Respiratory

Diseases in
Pregnancy
IGN BAGUS ARTANA

Outline
Introduction to respiratory system
Asthma
Acute bronchitis AECB
Pneumonia
Tuberculosis

RESPIRATION
Respiration refers to the processes involved in:
Oxygen transport from the atmosphere to the body tissue
Transportation of carbon dioxide produced in the tissue to
the atmosphere

Respiration components :
A Gas exchange system Lung
A Transport system Cardiovascular system

BASIC CONCEPTS:
Oxygen supply to body tissue is essential
The three key steps involved in gas
exchange :
Ventilation
Perfusion
Diffusion

VENTILATION
The movement of air
in/out of the respiratory
system
Determined by :
Respiratory rate (N: 12
20X/mnt)
Tidal volume (volume of each
breath)

Main mechanism :
pressure differences
Air flows from a highpressure area to a lowpressure area

VENTILATION
Inspiration :
Contraction of diaphragm
increasing intrathoracic
volume
External intercostal
muscles raise the rib cage
Results in a lowered
pressure within thoracic
cavity air flow into the
lungs

Expiration :
Passive, a result of elastic

VENTILATION
Impaired ventilation :
Obstructive disorders : narrowed airways and
increased resistance to airflow (Bronchial
Asthma, Chronic Obstructive Lung Diseases)
Restrictive disorders : impaired in lung
expansion so gaseous exchange is reduced
(Pleural Effusion, Atelectasis, Pneumothorax,
Interstitial Lung Diseases)

SPIROMETRY

PERFUSION
Alveoli contain a dense network
of capillaries
Capillaries blood air barrier
extremely thin
Gas exchange take place
Ventilation (V) / Perfusion (Q)
apprx 1 efficient gaseous
exchange
V/Q mismatched most
common cause of hypoxemia
(Pneumonia, Adult Respiratory
Distress Syndrome, Lung

DIFFUSION
Diffusion occurs across the
alveolar capillary membrane
depends on gasses (O2 or
CO2) partial pressure
gradients
Blood perfusing pulmonary
capillaries is mixed-venous
blood, so:
O2 diffuse from higher PO2
(environment of alveoli) into
the capillaries
CO2 diffuse from higher CO2
(blood in capillaries) into the

CLINICAL PRESENTATIONS:
Breathlessness, Cough,
Sputum, Haemoptysis, Wheeze,
CLINICAL
Chest pain, Hoarseness, Weigh
INVESTIGATIONS:
loss, Ankle sweeling
DIAGNOSIS:
Conginetal abnormalities, Pneumonia,
Tuberculosis, Asthma, COPD, Lung
cancer, Pleural Diseases .............

MANAGEMENT:
Pharmacological and Non-pharmacological
(Oxygen therapy, Asisted ventilation,
Physiotherapy, Surgery)

History and Physical

examination , Haematology
Pulse oximetry, Microbiology
Bronchoscopy ,
Percutaneous fine needle
aspiration ,
Open and thoracoscopic lung
biopsy , Histopatology,
Lung function test , Imaging

ASTHMA

Burden of Asthma

Asthma is one of the most common

chronic diseases worldwide with an
estimated 300 million affected
individuals

Prevalence increasing in many

countries, especially in children

A major cause of school/work absence

Definition of Asthma

A chronic inflammatory disorder of the

airways

Many cells and cellular elements play a

role

Chronic inflammation is associated with

airway hyperresponsiveness that leads to
recurrent episodes of wheezing,
breathlessness, chest tightness, and
coughing

Widespread, variable, and often

Mechanisms: Asthma
Inflammation

Source: Peter J. Barnes,

Asthma Inflammation: Cells and

Mediators

Source: Peter J. Barnes, MD

Pathologic airway changes induced in asthma

Mucous
gland
hypertroph
y
Edema

Mucus
Thickening of
basement
membrane
Adapted from National Asthma Education and Prevention Program. Expert Panel
Report: Guidelines for the diagnosis and management of asthma. NHLBI, NIH. 1991.

