BRONCHIOLITIS

Rafita Ramayati, prof.dr.SpA(K)

Rusdidjas, prof..dr.SpA(K)
Oke Rina Ramayani. dr. SpA
Bgn IKA FK-USU/RSHAM

INTRODUCTION / PENDAHULUAN
1. Penyebab sakit terbanyak pada anak kecil
2. Penyebab terbanyak dirawat di RS
3. Berhubungn dgn Chronic Respiratory Syndrom dewasa
4.Mungkin berhub.
nyata dgn mrobiditas dan mortalitas

Common cause of illness in young children

Common cause of hospitalization in young children
Associated with chronic respiratory symptoms in adulthood
May be associated with significant morbidity or mortality

DIAGNOSIS
Bronchiolitis adalah radang ok
infeksi akut dari bronchiolus,
ditandai dgn adanya wheezing dan
obstruksi sal. nafas pada anak
dibawah usia 2 tahun.
Acute infectious inflammation of the
bronchioles resulting in wheezing and
airways obstruction in children less than
2 years old
3

MICROBIOLOGY
Penyebabnya yg khas oleh viruses

Parainfluenza
RSV-most common
Human Metapneumovirus
Influenza
Rhinovirus
Coronavirus
Human bocavirus

Biasanya disertai dgn infecksi

Mycoplasma pneumonia
4

RESPIRATORY SYNCYTIAL
VIRUS (RSV)
Unik ada dimana-mana di dunia (world)
Outbreaknya tgt musim (seasons)
Temperate Northern hemisphere:
November to April, peak January or
February
Temperate Southern hemisphere: May to
September, peak May, June or July
Tropical Climates: rainy season
5

PARAINFLUENZA
Usually type 3, but may also be caused
by types 1 or 2
Epidemics in the early spring and fall

HUMAN
METAPNEUMOVIRUS
Paramyxovirus, ditemukan thn 2001
Bisa bersamaan dgn viruses lainnya
Penyebab bronchiolitis atau pneumonia
pada anak.

INFLUENZA
Symptom RSV sama dgn
Parainfluenza
Distribusi dan musim peny.= RSV
Biasanya epidemik di Northern
hemisphere January - April

RHINOVIRUS
Lebih dari 100 serotypes
Penyebab utama - common cold
Berhubungan dgn lower respiratory tract
disease pd anak dgn chronic lung disease
Sering ditemukan bersamaan dgn viruses
lainnya
Biasa timbul pd musin spring dan fall (musim
bunga dan musim rontok)
9

CORONAVIRUS
Penyebab terbanyak kedua dari common cold
Type yg Non-SARS (Severe acute
respiratory syndrome) dpt
menyebabkan bronchiolitis pd anak

10

HUMAN BOCAVIRUS
Ditemukan pd thn 2005
Timbul pd musin fall and winter;
Dpt menyebabkan - bronchiolitis dan
pertussis-like illness.

11

EPIDEMIOLOGY Bronchiolitis
Khas pd anak < 2 thn dgn peak incidence 2
to 6 bulan.
Dpt menyebabkan sakit sampai usia 5 thn
Penyebab terbanyak anak dirawat di RS pada
infants dan young children
Ditemukan 60% pada lower respiratory
tract illness pd tahun pertama kehidupan
anak
12

EPIDEMIOLOGY .
Pada survey di USA thn 1980-1996:
1.65 juta rawatan pd anak < 5 thn pada
periode tsb.
57% pd anak < 6 bln
81% pada anak <1 thn
Mean lama hari rawatan 3 hari
Pada usia > 17 thn rawatan 2 kali lipat
Pada rawatan RS anak pria lebih (62%)

13

FACTORS RESIKO DARI

SEVERITAS

Prematurity
Low birth weight
Age less than 6-12 weeks
Chronic pulmonary disease
Hemodynamically significant cardiac
disease
Immunodeficiency
Neurologic disease
Anatomical defects of the airways
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RISKO FACTOR
LINGKUNGAN

