GANGGUAN PARU AKIBAT IMMOBILISASI PADA GERIATRI

GERIATRI

GERIATRI DEFINITION

There is a strong association between advanced age and the decline in the integrity of physical barriers, protection against invading pathogens,and age-related changes in the immune system��1. Impairment of mucociliary clearance (that prevents attachment of bacteria� to the epithelium),�2. impairment of alveolar defense, �3. ineffective cough, and �4. swallowing disorders ��

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

• The most frequent respiratory viruses in the elderly populationare influenza virus and respiratory syncytial virus, which cause high morbidity and mortality.
• There are many reports of epidemic outbreaks, especially in nursing-home patients. It has also been reported that respiratory viruses may not only cause viral pneumonia but are also associated with bacterial infection (polymicrobial CAP)
• The most frequent bacterial pathogens associated with respiratory viruses are S pneumoniae, S aureus, and H influenzae

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

• Some diseases and syndromes have clinical signs and symptoms that can mimic pneumonia in elderly patients.

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• In adults over 65-years old, the incidence of tuberculosis is higher than in other age groups with the exception of the HIV-infected population

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

IMMOBILISASI

IMMOBILISASI -- GERIATRI

• Jackson et al. (2009) identified of independent predictors for CAP in older Adults:

1. lung diseases

2. heart diseases

3. weight loss

4. poor functional status, and

5. smoking

Ther Adv Infect Dis. 2014 feb; 2(1): 3-16

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1. Decreased Ventilation

- reduced tidal volume, minute ventilator volume

- decreased muscle strength

- deconditioning of respiratory muscle

- failure to fully expand the chest wall

🡪 reduced arterial oxygen

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2. Atelectasis and pneumonia

- impaired ability to clear secretions 🡪 accumulate in the lower parts of

the bronchial tree (ideal environtment for the development of bacteria)

🡪 blocking airways 🡪 atelectasis / hypostatic pneumonia

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COMPLICATIONS MECHANISM OF IMMOBILIZATION

Can Fam Physician. 1993 Jun; 39: 1440-2

GANGGUAN PARU AKIBAT IMMOBILISASI PADA GERIATRI

1. Bakteri (pneumonia, TB paru, dll)
2. Virus
3. Jamur

PNEUMONIA

DEFINITION

An acute infection of the lung parenchyma distal to the terminal bronchiole, associated with clinical or radiologic evidence of consolidation of part or parts of one or both lungs

ANATOMI PARU DAN TRACHEOBRONCHIAL TREE

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Lobus → Segmen → Lobulus → Asinus → Alveoli

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Asinus : Parenkim paru yang terletak distal dari bronkiolus terminalis (Bronkiolus respiratorius, duktus alveolaris, alveoli)

EPIDEMIOLOGY

KLASIFIKASI

1. Berdasarkan Tempat kejadian

a. Community acquired pneumonia

terjadi di dalam masyarakat

b. Hospital acquired pneumonia

Pneumonia yang terjadi di rumah sakit

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• Berdasarkan kuman penyebab

a. tipikal: Pneumonia dgn gejala klinis yg khas

b. Pneumonia atipikal: Pneumonia dgn gejala

klinis yg tidak khas

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3. Berdasarkan berat ringannya penyakit

Pneumonia ringan, sedang dan berat

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4. Berdasarkan bagian paru yang terkena

a. lobaris : 1 lobus paru

b. Bronchopneumonia : paru dan bronkus

c. Pleuropneumonia : pembungkus paru

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ETIOLOGI

IDSA/ATS Guidlines for CAP in Adults. CID 2007

ETIOLOGI ASIA DAN EROPA

PERSENTASE PENYEBAB CAP DI AS (2010)

• Streptococcus pneumoniae 20-60
• Haemophilus influenzae 3-10
• Staphylococcus aureus 3-5
• Gram-negative bacilli 3-10
• Legionella species 2-8
• Mycoplasma pneumoniae 1-6
• Chlamydia pneumoniae 4-6
• Viruses 2-15
• Aspiration 6-10
• Others 3-5

PATHOGENESIS

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

PATHOGENESIS

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Kolonisasi mikroorganisme di saluran nafas

aspirasi

Inokulasi mikroorganisme di saluran nafas bawah

INFEKSI

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

GAMBARAN KLINIS

SIGNS & SYMPTOMS

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

CLINICAL MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA IN THE ELDERLY PATIENT, EXPERT REVIEW OF RESPIRATORY MEDICINE, 10:11, 1211-1220

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Panduan ATS dan IDSA Joint effort 2007

merekomendasikan diagnosis klinis

berdasarkan :

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• Gejala dan tanda

• Foto toraks atau teknik pencitraan lainnya

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• Pemeriksaan mikrobiologi

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PEMERIKSAAN PENUNJANG�

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• Pasien rawat jalan : Rontgen toraks, kultur sputum

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• Pasien rawat inap : Rontgen toraks, kultur sputum, analisa gas darah, kimia darah

