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BRONCHOPNEUMONIA

Presented by

SUPERVISOR

Stefen Andrianus
110100009
Mutia Fri Fahrunnisa 110100071

: dr. Nelly Rosdiana, Sp. A (K)

BACKGROUND

According to WHO,Acute respiratory illness remains a

leading cause of childhood mortality, causing an


estimated 1.62.2 million deaths globally in children <
5 years.
In Indonesia, Pneumonia is the 2nd most common cause
of death in children after diarrhea (15,5%). A 2007
study conducted by the Indonesia Ministry of Health
shows that 30.470 children died from pneumonia that
year, which is equal to 83 children in a day.

DEFINITION
Pneumonia is defined as an inflammation of
lung tissue due to an infectious agent. 2

2. Banaszak, I.W., Breborowicz, A. Pneumonia in Children. Department of Pulmonology, Pediatric Allergy and Clinnical
Immunology, Poland: 2013.. Chapter 6: 54052

ETIOLOGY
The etiology of pneumonia based on Age 3

3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010

ETIOLOGY

3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010

ETIOLOGY

3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010

ETIOLOGY

3. Said, M.. Pneumonia dalam Respirologi. Ikatan Dokter Anak Indonesia. Jakarta: 2010

DIAGNOSIS
1. Clinical Manifestation
-

Cough
Fever
Sign of Respiratory Distress
- Tachypnoe
- Shortness of breath
- Chest retraction
- Grunting

Tachypnoe defined according to WHO criteria2

Age

Respiratory rate

0-2 months

>60

2-12 months

>50

1-4 years

>40

>5 years

>30

2. Banaszak, I.W., Breborowicz, A. Pneumonia in Children. Department of Pulmonology, Pediatric Allergy and Clinnical
Immunology, Poland: 2013.. Chapter 6: 54052

DIAGNOSIS
2. Physical Examination
dullness on percussion of the chest
decreased breath sounds
additional breath sounds such as ronchi and
wheeze

DIAGNOSIS
Additional Tests2
a. Complete blood test
b. Chest X-ray

Chest x-ray may shows:


Interstitial infiltrate
Alveolar infiltrate, consolidation of the lungs (air
bronchogram).
Bronchopneumonia, infiltrate which is equally spread in
both lungs.
c. Determination of etiology microbiological
investigations.
d. C-Reactive Protein (CRP)

TREATMENT & MANGEMENT


The treatment of pneumonia in children consists of appropriate

antibiotics for the offending organisms, supportive treatment such


as oxygen, iv fluid and the correction of acid base disorder 9.
Outpatient settings:
The first line antibiotic for outpatient settings is Amoxicillin 20 mg/kg
or Cotrimoxazole (4mg/kg of Trimetoprim and 20 mg/kg of
Sulfamethoxazole)
Inpatient settings
The first line antibiotics for inpatient settings is Beta Lactamase group
or Chloramphenicol. Antibiotic is administered for 7-10 days.
Antibiotic must be given as soon as possible in neonates. Broad
spectrum antibiotics such as the Beta Lactamase group or third
generation of cephalosporine are recommended. Upon stabilization,
iv antibiotics can be switched to oral antibiotics and patients can be
treated in the outpatient settings.

CASE REPORT
H, a 5 months old girl with a body weight of 7000 g

and a body length of 61 cm was admitted to the


emergency room in Haji Adam Malik General
Hospital Medan on 9th September 2015 at 06.00 pm
with a complain of shortness of breath.

HISTORY
The patient is the youngest child in the family. The patients mother

pregnancy and delivery history was unremarkable. She was born


with a birth weight of 3000 g. The mother said that she had been
noticing the shortness of breath for the past 11 days. Her child
breathlessness was not associated with activites and weather
changes.
Productive cough was notably present for the past 2 weeks. There

was no history of hemoptysis. History of contact with others with


similar symptoms was found, which was her older sister. Her older
sister has been experiencing chronic cough for more than 3 weeks.

HISTORY (CONT)
Intermittent fever was found, fever subsided with

antipyretics and the highest recorded temperature


was 39 degree Celcius.
History
of urination and defecation was
unremarkable.
Her mother was complaining about her child weight
loss. She was losing approximately 2 kg of body
weight for the past week.
She was treated in another hospital for 8 days and
was referred to RSUP HAM due to no improvement.

