PowerPoint Presentation

TB PARU DEWASAGROUP 8JOEL-ZAKIY-NADIAH-AIMI-AIN-ANDI ABHARINA-ALIF-SARAHVALERIA-ANDI SADID-ANDI RAYNALDI

Seorang perempuan berusia27 tahun datang ke Unit Gawat Darurat RS dengan keluhan batuk darah, dialami sejak 1 hari yang lalu. Batuk darah + 1 sendok makan,warna merah segar. Keluhan batuk berdahak dialami sejak 2 bulan sebelumnya, disertai dengan sering demam, berkeringat malam hari dan berat badan menurun. Riwayat kontak dengan ibunya yang batuk lama, riwayat minum obat TB tidak adaScenario

Pemeriksaan Fisis:Tanda vital TD: 100/70 mmHg, Pernapasan:24x/menit Nadi 100x/menit, Suhu : 37,9 CTB/ BB: 160 cm/ 45 kgKepala : Dalam batas normalLeher : Dalam batas normalThoraks : Bunyi pernapasan amforik di apeks paru kanan, Ronki basah di apeks paru kanan dankiriAbdomen : dalam batas normal

Pemeriksaan tambahanBTA pertama positif, BTA kedua dan ketiga negatifBTA 3x ulang negatif, negatif,negatifPemeriksaan foto torak : kavitas di paru kanan atas, infiltrate di paru kiri atas

Perempuan 27 tahun

batuk darah (1 hari lalu)

Batuk darah + 1 sendok makan (merah segar)

batuk berdahak 2 bulan sebelumnya

sering demam,

berkeringat malam hari

berat badan menurun.

Riwayat kontak dengan ibunya yang batuk lama

Bunyi pernapasan amforik di apeks paru kanan, Ronki basah di apeks paru kanan dan kiri

Pemeriksaan foto torak : kavitas di paru kanan atas, infiltrate di paru kiri atasKeywords

Amphoric soundan abnormal, resonant, hollow, blowing sound heard with a stethoscope over the thorax. It indicates a cavity opening into a bronchus or a pneumothorax.

Rhonchi Lung SoundsThese are low pitched, snore-like sounds. They are caused by airway secretions and airway narrowing. They usually clear after coughing.

Difficult Words

What is the anatomy and physiology of respiratory system?What are the causes and pathomechanism of bloody cough?What is the pathomechansim of fever?What cause sweating at night?Type and mechanism of cough?What is the mechanism of weight loss for this patient?Normal and abnormal breath sound?What are the mechanism of airborne transmitted disease?What are the diagnosis that can be done to this patient?What is the management for this patient?

Questions

Anatomi Sistem Respirasi...

FISIOLOGI

8

Proses respirasi berlangsung beberapa tahapVentilasi, pegerakan udara ke dalam dan ke luar paruPertukaran gas di dalam alveoli dan darah disebut pernapasan luarTransportasi gas melalui darahPertukaran gas antara darah dengan sel-sel jaringan disebut pernapasan dalamMetabolisme penggunaan oksigen di dalam sel serta pembuatan CO2 disebut pernapasan seluler.

Dasar-dasar ilmu penyakit paru.Halaman 7

Konduksi : cavum nasi, nasopharing, laryngs, trakea, bronkus, bronkiolus, bronkiolus terminalis.

Respirasi : Bronkiolus respirasi, duktus alveoli dan alveolus.

HISTOLOGI

The epithelium is thicker than the nonsensory epith & it serves as the receptor for smell. Its consists of :

- Olfactory cells: bipolar neurons that span the thickness of the epithelium.

- Supporting or sustentacular cells: columnar cells with apical microvilli.

- Basal cells: steam cells from which the olfactory & supporting cell differentiate.

- Brush cells

The Epithelium of RS is composed of 5 cell types :

Ciliated cells: covering the surface of epithGoblet cells: synthesize & secrete mucus.The mucus & other secr are move toward the pharynx by means of coordinated sweeping movements of cilia normally swallowed Brush cells: has blunt microvilli.Small granule cells: contain secretory granulesBasal cells: steam cell from which other cell types arise

L A R Y N G

LARYNX

TRACHEA

TRACHEA

BRONCHI

PATHOMECHANISM

JENIS JENIS BATUK

Jenis jenis batuk

MEKANISME BATUK

MEKANIK BATUKSecara mekanis batuk tdd 4 fase: 1. Fase iritasi2. Fase inspirasi3. Fase kompresi4. Fase ekspulsiFase iritasi : rangsangan reseptor oleh berbagai stimulus.Fase inspirasi : glotis secara refleks terbuka akibat kontraksi m. abduktor kartilago aritenoidea.

