PNEUMONIA

Preceptor :
dr. Deddy Satriya Putra, Sp.A (K)
Presented by:
Rindi Rosalina Fadly

Vitamin
A
deficienc
y

Malnutritio
n
Low birth
weight
(<2500 g)
Nonexclusive
breastfeedin
g Lack of measles
immunization

66 million
million

Indoor air
pollution

Zinc
deficienc
Unicef: WHO. 2006. Pneumonia the Forgotten Killer of Children
y Rudan igor, boschi-pinto cyntha, biloglav zrinka, mulholland kim, cambel harry. Epidemiology and etiology of childhood
pneumonia. Bulletin of the World Health Organization 2008;86:408416.

Introduction

Pneumonia is an inflammation of the lung parenchyma . Which is

the inflammation process spreads and form patches infiltrate located
in the pulmonary alveoli and terminal bronchioles

Bacterial inhaled into the

lungs through the respiratory
tract & this microorganisms
reach the alveoli and induce
inflammatory process

Said M. Pneumonia. in: Rahajoe NN, Supriyatno B, Setyanto DB. Buku Ajar
Respirologi Anak. Edisi 1.Jakarta, 2008: 350-62

Definition & Pathophysiology

tachypnea

Mild

Retraction

Severe

Unable to
Very severe
feed/drink,
unconsciousne
ss and
convulsions

CAP

Classification

HAP

0-20 days
E. Colli
Streptococcus
Group B
Listeria
monocytogens

3 weeks-3
months

4 months-5
years

Streptococcus
pneumonia
Influenza Virus
Respiratory
Synctical Virus

Streptococcus
pneumonia
Influenza Virus
Respiratory
Synctical Virus

Said M. Pneumonia. in: Rahajoe NN, Supriyatno B, Setyanto DB. Buku Ajar
Respirologi Anak. Edisi 1.Jakarta, 2008: 350-62

Etiology

Physical
Examinatio
n

History

chest
radiogra
ph &
Blood
Tests

Diagnosis

Outpatient
Outpatient

Inpatient
Inpatient

Age groups

Schavner stephani, Erickson Cherise, Stphens Kelsey. Community-acquired

pneumonia in children: A look at the IDSA guidelines. The Jour nal of Family
Practice. 2013: 1-7

immunizati
on status

Antibacterial therapy
(CAP)

Identity
AR, boy, 6 months old, came to hospital at January
26nd , 2015
Alloanamnesis
Parents of Patients
Chief complaint
Dyspnea since 5 hours before came to hospital

CASE ILLUSTRATION

5 hours before admitted to the hospital, the

patient looked like dyspnea. This dyspnea
is the first time happened without the
influence of position and activity. This kind
of dyspnea is unsounded, lips and finger
tip are not cyanosis. Convulsions (-)

Present illness history

3 days before admitted to the hospital, the

patient got high fever during the day. Fever
was decrease after given the medicine.
However, the fever became higher after the
effect of medicine over. Chills (-),
convulsions (-), unconsciousness (-)
Diarrhea (+), frequency 5-6 x/minute,
volume glass, Liquid consistency with
the pulp and mucilage, vomiting (+)
every cough, Volume 10 cc each time
vomiting. able to drink, urinate (+)

Present illness history

Since 1 week before admitted to hospital patient

that got cough that has been happened frequently
since a month ago, at the beginning is nonproductive cough,then starting to be productive
cough for the following week with cream colour
sputum. No one around with cough complaint.

Present illness history

Past illness
history
Asthma (-)
there is no
inpatient
history on
hospital
within 48
hours ago

History

Family illness
history
(-)

Immunization
history
BCG (+)
DPT (+)

General
appearance:
Moderate
illness

Vital sign:
BP : 110/70
Pulse : 120x/minute, reguler,
strong, adequate
RR : 60x/minute
T : 37,9C

Consciousness:
Composmentis

Nutritional status: 97%

height : 94cm
weight : 15 kg
upper arm circumference :
13 cm
Head circumference: 42

Physical examination

Skin : Pale (+), jaundice (-),

cyanosis (-), ptekie (-)

Head : Normopcephal

Eyes :
Hair : Black, not easily
removed

Normal
Conjunctival anemia (+/+)
Sklera ikteric (-/-)
Pupil isokor 2mm/2mm,
Light reflex: direct (+ / +), indirect (+ /
+)

Physical examination

Ears :

Congenital disease (-)

External canal: secretions
(-), inflammatory signs (-)

Nose:
Nasal flaring (+)

Mouth:

Neck:

Mucous membranes moist

Intact palate
The tongue is not dirty

Lymphadenopathy (-)
Stiff neck (-)

Physical examination

Thorax
Inspection:
subcostal
retraction (+)
Palpation:
normal
Percussion:
normal
Auscultation
: Ronkhi (+ /
+) in both of
lungs

Abdomen
Normal

Extremity
Normal

Physical examination

Neurological
Status
Normal

Work Diagnosis:
Pneumonia + Acute diarrhea without
dehydration

Nutrition Diagnosis:
Good nutrition

Differential Diagnosis:
Bronchiolitis

Infiltrates in peri
hilar sinistra and
the kardial dextra

bronchopneumonia

Chest radiograph

O2 1 L nasal cannula

IVFD kaEN 1B 12 TPM

Ceftriakson 2x350 mg (IV)

Nebulisasi salbutamol 2,5 mg/ 4 jam

Paracetamol 4 x 0,8 ml (drops)

