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Atikah Ayu Miranda

Mentored by dr. Andri Firdaus, Sp.A


■ Acute respiratory infections are divided into 2 major groups, namely

acute upper respiratory infection and acute under respiratory infection
which are the main problems are pneumonia and bronchiolitis
■ Based on WHO reports in 2015, pneumonia accounted for 15% of all
deaths of children under 5 years killing around 922.000 children. And
bronchiolitis is commonly reffered as disease of infancy, generally
regarding infants with peak incidence at the age of 2 to 6 months, more
than 80% of cases occur in the first year of life.
■ Bronchopneumonia, also sometimes known as lobular
pneumonia is an inflammation of localized lung parenchyma
which usually affects the bronchioles and also the surrounding
alveoli in the form of patches that often affect children and
toodlers caused by various etiologies such as bacteria, viruses,
fungi and foreign matter.
■ Bronchiolitis is inflammation of bronchioles characterized by
shortness of breath, wheezing and lung hyperinflation
■ Until now, pneumonia is the leading
cause of infant mortality in the
world. It is estimated that there are
1.8 million or 20% of child deaths
caused by pneumonia.
■ Bronchiolitis is an acute lower
respiratory infection that is
common in infants, generally
occurs at less than 2 years of age
with a peak incidence at the age of
the first 6 months.

■ Streptococcus pneumoniae is the most common cause of bacterial pneumonia in all

age groups. Virus are more often found in children less than 5 years. Respiratory
Syncytial virus (RSV) is the most common viral cause in children less than 3 years
■ Respiratory Syncytial Virus (RSV) is the most common agent found in isolation as
much as 75% in children less than 2 years who suffer from bronchiolitis and are

A. Bronchiolitis
B. Bronchopneumonia
Clinical Manifestation

A. Bronchiolitis
■ The initial symptoms that may arise are signs of acute respiratory infection in the
form of fever, cough, runny nose and sneezing.
■ One to two days later a cough arises accompanied by shortness of breath
■ Next can be found wheezing, cyanosis, grunting, vomiting after coughing, fussing
and decreased appetite
■ Nasal flaring and intercostal, supracostal and subcostal retractions
B. Bronchopneumonia
■ Symptoms and signs of pneumonia can be distinguished into common (non-specific)
symptoms, pulmonary, pleural or extrapulmonary symptoms.
■ Non-specific symptoms include fever, chills, cephalgia, restlessness and anxiety
■ Some patients may experience gastrointestinal disorders such as vomiting, bloating,
diarrhea or abdominal pain
■ After initial symptoms such as fever and cold cough, symptoms of nasal flaring,
tachypnea, dyspnea and apnea arise
■ Chest indrawing

■ A. Bronchopneumonia
WHO recommends the use of
increased breathing frequency and
subcostal retraction to classify
pneumonia in developing countries :
■ Brochiolitis
The diagnosis in most cases of bronchiolitis is clinically evident and does not require
diagnostic testing.
• Patients usually report a history of recent upper respiratory tract symptoms such as
• Lower respiratory tract symptoms such as cough, tachypnea, and increased work of
breathing follow the upper respiratory prodrome.
• Wheezing during expiratory, expiratory extends, hipersonor when percussion.
Hyperinflated chest, crackles, wheeze on auscultation

