Pemicu 4 KGD

Esteven Tanu Gunawan

405150069
Gagal Napas
Respiratory Failure

Hypercapnic: ventilator failure

(reduced ventilator effort,
increased resistance
Hypoxemic: damage to lung
tissue (pulmonary edema,
pneumonia, ARDS)
http://emedicine.medscape.com/article/167981-overview#show
all
Clinical Manifestation
Type I : Type II :
• Central cyanosis • Irritability
• Irritability • Confusion, somnolence, coma
• Impaired intellectual function • Tremor, myoclonic jerks, asterixis,
• Clouding of consciousness seizures
• Cardiac dysrhythmias • Headache, papilloedema
• Tachycardia, sweating, hypotension

GC Khilnani, C Bammigatti. Acute Respiratory Failure - Algorithmic Approach –Diagnosis and Management.
Diagnosis :
• ABG
• CBC
• Chemistry panel
• Renal & hepatic function
• Electrolytes
• Serum creatine kinase with fractionation & troponin I
• TSH
• Chest radiography
• Echocardiography
• Pulmonary Function Tests  FEV1, FVC, FEV1/FVC
• Pulmonary capillary wedge pressure
http://emedicine.medscape.com/article/167981-workup#showall
Management
• Progressive hypoxemia and hypercapnia  intubation and mechanical
ventilation
• Correction of hypoxemia and  facemask
GC Khilnani, C Bammigatti. Acute Respiratory Failure - Algorithmic Approach –Diagnosis and Management.
GC Khilnani, C Bammigatti. Acute Respiratory Failure - Algorithmic Approach –Diagnosis and Management.
Efusi Pleura
Pleural Effusion
• Pleural effusions result from fluid accumulating in the potential space
between the visceral and parietal pleura.
• Most common cause:
- Congestive heart failure
- Pneumonia
- Malignancy
- Pulmonary embolism
- Viral infection
Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 8 th Edition.
Fishman’s Pulmonary Disease and Disorders, 4 th Edition.
Rosen’s Emergency Medicine, 9th Edition.
Clinical Features :
• Symptoms associated with pleural effusion are most often
caused by the underlying disease process
• Small pleural effusions often asymptomatic
• A new or enlarging pleural effusion localized pain or
pain referred to the shoulder
• Viral pleuritis and pulmonary infarction chest pain
• Volume of pleural fluid reaches 500 mL  dyspnea on
exertion or at rest

Marx JA, Hockberger RS, Walls RM, et al, editors. Rosen’s Emergency Medicine Concepts & Clinical Practice. 8 th ed.
Philadelphia: Elsevier; 2014.
Physical examination :
• Classic physical signs of pleural effusion include
diminished breath sounds, dullness to percussion,
decreased tactile fremitus
• Auscultation  Egophony and enhanced breath sounds
can often be appreciated at the superior border of the
effusion because of underlying atelectatic lung tissue
PP :
• Classic radiographic
• USG
• Pleural fluid analysis
• A predominance of monocytes or lymphocytes

Marx JA, Hockberger RS, Walls RM, et al, editors. Rosen’s Emergency Medicine Concepts & Clinical Practice. 8 th ed.
Philadelphia: Elsevier; 2014.
Rosen’s Emergency Medicine, 9th Edition.
Rosen’s Emergency Medicine, 9th Edition.
Fishman’s Pulmonary Disease and Disorders, 4 th Edition.
Fishman’s Pulmonary Disease and Disorders, 4 th Edition.
Management :
• In patients with large effusions, urgent therapeutic
thoracentesis  stabilize respiratory or circulatory status.
• Empyema needs insertion of a chest tube
• Pleura effusion associated with hemothorax tube
thoracostomy  If bleeding exceeds 200 mL/hr 
thoracotomy
• NSAID treating pleural pain
• After thoracocentesis  CXR find complication

Marx JA, Hockberger RS, Walls RM, et al, editors. Rosen’s Emergency Medicine Concepts & Clinical Practice. 8 th ed.
Philadelphia: Elsevier; 2014.
Avian Influenza
• Avian influenza is an infectious disease caused by the common type A
influenza virus in poultry (H5N1)
• The spread of the virus avian influenza occurs through the air (droplet
infection) where the virus can be embedded in the mucous membranes lining
the airway or directly enter the alveoli (depending on the size of the droplet)
 exposed to mucoproteins containing sialic acid that can bind viruses (alpha
2,6 sialiloligosacarid)
• Incubation period  3 days
• Sign & symptoms  influenza like illness (cough, cold, and fever), cephalgia,
sore throat, myalgia, malaise, diarrhea, conjunctivitis
• Lab  leukopenia, lymphophenia, trombositopenia
• Diagnositic  comfortmation test (culture and identification about H5N1
viruses, Real Time Nested PCR, serology (IFA test, netralitation test, screening
test), hematology, chemical, radiology
• Treatment  antivirus (48 hours first), M2 blocker, neuramidase blocker,
Depkes RI  Oseltamivir 2x75mg for 5 days.
Asma Akut (Eksaserbasi akut)
Status asthmaticus
• an acute exacerbation of asthma
• remains unresponsive to initial treatment with bronchodilators
• bronchospasm, airway inflammation, and mucus plugging  difficulty
breathing, carbon dioxide retention, hypoxemia, and respiratory
failure
Faktor Resiko
• Riwayat asma fatal yg membutuhkan intubasi dan ventilasi mekanik
• Rawat inap atau Emergency care visit untuk asma dalam 1 tahun terakhir
• Sedang dalam atau baru berhenti menggunakan corticosteroid oral
• Sedang tidak menggunakan corticosteroid inhale
• Penggunaan SABA berlebihan, khususnya lebih dari 1 canister salbutamol
perbulan
• Riwayat gangguan psikis atau masalah psikososial
• Alergi makanan pada pasien dengan asma
• Ketidakpatuhan pasien dalam menjalani terapi asma
Algoritma

