diagnosis pneumonia -121111
TRANSCRIPT
![Page 1: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/1.jpg)
Diagnosis dan Tatalaksana Pneumonia
Fathiyah IsbaniahDepartemen Pulmonologi dan Ilmu Kedokteran
Respirasi FKUI-RS Persahabatan
Diagnosis dan tatalaksana pneumonia 1
![Page 2: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/2.jpg)
Diagnosis dan tatalaksana pneumonia 2
![Page 3: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/3.jpg)
Pendahuluan
• Penyakit infeksi saluran napas masalah utama pd negara sedang berkembang
• SEAMIC Health statistic 2001 pneumonia penyebab kematian no. 6 di Indonesia
• Crude Fatality Rate (CFR) 2009 6.63
Diagnosis dan tatalaksana pneumonia 3
![Page 4: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/4.jpg)
Diagnosis dan tatalaksana pneumonia 4
![Page 5: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/5.jpg)
Diagnosis dan tatalaksana pneumonia 5
![Page 6: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/6.jpg)
Diagnosis dan tatalaksana pneumonia 6
![Page 7: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/7.jpg)
Indonesia Death causes , all age 2007
Laporan hasil riset kesehatan dasar (RISKESDAS, 2007))
Perc
enta
ge
Diagnosis dan tatalaksana pneumonia 7
![Page 8: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/8.jpg)
Prevalence of acute upper respiratory tract and pneumonia in Indonesia, 2007Pe
rcen
tage
Laporan hasil riset kesehatan dasar (RISKESDAS, 2007))
Diagnosis dan tatalaksana pneumonia 8
![Page 9: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/9.jpg)
Provinces with high prevalence of upper respiratory tract infection and pneumonia
• Nusa Tenggara Timur• Aceh• Papua Barat• Gorontalo• Papua
Diagnosis dan tatalaksana pneumonia 9
![Page 10: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/10.jpg)
Prevalence of pneumoniaAccording to age range
1-45-14
Years old
Perc
enta
ge
Laporan hasil riset kesehatan dasar (RISKESDAS, 2007))Diagnosis dan tatalaksana pneumonia 10
![Page 11: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/11.jpg)
Mekanisme pertahanan Paru
• Mekanisme pembersihan di saluran napas penghantar: epitel saluran napas, lendir, humoral lokal, refleks bersin & batuk, dll
• Mekanisme pembersihan di saluran napas pertukaran: cairan alveolar, makrofag, netrofil
• Mekanisme pembersihan saluran udara subglotik: refleks batuk
Diagnosis dan tatalaksana pneumonia 11
![Page 12: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/12.jpg)
Suatu peradangan paru yang disebabkan oleh mikroorganisme (bakteri, virus, jamur dan parasit)
Definisi
Etiologi
• Bakteri (Gram positif, Gram negatif)• Virus• Jamur• protozoa
Diagnosis dan tatalaksana pneumonia 12
![Page 13: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/13.jpg)
Diagnosis dan tatalaksana pneumonia 13
![Page 14: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/14.jpg)
Patogenesis
• Ketidakseimbangan antara daya tahan tubuh, mikroorganisme & lingkungan
• Kemampuan mikroorganisme utk sampai & merusak epitel– Inokulasi langsung – Penyebaran melalui pembuluh darah– Inhalasi bahan aerosol– Kolonisasi di permukaan mukosa
Diagnosis dan tatalaksana pneumonia 14
![Page 15: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/15.jpg)
Pembagian
• Community Acquired Pneumonia (CAP)• Hospital Acquired pneumonia (HAP)• Ventilator Associated Pneumonia (VAP)• Health Care Associated Pneumonia (HCAP)
Diagnosis dan tatalaksana pneumonia 15
![Page 16: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/16.jpg)
Diagnosis• Gambaran klinis: akut– Anamnesis:
• Demam menggigil, ≥ 40 C• Batuk dahak mukoid atau purulen• Sesak napas• Nyeri dada
– Pemeriksaan fisis• Tergantung dari luas lesi di paru• Inspeksi tertinggal• Palpasi fremitus mengeras• Perkusi redup• Auskultasi ronki basah (halus, kasar)
Diagnosis dan tatalaksana pneumonia 16
![Page 17: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/17.jpg)
• Pemeriksaan penunjang– Gambaran radiologi: infiltrat – konsolidasi dengan air
bronchogram• Pemeriksaan laboratorium– Peningkatan jumlah leukosit (10.000 -30.000 ul atau ≤
4.500 ul)– Pergeseran ke kiri– Pemeriksaan sputum (mikroorganisme) kultur &
resistensi– Pemeriksaan kultur darah
Diagnosis dan tatalaksana pneumonia 17
![Page 18: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/18.jpg)
Foto toraks
Diagnosis dan tatalaksana pneumonia 18
![Page 19: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/19.jpg)
Cara pengambilan dan pengiriman dahak
• Pengambilan dahak dilakukan pagi hari• Kumur-kumur, inspirasi dalam
membatukkan dahak• Botol steril, tutup rapat• Dikirim ke laboratorium segera (< 4 jam)• Dapat dinebulisasi dengan NaCl 3%• Syarat: sel PMN > 25/lpk dan sel epitel <
10/lpkDiagnosis dan tatalaksana pneumonia 19
![Page 20: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/20.jpg)
Pewarnaan Gram
Diagnosis dan tatalaksana pneumonia 20
![Page 21: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/21.jpg)
Penilaian derajat
