the most widely used for acute asthma attack, by relaxing

airway smooth muscle. Theophylline, aminophylline and antimuscarinic agent are also used for

acute asthma attack. Long term control can be achieved with an anti-inflammatory agent such

as corticosteroid (systemic or inhaled), with leucotriene antagonist, mast cell stabilizers

(cromolyn or nedocromil). Long acting B2 agonists such as Salmeterol and Formeterol, are

effectively in improving asthma control, when taken regularly.

Learning Tasks

The patient complained about a sore throat and a nasty cough. It started two weeks ago with a

cold. The cold was over within a week, but he continued coughing, especially at night. He is a

heavy smoker. After physical examination you diagnosed a dry, tickling cough.

Task 1

1) Differentiate between Antitussive, Expectorant, Mucolytic! 2) Differentiate the effects of Codeine, Dextromethorphan and Diphenhydramine! 3) List the side effects of Codeine! 4) In this patient, what kind of anti cough you give best?

Task 2

If the patient also has sneezing, rhinorrhea and congested nose and then you diagnosed as

rhinitis.

1) List the group of drugs used for Rhinitis! 2) List the drugs used as oral nasal decongestant, and describe the important side effects! 3) List the side effects of intranasal decongestant! 4) What is the drug of choice for patient suffer from Rhinitis Medicamentosa?

LECTURE 11 PHARMACOLOGICAL AND NON PHARMACOLOGICAL INTERVENSION II

Prof. dr. GM Aman

Learning Task

If the patient come with cough, breathless, and in your examination, you found wheezing. After

physical examination you diagnosed Acute attack of bronchial asthma.

1. Chose the drug of first choice for this patient! 2. List the side effects of this drug! 3. Compare the effect of this drug with Salmeterol! 4. Theophyllin is a bronchodilator, but has a narrow safety margin. List the side effects &

toxic effect of Theophyllin! 5. Ipratropium not as effective as Salbutamol in treating bronchial asthma. What is the main

use of Ipratropium? 6. Cromolyn and Nedocromil are often used for Asthma bronchial. Describe the mechanism

of action of Cromolyn (Disodium Cromoglycate)! 7. To decrease the side effet of Corticosteroid in asthma patient, Corticosteroid often use

as inhaled Corticosteroid. What are the side effect of inhaled Corticosteroid? 8. List the anticough that are contraindicated in acute asthma attack! 9. If you need anticough, what drug you give best?



32

LECTURE 12 RESPIRATORY IMAGING

dr. Elysanti, Sp.Rad

The imaging investigations of the chest may be considered under the following heading:

1. Simple X- ray (conventional X-ray).

2. Chest screening.

3. Tomography.

4. Bronchography.

5. Pulmonary angiography.

6. Isotope scanning.

7. Computed tomography(CT-scan).

8. MRI.

9. Needle biopsy.

The conventional Chest X-ray has to diagnose the anatomical disorders of the chest for

example:

1. Lungs disease-----pneumonia, mass, atelectasis etc.

2. Pleural disease----pleural effuse, pneumothorax etc.

3. Cardiac disease----cardiomegali.

4. Bone disorders-----fracture.

5. Soft tissue disease—emphysema cutis.

Sometimes conventional X-ray diagnostic can not enough for diagnostic of the chest disorders,

for this the CT scan, MRI, bronchography, and arteriography can be help.

Learning Tasks

A male patient, 68 years old, with chronic cough and hemoptoe.

1. What is the imaging choice for establish the diagnosis ?

2. What kind of diagnosis you will consider if the imaging revealed some consolidation at

the apex of the right lung accompanied by rib destruction?

A 1- month old female patient is suffered from fever and dyspneu.

1. What kind of abnormality you hope to see on the chect X ray film?

2. What do you thing about the diagnosis of the disease?



33

LECTURE 13 BRONCHIOLITIS AND ASTHMA IN CHILD

dr. IB Subanada, SpA

Bronchiolitis is an acute inflammatory disease of the lower respiratory tract (bronchioles)

caused predominantly by respiratory syncytial virus (RSV). The inflammation response

characterized by bronchiolar epithelial necrosis, bronchiolar occlusion, and peribronchiolar

collection of lymphocytes. Bronchiolus become edematous and obstructed with mucus and

celluler debris, which may lead to partial or complete collapse of the bronchioles. By the age 2

years nearly all children have been infected, with severe disease more common among infants

aged 1-3 months.

The clinical manifestation, initially upper respiratory signs and symptoms and followed by

obstructed bronchioles signs and symptoms.

The white blood cell and differential counts are usually normal. Chest x-ray reveals

hyperinflation, peribronchial cuffing, and atelectasis.

The mainstay of therapy is supplemented oxygen with close monitoring and supportive

care.

There are higher incidence of wheezing and asthma in children with history of

bronchiolitis. Pooled hyperimmune RSV intravenous immunoglobulin (RSV-IVIG) and

palivizumab intramuscular are effective to preventing severe RSV disease in high risk infants.

The case fatality rate is less than 1%.

Learning Tasks

A 6-months old male infant came to Outpatient Clinic, Department of Child Health, Medical

School, Udayana University, Sanglah Hospital, Denpasar with the chief complaint of difficult to

breath since yesterday. According to his mother, three days before, he suffered from coryza,

cough, and low grade fever. On physical examination, fast breathing, wheezing and a prolonged

expiratory phase were found. Please discuss his mother the disease of the infant!

Learning Tasks

1. Explain the pathological concept of asthma in child!

2. Explain the clinical manifestations of asthma in child!

3. Explain the diagnosis principles of asthma in child!

4. Determine the severity of asthma and the degree of asthma attack in child!

5. Construct management plans for asthma attack in child (reliever) and determine the

need for controller management!

6. Identify the need for referral!



34

LECTURE 14 TB IN CHILD

dr. Ni Putu Siadi Purniti, SpA

Tuberculosis (TB) is systemic infection cause by Mycobacterium tuberculosis complex : M

tuberculosis, M. Bovis, M. africanum, M. microti, and M. canetti. Tuberculosis infection occurs

after inhalation of infective droplet nuclei containing M. tuberculosis. A reactive tuberculin skin

test and the absence of clinical and radiographic manifestations are the hallmark of this stage.

