FOTO

CURRICULUM VITAE
WAHYUNI INDAWATI,MD
EDUCATION :
Medical Doctor and Pediatrician in Cipto Mangunkusumo Hospital Faculty of Medicine Universitas of Indonesia
Consultant Pediatric Respirologist in Cipto Mangunkusumo Hospital Faculty of Medicine Universitas of Indonesia
TRAINING :
Cystic Fibrosis : Sophia Children Hospital Rotterdam, Netherlands
Bronchoscopy : NUH Singapore and Hongkong University, Cipto Mangunkusumo Hospital
Pediatric TB : Stellenbosch University South Africa
POSITION : Medical Staff of Respirology Division Child Health Department Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia
ORGANIZATION :
Secretary of Community Affair Indonesian Pediatric Society 2011-2014
Secretary of Respirology Working Group Indonesian Pediatric Society 2017-2020
Secretary of Pediatric Pharmacy Taskforce 2017-2020
Member of National Childhood TB Working Group- MoH
Boardmember of Asian Pediatric Interventional Pulmonology Association (APIPA)
Member of American Thoracic Society and European Respiratory Society
Member of World Association Bronchology and Interventional Pulmonology
COMMUNITY ACQUIRED
PNEUMONIA IN DAILY
PRACTICE : HAVE WE
SELECTED THE PROPER
MODALITIES?
WAHYUNI INDAWATI
RESPIROLOGY DIVISION CHILD HEALTH DEPARTMENT
CIPTO MANGUNKUSUMO HOSPITAL
FACULTY OF MEDICINE UNIVERSITAS INDONESIA
 In loving memory
Of a life so beautifully lifed and a heart so
deeply loved

Dr. Nastiti Noenoeng Rahajoe, Sp.A(K)

February 2, 1938 – August 28, 2020
GLOBAL DEATH AMONG CHILDREN UNDER FIVE

Pneumonia is the main killer in children under 5

Pneumonia Pneumonia
(post-neonatal), 13% (neonatal), 3%

The United Nations Children's Fund (UNICEF). Comitting to Child Survival: A Progress Renewed. Progress Report 2015. UNICEF. September 2015.
http://www.unicef.org/publications/index_83078.html. Accessed January 22, 2016
 INDONESIA AND PNEUMONIA
Top countries with Pneumonia
• Indonesia is one of the 10 countries with
the highest number of under-five deaths
in 2015
• And 14% of death among children under
five in Indonesia due to Pneumonia

In Indonesia EVERY HOUR

2-3 children under-five died
due to pneumonia

The United Nations Children's Fund (UNICEF). Comitting to Child Survival: A Progress
Renewed. Progress Report 2015. UNICEF. September 2015.
http://www.unicef.org/publications/index_83078.html. Accessed January 22, 2016

Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE) provisional estimates 2015
COVID-19 UPDATE
SITUATION 9.5%

(3 SEPTEMBER 2020) (17.505)

1.9%
(147)

https://www.who.int/emergencies/diseases/novel-coronavirus-2019
https://covid19.go.id/peta-sebaran
Child deaths from COVID-19= 0.84%
 PNEUMONIA
Inflammation of the lung parenchyme

parenchyme: alveoli & interstitial tisue

Infection, aspiration, radiation, ...

7
DEFINITION
 Pneumonia is defined as an acute lower respiratory infection (ALRI)
typically associated with :
o fever,
o respiratory symptoms,
o and evidence of parenchymal involvement
 by either physical examination
 or the presence of infiltrates on chest radiography.