Epitheli
al
damage
Airway
smooth
muscle
Inflammator
y cell
infiltration
Vascular
dilatation

Mekanisme Dasar
Faktor risiko asma

INFLAMASI
Obstruksi jalan nafas

Hiper-aktivitas
Jalan nafas
Faktor risiko
(Terjadi eksaserbasi)

Gejala
Klinis

Symptoms
Coughing and wheezing are the most common
symptoms of childhood Asthma
Breathlessness, chest tightness or pressure, and
chest pain also are reported
Poor school performance and fatigue may indicate
sleep deprivation from nocturnal symptoms

Cough
Nocturnal cough, recurring seasonal cough, or
cough in response to specific exposures
Although wheezing hallmark of asthma, cough is
often sole presenting complaint
Most common cause of chronic cough in children
older than 3 years is asthma

Wheeze
Wheezing is a high-pitched, expiratory sound
produced when air forced through narrow airways
Asthma wheeze tends to be polyphonic (varied in
pitch)
When airflow obstruction severe, can appreciate
wheeze with inspiration and expiration.

Asthma Diagnosis

History and patterns of symptoms

Measurements of lung function
- Spirometry
- Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify
risk factors
Extra measures may be required to
diagnose asthma in children 5 years and
younger and the elderly

Levels of Asthma Control

(Assess patient impairment)
Characteristic
Daytime symptoms
Limitations of
activities

Controlled
(All of the following)

Twice or less
per week

Partly controlled
(Any present in any week)

More than
twice per week

None

Any

Nocturnal symptoms
None
/ awakening

Any

Need for rescue /

reliever treatment
Lung function
(PEF or FEV1)

Uncontrolled

Twice or less
per week

More than
twice per week

Normal

< 80% predicted or

personal best (if
known) on any day

3 or more
features of
partly
controlled
asthma
present in
any week

Assessment of Future Risk (risk of exacerbations, instability, rapid

decline in lung function, side effects)

TO STEP 3
TREATMENT, SELECT
ONE OR MORE:

Shaded green - preferred controller options

TO STEP 4
TREATMENT, ADD
EITHER

Asthma Treatment

Controller
Medications

Reliever
Medications

Controller Medications

Inhaled glucocorticosteroids
Leukotriene modifiers
Long-acting inhaled 2-agonists in
combination with inhaled
glucocorticosteroids
Systemic glucocorticosteroids
Theophylline
Cromones
Anti-IgE

Reliever Medications
Rapid-acting inhaled 2agonists
Systemic
glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral 2-agonists

Asthma
Asthma Management
Management and
and Prevention
Prevention Program

Component 4: Manage Asthma

Exacerbations
Exacerbations of asthma are episodes of
progressive increase in shortness of breath,
cough, wheezing, or chest tightness
Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
Severe exacerbations are potentially lifethreatening and treatment requires close
supervision

Parameter

Mild

Moderate

Severe

Breathless

Walking
Can lie down

Talking
Infantsofter shorter
cry; difficulty feeding
Prefers sitting

At rest
Infantstops feeding
Hunched forward

Talks in

Phrases

Sentences

Words

Alertness

May be agitated

Usually agitated

Usually agitated

Respiratory rate

Increased

Increased

Often >30/min

Accessory muscles and

suprasternal retractions

Usually not

Usually

Usually

Paradoxical
thoracoabdominal
movement

Wheeze

Moderate, often
only end
expiratory

Loud

Usually loud

Absence of wheeze

Pulse/min

<100

100-120

>120

Bradycardia

Pulsus paradoxus

Absent <10 mm
Hg

May be present 10-25

mm Hg

Often present >25 mm Hg

(adult) 20-40 mm Hg (child)