• Pneumonia Patient Outcome research Team (PORT): usia, perawatan di rumah, penyakit penyerta, pemeriksaan fisis (perubahan status mental, pernapasan ≥ 30 x/menit, tekanan sistolik < 90 mmHg), suhu tubuh ≤ 35 C atau ≥ 40 C), hasil laboratorium
• CURB-65: > 65 tahun, confusion, frekuensi napas ≥ 30 x/menit, tekanan darah (sistolik ≤ 90 mmHg, diastolik ≤ 60 mmHg)
Diagnosis dan tatalaksana pneumonia 21
![Page 22: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/22.jpg)
Indikasi rawat inap (PDPI)• Skor PORT lebih dari 70• Bila skor PORT kurang dari 70 maka penderita
tetap perlu dirawat inap bila dijumpai salah satu dari kriteria dibawah ini.– Frekuensi napas ≥ 30/menit– PaO2/FiO2 kurang dari 250 mmHg– Foto toraks paru menunjukkan kelainan bilateral– Foto toraks paru melibatkan ≥ 2 lobus– Tekanan sistolik ≤ 90 mmHg– Tekanan diastolik ≤ 60 mmHg
• Pneumonia pada pengguna NAPZA
Diagnosis dan tatalaksana pneumonia 22
![Page 23: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/23.jpg)
Komplikasi
• Efusi pleura• Empiema• Abses paru• Pneumotoraks• Gagal napas• Sepsis
Diagnosis dan tatalaksana pneumonia 23
![Page 24: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/24.jpg)
Penatalaksaan
• Berdasarkan hasil pemeriksaan mikroorganisme, kultur dan resistensi
• Terapi empiris– Penyakit berat dan dapat mengancam jiwa– Bakteri patogen yg berhasil diisolasi belum tentu
sebagai penyebab pneumonia– Hasil pembiakan memerlukan waktu
Diagnosis dan tatalaksana pneumonia 24
![Page 25: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/25.jpg)
• Faktor modifikasi: keadaan yang dapat meningkatkan risiko infeksi dengan dengan mikroorganisme patogen spesifik– Pneumokokus resisten penisilin– Bakteri Gram negatif– Pseudomonas aeruginosa
Diagnosis dan tatalaksana pneumonia 25
![Page 26: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/26.jpg)
Diagnosis dan tatalaksana pneumonia 26
![Page 27: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/27.jpg)
Diagnosis dan tatalaksana pneumonia 27
![Page 28: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/28.jpg)
AntibiotikRawat jalan•Pasien sebelumnya sehat, tidak ada faktor drug resistant S.pneumonia– Makrolid (azitromisin, claritromisin, eritromisin),
doksisiklin•Disertai faktor komorbid (penyakit kronik): jantung, paru, renal, DM, alkoholisme, kondisi imunosupresi– Fluorokuinolon respirasi (moksifloksasin, levofloksasin
750 mg) atau– Beta-laktamase + makrolid
Diagnosis dan tatalaksana pneumonia 28
![Page 29: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/29.jpg)
Rawat inap, non-ICU•Fluorokuinolon respirasi atau•Beta-laktam + makrolid
Diagnosis dan tatalaksana pneumonia 29
![Page 30: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/30.jpg)
Rawat inap-perawatan ICU– Beta-laktam + azitromisin atau– Fluorokuinolon respirasi
•Infeksi pseudomonas: – Beta-laktam antipneumokokal-antipseudomonas
(piperacilin-tazobactam, cefepime, meropenem) + ciprofloksasin atau levofloksasin 750 mg atau
– Beta-laktam + aminoglikosid + azitromisin atau– Beta-laktam + aminoglikosid + antipneumokokal
fluorokuinolon•Methicillin resistant staphylococcus aureus (MRSA): • Vancomycin, atau• Linezolid
Diagnosis dan tatalaksana pneumonia 30
![Page 31: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/31.jpg)
Diagnosis dan tatalaksana pneumonia 31
![Page 32: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/32.jpg)
Evaluasi pengobatan
• Switch therapy: Intravena oral• Evaluasi 24-72 jam• Respons minimal atau tidak ada? Faktor
pasien, obat atau bakteri penyebab
Diagnosis dan tatalaksana pneumonia 32
![Page 33: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/33.jpg)
Pencegahan
• Pola hidup sehat• Vaksinasi (pneumokokal, influenza)• Respiratory hygene: etiket batuk, alat
pelindung diri (masker, respirator)
Diagnosis dan tatalaksana pneumonia 33
![Page 34: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/34.jpg)
Udara(airborne)
Nuklei < 5 μm TB, campak, varisela
Droplet Nuklei > 5 μm Influenza, menigococal,
pertusisKontak Penularan dengan
langsung atau tidak langsung
Kuman resisten obat, RSV
Darah Paparan thd darah HIV, hepatitis B
Pencegahan berdasarkan penularan
![Page 35: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/35.jpg)
![Page 36: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/36.jpg)
Kesimpulan
• Tenaga medis di Puskesmas: mengenali gejala dan perawatan, tahu kapan untuk merujuk ke fasyankes yang lebih tinggi
• Pasien pneumonia rawat jalan pemilihan antibiotik oral
• Konseling pasca perawatan pneumonia• Edukasi masyarakat
Diagnosis dan tatalaksana pneumonia 36
![Page 37: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/37.jpg)
Masalah saat ini
• Pemilihan pengobatan (antibiotik terbatas)• Pneumonia pada immunocompromised– Geriatri– HIV/ADS
• Diagnosis kultur dan resistensi MO membutuhkan waktu
• Pencegahan vaksinasi biaya
Diagnosis dan tatalaksana pneumonia 37
![Page 38: Diagnosis Pneumonia -121111](https://reader031.vdocument.in/reader031/viewer/2022020400/55cf8d2b5503462b1392a579/html5/thumbnails/38.jpg)
Diagnosis dan tatalaksana pneumonia 38