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260&ty=33&accion=L&origen=bronco&web=www.archbronconeumol.org&lan=en&
fichero=260v44n11a13128558pdf001.pdf
http://www.pneumonologia.gr/articlefiles/20060307_review1.pdf
http://www.healthinfonet.ecu.edu.au/uploads/resources/20047_20047.pdf
http://spp.4digital-dev.com/uploads/files/spp/PDF78.pdf
http://www.ajronline.org/doi/full/10.2214/AJR.09.3053
Page : 44
Bronchiectasis is the chronic dilation and distortion of the bronchi due to the
destruction of its bronchial walls, elastic tissue and smooth muscle components.
The mucociliary escalator is impaired by the destruction of the bronchial walls,
which results in the accumulation of secretions and the possibility of mucus
plugging. With mucous plugging, hyperinflation or atelectasis of the distal alveolar
units is possible. There are three anatomic types of bronchiectasis
Sacular- the most advanced form of bronchiectasis, with complete destruction of the
cartilage, elastic tissue, and smooth muscle. The bronchi increase in diameter until
they end in large sacs.
Cylindrical or tubular- characterized by the absence of normal bronchial tapering.
The bronchi appear as regularly shaped cylinder.
Varicose- the bronchi are distorted in an irregular fashion and appear to have a
bulbous shape.
Bronchiectasis can be either acquired or congenital. Acquired bronchiectasis may
occur in children who have repeated episodes of pneumonia, especially those
caused by the respiratory complication by childhood diseases, such as pertussis
(whooping cough) or influenza. They may then develop bronchiectasis as an adult.
Congenital bronchiectasis can occur when a patient is born with cystic fibrosis and
later develops bronchiectasis.
As with the other obstructive disease discussed so far, a patient with bronchiectasis
will have higher-than normal heart rate, respiratory rate, and blood pressure.
Patient will use pursed-lip breathing and the accessory muscles of ventilation for
both inspiration and expiration. Chest findings will reveal a decrease in tactile and
vocal fremitus and diminished breath sounds with crackles, wheezes, and ronchi.
The patient usually has a productive cough with large amounts of foul-smelling,
blood-tinged sputum. Bronchiectasis is diagnosed using a CAT scan.
Treatment
Treatment for bronchiectasis is consistent with treatment for the other obstructive
diseases mentioned so far. Physicians prescribe respiratory modalities that aid in
the mobilization of bronchial secretions such as chest physical therapy, PEP therapy,
and suctioning. Drugs such as bronchodilators, mucolytics, expectorants, and
antibiotics are also useful to combat bronchiectasis. Hypoxemia should be treated
with the use of pulse oximetry and arterial blood gas tests.
Page : 94
Chest Physical Therapy (CPT)
Chest Physical Therapy (CPT) is combination of techniques developed for the
mobilization of pulmonary secretions and the promotion of greater use of the
respiratory muscles for the improvement in the distribution of ventilation.
Techniques include in chest physical therapy include postural therapy, chest
percussion, chest vibration, and cough techniques. Patients who may benefit from
CPT include those who suffer from bronchiectasis, chronic bronchitis, and cystic
fibrosis. CPT can also be used to treat absorption atelectasis by mobilizing
secretions, to help COPD patients with inefficient breathing patterns, and to prevent
postoperative respiratory complication.
Postural Drainage
When the natural mucus-clearing mechanism of the body, the mucociliary escalator,
becomes diseased or ineffective, it can be greatly enhanced by gravity. Postural
drainage is a technique that facilitates mucus drainage of a particular lung segment
by positioning the body to allow mucus to flow in the direction of gravity. Once the
mucus has reached the central airways, it can then be either expectorated by
coughing or removed by suctioning, which we will discuss later on this chapter.
Illustrates the different positions used for postural drainage and the particular lung
segments that are being drained.