Absence suggests
respiratory muscle
fatigue

PEF after initial

bronchodilator %
predicted or % personal
best

Over 80%

Approximately 6080%

<60% predicted or personal

best (<100 L/min adults) or
response lasts <2 hours

PaO2 (on air) and/or

Normal
Test not usually
necessary

>60 mm Hg

<60 mm Hg
Possible cyanosis

PaCO2

<45 mm Hg

<45 mm Hg

>45 mm Hg:
Possible respiratory failure

SaO2% (on air)

>95%

91-95%

<90%

Respiratory arrest
imminen

Drowsy or confused

Asthma
Asthma Management
Management and
and Prevention
Prevention Program

Component 4: Manage Asthma

Exacerbations
Treatment of exacerbations depends on:
The patient
Experience of the health care professional
Therapies that are the most effective for
the particular patient
Availability of medications
Emergency facilities

Asthma
Asthma Management
Management and
and Prevention
Prevention Program

Component 4: Manage Asthma

Exacerbations
Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled
2-agonist
Early introduction of systemic
glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial
measures of lung function

Acute Bronchitis
Acute Exacerbations of Chronic
Bronchitis

Etiology
Associated with respiratory viruses, including
rhinovirus, coronavirus, inuenza viruses, and
adenovirus.
Mycoplasma pneumoniae,Chlamydia
pneumoniae, and Bordetella pertussis may also
cause bronchitis.
Secondary invasion with bacteria such as
Haemophilus inuenzae and Streptococcus
pneumoniae may also play a role in acute
bronchitis

Acute bronchitis
Acute bronchitis is an inammation of the
tracheobronchial tree, usually in association with a
generalized respiratory infection

Etiology
Table 1. List Of Pathogen As The Etiology Of Several Lung Infection

Clinical Findings
Cough is the most prominent manifestation of acute
bronchitis. Initially, the cough is nonproductive, but later
mucoid sputum is produced
Symptoms of tracheal involvement include burning
substernal pain associated with respiration and a very
painful substernal sensation with coughing

Clinical Findings
There are no signs of consolidation and the chest
radiograph shows no opacity

Management
If there is a predominant microorganism seen in the presence of
more than 25 polymorphonuclear neutrophils and fewer than 10
squamous epithelial cells per low-power eld
antibiotic therapy directed against S. pneumoniae and H. inuenzae
should be instituted

Most patients, however, do not require antibiotic therapy for acute

bronchitis; it is a self-limited disease

Management

Acute Bronchitis Management

Table 3. Recognized Causes of Acute Bronchitis and Options for Therapy

Pathogen (VIRUS)

Comments

Option for therapy

Influenza virus

Precipitous onset with fever, chills, headache,

and cough. Myalgias are common and may
be accompanied by myositis, myoglobinuria,
and
elevated serum levels of muscle enzymes.

Oseltamivir for 5 days at a dose

of 75 mg twice daily or
zanamivir for 5 days at a dose
of two puffs (5 mg/puff) twice
daily, for a total daily dose of 20
mg

Parainfluenzavirus

Epidemics may occur in autumn. Outbreaks

may occur in nursing homes. Croup in a child
at home suggests the presence of the
organism.

None available

Respiratory syncytial
virus

Family history is important: approximately

45% of family members exposed to an infant
(1 yr of age) with bronchiolitis become
infected. Outbreaks occur in winter or spring.
Twenty percent of adults have ear pain.

None available

Coronavirus

Pathogen can cause severe respiratory

symptoms in elderly patients. Epidemics of
strain 0C43 with high attack rates have been
reported among military recruits.

None available

Adenovirus

Infection is clinically similar to influenza, with

abrupt onset with fever

None available

Rhinovirus

Fever is uncommon, and infection is

generally mild

None available

Table 3. Recognized Causes of Acute Bronchitis and Options for Therapy (cont)
Pathogen
(ATYPICAL)

Comments

Option for therapy

Bordetella pertussis

Incubation period is 13 wk. Primarily

affects adolescents and young adults. In
some series, 10 to 20% of patients have
cough with a duration of
>2 wk.
Whooping occurs in a minority of patients.
Fever is uncommon. A marked
leukocytosis with lymphocytic
predominance can occur.