Sumber : Gina 2018

Algoritma

Sumber : Gina 2018

Aspirasi Trakea
Tracheal Aspiration
• Pulmonary aspiration is the entry of material (such
as pharyngeal secretions, food or drink, or stomach
contents) from the oropharynx or gastrointestinal
tract into the larynx (voice box) and lower respiratory
tract (the portions of the respiratory system from
the trachea—i.e., windpipe—to the lung).
• A person may either inhale the material, or it may be
delivered into the tracheobronchial tree during positive
pressure ventilation.
Symptoms:
include coughing, difficulty
breathing and in some cases
choking.
Treatments :
include making sure the airway is
open, close observation and, in case
of infection, antibiotics.
Pneumoni Aspirasi
Aspiration Pneumonia
• Pneumonia is a breathing condition in which there is swelling or an
infection of the lungs or large airways.
• Aspiration pneumonia occurs when food, saliva, liquids, or vomit is
breathed into the lungs or airways leading to the lungs, instead of
being swallowed into the esophagus and stomach.

https://medlineplus.gov/ency/article/000121.htm
Causes
• The type of bacteria that caused the pneumonia depends on:
• long-term nursing facility.
• Recently hospitalized.
• Recent antibiotic use
• Immune system is weakened

https://medlineplus.gov/ency/article/000121.htm
Risk factors
• Risk factors for breathing in (aspiration) of foreign
material into the lungs are:
• Being less alert due to medicines, illness, or other reasons
• Coma
• Drinking large amounts of alcohol
• Receiving medicine to put you into a deep sleep for surgery
(general anesthesia)
• Old age
• Poor gag reflex in people who are not alert (unconscious or
semi-conscious) after a stroke or brain injury

https://medlineplus.gov/ency/article/000121.htm
Symptom
• Poor oral hygiene and throat clearing or wet coughing after eating.
• Chest pain
• shortness of breath
• wheezing
• fatigue
• blue discoloration of the skin
• cough, possibly with green sputum, blood, or a foul odor
• difficulty swallowing
• bad breath
• excessive sweating
https://www.healthline.com/health/aspiration-
pneumonia#takeaway9
Diagnosed
• Signs of pneumonia during a physical exam, such • blood culture : Because pneumonia is a serious
as a decreased flow of air, rapid heart rate, and a
crackling sound in your lungs.
• chest X-ray
• arterial blood gas
• Bronchoscopy : Bronchoscopy is indicated in
patients with chemical pneumonia only when
aspiration of a foreign body or food material is
suspected.
• Ultrasonography is helpful when confirming and
locating pleural effusions.
• Computed tomography (CT) scan of the chest is
not required in the evaluation of all cases of
suspected aspiration pneumonia. This imaging
modality may be helpful in further characterizing
pleural effusions and empyema and in detecting
necrosis within infiltrates and cavitary lesions.
condition, it requires treatment. must have some of
test results within 24 hours. Blood and sputum
cultures will take three to five days.
• Thoracentesis, also known as pleural fluid
aspiration, is a diagnostic and therapeutic procedure
in which fluid (or air) is removed from between the
visceral and parietal pleurae. Analysis of the
specimen can help determine the underlying cause
of the pleural effusion as well as relief of symptoms
attributed to the presence of pleural fluid. A chest
radiographs should be obtained both before and
after this procedure to detect complications from
the thoracentesis.
• Mechanical ventilation may be required in severe
cases of chemical pneumonitis that cause acute
respiratory distress syndrome (ARDS) and in
respiratory insufficiency due to aspiration
pneumonia.

