TB PARU DEWASA

GROUP 8
JOEL-ZAKIY-NADIAH-AIMI-AIN-ANDI
ABHARINA-ALIF-SARAHVALERIA-ANDI
SADID-ANDI RAYNALDI

Scenario

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 ada

Pemeriksaan Fisis:
Tanda vital TD: 100/70 mmHg, Pernapasan:24x/menit Nadi 100x/menit, Suhu :
37,9 C
TB/ BB: 160 cm/ 45 kg
Kepala : Dalam batas normal

Leher : Dalam batas normal

Thoraks : Bunyi pernapasan amforik di apeks paru kanan, Ronki basah di
apeks paru kanan dankiri
Abdomen : dalam batas normal
Pemeriksaan tambahan
BTA pertama positif, BTA kedua dan ketiga negatif
BTA 3x ulang negatif, negatif,negatif
Pemeriksaan foto torak : kavitas di paru kanan atas, infiltrate di paru kiri atas

Keywords
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 atas

Difficult Words

Amphoric sound
an 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 Sounds
These are low pitched, snore-like sounds. They are caused by
airway secretions and airway narrowing. They usually clear after
coughing.

Questions

1. What is the anatomy and physiology of respiratory system?

2. What are the causes and pathomechanism of bloody cough?
3. What is the pathomechansim of fever?
4. What cause sweating at night?
5. Type and mechanism of cough?
6. What is the mechanism of weight loss for this patient?
7. Normal and abnormal breath sound?
8. What are the mechanism of airborne transmitted disease?
9. What are the diagnosis that can be done to this patient?
10. What is the management for this patient?

Anatomi Sistem Respirasi...

FISIOLOGI
Proses inspirasi

Kontraksi otot
diafragma dan
interkostalis
eksterna

Volume toraks
membesar

Tekanan intra
pleura menurun

Paru mengembang

Tekanan intra
alveolar menurun

Udara masuk ke
dalam paru

Proses
ekspirasi

Otot inspirasi
relaksasi

Volume torak
mengecil

Tekanan
intrapleura
meningkat

Volume paru
mengecil

Tekanan intra
alveol
meningkat
Udara
bergerak
keluar paru


Proses respirasi berlangsung beberapa tahap
1. Ventilasi, pegerakan udara ke dalam dan ke luar paru
2. Pertukaran gas di dalam alveoli dan darah disebut pernapasan luar
3. Transportasi gas melalui darah
4. Pertukaran gas antara darah dengan sel-sel jaringan disebut
pernapasan dalam
5. Metabolisme penggunaan oksigen di dalam sel serta pembuatan CO2
disebut pernapasan seluler.

Dasar-dasar ilmu penyakit paru.Halaman 7

HISTOLOGI

Konduksi : cavum nasi, nasopharing, laryngs, trakea,

bronkus, bronkiolus, bronkiolus terminalis.
Respirasi : Bronkiolus respirasi, duktus alveoli dan
alveolus.

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.


The Epithelium of RS is composed of 5 cell
types :

Ciliated cells: covering the surface of epith

Goblet 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 granules

Basal cells: steam cell from which other cell types arise

LAR Y N G

LARYNX

TRACHEA

TRACHEA

BRONCHI

PATHOMECHANISM

JENIS JENIS BATUK

Jenis jenis batuk

Berdasarkan
produktivitas

Berdasarkan
waktu
berlangsungnya

Batuk Produktif
Batuk tidak
Produktif

Batuk akut
Batuk sub-akut
Batuk kronis

Batuk Produktif / Batuk Berdahak

Pengeluaran dahak (sputum) dari tenggorokan
Diproduksi sebagai mekanisme pertahanan tubuh

Batuk Kering / Batuk Tidak Berdahak

Tidak diproduksi dahak
Biasanya bukan mekanisme pengeluaran zat asing

Batuk Akut
Terjadi selama 3 8 minggu
Umumnya relatif ringan & bisa sembuh sendiri

Batuk Sub-Akut
Gejala mirip batuk akut

Batuk Kronis
Terjadi > 8 minggu
Tanda dan gejala penyakit yang lebih berat

MEKANISME BATUK

PATOMEKANISME BATUK
MEKANIK BATUK

Secara mekanis batuk tdd 4 fase:

1. Fase iritasi
2. Fase inspirasi
3. Fase kompresi
4. Fase ekspulsi

Fase 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 ekspulsi

Komponen refleks Batuk

Mechanism of bloody cough

Compilation of pathophysiology (respiratory system) USM page 173

Aspiration

Foreign bodies

Airway irritants

Inflammation
of airway

Narrowing of
trachea

Deep
inspiration,
closure of
glottis

Efferent
laryngeal nerve
and spinal
nerve

Afferent vagus
nerve to brain

Irritation of
respiratory tract

Bleeding lesion
in RT
(cough with
blood)

COUGH

Prolonged
cough

Stimulation of
cough receptor

Type of bloody cough

Blood-tinged sputum: common

-either white mucus sputum, or yellow purulent sputum
-bronchitis or laryngitis

Rusty sputum (prune-juice sputum): reddish-brown, watery, hemorrhagic

sputum.
-containing blood,bacteria, mucus
-lobar pneumonia

http://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

bakteri infeksius
(M.tuberculosis)

