PNEUMONIA

Pneumonia

Definsi

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, which makes breathing painful and limits oxygen intake. (WHO)

Pneumonia is an infection of the lungs. It can spread from person to person. (healthfinder.gov)

Acute inflammation of lung parenchyma,  Inflammatory infiltrate in alveoli ( = consolidation)

Etiologi

Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. The most common are:

a.      Streptococcus pneumoniae – the most common cause of bacterial pneumonia in children;

2. Haemophilus influenzae type b (Hib) – the second most common cause of bacterial pneumonia;
3. respiratory syncytial virus is the most common viral cause of pneumonia;
4. in infants infected with HIV, Pneumocystis jiroveci is one of the commonest causes of pneumonia, responsible for at least one quarter of all pneumonia deaths in HIV-infected infants. (WHO)

Cara Transmisi

The viruses and bacteria that are commonly found in a child's nose or throat, can infect the lungs if they are inhaled. They may also spread via air-borne droplets from a cough or sneeze. In addition, pneumonia may spread through blood, especially during and shortly after birth. (WHO)

Faktor pencetus

While most healthy children can fight the infection with their natural defences, children whose immune systems are compromised are at higher risk of developing pneumonia. A child's immune system may be weakened by malnutrition or undernourishment, especially in infants who are not exclusively breastfed. (WHO)

Pre-existing illnesses, such as symptomatic HIV infections and measles, also increase a child's risk of contracting pneumonia.

The following environmental factors also increase a child's susceptibility to pneumonia:

• indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung)
• living in crowded homes
• parental smoking.

Patofisiologi/ patogenesis

Pneumonia dapat terjadi akibat menghirup bibit penyakit di udara, atau kuman di tenggorokan terisap masuk ke paru-paru. Penyebaran bisa juga melalui darah dari luka di tempat lain, misalnya di kulit. Bakteri pneumokokus secara normal berada di tenggorokan dan rongga hidung (saluran napas bagian atas) pada anak dan dewasa sehat, sehingga infeksi pneumokokus dapat menyerang siapa saja dan dimana saja, tanpa memandang status sosial. Percikan ludah sewaktu bicara, bersin dan batuk dapat memindahkan bakteri ke orang lain melalui udara. Terlebih dari orang yang berdekatan misalnya tinggal serumah, tempat bermain, dan sekolah. Jadi, siapa pun dapat menularkan kuman pneumokokus.

           Bakteri masuk ke dalam paru-paru melalui udara, akan tetapi kadang kala juga masuk melalui sistem peredaran darah apabila pada bagian tubuh kita ada yang terinfeksi. Sering kali bakteri itu hidup pada saluran pernafasan atas yang kemudian masuk ke dalam arteri. Ketika masuk ke dalam alveoli, bakteri melakukan perjalanan diantara ruang antar sel dan juga diantara alveoli. Dengan adanya hal tersebut, sistem imun melakukan respon dengan cara mengirim sel darah putih untuk melindungi paru-paru. Sel darah putih (neutrofil) kemudian menelan dan membunuh organisme tersebut serta mengeluarkan sitokin yang merupakan hasil dari aktivitas sistem imun itu. Hal ini yang mengakibatkan terjadinya demam, rasa dingin (menggigil), lemah yang merupakan gejala umum dari pneumonia yang disebabkan oleh bakteri ataupun jamur. Neutrofil, bakteri, dan cairan mempengaruhi keadaan sekitarnya dan juga mempengaruhi transportasi O2.

           Perjalanan bakteri dari paru-paru ke dalam peredaran darah mengakibatkan penyakit yang serius seperti sepsis, yaitu suatu keadaan tekanan darah rendah yang kemudian mempengaruhi sistem faal otak, ginjal, dan jantung.

Adapun cara mikroorganisme itu sampai ke paru-paru bisa melalui:
- Inhalasi (penghirupan) mikroorganisme dari udara yang tercemar
- Aliran darah, dari infeksi di organ tubuh yang lain
- Migrasi (perpindahan) organisme langsung dari infeksi di dekat paru-paru.