Older siblings (Sdra2 lainnya)

Concurrent birth siblings (Sdra yg baru lahir)
Native American heritage (turunan)
Passive smoke exposure (perokok pasif)
Household crowding (ramai2 serumah)
Child care attendance (pembantu rmh tangga)
High altitude (daerah pegunungan)
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PATHOGENESIS
-Virus masuk kedlm sel bronchiolar
merusak dan membuat radang.
-Perobahan patologik
dimulai 18-24 jam sesudah infeksi.
-Bronchiolar
sel necrosis. Cilia hancur, ada lymfocytik
infiltration.
-Edem, mucous berlebihan, menyumbat
saluran nafas atelectasis.
[atel + ectasi] = 1). incomplete expansion of the lung or
portion of a lung, 2). Airlessness or collaps yg tadinya
ada udara.

16

PATHOGENESIS BRONCHIOLITIS
Bronchial Tree
1. *Terminal Br.
2. *Resp. Bron.
3. *Alveoli

Virus penetrasi sel bronciolar

rusak, radang , NECROSIS
Mocous berlebihan , Edem
menyumbat sal.nafas
ATELCTASIS. [Airlessness or
collaps yg tadinya ada
udara.]

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Alveoli tanpa udara

18

Alveoli tanpa udara

19

CLINICAL FEATURES
Gejala Klinik
Mulai dgn upper respiratory tract
symptoms: nasal congestion,
rhinorrhea, mild cough, low-grade fever
Progress in 3-6 days to rapid
respirations (pernafasan cepat), chest
retractions, wheezing

20

EXAM / PEMERIKSAAN
Tachypnea (Tachos = cepat)
80-100 in infants
30-60 in older children
Fase expiratory memanjang , ada rhonchi, /
wheezes dan seluruh paru bisa ada rhonci
basah..
Mungkin ada dehydration
Mungkin ada conjunctivitis or otitis media
Mungkin cyanosis or apnea
21

DIAGNOSIS
Diagnosis Clinis, tgt anamnesis dan
pemeriksaan physical.
Dibantu dgn CXR (Chest X Rays) :
hyperinflation, flattened diaphragms, air
bronchograms, peribronchial cuffing,
(mengembung) patchy infiltrates,
atelectasis
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Hyperinflation / trapping udara)

Diafragma datar (flatten)

23

VIRAL IDENTIFICATION
Umumnya tidak perlu pd outpatients
dan jarang merobah treatment or
outcomes (hasilnya)
Mungkin antibiotic tak dipakai.
Mungkin dpt dibantu dgn isolation,
prevention (cegah) of transmission
Bisa ditolong dgn guide antiviral therapy
24

VIRAL IDENTIFICATION
Nasal wash or aspirate
Rapid antigen detection for RSV,
parainfluenza, influenza, adenovirus
(sensitivity 80-90%)
Direct dan indirect immunofluorescence
tests
Culture dan PCR
25

DIFFERENTIAL DIAGNOSIS

Viral-triggered asthma
Bronchitis or pneumonia
Chronic lung disease
Foreign body aspiration
Gastroesophageal reflux or dysphagia leading to
aspiration
Congenital heart disease or heart failure
Vascular rings, bronchomalacia, complete tracheal
rings or other anatomical abnormalities
26

PERJALANAN PENYAKIT
(COURSE)
Tgt dari co-morbidities
Biasanya self-limited
Symptoms hilang dlm beberapa minggu,
umumnya kembali ke baseline - 28 hari
Pd infants > 6 months, rata2 tinggal di RS 34 hari, symptoms sembuh 2-5 hari tetapi
wheezing biasa bertahan sampai lebih dari 1
minggu.
Perobahan pola tidur dan makan, bisa
bertahan sampai 2-4 minggu.
27