A. Bronchopneumonia
Criteria for hospitalization :
1. Mild pneumonia
■ Outpatient
■ First line antibiotics orally, for example amoxicillin 25 mg/KgBB/times given 2 times
a day for 3 days or cotrimoxazole 4 mg TMP/KgBB/times given 2 times a day for 3
2. Severe pneumonia
■ Oxygen to maintan saturation >92%, monitored every 4 hours, including
examination of oxygen saturation
■ If oral intake is lacking, intravenous fluids can be given and strict fluid balances are
carried out to prevent excessive hydration
■ In children with severe respiratory distress, oral feeding should be avoided
■ If the temperature of ≥ 390 C can be given paracetamol
■ Administration of antibiotic:
- Amoxicillin 25-50 mg/KgBB IV or IM every 6 hours, closely monitored within the first
72 hours. If the child respons well then it is given 5 days. Furthermore, therapy is
continued with oral amoxillin 15 mg/KgBB/times 3 times a day for the next 5 days
- If the clinical condition worsens before 48 hours or there is a severe condition suc
as unable to breastfeed or drink/eat or vomit everything, convulsions, letargis or
unconsciousness, cyanosis, severe respiratory distress then chloramphenicol 25
mg/KgBB/times IM or IV is added every 8 hours
- Second line antibiotics : Ceftriaxone 80-100 mg/KgBB IM or IV once a day
■ Return criteria
- Symptoms and signs of pneumonia disappear
- Adequate oral intake
- Giving antibiotics can be continued at home (orally)
- The family understands and agrees to provide therapy and control plans
- Home conditions allow for continued care at home
B. Bronchiolitis
RSV virus infections are usually self limiting, so treatment is usually only supportive
1. Oxygenation
Oxygen is given to all children by wheezing and severe respiratory distress, the
recommended method is with a nasal prongs, nasal catheter or nasopharyngeal
catheter with oxygen levels 30-40%.
2. Liquid
Giving fluids is very important to correct metabolic and respiratory acidosis that
may arise and prevent dehydration due to discharge through the mechanism of
evaporation due to rapid breathing patterns and difficulty drinking. If dehydration
doesn’t occur, maintenance fluids can be given either intravenously or nasogastricly
3. Bronchodilators and corticosteroids
Albuterol and epinephrine and systemic cortosteroids should not be given.
Hypertonic saline nebulisation can be given to treated children. Nebulisation is useful to
increase the work of the mucociliary airway to clear mucus and cellular debris found in
the respiratory tract.
4. Antivirus
The American Academy of Pediatrics recommends the use of ribavirin in
conditions that are expected to become more severe, such as those with bronchiolitis
with cardiac abnormalities, cystic fibrosis, chronic pulmonary disease,
immunodeficiency, and in premature babies.
5. Antibiotics
Anti-bacterial is not necessary because most cases are caused by viruses,
unless additional infection is suspected.
6. Physiotherapy
Chest physiotherapy in bronchiolitis children with vibrational or percussion
techniques (5 trials) or passive breathing techniques is no better than reducing the
duration of oxygen therapy.
The differences between bronchiolitis and bronchopneumonia in
Bronchiolitis Bronchopneumonia

 History :  History
- Early symptoms of acute respiratory infection due to - Preceded with acute respiratory infection for several
viruses days
- Then cough arises accompanied by shortness of - Fever (39-400 C), often seizures
breath - Dyspnea, rapid breathing, nasal flaring and cyanosis
- Wheezing, whimpering, breathing sounds, vomiting around the nose and mouth
after coughing, fussing and decreased appetite - Initially dry cough then becomes productive
- There is a history of contact with people with acute
respiratory infection

 Physical examination  Physical examination

- Tachypnea, dyspnea - Tachypnea, dyspnea, nasal flaring, cyanosis around the
- Lungs : nose and mouth
 Inspection : retraction, hyperinflation chest wall - Lungs :
 Palpation : decreased vocal fremitus  Inspection : chest indrawing
 Percussion : hipersonor  Palpation : increased vocal fremitus on affected side
 Auscultation : wheezing, fine inspiratory crackles  Percussion : dull
 Auscultation : low breath sounds accompanied
crackles or rhonchi

 Supporting examination  Supporting examination

- Normal leukocytes or slightly increased - Leukocytosis, usually 15.000-40.000/mm3
- Blood gas analysis : hypercapnia - Hb values usually remain normal or slightly decreased
- X rays : hyperinflation, air trapping, atelectasis can - Increased LED
occur - Sputum culture (+)
- Viral isolation : possible (+) - Blood gas analysis : hypoxemia and hypercarbia
- Blood culture : negative

A. Bronchiolitis
Mostly the children with bronchiolitis recover uneventfully but several studies have
noted an increased risk of bronchial asthma in children who initially suffer from

B. Bronchopneumonia
With appropriate and adequate administration of antibiotics, mortality can be reduced
to less than 1%.