Cara penularan bakteri pneumonia sampai saat ini belum diketahui pasti, namun ada beberapa hal yang memungkinkan seseorang beresiko tinggi terserang penyakit Pneumonia. Hal ini diantaranya adalah :

1.       Orang yang memiliki daya tahan tubuh lemah.

Seperti penderita HIV/AIDS dan para penderita penyakit kronik seperti sakit jantung, diabetes mellitus. Begitupula bagi mereka yang pernah/rutin menjalani kemoterapi dan meminum obat golongan Immunosupressant dalam waktu lama, dimana mereka pada umumnya memiliki daya tahan tubuh (Imun) yang lemah.

2.       Perokok dan peminum alkohol.

Perokok berat dapat mengalami iritasi pada saluran pernafasan (bronchial) yang akhirnya menimbulkan secresi muccus (riak/dahak), Apabila riak/dahak mengandung bakteri maka dapat menyebabkan pneumonia. Alkohol dapat berdampak buruk terhadap sel-sel darah putih, hal ini menyebabkan lemahnya daya tahan tubuh dalam melawan suatu infeksi.

3.       Pasien yang berada di ruang perawatan intensive (ICU/ICCU).

Pasien yang dilakukan tindakan ventilator (alat bantu nafas) ‘endotracheal tube’ sangat beresiko terkena Pneumonia. Disaat mereka batuk akan mengeluarkan tekanan balik isi lambung (perut) ke arah kerongkongan, bila hal itu mengandung bakteri dan berpindah ke rongga nafas (ventilator) maka potensial tinggi terkena pneumonia.

4.       Menghirup udara tercemar polusi zat kemikal.

Resiko tinggi dihadapi oleh para petani apabila mereka menyemprotkan tanaman dengan zat kemikal (chemical) tanpa memakai masker adalah terjadi iritasi dan menimbulkan peradangan pada paru yang akibatnya mudah menderita penyakit Pneumonia dengan masuknya bakteri atau virus.

5.       Pasien yang lama berbaring.

Pasien yang mengalami operasi besar sehingga menyebabkannya bermasalah dalah hal mobilisasi merupakan salah satu resiko tinggi terkena penyakit pneumonia, dimana dengan tidur berbaring statis memungkinkan riak/muccus berkumpul dirongga paru dan menjadi media berkembangnya bakteri. (Universitas Indonesia)

How do people "catch pneumonia"?

Some cases of pneumonia are contracted by breathing in small droplets that contain the organisms that can cause pneumonia. These droplets get into the air when a person infected with these germs coughs or sneezes. In other cases, pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat, or nose inadvertently enter the lung. During sleep, it is quite common for people to aspirate secretions from the mouth, throat, or nose. Normally, the body's reflex response (coughing back up the secretions) and their immune system will prevent the aspirated organisms from causing pneumonia. However, if a person is in a weakened condition from another illness, a severe pneumonia can develop. People with recent viral infections, lung disease, heart disease, and swallowing problems, as well as alcoholics, drug users, and those who have suffered a stroke or seizure are at higher risk for developing pneumonia than the general population. As we age, our swallowing mechanism can become impaired as does our immune system. These factors, along with some of the negative side effects of medications, increase the risk for pneumonia in the elderly.
Once organisms enter the lungs, they usually settle in the air sacs and passages of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus (the body's inflammatory cells) as the body attempts to fight off the infection.

The only pain fibers in the lung are on the surface of the lung, in the area known as the pleura. Chest pain may develop if the outer aspects of the lung close to the pleura are involved in the infection. This pain is usually sharp and worsens when taking a deep breath and is known as pleuritic pain or pleurisy. In other cases of pneumonia, depending on the causative organism, there can be a slow onset of symptoms. A worsening cough, headaches, and muscle aches may be the only symptoms.

Children and babies who develop pneumonia often do not have any specific signs of a chest infection but develop a fever, appear quite ill, and can become lethargic. Elderly people may also have few symptoms with pneumonia. (MedicineNet.com)

Manifestasi Klinis

the symptoms of viral pneumonia may be more numerous than the symptoms of bacterial pneumonia.

The symptoms of pneumonia include:

• rapid or difficult breathing
• cough
• fever
• chills
• loss of appetite
• wheezing (more common in viral infections).