Tuberculosis disease occurs when sign and symptoms or radiographic changes becaome

apparent. In the year 2001 prevalens rate of TB is 5,6/100.000 population, of these, 931 (6 % )

cases occurred in children < 15 year of age (rate 1,5/100.000 population). Transmission of M

tuberculosis is person to person, usually by airborne mucus droplet nuclei, particles 1-5 µm in

diameter that contain M tuberculosis. In the United States, most children are infected with M.

tuberculosis in their home by adult patient tuberculosis close to them. The tubercle bacilli

multiply initially within alveoli and alveolar duct. Most of bacilli are killed, but some survive within

nonactivated macrophages, which carry them through lymphatic vessels to the regional lymph

nodes. When the primary infection is the lung, the hilar lymph nodes ussualy are involved. The

primary complex of tuberculosis includes local infection at the portal of entry ( primary focus)

and the regional lymph nodes that drain the area. During the development of the primary

complex, tubercle bacilli are carried to most tissues of the the body through the blood and

lymphatic vessels.Pulmonary tuberculosis that occurs more than a year4 after the primary

infection is usually caused by endogenous regrowth of bacilli persisting in partially encapsulated

lesions. The majority of children with tuberculosis infection develop no signs or symptoms at any

time. Occasionally, infection is marked by low grade fever and mild cough, and rarely by high

fever, cough, malaise, and flu like symptoms. Several drugs are used to effect a relatively rapid

cure and prevent the emergence of secondary drug resistance during therapy. The standard

therapy of intrathoracic tuberculosis (pulmonary disease and/or hilar lymphadenopathy) in

children, recommended by the CDC and AAP, is 6 month regiment of isoniazid (INH), rifampin

(RIF) supplemented in the first 2 month of treatment by pyrazinamide (PZA).

Learning Tasks

In Outpatient Clinic Department of Pediatric, the baby 10 month of age carried by the

mother with the chief complaint is loss of weight since 3 month, suffered low grade fever,

chronic cough, malaise and flu like symptoms. The grandfather whom was diagnosed

pulmonary tuberculosis and she has been in recent closed contact. In physical examination

found that there were enlargement of neck lymph nodes.

Learning Resources

Nelson Textbook of Pediatrics Ed. 17 th 2004: pp 958-972



35

LECTURE 15 PULMONARY TB AND EXTRAPULMONARY TB

dr. IB Sutha, SpP

WHO estimates that about 9.27 million new cases in 2007 compared with 2.24 million

cases in 2006, with 44% or 4.1 million cases of the infectious cases (sputum smear new cases

with positive). TB problem in Indonesia is a national problem, the case is increasing and

increasingly concerned with the increasing HIV infection and AIDS are rapidly growing

emergence of multi-drug resistance TB problem.

Tuberculosis is an infectious disease directly caused by the bacteria Mycobacterium

tuberculosis that primarily attacks the lungs. TB bacteria are rod-shaped, aerobic with a

complex cell wall structure, it was mainly composed of fatty acids that are acid resistant and can

survive in a dormant form.

TB germs enter through inhalation of the bacteria will reach the alveoli and catched by

alveolar macrophages, the bacteria will die. If the germs stay alive it will proliferate to form

primary apex (Primer Apex) and will limphogen or hematogenous spread. Primary apex

surround by limphogen spreading form the "primary complex of Ghon" and formed specific

cellular immunity is characterized by a positive tuberculin test. If the immunity is low, complex

primary complications, the patient became ill and the symptoms and clinical signs of disease. M.

tuberculosis may attack any organ of the body and most importantly the lungs.

Clinical symptoms involve respiratory symptoms and prodromal symptoms, whereas

clinical signs obtained at once with the examination depends on the type and extent of lesions in

the lungs and surrounding organs. Radiological examination of the thorax will get the infiltrates,

fibrosis and kaverna. Bacteriological examination by smear and culture of sputum smear

examination.

TB treatment follow national treatment program. Tuberculosis control which refers to the

eradication of TB WHO guideline.

General Objectives

1. Knowing the microbiology, epidemiology and pathogenesis of tuberculosis.

2. Knowing the clinical symptoms, clinical and radiological signs of pulmonary TB and

extra-pulmonary TB.

3. Able to clasify Tuberculosis.

4. Able to explain treatment program of tuberculosis and side effect.

5. Able to describe the prevention of tuberculosis and MDR TB.

Triger

A male patient aged 25 years came to a health center with complaints of bloody cough every

time since one month ago. That was not originally phlegm but since two weeks ago a yellowish

productive cough. The coughing did not disappear with anti-cough medicine. Shortness of

breath and chest pain is absent. Patients feel the slightly fever and night sweating and also

weakness, no appetite. Patients had never been sick before, enough food, smoking and family

sometimes there is no similar illness. Physical examination has been found: look thin, alert

state, blood pressure 110/70 mmHg; pulse rate 108 x/mnt; Respiration rate 24 breaths/mnt



36

T.aksila 370C. Lymph nodes enlargement on the right neck. On chest examination: symmetrical

right-left chest, normal heart, vesicular breath sounds in the chest and rhales on the third

upright.

Learning Tasks:

1. What should you do to ensure the diagnosis of this patient?

2. What should you do for this patient with enlargement of gland in the neck?

3. If the sputum smear examination results - / +2 / -, what is diagnosis?

4. Explain the treatment program appropriate to this patient!

5. Explain about patient monitoring and Communication-Information-and Education for this

patient and his family?

TB IN THE IMMUNOCOMPROMISED HOST

dr. Made Bagiada, SpPD-KP

Sebagai seorang dokter yang bekerja di tingkat pelayanan primer, pemahaman tentang

diagnosis dan penatalaksanaan TB pada imunokompromais sangatlah penting. Kejadian TB

lebih tinggi pada imunokompromais dibanding dengan non-imunokompromais. Penyakit infeksi

kronik ini bila tidak ditangani dengan baik menyebabkan morbiditas dan mortalitas yang tinggi.