Respon imun
TNF-

Demam

keringat

TNF-
meningkat

Monosit keluar dari

aliran darah

Monosit
menjadi
makrofag
migrasi bagi
MTB

Mechanism of weight loss

Initial entry tubercle bacilli into the lung

Non speific acute inflammatory response

Release cytokine

Proteolysis

Release of serotonin

Melanocortine triggered in
hypothalamus

Apetite decrease

BREATH SOUND
LOCATION

SOUND QUALITY

CHARACTERISTIC

Over trachea

- Loud
- Harsh like air blown
through pipe

- Expiration longer
- Similar loudness
- Pause between

BRONCHIAL - Over large

airways
- Body of sternum

- More tubular
- High pitch

- Expiration louder and

longer
- Pause between

BRONCHOV
ESICULAR

- Posterior chest
between scapula
- 1&2 inter muscle
anteriorly

- Medium pitched

- Inspiration&expiration
equal length/loudness
- Pause between

VESICULAR

- Most of lung

- Soft and low pitch

- Rustling sound
normally

- Inspiration
longer&louder
- Without pause between

TRACHEAL

ABNORMAL BREATH SOUND

FINE CRACKLE

Sound like when salt heated on frying pan

COARSE CRACKLE

Sound like water poured from a bottle

- Higher pitch
- Low intense
- Shorter duration

- Lower pitch
- Less intense
- Longer duration

Only during inspiration

During inspiration and expiration

Rhonchi
Low pitched honking or groaning sound
Result from movement of air past bronchi partially obstructed by
thick secretion
Found in increase airway secretion disease (pneumonia, chronic
bronchitis, asthma)
Wheezing
Polyphonic
- Most common type
- Typical COPD and asthma
Monophonic
- Single pitched result from narrow single airway

Amphoric Sound
High pitch bronchial sound
Heard when bronchus is in
communication with a large cavity
or with a pneumothorax
Can be compared to sound blown
through a blowpipe

Ronchi Sound

Prolong, uninterrupted sound due to partial

obstuction in narrowed bronchus or bronchiole
Narrowing occur due to :
1. Mucosal swelling
2. viscid thick secretion
3. spasm
4. Infiltration of the wall

 2 types of ronchi :
1) Sibilant
- high pitch, produce in the smaller bronchi
2) Sonorous
- low pitch, produce in the large bronchi
Ronchi sound may caused by :
1) Bronchitis
2) Bronchial asthma
3) Obstruction of bronchial tube by a tumour or
foreifn body

Airborne transmitted
diseases

mechanism

Airborne
transmission is
the
dissemination
(spread) of
microorganisms
by
aerosolization.

Organisms that
are airborne, are
small particles
that result from
the evaporation
of large droplets

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

remain
suspended in the
air for long
periods of time

Microorganisms
widely dispersed
through air current
and inhaled by
susceptible host

Tuberculosis

Influenza

DISEASES

Chickenpox

Measles

Tuberculosis
(TB)

Definisi

Infeksi bakteri menahun yang disebabkan oleh Mycobakterium tuberculosis

Ditandai dengan pembentukan granuloma pada jaringan 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.

EPIDEMIOLOGY OF TB

Tuberculosis remains one of the deadliest diseases in the world. The World Health Organization
(WHO) estimates that each year more than 8 millionsnew cases of tuberculosis occur and
approximately 3 million persons die from the disease

Ninety five percent of tuberculosis cases occur in developing countries, where few resources are
available to ensure proper treatment and where human countries, where few resources are
available to ensure proper treatment and where human
immunodeficiency virus (HIV) infection may be common

It is estimated that between 19 and 43% of the worlds population is infected with
Mycobacterium tuberculosis, the bacterium that causes tuberculosis infection and diseases

. In the United States, an estimated 15 million people are infected with

M.Tuberculosis Although the tuberculosis case rate in the United States has
declined during the past few years, there remains a huge reservoir of
individuals who are infected with M. tuberculosis

Without application of effective treatment for latent infection, new cases of

tuberculosis can be expected to develop from within this group. Tuberculosis
is a social disease with medical implications

It has always occurred disproportionately among disadvantaged populations

such as the homeless, malnourishes and over crowded.

Risk Factors of Tuberculosis

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

 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 appetite
Organs 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 TUBERCULOSIS
The first infection with Mycobacterium
Tuberculosis (Mycobacterium is inhaled)
Reaching the lung

Primary Tuberculosis
Reaching the draining lymph nodes
Exudation and infiltration with neutrophil
granulocytes
Macrophages ingest the bacilli
Formation of Ghon Complex

PATHOGENESIS OF TUBERCULOSIS
Secondary Tuberculosis
Reinfection or reactivation

Small granules

Fibrocaseosa granuloma (Tuberculoma)

Liquefied granuloma
Open into a bronchus / cavitation of the
tuberculoma / dissemination