Gereige RS, Laufer PM. Pneumonia. Peds in Rev 2013

8
1 Acute upper
resp infection

2 Bacteremia

3 Adjacent org

Pathogenesis
9
PNEUMONIA, SYMPTOMS

Respiratory
symptoms
Infection

10
SIMPLE CLINICAL MANIFESTATION
Entry: cough
 Fast breathing
Age respiratory rate
< 2 mo 60
2 - 12 mo 50
1 - 5 yr 40

 Chest indrawing
WHO PNEUMONIA CLASSIFICATION
Entry: Cough
Signs Classification
• No fast breathing Other respiratory illness
• Fast breathing Pneumonia
•Fast breathing Severe pneumonia
•Chest indrawing
• Severe resp distress Very severe pneumonia
• Central cyanosis
• Not able to drink
WHO, Hosp care for children, 2007
(Palafox et al. Arch Dis Child 2000;82 :41-5)
 Acute lower respiratory infection

symptom
Pneumonia  volume  V
pathophys
 V/Q mismatch  diffusion
 hypoxemia  hypoxia
 compensation  WoB
pathology

adaptive
response

Insult pathophysiology
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OXYGEN SATURATION
Detection of hypoxemia
◼ Blood gas analysis
◼ Pulse oxymetry

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PNEUMONIA, PATHOLOGY

www.medicsindex.ning.com 16
WHEN TO PERFORM CHEST X RAY?

Hazir T, et al. BMJ 2006:1-4

Lakhanpaul M, Atkinson M, Stephenson T. Community Acquired
Pneumonia in Children: A clinical update.
OTHER INVESTIGATION
EPIDEMIOLOGY ETIOLOGY

60%
bacterial

Pediatrics 2004; 113:701-701

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EPIDEMIOLOGY, AGE - ETIOLOGY

Pediatrics 2004; 113:701-701

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CAP PATHOGEN ACCORDING TO AGE
Neonates 1-2 months 3-12 months 1-5 years >5 years
Streptococcus Chlamydia Viruses Viruses S pneumoniae
group B trachomatis
Enteric gram Ureaplasma Streptococcus S pneumoniae M pneumoniae
negative urealyticum pneumoniae
Viruses H influenzae Mycoplasma C pneumoniae
pneumoniae
Bordetella Staphylococcus Chlamydia
pertussis aureus pneumoniae
Moraxella
catharrhalis

Disorders of resp tract in children, Kendig’s, 2012

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TREATMENT OF CAP

 Treatment decision, indication

 Respiratory management, oxygen therapy
 Antibiotic therapy
 Other supportive care
TREATMENT DECISIONS

 Based on :
 Etiology of the infectious
 Antibiotic must be targeted
organism  The likely organism
 The age
 Bearing in mind the age
 Clinical status (severity of
illness)  The history of exposure

 Local susceptibility patterns  The possibility of

of common pathogens resistance
 Socioeconomic conditions  Other pertinent history
CRITERIA FOR HOSPITALIZATION
1. Children aged <3 mo
2. Fever (>38.50 C), refusal to feed and vomiting, dehydration
3. Respiratory distress & oxygen requirement
4. Systemic manifestation
5. Failure of previous antibiotic therapy
6. Recurrent pneumonia
7. Severe underlying disorders (i.e. immunodef, CLD)
8. Non compliant patient/parent

Guideline CAP:Pediatric, Alberta medical association, 2001

British Thoracic Society guidelines for the management of CAP in children, 2011
CARE OF CHILD WITH CAP
Admitted to PICU
Hospitalization
 Requires invasive ventilation
• Moderate to severe CAP
 Requires use noninvasive positive
• The age less than 3-6 months pressure ventilation
• Suspected or documented  Impending respiratory failure
cause by pathogen with  Has sustained tachycardia, inadequate
increase virulence (CA- blood pressure or need for
MRSA) pharmacologic support of blood
pressure or perfusion
• Who are unable to comply
with therapy and to be  Has the pulse oximetry < 92% on
inspired oxygen of ≥ 0,5
followed up
 Has altered mental status due to
hypercarbia or hypoxemia
RESPIRATORY MANAGEMENT

 Initial priorities: the identification & treatment of

 Respiratory distress, hypoxemia and hypercarbia
 Grunting, flaring, severe tachypnea and retractions

→ should prompt immediate respiratory support

OXYGEN THERAPY

 Agitation may be an indicator that a child is hypoxic. [IVb]