When pneumonia becomes severe, children may experience lower chest wall indrawing, where their chests move in or retract during inhalation (in a healthy person, the chest expands during inhalation). Infants may be unable to feed or drink and may also experience unconsciousness, hypothermia and convulsions. (WHO)

The most common symptoms of pneumonia are: (American Lung Association)

• Cough (with some pneumonias you may cough up greenish or yellow mucus, or even bloody mucus)
• Fever, which may be mild or high
• Shaking chills
• Shortness of breath, which may only occur when you climb stairs

Additional symptoms include:

• Sharp or stabbing chest pain that gets worse when you breathe deeply or cough
• Headache
• Excessive sweating and clammy skin
• Loss of appetite, low energy, and fatigue
• Confusion, especially in older people

Symptoms also can vary, depending on whether your pneumonia is bacterial or viral.

• In bacterial pneumonia, your temperature may rise as high as 105 degrees F. The pneumonia causes profuse sweating, and rapidly increased breathing and pulse rate. Lips and nailbeds may have a bluish color due to lack of oxygen in the blood. A patient's mental state may be confused or delirious.
• The initial symptoms of viral pneumonia are the same as influenza symptoms: fever, a dry cough, headache, muscle pain, and weakness. Within 12 to 36 hours, there is increasing breathlessness; the cough becomes worse and produces a small amount of mucus. There is a high fever and there may be blueness of the lips.

Klasifikasi

from Edward C. Rosenow III, M.D.

Walking pneumonia is an informal term for pneumonia that isn't severe enough to require bed rest or hospitalization. You usually aren't sick enough to stay home from work or school, so you are out walking around. Chances are you won't see a doctor for your mild symptoms. If you do see a doctor, you may not seem sick enough to need a chest X-ray, which is the only way to diagnose any kind of pneumonia.

Walking pneumonia is often caused by a type of bacterium that produces milder symptoms that appear more gradually than do those of other types of pneumonia. The illness often is brought home by young children who contract it at school. Family members of infected children typically begin having symptoms two or three weeks later. This kind of pneumonia usually doesn't need treatment with an antibiotic.

Aspiration pneumonia happens when anything other than air gets into the lung. An example of this is when a person cannot stop vomit from going into the lungs. Patients with barin injury or other conditions that affect their ability to swallow are more likely to have vomit or food go down the trachea and into the lungs.

When vomit, food or liquid, other than clean frsh water, enter the lungs, it causes a chemical reaction that lead to inflammation of the lungs. Often this inflammation causes bacteria to multiply and make the pneumonia worse.

Aspiration pneumonia is lung infection caused by inhaling mouth secretions, stomach contents, or both.

Chemical pneumonitis is lung irritation caused by inhalation of substances toxic to the lungs.

Aspiration Pneumonia: Tiny particles from the mouth frequently dribble or are inhaled (aspirated) into the airways. Usually they are cleared out by normal defense mechanisms (such as coughing) before they can get into the lungs and cause inflammation or infection. When such particles are not cleared (because of impaired defense mechanisms or because the volume of aspirated material is so large), they can cause aspiration pneumonia. Older people and people who are debilitated, have trouble swallowing (as may happen from a stroke), are intoxicated by alcohol or drugs, or are unconscious from anesthesia or a medical condition are especially at risk for this type of pneumonia.

Symptoms of pneumonia do not begin for at least a day or two. The sputum may smell foul. Treatment requires antibiotics. Many antibiotics, including clindamycin, amoxicillin plus clavulanate, ampicillin, and imipenem, can be used. If a solid particle was inhaled, bronchoscopy may be needed to remove it (see Diagnosis of Lung Disorders: Bronchoscopy).

Chemical Pneumonitis: Chemical pneumonitis occurs when a person inhales (aspirates) material that is toxic to the lungs. The problem is more the result of irritation than infection. A commonly inhaled toxic material is stomach acid, so that chemical pneumonitis may result whenever a person inhales what has been vomited up. Inhalation of vomit can occur when a person who vomits is not completely awake, as can happen after a seizure, stroke, or drug or alcohol overdose. Chemical pneumonitis may also be caused by inhalation of laxative oils (such as mineral, castor, and paraffin oils) and hydrocarbons (such as gasoline, kerosene, and petroleum products). Sudden shortness of breath and a cough develop within minutes or hours. Other symptoms may include fever and pink frothy sputum. In less severe cases, the symptoms of aspiration pneumonia may occur a day or two after inhalation of the toxin.

The diagnosis of chemical pneumonitis is usually obvious from the sequence of events if this information is available. Chest x-rays and measurements of oxygen concentrations in arterial blood may help. When the diagnosis remains unclear, bronchoscopy is sometimes done.

