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RHU Quezon Lecture Series # 2 January 30, 2011 Paolo Victor N. Medina MD Municipal Health Officer Quezon, Quezon
Mga Layunin
Ipakilala sa RHU staff ang madalas na ginagamit na grading ng antas ng ebidensiya sa tinatawag na Evidence Based Medicine Mabilisang pagbabalik-aral sa anatomiya ng Daanang Hangin (respiratory tract) ng katawan Balikan ang depinisyon ng Pneumonia/Pulmonya
Ano ang pulmonya? Papaanong masasabing may pulmonya ang isang tao?
Mga Layunin
Matutunan ang basic na gamutan ng Pulmonya
2010 Clinical Practice Guidelines (para sa matatanda) IMCI 2007 Technical Update (para sa mga bata)
Mga paalala
Grading System for the Strength of the Recommendations and Quality ofDefinition Evidence Grade
Strength of Recommendation
A B C Good evidence to support a recommendation for or against use Moderate evidence to support a recommendation for or against use Poor evidence to support a recommendation for or against use
Quality of Evidence
Level I Level II Evidence from 1 randomized control trial Evidence from >1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from >1 center); from multiple time series; or from dramatic results of uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports from expert committees
Level III
Hanggat maari, DAPAT may chest x-ray ang bawat pasyenteng pinaghihinalaang may pneumonia (Grade A Evidence) CAP CPG 2010
Matutukoy kung gaano kalala ang pulmonya Masisiguro ang diagnosis ng pulmonya Makikita kung may ibang sakit ang pasyente na maipapaliwanag ang kanyang mga sintomas
Subalit para sa mga lugar o sitwasyong walang sapat na resources o mga pasilidad, pwede nang hindi gawin ang X-ray sa mga sumusunod na kundisyon:
Mga relatively malusog na tao na may stable co-morbid conditions Normal/Stable vital signs and assuring PE findings AND nakakasisiguro tayo sa follow-up ng pasyente at pagsunod sa payo
Hindi na rin kailangan ang CXR kung susundin ang IMCI guidelines (para sa mga 0-5) Kung magpapagawa ng CXR para sa pasyente, kung gumaganda naman ang
Kailan Dapat I-refer ang Pasyente sa Ospital (Adult)? pagbasehan ang mga Kailangang
sumusunod sa pagdedesisyon kung sa ospital ba dapat gamutin ang pasyente o pwedeng outpatient (Grade A Evidence)
Kondisyon ng pasyente sa oras ng pagkonsulta Kung ang kanyang ibang sakit (comorbid condition) ay hindi stable CXR Findings Base sa mga ito, mayroong management-oriented risk
Ang mga pasyenteng mapapabilang sa kategoryang Low-risk ang maaaring gamutin bilang outpatient (Grade A Evidence) Kung ang pasyente ay nasa categoryang Moderate-risk o Highrisk kinakailangang ma-ospital ang pasyente para sa mas tutukang pagbabantay at gamot na padadaanin sa swero (Grade A
Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010)
LOW-RISK CAP
Presence of:
Stable vital signs: RR < 30 breaths/min, PR < 125 beats/min Temp > 36 C or < 40 C SBP 90mmHg, DBP > 60mmHg
No altered mental state of acute onset No suspected aspiration No OR stable comorbid conditions CXR
Localized infiltrates No evidence of pleural effusion or abscess
Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010) MODERATE-RISK CAP
ANY of the following:
Unstable vital signs: RR 30 breaths/min, PR 125 beats/min Temp 40 C or 36 C SBP < 90, DBP 60 Altered mental state of acute onset Suspected aspiration Decompensated co-morbid condition CXR
Multilobar infiltrates Pleural effusion or abscess
Clinical Features of Patients with CAP According to Risk Categories (CAP CPG 2010) HIGH-RISK CAP
ANY of the criteria under moderate risk CAP category PLUS Severe Sepsis and Septic Shock Need for mechanical ventilation
Co-morbid Illness Compliant Caregiver Ability to Follow-up Presence of Dehydration Ability to Feed Age Respiratory Rate 2-12 mos 1-5 years > 5 years
Signs of Respiratory Failure a. Retraction b. Head bobbing c. Cyanosis d. Grunting e. Apnea f. Sensorium
Intercostal/Subcost Present al Present Present Present Present Present None Lethargic/Stupor None ous/Comatose Irritable Present Present
Supraclavicular/Int ercostal/Subcostal
None
None
In our setting (dito sa Quezon RHU), we can still try using cotrimoxazole but IT IS NOT RECOMMENDED (dahil sa resistance sa gamot) For Low-risk CAP with stable comorbid illness REFER TO RHU MD =)
Co-amoxiclav Cefuroxime
Severe Pneumonia:
Ideally hospitalization But if not feasible due to lack of resources/logistics, oral amoxicillin may be given
Cotrimoxazole:
40 mg/kg sulfamethoxazole per day (BID) x 7 days IMCI 4mg/kg trimethoprim per dose BID
Pag-iwas sa Pneumonia
ADULT:
Ang bakuna laban sa influenza ay inirerekomenda para sa pag-iwas sa Pulmonya (Grade A) Ang bakunang tinatawag na pneumococcal vaccine ay inirerekomenda para maiwasan ang invasive pneumococcal disease (Grade A) SMOKING CESSATION is recommended for all patients with CAP
Pag-iwas sa Pneumonia
Recommendations for Pneumococcal Vaccination (one time vaccination):
> 60 years old Persons with chronic illnesses Immunocompromised persons (mahina ang resistensiya, depensa ng katawan) Mga nakatira sa nursing home o iba pang long term care facilities Mga naninigarilyo o may hika edad 19 to 64
Pag-iwas sa Pneumonia
50 years old Chronic illness Immunosuppression (HIV, CA, etc) Buntis na nasa 2nd or 3rd trimester Mga nakatira sa nursing home o iba pang katulad na pasilidad Health care personnel Household contacts and caregivers of children < 5 years and adults 50 Household contacts (including children) and caregivers of persons with medical conditions that put them at high risk for severe complications from influenza
THE END
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