 Patients whose oxygen saturation is ≤ 92% while breathing
air should be treated with oxygen given by nasal cannulae,
high-flow delivery device, head box or face mask to maintain
oxygen saturation >92%. [B]
ANTIBIOTIC THERAPY
 Bacterial pneumonia cannot be reliably distinguished from viral
pneumonia on the basis of any single parameter; clinical, laboratory or
chest radiograph findings
 Whether to treat with antibiotics? giving antibiotic for pneumonia in
children is justified and rational in Indonesia
 Which antibiotic and by which route?
 When to change to oral treatment if intravenous treatment Initiated?
 Duration of treatment?
ANTIBIOTIC CHOICES
We found that for outpatient treatment of pneumonia,
oral amoxycillin in children with severe pneumonia
without hypoxia and who are feeding well, may be
effective
2013

Review 2016:
No new evidence
2014 to change
Amoxicillin is the antibiotic of choice
ANTIBIOTIC, WHO 2014
AGE CATEGORY OF TREATMENT DURATION
PNEUMONIA
Children Fast breathing oral amoxicillin: at least 40 5 days
no chest indrawing mg/kg/dose twice daily 3 days In areas with low
no general danger sign (80mg/kg/day) HIV prevalence

2–59 months Severe pneumonia first-line treatment.

(chest indrawing) — Ampicillin: 50 mg/kg, or benzyl at least five days
HIV (-) penicillin: 50 000 units per kg
IM/IV every 6 hours
— Gentamicin: 7.5 mg/kg IM/IV
once a day at least five days
Second – line
Ceftriaxone
(50–100 mg/kg/day every 12–24
hours
HIV INFECTION/ EXPOSURE TO HIV

 Treat as for severe pneumonia

 Ampicillin plus gentamicin IM or IV for 10 days

 If does not improve within 48 h

 Ceftriaxone 80 mg/kg IV once daily
 If ceftriaxone is not available : Gentamicin plus cloxacillin

 For children age < 12 months

 High-dose cotrimoxazole (8 mg/kg trimethoprim) IV or Orally 3 times a day for 3 weeks

 For children age 12 – 59 months

 Treatment PCP if there are clinical signs of PCP
ANTIBIOTIC CHOICES
Outpatient
 Almost all national and international childhood
pneumonia guideline recommends amoxicillin as
the first line antibiotic, for all ages
o Efficacy against streptococcus
o Safety profile
o Availability
o Price
 For school age – atypical agent – macrolides
 Allergy: cephalosporin 2nd or 3rd gen, clindamycin
or macrolides
ANTIBIOTIC TREATMENT
Empirical antibiotic → local resistance rates

Clinical improvement does not occur

Re-evaluation:
Complication, resistance, and etiology

Consider the turn of antibiotics,

selection in accordance with the
evaluation results
RESPONSE MONITORING
 Late improvement, no improvement, or
 Adequate antibiotic, clinical response in getting worse
the first 48-72 hours o Antibiotic: not right choice? Dosage?
o Fever subside, gradually Delivery? Resistance?
o Dyspnea getting better o Comorbidities?
o Decrease oxygen need o Complications?
o Sleep better  Re-exam
 Clinical improvement: no need any o Laboratory markers
supporting examination o CXR
 Change 2nd line, or add macrolide
SUPPORTIVE CARE

Paracetamol if high
- To ensure optimal fever
oxygen delivery
-Gentle suction any
thick secretion
Daily maintenance fluid :
- Fluids appropriate his or her age but avoid
over hydration
- Encourage breastfeeding and oral fluids
If wheeze is present, give - If cannot drink, insert a nasogastric tube/ NGT
rapid-acting bronchodilator
and start steroid when - Ensure normal level of Hb
appropriate - Delivery of adequate of glucose, electrolyte
balance and other
FRAMEWORK OF PNEUMONIA CONTROL
SUMMARY
 Pneumonia is still a major morbidity and mortality in children all over the
world especially developing countries
 The main diagnostic modality is clinical sign (lower respiratory infection
symptoms with evidence of hypoxemia)
 Other supportive diagnostic modality should use properly
 Treatment modality consist of supportive care and Antibiotic
 Judicious antibiotic choices should be based on age and common pathogen
 Penicillin based ( Amoxicillin/ Ampicillin ) and Macrolides are still drug of
choices of community acquired pneumonia in children
THANK YOU