Approach to

Respiratory
Tract
Infection
 INTRODUCTION
L
O Lower respiratory tract infection:
W describes a range of symptom and signs, varying in
E severity from non pneumonic in the healthy people
R through to pneumonia or life threatening
exacerbations in patient with severe disabling
R chronic obstructive pulmonary disease (COPD).
E
S
Common symptom:
P
1.Cough
T 2.Sputum production
R 3.Breathlessness
A 4.Wheeze
C 5.Chest pain
T 6.Fever
7.Sore throat
I 8.Coryza
N
F
 ANATOMY
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 ANATOMY
L
O
W
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TOP:
Defenses of the
Lungs against
Pathogens

RIGHT:
Alveolar macrophage
 DISEASES
L
O 1. ACUTE INFECTIONS
W
E a. Bronchitis
R
b. Pneumonia
R Typical
E
S Atypical
P

T
R
A 2. CHRONIC INFECTIONS
C
T a. Tuberculosis
I b. Cystic fibrosis
N
F
 BRONCHITIS

Bronchitis is an
inflammation of the
lining of the bronchial
tubes, the airways that
connect the trachea to
the windpipe.

Structure of the
bronchi
It may be caused by
viral, bacterial or
environmental factors.

Slide 002
 ACUTE BRONCHITIS

Among the two types of bronchitis, acute

bronchitis is more common and usually is caused
by a viral agents.

Bacterial etiologic agent: Mycoplasma

pneumoniae
Secondary bacterial infection of S. pneumoniae
and H. influenzae may play a role in
pathogenesis
 Etiologic Agent

Mycoplasma pneumoniae
0.2 m diameter.
Lacks cell wall
Slow growth
Aerobic
Fried egg appearance
 Pathogenesis

Mode of entry Adherence Effects on the

lower respiratory
system
Enters lower Attach to Cause ciliated
respiratory tract specific cells to slough
with inspired air receptors in of
or by aerosol respiratory
inhalation epithelium Causes
inflammatory
response that
thickens
bronchial tube
and alveoli
 CHRONIC BRONCHITIS

Chronic bronchitis is a cough that persists for

two to three months each year for at least two
years. Smoking is the most common cause of
chronic bronchitis.
 CHRONIC BRONCHITIS

Nonencapsulated strains of H. influenzae, S.

pneumoniae and Moraxella catarrhalis are
frequently cultured in bronchi of patients,
although it is difficult to incriminate the cause of
infection due to chronic colonization of the
bronchi.
 CHRONIC BRONCHITIS

The lines that leave the right hilum horizontally show irregular borders
because of chronic inflammation.
 Pneumonia
Secara klinis pneumonia didefinisikan
sebagai suatu peradangan paru yg
disebabkan oleh mikroorganisme
(bakteri,virus, jamur, parasit)
Sedangkan peradangan paru yg
disebabkan oleh non mikroorganisme
( bahan kimia, eadiasi, aspirasi bahan
toksik, obat2an dll) disebut pneumonitis
 Patogenesis
Ketidakseimbangan antara : daya tahan tubuh,
mikroorganisme, dan
lingkunganmikroorganisme dapat berkembang
biak dan menimbulkan penyakit.
Beberapa cara mikroorganisme mencapai
permukaan saluran nafas:
- Inokulasi langsung
- Penyebaran melalui hematogen
- Inhalasi bahan aerosol
- Kolonosasi di permukaan mukosa
 Patologi
Reaksi radang berupa edema seluruh
alveoliinfiltrasi sel-sel PMN dan
diapedesis eritrositfagositosis, sel-sel
PMN mendesak bakteri ke permukaan
alveoli dan dg bantuan lekosit yg lain
melalui pseudopodosis sitoplasmik
mengelilingi bakteri tsb kemudian
dimakan.
Akan tampak 4 zona pada daerah
parasitik tsb
 Zona luar : alveoli yg terisi dg bakteri dan
cairan edema
Zona permulaan konsolidasi : terdiri dari
PMN dan beberapa eksudasi sel darah
merah
Zona konsolidasi yang luas : daerah tempat
terjadi fagositosis yg aktif dg jumlah PMN yg
banyak
Zona resolusi : daerah tempat terjadi
resolusi dg banyak bakteri yg mati, lekosit,
dan alveolar makrofag.
 Klasifikasi Pneumonia
Berdasar Klinis dan epidemiologis
Community Acquired Pneumonia
Hospital Acquired Pneumonia/ nosocomial Pneumonia
Pneumonia aspirasi
Pneumonia pada immunocompromised
Berdasar penyebab
Pneumonia Tipikal
Pneumonia Atipikal
PneumoniaVirus
Pneumonia Jamur
Berdasarkan predileksi infeksi
Pneumonia Lobaris
Bronkopneumonia
Pneumonia Interstisial
 Pneumonia
ATS/IDSA Guidelines Definitions
Community-acquired pneumonia (CAP) is an acute
infection of the pulmonary parenchyma in an individual
who is not hospitalized or residing in a long term care
facility before the onset of symptoms.

