Pneumonia

clinical & practical approach

Darmawan B Setyanto
Dept of Child Health
FMUI Jakarta
Darmawan B Setyanto, MD
Born: 11 April 1961

Education:
◼ Medical Doctor, Faculty of Medicine, University of Indonesia, 1986
◼ Pediatrician, Faculty of Medicine, University of Indonesia, 1997
◼ Respirology Consultant, 2005

Current position :
◼ Head of Respirology Division, Dept of Child Health, Faculty of
Medicine, University of Indonesia

Organization:
◼ Chairman of Respirology Coordination Working Unit, Indonesian
Pediatric Society 2008-2014
◼ IPS: Member of C Board, CPD committee, Paediatrica Indonesiana,
IPS Bulletin
◼ APSR, ERS, EAACI member
Pneumonia

the forgotten killer

of children
 Pneumonia, the forgotten killer
◼ One among the major cause of mortality
◼ Pneumonia kills more children than any other
illness – more than AIDS, malaria & measles
combined
◼ Yet, no adequate concern
Outline
◼ Knowing the problem
◼ Two parallel settings
◼ Knowing the disease
◼ Facing the disease
◼ Risk factors & prevention
Outline
◼ Knowing the problem
◼ Two parallel settings
◼ Knowing the disease
◼ Facing the disease
◼ Risk factors & prevention
Outline
◼ Knowing the problem
◼ Two parallel settings
◼ Knowing the disease
◼ Facing the disease
◼ Risk factors & prevention
Two parallel setting

hospital puskesmas

clinical

complete program
diagnostic
tools limited
resources
Primary care setting
◼ Limited
o Knowledge
o Human resources
o Facilities
o Fund
◼ Should be
o Simple
o Affordable
o Mass oriented
 WHO simple practical approach
symptom
Entry: cough

pathophys
◼ Fast breathing
Age RR
pathology <2 mo 60
2 - 12 mo 50
adaptive 1 - 5 yr 40
response ◼ Chest indrawing

Insult
 WHO pneumonia classification
Entry: cough

Signs Classification
• No fast breathing Other respiratory illness
• Fast breathing Non-severe pneumonia
•Fast breathing Severe pneumonia
•Chest indrawing
• Severe resp distress Very severe pneumonia
• Central cyanosis
• Not able to drink
WHO, Hosp care for children, 2007
 Next: oxygen saturation
symptom Detection of hypoxemia
◼ Blood gas analysis
◼ Pulse oximetry
pathophys

pathology

adaptive
response

Insult
Outline
◼ Knowing the problem
◼ Two parallel settings
◼ Knowing the disease
◼ Facing the disease
◼ Risk factors & prevention
Respiratory anatomy, function
Naso-
pharyngeal
AIRWAY airway
Air passage
Airflow Larynx

Conducting Tracheo-
zone bronchial
tree

Respiratory Zone

Diffusion
Medical problem pathway

Diagnosis & Treatment

symptomatology

pathophysiology

pathology
pathogenesis adaptive
responses

insults
 What is ‘INFLAMMATION’?
symptom
organism
body system
pathophys organ
tissue
cellular
pathology biochemical
Ongoing pathology
adaptive
response symptomatology

Insult
 Selesma 

Flu virus
Rhinovirus

Flu!
Spectrum of ARI
Common cold / rhinitis /
rhino-pharyngitis / naso-pharyngitis
AIRWAY
Rhino-sinusitis
Air passage
Airflow Acute otitis media

(Tonsilo)-pharyngitis
Conducting
zone Croup (acute laryngitis)

(Rhino)-bronchitis

Respiratory Zone
Pneumonia
Diffusion
 Pneumonia
Inflammation of the lung parenchyme

parenchyme: alveoli & interstitial tisue

pneumonitis, alveolitis

Infection, aspiration, radiation, ...

 Pneumonia, etiology
symptom
▪ Virus
▪ Bacteria
pathophys ▪ Fungi
▪ Atypical pathogen
pathology
➢Influenced by age
adaptive
response

Insult
1 Acute upper
resp infection

2 Bacteremia

3 Adjacent org

Pathogenesis
 Pneumonia, symptomatology
symptom
◼ Preceeded by AURI: fever, rhinorrhea, & cough
◼ Fever: viral < bacterial - generally
pathophys ◼ Tachypnea – most consistent
◼ Dyspnea -  Work of Breathing (WoB) -
accessory resp muscle: nasal flaring, retraction
pathology
of suprasternal, intercostal, arcus costal
(epigastrium)  chest indrawing
adaptive ◼ Grunting - infants
response
◼ Head nodding/bobbing – younger children
◼ Chest pain – older children
◼ Cyanosis
Insult
 Acute lower respiratory infection

symptom
Pneumonia  volume  V
pathophys  V/Q mismatch  diffusion
 hypoxemia  hypoxia
 adaptive response  WoB
pathology
 tachypnea  dyspnea
adaptive
response