Macrolides as first-line therapy

Azithromycin for 5 days at a
dose of 500 mg on day 1 and
250 mg on days 25 or
Erythromycin for 14 days at a
dose of 500 mg 4 times daily
Clarithromycin for 7 days at a
dose of 500 mg twice daily
Second-line therapy
Trimethoprim-sulfamethoxazole
for 14 days at a dose of 1600
mg once daily or 800 mg twice
daily

Mycoplasma
pneumoniae

Incubation period is 23 wk. Gradual onset

(23 days) distinguishes this infection from
influenza. Clusters occur among military
recruits and students in boarding schools.

Azithromycin for 5 days at a dose

of 500 mg on day 1 and 250 mg on
days 25
or
doxycycline for 5 days at a dose of
100 mg twice daily or no therapy

Chlamydophila
pneumoniae

Incubation period is 3 wk. Onset of

symptoms, which include hoarseness
before cough, is gradual. Clusters reported
among military recruits, college students,
and patients in nursing homes.

Azithromycin for 5 days at a dose

of 500 mg on day 1 and 250 mg on
days 25
or
doxycycline for 5 days at a dose of
100 mg twice daily or no therapy

Acute Exacerbation of
Chronic Bronchitis (AECB)

Microbial
colonization
Bacterial
products

Bacterial
products

Airway
inflammation

Pathogenesis of
Chronic Bronchitis
(Balter et al, 2003)

Cigarette smoke
Viral infection

Impaired local
defense

Tissue
damage

Loss of cilia
Damaged
epithelium
Altered mucus
Local IgA
breakdown

AECB: Etiology
Role of bacteria considered leading cause
Other causes: viruses, allergens, pollution, increased
smoking

Clinical manifestations of bacterial vs nonbacterial

etiology indistinguishable
AECB
Core bacterial pathogens: H influenzae, S
pneumoniae, M catarrhalis
Complicated: Enterobacteriaceae
Severe: Pseudomonas spp, others
Role of atypicalsdebated, Chlamydia
File Jr TM. RTI Forum. 2006. Shanghai

AECB: Etiology
H. influenzae

S. pneumoniae

S. pneumoniae,
H. influenzae and
M. catarrhalis
account for ~80%
of bacterial isolates

18%
49%
Other

19%

14%
M. catarrhalis

Suwangool P. RTI Forum 2006. Shanghai

AECB Stratification
(Anthonisen et al, 1987)
Increased dyspnea
Increased Sputum
Sputum purulence
Type I:
all three
symptoms

Type II:
two
symptoms

Treat

Probably
Treat if
include
Purulence

Type III:
one
symptom

No
treat

Anthonisen NR et al. Ann Intern Med. 1987;106:196 .

Antibiotics in AECB: Results

% Deterioration

35
30
25

P < .05

20

Placebo

15

Antibiotic

10
5
0

All

Type 1

Type 2

Type 3

Type of Exacerbation
Anthonisen NR et al. Ann Intern Med. 1987;106:196.

RISK FACTORS:
Number of AECBs
Comorbidity
FEV1
Steroid use
Recent antibiotics

Balter MS, et al. Can Respir J. 2003;10(Suppl B):3B-32B.

Guidelines for management of AECB

I, Chronic bronchitis w/o
risk factors (Simple)
< 4 exacerbations/yr
No comorbid illness
FEV1 >50%

II, Chronic bronchitis w

Risk factors (Complicated)

III, Chronic suppurative

bronchitis

>4 exacerbations/yr

As in group II

Cardiac disease

FEV1 usually <35%

Multiple risk factors

FEV1 <50%
Home O2
Chronic oral steroids

H. influenzae
H. Spp
M. catarrhalis
S. pneumoniae

Ab use in past 3 mo
Group I plus
Klebsiella spp +
Other gram-negatives
Increased -lactam
resistance

Group II plus
P. Aeruginosa &
Multi-resistant
Enterobacteriaceae

Balter MS, et al. Can Respir J. 2003;10(Suppl B):3B-32B.