Di Indonesia dengan beban TB tinggi (nomor 5 di dunia) akan lebih tinggi lagi dengan

meningkatnya prevalensi penderita HIV/AIDS.

TB adalah penyakit infeksi kronis yang disebabkan oleh M.tuberculosis. Tempat masuk

dan target organ terbanyak adalah paru. Orang yang terinfeksi M.tuberculosis hanya sebagian

kecil yang menjadi sakit TB dan sebagian besar tidak menjadi sakit (latensi). Orang yang tidak

sakit (latensi) akan menjadi sakit (reaktivasi) atau TB aktif bila terjadi penurunan daya tahan

tubuh atau imunitas (imunokompromais). Secara umum klinis TB ditandai dengan batuk-batuk

produktif lebih dari 2 – 3 minggu disertai dengan gejala-gejala respiratorik lainnya dan gejala

non-respiratorik. Namun, manifestasi klinis dari TB pada individu imunokompromais terletak

pada derajat beratnya penurunan imunitas. Sering tanda dan gejala TB atipikal, sering terjadi

kesalahan diagnosis, sehingga prognosis menjadi lebih buruk.

Imunokompromais adalah suatu kondisi dimana sistem kekebalan tubuh seseorang

melemah atau tidak ada. Individu yang imunokompromais kurang mampu melawan atau

memerangi infeksi karena respon imun yang berfungsi tidak benar. Contoh orang

imunokompromais adalah mereka yang terinfeksi HIV atau AIDS, wanita hamil, atau sedang

menjalani kemoterapi atau terapi radiasi untuk kanker. Kondisi lain dengan imunokompromais,

seperti kanker tertentu dan kelainan genetik, diabetes mellitus, dan penderita yang

mendapatkan terapi TNF-α. Individu immunocompromised kadang-kadang lebih rentan

terhadap infeksi serius dan /atau komplikasi dibanding orang sehat. Mereka juga lebih rentan

untuk mendapatkan infeksi oportunistik, yaitu infeksi yang biasanya tidak mengenai orang yang

sehat.

Dalam keadaan penderita dengan imunokompromais, seorang dokter harus dapat

mengenali penyakit TB aktif. Diagnosis TB pada imunokompromais adalah dengan menemukan

kuman BTA pada sputum baik dengan pemeriksaan langsung BTA maupun kultur. Pengobatan

TB penderita imunokompromais sama dengan pada non-imunokompromais dan pengobatan



37

TB-nya diutamakan. Dokter harus mampu mengidentifikasi penderita TB pada

imunokompromais yang tidak respon (resisten) dengan obat TB, sehingga dapat melakukan

tindakan lebih dini untuk menurunkan perburukan prognosis (kematian).

General Objektif

1. Mampu menjelaskan penegakan diagnosis TB pada imunokompromais.

2. Mampu menyusun program pengobatan jangka panjang penderita TB pada

imunokompromais.

3. Mampu mengidentifikasi kemungkinan gagal respon pengobatan (resisten) penderita TB

pada imunokompromais.

4. Mampu menyusun pengobatan utama pada penderita TB dengan imunokompromais.

5. Mampu mengidentifikasi penderita TB dengan imunokompromais yang perlu rujukan

lebih lanjut.

Trigger

Anda sebagai seorang dokter yang bekerja di sebuah Puskemas, datang seorang pasien laki-

laki, usia 28 tahun. Dia mengeluhkan panas badan sejak lebih kurang 2 minggu. Demam tidak

begitu tinggi dan tidak sampai menggigil. Disamping demam juga ada batuk-batuk ringan tanpa

disertai dahak yang dialami lebih dari 1 minggu. Penderita sudah minum obat penurun panas

dan obat batuk yang dibeli di warung tapi tidak ada kesembuhan. Berat badan penderita

dirasakan menurun drastis belakangan ini. Napsu makan berkurang sehingga badan penderita

dirasakan semakin kurus. Penderita adalah seorang sopir pengangkut barang jawa – bali,

sudah menikah dan mempunyai anak wanita usia 4 tahun. Sesekali penderita minum bir.

Penderita mempunyai tattoo di badannya yang dibuat sewaktu penderita klas 1 SMA.

Learning Task

1. Jelaskan bagaimana saudara memastikan bahwa pasien tersebut memang menderita

TB dan imunokompromais!

2. Mengapa TB laten menjadi reaktivasi (TB aktif)?

3. Bagaimana saudara mengenali pasien TB imunokompromais mengalami Immune

Reconstitution Inflammatory Syndrome (IRIS)?

4. Jika ternyata pasien tersebut menderita TB dengan imunokompromais bagaimana cara

menyusun pengobatan penderita?

5. Bagaimana cara menilai respon pengobatan TB pada pasien dengan

imunokompromais?

6. Jelaskan kriteria TB pada imunokompromais!



38

LECTURE 16 ASTHMA

Prof. IB Rai

Airway hyper responsiveness is known as the denominator underlying all form of asthma.

The basis of this abnormal bronchial response is not fully understood. Most current evidence

suggests that bronchial inflammation is the substrate for this hyper responsiveness, manifested

by the presence of inflammatory cells and by damage of bronchial epithelium. In extrinsic

(allergic) asthma, bronchial inflammation is caused by type I hypersensitivity reactions, but in

intrinsic asthma, the cause is less clear. Incriminated in such cases are viral infections of the

respiratory tract and inhaled air pollutant such as sulfur dioxide, ozone and nitrogen dioxide.

General Objektif:

1. Mampu menjelaskan penegakan diagnosis asma. 2. Mampu menyusun program pengobatan jangka panjang asma. 3. Mampu mengidentifikasi pasien dengan serangan asma akut. 4. Mampu memberikan pengobatan awal pasien dengan serangan asma akut. 5. Mampu mengidentifikasi pasien asma akut yang perlu perawatan inap di rumah sakit,

dan merujuknya.

Triger

Anda sebagai seorang dokter yang bekerja di sebuah Puskesmas kota, datang seorang pasien

wanita, usia 36 tahun. Dia menyampaikan bahwa telah menderita asma sejak usia remaja.