Insult pathophysiology 26
 Pneumonia, pathology imaging
symptom

pathophys

pathology

adaptive
response

Insult
 Pneumonia, adaptive response
symptom

pathophys

pathology
◼ Leucocytosis
adaptive ◼ Neutrophyl domination
response ◼ CRP – C-reactive protein – inflammation
◼ Procalcitonin – bacterial

Insult
Outline
◼ Knowing the problem
◼ Two parallel settings
◼ Knowing the disease
◼ Facing the disease
◼ Risk factors & prevention
Two parallel setting

hospital puskesmas

clinical

complete program
diagnostic
tools limited
resources
 Pneumonia, DIAGNOSIS
symptom
Combination of all aspects
◼ Clinical course
pathophys ◼ Symptomatology
◼ Pathophysiology: hypoxemia – BGA, pulse
oxymetry
pathology
◼ Pathology – imaging
◼ Adaptive response – blood, inflammation
adaptive marker
response
◼ Insults – definitive, but dificult, specimen
availability. Blood culture – not a representative
specimen
Insult
 Pneumonia, TREATMENT
symptom
Severe Pneumonia
◼ Hospitalization
pathophys ◼ Antibiotic administration
o Penicillin, Chloramphenicol
pathology o Amoxycillin + Clavulanic Acid
o Cephalosporine
adaptive ◼ Intra Venous Fluid Drip
response ◼ Oxygen
◼ Detection & management of complications

Insult
Antibiotic for pneumonia
Reasons:
◼ Mortality! Antibiotic for
pneumonia is
rational!

◼ Many studies have sought clinical features which might

help to direct treatment options. These studies have
confirmed previous evidence that there is no way of
reliably distinguishing clinically (or radiologically)
between etiological agents, complicated by mixed
infections
Outline
◼ Knowing the problem
◼ Two parallel settings
◼ Knowing the disease
◼ Facing the disease
◼ Risk factors & prevention
Risk factors
Low birth weight

Not breastfed Malnutrition

Incomplete Vit A deficiency

immunization
PNEUMONIA
Young age Cold weather

High prevalence
‘Kumis pa joko’ pathogen carrier

Exposure to indoor & outdoor pollution

ETS, biomass fuel, vehicle & industry pollution
Underlying med cond’n: Neuro,Respi,Cardio,GH,Al-Im,
Thank you
Presented at:
◼ Online symposium
◼ World Pneumonia Day
◼ Indonesian Pediatric Society
◼ IDAI building
◼ Wed, 04 Dec 2019
Kasus, Anamnesis
◼ Galih Himawan Indra, lelaki 2 tahun 11 bulan dibawa ke
puskesmas karena demam, batuk dan pilek. Pasien
mengalami demam sejak 3 hari sebelum ke puskesmas.
Batuk dan pilek muncul 1 hari kemudian. Sebelum
pasien, kakaknya yang berumur 6 tahun sakit serupa, 5
hari lebih awal daripada pasien, dan sekarang sudah
membaik. Demam naik turun namun suhu tubuh tidak
diukur. Pasien menjadi rewel, dan nafsu makan
berkurang.
Anamnesis lanjutan
◼ Batuk berlangsung sepanjang siang dan malam hari.
Pasien kadang terbangun pada malam hari. Pilek meler
warna putih, ada bersin dan tampak kesulitan bernapas
karena tersumbat hidungnya. Terdengar suara lendir di
hidung. Ibu pasien mendengar suara napas grok-grok di
dada pasien, yang lebih jelas terdengar pada malam
hari. Saat ibunya meletakkan tangan di dada atau
punggung pasien terasa bergetar-getar. Pasien juga
mengeluh rasa tidak nyaman di tenggorokan, nyeri
telinga kanan dan nyeri kepala. Pasien mengalami sakit
serupa sekitar 3 bulan yang lalu.
Pemeriksaan fisis
◼ Pada pemeriksaan fisis pasien, berat badan 13,5 kg,
tampak rewel. Mulut agak terbuka, agaknya karena
obstruksi nasal, terdengar snuffles (suara lendir di
hidung), dan tampak ingus putih agak kental di kedua
lubang hidung. Laju nadi 118x/menit, laju napas
34x/menit, suhu 380 C. Tidak tampak napas cuping
hidung atau retraksi. Faring agak hiperemis, tonsil
ukuran T2-T2, tidak tampak detritus. Liang telinga intak,
tidak tampak keluar cairan. Pada auskultasi terdengar
suara napas bronkovesikuler, ronki basah kasar, tidak
terdengar mengi.