ACUTE RESPIRATORY INFECTIONS (ARI)

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

Dr. Fifi Sofiah, SpA(K)

Acute Respiratory Infections (ARI)/Infeksi Respiratori Akut (IRA)
≈ Infeksi Saluran Pernapasan Akut (ISPA) - Kemenkes
2

• Infeksi akut yang menyerang salah satu bagian/lebih dari

saluran napas mulai hidung sampai alveoli termasuk
Kemenkes adneksanya (sinus, rongga telinga tengah, pleura)

• Infeksi respiratori atas dan adneksanya hingga parenkim

paru
Buku Ajar
Respirologi
• Akut: infeksi yang berlangsung hingga 14 hari

Pneumonia
• Infeksi akut yang mengenai jaringan paru-paru (alveoli)
(Kemenkes)

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Sign & Symptom
3

 Rinorrhea
 Cough
 Sneezing
 Tachypnea, chest indrawing (important in IMCI)
 Dyspnea, eq: nasal flaring, grunting, head bobbing,
retraction, cyanosis, etc

Severe sign/symptom:
Decreased conciousness, difficult to drink/eat, seizure
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 Acute Respiratory Infections (ARI)
4
Kompetensi Dokter Umum (SKDI 2012)
Acute Respiratory Infection (ARI):
1. Acute Upper Respiratory Infection (AURI):
Rhinitis (4A) Pharyngitis (4A)
Common Cold (4) Tonsilitis (4A)
Acute Rhinosinusitis (2) Otitis Media (4A)
2. Acute Lower Respiratory Infection (ALRI):
Epiglottitis (3A)
Croup (Laryngotracheobronchitis) (3A)
Bronchitis (4A)
Bronchiolitis (3B)
Pneumonia (Uncomplicated) (4A)
Pertusis (4A)

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5 Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang
 Acute Respiratory Infections (ARI)
6

Developed and developing countries

 High morbidity

 5-8 episodes/year/child

 30-50 % outpatient visit

 10-30 % hospitalization

Developing countries
 High mortality

 30-70 times higher than in developed countries

 1/4-1/3 death in children <5 year of age

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 EPIGLOTTITIS

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed
 EPIGLOTTITIS
 A life-threatening emerg.
 >90% Haemophilus
influenzae type b (Hib),
S. aureus, S. pneumoniae,
C. albicans, virus & trauma
 Age: 2-7 yr, peak: 3,5 yr

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FK Unsri Palembang
 EPIGLOTTITIS
 Endoscopy: epiglottis red &
swollen, arytenoids & other
supraglottic tissues inflamed
 Treatment:
 O2, sitting position, IV
route
 Prepare for intubation or
tracheostomy
 Send Cultures
 Cephalosporin 3rd gen
 cefotaxime or
ceftriaxone
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FK Unsri Palembang Epiglottitis Normal
 CROUP

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed
 Blok 14 Sistem Respirasi Angkatan 2016
FK Unsri Palembang

CROUP
 Laryngotracheobronchitis
 >80% of acute stridor in
children
 HPIV-1 (60%), HPIV-2,3 & 4,
Influenza virus A & B, other
virus
 Age: 6 mth-3 yr, peak:1-2 yr

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CROUP
• Endoscopy: 2 “sets” of vocal
cords
 Rontgen: steeple sign/pencil
sign
 Subglottic and tracheal
swelling  stridor & other
signs of respiratory
obstruction
 Severe cases  affects the
small airways  bronchial
constriction, oedema, &
atelectasis.
 Severe  O2 + epinephrine
nebulization  intubation

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FK Unsri Palembang
 BRONCHIOLITIS

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed
 Bronchiolitis
14

 Bronchioles inflammation
 Clinicalsyndromes:
fast breathing, retractions, wheezing
 Predominantly < 2 years of age
(2 – 6 months)
 Difficult to differentiate with pneumonia

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 Pathophysiology
15

Infection on cilliary epithelia on bronchioli 

inflammationoedema, mucus secretion, deposit of
cell debris peribronchial lympocyte infiltration &
sub mucosal oedema bronchioli obstruction

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 Etiology
16

 Etiology
Predominantly RSV (Respiratory Syncytial Virus),
adenovirus etc.
 Diagnosis
Etiological diagnosis
 Microbiologic examination
Clinical diagnosis
 Signs and symptoms
 Age
 Resource of infection