Treatment consists of oxygen therapy (see Rehabilitation for Lung and Airway Disorders: Oxygen Therapy) and mechanical ventilation (see Respiratory Failure and Acute Respiratory Distress Syndrome: Acute Respiratory Distress Syndrome (ARDS)) if necessary. The windpipe (trachea) may be suctioned to clear secretions and aspirated food particles out of the airways. Bronchoscopy may also be used for this purpose.

Antibiotics are usually given because doctors cannot easily distinguish this form of aspiration pneumonia from a bacterial infection. Up to 30 to 50% of people with serious chemical pneumonitis due to inhaled stomach acid die.

Last full review/revision April 2008 by John G. Bartlett, MD

Community-acquired pneumonia refers to pneumonia you get, or acquire, from your community, such as at school, work, or the gym.

Hospital-acquire or nosocomial pneumonia is a serious pneumonia acquired at a hospital or healthcare facility. It usually affects patients who are:

Ö     On a mechanical ventilator,

Ö     In the intensive care unit,

Ö     Or have a weak immune system

Pnemonia berdasarkan:

Ö     Aetiology (Viral pneumonia, bacterial pneumonia)

Ö     Morpological class. - Bronchopneumonia vs. Lobarpneumonia.

Ö     Community acquired vs hospital acquired (nosocomial) infection.

Ö     The patient's immune status.

Berdasarkan pedoman tersebut pneumonia dibedakan atas : (Universitas Indonesia)

1.       Pneumonia sangat berat, (bila ada sianosis sentral dan tidak sanggup minum), harus di rawat di RS dan pemberian antibiotik.

2.       Pneumonia berat (bila ada retraksi, tanpa sianosis dan masih sanggup minum), harus di rawat di RS dan pemberian antibiotik.

3.       Pneumonia (bila tidak ada retraksi tetapi nafas cepat)

4.       Bukan pneumonia (bila tidak ada nafas cepat, tidak perlu di rawat, tidak perlu antibiotik namun dilakukan pemeriksaan lain dan pengobatan yang sesuai.

Pemeriksaan fisik+penunjang

Physical exam: Your doctor will listen to your lungs with a stethoscope. If you have pneumonia, your lungs may make crackling, bubbling, and rumbling sounds when you inhale. You also may be wheezing, and it may be hard to hear sounds of breathing in some areas of your chest.

Chest X-ray (if your doctor suspects pneumonia)

Some patients may need other tests, including:

• CBC blood test to check white blood cell count
• Arterial blood gases to see if enough oxygen is getting into your blood from the lungs
• CT (or CAT) scan of the chest  to see how the lungs are functioning
• Sputum tests to look for the organism (that can detected by studying your spit) causing your symptoms
• Pleural fluid culture if there is fluid in the space surrounding the lungs
• Pulse oximetry to measure how much oxygen is moving through your bloodstream, done by simply attaching a small clip to your finger for a brief time
• Bronchoscopy, a procedure used to look into the lungs' airways, which would be performed if you are hospitalized and antibiotics are not working well (American Lung Association)

Pemeriksaan Fisik : (Universitas Indonesia)

·         Tergantung luas lesi paru

·         Inspeksi : bagian yang sakit tertinggal

·         Palpasi : fremitus dapat mengeras

·         Perkusi : redup

·         Auskultasi : suara dasar bronkovesikuler sampai bronkial, suara tambahan bronki basah halus sampai bronki basah kasar pada stadium resolusi.

Pemeriksaan Penunjang

·         Gambaran radiologis: foto toraks PA/ lateral, gambaran infiltrat sampai gambaran konsolidasi (berawan), dapat disertai air bronchogram.

·         Pemeriksaan laboratorium: terdapat peningkatan jumlah leukosit lebih dari 10.000/μl kadang dapat mencapai 30.000/μl.

·         Untuk menentukan diagnosis etiologi dilakukan pemeriksaan biakan dahak, biakan darah, dan serologi.

·         Analisis gas darah menunjukkan hipoksemia; pada stadium lanjut asidosis respiratorik.