Lacto B 2X1

Zinc 1 x 1 tablet

Oralit 50 cc/every time diarrhea

Therapy

Quo ad vitam

: Bonam

Quo ad functionam : Bonam

Prognosis

Date

Subjective

Objective

Therapy

27/1/201
5

Fever (+),
cough (+),
dyspnea ,
diarrhea (+)
2x

RR : 50x/minute
T : 37,9 c
nasal flaring (+)
subcostal retraction (+)
ronkhi (+ /+) in both of lungs

Dexametason 3x1
mg IV

28/1/201
5

Fever (-),
cough (+),
dyspnea ,
diarrhea (-)

RR : 48x/minute
T : 36,5 c
nasal flaring (-)
subcostal retraction (+)
ronkhi (+ /+) in both of lungs

Dexametason (-)
Nebulisasi
salbutamol
2,5
mg/ 8 hour

29/1/201
5

Fever (-),
cough (+),
dyspnea (-),
diarrhea (+)
1x

RR : 40x/minute
T : 36,3 c
nasal flaring (-)
subcostal retraction (-)
ronkhi (+ /+) in both of lungs

Use IV plug
Nebulisasi
salbutamol 2,5
mg/ 8 hour

Follow Up

Dyspnea

This dyspnea is
the first time
happened

without the
influence of
position and
activity

unsounded,
lips and
finger tip
are not
cyanosis

Discussion (Diagnosis)
Said M. Pneumonia. Dalam: Rahajoe NN, Supriyatno B, Setyanto DB. Buku Ajar Respirologi Anak. Edisi 1.Jakarta, 2008: 350-62.
World Health Organization. Pneumonia. Fact sheet No. 331. 2009. Available at: http://www.who.int/mediacentre/factsheets/fs331/en/

Tachypnea (RR : 60 x/minutes)

Nasal flaring
Subcostal retraction
Ronkhi (+ /+) in both of lungs
T : 37,9C

6 months old
(2 months-5 years)
able to drink
convulsions (-),
unconsciousness (-)

Severe
Pneumonia

Discussion (Diagnosis)
Said M. Pneumonia. Dalam: Rahajoe NN, Supriyatno B, Setyanto DB. Buku Ajar Respirologi Anak. Edisi 1.Jakarta, 2008: 350-62.
World Health Organization. Pneumonia. Fact sheet No. 331. 2009. Available at: http://www.who.int/mediacentre/factsheets/fs331/en/

There is no inpatient
history on hospital
within 48 hours ago

CAP

Diarrhea + Leukocytosis
Suspect bacterial
pneumonia

Diarrhea in patients with

CAP should therefore bring to mind
possible
Infection of bacterial

Discussion (Classification)
Schavner stephani, Erickson Cherise, Stphens Kelsey. Community-acquired pneumonia in children: A look at the IDSA guidelines. The Jour
nal of Family Practice. 2013: 1-7
Reisinger E, Frithsze C, Krause R, Krejs G. Diarrhea Caused by Primarily Non-Gastrointestinal Infections. Nat Clin Pract Gastroenterol
Hepatol.2005;2(5):216-222

Indications for Hospitalization:

Severe pneumonia
6 months old with suspected bacterial CAP
There is concern about careful observation at home
Pediatric community guidelines dari Infectious Diseases
Society of America (IDSA): Oxygen saturation <92%, 36 months with suspect bacterial CAP, Suspect CAMRSA.

Indications for ICU: (-)

Altered mental status (-), unconsciousness (-),
sustained tachycardia and the child requires
invasive ventilation (endotracheal tube)

Discussion (inpatient)

Oxygen 1L/minute +pulse oximetry

The guidelines strongly recommend using

pulse oximetry with all children who

have pneumonia or suspected hypoxemia

Limitations of pulse oximetry

on room availability
hospitalization in Arifin Ahmad
and space constraints on the
high care unit

Discussion (Therapy)

Intravenous fluid drop for maintenance

Oral intake should cease when a child is in
severe respiratory distress

enteral tube feeding

breastmilk

correction to disturbing of acidbase stability, electrolit and

blood sugar

Discussion (Therapy)

Suspect bakterial CAP + Severe pneumonia

Ceftriaxon 2 x 350 mg

6 months old
BCG dan DPT

Discussion (Therapy)

Patient got dexametaxon on the first day on

treatment. Based on treatment guidelines of
pneumonia on children, DEXAMETAXON IS NOT
RECOMMENDED
On some research, dexametason is used to reduce
cytokines, such as those on plasma interleukin-6,
neutrophil counts, CRP levels in serum

Reduction in levels of markers of

systemic inflammation and duration of
mechanical ventilation, ICU stay, and
decrease mortality

Discussion (Therapy)

Hyperglycemia,
hypertension,
nosocomial
infection, rebound
inflamation

Very severe
pneumonia

Nebulized salbutamol

Relaxation of bronchial smooth

muscle and improve
mucocilliary clearance
Severe pneumonia with oxygen
saturation <92%

Discussion (Therapy)
Pudjiadi AH, Hegar B, Handryastuti S et al. Pedoman Pelayanan Medis Ikatan Dokter Anak Indonesia. Jilid I. Jakarta, 2010: 250-5

Diarrhea clinical manifestation of

extrapulmonary

Treatment Etiology and supportive

Antibiotic-associated diarrhea
Complaint about
diarrhea since 3 days
before admitted to the
hospital and based
from follow up
diarrhea dcreased
until 0-2x/days

Discussion (Therapy)
Farthing M, Salam M, Lindberg G, Dite P, Khalif I, Lindo E, et all. Acute diarrhea in adults and children: A global perspective. World
Gastroenterology Organisation. 2012

Thank You