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Bronchiolitis
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 Anamnesis
 Cough, runny nose
 Low grade fever
 Vomiting (usually after cough)
 Dyspnea
 Irritability
 Anorexic
 Cyanosis

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 Bronchiolitis
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 Physical exam
 Fever, tacypnea, tachycardia,
 Nasal flaring, retractions/chest indrawaing,
prolonged expiration time, wheezing
 Severe symptoms cyanosis, apnea

 Laboratory exam
 Routine blood exam & electrolyte WBC
count usually within normal

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Bronchiolitis
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 Radiologic examination
diffuse hyperinflation
 flatdiaphragm,
 subcostal >

 retrosternal space >

peribronchial infiltrates
pleural effusion (rare)

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Bronchiolitis
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 Management
 Supportive

 Severe disease
hospitalization
intra venous fluid drip
oxygen
(antibiotics)
 Bronchodilator: controversial

 Corticosteroid: controversial

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 Bronchiolitis
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 Natural history & complications

 Improved clinical findings : in 3-4 days
 Improved radiological features: in 9 days

 Persistent respiratory obstruction : 20%

 Respiratory failure : 25 %
 Lung collaps (rare)

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 Bronchiolitis
22

 Correlation with Asthma

 30 % - 50 % becomes asthmatic patients
 Similarity in : - pathogenic mechanisms

- pathologic disorders

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 PNEUMONIA

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed
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 Magnitude of the Problem in Indonesia
26

Pneumonia in children (< 5 years of age)

 Morbidity Rate 10-20 %

 Mortality Rate 6 / 1000

 Pneumonias kill

 50.000 / a year
 12.500 / a month

 416 / a day = passengers of 1 jumbo jet plane

 17 / an hour

 1 / four minutes

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 Upaya Pengendalian Pneumonia
Promotif Preventif Diagnostik Kuratif
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 PROMOTIF
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 Faktor risiko mortalitas pneumonia
di negara berkembang
29

 Prevalens kolonisasi
 Umur bakteri patogen di
 Berat badan lahir nasofaring
 Imunisasi yang tidak  Immunocompromised
lengkap  Pajanan terhadap
 Tidak mendapatkan polusi udara
ASI yang adekuat  Kepadatan hunian
 Status gizi kurang  Ventilasi udara rumah
 Defisiensi vitamin A yang tidak baik

The United Nations Children’s Fund (UNICEF), World Health Organization (WHO). Pneumonia the forgotten killer of children. 2006

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 Pencegahan
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Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Vaccine-preventable deaths – WHO 2012
32

Pneumococcal disease is the leading cause of vaccine-preventable death

in children aged <5 year worlwide 1,2

WHO recommends including PCV in childhood immunization programs 3

1. World Health Organization. Initiative for Vaccine Research. Acute respiratory infections (update September 2009).
http://www.who.int/vaccine_research/diseases/ari/en/index1.html. Accessed October 16, 2013. 2. World Health Organization. Global
immunization data (2012 data). July 2013. http://www.who.int/immunization_monitoring/Global_Immunization_Data_v2.pdf. Accessed
October 16, 2013. 3. World Health Organization. Pneumococcal vaccines. WHO position paper—2012. Wkly Epidemiol Rec.
2012;87(14):129-144. Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang
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 KENALI KELOMPOK RISIKO TINGGI !
35 Risk group Condition
Chronic heart disease (Particularly cyanotic congenital heart disease and
cardiac failure)
Chronic lung disease†(Including asthma if treated with high-dose oral
Immunocompetent corticosteroid )
children
Diabetes mellitus

PJB, Asma, DM, HIV,

Cerebrospinal fluid leaks
Cochlear implant
Children with functional
or anatomic asplenia Thalassemia,
Sickle cell disease and other hemoglobinopathies
Congenital or acquired asplenia, or splenic dysfunction

Keganasan, CKD
HIV infection
Chronic renal failure and nephrotic syndrome
Diseases associated with treatment with immunosuppressive drugs or
Children with radiation therapy, including malignant neoplasms, leukemias, lymphomas
immunocompromising and Hodgkin disease; or solid organ transplantation
conditions Congenital immunodeficiency Includes B- (humoral) or T-lymphocyte
deficiency; complement deficiencies, particularly C1, C2, C3, and C4
deficiency; and phagocytic disorders (excluding chronic granulomatous
disease).
Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri PalembangAdvisory Committee on Immunization Practices, 2010.
 Patofisiologi
STADIUM I: HIPEREMIA/ KONGESTI
Inokulasi mikroorganisme respon peradangan akumukasi sel MN
pd submukosa & ruang perivaskuler obstruksi parsial jalan napas
Penyakit bertambah berat jika sel alveolar tipe II kehilangan
integritas strukutralnya produksi surfaktan berkurang edema
STADIUM II: HEPATISASI MERAH