Guidelines for management of AECB

I, Chronic bronchitis w/o
risk factors (Simple)
< 4 exacerbations/yr
No comorbid illness
FEV1 >50%

II, Chronic bronchitis w

Risk factors (Complicated)

III, Chronic suppurative

bronchitis

>4 exacerbations/yr

As in group II

Cardiac disease

FEV1 usually <35%

FEV1 <50%

Multiple risk factors

Home O2
Chronic oral steroids

2nd generation macrolide

2nd/3rd cephalosporin,
Amoxicillin
Doxycycline
Trimeth/sulfameth

Ab use in past 3 mo
Fluoroquinolone
-lactam/-lactamase
inhibitor

Tailor to pathogen
Ciprofloxacin

Balter MS, et al. Can Respir J. 2003;10(Suppl B):3B-32B.

PNEUMONIA

Pneumonia Definition
An

acute infection of the pulmonary parenchyma that is

associated with at least some symptoms of acute infection,
accompanied by an acute infiltrate on CXR or auscultatory
findings consistent with pneumonia

Pneumonia
The

major cause of death in the world

The 6th most common cause of death in the U.S.
Annually in U.S.: 2-3 million cases, ~10 million physician
visits, 500,000 hospitalizations, 45,000 deaths, with average
mortality ~14% inpatient and <1% outpatient

Pneumonia - Symptoms

Cough (productive or nonproductive)

Dyspnea
Pleuritic chest pain
Fever or hypothermia
Myalgias

Chills/Sweats
Fatigue
Headache
Diarrhea (Legionella)
URI, sinusitis (Mycoplasma)

Findings on Exam
Physical:
Vitals:

Fever or hypothermia
Lung Exam: Crackles, rhonchi, dullness to percussion or egophany.

Labs:
Elevated

WBC
Hyponatremia Legionella pneumonia
Positive Cold-Agglutinin Mycoplasma pneumonia

Chest X-ray

RUL

LUL

RUL

Lingula

LUL

RML
RLL

Lingula

LLL

RML
RLL

LLL

Chest X-ray Pneumonia

Chest X-ray - Pneumonia

Chest X-ray -- Pneumonia

Types of Pneumonia

Community-Acquired (CAP)
Health-Care Associated Pneumonia (HCAP)

Hospitalization for > 2 days in the last 90 days

Residence in nursing home or long-term care facility
Home Infusion Therapy
Long-term dialysis within 30 days
Home Wound Care
Exposure to family members infected with MDR bacteria

Hospital-Acquired Pneumonia (HAP)

Pneumonia that develops after 5 days of hospitalization

Includes:

Ventilator-Associated Pneumonia (VAP)

Aspiration Pneumonia

Common Bugs for Pneumonia

Community-Acquired
Streptococcus pneumoniae
Mycoplasma pneumoniae
Chlamydophila psittaci or
pneumoniae
Legionella pneumophila
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Nocardia
Mycobacterium tuberculosis
Influenza
RSV
CMV
Histoplasma, Coccidioides,
Blastomycosis

HCAP or HAP
Pseudomonas aeruginosa
Staphylococcus aureus
(Including MRSA)
Klebsiella pneumoniae
Serratia marcescens
Acinetobacter baumanii

Diagnosis of pathogen
Sputum

Culture

< 10 Squamous Epithelial Cells

> 25 PMNs

Blood

Cultures
Strep. pneumo urinary antigen
Legionella urinary antigen
HIV test?