Postural drainage position are usually held for 3 to 15 minutes but are modified
according to the patients condition and tolerance. The head-down position
(Trendelenburg) should not exceed 25 o below horizontal. Postural drainage is more
effective for patients with condition characterized by excessive sputum production
of greater than 25 to 30 mL/day.
Chest Percussion
Chest Percussion is a means of improving the mobilization of secretion by manually
striking the chest wall with cupped hands or by placing a mechanical percussor on
the chest wall. The clapping of cupped hand againts the chest wall will trap air
between the hands and the chest wall. This produces an energy wave that is
transmitted through the chest wall to the lung tissues. This energy wave will loosen
mucus and allow for better mobilization of secretions. This techniques are perform
with the patient in the postural drainage position needed to drain the affected lung
segment. Percussion should be perform over the affected segment for about 2 to 5
minutes. Percussion should not be performed over the following areas:
Spine
Sternum
Scapulae
Clavicles
Surgical sites
Areas of trauma
Breast tissue
Chest Vibration
Chest Vibration are created by placing one hand on top of the other over a specified
lung segment. A very rapid vibrating motion is then gently applied to the chest wall
using moderate pressure. Chet vibration becomes an extremely effective means of
mobilizing secretions toward the gravity-dependent major airways in conjunction
with postural drainage and following chest percussion. For chest vibration to be
maximally effective, the patient should be instructed to take a deep breath with
vibration being applied during exhalation.
Cough techniques
Most bronchial hygiene therapies will not be successful in fully clearing secretions if
the patient does not have an effective cough. The first step in assisting a patient to
have a more effective cough is to place the patient into a sitting or semi-Fowlers
position and instruct him or her to inhale deeply through the nose. A breath hold of
3 to 5 seconds should follow the deep inhalation. The patient should then perform a
strong cough. However, for various reasons, the patient may not be able to give a
strong enough effort. In some disease states, such as emphysema, a strong cough
is contraindicated as it may produce a spontaneous pneumothorax.
A variation of a single strong, productive cough is the huff cough, used for patients
with poor cough effort due to pain. For this cough the patient should be instructed
to clasp his or her arms across the abdomen and produce 1 or 2 forced expirations
of middle to low lung volumes without taking a prior deep breath. A pillow should be
used to splint any chest wall or abdominal incisions to help decrease pain and
improve
Hal 55
Hal : 56
PATOGENESA
1. Faktor radang dan nekrosis :
Radang menyebabkan silia tidak berfungsi. Epitel columnar mengalami
degenerasi dan diganti menjadi epitel bertatah, mengalami nekrosis elemen
kartilago muscularis dan jaringan elastis yang berakibat dinding bronkus
melebar tak teratur dan permanen.
Bila ulserasi mengenai pembuluh darah, terjadi hemoptisis yang berulang.
Selain itu timbul hipertropi pembuluh darah serta banyak timbul anastomosa
antar vena bronkialis dengan vena pulmonalis (right to left shunt) dengan
akibat timbulnya hipoksemia kronis dan berakhir dengan timbulnya
Korpulmonale kronis.
2. Faktor mekanik :
a. Distensi mekanis sebagai akibat adanya secret yang menumpuk dalam
bronkus atau adanya tumor atau pembedaran kelenjar limfe.
b. Meningkatnya tekanan intra bronkial akibat batuk.
c. Penarikan didnding bronkus oleh karena fibrosis jaringan paru.
Sebagai akibatnya timbul pelebaran lokal yang permanen lokal dari bronkus.
Tidak khas, Hb bias rendah (anemia), bias pula tinggi bila ada polycythemia sekunder
sebagai akibat dari insufisisensi paru. Leukositosis dengan laju endap darah yang tinggi bila
ada infeksi sekunder.
Sputum : hapusan dengan pengecetan Zn/TTH dan garam
Pemeriksaan Radiologi :
Foto thoraks PA dan Lateral : tampak infiltrate pada paru bagian basal dengan daerah
radiolucent yang multiple menyerupai sarang lebah (Honey comb appereance)
Bronkografi : merupakan sarana diagnose pasti untuk bronkiektasis, karena dengan bahan
kontras yang dimasukkan ke saluran napas akan tampak kelainan ektasinya.
