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COVID-19
PENDAHULUAN
Background
December 2019, pneumonia
Spread worldwide rapidly 🡪
caused by new Corona Virus 🡪
SARS-CoV-2 PANDEMIC (WHO, March 2020)
 WHO Global Health Emergency
• 31 December 2019: 27 cases of pneumonia of unknown aetiology
were identified in Wuhan City, Hubei province in China
• 7 January 2020: The Chinese Centre for Disease Control and
Prevention (CCDC), and was subsequently named Severe Acute
Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).
• On 30th January 2020: WHO declared outbreak a Public Health
Emergency of International Concern
• 11 February 2020: The coronavirus disease was named COVID-19 by
the World Health Organization (WHO)
Sohrabi C et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery 76
(2020) 71–76
WHO. Int. Corona Virus (COVID 19) Report. Access 13 April 2020
 Latar Belakang

4 April 2021 (Confirmed case 130.422.190 Total kematian 2,842,135 )

World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. 2021

 Indonesia 4 April 2021

World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. 2020

Nature Reviews Immunology, volume 20, June 2020,343
Postulated pathogenesis of SARS-CoV-2 infection. Antibody-dependent enhancement (ADE); ACE2:
angiotensin-converting enzyme 2; RAS: renin-angiotensin system; ARDS: acute respiratory distress
syndrome. Red words represent the important turning points in SARS-CoV-2 infection Yuefei Jin. Viruses 2020, 12, 372
 Evidence used of underlying medical conditions that increase
a person’s risk of severe illness from COVID-19 (CDC update)
Evidence of Impact on COVID-19
Level of Evidence Condition Notes
Severity
Strongest and most consistent Serious heart condition, such as heart Cohort study (1,2), Meta analysis (3,4), Case On previous version of list as “Serious
evidence failure, coronary artery disease, or series (5) Heart conditions”
cardiomyopathies
Cancer Systematic Review (6), Cohort study (7,8), Case New to updated list as of July 17, 2020
series (9)
Chronic kidney disease Case series (10,11,12), Cohort studies On previous version of list as “Chronic
(13,14,15) kidney disease requiring dialysis”
COPD Meta analysis (4,16), Case series (17), Cohort On previous version of list
study (14)
Obesity (BMI > 30) Cohort study (18, 19, 20, 21, 22), Cross- On previous version of list as “Severe
sectional (23) obesity (BMI > 40)”
Sickle cell disease Case series (24, 25, 26, 27, 28) On previous version of list

Solid organ transplantation Case series (12, 29, 30, 31, 32, 33, 34) New to updated list at of June 25, 2020

Type 2 diabetes mellitus Case series (11), Longitudinal study (35), Cohort On previous version of list
study (36,37), Meta analysis (38)
Evidence used of underlying medical conditions that increase
a person’s risk of severe illness form COVID-19 (CDC update)
Level of Condition Evidence of Impact on COVID-19 Severity Notes
Evidence
Mixed Evidence Asthma Cohor study (14,39,40,41), Case series (17) On previous version
of list
Cerebrovascular Meta analysis (42,43,44, 45), Synthesis of New to updated list
disease evidence (46), Cohort study (1,2,47,48,49) as of June 25, 2020
Hypertension Cohort study (1,2,49,50,51), Systematic New to updated list
review (52), Meta analysis (3,4,53) as of June 25, 2020
Pregnancy Systematic review (54), Case control study
(55), Case series (56,57,58,59), Cohort study
(60,61,62)
Smoking Meta analysis (3,63,64,65,66) On previous version
of list
Use of corticosteroids or Case series (67,68,69), Cohort study (70,71) On previous version
other of list
immunosuppressive
medications
Evidence used of underlying medical conditions that increase
a person’s risk of severe illness form COVID-19 (CDC update)
Level of Condition Evidence of Impact on COVID-19 Severity Notes
Evidence
Limited Evidence Bone marrow Review (72) On previous version
transplantation of list
HIV Case series (73,74) On previous version
of list
Immune deficiencies Case series (75), Systematic review (76) On previous version
of list
Inherited metabolic Cohor study (47,77) Specific to pediatric
disorders populations at this
time
Liver disease Meta-analysis (78), Cohort study (79,80), On previous version
Literature review (81) of list
Neurologic conditions Cross-sectional study (82), Cohort study Specific to pediatric
(41,49,77) populations at this
time
Evidence used of underlying medical conditions that increase
a person’s risk of severe illness form COVID-19 (CDC update)
Level of Condition Evidence of Impact on COVID-19 Severity Notes
Evidence
Limited Evidence Other chronic lung Meta-analysis (4), Case series (17), Cohort On previous version
disease study (14,83) of list
Pediatric Systematic review (84,85), Cross-sectional New to updated list
study (82,86), Cohort study (77,87,88) as of July 17, 2020
Thalassemia Case series (89), Cross-sectional study (90) On previous version
of list
Type 1 diabetes mellitus Case series (11), Cohort study (36,37), Meta- On previous version
analysys (38) of list
EPIDEMIOLOGI
Image courtesy of Olivia Wong, DO. Data from the CDC, WHO, and JHU CSSE.[12,13,23]
GEJALA KLINIS
Clinical symptoms associated with COVID-19
and risk factors
Clinical presentation Presenting signs and symptoms of COVID-19 vary.
Most persons experience fever (83–99%), cough (59–82%), fatigue (44–
70%), anorexia (40–84%), shortness of breath (31–40%), myalgias (11–35%).
Other non-specific symptoms, such as sore throat, nasal congestion,
headache, diarrhoea, nausea and vomiting, have also been reported (17, 48-
50). Loss of smell (anosmia) or loss of taste (ageusia) preceding the onset of
respiratory symptoms has also been reported.
Older people and immunosuppressed patients in particular may present
with atypical symptoms such as fatigue, reduced alertness, reduced mobility,
diarrhoea, loss of appetite, delirium, and absence of fever .
Symptoms such as dyspnoea, fever, GI symptoms or fatigue due to
physiologic adaptations in pregnant women, adverse pregnancy events, or
other diseases such as malaria, may overlap with symptoms of COVID-19.
COVID-19 disease severity