Special Clues on Chest X-ray

Lobar

pneumonia Strep. Pneumonia

Diffuse interstitial infiltrates Pneumocystis
RUL infiltrate Tuberculosis
Diffuse interstitial infiltrates Tuberculosis in HIV

Inpatient or Outpatient Treatment of CAP

Patients

safety at home
CURB-65 or PORT score
Clinical Judgement

Treatment of CAP
Outpatient:

Macrolide (Azithromycin)
Fluoroquinolone (Levofloxacine, Moxifloxacin)
Doxycycline

Inpatient:

Beta-Lactam + Macrolide
Ceftriaxone

+ Azithromycin

Fluoroquinolone
For

suspicion of highly resistant Strep. pneumoniae

Treatment of HCAP, HAP, VAP

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

Special Cases!

HIV
Pneumocystis jirovecii
Mycobacterium tuberculosis
Cryptococcus
Histoplasmosis

Transplant Patients
Fungi (Aspergillosis, Cryptococcus, Histoplasmosis)
Nocardia
CMV

Neutropenic Patients
Fungi ( Aspergillosis)
Gram-negatives

More Special Cases

Smokers: S. pneumo, H. influenzae, M.

catarrhalis
Alcoholics: S. pneumo, Klebsiella,
anaerobes
IV Drug User: S. aureus, Pneumocystis,
anaerobes
Splenectomy: encapsulated organisms
(S. pneumo, H. influenzae)
Cystic fibrosis: Pseudomonas, S.
aureus

Deer mouse exposure: Hantavirus

Bat exposure: Histoplasma capsulatum
Rat exposure: Yersinia pestis
Rabbit exposure: Francisella tularensis
Bird Exposure: C. psitacci,
Cryptococcus neoformans
Bioterrorism: Bacillus anthracis, F.
tularensis, Y. pestis

Tuberkulosis paru

INTRODUCTION

TUBERCULOSIS IS A CHRONIC INFECTIOUS DISEASE

CAUSED BY M.TUBERCULOSIS/M.BOVIS
MAINLY AFFECTING THE LUNG CAUSING PULMONARY TB
ALSO AFFECT OTHER PARTS CAUSING EXTRA
PULMONARY TB
CHARACTERIZED BY

Cough lasting > 3 weeks and not respond to usual antibiotic.

Production of purulent, sometimes blood- stained sputum
Evening rise of temp.
Night sweats
Weight loss

CHARECTERISTICS OF M. TUBERCULOSIS

gram positive bacilli

Non motile, non sporing,&

noncapsulated

Strict aerobes

Branching filamentous forms

fungal mycelium
=>MYCOBACTERIUM

A.F.B => when stained by Carbol

Fuschin by

Z-N Stain they resist

decolorisation by 25% H2S04 &
Absorb alcohol

Cell wall is lipid rich with mycolic

acid which is essential & unique
component

CAUSES

The primary cause of TB, mycobacterium tuberculosis , is a small

aerobic non-motile bacillus.

The m. Tuberculosis complex includes four other tb-causing

mycobacteria: M. bovis, M. africanum, M. canetti and M. microti. M.
africanum is not widespread, but in parts of Africa it is a significant
cause of tuberculosis.

The high lipid content of this pathogen accounts for many of its unique
clinical characteristics.

M. microti is mostly seen in immuno-deficient people, although it is

possible that the prevalence of this pathogen has been underestimated.

RISK FACTORS OF
TUBERCULOSIS
Low

socioeconomic status

Crowded

living conditions

Diseases

that weakens immune system like HIV

Person

on immunosuppresants like steroid

Health

care workers

Alcoholism
Recent

tubercular infection(within last 2 year)

HIV infection
Children exposed to high risk adults
Close

contacts of persons known or suspected to have active disease

Silicosis
Prolonged
Other
Low

corticosteroid therapy

immunosuppressive therapy

body weight (10%

Diabetes

mellitus

Residents
Patients

or more below the ideal)

and employees of

with CRF

high-risk congregate settings

Signs and symptoms:

When the disease becomes active, 75% of the

cases are pulmonary TB, that is, TB in the
lungs.

Symptoms include chest pain, coughing up

blood, and a productive, prolonged cough
for more than three weeks.