HAP( Hospital Acquired Pneumonia) ; occurs 48 hours

or more after admission

VAP ( Ventilator Associated Pneumonia) ; pneumonia

that arises more than 48-72 hours after endotracheal
intubation
 Gambaran Klinis
Anamnesis
Demam, menggigil, suhu meningkat dapat
melebihi 40c
Batuk dg dahak mukoid atau purulen, kadang
disertai darah, sesak nafas dan nyeri dada
Pemeriksaan Fisik :
Tergantung luas lesi di paru. Inspeksi :pada
bagian yg sakit tertinggal saat bernafas.Vocal
fremitus mengeras, perkusi redup,auskultasi suara
nafas bronkovesikuler sampai bronkial, ronkhi
basah halus, basah kasar
 Pemeriksaan Penunjang
1. Gambaran Radiologis : (pemeriksaan
penunjang utama)
Infiltrat sampai konsolidasi dengan air
bronchogram
2. Pemeriksaan Laboratorium:
a.Peningkatan jumlah lekosit.
b.Untuk menentukan diagnosis: perlu
pemeriksaan dahak, kultur darah, dan
serologi, etiologi
c. Analisis Gas Darah
Pneumonia Severity Index
CURB Index
 Perbedaan gambaran klinik pneumoni atipik
dan tipik
Tanda &gejala Pneumonia Atipik pneumonia Tipik

Onset gradual akut

suhu Kurang tinggi Tinggi, menggigil
Batuk Non Produktif produktif
Dahak Mukoid purulen
Nyeri
kepala,mialgia,sakit
Gejala lain jarang
tenggorokan,suara
parau,skt telinga
Gejala luar paru sering Lebih jarang
Gram stain Flora normal atau
Kokus gr+ atau gr-
(sputum) spesifik
Chest Xray Patchy atau normal Konsolidasi lobar
 Types of Pneumonia
(according to affected site)

Lobar pneumonia
in one distinct lobe of the lung
PMN exudate in response to infection
clots in alveoli thus solidifying them
One lobe in complete consolidation
Usual causative agents:
Streptococcus pneumoniae
Klebsiella pneumoniae
Lobar pneumonia
(Klebsiella pneumoniae)
 Types of Pneumonia
(according to affected site)

Bronchopneumonia
Diffuse, patchy consolidation throughout both lungs
Goes through the bronchioles and bronchi, enabling
its spread to both lungs
Common in hospital-acquired pneumonias
Etiologic agents:
S. aureus
K. pneumoniae
E. coli
P. aeruginosa
Bronchopneumonia
Bronchopneumonia
 Types of Pneumonia
(according to affected site)

Interstitial pneumonia
Invades lung interstitium
Usual in viral infections
Sometimes can be caused by Mycoplasma
pneumoniae
More often caused by agents of atypical
pneumonia
Interstitial Pneumonia
 TYPICAL PNEUMONIA

Streptococcal Pneumonia

Causative agent: Streptococcus pneumoniae

Normal inhabitant of the upper respiratory
tract
Usually causes bronchopneumonia in infants,
young children and aged adults and lobar
pneumonia in younger adults
 Signs and Symptoms

Acute or subacute onset of fever, cough with or

without sputum production

Other common symptoms: rigor, sweats, chills,

chest discomfort, pleurisy, fatigue, anorexia,
headache, and abdominal pain
 Diagnosis

Gram staining gram positive cocci in chains

Lung fluid sample
XRay
Sputum test: presence of blood and sputum
color
Blood test: white blood cell count, detection of
antibodies
Haemophilus influenzae Pneumonia

Etiological agent:
Haemophilus influenzae
Classified into 2 broad categories:
nontypeable (noncapsulated) common cause
pneumonia
typeable (encapsulated)

Has 6 serotypes (based of characteristics of

the capsule): a to f.
Serotype B occasionally causes pneumonia
Haemophilus influenzae Pneumonia

Signs and Symptoms:

rapid or difficult breathing
Cough
Fever
Chills
loss of appetite
 Haemophilus
influenzae

Diagnosis:
non-motile gram-
negative
coccobacilli
 Nosocomial Pneumonia
Etiological agents:
(arranged according to frequency)
a. Klebsiella pneumoniae
b. Staphylococcus aureus
c. Pseudomonas aeruginosa
d. Escherichia coli
e. Serratia marcescens
f. Proteus mirabilis
g. Acinetobacter baumannii
 Nosocomial Pneumonia
Signs and Symptoms:
sudden onset, prostration (exhaustion)
high fever, chills, flu-like symptoms
Hemoptysis (coughing up blood)
Pleuritic chest pain and dyspnea (difficult
respiration)
 Chest radiography frequently demonstrates cavity formation and
swelling of the affected lobe caused by K. pneumoniae, which causes bulging of the
interlobar fissures.
 ATYPICAL PNEUMONIA

Atypical pneumonia is a pneumonia not

caused by one of the more traditional
pathogens. It can be caused by a variety of
microorganisms.

When developed independently from another

disease it is called Primary Atypical Pneumonia
(PAP)
 Mycoplasmal Pneumonia

Mycoplasma
pneumoniae
has a plasma
membrane but no
cell wall
aerobic
Motile and slender
measuring 0.1 by
2m
 Signs and Symptoms

Initial symptom
sore throat in many cases and hoarseness may occur within a
few days
On physical examination
rales (abnormal rattle or crackling sound heard in a
stethoscope during breathing) are often the only abnormality
detected
fever
non-productive cough
Headache
 Legionnaires Disease
Legionella pneumophila
rod-shaped, gram-negative
Flagellated
non-sporulating
Aerobic
non-fermentative
produces beta-lactamase
 Sign and Symptoms
Typically begins with headaches
Chest pains
Fever
Mental status change
Chills
Dry cough
Sputum sometimes streaked with blood
Diarrhea
Progression of Legionnaires disease in an HIV+ patient.
 Pengobatan
Antibiotika dan terapi suportif
Antibiotika sebaiknya berdasarkan data
mikroorganisme dan hasil uji kepekaannya
Dapat diberikan terapi secara empiris, dengan
alasan :
1. penyakit yg berat dpt mengancam nyawa
2. bakteri patogen yg berhasil diisolasi belum
tentu sbg penyebab pneumonia
3. hasil pembiakan bakteri memerlukan waktu
CAP Empiric therapy
CAP Empiric therapy
CAP Empiric therapy