HISTORY (CONT)
History of medication: Unclear
Family History: Hs sister was suffering from

chronic cough for more thatn 3 weeks


History of parents medication: Unclear
History of Pregnancy: The mothers age was 38
years old during pregnancy with a 36 weeks
gestation.

HISTORY (CONT)
History of Birth: Birth was assisted by a midwife. The

patient was born pervaginal and cried immediately after


birth. Body weight at birth was 3000 gram, body length
at birth was unclear, and head circumference at birth was
unclear.
History of feeding: breast fed from birth until now (5
months)
History of immunization: Incomplete immunization
(polio 2 times).
History of growth and development: The patients
mother reported that H grew normally. H can now rolls
from supine to prone.

PHYSICAL EXAMINATION

Present Status
Level of consciousness: alert.
Body temperature: 37,4C.
BW: 7 kg, BH: 61 cm. L/A: -2<Z<0, W/A: 0<Z<2,

W/L: 1<Z<2.
Anemic (-), icteric (-), dyspnea (+), cyanosis (-),
Edema (-).

Localized status
Head:

Eye: light reflex +/+, conjunctival pallor (-/-)


Ear: unremarkable
Nose: O2 nasal canule

Mouth: unremarkable

Neck:

Jugular Vein Pressure: R+2 cm H2o

Localized Status (Cont)


Thorax:

Symmetric fusiform.
Retractions (+) on the suprasternal and epigastric area.
RR: 54x/I, regular, Ronchi (+,+) and stridor (+,+) in all lung
fields.
Dullness to percussion was found in all lung fields.
HR 144 x/I, M1>M2, T1>T2, A2>A1, P2>P1, Continous
murmur grade IV/IV.

Localized Status (Cont)


Abdomen:

Soft, normal peristaltic, liver and spleen were both unpalpable.

Extremities:

Pulse: 139x/i, regular, with adequate pressure and volume,


warm, CRT < 3, blood pressure: 100/60 mmHg, SaO2 : 98%.

Chest X-Ray
Results: CTR of
56% , Aorta
dilatation (-),
Pulmonal artery
dilatation (-),
downward apex of
the heart,
Congestion (+),
Infiltrate (+)
Conclusion :
Cardiomegaly with
congestion

LABORATORY FINDINGS
Test

Result

Unit

Hemoglobin

10.20

g%

Reference
Range
10.7-17.1

Erythrocyte

4.14

106/mm3

3.75-4.95

Leukocyte

18.25

103/mm3

6.0-17.5

Thrombocyte

311

103/mm3

217-497

Hematocrite

29.40

38-52

Eosinophil

4.10

1-6

Basophil

0.500

0-1

Neutrophil

25.60

37-80

Lymphocyte

50.70

20-40

Monocyte

19.10

2-8

LABORATORY FINDINGS (CONT)


Test

Unit

Reference Range

103/L

1.9-5.4

9.25

103/L

3.7-10.7

Absolute
count

Monocyte 3.48

103/L

0.3-0.8

Absolute
count

Basophil 0.09

103/L

0-0.1

Absolute
count

Result
Neutrophil 4.68

Absoulute
Lymphocyte count

MCV

71.00

fL

93-115

MCH

24.60

pg

29-35

MCHC

34.70

g%

28-34

Blood Gas Analysis


Test

Result

Unit

Reference
Range

pH

7.470

7.35-7.45

PCO2

23.0

mmHg

38-42

PO2

201.0

mmHg

85-100

Bicarbonate(HCO3)

16.7

mmol/L

22-26

Total CO2

17.4

mmol/L

19-25

Base Excess

-5.9

mmol/L

(-2)-(+2)

O2 Saturation

100.0

95-100

Electrolyte
Test

Result

Unit

Reference
Range

Calcium

8.8

mg/dL

8.4-10.8

Sodium

138

mEq/L

135-155

Potassium

3.8

mEq/L

3.6-5.5

Chloride

100

mEq/L

96-106

Peripheral Blood Smear Morphology


Erythorcyte: Microcytic hypochromic with

anisocytosis.
Leukocyte: Atypical Lymphocytes (+)
Thrombocyte: Normal

Differential Diagnosis
Bronchopneumonia dd Bronchiolitis + Ventricel

Septal Defect dd Patent Ductus Arteriosus.