RBC, fibrin, PMNs mengisi alveoli

STADIUM III: HEPATISASI KELABU

Konsolidasi lekosit dan fibrin pada alveoli yang terinfeksi

STADIUM IV: RESOLUTION
Eksudat diabsorbsi oleh makrofag
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Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Diagnosis Pneumonia
38

 MTBS (manajemen
terpadu balita sakit)
 “best practice”

Dokter dan Dr Sp Anak

 Mempertajam klinis
dan penunjang selain
MTBS

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Gejala Pneumonia
39

Gejala Infeksi Umum:

 Demam, sakit kepala, gelisah, malaise, nafsu makan ,
keluhan GIT (spt mual, muntah, diare)
Gejala Gangguan Respiratori:
 Batuk, napas cepat, tanda dispnu, mis. napas cuping
hidung, grunting (merintih), stridor, head bobbing,
retraksi, sianosis, PF: pekak perkusi, suara napas
melemah, ronki, dll
Gejala Berat:
 Penurunan kesadaran, kesulitan minum/makan, kejang

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Pemeriksaan Fisis
40

• Napas Cepat
(frekuensi napas lebih dari normal berdasarkan usia)

Usia FN

<2 bln ≥60 x/m

2-12 bln ≥50x/m
1-5 thn ≥40x/m

5-8 thn ≥30 x/m

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang
 PEMERIKSAAN PENUNJANG
41

 Lakukan pemeriksaan  Lakukan Foto

saturasi oksigen pada Toraks jika
semua pasien yang memungkinkan
dicurigai pneumonia

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Radiological exam
42

 Not a routine procedure  indicated for:

 Severe clinical symptom
 Poor response to therapy

 Deterioration in clinical symptoms

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Radiological exam
43

 Interstitial infiltrate  increased

bronchovasculature, peribronchial cuffing,
hyperaerated
 Alveolar infiltrate  consolidation with air
bronchogram
 Consolidation in one lobe lobar pneumonia
 Bronchopneumonia  infiltrate spreading to
peripheral area, increased peribronchial
vasculature

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 Radiological exam
44

Consolidation in lower right lobe Consolidation in upper right lobe

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 Laboratory Findings
45

 Peripheral WBC (White Blood Cells):

 In viral pneumonianormal or elevated usually not
higher than 20,000/mm3, with a lymphocyte
predominance.
 Bacterial pneumonia (occasionally, adenovirus
pneumonia) is often associated with an elevated WBC
count in the range of 15,000-40,000/mm3 and a
predominance of granulocytes
 Low WBC count/ leucopenia  poor prognosis

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 Laboratory Findings
46

CRP ( C-reactive protein)

 lower in viral infection

 No conclusive evident to distinguish viral or

bacterial infection

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 Management
47

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 Management
48

Causative
 Proper and rapid antibiotic administration  key to
succesful management
 Empirical antibiotic therapy no rapid
microbiology test  early identification of
causative microorganism not possible
 Mild symptoms  treat in outpatient

care, oral antibiotic

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 Management
49

ANTIBIOTICS:
• Best predictor of etiology : AGE

• Empirical vs microorganism found

• Pneumonia nature

– Community acquired pneumonia  gram positive

– Hospital acquired pneumonia  gram negative
• Spesific radiology findings (lobar pneumonia,
pneumatocele)

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 Antibiotic consideration for pneumonia related to age group
50

Newborn and very Infants and preschool

young infants age children
School age children
(< 3 months) (3 months – 5 years)
( > 5years)
Etiology: Etiology :
Etiology :
Group B Streptococci S pneumoniae
M pneumoniae
Gram negative H influenzae
K pneumoniae
Enteric bacteriae S aureus
S Pneumoniae
C trachomatis Antibiotic:
Antibiotic:
S aureus Beta-lactam
Macrolide
Antibiotic: ampicilin
erythromyin
ampicilin amoxycilin,
claritromycin
amoxycilin amoxycilin/clav acid
azithromycin
amoxycilin/ cephalosporin
Tetracyclin and
clavulanic acid Co-trimoxazole)
doxyciclin (> 8 years)
+ gentamicin Macrolide
+ third generation Erythromycin,
cephalosporin Newer macrolide

