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SINDROMA “CROUP” B.RUDYANTO B.RUDYANTO Divisi Respirologi Bagian Ilmu Kesehatan Divisi Respirologi Bagian Ilmu Kesehatan Anak Anak FK UHT/RSAL DR. RAMELAN FK UHT/RSAL DR. RAMELAN Surabaya Surabaya

CROUP Kuliah 2006

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Page 1: CROUP Kuliah 2006

SINDROMA “CROUP”

B.RUDYANTOB.RUDYANTO

Divisi Respirologi Bagian Ilmu Kesehatan AnakDivisi Respirologi Bagian Ilmu Kesehatan Anak

FK UHT/RSAL DR. RAMELANFK UHT/RSAL DR. RAMELAN

SurabayaSurabaya

Page 2: CROUP Kuliah 2006

DefiniDefinisi Sindroma CROUPsi Sindroma CROUP

Kelompok penyakit pada laring, Kelompok penyakit pada laring, trakea dan bronkustrakea dan bronkus

Terutama disebabkan virusTerutama disebabkan virus CCiri khas : iri khas : batuk, suara parau, batuk, suara parau,

stridor inspiratoirstridor inspiratoir

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ISPA ATAS•Common cold

•Faringitis

•Sinusitis

•Otitis media

•CROUP

ISPA BAWAH

•Bronkitis

•Bronkiolitis

•Pneumonia

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Epidemiologi Sindroma CROUP

•Usia terbanyak : 3 bulan- 4 tahun•Gejala klinis berat dibawah usia 3 tahun•Anak laki-laki lebih sering•Lama sakit : 5 – 6 hari•Puncak : musim dingin/ hujan

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Croup: Epidemiologi

Page 7: CROUP Kuliah 2006

PATOFISIOLOGI SINDROMA CROUP

INFEKSIINFEKSI

MEKANISMEKANIS

ALERGIALERGI

SPASME + SEMBAB LARINGSPASME + SEMBAB LARING

OBSTRUKSI SALURAN NAPASOBSTRUKSI SALURAN NAPAS

ATASATAS

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PatogenesisPatogenesis Sindroma CROUP Sindroma CROUP

Penyempitan subglotis karena Penyempitan subglotis karena inflamasi.inflamasi.

““Cricoid ring” menyebabkan Cricoid ring” menyebabkan penyempitan.penyempitan.

Pembengkakan 1mm Pembengkakan 1mm menyebabkan obstruksi 65% pada menyebabkan obstruksi 65% pada bayi.bayi.

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PatogenesisPatogenesis Sindroma CROUP Sindroma CROUP

Atelektasis/mucus pluggingAtelektasis/mucus plugging Ventilation/perfusion mismatchVentilation/perfusion mismatch Tekanan negatif intrapleura Tekanan negatif intrapleura

menyebabkan edema paru.menyebabkan edema paru. Hipoksia/hiperkarbiaHipoksia/hiperkarbia

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PENYEBAB SINDROMA CROUP

INFEKSI : terbanyak infeksi virusINFEKSI : terbanyak infeksi virus

Bakteri : H. influenza , C.diphteriBakteri : H. influenza , C.diphteri

Virus: P. influenza 1,2,3, Infuenza,Virus: P. influenza 1,2,3, Infuenza,

Adeno, Entero, RSV, morbilli Adeno, Entero, RSV, morbilli

. MEKANIK: Benda asing. MEKANIK: Benda asing

Pasca pembedahanPasca pembedahan

Penekanan masa ekstrinsikPenekanan masa ekstrinsik . ALERGI : Sembab angioneurotik. ALERGI : Sembab angioneurotik

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Penyebab CROUP: Infeksi.....

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GEJALA KLINIS SINDROMA CROUP

MULAI SUARA SERAK,MULAI SUARA SERAK, BATUK MENGGONGGONGBATUK MENGGONGGONG STRIDOR INSPIRATOIRSTRIDOR INSPIRATOIRBILA OBSTRUKSI > STRIDOR >>BILA OBSTRUKSI > STRIDOR >>JIKA PAYAH : STRIDOR MELEMAHJIKA PAYAH : STRIDOR MELEMAH

RETRAKSI SUPRAKLAVIKULAR,SUPRASTERNAL,RETRAKSI SUPRAKLAVIKULAR,SUPRASTERNAL, INTERKOSTAL,EPIGASTRIALINTERKOSTAL,EPIGASTRIAL

HIPOKSIA GELISAH, JIKA PAYAH : DIAMHIPOKSIA GELISAH, JIKA PAYAH : DIAMBERTAMBAH BERAT : GAGAL NAPASBERTAMBAH BERAT : GAGAL NAPAS