Dalam 3 bulan terakhir ini, dia mengalami serangan asma hampir setiap 3 hari , termasuk

serangan di malam hari. Untungnya, kata pasien, serangan asmanya dapat diatasi dengan obat

semprot yang dia miliki. Pasien menginginkan agar terbebas dari penyakitnya ini.

Learning Task

1. Jelaskan bagaimana saudara memastikan bahwa pasien tersebut memang menderita asma!

2. Apakah asma pasien tersebut dalam keadaan terkontrol? Jelaskan! 3. Apakah inhaler yang dipergunakan oleh pasien tersebut termasuk ke dalam kelompok

pelega (reliever)? Jelaskan perbedaan fungsi antara reliever dan controller, dan sebutkan obat-obat dari kedua kelompok tersebut!

4. Susun rencana penatalaksanaan jangka panjang pasien tersebut! 5. Apabila suatu saat pasien tersebut mengalami suatu serangan asma akut, terapi apa

yang akan saudara berikan? 6. Jelaskan kreteria serangan asma akut berat!



39

LECTURE 16

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

dr. IGN Bagus Artana, SpPD

Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by

airflow limitation that is not fully reversible. COPD is the fourth leading cause of death in the

world and the number of patients is projected to increase worldwide in the future. Tobacco

accounts for an estimate of 90% to the risk of developing COPD. Patient with COPD first

complaining chronic cough with sputum and followed by dyspnea. This condition worsening

progressively until the patient unable to do his daily activities.

Treatment aim for COPD is to decrease symptom, without stopping the progression of this

disease. Prevention is more important in this condition, such as by smoking cessation program.

General Objektif:

1. Mampu menjelaskan penegakan diagnosis PPOK serta penilaian kombinasi pasien. 2. Mampu menyusun rencana pengobatan pada kasus PPOK stabil. 3. Mampu menangani factor risiko pasien PPOK. 4. Mampu menentukan eksaserbasi akut dari PPOK. 5. Mampu menjelaskan manajemen gawat darurat pasien dengan PPOK eksaserbasi akut.

Triger Seorang pasien laki-laki usia 70 tahun datang bersama anaknya kepoliklinik paru Rumah Sakit Daerah tempat anda bertugas dengan mengeluh sesak nafas. Sesak nafas dirasakan sangat berat, berpakaian pun pasien mengaku sesak. Sebelumnya pasien memang merokok sejak usia 20 tahun sebanyak 2 pak sehari. Pasien juga mengatakan sering opname di rumah sakit karena serangan sesak nafas yang sangat berat. Pasien dan keluarganya ingin mengetahui dengan pasti mengenai penyakitnya serta tindak lanjut penanganannya. Learning Task

1. Jelaskan bagaimana penegakan diagnosis pasien tersebut! 2. Bagaimanakan kombinasi penilaian pasien ini? Data apa saja yang saudara perlukan

untuk melengkapi kombinasi penilaian tersebut? 3. Sebutkan dan jelaskan obat-obat yang dapat digunakan untuk menangani kasus PPOK

stabil! 4. Bagaimana anda menyusun rencana penatalaksanaan pasien ini secara komprehensif? 5. Bagaimana penatalaksanaan pasien ini apabila mengalaami PPOK eksaserbasi akut?



40

LECTURE 17 PLEURAL EFFUSION

dr. Putu Andrika, SpPD-KIC

Membran tipis pleura terdiri dari dua lapisan yaitu pleura visceralis dan pleura parietalis.

Penumpukan cairan melebihi jumlah fisiologis 10-20 ml disebut efusi pleura, akibat dari

peningkatan produksi yaang melebihi kemampuan absorpsi.

Penting untuk menegakkan diagnosis berdasarkan anamnesis yang baik dan

pemeriksaan fisik yang teliti, pemeriksaan radiologi torak serta melakukan pungsi pleura.

Analisis cairan pleura akan sangat berguna untuk menuntun kearah penyebab efusi pleura.

Dibedakan cairan efusi yang transudat dan eksudat.

Volume efusi pleura yang banyak akan menimbulkan gangguan fungsi respirasi yang

memerlukan pengeluaran cairan efusi melalui aspirasi cairan pleura (torako sentesis) atau

melalui pemasangan chest cube (Water Seal Drainage).

Dalam mengelola pasien dengan efusi selain menangani keluhan akibat menumpuknya

cairan efusi juga harus menangani penyebab terjadinya efusi tersebut.

General Objektif:

1. Mampu menjelaskan penegakan diagnosis efusi pleura.

2. Mampu menilai analisis cairan pleura.

3. Mampu merencanakan pemeriksaan penunjang untuk mendapatkan penyebab

terjadinya efusi pleura.

4. Mampu mengidentifikasi kasus yang memerlukan penanganan segara dan kasus yang

harus dirujuk ke rumah sakit.

Triger:

Seorang wanita muda datang dengan keluhan sesak nafas yang semakin memberat sejak

seminggu. Pada pemeriksaan fisik didapatkan frekwensi nafas 24 x/mnt, suhu tubuh 37,5 o C,

pemeriksaan torak asimetris, kanan tertinggal, perkusi redup dan suara nafas melemah di

bagian kanan bawah. Penderita juga mengeluh batuk batuk sejak 3 bulan yang lalu dan pernah

batuk berisi darah segar sedikit, juga nampak semakin kurus.

Learning Task

1. Apakah kemungkinan penyebab keluhan pasien tersebut?

2. Pemeriksaan penunjang apa yang diperlukan?

3. Perlukah melakukan parasentesis? Jelaskan!

4. Perlukah pemasangan WSD? Apa alasannya?



41

PNEUMOTORAKS

dr. Yasa, SpBTKV

Pneumotoraks merupakan salah satu kegawatdaruratan di bidang paru yang berarti

terisinya rongga pleura oleh udara. Pneumotoraks ini perlu mendapatkan perhatian serius,

karena dengan penanganan yang cepat dan tepat akan sangat mengurangi angka

kematiannya. Sebagai seorang dokter yang ada di fasilitas kesehatan primer, sangat diperlukan

pengetahuan mengenai keadaan ini.