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 Tata Laksana
51

Kausatif
 Pemberian antibiotik tepat dan dosis adekuat

 kunci tata laksana

 Terapi antibiotik empirik

bila tidak bisa kultur mikrobiologi (tidak mungkin

mengidentifikasi mikroorganisme)
 Gejala ringan  pasien rawat jalan dg (MTBS):
 Amoksisilin 80-100 mg/kgBB/hr terbagi 2 dosis
bila tidak perbaikan: 
 Eritromisin 40-60 mg/kgBB/hr terbagi 3-4 dosis
Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang
 Dosis Amoksisilin
Anak Usia 2-59 Bulan dengan Pneumonia (MTBS)
52

Kategori Umur/BB Amoksisilin Amoksisilin Eritromisin

Pneumonia Tablet Sirup Sirup dalam
(250 mg) 125 mg 5 ml
dalam 5 ml (St=sendok
(St=sendok takar)
takar)

Dengan 2-12 bulan 2x1 2 x 10 ml 3 x 5 ml

napas cepat (4-10 kg) tablet/hr (2 St) (1 St)

12-59 bulan 2x2 2 x 20 ml 3 x 10 ml

(10-19 kg) tablet/hr (4 St) (2 St)
Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang
 ANTIBIOTIK (NON HIV )
53

- Ampisilin 50mg/kg atau benzilpenicillin

50.000U/kg IM atau IV/6 jam (min 5 hari)
- Dan Gentamisin 7.5 mg/kg IM atau IV sekali
sehari (min 5 hari)
- Jika dalam 48 jam tidak membaik 
gentamisin + kloksasilin (50 mg/kg IM/IV tiap 6
jam

- AB Lini kedua : Seftriakson (80 mg/kg IM /IV

sekali sehari)

Blok 14 Sistem Respirasi Angkatan 2016 FK Unsri Palembang

 Management
54

Supportive
Mild symptoms  Outpatient
Inpatient :
IVFD
Oxygen
Analgetic/antipyretic

Tabung silinder Oksigen konsentrator Oksigen sentral

 TERAPI SUPORTIF LAIN
55

Pastikan patensi Antipiretik jika

jalan napas demam tinggi

Status hidrasi :
- Atasi dehidrasi/jika perlu
Jika mengi dapat diberikan koreksi suhu
bronkodilator - Asupan ASI/oral jika mungkin
- Jika tidak bisa oral beri NGT
Koreksi ggn elektrolit, asam basa
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 KOMPLIKASI
56

Jika dalam 48 – 72 jam klinis tidak

membaik/bahkan memburuk pikirkan komplikasi :
Lakukan pemeriksaan foto toraks
O Pneumatocele

O Parapneumonic effusion (termasuk empiema)

O Pneumotoraks / Pneumomediastinum

O Abses Paru

O Sepsis (Septic shock, penyebaran infeksi ke organ

lain seperti meningitis, peritonitis dll)

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 KOMPLIKASI
57

Abses Paru Pneumomediastinum

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 Other Complications
58

 Pericarditis
 Hematologic spread
 Meningitis

 Osteomyelitis

 Suppurative arthritis

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 PERTUSIS

Reference:
Buku Ajar Respirologi Anak
Nelson Textboox of Pediatrics 18th ed
 Pertusis
60

 Masa inkubasi: 6-20 hari

 gejala timbul 7-10 hari terinfeksi
 Lama penyakit: 6-8 minggu
 Fase penyakit:
1. Kataral (1-2 minggu): spt influenza, batuk ringan, pilek,
demam ringan, anoreksia
2. Spasmodik/paroksismal (1-4 minggu): batuk memberat tjd
paroksismal brp batuk beruntun bisa >10x/hari, batuk
panjang tanpa inspirasi diantaranya dan diakhiri dg
whoop (pd bayi diakhiri dg muntah atau biru/henti napas,
sakit berat, iritabel), berkeringat, gelisah bisa sp muka
merah/biru,
3. Konvalesen (lk 2 minggu)
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 Pertusis
61

Batuk Rejan
Whooping cough

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