CASE PRESENTATION Pulmonary TBC with respiratory failure

CASE PRESENTATIONPulmonary TBC with respiratory failurePreceptor : dr. Listiana K., Sp.An-KICIdentitas PenderitaNama : Ny. R.Umur: 52 tahunJenis Kelamin :perempuanAlamat : Cijawura HilirRuangan: ICU-IsolasiTgl masuk : 4 April 2011No. Reg/ RM : 11005919/ 00976099Diagnosis masuk : TB Paru bilateral + gagal napas AnamnesisKeluhan Utama : Sesak nafasSejak 1 minggu SMRSI, pasien mengeluh sesak napas, sesak napas dirasakan terus-menerus, semakin lama semakin bertmbah berat, terutama dirasakan saat berbaring, sesak dirasakan berkurang bila tidur dengan menggunakan 1 bantal.1 bulan SMRSI pasien mengeluh batuk, berdahak, tidak disertai darah,tidak disertai keringat malam.Pasien juga mengalami penurunan BB sejak batuk, + 6 kg.BAB : dalam batas normalBAK : dalam batas normalAnamnesisRPD : maag (+), tidak ada penyakit lain.RPK : keluarga (-), tetangga ada yang menderita TB.UB : pasien sebelumnya sudah berobat jalan dan minum obat dengan teratur, namun tidak ada perbaikan. TB Putus obat

Pemeriksaan FisikKeadaan UmumKesadaran : soporKesan Sakit : beratKeadaan gizi: kurang

Tanda VitalTekanan darah: 100/80 mmHgRespirasi : 34x/menitNadi : 100x/menitSuhu : 36,9 cKepala : Conjungtiva : anemis +/+ , Sklera : sub ikterik , Pupil bulat isokor, diameter 3mm kanan=kiri, refleks cahaya +/+, PCH +/+Leher : KGB ttmThoraks :Pulmo Inspeksi: Pergerakan tidak simetris, Retraksi intercostal +/+ Palpasi: Pergerakan tidak simetris Perkusi: dull pada lapang paru kiri dan kanan Auskultasi: VBS +/+, Ronchi +/+, Wheezing +/+Cor: BJM, reguler, murmur

Abdomen :Inspeksi: datarAuskultasi: Bising usus + normalPerkusi: Timpani, nyeri perkusi -, shifting dullness -Palpasi: Soepel, defence muscular -, massa -, hepar dan lien tidak teraba membesar

GenitalTidak dilakukan pemeriksaan

EktremitasAkral hangat, CRT < 2 detik, oedem -/-PEMERIKSAAN PENUNJANGLab2-4-114-4-116-4-117-4-118-4-11Hb13,511,5---Ht38,834---Leukosit917018630---Trombo294000237000---GDS102247---LED57----SGOT49-547461-SGPT48-519551-GamaGT111-83--Na127132---K3,64,3---Asam Urat5,8---2-4-114-4-116-4-117-4-118-4-11Kreatinin0,61---Ureum3044---D-Dimer-2---Fibrinogen-297---PT-18,4---ApTT-36,7---Laktat-9,2---Cl-100---Ca-7,9---Mg-2,04---Alkaline fosfatase--105--

GDP--137--GD2pp--119--Lab4-4-2011 (12.30)4-4-2011 (17.00)5-4-20116-4-0117-4-118-4-11PH7,2177,1937,3537,2357,4327,500PCo245,730,935,354,636,635,0PO2791948011713697HCO318,511,61922,324,127,0SaO294,1097,755,2096,498,297,40BE-9,50-15,5-5,3-4,90,44,10AGD4-4-11 : Asidosis Metabolik & Respiratorik dengan Mild Hipoksemia4-4-11 : Asidosis Metabolik partially compensated + Hiperoksemia5-4-11 : Asidosis Metabolik uncompensated + Normoksemia6-4-11 : Asidosis Respiratorik uncompensated + hiperoksemia7-4-11 : Hiperoksemia8-4-11 : alkalosis metabolik uncompensated + normoksemiaTanggal 4-4-2011Nadi : 140x/menitRespirasi : 40x/menitSuhu : 36 0cTD : 150/70 mmHgMAP : 130 mmHgSaO2: 96%CVP: 21 cmH2OGCS E1M1VTVentilasi MekanikMode: PSIMVPEEP: 5RR: 15PS: 40PC: 16FiO2: 50%

Intake 2674Output 750Balance cairan +1924Tanggal 5-4-2011Nadi : 120x/menitRespirasi : 40x/menitSuhu : 37,6 cTD : 110/83 mmHgMAP : 87 mmHgSaO2: 98%CVP: 20 cmH2OGCS E4M5VT

Ventilasi MekanikMode: ASVPEEP: 10RR: 35FiO2: 40%

Intake 2417Output 1392Balance cairan +1025

Tanggal 6-4-2011Nadi : 120x/menitRespirasi : 27x/menitSuhu : 37 cTD : 90/64 mmHgMAP : 80SaO2: 100%CVP: 24 cmH2OGCS E3M4VTVentilasi MekanikMode: ASVPEEP: 10RR: 30FiO2: 70%