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• Bila dicurigai adanya resistensi obat disarankan untuk kultur dan resistensi sputum dan pengecatan gram

Foto toraks

• merupakan alat diagnostik yg penting
• Melihat infiltrat baru ataupun progresif:
• Konsolidasi pd bagian lobus
• Konsolidasi pd bagian segmental
• Infiltrat yg Patchy
• Kavitas pd paru
• Limphadenopati
• Efusi Pleura

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Pemeriksaan Sputum

• Pemeriksaan sputum yg plg penting adlh

kultur sputum dan pengecatan gram

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• 30-50% kuman patogen tdk dpt diidentifikasi

dgn pemeriksaan ini karena terkontaminasi

TATALAKSANA CAP

1. The Severity of Pneumonia

SKORING

• Pneumonia Severity Index (PSI)
• CURB 65

�PORT SCORING – PNEUMONIA SEVERITY INDEX�

STRATIFIKASI DAN REKOMENDASI TEMPAT PERAWATAN

CURB 65 Rule – Management of CAP

Fine MJ et al. N Engl J Med. 1997;336:243-250.

Capelastegui A et al.  Eur Respir J. 2006;27:151-157

Each gets one point

BTS – British Thoracic society

2. Antibiotic Rules

TIME TO USE ANTIBIOTICS

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• Time to first antibiotic dose 🡪 For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED

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• Early treatment (within 48 h of the onset of symptoms), with oseltamivir or zanamivir is recommended for influenza A.

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• Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen.

DURATION OF ANTIBIOTIC THERAPY

• Patients with CAP should be treated for a minimum of 5 days, should be afebrile for 48–72 h, and should have no more than 1 CAP-associated sign of clinical instability (table 10) before discontinuation of therapy

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• A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis

Antibiotik ideal untuk pneumonia

• Bacterisid +++
• Resisten rendah
• Dapat membunuh kuman respiratoar dengan obat tunggal
• Dosis sekali/ hari
• Aman
• Dapat menembus sistem pernafasan jauh
• Murah

Antibiotics for CAP

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Terapi empiris antibiotik

(IDSA/ATS 2007)

TREATMENT OF HAP, VAP

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• Antipseudomonal cephalosporin (Cefepime, Ceftazidime) + Vancomycin
• Anti-pseudomonal Carbapenem (Imipenem, Meropenem) + Vancomycin
• Beta-Lactamase/Beta-Lactamase Inhibitor (Pip-Tazo – Zosyn) + Pseudomonal Fluoroquinolone (Cipro) + Vancomycin
• Aminoglycoside (Gentamycin, Amikacin) + Vancomycin

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PNEUMOCOCCAL VACCINE

• What does it cover?
• Protects against 23 serotypes of Strep. Pneumoniae (90% of invasive pneumonia infections)
• Who should get it?
• Anyone over age 65
• Anyone with chronic medical problem such as cancer, diabetes, heart disease, lung disease, alcoholism, cirrhosis, sickle cell disease, kidney failure, HIV, damaged spleen or no spleen, CSF leaks
• Anyone receiving cancer therapy, radiation, steroids
• Alaskan natives and certain Native American populations
• How often to get it?
• Give second dose if >5 years from first dose if > 65, cancer, damaged spleen, kidney disease, HIV or any other condition lowering immune system function

KOMPLIKASI

• Gagal napas (ARDS, Acute respiratory distress syndrome)
• Septic shock
• Efusi pleura/ Empiema (penumpukan cairan dalam rongga pleura, dapat berupa nanah)
• Abses di paru
• Gagal ginjal
• Penyebaran kuman didalam darah (bakteriemia))

TERIMA KASIH

APA YANG HRS DIEVALUASI BILA GAGAL TERAPI PNEUMONIA?

Incorrect diagnosis

Host issues

Pathogen issues

Failure of empirical treatment

Correct diagnosis

Drug issues

Bacterial

Nonbacterial

Error in drug selection

Error in dose/route

Compliance

Adverse drug reaction

Local factor

Inadequate host response

Complication

Glucocorticoids

The role of glucocorticoids in acute bacterial pneumonia has yet to be clearly elucidated. Classic teaching warns that the use of glucocorticoids in infection may impair the immune response. However, findings demonstrate that local pulmonary inflammation may be reduced with systemic glucocorticoids. In a 2015 meta-analysis of 13 randomized controlled trials evaluating the use of systemic corticosteroids in patients hospitalized for CAP, it was found with high certainty that systemic corticosteroid steroid treatment reduced the duration of hospitalization by approximately 1 day and had a 5% absolute reduction in risk for mechanical ventilation.

The study also found that patients with severe pneumonia who received systemic corticosteroids had an apparent mortality benefit over patients with severe pneumonia who did not receive systemic corticosteroids, which may be related to the higher incidence of acute respiratory distress syndrome and the need for mechanical ventilation in patients with severe pneumonia.

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