PENILAIAN SEVERITY
Menurut AAP seviritas peny. tgt dari: signs
and symptoms yg berhubungan dgn susah
makan (feeding) dan respiratory distress :
:tgt ada/tidaknya : tachypnea, nasal flaring,
dan hypoxemia.
Biasanya diberi IV hydration, supplemental
oxygen and/or mechanical ventilation
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Resiko Seviritas Penyakit,

ada / tidak
Toxic or ill-appearing ( tanda toxic
muntah, malaise, anorexia, feeding
probleem, coated tongue)
Oxygen saturation < 95% on room air
Usia kurang dari 3 months
Respiratory rate > 70
Atelectasis on CXR
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HOSPITALIZATION
DIRAWAT DI RS:
Children with severe disease
Toxic with poor feeding, lethargy, dehydration
Moderate to severe respiratory distress (RR >
70, dyspnea, cyanosis)
Apnea
Hypoxemia
Parent unable to care for child at home
(Orang tua tak sanggup merawat dirumah)
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TREATMENT
Supportive care
Pharmacologic therapy
Ancillary evaluation

31

ANCILLARY TESTING
(TAMBAHAN PEMERIKSAAN)
Most useful in children with
complicating symptoms--fever, signs of
lower respiratory tract infection
CBC (Complete Blood Count)--to help
determine bacterial illness
Blood gas--evaluate respiratory failure
CXR--evaluate pneumonia, heart
disease
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SUPPORTIVE CARE
(PERAWATAN SUPPORTIF)
Respiratory support and maintenance of
adequate fluid intake
Saline nasal drops (tetesi hidung dgn saline)
with nasal bulb suctioning (isap lendir dgn
balon pengisap)
Routine deep suctioning (pengisapan lebih
kedalam ) non recommended
Antipyretics
Rest
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MONITORING.
For determining deteriorating respiratory
status (penentuan perburukan peny.)
Continuous HR, RR and oxygen saturation
Blood gases if in ICU (Kl di ICU koreksi
Blood gas) or has severe distress (atau
penyakit tambah hebat)
Change to intermittent monitoring as status
consistently improves (Intermitten monitoring
kalau status peny.membaik)
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FLUID ADMINISTRATION
IV fluid administration in face of dehydration
due to increased need (fever and tachypnea)Beri IVFD yg cukup- and decreased intake
Kurangi kl tachypnu dan resp. dystress(tachypnea and respiratory distress)
Monitor for fluid overload as ADH levels may
be elevated -Monitor kelebihan cairan ok.
ADH bisa meningkat35

CHEST PHYSIOTHERAPY
Not recommended
Does not improve clinical status, reduce
oxygen need or shorten hospitalization
May increase distress and irritability

36

BRONCHODILATORS
Generally not recommended or helpful
-Tdk
dianjurkan /todak menolong Subset of children with significant wheezing or a
personal or family history of atopy or asthma may
respond
-Pd sebahaguab anak dgn wheezing atau ada
riwayat family atopy atau asthma bisa menolong Trial with Albuterol or Epinephrine may be
appropriate
Mungkin menolong dengan Albuterol
atau Ephinephrine Therapy should be discontinued if not helpful or
when respiratory distress improves
-Terapi dihentikan kl resp. dystres tdk berobah37

CORTICOSTERIODS
Not recommended in previously healthy
children with their first episode of mild to
moderate bronchiolitis
-Tdk dianjurkan pd serangan pertama yang
ringan atau sedang May be helpful in children with chronic lung
disease or a history of recurrent wheezing
-Mungkin membantu pd anak dgn penyakit
kronik atau wheezing berulang Prednisone, prednisolone, dexamethasone
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INHALED
CORTICOSTEROIDS
Not helpful acutely to reduce symptoms,
prevent readmission or reduce hospitalization
time
-Pada peny. Akut tdk menolong
menghilangkan gejala No data on chronic use in prevention of
subsequent wheezing
-Pada Peny. Kronik dlm mencegah whezing
belum ada data.39