Intake 786Output 485Balance cairan +301Tanggal 7-4-2011Nadi : 115x/menitRespirasi : 27x/menitSuhu : 37 0cTD : 115/75 mmHgMAP : 95 mmHgSaO2: 97%CVP: 18 cmH2OGCS E3M5VTVentilasi MekanikMode: PSIMVPEEP: 10RR: 27FiO2: 45%

Intake 2121Output 1005Balance cairan +1116Tanggal 8-4-2011Nadi : 120x/menitRespirasi : 20x/menitSuhu : 37,3 0cTD : 90/66 mmHgMAP : 75 mmHgSaO2: 97%CVP: 15 cmH2OGCS E3M5VTVentilasi MekanikMode: PSIMVPEEP: 10RR: 29FiO2: 50%

Intake 756Output 340Balance cairan +416Pemeriksaan PenunjangRo Thoraks :4 April 2011

Pemeriksaan penunjangMikrobiologi (8-4-2011)Biakan dan tes resistensi Spesimen : darah Isolate 1 : negatif4 ap5 ap6 ap7 ap8apRL1500cc/24jam1500cc/24jam1500cc/24jam

STOPSTOPPropofolPrn 1cc bolusPrn 1cc bolus

Prn 1cc bolus

Prn 1cc bolus

Drip 20 mg/jDobutamine1,2 cc/j1,2cc/j1,2cc/j1,2cc/j

1,2cc/jTetraHES250cc----Raivas (Norepinefrin)1,5 cc/j1,5cc/j1,5cc/j1,5cc/j

3cc/jIsoket (isosorbit dinitrat)2,5 cc/ j2,5 cc/ j

2,5 cc/j--FentanylPrn 50mg bolusPrn 50mg bolus

Prn 50mg bolus

Prn 50mg bolus

-4 ap5 ap6 ap7 ap8apAdrenalin3 ampul (1mg/ml)----TB kit1X III1X III

1xIIISTOPSTOP Baquinor (Ciprofloxacin)2x200mg2x200mg2x200mg

2x200mg2x200mg Vectrine(Erdostene)3x300mg

3x300mg3x300mg3x300mg

-4 ap5 ap6 ap7 ap8apEtaphylline (Bronkodilator)2x1252x1252x1252x125

2x125Curcuma3x200mg3x200mg3x200mg3x200mg

3x200mgCap NaCl3x 1gr3x1 gr3x1gr3x1gr

-Hexilon (metilprednisolon)1x1 vial (125 mg)----Combivent + Flexotide4x14x14x14x1

4x1Kalmetasone (Dexametason)-3x2cc (4mg/ml)---Rantin (Ranitidine)-2x1 amp (50mg/2ml)2x1 amp(50mg/2ml)2x1 amp (50mg/2ml)

2x1(50mg/2ml)Pantozol --2x1 amp??Prosogan(Lanzoprazole)--2x1 amp??4 ap5 ap6 ap7 ap8 apFarmadol (Parasetamol)-4x500 mg4x500mg4x500mg

4x500mgBisolvon (Bromhexin Hcl)-3x1 amp (4mg/ 2ml)3x1 amp (4mg/ 2ml)

3x1 amp (4mg/ 2ml)

3x1 amp(4mg/2ml)Tomit (Metoclopramide)-3x1 amp(10mg/2ml)3x1 amp(10mg/2ml)

3x1 amp(10mg/2ml)

3x1 amp(10mg/2ml)INFUS (7-4-2011)Aminofusin L 6001000 ccTriofosin E 1000500 cc63 cc/ jamDefinisiKegagalan sistem pernafasan untuk mempertahankan pertukaran gas yang adekuat dengan PaO2 < 8 kPa (60 mmHg) dan/atau PaCO2 > 6.6 kPa (50 mmHg).

KlasifikasiType I respiratory failure (Hypoxaemic respiratory failure)Type II respiratory failure (Hypercapnic respiratory failure)

Type I respiratory failureKegagalan oksigenasipH pO2 pCO2

Etiologi :Pneumonia- Pulmonary oedemPulmonary fibrosis- BronchiectasisAsthma- ARDSPneumothorax- ObesityPulmonary embolismPulmonary arterial hypertensionCyanoticcongenital heart disease

PenyebabMasalah konduksi jalan nafas (severe asthma)Masalah alveolar (pneumonia, edema pulmonal, ARDS, atelektasis)Pulmonary vascular (pulmonary thromboembolism, fat embolism)

Mekanisme FiO2Ventilation-perfusion mismatchRight-to-left shuntDiffusion abnormalitiesType II respiratory failurePump failurepH pCO2 pO2Etiologi :Chronic obstructive pulmonary diseaseMyasthenia gravisPolyneuropathyPoliomyelitisPulmonary oedemaAdult respiratory distress syndrome