Diagnosis pneumotoraks dapat ditegakkan dari anamnesis, pemeriksaan fisik dan foto

polos dada. Pneumotoraks dapat dibagi berdasarkan berbagai kriteria, tetapi yang paling sering

adalah dibagi menurut terjadinya (pneumotoraks artifisial, traumatic, serta spontan) serta

berdasarkan jenis fistelnya (pneumotoraks terbuka, tertutup, dan ventil).

Beberapa kondisi pneumotoraks akan sangat mengancam nyawa, sehingga memerlukan

penanganan yang tepat dan segera. Penatalaksanaan pneumotoraks pada prinsipnya adalah

mengeluarkan udara yang ada di rongga pleura tersebut, terapi penyebabnya, serta edukasi

untuk mencegah berulangnya pneumotoraks pada pasien yang memiliki risiko.

General Objektif:

1. Mampu menjelaskan penegakan diagnosis pneumotoraks.

2. Mampu menyebutkan beberapa penyebab pneumotoraks yang sering dijumpai.

3. Mampu menjelaskan beberapa pembagian jenis pneumotoraks.

4. Mampu menyusun rencana penatalaksanaan pasien dengan pneumotoraks.

Triger

Seorang pasien laki-laki usia 30 tahun datang kePuskesmas tempat anda bertugas dengan

mengeluh sesak nafas tiba-tiba dan sangat berat. Pasien sebelumnya dengan riwayat

menderita penyakit TB paru dan sudah berobat dengan lengkap. Sebelumnya pasien sempat

terbatuk-batuk, kemudian tiba-tiba sesak nafas. Pasien ini tampak sesak dan sianosis.

Learning Task

1. Jelaskan temuan fisik dan foto polos dada yang kemungkinan ditemukan pada pasien

pneumotoraks tersebut!

2. Sebutkan beberapa penyebab pneumotoraks yang anda ketahui!

3. Bagaimana penatalaksanaan kasus dengan pneumotoraks tersebut?



42

LECTURE 18

BRONCHITIS AND BRONCHIECTASIS

dr. Dewa Artika, SpP

Untuk menentukan suatu Bronkitis dan Bronkiektasis tidaklah terlalu sulit, tapi diperlukan

suatu pemahaman untuk mendiagnosis dan penatalaksanaan Bronkitis dan Bronkiektasis

dengan baik dan benar. Disamping prevalensinya cukup tinggi, penyakit ini bila tidak ditangani

dengan baik, akan berlanjut menjadi lebih parah.

Bronkitis adalah inflamasi saluran napas sentral yang mengenai mukosa ditandai oleh

batuk dengan dahak, sering disertai dengan panas dan sesak.Bronkiektasis adalah kelainan

pada dinding bronkus besar dan sedang berupa kelemahan otot sehingga terjadi pelebaran

lumen, karena proses infeksi transmural dan pelepasan mediator.

Diagnosis Bronkitis berdasarkan pada anamnesa, pemeriksaan fisik dan foto toraks,

sedang bronkiektasis ditegakkan dengan anamnesa, pemeriksaan fisik, foto toraks, CT Scan,

dan kultur sputum.

Prinsip penatalaksanaan Bronkitis dan Bronkiektasis adalah dengan menghilangkan batuk

dan produksi dahak. Bila disertai tanda infeksi dapat ditambahkan antibiotika. Pada

Bronkiektasis perlu dilakukan Chest Fisioterapi atau bronkoskopi untuk mempermudah

pengeluaran sputum. Pada keadaan eksaserbasi sering disebabkan oleh infeksi apakah viral

atau bakteri.

General Obyektif

1. Mampu menjelaskan penegakan diagnosis bronkitis dan bronkiektasis. 2. Mampu menyususn program pengobatan jangka panjang. 3. Mampu mengidentifikasi pasien dengan keadaan eksaserbasi. 4. Mampu memberikan pengobatan awal pasien dengan serangan akut. 5. Mampu mengidentifikasi pasien eksaserbasi yang perlu rawat inap dan merujuknya.

Triger

Seorang penderita laki umur 35 th datang dengan keluhan : batuk berdahak sejak 3 bulan dan

memberat sejak 5 hari yang lalu dan disertai dengan panas badan. Bila diperhatikan dahaknya

ada 3 lapis yaitu dari atas sampai bawah mulai dari yang bening sampai keruh dan batuknya

terutama pagi hari. Dikatakan pula setahun lalu pernah menderita sakit seperti ini dan kadang

disertai sesak napas, bila dahaknya sulit dikeluarkan.

Learning Task

1. Jelaskan bagaimana saudara memastikan bahwa pasien tersebut menderita bronchitis! 2. Bagaimana sdr membedakan dengan bronkiektasis? 3. Apakah penderita tsb dalam keadaan eksaserbasi? Jelaskan! 4. Jelaskan prinsip pengobatan pasien dg bronkitis dan bronkiektasis! 5. Obat-obat apa saja yang diperlukan pada pasien tsb diatas? 6. Apa yang dikerjakan bila sputum pasien tsb diatas sulit dikeluarkan?



43

KANKER PARU (LUNG CANCER)

dr. Gede Ketut Sajinadiyasa, SpPD

Kanker Paru merupakan penyebab kematian tersering diantara kematian oleh karena

kanker di seluruh dunia baik pada laki-laki ataupun perempuan. Insiden kanker paru di dunia

diperkirakan 1,3 juta kasus per tahunnya. Kanker paru terjadi sebagai akibat proses yang

komplek antara paparan karsinogen dan kerentanan genetik. Faktor kebiasaan dan lingkungan

berhubungan dengan terjadinya kanker paru dan merokok merupakan faktor risiko utama. Jenis

histologi kanker paru sebagian besar adalah Small Cell Lung Cancer (SCLC) dan Non Small

Cell Lung Cancer(NSCLC) . NSCLC terdiri atas squamus cell carcinoma, adeno carcinoma dan

large cell carcinoma. Manifestasi klinis dari kanker paru dapat asimtomatik pada stadium awal

dan baru bergejal pada stadium lanjut. Pasien biasanya datang dengan keluhan batuk, batuk

darah, sesak, nyeri dada dan suar serak. Sering juga dijumpai tanda-tanda syndrome

paraneoplastik dan gejala umum seperti anoreksia, asthenia dan berat badan yang menurun.