Mild disease Symptomatic patients (Table 1) meeting the case definition for
COVID-19 without evidence of viral pneumonia or hypoxia.
See the WHO website for most up-to-date case definitions .

Moderate disease Pneumonia Adolescent or adult with clinical signs of pneumonia (fever,
cough, dyspnoea, fast breathing) but no signs of severe
pneumonia(54).
Fast breathing (in breaths/min): < 2 months: ≥ 60; 2–11
months: ≥ 50; 1–5 years: ≥ 40 .
While the diagnosis can be made on clinical grounds; chest
imaging (radiograph, CT scan, ultrasound) may assist in
diagnosis and identify or exclude pulmonary complications.
COVID-19 disease severity

Severe disease Severe pneumonia Adolescent or adult with clinical signs of pneumonia (fever,
cough, dyspnea, fast breathing) plus one of the following:
respiratory rate > 30 breaths/min; severe respiratory distress;
or SpO2 < 90% on room air .
While the diagnosis can be made on clinical grounds; chest
imaging (radiograph, CT scan, ultrasound) may assist in
diagnosis and identify or exclude pulmonary complications.
COVID-19 disease severity

Critical disease Acute respiratory Onset: within 1 week of a known clinical insult (i.e.
distress syndrome pneumonia) or new or worsening respiratory symptoms.
(ARDS) Chest imaging: (radiograph, CT scan, or lung ultrasound):
bilateral opacities, not fully explained by volume overload,
lobar or lung collapse, or nodules.
Origin of pulmonary infiltrates: respiratory failure not fully
explained by cardiac failure or fluid overload. Need objective
assessment (e.g. echocardiography) to exclude hydrostatic
cause of infiltrates/oedema if no risk factor present.
Oxygenation impairment in adults :
• Mild ARDS: 200 mmHg < PaO2/FiO2a ≤ 300 mmHg (with
PEEP orCPAP ≥ 5 cmH2O).b
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg
(with PEEP≥ 5 cmH2O).b
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5
cmH2O).b
COVID-19 disease severity

Critical disease Sepsis Acute life-threatening organ dysfunction caused by a

dysregulated host response to suspected or proven infection.
Signs of organ dysfunction include: altered mental status,
difficult or fastbreathing, low oxygen saturation, reduced urine
output, fast heart rate, weak pulse, cold extremities or low
blood pressure, skin mottling, laboratory evidence of
coagulopathy, thrombocytopenia, acidosis, high lactate, or
hyperbilirubinemia.
Septic shock Persistent hypotension despite volume resuscitation, requiring
vasopressors to maintain MAP ≥ 65 mmHg and serum lactate
level > 2 mmol/L.

Other complications that have been described in COVID-19 patients include acute, life-threatening condtions such as: acute pulmonary embolism, acute coronary syndrome, acute
stroke and delirium. Clinical suspicion for these complications should be heightened when caring for COVID-19 patients, and appropriate diagnostic and treatment protocols available

a
If altitude is higher than 1000 m, then the correction factor should be calculated as follows: PaO2/FiO2 x barometric pressure/760.
b
When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests ARDS (including in non-ventilated patients).
DIAGNOSTIK
Diagnostic Clinical Evaluation, based on :
• Anamnesis / History Taking

• Physical Examination

• Laboratory Examination

• Imaging
Kompendium Diagnostik dan Pengobatan COVID-19 (interim)
Perhimpunan Respirologi Indonesia (perpari)
Indonesia Journal Chest | Vol.7 No.1 Jan-Juni. 2020