RIBAVIRIN
Not routinely recommended due to modest
effectiveness and cost
-Belum rutin digunakan May be useful in infants with confirmed RSV at
risk for more severe disease
-Mungkin berhasil pada RSV Must be used early in the course of the illness
Harus dipakai pada awal sakit True of other antiviral agents, such as those for
Influenza, as well
-Antiriral yang lain dari diatas mungkin bisa
dipakai-

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ANTIBIOTICS
Not useful in routine bronchiolitis (tdk diberi)
Should be used if there is evidence of
concomitant bacterial infection (diberi bila
ada):
Positive urine culture
Acute otitis media
Consolidation on CXR
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COMPLICATIONS
Highest in high-risk children
Apnea
Most in youngest children or those with previous
apnea
Respiratory failure
Around 15% overall
Secondary bacterial infection
Uncommon, about 1%, most in children requiring
intubation

42

DISCHARGE CRITERIA /
KRITERIA PULANG DARI RS.
RR < 70
Caretaker capable of bulb suctioning
(penjaga anak bisa memakai balon isap)
Stable without supplemental oxygen
(bisa
stabil tanpa pemakaian oxygen)
Adequate PO intake to maintain hydration
-I(ntake cairan per oral harsus cukup) Adequate home support for therapies such as inhaled
medication (Dirumah harus ada obat semprot)
Caretaker educated and confident
(Penjaga anak udah dilatih dan percaya diri)

43

CARETAKER EDUCATION
(Edukasi utk perwatan)
Expected clinical course (Tau perjalan
penyakit)
Proper suctioning techniques
(Bisa melakukan Teknik pengisap lendir)
Proper medication administration
(Tau cara pembemberian obat)
Indications for contacting physician
(Tau indikasi utk memanggil Dokter)
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OUTCOMES-MORTALITY (Hasil
Pengobatan Mortalitas)
Overall rate < 2% in hospitalized children
-<2% meninggal di RS
Mean mortality 2.8 per 100,000 live births
-Mean mortality 2.8% per 100.000 lahir hidup
79% of deaths occurred in children less than I year old
-79% meninggal sblm usia 1 thn
Death 1.5 times more likely in boys
-Anak laki 1.5 x lebih banyak.
Approximately 20% of deaths were in children with
underlying
medical conditions
-20%
meninggal pd anak .
Mortality rate decreases with increasing birth weight
(29.8/100,000 if < 1500 grams, 1.3/100,000 if > 2500 grams)
-Mortalityrate berkurang bila BB lahir meningkat.

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ASSOCIATION WITH
ASTHMA
Infants hospitalized with bronchiolitis, especially RSV, are at
increased risk for recurrent wheeze and decreased PFTs
(dirawat ok RSV, wheezing
berulang dan Pulmonary Function Test menurun)
Frequent wheezing odds ratio 4.3
Infrequent wheezing odds ratio 3.2
Reduced FEV1 up to age 11 (Forced Expiratory Volume yg
berkurang

Association of RSV with later asthma

(berhubungan RSV dgn yang berakhir dgn astma)
May reflect predisposition for asthma or increased risk factors for
asthma

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PREVENTION
Good hand washing
-Cuci tangan yg benar
Avoidance of cigarette smoke
-Hindari asap rokok
Avoiding contact with individuals with viral illnesses
-Cegah
kontak dgn orang dgn peny. virus
Influenza vaccine for children > 6 months and
household contacts of those children
-Beri influenza vaksin pd anak > 6 bulan dan penjaga
anak.
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PALIVIZUMAB (obat anti

bodies thd RSV)
Humanized monoclonal antibody against
RSV
Indications
Prematurity
Chronic lung disease

Congenital heart disease

Given monthly through RSV season
48

Viral Bronchiolitis
Penyebab
terbanyak adalah
Respiratory Syncytial Virus (RSV)
Metapneumovirus
Parainfluenza Virus

49

TKS

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