Diagnosis kanker paru dapat ditegaknya dengan anamnesis, pemeriksaan fisik dan

pemeriksaan penunjang. Pemeriksaan penunjang yang umum dikerjakan seperti sitologi

sputum, rontgen dada, ct scan toraks, Biopsi(FNAB/TTB), bronkoskopi, PET scan dan lainnya.

Setelah diagnosis ditegakkan dan sebelum memulai pengobatan ditentukan stadium penyakit

dan status performan. Dengan diketahuinya jenis histology dan stadium penyakit kemudian

ditentukan modalitas terapi. Modalitas terapi pada pasien kanker paru diantaranya adalah

pembedahan, kemoterapi, radiasi dan target terapi.

General Objektif

1. Mengetahui patogenesis, faktor risiko, dan usaha preventif kanker paru.

2. Dapat mengetahui klasifikasi kanker paru.

3. Mengetahui proses penegakan diagnosis dan stadium kanker paru.

4. Mengetahui modalitas penunjang dalam penegakan diagnosis.

5. Mengetahui modalitas terapi kanker paru dan merujuk.

Triger

Seorang pasien laki-laki umur 65 tahun datang ketempat pratek saudara sendirian dengan

keluhan batuk berdarah. Satu minggu yang lalu pasien sempat menjalani cek up didapatkan

pada foto rontgen dada, tumor dengan ukuran diameter 2,5 cm pada hilus kiri menempel di

pinggang jantung kiri. Pada pemeriksaan USG abdomen didapatkan tumor multiple ukuran

diameter sekitar 1-1,5 cm pada hati, sedang pemeriksaan yang lain dalam batas normal. Pasien

memiliki kebiasaan merokok sejak umur 20 tahun dengan jumlah 1-2 bungkus per-harinya.

Learning Task

1. Apa yang saudara lakukan untuk memastikan diagnosis pasien ini?

2. Kalau diperlukan tindakan invasive, prioritas tindakan yang saudara usulkan? Jelaskan

alasannya!

3. Bila ini kanker paru, apa kemungkinan klasifikasi histologinya?

4. Tentukan stadium pasien ini dan status performannya serta alasannya!

5. Tentukan modalitas terapinya!



44

LECTURE 19 DISORDERS OF NOSE AND SINUS

dr. Ratna, SpTHT

Nasal foreign bodies are commonly encountered in emergency departments. Although

more frequently seen in the pediatric, they can also occur in adult. Children’s interests in

exploring their bodies make them more prone to lodging foreign bodies in their nasal cavities.

References

1. Textbook Diseases of the Ear, Nose and Throat edited by Martin Burton CHURCHILL LIVINGSTQNE 15TH ED 2000: Section 5 The Larynx, Pharynx and Oesophagus. Pp 165-206

LECTURE 20 DISORDERS OF PHARYNX AND LARYNX

Prof. Suardana, SpTHT, dr. Dewa Artha Eka Putra, SpTHT

The Adenoids (pharyngeal tonsils) are a triangular mass of lymphoid tissue located on the

posterior aspect of the boxlike nasopharynx. The nasopharynx serves as a conduit for Inspired

air and Sinonasal Sections that drain from the nasal cavity into the oropharynx. a resonance box

for for speech and a drainage area for the Eustachian tube — middle ear mastoid complex.

Adenoid have three types of Surface epithelium ciliated pseudostratified squamous, and

transitional.

The Adenoids and tonsils, like all lymphoid tissue, enlarge when infected. Although

lymphoid tissue does act to fight infection. Some time bacteria and viruses can lodge within it

and survive. Group A B—hemolytic streptococcus (GABHS) is classically described as the only

bacterium implicated frequently in acute Adenoiditis or tonsilitis.

Chronic infection, either viral or bacterial, can keep the pad of adenoids enlarged for

years, even into adulthood. Some viruses, Such as the Epstein Barr virus, can cause dramatic

enlargement of lymphoid tissue.

Clinical classification of the adenoid : Acute adenoiditis, recurrent Acute Adenoiditis,

chronic adenoiditis and obstructive Adenoid Hyperplasia. Clinical classification of the tonsils:

acute tonsillitis, recurrent acute tonsillitis, chronic tonsillitis, and obstructive tonsilar hyperplasia.

The main symptoms of adenoid diseases is Rhinorhea, chronic nasal obstruction

(associated with Snoring and obligate mouth breathing), malodorous, cough, post nasal drip,

sinusitis, otitis media and a hyponasal voice. The main symptomsof tonsils diseases are: sore

throat, dysphagia, fever, halithosis, muffled voices, snoring, and other symptomsof sleep

disturbance and tender cervical adenopathy.

Adenoiditis is best diagnosed by clinical history, physical examination,

nasopharyngoscopy, and radiography. The physical examination should include both anterior

and posterior rhinoscopy. A lateral neck radiograph and sinus radiography taken to show soft

tissue density, can show the adenoids and sinus. Tonsilitis is diagnosed by clinical history,

physical examination, throat culture, and flexible laryngoscope.



45

Management of diseases of the adenoids and tonsils: antimicrobial, intranasal steroids

and adenoidectomy. Indications for tonsillectomy and adenoidectomy are obstruction, infection

and Neoplasia.

The anatomy of the larynx consist of cart.Haginous framework bound together by

ligaments and covered with muscle and mucous membrane. The most important cartilage is the

arytenoid cartilages which is can rotate and slide on the cricoid cartilage and thus play an

important role in the movement of the vocal cords. The epiglottis is a leaf-shape cartilage of the

larynx which is attached to the base of the tongue by the glossoepiglottic ligament and inner

part of thyroid cartilage. The thyroid cartilage is that which makes the prominence upon the front

of the neck known as ‘Adam’s apple, particularly visible in man. Interior of the larynx can looking

down by laryngoscopy indirect or direct. The function of the larynx includes protection of lower

respiratory tract and phonation. The protection of respiratory tract acting by the epiglottis,

sensory nerve supply which is produce cough and vocal cords. Voices or phonation is produce

by vocal cords function consist adduction and abduction movement and vibration of the vocal

cords.