Systemic symptoms include

fever, chills, night sweats, appetite
loss, weight loss, pallor, and often a
tendency to fatigue very easily.
In the other 25% of active cases, the infection moves from the lungs, causing other kinds of
TB, collectively denoted extrapulmonary tuberculosis. This occurs more commonly
in immunosuppressed persons and young children.
Extrapulmonary infection sites include the pleura in tuberculosis pleurisy, the central
nervous system in meningitis, the lymphatic system in scrofula of the neck,
the genitourinary system in urogenital tuberculosis, and bones and joints in Pott's disease of
the spine.

Transmission of the disease

Pulmonary tuberculosis is a disease of respiratory

transmission, Patients with the active disease (bacilli)
expel them into the air by:

coughing,

sneezing,

shouting,

or any other way that will expel bacilli into the air

Transmission is dependent on closeness and time of

contact

Once inhaled by a tuberculin free person, the bacilli

multiply 4 -6 weeks and spreads throughout the body.
The bacilli implant in areas of high partial pressure of
oxygen:

lung

renal cortex

reticuloendothelial system

Evaluation for
TB
1.HIV test
2.Medical history
3.Physical examination
4.Bacteriologic or histologic
exam
(Chest radiograph if
indicated)

Medical History
HIV

status

Symptoms
History
Past

of disease

of TB exposure, infection, or disease

TB treatment

Demographic
Other

risk factors for TB

medical conditions that increase risk for TB

disease (e.g., diabetes)

Symptoms of
Pulmonary TB
Productive, prolonged
cough
(duration of 2-3 weeks)
Chest pain
Hemoptysis (bloody
sputum)
Signs may vary based on
HIV status

Specimen Collection
Procedure
Obtain 3 sputum specimens for
smear examination
and culture

Spot, first morning, spot

Follow infection control
precautions during
specimen collection

Alur Diagnosis
TB Paru

Be
carefully
with the
imaging
interpreta
tion

Klasifikasi penyakit TB paru

Berdasarkan hasil pemeriksaan dahak (BTA) TB paru dibagi atas:
TB paru BTA (+)

Sekurang-kurangnya 2 dari 3 spesimen dahak menunjukkan hasil BTA positif.

Hasil pemeriksaan satu spesimen dahak menunjukkan BTA positif dan kelainan
radiologi menunjukkan gambaran tuberkulosis aktif. Hasil pemeriksaan satu
spesimen dahak menunjukkan BTA positif dan biakan positif.

TB paru BTA (-).

Hasil pemeriksaan dahak 3 kali menunjukkan BTA negatif, gambaran klinis dan
kelainan radiologi menunjukkan TB aktif. Hasil pemeriksan dahak 3 kali
menunjukkan BTA negatif dan biakan M. TB positif.

Klasifikasi penyakit TB paru

Berdasarkan tipe pasien TB paru dibagi atas:
Kasus Baru.

Adalah pasien yang belum pernah mendapat pengobatan dengan OAT atau sudah
pernah mendapat OAT kurang dari satu bulan.

Kasus kambuh (relaps).

Adalah pasien TB yang sebelumnnya pernah mendapat pengobatan TB dan telah

dinyatakan sembuh atau pengobatan lengkap kemudian kembali lagi berobat
dengan pemeriksaan dahak BTA positif atau biakan positif. Bila BTA negatif atau
biakan negatif tetapi gambaran radiologi dicurigai lesi aktif / perburukan dan
terdapat gejala klinis maka harus dipikirkan beberapa kemungkinan:

Lesi non-TB (pneumonia, bronkiektasis, jamur, keganasan).

TB paru kambuh yang ditentukan oleh dokter spesialis yang berkompeten menangani kasus TB.

Kasus putus obat (drop out)

Adalah pasien yang telah menjalani pengobatan 1 bulan dan tidak mengambil
obat 2 bulan berturut-turut atau lebih sebelum masa pengobatan selesai.

