mts sindroma croup
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UIITRANSCRIPT
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Sindroma Croup ~ Laringo-trakeobronkitis
mts darmawan
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Sinonim
Laringotrakeobronkitis akutLaringotrakeobronkitisLaringotrakeitisAcute Spasmodic Laryngitis
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PendahuluanPeradangan akut subglotis laring, trakea, & bronkus. Gejala : – Batuk menggonggong– Suara parau– Stridor inspiratoir
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Etiologi
INFEKSI Virus : terbanyak.Bakteri Jamur : Candida albican
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EtiologiA. Virus
1. Parainfluenza virus tipe I,II,III (50-75%)2. Virus influenza tipe A dan B.3. Adenovirus.4. Enterovirus.5. Respiratory syncytial virus (RSV).6. Measles.7. Coxsackievirus.8. Rhinovirus.9. Echovirus.10. Reovirus.11. Metapneumovirus.
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Etiologi
B. Bakteri (infeksi sekunder)
1. Streptococcus pyogenes.2. Streptococcus pneumoniae.3. Staphylococcus aureus.4. Haemophilus influenzae.5. Moraxella catarrhalis.6. Mycoplasma pneumoniae.7. Hemofilus influenza tipe B
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EpidemiologiPenyebab tersering obstruksi sal nafas atas anakPuncak : 6 bulan-6 tahun. Jarang > 6 tahun, but ada jg 12-15 tahun.Insidensi maks usia 1-2 tahunInsidens + 4,6 / 100 anakRasio pria : wanita sebesar 1,5 : 1.
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Anatomi Global Saluran Napas
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PatofisiologiVirus dari nasofarings - ke larings & trakeaTjd inflamasi, eritema & edema subglottic larynx dan trachea, khususnya di dekat kartilago cricoid : klinis terpenting (most clinically significant) → obstruksiSubglotis : merup bagian tersempit pada pediatric airway
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Patofisiologi Obstruksi → ↑ kecepatan & turbulensi aliran udaraSaat udara lewati plica vocalis & lipatan arytenoepiglottic, getarkan struktur tsb → stridor inspirasiAwal stridor bernada rendah (low pitched), keras & terdengar saat inspirasi
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PatofisiologiBila obstruksi memberat → stridor melemah, nada tinggi (high pitched) & terdengar juga saat ekspirasi.
Plica vocalis edema : parau. Berlanjut → brokus & alveoli : laringotrakeobronkitis & laringotrakeo-bronkopneumonitis
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Patofisiologi
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Manifestasi Klinis
1. Diawali ISPA ringan :
Demam 38-39°C, but dapat > 40°C)Pilek Suara serakBatuk ringanDlm 12-48 jam terjadi fase 2 :
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Manifestasi Klinis … lanjutan
2. Obstruksi akibat inflamasi subglotis :
Suara serakBatuk menggonggong (croupy/ barky cough)Stridor inspirasi : KHAS
Gejala berhenti 3-7 hari
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Manifestasi Klinis
Thoraks : – retraksi supraklavikular, suprasternal,
interkostal, epigastrial/ subkostal
Bila hipoksia – Gelisah– hipoksia bertambah berat : anak diam,
lemas, kesadaran menurun
Pada kondisi berat : gagal napas. Pd kasus berat penyembuhan : 7-14 hari
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KlasifikasiLedwith & Rittichier (2000) :
1. Ringan- Batuk menggonggong, tanpa ada / riw stridor atau retraksi
2. Sedang- serak, batuk menggonggong- riw / stridor (+) inspirasi saat istirahat - dan atau retraksi
3. Berat- Ggn status mental- retraksi berat- sianosis.
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Skor Westley, 1978STRIDOR INSPIRASI-None-At rest, with Stethoscope-At rest, no stethoscope
NILAI 0 1 2
KESADARAN-Normal-Penurunan Kesadaran
0 5
ALIRAN UDARA-Normal-Turun- Amat terbatas
0 1 2
SIANOSIS-None-Ada saat gelisah- Ada saat istirahat
0 4 5
RETRAKSI-None-Ringan -Sedang-Berat
0 1 2 3
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Nilai skor< 3 : croup ringan ~ mild
3-6 : croup sedang ~ moderate
> 6 : croup berat ~ severe
Rona E Molodow, 2007.
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Pemeriksaan Penunjang
Ro polos leher AP :
Steeple sign (50%) : penyempitan area subglotis
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Steeple Sign
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Steeple Sign
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Alur Diagnosis & Terapi
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Indikasi Rawat Inap
1. Sianosis, hypoxia ~ or keduanya2. Depressed sensorium / pe ↓ kesadaran3. Gagal napas 4. Stridor saat istirahat (stridor at rest)5. Perburukan6. Asupan gizi kurang (poor oral intake),
dehidrasi7. Stridor persisten8. Skor Croup > 29. Sosial
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TatalaksanaTergantung stadiumTujuan :– ↓ edema– Lunakkan sekret– Lancarkan airway.
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TatalaksanaMenangis terus-menerus → – kebutuhan O2 ↑– otot pernafasan lelah– perburuk obstruksi.