Penatalaksanaan

In 2009, WHO and UNICEF launched the Global action plan for the prevention and control of pneumonia (GAPP). The aim is to accelerate pneumonia control with a combination of interventions to protect, prevent, and treat pneumonia in children with actions to:

• protect children from pneumonia include promoting exclusive breastfeeding and hand washing, and reducing indoor air pollution;
• prevent pneumonia with vaccinations;
• treat pneumonia are focused on making sure that every sick child has access to the right kind of care -- either from a community-based health worker, or in a health facility if the disease is severe -- and can get the antibiotics and oxygen they need to get well.  (WHO)

A shot to help protect you from a common type of bacterial pneumonia . This shot is called PPSV or pneumococcal vaccine. Most people will only need to get the shot once. (healthfinder.gov)

Who needs to get a pneumonia shot?
Doctors recommend that the following people get the pneumonia shot:People age 65 or older

·         People younger than age 65 who have:

§  Diabetes

§  Heart failure

§  Asthma

§  A breathing condition like COPD (chronic obstructive pulmonary disease)

·         People who smoke

Talk to your doctor to find out if you need a pneumonia shot.

Are there any side effects?
The pneumonia shot is very safe. Some people may have redness or pain where the shot is given.

Most people can be treated at home by following these steps: (American Lung Association)

• Drink plenty of fluids to help loosen secretions and bring up phlegm.
• Get lots of rest. Have someone else do household chores.
• Do not take cough medicines without first talking to your doctor. Cough medicines may make it harder for your body to cough up the extra sputum.
• Control your fever with aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen or naproxen), or acetaminophen. DO NOT give aspirin to children.

Viral Pneumonia è Typical antibiotics will not work for viral pneumonia; sometimes, however, your doctor may use antiviral medication.  Viral pneumonia usually improves in 1 to 3 weeks.
Bacterial Pneumonia

·          mild pneumonia who are otherwise healthy è oral macrolide antibiotics (azithromycin, clarithromycin, or erythromycin).  

·         Patients with other serious illnesses, such as heart disease, chronic obstructive pulmonary disease, or emphysema, kidney disease, or diabetes are often given more powerful and/or higher dose antibiotics.

·         proper diet and oxygen to increase oxygen in the blood when needed.

·         In some patients, medication to ease chest pain and to provide relief from violent cough may be necessary.

Diagnosis Banding

·         Decompensatio Cordis è Keluhan sesak biasanya berhubungan dengan aktivitas (sesak terutama dirasakan penderita bila beraktivitas).

·         CHD (Chronic Heart Dissease)è Ditandai dengan sianosis disekitar mulut atau ujung-ujung jari.

·         Aspirasi benda asing

·         Ada riwayat tersedak atau tenggelam.

Prognosis

Pneumonia can be a serious and life-threatening infection. This is true especially in the elderly, children, and those who have other serious medical problems, such as COPD, heart disease, diabetes, and certain cancers. Fortunately, with the discovery of many potent antibiotics, most cases of pneumonia can be successfully treated. In fact, pneumonia can usually be treated with oral antibiotics without the need for hospitalization. (MedicineNet.html)

Gejala yang didapat:

1.      Mengapa bisa batuk berdahak kental warna hijau?

When the air we breathe contains germs, our immune system protects the lungs from infection. In fact, the bacteria and viruses that can cause pneumonia are commonly found in the air we breathe, but our body normally keeps them from entering our lungs and causing a problem. Sometimes germs can get past defenses of the respiratory system causing pneumonia.

When a person has pneumonia, lung tissue can fill with pus and other fluids. This makes it hard for oxygen to reach the bloodstream. With pneumonia, a person develops a cough and fever and it might be hard to breathe. (www.X-Plain.com)

2.      Mengapa badan bisa panas?

3.      Mengapa saat diperkusi hasilnya redup pada lobus media pulmo dextra?

4.      Mengapa bisa terdapat ronki basah?

5.      Mengapa saat diberi obat batuk tidak mempan?

6.      Bagaimana kira-kira hasil gambaran radiologi penderita?

foto toraks PA/ lateral, gambaran infiltrat sampai gambaran konsolidasi (berawan), dapat disertai air bronchogram.

A loss of the sharply defined contour of the diaphragm represents the presence of an abnormality of the adjacent lung.  This could represent pneumonia, or possibly a neoplasm.

The lateral right diaphragm is obscured (lower black arrows) by a right lower lobe pneumonia (upper arrows) MSU Department of Radiology

 Dari banyak sumber. Insyaallah terpercaya.