Bronkoskopi : tidak bias digunakan untuk melihat ektasisnya akan tetapi bias untuk
mengetahui adanya tumor atau benda asing, sumber hemoptoe atau asal sputumnya.
Pemeriksaan faal paru : untuk melihat akibatnya yaitu restriktif dan/atau obstruktif.
GAMBARAN KLINIK
Hal 59
Penyakit Paru Obstruktif Kronik bukan suatu diagnose, melainkan suatu kumpulan gejala
klinik, di mana terdapat unsur obstruksi jalan napas yang sifatnya menahun. Penyakit
Paru Obstruktif Kronik ialah suatu kelainan klinik, dengan etiologi belum jelas, ditandai
batuk-batuk kronis disertai dahak dan sesak, napas berbunyi akibat meningkatnya
tahanan jalan napas.
Hal 13
Tuberkulosa Paru (TB Paru) adalah penyakit menular yang disebabkan oleh hasil basil
mikobakterium tuberkulosa Tipe Humanus (jarang oleh Tipe M. Bovinus). TB Paru
merupakan penyakit infeksi penting saluran napas bagian bawah setelah eradikasi
penyakit malaria. Basil mikobakterium tuberkulosa tersebut masuk ke dalam jaringan
paru melalui saluran napas (droplet infection) sampai alveoli, terjadilah infeksi primer
(Ghon). Selanjutnya menyebar ke kelenjar getha bening setempat dan terbentuklah
Primer Kompleks (Ranke) dinamakan TB primer, yang dalam perjalanan lebih lanjut
sebagian besar akan mengalami penyembuhan.
TB Paru Primer, keradangan terjadi sebelum tubuh mempunyai kekebalan spesifik
terhadap basil mikobakterium tuberkulosa, yang kebanyakan didapat pada usia anak 1-3
tahun. Sedangkan yang disebut Tuberkulosa Post Primer (reinfection) adalah keradangan
jaringan paru oleh karena terjadi penurunan ulang yang mana di dalam tubuh terbentuk
kekebalan spesifik terhadap basil TB tersebut. Secara epidemiologi, menurut WHO,
terdapat 10-12 juta penderita yang mem[unyai kemampuan menularkan, dengan angka
kematian 3 juta penderita tiap tahun, dan keadaan tersebut 75% terdapat di Negara yang
sedang berkembang dengan sosio ekonomi rendah, termasuk Indonesia. Di Indonesia
merupakan penyakit rakyat nomor satu dan penyebab kematian nomor tiga.
Hal 14
Mikobakterium tuberkulosa tipe humanus atau tipe Bovinus (masih banyak tipe lainnya)
adalah tipe yang paling dominan dalam menimbulkan penyakit pada manusia. Basil
tersebut berbentuk batang, sifat aerob, mudah mati pada air mendidih (5 mneit pada suhu
80oC, 20menit pada suhu 60 C), mudah mati dengan sinar matahari, tahan hidup
berbulan-bulan pada suhu kamar yang lembab. Identifikasi/pengenalan basil dengan cara
hapusan, fluorescence, pembiakan dan pada hewan percobaan. Bahan-bahan untuk
identifikasi diambil dari dahak langsung, kerokan laring, kumbah lambung, kumbah
saluran napas dengan bronkoskopi serta dapat pula dari cairan pleura.
Cara penularan yang lain adalah, melalui saluran napas yang dikenal sebagai
droplet infection, dimana basil tuberkulosa (basil TB) tersebut dapat masuk sampai
alveolar sac. Penularan mudah terjadi bila terjadi hubungan erat dan lama dengan
penderita TB paru yang aktif, yakni golongan penderita yang disebut open case.
Penularan lain yaitu dengan debu yang mengandung basil TB yang beterbangan di udara.