MekanismeLow minute ventilationHigh dead space ventilationPenyebab1. Respiratory centre problems (eg. brainstem stroke, opioid-induced respiratory suppression)2. Cervical cord lesion3. Motor neuron problems (eg motor neuron disease)4. Neuropathy (eg. Guillain-Barre syndrome)5. Neuromuscular junction problems ( myasthenia gravis)6. Muscle problems (eg. muscular dystrophy)7. Ribcage problems (eg. severe kryphoscoliosis)8. Upper airway obstruction (eg. epiglottitis)9. Extrapulmonary problems with diaphragmatic splinting (eg. severe ascites, intestinal obstruction)

Gejala KlinikPerubahan status mental agitasi atau drowsinessEvidence of labourious breathing nasal flaring, use of accessory muscles, retraction of supraclavicular flossa or intercostal spaces, takipnoe, paradoxical breathing patternDiaphoresis, takikardi dan hipertensiSianosis sentral

PemeriksaanAnalisis Gas DarahFoto ThoraxEKG, EchocardiographyElektrolitComplete blood countUrinalisis untuk keracunanCT Scan thorax pada kasus tertentuRespiratory Failure Etiology

33FIO2Ventilation without perfusion(deadspace ventilation)Diffusion abnormalityPerfusion without ventilation (shunting)HypoventilationNormal

This slide illustrates the various pathophysiological mechanisms which cause respiratory failure. Pathogenesis of tuberculosis

GEJALA KLINIKCNS:Nyeri KepalaGangguan penglihatanKecemasanBingungHilang IngatanLemahPenurunan fungsi

Gejala KlinikPulmonal:Batuk Nyeri dadaProduksi sputumStridorDyspnea

Cardiac:OrthopneaEdema periferNyeri dada

Lain-lain:Demam, nyeri perut, Anemia, perdarahan

KlinisRespiratory compensationSympathetic stimulationTissue hypoxiaHaemoglobin desaturation

Clinical signs of respiratory failure can be divided into signs of respiratory compensationClinicalRespiratory compensationTachypnoea RR > 35 Breath /minAccessory musclesRecesssionNasal flaringSympathetic stimulationTissue hypoxiaHaemoglobin desaturation

Such as tachypnoea, use of accessory muscles, recession and nasal flaringClinicalRespiratory compensationSympathetic stimulationHRBPsweatingTissue hypoxiaHaemoglobin desaturation

Signs of sympathetic stimulation such as tachycardia, hypertension and sweatingClinicalRespiratory compensationSympathetic stimulationTissue hypoxiaAltered mental stateHR and BP (late)Haemoglobin desaturation

Signs of tissue hypoxia such as altered mental status and at a very late stage bradycardia and hypotensionClinicalAltered mental statePaO2 +PaCO2 acidosis dilatation of cerebral resistance vesseles ICP

Disorientation, Headache, coma, asterixis, personality changesPENATALAKSANAANPrinsip manajemen gagal nafasAirway managementObjektif primer : Mengatasi dan mencegah progresifitas hipoksemiaObjektif sekunder :Mengontrol PaCO2 dan asidosis respiratorikMengatasi penyakit yang mendasari

Pertimbangkan ventilasi mekanikIndikasi Ventilasi MekanikKegagalan ventilasi dan kegagalan pertukaran gasPaO2< 55 mm Hg atau PaCO2 > 60 mm Hg meskipun telah diberikan terapi O2.Memburuknya status respirasi Respiratory fatigue: for relief of metabolic stress of the work of breathing

PENATALAKSANAANTerapi suportif :Manajemen saluran nafas (airway)Pertahankan Oksigenasi dan VentilasiOksigenasi pada Kegagalan Ventilasi :Cara sederhana dengan flow rendahSasaran : PaO2 >50 60 mmHgCara pemberian: Nasal kanulaMasker (venturi mask)VentilatorPertimbangkan terapi cairan (fluid balance)Nutritional therapy

PENATALAKSANAANOksigenasi pada Kegagalan Oksigenasi :Pemberian O2 : bergantung PaO2Nasal kanula atau maskerFIO2 40 60%VentilatorBronkospasme : bronkodilatorInfeksi : Antibiotika (bergantung hasil tes resistensi kuman)Retensi sputum : HidrasiNebulisasiFisioterapi dadaSuction/penghisapanPROGNOSISQuo ad vitam : ad malamQuo ad functionam : ad malam

DAFTAR PUSTAKALee, WL and Slutsky, AS. Hypoxemic respiratory failure, including acute respiratory distress syndrome, pp 2352-2353. Murray and Nadels Textbook of Respiratory Medicine, 4th ed. Philadelphia: Elsevier, 2005, pp. 2352-2353.Sigillito R, DeBlieux P: Evaluation and initial management of the patient in respiratory distress. Emerg Med Clin North Am. 2003;21:239.

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