PATOMEKANISME BATUK

Fase inspirasi tidak terjadi jika rangsangan pada reseptor di laring.Volume paru besar efisiensi mekanis lebih baik regangan otot ekspirasi me elastisitas paru dan aktivasi slow adapting pulmonary stretch receptor pe usaha ekspirasi.Fase kompresi : menutupnya glotis otot-otot abdominal & intercostal kontraksi tek. intrapleural & tek. alveolar (300 mmHg).Fase ekspulsiPATOMEKANISME BATUK

Komponen refleks Batuk

Mechanism of bloody cough Compilation of pathophysiology (respiratory system) USM page 173

Aspiration

Blood-tinged sputum: common -either white mucus sputum, or yellow purulent sputum -bronchitis or laryngitisRusty sputum (prune-juice sputum): reddish-brown, watery, hemorrhagic sputum. -containing blood,bacteria, mucus -lobar pneumonia

Type of bloody coughhttp://www.coughingupblood.org/

Gelatinous bloody sputum (currant-jelly sputum): thick, bloody, mucoid sputum.-caused by endobronchial plug of blood, mucus, debris and bacteria -pneumonia

Pink frothy sputum: results from blood (pink) and air (frothy) mixing with secretions in the alveoli. -acute pulmonary edema

Pure coughing up blood: without sputum. -common cause: vascular rupture and hemorrhage of bronchi -pulmonary tuberculosis, bronchial tuberculosis, bronchiectasis, bronchial stones.http://www.coughingupblood.org/

Mechanism of Fever

Mekanisme Keringat Malam

Mechanism of weight loss

BREATH SOUND

LOCATIONSOUND QUALITYCHARACTERISTICTRACHEALOver tracheaLoudHarsh like air blown through pipeExpiration longerSimilar loudnessPause between BRONCHIALOver large airwaysBody of sternumMore tubularHigh pitchExpiration louder and longerPause betweenBRONCHOVESICULARPosterior chest between scapula1&2 inter muscle anteriorly- Medium pitchedInspiration&expiration equal length/loudnessPause betweenVESICULAR- Most of lungSoft and low pitchRustling sound normallyInspiration longer&louderWithout pause between

FINE CRACKLECOARSE CRACKLESound like when salt heated on frying panSound like water poured from a bottleHigher pitchLow intenseShorter durationLower pitchLess intenseLonger durationOnly during inspirationDuring inspiration and expiration

ABNORMAL BREATH SOUND

RhonchiLow pitched honking or groaning soundResult from movement of air past bronchi partially obstructed by thick secretionFound in increase airway secretion disease (pneumonia, chronic bronchitis, asthma)

WheezingPolyphonic - Most common type - Typical COPD and asthmaMonophonic - Single pitched result from narrow single airway

Amphoric Sound

High pitch bronchial soundHeard when bronchus is in communication with a large cavity or with a pneumothoraxCan be compared to sound blown through a blowpipe

Prolong, uninterrupted sound due to partial obstuction in narrowed bronchus or bronchioleNarrowing occur due to :1. Mucosal swelling2. viscid thick secretion3. spasm4. Infiltration of the wall

Ronchi Sound

2 types of ronchi :1) Sibilant - high pitch, produce in the smaller bronchi2) Sonorous - low pitch, produce in the large bronchi

Ronchi sound may caused by :1) Bronchitis2) Bronchial asthma3) Obstruction of bronchial tube by a tumour or foreifn body

Airborne transmitted diseases

mechanismwww.nlm.nih.gov/medlineplus/ency/article

Tuberculosis(TB)

Infeksi bakteri menahun yang disebabkan oleh Mycobakterium tuberculosis

Ditandai dengan pembentukan granuloma padajaringan yang terinfeksi.