DIAGNOSIS

GEJALA
A. GEJALA RESPIRATPRIK
-. BATUK 2 MINGGU
-. BATUK DARAH
-. SESAK NAPAS
-. NYERI DADA
B. GEJALA SISTEMIK
-. DEMAM
- ANOREKSIA
-. MALAISE
- BERAT BADAN
-. KERINGAT MALAM MENURUN

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


Laboratorium
Pemeriksaan spesimen
Bahan Pemeriksaan :

Dahak, cairan pleura, bilasan

bronkus, kurasan bronkoalveolar,
bilasan lambung, liquor
cerebrospinal, urin, feses dan
jaringan biopsi

Laboratorium

Cara Pengambilan & Pengiriman :

n
Dahak, 3 kali setiap pagi / SPS
n
Pengiriman dalam pot (cair), pada
gelas objek (difiksasi) atau dahak
dengan kertas saring
n
Tulis identitas penderita sesuai
formulir permintaan

Laboratorium

Pemeriksaan dahak & bahan lain :

Pemeriksaan bakteriologik
Mikroskopik
biasa
fluoresens

Biakan & uji resistensi

konvensional
biakan radiometrik

Interpretasi Hasil
n Mikroskopik positif
- 3 x pos
- 2 x pos, 1 x neg.

- 1 x pos, 2 x neg --- ulang BTA 3 x

bila hasil 1 x pos, 2 x neg.

Mikroskopik negatif
- 3 x neg.
- 1 x pos, 2 x neg --- ulang BTA 3 x
bila hasil 3 x neg.

Tuberculosis. Ziehl-Neelson acid fast stain in an area of

granulomas showing positive stain for acid fast bacilli

Pemeriksaan
Radiologik

Standar :
Foto toraks PA dengan / tanpa
lateral

Gambaran lesi TB aktif

Bayangan berawan/nodular

Kaviti, lebih dari satu dikelilingi

bayangan opak berawan/nodular

Bercak milier

Efusi pleura unilateral (umumnya)

Gambaran Lesi TB Inaktif

n
n
n

Fibrotik
Kalsifikasi
Penebalan pleura

PENANGANAN
FARMAKOLOGI

TUJ UAN PENGOBATAN

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

Dua fase pengobatan

tuberkulosis

Fase intensif : 2-3 bulan

Fase lanjutan : 4-7 bulan

OBAT ANTI TUBERKUL OSA (OAT)

Obat Utama

Obat L ini Kedua

Rifampisin (R)

Quinolon

Isoniazid (H)

Kanamisin

Pirazinamid (Z)

Makrolide

Etambutol (E)

Amok.+ As. klav.

Streptomisin (S)

Der. Rif. /INH

Kombinasi dosis tetap

combination)

(fixed dose

Ever treated case ?

No

Yes

(New case)

Pulmonary
AFB
smear
(+)

Cat I

(Old case)

Extrapulmonary

AFB
smear
(-)

severe

not severe

Cat I

Cat III

severe

not severe

Cat I

Cat III

TAI

Cat II
Cat I
Cat III

Relapse

Failure

Chronic

Cat II

Cat II

Cat IV

 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)

Click to edit Master text styles

Second level
Third level
Fourth level
Fifth level

EFEK SAMPING RINGAN

EFEK SAMPING

PENYEBAB

PENANGANAN

Tdk nafsu makan,

mual, sakit perut

Rifampisin

Obat diminum
malam sebelum tidur

Nyeri sendi

pyrazinamid

Beri
aspirin/allopurinol

Kesemutan s/d rasa

terbakar di kaki

INH

Warna kemerahan
pada kulit

Rifampisin

Beri Vit. B6
(piridoksin) 100 mg
per hari
Beri penjelasan,
tidak perlu diberi
apa-apa

EFEK SAMPING BERAT

EFEK SAMPING

PENYEBAB

PENANGANAN

Gatal dan kemerahan

pada kulit

Semua jenis OAT

Tuli

Streptomisin

Streptomisin dihentikan

Gangguan
keseimbangan
Ikterik

Streptomisin

Streptomisin dihentikan

Beri antihistamin &

dievaluasi ketat

Hampir semua OAT

Hentikan semua OAT

sampai ikterik hilang

Bingung & muntahmuntah

Hampir semua obat

Hentikan semua OAT &

lakukan uji fungsi hati

Gangguan penglihatan

Ethambutol

Hentikan Ethambutol

Purpura dan renjatan

(syok)

Rifampisin

Hentikan Rifampisin

PENANGANAN NON
FARMAKOLOGI ( NUTRISI )

Diet Tinggi Lemak Rendah KH

Tujuan: u/mengurangi CO2 dan kerja pernapasan

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


RQ KARBOHIDRAT
RQ PROTEIN

: 0,8

RQ LEMAK

: 0,7

:1

Pasien tanpa Hiperkapnik :

KH 50-60 %
Lemak 20-30%
Protein 15-20%

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

Preventive Measures

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 dunia
Keberhasilannya hanya 50%
BCG tidak mampu mengelak dari dijangkiti TB, tapi ia mampu mengurangkan
kadar extrathoracic TB pada kanak-kanak, terutama pada TB meningitis.

Thank you

^^