Bronchiolitis + Patent Ductus Arteriosus.

DIAGNOSIS
Bronchopneumonia dd Bronchiolitis + Ventricel

Septal Defect dd Patent Ductus Arteriosus

TREATMENT
O2 1 litre/i
IVFD D5% NaCl 0.225% microdrips 10gtt/i
Amoxicillin IV 350 mg q12h
Nebulized NaCl 0.9 % 2,5 cc q8h
Furosemide 7 mg PO q12h
Captopril 3.125 mg PO q12h
Digoxin 0.035 mg PO q12h

9th September 2015


S
O
Dypsnea
Sensorium: alert, T: 37,4 oC,
Head: eye: light reflex +/+,
conjuctival
pallor:
-/-,
mouth/nose/ear:
unremarkable.
Thorax: symmetric fusiform,
retraction (+) HR: 144x/i,
continuous murmur(+), RR:
54x/i, Ronchi +/+, Stridor +/
+
Abdomen:
soft,
normal
peristaltic, non-tender, liver
and
spleen
are
both
unpalpable.
Extremities: Pulse: 144x/i,
regular
with
adequate
pressure and volume, warm,
CRT < 3, pretibial edema
(-)
Physiological
APR(+), KPR (+)

reflexes:

Pathological reflexes (-)

A
Bronchopneum
onia

P
O2 1-2L/i through
nasal cannula
Ceftriaxone
mg IV bid
Consult
Cardiologist.

350

10th September 2015


S
O
A
o
Dypsn Sensorium : alert, T : 37,0 C, BP: 100/60 Bronchopneum
ea
mmHg
onia
Head: eye: light reflex +/+, conjunctival Bronchiolitis
pallor:
-/-,
mouth/nose/ear:
Diapers rash
unremarkable.
Thorax: symmetric fusiform, retraction Large VSD
(+) HR: 128x/i, continuous murmur (+), Moderate PDA
RR: 66x/i, Ronchi +/+, Stridor +/+
Mild TR
Abdomen: soft, normal peristaltic, nontender, liver and spleen are both
unpalpable.
Extremities: Pulse: 128x/i, regular with
adequate pressure and volume, warm,
CRT < 3, pretibial edema (-)
Physiological reflexes: APR(+), KPR (+)
Pathological reflexes (-)
Meningeal sign (-)
Echochardiography result:
Large VSD
Moderate PDA
Mild TR
Recommendations: consult nutritionist
and Endocrine & Metabolic Diseases

P
O2 1-2L/i through
nasal cannula
D5% NaCl 0,225% IV
microdrips: 10gtt/i
Ceftriaxone 350 mg
IV bid
Mizol TP q8h
Nebule NaCl
2,5cc tid

0,9%

11th September 2015


S
O
A
P
Dyspnea( Sensorium : alert, T : 36,6 Bronchopneumon O2 1-2L/i through
o
+)
C, BP: 100/70 mmHg
ia
nasal cannula
Fever (-)

Head: eye: light reflex+/+, Bronchiolitis


conjunctival
pallor:
-/-,
Diapers rash
mouth/nose/ear:
unremarkable.
Large VSD
Thorax: symmetric fusiform, Moderate PDA
retraction (+) HR: 120x/i,
continuous murmur(+), RR: Mild TR
60x/i, Ronchi +/+, Stridor +/
+
Abdomen:
soft,
normal
peristaltic, non-tender, liver
and
spleen
are
both
unpalpable.
Extremities: Pulse: 120x/i,
regular
with
adequate
pressure and volume, warm,
CRT < 3, pretibial edema
(-)
Physiological
APR(+), KPR (+)

reflexes:

D5% NaCl 0,225%


IV
microdrips:
10gtt/i
Ceftriaxone
mg IV bid

350

Mizol TP q8h
Nebule NaCl 0,9%
2,5cc tid
Furosemide
PO q12h

7mg

Captopril 3,125mg
PO q12h
Digoxin 0,035 mg
PO q12h

12th September 2015 14th September


2015
S
O
A
Improvemen Sensorium : alert, T : 36,8 Bronchopneu
o
t in SOB
C, BP: 100/60 mmHg
monia
Fever (-)

Head: eye: light reflex +/+, Bronchiolitis


conjunctival
pallor:
-/-,
Diapers rash
mouth/nose/ear:
unremarkable.
Large VSD
Thorax: symmetric fusiform, Moderate PDA
retraction (-) HR: 108x/i,
continuous murmur(+), RR: Mild TR
32x/i, Ronchi -/-, Stridor -/Abdomen:
soft,
normal
peristaltic, non-tender, liver
and
spleen
are
both
unpalpable.
Extremities: Pulse: 108x/i,
regular
with
adequate
pressure and volume, warm,
CRT < 3, pretibial edema
(-)
Physiological
APR(+), KPR (+)

reflexes:

P
Amoxicillin
IV q8h
Furosemide
PO q12h

3,5cc
7mg

Captopril 3,125mg
PO q12h
Digoxin 0,035 mg
PO q12h
Nebule NaCl 0,9%
2,5cc tid
Mizol TP q8h


15th September 2015
S
O
SOB (-) Sensorium : alert, T : 36,5 oC,
BP: 110/700 mmHg
Fever
(-)
Head: eye: light reflex +/+,
conjunctival
pallor:
-/-,
mouth/nose/ear:
unremarkable.

A
Bronchopneumoni
a

P
Amoxicillin
IV q8h

Bronchiolitis

Furosemide
PO q12h

Diapers rash
Large VSD

Thorax: symmetric fusiform, Moderate PDA


retraction (-) HR: 106x/i,
continuous murmur(+), RR: Mild TR
30x/i, Ronchi -/-, Stridor -/Abdomen: Seopel, Normal
peristaltic, non-tender, liver
and
spleen
are
both
unpalpable.
Extremities: Pulse: 108x/i,
regular
with
adequate
pressure and volume, warm,
CRT < 3, pretibial edema (-)
Physiological
APR(+), KPR (+)

reflexes:

Pathological reflexes (-)

3,5cc
7mg

Captopril 3,125mg
PO q12h
Digoxin 0,035 mg
PO q12h
Nebule NaCl 0,9%
2,5cc tid
Mizol TP q8h

16th September 2015


Patient was discharged from the hospital

DISCUSSION
Theory

Cases

The incidence of pneumonia is highest in Our patient is a 5 months old baby.


children under 5 years of age.
The diagnosis of pneumonia is made by the
presence of respiratory distress, such as
tachypnoe, history of breathlessness or
difficulty in breathing chest retractions,
nasal flaring, grunting, use of accessory
muscles of respiration. Tachypnoe is a very
sensitive marker of pneumonia. Between
50-80% of children with WHO-defined
tachypnoe had radiological signs of
pneumonia.
Chest x-ray may shows: interstitial
infiltrate, alveolar infiltrate, consolidation
of
the
lungs
(air
bronchogram),
Bronchopneumonia, infiltrate which is
equally spread in both lungs.

Our patients presenting complaint was


shortness of breath. Chest retractions,
grunting, and tachypnoe was found on
physical examinations.
Her chest X-ray revealed infiltrate which
was equally spread in both lungs. This
finding
suggests
the
diagnosis
of
Bronchopneumonia.

The treatment of pneumonia in children


consists of appropriate antibiotics for
the offending organisms, supportive
treatment such as oxygen, iv fluid and
the correction of acid base disorder.
First-line recommended therapy in
previously healthy children regardless
of age is Amoxicillin, as it provides
sufficient coverage against the most
common invasive bacterial pathogen,
namely Streptococcus pneumoniae.

The treatments for this patient include


oxygen 1 litre/i given through nasal
canule, IVFD D5% NaCl 0.225%
microdrips 10 gtt/i, and Amoxicillin IV
350mg q12h.

SUMMARY
H, A 5 months old baby girl, was admitted to the

emergency department due to breathlessness and was


diagnosed with bronchopneumonia and ventricular
septal defect. The diagnosis was made based on her
history, physical examinations ,lab studies, chest X-ray
and echocardiography. The patients treatments consist
of:

O2 1 litre/i
IVFD D5% NaCl 0.225% microdrips 10gtt/i
Amoxicillin IV 350 mg q12h
Nebulized NaCl 0.9 % 2,5 cc q8h
Furosemide 7 mg PO q12h
Captopril 3.125 mg PO q12h
Digoxin 0.035 mg PO q12h