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Anatomi & Etiologi Stridor

ExtratExtratorakalorakal• SupraglotSupraglotisis

–Epiglotitis, Epiglotitis, abses abses retroretroffararinging, di, diffteriateria

• GlotiGlotiss & Subgloti & Subglotiss–Croup, larCroup, lariingomalangomalassia, traia, trakkeomalaeomalassia, ia,

paralysisparalysis pita suara pita suara IntratoraIntratorakalkal

–Vascular rings/webs, Vascular rings/webs, Benda asingBenda asing, , penekanan karena tumor/ kelenjar getah penekanan karena tumor/ kelenjar getah beningbening

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Grading of Stridor

Grade 1Grade 1 Inspiratory obstruction only. A dry Inspiratory obstruction only. A dry barking barking cough, but the cry is not affectedcough, but the cry is not affected

Grade 2Grade 2 Inspiratory and mild expiratory Inspiratory and mild expiratory obstruction obstruction (i.e. expiratory stridor and/or (i.e. expiratory stridor and/or prolonged prolonged expiration)expiration)

Grade 3Grade 3 Inspiratory and active expiratory Inspiratory and active expiratory obstruction (i.e. visible or palpable contraction of the obstruction (i.e. visible or palpable contraction of the abdominal muscles), or pulsus paradoxicus abdominal muscles), or pulsus paradoxicus (pulse (pulse at wrist becomes softer on inspiration)at wrist becomes softer on inspiration)

Grade 4Grade 4 Marked retractions, apathy, cyanosisMarked retractions, apathy, cyanosis

Continued...

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Grading of Stridor (Contd…)

Croup of Grade 2 or greater Croup of Grade 2 or greater requires treatment in hospital. requires treatment in hospital. Remember that this grading Remember that this grading assesses degree of obstruction assesses degree of obstruction to breathing and not the stridor. to breathing and not the stridor. Stridor may become softer as Stridor may become softer as the obstruction increases.the obstruction increases.

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5 PENYAKIT CROUP OLEH KARENA INFEKSI

LARINGITIS DIFTERIALARINGITIS DIFTERIA EPIGLOTITIS AKUTAEPIGLOTITIS AKUTA LARINGITIS AKUTALARINGITIS AKUTA LARINGOTRAKEOBRONKITIS LARINGOTRAKEOBRONKITIS

AKUTAAKUTA LARINGITIS SPASMODIKLARINGITIS SPASMODIK

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EPIGLOTITIS AKUT

• DEFINISI : KERADANGAN AKUT EPIGLOTIS,• BIASA DISEBABKAN OLEH INFEKSI

BAKTERI

= BACTERIAL CROUP

= SUPRAGLOTTIC CROUP• ETIOLOGI :TERBANYAK H. INFLUENZA B• UMUR : 3 – 7 TAHUN• MERUPAKAN KEADAAN GAWAT DARURAT,

DIAGNOSIS HARUS SECEPAT MUNGKIN• TERAPI YANG CEPAT DAN TEPAT, DAPAT

MENURUNKAN KEMATIAN

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EpiglotitisEpiglotitis

Etiologi:

Haemophilus influenza

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GEJALA KLINIS EPIGLOTITIS :

- MENDADAK PANAS TINGGI

- STRIDOR INSPIRATOIR + RETRAKSI

CEPAT TIMBUL

- NYERI EPIGLOTIS : SUARA KECIL (PELAN), NYERI TELAN

- “TOKSIS”, SAKIT KERAS, TAKUT , “NGILER “,

GELISAH, SIANOSIS

- EPIGLOTIS BENGKAK DAN MERAH SEPERTI

BUAH CHERRY

- DAPAT CEPAT TERJADI : GAGAL NAPAS

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Epiglotitis

GbrGbr kiri: Obstruksi total saluran napas ataskiri: Obstruksi total saluran napas atas

Gbr kanan: Saluran napas terbuka setelahGbr kanan: Saluran napas terbuka setelah

dilakukan intubasidilakukan intubasi

Do Do notnot look in throat look in throatDo Do notnot use obstructed airway maneuver use obstructed airway maneuver

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DIAGNOSIS EPIGLOTITIS:

- GEJALA KLINIS - PEMERIKSAAN FISIK - FOTO LEHER LATERAL: OBSTRUKSI SUPRAGLOTIS KARENA PEMBENGKAKAN EPIGLOTIS (THUMB SIGN)