https://www.healthline.com/health/aspiration-
pneumonia#takeaway9
Radiograph
• Chest Radiography
• Radiographic evidence of
aspiration pneumonia
depends on the position of
the patient when the
aspiration occurred. The right
lower lung lobe is the most
common site of infiltrate
formation due to the larger
caliber and more vertical
orientation of the right
mainstem bronchus.
• Chemical pneumonitis
• Chest radiographic findings in patients with
chemical pneumonitis are characterized by the
presence of infiltrates, predominantly the
alveolar type, in one or both lower lobes, or
diffuse simulation of the appearance of
pulmonary edema. Volume loss in any lobar area
suggests obstruction (eg, by aspirated food
particles or other foreign bodies) in the
bronchus.
• Bacterial pneumonia
• Chest radiographic findings in patients with
anaerobic bacterial pneumonia typically
demonstrate an infiltrate with or without
cavitation in one of the dependent segments of
the lungs (ie, posterior segments of the upper
lobes, superior segments of the lower lobes).
https://emedicine.medscape
.com/article/296198-
overview#a25
Treatment
• People with trouble swallowing may need to stop taking food by mouth.
• Antibiotics
• Need supportive care if aspiration pneumonia causes breathing problems. Treatment
includes supplemental oxygen, steroids, or help from a breathing machine.
• Prehospital care should focus on stabilizing the patient's airway, breathing, and
circulation. In patients found with signs of gastric aspiration (ie, vomitus) suctioning of
the upper airway may remove a significant amount of aspirate or potential aspirate.
• Other measures include the following:
• Oxygen supplementation
• Cardiac monitoring and pulse oximetry
• Intravenous (IV) catheter placement and IV fluids, as indicated

https://www.healthline.com/health/aspiration-
pneumonia#takeaway9
IDSA Guidelines
• The 2011 Infectious Diseases Society of America (IDSA) guidelines for the
management of MRSA infections include the following recommendations
for the treatment of pneumonia :
• Empirical therapy for MRSA pending laboratory results for patients with
community-acquired pneumonia (CAP) and any of the following: (1) Admission to
the ICU; (2) Necrotizing or cavitary infiltrates; or (3) Empyema
• Intravenous vancomycin or linezolid 600 mg PO/IV twice daily or clindamycin 600
mg PO/IV thrice times daily, if the strain is susceptible, for 7-21 days, depending on
the extent of infection
• In patients with MRSA pneumonia complicated by empyema, antimicrobial
therapy should be used in conjunction with drainage procedures
Prevented
• Avoid behaviors that can lead to aspiration, such as excessive
drinking.
• Be careful when taking medications that can make you feel drowsy.
• Receive proper dental care on a regular basis.
• May recommend a swallow evaluation by a licensed speech
pathologist or swallow therapist.

https://www.healthline.com/health/aspiration-
pneumonia#takeaway9
COPD Eksaserbasi
Chronic Obstruction Pulmonary
Disease
• COPD: caused by an airway inflammation 
destruction of alveoli, loss of lung elasticity,
closure of small airways  failure of gas
exchange
• Acute exacerbation of COPD
• Change in symptoms beyond normal day-to-day
variations
• May associated with virus, bacteria or air pollution
Etiology

Rosen’s emergency medicine. 8th ed..

Gagal Napas pada Penyakit Paru
Obstrukstif Kronik
• Gambaran klinis :
• Pink puffer  dispnea, tidak ada sianosis saat istirahat
• Blue bloater (gagal napas 2) sianosis saat istirahat, kor
pulmonal, edema
• PaO2 menurun secara kronis dan PaCO2 meningkat  memburuk
pada infeksi akut  gagal napas eksaserbasi akut
• Selama eksaserbasi akut, PaCO2 dapat meningkat dan pH turun
secara signifikan  karena penyesuaian ginjal terjadi lambat  pH
arterial (proporsi hiperkapnia akut dan kronik)a
• Hiperkapnia kronik beresiko mengalami depresi respirasi dan
peningkatan PaCO2  fatal jika diberikan oksigen terlalu tinggi 
dapat disebabkan oleh hilangnya usaha hipoksik pada penurunan
sensitivitas CO2
COPD :
Diagnostic Alogarithm

Clinical emergency
medicine, Lange. p. 95-
ARDS
ARDS
• Clinical syndrome of severe dyspnea of rapid onset, hypoxemia, and diffuse
pulmonary infiltrates leading to respiratory failure.
• ARDS is caused by diffuse lung injury from many underlying medical and
surgical disorders

Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo S, editors. Harrison’s Principles of Internal Medicine. 19 th ed.
McGrawHill; 2015.
 Pathophysiology :
• The natural history of ARDS is marked by three phases—
exudative, proliferative, and fibrotic

Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo S, editors. Harrison’s Principles of Internal Medicine. 19 th ed.
McGrawHill; 2015.
Kasper DL, Hauser SL,
Jameson JL, Fauci AS,
Longo DL, Loscalzo S,
editors. Harrison’s
Principles of Internal
Medicine. 19th ed.
McGrawHill; 2015.
Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo S, editors. Harrison’s Principles of Internal Medicine. 19 th ed.
McGrawHill; 2015.
Approach to treatment