Kuman aerob yang dapat hidup terutama di paru / berbagai organ tubuh lainnya yang bertekanan parsial tinggi.

menyerang paru tetapi dapat menyebar kehampir seluruh bagian tubuh termasuk meninges, ginjal, tulang, nodus limfe.

Definisi

EPIDEMIOLOGY OF TB

51

Weakened Immune System - number of disease or drug can weaken our immune system : HIV/AIDS, certain cancers, Diabetes,

Substance abuse - long terms drug or alcohol use weaken immune system and make more vulnerable to tuberculosis

Risk Factors of Tuberculosis

International Connection - TB risk higher for people who live or travel to country have high rate of tuberculosis

Tobacco use - Using tobacco greatly increases the risk of getting TB and dying of it

Lack of Medical Care - lack access to the medical care needed to diagnose and treat TB

Sign and symptom (TB)

Latent TB.: TB infection, but the bacteria is inactive and cause no symptoms. Active TB.This condition makes you sick and can spread to others. Signs and symptoms of active TB include: -Cough -Unintentional weight loss -Fatigue -Fever -Night sweats -Loss of appetiteOrgans that are affected :lungs. -Coughing that lasts three or more weeks -Coughing up blood or sputum -Chest pain, or pain with breathing or coughing

http://www.mayoclinic.com/health/tuberculosis/DS00372/DSECTION=symptoms

PATHOGENESIS OF TUBERCULOSISPrimary Tuberculosis

The first infection with Mycobacterium Tuberculosis (Mycobacterium is inhaled)Reaching the lungReaching the draining lymph nodesExudation and infiltration with neutrophil granulocytesMacrophages ingest the bacilliFormation of Ghon Complex

PATHOGENESIS OF TUBERCULOSISSecondary Tuberculosis

Reinfection or reactivationSmall granulesFibrocaseosa granuloma (Tuberculoma)Liquefied granulomaOpen into a bronchus / cavitation of the tuberculoma / dissemination

DIAGNOSIS

GEJALAGEJALA RESPIRATPRIKBATUK 2 MINGGUBATUK DARAHSESAK NAPASNYERI DADAB. GEJALA SISTEMIKDEMAM- ANOREKSIAMALAISE- BERAT BADANKERINGAT MALAM MENURUN

PEMERIKSAAN FISIK:-TERGANTUNG LUAS & KELAINAN STRUKTURAL PARULOKALISASI UMUMNYA APEX LOB SUPERIOR SEGMEN POSTERIOR; APEX LOBUS INFERIOR SUARA NAPAS MELEMAH : RONKI BASAH TANDA-TANDA PENARIKAN PARU, DIAFRAGMA& MEDIASTINUM.

Laboratorium

Pemeriksaan spesimenBahan Pemeriksaan :Dahak, cairan pleura, bilasan bronkus, kurasan bronkoalveolar, bilasan lambung, liquor cerebrospinal, urin, feses dan jaringan biopsi

Laboratorium

Cara Pengambilan & Pengiriman :Dahak, 3 kali setiap pagi / SPSPengiriman dalam pot (cair), pada gelas objek (difiksasi) atau dahak dengan kertas saringTulis identitas penderita sesuai formulir permintaan

Laboratorium

Pemeriksaan dahak & bahan lain :

Pemeriksaan bakteriologik Mikroskopik biasa fluoresens

Biakan & uji resistensi konvensional biakan radiometrik

Mikroskopik positif - 3 x pos- 2 x pos, 1 x neg.- 1 x pos, 2 x neg --- ulang BTA 3 xbila hasil 1 x pos, 2 x neg. Mikroskopik negatif- 3 x neg.- 1 x pos, 2 x neg --- ulang BTA 3 xbila hasil 3 x neg.Interpretasi Hasil

Tuberculosis. Ziehl-Neelson acid fast stain in an area of granulomas showing positive stain for acid fast bacilli

Standar : Foto toraks PA dengan / tanpa lateralPemeriksaan Radiologik

Gambaran lesi TB aktifBayangan berawan/nodular Kaviti, lebih dari satu dikelilingi bayangan opak berawan/nodularBercak milierEfusi pleura unilateral (umumnya)

Gambaran Lesi TB InaktifFibrotikKalsifikasiPenebalan pleura

PENANGANAN FARMAKOLOGI

menyembuhkan mencegah kematian mencegah kekambuhan mencegah resistensi terhadap OAT memutuskan mata rantai penularan TUJUAN PENGOBATAN