Tingkat Positivitas Sensitivitas dan Spesifitas Berdasarkan Tempat

Pengambilan Specimen Swab

No. Jenis Spesimen Positivitas

(%)
1 Cairan bilasan Bronkoalveolar 93
2 Sikatan dengan Fiberoptik Bronkoskopi 46
3 Sputum 72
4 Swab hidung 63
5 Swab Faring 32
6 Feces 29
7 Darah 1
8 Urine
Catatan: Swab hidung hanya akan mendeteksi 2/3 dari seluruh kasus dan swab faring hanya akan mendeteksi 1/3 dari seluruh kasus
0

Wang dkk. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. Jama. 2020:e203786
Physical Examination
a) Febrile with/without chills/rigors
b) Difficulty breathing
c) Tachycardia
d) Tachypnea
e) Cyanosis
f) Rales
Laboratory
Laboratory medicine plays an essential role in the early detection, diagnosis, and
management of the diseases.
Laboratory (classic COVID-19)
• Leukosit 🡪leukopenia
• Absolute limfosit count (ALC) 🡪 <1500/μL
• Neutrofil limfosit ratio > 3,13
• Trombocyt 🡪 trombocytopenia
• C-reactive protein 🡪 >10 mg/dL
• Procalcitonin 🡪 normal
• Pulse oxymetri 🡪 silent hypoxia
KLASIFIKASI
PERJALANAN PENYAKIT
Klasifikasi Tahapan Penyakit COVID-19 dan
Target Terapi Potensial

Lauer SA, dkk. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020:M20-0504.
Natural History of COVID-19
Day Symptoms
1 Fever, fatique, muscle pain, dry cough
A few days before: nausea and diarhoea
5 Breathing problems (especialy elderly) / pre-existing health conditions
7 Admitted in the hospital
8 15% develop ARDS
10 Worsening the symptoms 🡪 ICU
Milder symptoms: abdominal pain and loss of appetice
Mortality rate: + 2%

17 On average: 2,5 weeks

Patient who recover 🡪 discharged

Hafeez A. EJMO 2020;4(2):116-25

Perjalanan penyakit pada COVID-19 dan
onset gejala

Susilo A, dkk. Coronavirus Disease 2019: Tinjauan Literatur Terkini. Jurnal Penyakit Dalam Indonesia. Article review. 2020;7(1):11.
Managemen Klinis
Skematik yang menampilkan sistem respon imun sel inang
terhadap virus dan proses virus dengan target sel

Sanders JM, dkk. Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19): A Review. Jama. 2020.
https://www.who.int/news-room/detail/04-07-2020-who-discontinues-hydroxychloroquine-and-lopinavir-ritonavir-treatment-arms-for-covid-19
Intervensi dini pada kondisi pasien sakit
kritis

Sun Q, dkk. Lower mortality of COVID-19 by early recognition and intervention: experience from Jiangsu Province. Ann Intensive Care. 2020;10(1):33
http://www.ox.ac.uk/news/2020-06-16-dexamethasone-reduces-death-hospitalised-patients-severe-respiratory-complications
PREDIKTOR
Prediktor pasien COVID-19 dengan risiko
rendah dan tinggi terjadinya progresi penyakit
Risiko Rendah Progresi Risiko Tinggi Progresi
∙ Usia < 30 tahun ∙ Usia > 30, khususnya > 50
∙ Tidak ada penyakit komorbiditas ∙ Terdapat penyakit komorbiditas (penyakit paru kronis,
∙ Manifestasi klinis : penyakit jantung dan ginjal, A1c > 7,2%, imunosupresi)
- Tidak ada sesak napas ∙ Manifestasi klinis :
- Laju pernapasan ≤ 20 x/menit - Sesak napas
- SpO2 % normal - Laju pernapasan > 20 x/menit
- Tidak memerlukan terapi oksigen tambahan - SpO2 % abnormal (<95%)
∙ Foto toraks normal - Membutuhkan terapi oksigen tambahan
∙ Hasil laboratorium:* ∙ Foto toraks dengan pneumonia
- CRP ≤ 60 mg/L ∙ Hasil laboratorium*
- LDH ≤ 550 U/L - CRP ≥ 60 mg/L
- Limfosit ≥ 1x109/L - LDH > 550 U/L
- Neutrofil ≤ 3x109/L - Limfosit < 1x109/L
- Neutrofil > 3x109/L
- Lain-lain: meningkatnya nilai feritin, D-Dimer > 1
µg/mL, dan/atau nilai troponin

Young BE, Ong SWX, Kalimuddin S, Low JG, Tan SY, Loh J, dkk. Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. Jama. 2020;323(15):1488-94.
Fan BE, Chong VCL, Chan SSW, Lim GH, Lim KGE, Tan GB, dkk. Hematologic parameters in patients with COVID-19 infection. Am J Hematol. 2020.
Kriteria pulang
https://www.who.int/publications/i/item/criteria-for-releasing-covid-19-patients-from-isolation
PENCEGAHAN
Image from the CDC.
TERIMA KASIH