Awasi HR, RR , respiratory mechanics, dan pulse oximetry untuk antisipasi hipoksia dini
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TatalaksanaPrinsip dasar :
anak senyaman mungkin didekap OTHindari tindakan tidak perlu Standar Tx :– Humidifikasi, EBM kurang– Epinefrin rasemik– Steroid
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1. Humidifikasi (mist therapy)
Lunakkan sekret / me↓ viskositas sekret → Cool mist therapyHot mist therapy dapat membakar wajah anak : gelisah kmd hiperventilasi → perburuk sumbatan jalan napas
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2. Nebulizer vasokonstriktor
Epinephrine menstimulasi α & β2 : vasokonstriksi precapillary arterioles, me↓ airway edema. ES takikardia & hipertensi : hanya diberikan pada croup sedang-berat
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2. Nebulizer vasokonstriktor
a. Epinephrine rasemik 2,25%
Campuran 1:1 d-isomer dan l-isomer epinefrin. Hsl reduksi metil-amino-aceto-katekolamin o/ Al amalgam (reduksi elektroktrolitik). Dpt dipecah mjd isomer d-adrenalin & Laevoadrenalin. L-adrenalin memiliki efek vasopresor > baik dibanding d-A.
Baik u croup sedang - berat
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Dosis : 0,5 ml epinefrin 2,25% dicampur 3-4,5 mL NaCl :
– <20 kg : 0,25 mL– 40 kg : 0,5 mL– >40 kg : 0,75 mL– dapat diulang 20-30 min
Versi lain : 0,25-0,75 ml dalam 2,5 ml NaCl→ nebuliser + 10-20 min
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2. Nebulizer vasokonstriktor
Jika epinephrine rasemik tidak tersedia, gunakan campuran 5 ml l-isomer epinefrin & NacL perbandingan 1:100.
b. Epinephrine - Nebulisasi 5 mL (5 mg) dari 1:1000 dalam 2 mL NaCl- dapat diulang 20-30 min
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BLPL dalam 3 jam bila
Stridor (-) saat istirahatUdara yg masuk airway normalKesadaran baikSkor Croup < 2
Dramatik
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3. Kortikosteroid↓ edema, terutama udem subglotis
a. Dexamethasone - Dosis : 0,15-0,6 mg/kgBB po/im dosis tunggal; max 10 mg/dosis- Oral sama efektifnya dg im
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Kortikosteroid
b. Prednisone atau prednisolone Dosis: 1 mg/kg po/12 jam selama 24 jam setelah extubation; max 60 mg/24 jam
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Kortikosteroid
c. Budesonide Dosis: * 2 mL (0,5 mg) nebulizer.* Atau 2 mg dlm 4 ml NaCldiulang 1 mg budesonid dlm 2 ml NaCl/12 jam
Kombinasi budesonid nebuliser dg deksametason po berefek > dr pd budesonid saja
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Kortikosteroid
BudesonideES sistemik minimalLebih efektif (cepat keluar dari UGD)
Budesonide dan deksametason lebih sering dipakai.
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4.Heliox
Campuran helium & O2 Efek : me↑ oksigenasi darah. Pada croup berat : Os akan nyaman & tidak perlu ET
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Penatalaksanaan di MRS : masuk PICU
O2Cairan iv sesuai BB & status hidrasi.Pemberian inhalasi NaCl
AB :Ampisilin 100 mg/kgBB/hari, iv, terbagi 4 dosisKloramfenikol : 50 mg/kgBB/hari, i.v, terbagi 4 dosisSefalosporin Generasi 3 (Cefotaksim atau Ceftriakson)
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5.Intubasi endotrakeal (ET) atau trakeostomi
Pada croup berat yg tak responsif dg Tx standarIndikasi ET atau trakeostomi :hiperkarbia & gagal nafas mengancam :– pe↑ stridor inspirasi, frekuensi respirasi, denyut
jantung, adanya retraksi, – Sianosis– perubahan status mental / pe ↓
kesadaranPipa ET sebaiknya 2 ukuran < kecil dr pd anak
sehat, krn tjd udem laring
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Komplikasi
Jarang, mis: Edema paruPneumothoraxLymphadenitisotitis mediaKondisi superinfeksi bakteri dapat menyebabkan pneumonia atau trakeitis bakterial
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Diagnosis Banding1. Airway foreign body2. Bacterial tracheitis3. Diphtheria (Laringitis difteri)4. Epiglottitis (Epiglotitis akut)5. Inhalation injury6. Laryngomalacia7. Neoplasm (menekan trachea)8. Peritonsillar abscess9. Retropharyngeal abscess10. Subglottics Stenosis11. Vascular ring, right aortic arch12. Angioneurotic edema
13.Aspirated foreign body14.Laryngeal web15.Laryngeal papillomatosis16.Laryngeal hemangioma17.Spasmodic croup18.Subglottic hemangioma19.Vocal cord paralysis20.Measles (campak)21.Uvulitis22.Laryngeal tuberculosis23.Laryngeal fracture
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PrognosisBaik sekali (excellent).
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Ket
Croup : self-limiting diseaseNamun, jika udem subglotis berlanjut → kesulitan bernafas : stridor inspirasi
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BRONCHIOLITIS
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DIAGNOSISAcute infectious inflammation of the bronchioles resulting in wheezing and airways obstruction in children < 2 years old
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CLINICAL FEATURESBegin with upper respiratory tract symptoms: hidung buntu, pilek, batuk ringan, demam subfebris Progress in 3-6 days to rapid respirations, chest retractions, wheezing
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EXAMTachypnea– 80-100 in infants– 30-60 in older children
Fase expiratory diperpanjang, wheezing and ronki basah kasar & halusPossible dehydrationPossible conjunctivitis or otitis mediaPossible cyanosis or apnea
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HOSPITALIZATIONChildren with severe diseaseToxic with poor feeding, lethargy, dehydrationModerate to severe respiratory distress (RR > 70, dyspnea, cyanosis)ApneaHypoxemiaParent unable to care for child at home
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TREATMENTSupportive carePharmacologic therapyAncillary evaluation
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