Dua fase pengobatan tuberkulosis

Fase intensif : 2-3 bulanFase lanjutan : 4-7 bulan

OBAT ANTI TUBERKULOSA (OAT)Obat UtamaRifampisin (R)Isoniazid (H)Pirazinamid (Z)Etambutol (E)Streptomisin (S)

Obat Lini Kedua QuinolonKanamisinMakrolideAmok.+ As. klav.Der. Rif. /INH

Kombinasi dosis tetap (fixed dose combination)

Ever treated case ?No (New case)Yes (Old case)PulmonaryExtrapulmonaryTAIRelapseFailureChronicAFB smear (+)AFB smear (-)severenot severeCat Iseverenot severe Cat ICat IIICat II Cat I Cat IIICat II Cat IICat IV

Cat ICat III

New case : tidak pernah mendapat OAT, atau pernah tp tidak > 1 bl Relapse (kambuh) : Sudah mendapat OAT & dinyatakan sembuh, kembali berobat dg dahak BTA (+) . Treatment Failure : BTA msh (+) setelah tx 5 bl atau lebih, atau BTA awal negatif, menjadi positif pd akhir bulan ke-2.

Return after interruption (default) : px telah mendapat OAT lebih dari 1 bulan & kembali berobat setelah berhenti lebih dari 2 bulan Transfer in : pindah berobat ke tempat lain stlh terdaftar Chronic TB : BTA tetap (+) setelah selesai tx ulang (kat- 2)

EFEK SAMPING RINGAN EFEK SAMPING PENYEBAB PENANGANAN Tdk nafsu makan, mual, sakit perutRifampisin Obat diminum malam sebelum tidurNyeri sendipyrazinamidBeri aspirin/allopurinolKesemutan s/d rasa terbakar di kakiINHBeri Vit. B6 (piridoksin) 100 mg per hari Warna kemerahan pada kulit RifampisinBeri penjelasan, tidak perlu diberi apa-apa

EFEK SAMPING BERAT EFEK SAMPINGPENYEBABPENANGANANGatal dan kemerahan pada kulitSemua jenis OATBeri antihistamin & dievaluasi ketatTuli Streptomisin Streptomisin dihentikanGangguan keseimbanganStreptomisin Streptomisin dihentikanIkterik Hampir semua OATHentikan semua OAT sampai ikterik hilangBingung & muntah-muntahHampir semua obatHentikan semua OAT & lakukan uji fungsi hati Gangguan penglihatanEthambutolHentikan EthambutolPurpura dan renjatan (syok)RifampisinHentikan Rifampisin

PENANGANAN NON FARMAKOLOGI ( NUTRISI )

Tujuan: u/mengurangi CO2 dan kerja pernapasan

Diberikan bila:Pemberian dextrose berlebihan RQ RQ> 1,0 VCO2 kerja pernapasan

Diet Tinggi Lemak Rendah KH

RQ KARBOHIDRAT : 1

RQ PROTEIN: 0,8

RQ LEMAK : 0,7

Pasien tanpa Hiperkapnik :KH 50-60 %Lemak 20-30%Protein 15-20%

Pasien Hiperkapnik :KH 25-30 %Lemak 50-55%Protein (15-20%)

Pemberian diit tinggi lemak pada penderita PPOK lebih bermanfaat ketimbang pemberian diit tinggi karbohidrat. Pemberian minuman yang kaya karbohidrat menunjukkan peningkatan peningkatan bermakna nilai prediksi CO2, konsumsi oksigen, respiratory quotient, dan tekanan arteri CO2, serta penurunan kemampuan berjalan enam menit dibandingkan dengan pemberian minuman yang kaya lemak. 82

Langkah peventif yang umum Menutup mulut dengan tissue setiap kali batuk.Mengelak dari menerima tetamu

Vaksinasi Vaksin BCG diperbuat daripada strain M. bovis diberikan kepada >80 % kanak-kanak di duniaKeberhasilannya hanya 50%BCG tidak mampu mengelak dari dijangkiti TB, tapi ia mampu mengurangkan kadar extrathoracic TB pada kanak-kanak, terutama pada TB meningitis.Preventive Measures

Thank you ^^