Klasifikasi penyakit TB paru

Berdasarkan tipe pasien TB paru dibagi atas:
Kasus gagal.

Adalah pasien BTA positif yang masih tetap positif pad akhir bulan ke-5 atau akhir
pengobatan.

Kasus kronik.

Adalah pasien dengan hasil pemeriksaan BTA masih positif setelah selesai
pengobatan ulang dengan pengobatan kategori 2 dengan pengawasan yang baik.

Kasus bekas TB.

Hasil pemeriksaan BTA negatif dan biakan juga negatif dan gambaran radiologi
paru menunjukkan lesi TB yang tidak aktif, atau foto serial menunjukkan gambaran
yang menetap. Riwayat pengobatan OAT adekuat akan lebih mendukung. Pada
kasus dengan gambaran radiologi meragukan dan telah mendapat pengobatan
OAT 2 bulan serta foto toraks ulang tidak ada gambaran radiologi.

TREATING TB DISEASE
(GENERAL PRINCIPLES)

Always treat with multiple drugs.

Never add a single drug to a failing regimen.

DOTS (Directly Observed Treatment Shortcourse) is given.

Treatment course depends on the categories of the patient.

Usually 6 months, sometimes 9 months.

Four drugs for two months.

Isoniazid Rifampicin Ethambutol - Pyrazinamide

Two drugs for four or seven months.

Isoniazid - Rifampicin

MEDICAL MANAGEMENT

PULMONARY TB is treated primarily with antituberculosis

agents for 6 to 12 months.

First Line Antitubercular Medications

Streptomycin

15mg/kg

Isoniazid

or INH(Nydrazid) 5 mg/kg(300 mg max perday)

Rifampin

10 mg/kg

Pyrazinamide

15 30 mg/kg

Ethambutol(Myambutol)

15 -25 mg/kg daily for 8 weeks and

continuing for up to 4 to 7 months

MEDICAL MANAGEMENT
Second Line Medications .
Capreomycin
Ethionamide

12 -15 mg/kg
15mg/kg

Paraaminosalycilate
Cycloserine
Vitamin

sodium 200 -300 mg/kg

15 mg/kg

b(pyridoxine) usually adminstered

with INH

MEDICAL MANAGEMENT
Third

Line Drugs

Other

drugs that may be useful, but are not on the

WHO list of SLDs:

Rifabutin
Macrolides:e.g.,clarithromycin
Linezolid(LZD)
Thioacetazone(T)
Thioridazine
Arginine

(CLR)

Paduan obat OAT dan

peruntukannya
Kategori 1 (2HRZE/4RH) / (2HRZE/4H3R3)

Paduan obat ini diberikan untuk pasien baru:

Pasien baru TB paru BTA positif.

Pasien TB paru BTA negatif foto toraks positif.

Pasien TB ekstra paru.

Kategori 2 (2HRZES/HRZE/5H3R3E3)

Paduan obat ini diberikan untuk pasien BTA positif yang telah diobati sebelumnya :

Pasien kambuh

Pasien gagal

Pasien dengan pengobatan setelah terputus.

Recommended Doses (Per Kg Body Weight) Of Essential

Anti-tuberculosis Drugs
Anti-tuberculosis
drug

Mode of action

Recommended dose (mg/kg)

Daily

3 x per week

5 (4-6)a
Bactericidal
Isoniazid (H)

Bactericidal

Rifampicin (R)

Bactericidal

Pyrazinamide (P)
Ethambutol (E)
Streptomycin (S)
Thioacetazone (T)

Bacteriostatic
Bactericidal
Bacteriostatic

10 (8-12)

10 (8-12)

10 (8-12)

25 (20-30)

35 (30-40)

15 (15-20)

30 (25-35)

15 (12-18)

15 (12-18)

2.5

Not applicable

Standar
Terapi

Standar
Terapi
Dosis Standar
(mg/kg)
Periksa BB pasien

Standar
Terapi
Dosis Standar
(mg/kg)

THANK YOU