LABORATORIUM: LEKOSIT MENINGKAT,

PERGESERAN KE KIRI

HAPUSAN TENGGOROKAN +

BIAKAN DARAH :

H. INFLUENZAE TIPE B

Page 22: CROUP Kuliah 2006

Comparison of the Features of Epiglottitis and

Croup CharacteristicCharacteristic EpiglottitisEpiglottitis CroupCroup

AgeAge Any ageAny age 6months-12yrs6months-12yrs

OnsetOnset SuddenSudden GradualGradual

LocationLocation SupraglotticSupraglottic SubglotticSubglottic

TemperatureTemperature High feverHigh fever Low-grade feverLow-grade fever

DysphagiaDysphagia SevereSevere Mild or absentMild or absent

DyspneaDyspnea PresentPresent PresentPresent

DroolingDrooling PresentPresent PresentPresent

CoughCough UncommonUncommon Characteristic coughCharacteristic cough

PositionPosition Leaning forward, Leaning forward, mouth openmouth open

comfortablecomfortable

X-RayX-Ray Thumb signThumb sign Steeple signSteeple sign

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Foto Leher AP dan lateral

Thumb Sign

Can be found in normal childrenOnly seen in 50% with epiglottitis

Can be seen in all children during inspirationSeen in less than 50% of Croup cases

Steeple Sign

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TATALAKSANA EPIGLOTITIS AKUT :

MRS DI ICU

-CAIRAN I.V. + O2 + UAP + STEROID

-ANTIBIOTIKA: AMPISILIN 100 MG/KG/24 JAM IV, 4 X SEHARI

ATAU KLORAMFENIKOL : 50 MG/KG/24JAM IV,

4 X SEHARI

ATAU SEFALOSPORIN GEN 3 (CEFOTAKSIM ATAU

CEFTRIAKSON )

-ANTIPIRETIK

-SERING : MEMERLUKAN TRAKEOSTOMI

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LARINGITIS AKUT / LARINGO-TRAKEO-LARINGITIS AKUT / LARINGO-TRAKEO-BRONKITIS AKUTABRONKITIS AKUTA

DEFINISI: Keradangan pada laring/ laring-trakea-DEFINISI: Keradangan pada laring/ laring-trakea-

bronkusbronkus

ETIOLOGI: penyebab >>> virus,ETIOLOGI: penyebab >>> virus,

70% V. Para influenza, V ,Influenza, 70% V. Para influenza, V ,Influenza,

adenovirus , RSV, V. morbilliadenovirus , RSV, V. morbilli

UMUR : 3 bulan – 5 tahunUMUR : 3 bulan – 5 tahun

PADA LTB : dapat terjadi infeksi sekunder karenaPADA LTB : dapat terjadi infeksi sekunder karena

bakteribakteri

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GEJALA KLINIS LARINGITIS AKUTA

SERING PADA ANAK, BIASANYA RINGANSERING PADA ANAK, BIASANYA RINGAN SELALU DIDAHULUI ISPA ATASSELALU DIDAHULUI ISPA ATAS GEJALA KLINIS : PANAS, PILEK,BATUK 2 – 3 GEJALA KLINIS : PANAS, PILEK,BATUK 2 – 3

HARI, MENDADAK SUARA PARAU, BATUKHARI, MENDADAK SUARA PARAU, BATUK

MENGGONGGONG, STRIDOR INSPIRATOIRMENGGONGGONG, STRIDOR INSPIRATOIR KESUKARAN NAPAS : TIDAK BERATKESUKARAN NAPAS : TIDAK BERAT FARING : HIPERAEMIFARING : HIPERAEMI

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GEJALA KLINIS LARINGO-TRAKEO-BRONKITIS AKUT

PENYAKIT MENJALAR KE BRONKUSPENYAKIT MENJALAR KE BRONKUS

KESUKARAN BERNAPAS >>>KESUKARAN BERNAPAS >>>

PANAS PANAS

FISIS : TANDA-TANDA BRONKITISFISIS : TANDA-TANDA BRONKITIS

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DIAGNOSIS LA/LTBA

BERDASARKAN GEJALA KLINISBERDASARKAN GEJALA KLINIS

PEMERIKSAAN FISISPEMERIKSAAN FISIS X FOTO LEHER : PEMBENGKAKAN JARINGAN X FOTO LEHER : PEMBENGKAKAN JARINGAN

SUBGLOTISSUBGLOTIS LABORATORIUM: DARAH : NORMALLABORATORIUM: DARAH : NORMAL

JIKA INF. SEKUNDER BAKTERIJIKA INF. SEKUNDER BAKTERI

LEKOSITLEKOSIT

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DIAGNOSIS LA/LTBA

Foto leher AP:

“steeple sign”

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Tatalaksana LA / LTBTatalaksana LA / LTB

UAPUAP• NaCl fisiologisNaCl fisiologis

Nebulisasi Recemic EpinephrineNebulisasi Recemic Epinephrine• Gd II + stridorGd II + stridor

DEDEKSKSAMETASONAMETASON• IV / IIV / IM M / PO / PO – 0.6 mg/kg– 0.6 mg/kg• NEBNEBULISASI BUDESONIDEULISASI BUDESONIDE / FLUTIKASON/ FLUTIKASON• PREDNISOLONPREDNISOLON

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TATALAKSANA LA/LTBA

UMUMNYA TIDAK PERLU MRSUMUMNYA TIDAK PERLU MRS LA: TIDAK PERLU ANTIBIOTIKALA: TIDAK PERLU ANTIBIOTIKA LTBA: DAPAT DIBERI PENISILIN +/ KLORAMF.LTBA: DAPAT DIBERI PENISILIN +/ KLORAMF. UAP/NEBULASI:BILA ADA RACEMIC EPINEFRINUAP/NEBULASI:BILA ADA RACEMIC EPINEFRIN ANTIPIRETIK : BILA PERLUANTIPIRETIK : BILA PERLU SAKIT BERAT: MRS : O2 +UAP, CAIRAN IVSAKIT BERAT: MRS : O2 +UAP, CAIRAN IV AMPISILIN IVAMPISILIN IV STEROID: DEKSAMETASON IVSTEROID: DEKSAMETASON IV 0,5 mg/kg/24 jam, 3 X/hari 1-2 hari0,5 mg/kg/24 jam, 3 X/hari 1-2 hariJARANG : TRAKEOSTOMIJARANG : TRAKEOSTOMI

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SPASMODIC LARYNGITIS(ALLERGIC CROUP, PSEUDO CROUP )

ETIOLOGI : VIRUSETIOLOGI : VIRUS

ALERGIALERGI

FAKTOR PSIKOLOGISFAKTOR PSIKOLOGIS UMUR : 1 - 3 TAHUNUMUR : 1 - 3 TAHUN KLINIS: Bisa pilek/serak atau tanpa pilek/serakKLINIS: Bisa pilek/serak atau tanpa pilek/serak

malam batuk menggonggong,stridor insp, malam batuk menggonggong,stridor insp,

gelisah, tanpa panasgelisah, tanpa panas

gejala : pagi berkurang, malam menghebatgejala : pagi berkurang, malam menghebat

berulang-ulang, ada predisposisi keluargaberulang-ulang, ada predisposisi keluarga

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SPASMODIC LARYNGITIS

DIAGNOSIS: KLINIS DAN PEMERIKSAAN DIAGNOSIS: KLINIS DAN PEMERIKSAAN FISIS, LABORATORIUM : NORMALFISIS, LABORATORIUM : NORMAL

PENGOBATANPENGOBATAN

Tidak perlu rawat inap, tidak perlu Tidak perlu rawat inap, tidak perlu

antibiotikaantibiotika

Yang penting : pemberian uapYang penting : pemberian uap

SSeringkalieringkali setelah muntah, laringospasmussetelah muntah, laringospasmus

hilanghilang

Page 34: CROUP Kuliah 2006

CaseCase

An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation

The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier

Page 35: CROUP Kuliah 2006

CaseCase

An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation. No resp. Distress.

The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier

Mild disease, doesn’t need admission

Page 36: CROUP Kuliah 2006

Case

An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation

The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier

Mild disease, doesn’t need admission

Bronchodialators not indicated in Croup

Page 37: CROUP Kuliah 2006

CaseCase

An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation

The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier

Mild disease, doesn’t need admission

Bronchodialators not indicated in Croup

antibiotics if there is an indication

Page 38: CROUP Kuliah 2006

Case

An 18 month old infant has had a hoarse, barking cough, rhinorrhea and a low-grade fever for 3 days; He develops stridor when agitated. Findings include: rectal temp 38.3oC, RR 28, and inspiratory stridor on auscultation

The BEST course of management for this patient isA.A. Nebulized bronchodilatorNebulized bronchodilatorB.B. Oral antibioticOral antibioticC.C. Oral bronchodilatorOral bronchodilatorD.D. Observation in the hospitalObservation in the hospitalE.E. Use of a cool mist humidifierUse of a cool mist humidifier

Treatment of choice for mild croup despite lack of

supporting evidence

Page 39: CROUP Kuliah 2006

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