Patient with a foreign body in his/her pharynx, or oesophagus, usually knows what has

happened and is usually right. It can stick in his tonsils, his vallecula, his pyriform fossa, or in his

postcricoid region. Most fish bones stick in accessible regions, usually the back of the tongue or

tonsils. Foreign bodies seldom stick in the larynx itself, except when an affluent, elderly, and

often intoxicated diner gets a piece of steak caught in his larynx, as a result of which he gasps

and collapses. Treat him immediately.

Throat

Normal Vocal cord and disorders

The symptoms of laryngeal disorders are hoarseness, dysphonia and stridor. Hoarseness

is caused by an abnormal flow of air past the vocal cords. The voice is harsh when turbulence is

created by the irregularity of the vocal cords. The irregularity of the vocal cord caused by vocal

nodule, edema of the vocal cord and laryngitis. Dysphonia is weakness of the voice caused by

paresis or paralysis of the vocal cords. And aphonia is loss of voice. Stridor is a high pitch

sound, is produce by lesion that narrowing the airway. If narrowing of the airway upper the vocal

cord produce inspiratory stidor, and if narrowing the airway below the vocal cord will produce

inspiratory and expiratory stridor.



46

Some lesion will be discussed are vocal cord nodule, vocal cord paralysis, laryngeal

palillomas and gastrolaryngopharyngeal reflux disease. Vocal nodule or Singer’s nodes is

benign lesion in the vocal cord particularly at the site of the junction of the anterior third and

posterior two-thirds of the cord (halfway along the membranous cord). This condition is caused

by misuse of the voice or overuse as well as singers, teachers, priest, actors who have not

undergone formal voice training. Misuse of the voice also happen in the schoolchildren,

sometime call by screamer’s node.

Vocal cord paralysis causes of dysphonia symptom, define as weakness or even though

temporary loss of the voice (aphonia). A vocal cord may paralysed by mechanical fixation of the

arytenoids or vocalis muscle or by nerve paralysis. Paralysis may be unilateral or bilateral and

the cords paralysed in abduction or adduction. Abduction paralysis causes loss of the voice

because the cord can not move to the midline position and adduction paralysis, the cords can

not move to the lateral position and cause severe stridor.

Laryngeal papilloma is a benign lesion single or multiple, non keratinizing papilloma in

characteristic is due by infection of human papilloma virus type 6 and 11. Papillomatosis present

more frequently in children than in adult, the peak incidence occurring between 2 and 5 years of

age, and very common of high recurrent. Relaps or recurrent may be precipitated by trauma or

immunosuppressive condition.

Gastrolaryngeal reflux is very common condition to causes hoarseness. The pathology of

gastro-esophageal-laryngeal reflux disease may be a result of direct effect of gastric acid, bile

salts or enzymes on mucosa of the larynx.

Learning Tasks

1. Describe and discuss of specific symptoms of the larynx disease & disorders! 2. Describe and discuss etiology and patophysiology of hoarseness, dysphonia and stridor

with its clinical implication! 3. Manage and provide initial management or refer patient with certain larynx disease and

disordes!

Learning Tasks

1. Describe and discuss of etiology of adenoid diseases! 2. Explain pathogenesis of adenoid diseases! 3. Describe and discuss of clinical classification of diseases in the adenoids! 4. Describe clinical evaluation to support diagnosis of the adenoid diseases! 5. Manage and provide initial management or refer patient with certain adenoid diseases! 6. Explain indications for adenoidectomy! 7. Describe complications of adenoid diseases and adenoidectomy!

Learning Resources

1. Textbook Diseases of the Ear, Nose and Throat edited by Martin Burton CHURCHILL LIVINGSTQNE 15TH ED 2000: Section 5 The Larynx, Pharynx and Oesophagus. Pp 165-206.

2. Textbook Current Medical Diagnosis & Treatment Edited by Lawrence M.Tierney,Jr. Stephen J.Mc Phee, Maxine A.Papadakis 45 Ed 2006: Diseases of the Larynx p209-213.

3. Linda Brodsky. Christhopher Poje. Tonsilitis, Tonsillectomy and Adenoidectomy. In BaiIe BJ Editor. Head and Neck Surgery-Otolaryngologv 3 ed. Philadelphia Lippincort Williams and Willkins; 2001 p 979— 991.



47

BASIC CLINICAL SKILLS

Topik BCS PIC

Pemeriksan fisik toraks pasien dewasa dr. Saji

Radioimaging dr. Elysanti

Pemasangan dan perawatan WSD dr. Yasa

Pengambilan cairan pleura, pungsi pleura, dekompresi jarum dr. Yasa

Spirometri dr. Muliarta

Nebulisasi dan terapi oksigen dr. Sutha

Pemeriksaan fisik toraks pada pasien bayi dan anak dr. Ayu Setyorini

Bronchoscopy, Provocation test dr. Artana

CPEP pada bayi dr. Arya Byantara

Rhinoskopi posterior THT

Pelaksanaan BCS

Hari Ruang 1 Ruang 2 Ruang 3

1 Pemeriksaan Fisik Thorax

dewasa Radio Imaging

Pemasangan dan

perawatan WSD

2

Pengambilan Cairan

Pleura, Punksi Pleura,

Decompresi jarum

Spirometri Nebulisasi dan terapi

oksigen

3 Radio Imaging Pemeriksaan Fisik Thorax

Bayi-Anak

Pemeriksaan Fisik Thorax

dewasa

4

Bronchoscopy,

Provocation test, Radio

Imaging

CPEP pada Bayi Pemeriksaan Fisik Thorax

dewasa

5 Pemeriksaan Fisik Thorax

Bayi-Anak

Perawatan WSD,

Decompresi Jarum Rhinoskopi Posterior



48

PENGGUNAAN SPIROMETER MERA

1. Letakkan alat (Spirometer Mera) di atas meja di hadapan orang yang akan diperiksa.

2. Orang yang diperiksa berdiri tegak sambil memegang Spirometer.

3. Orang yang diperiksa menarik nafas maksimal kemudian masukkan mulut ke dalam

mouth piece spirometer. Lakukan maneuver (ekspirasi maksimal secepat-cepatnya,

sekuat-kuatnya, dan selama-lamanya selama satu kali maneuver).

4. Hitung FEV1 dan FVC dari grafik spirometer.

5. Hitung estimated FVC berdasarkan tabel di bawah.

6. Hitung %FVC dengan rumus:

%FVC= (FVC X Estimated FVC) x 100%

7. Hitung % FEV1 dengan rumus:

% FEV1= (FEV1/FVC) x 100%



49

PENGGUNAAN SPIROMETER

1. Letakkan alat (Spirometer) di atas meja di hadapan orang yang akan diperiksa.

2. Orang yang diperiksa berdiri tegak sambil memegang Spirometer.

3. Pasang noseclip seperti pada gambar .

4. Orang yang diperiksa menarik nafas maksimal kemudian masukkan mulut ke dalam

mouth piece spirometer. Lakukan Maneuver (Ekspirasi maksimal secepat-cepatnya,

sekuat-kuatnya, dan selama-lamanya selama satu kali maneuver.

5. Print hasil perekaman.

6. Catat %FVC.

7. Catat% FEV1.

8. Buat Kesimpulan terkait hasil pemeriksaan.



50

REFERENCES

1. Essential Clinical Anatomy, 2nd ed, Keith L. Moore and Anne M.R.Agur, Lippincott William & Willems, Philadhelpia, 2002.

2. Bloom & Fawcett’s Concise Histology, 2nd ed, Fawcett D.N., Jensh, R.P, London, 2002. 3. Textbook of Medical Physiology, 10th ed, A.C. Guyton, Hall, Philadelphia, WB Saunders

Co, 2000. 4. Medical Biochemistry, Baynes J and Dominiczak, London, 1999. 5. Katzung & Trevor’s Pharmacology, Examination & Board Review, 6th ed. A.J. Trevor,

B.G. Katzung, Susan B Masters. 6. Robbins Basic Pathology, 7th ed, Kumar V, Cotran RS, Robbins SL. WB Saunders,

Philadelphia, 2003. 7. Textbook of disorder and injuries of the musculoskeletal system, Robert B. Salter MD

Apley’s system Orthopaedics and Fractures. Apley, Solomon. 8. Harrison’s, 16th ed. 2005. 9. Nelson Textbook of Pediatrics Ed. 17 th 2004: pp 958-972

10. Textbook Diseases of the Ear, Nose and Throat edited by Martin Burton CHURCHILL LIVINGSTQNE 15TH ED 2000: Section 5 The Larynx, Pharynx and Oesophagus. Pp 165-206.

11. Textbook Current Medical Diagnosis & Treatment Edited by Lawrence M.Tierney,Jr. Stephen J.Mc Phee, Maxine A.Papadakis 45 Ed 2006: Diseases of the Larynx p209-213.

12. Linda Brodsky. Christhopher Poje. Tonsilitis, Tonsillectomy and Adenoidectomy. In BaiIe BJ Editor. Head and Neck Surgery-Otolaryngologv 3 ed. Philadelphia Lippincort Williams and Willkins; 2001 p 979— 991.

ADDITIONAL TEXTBOOK

13. Review of Medical Physiology, 10th ed, W.F. Ganong, California : LANGE Medical Publications.

14. Human Physiology – An Integrated Approach. 2nd ed. Silverthorn, 2001 New Jersey : Prentice-Hall Inc.

15. Pocket Companion to Textbook of Medical Physiology, 10th ed, A.C. Guyton, Hall, Philadelphia, WB Saunders Co, 2000, pp. 52 – 95



51

CURRICULUM MAP

Smstr Program or curriculum blocks

10 Senior Clerkship

9 Senior Clerkship

8 Senior clerkship

7

Medical Emergency (3 weeks) BCS (1 weeks)

Special Topic: -Travel medicine (2 weeks)

Elective Study III (6 weeks)

Clinic Orientation (Clerkship) (6 weeks)

6

The Respiratory System and Disorders (4 weeks) BCS (1 weeks)

The Cardiovascular System and Disorders (4 weeks) BCS (1 weeks)

The Urinary System and Disorders (3 weeks) BCS (1 weeks)

The Reproductive System and Disorders (3 weeks) BCS (1 weeks)

5

Elective Study II (1 weeks)

Alimentary & hepato- biliary systems & disorders (4 Weeks) BCS (1 weeks)

The Endocrine System, Metabolism and Disorders (4 weeks) BCS (1 weeks)

Clinical Nutrition and Disorders (2 weeks) BCS (1 weeks)

Special Topic : - Palliative medicine -Compleme ntary & Alternative Medicine - Forensic (3 weeks)

Elective Study II (1 weeks)

4

Musculoskeletal system & connective tissue disorders (4 weeks) BCS (1 weeks)

Neuroscience and neurological disorders (4 weeks) BCS (1 weeks)

Behavior Change and disorders (4 weeks) BCS(1 weeks)

The Visual system & disorders (2 weeks) BCS (1 weeks)

3

Hematologic system & disorders & clinical oncology (4 weeks) BCS (1 weeks)

Immune system & disorders (2 weeks) BCS(1 weeks)

Infection & infectious diseases (5 weeks) BCS (1 weeks)

The skin & hearing system & disorders (3 weeks) BCS(1 weeks)

2

Medical Professionalism (2 weeks) BCS (1 weeks)

Evidence-based Medical Practice (2 weeks)

Health System-based Practice (3 weeks) BCS (1 weeks)

Community-based practice (4 weeks)

Special Topic - Ergonomi - Geriatri

(2 weeks)

Elective Study I (2 weeks)

1

Stadium Generale and Humaniora (3 weeks)

Medical communication (3 weeks) BCS (1 weeks)

The cell as bioche- mical machinery (3 weeks) BCS(1 weeks)

Growth & development (4 weeks) BCS: (1 weeks)

Pendidikan Pancasila & Kewarganegaraan (3 weeks)



52

study guide the respiratory system and disorders...able to manage major lung diseases (tbc, asthma,...

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