■ Bronchopneumonia is pneumonia in the lobular part which is

characterized by infiltrate patches that are characterized by symptoms
of high fever, restlessness, dyspnoea, rapid and shallow breathing
(sounds of crackles), vomiting, diarrhea, dry and productive cough
■ The most common cause of pneumonia itself is Streptococcus
■ Bronchiolitis is a small airway infection or bronchiole that is clinically
characterized by the first episode of wheezing in infants preceded by
symptoms of upper respiratory infection
■ The most common cause of bronchiolitis is Respiratory Syncytial Virus (RSV).
■ What distinguishes bronchopneumonia and bronchiolitis in children is that it
can be seen from the physical examination of the hyperinflation chest shape
in bronchiolitis patients, decreased vocal fremitus in bronchiolitis, hipersonor
when percussed on bronchiolitis. When auscultating, wheezing sounds will be
heard in bronchiolitis. The results of chest x-rays in bronchiolitis will also
show hyperinflation in bronchiolitis.
■ In bronchiolitis, RSV virus infection is usually self limiting, so treatment is
usually only supportive. But in bronchopneumonia antibiotics are needed to
treat bronchopneumonia.

1. Supriyatno B. Infeksi respiratorik bawah akut pada anak. Sari pediatri 2006;8(2):100-6
2. Junawanto I, Goutama IV, Sylvani. Diagnosis dan penanganan terkini bronkiolitis pada
anak. CDK 2016;43(6):427-30
3. Watts KD, Goodman DM. Wheezing in infants: Bronchiolitis. In: Behrman RE, Kliegman
RM, Arvin AM, editors. Nelson textbook of pediatrics. 19th ed. Philadelphia: WB Saunders;
2011. p. 1456-9.
4. Ikatan dokter anak Indonesia. Bronkiolitis. In: Pedoman pelayanan medis ikatan dokter
anak Indonesia. Jilid 1. Jakarta: IDAI;2009.p.30-2
5. Subanada IB, Purniti NPS. Faktor-faktor yang berhubungan dengan pneumonia bakteri
pada anak. Sari Pediatri 2010;12(3):184-9
6. Katleya F, Anam MS, Dadiyanto DW. Rasio jumlah neutrofil-limfosit pada awal masuk
rawat sebagai faktor risiko luaran pneumonia anak. Sari pediatri 2015;17(1):47-51
7. Dicky AKN, Wulan AJ. Tatalaksana terkini bronkopneumonia pada anak di Rumah Sakit
Abdul Moeloek. J Medula Unila 2017;7(2);6-12
8. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, The management
of community-acquired pneumonia in infants and children older than 3 months of age:
clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious
Diseases Society of America. Clin Infect Dis 2011;53(7):25-76
9. Subanada IB, Setyanto DB, Supriyatno B. Faktor-faktor yang berhubungan dengan
bronkiolitis akut. Sari Pediatri 2009;10(6):392-6
10. Mustafa G. Bronchiolitis: The recent evidence. J Ayub Med Coll Abbottabad 2014;26(4):602-
11. Artawan, Purniti PS, Sidiartha L. Hubungan antara status nutrisi dengan derajat keparahan
pneumonia pada pasien anak di RSUP Sanglah. Sari Pediatri 2016;17(6):418-22
12. Mansbach JM. Respiratory viruses in bronchiolitis and their link to recurrent wheezing and
asthma. Clin Lab Med. 2009; 29(4): 741–55
13. McCance KL, Huether SE. Pneumonia. In: Pathophysiology: The biologic basis for
disease in adults and children. Vol 2. Missouri: Elsevier Mosby;2006.p. 1228-30
14. Ikatan Dokter Anak Indonesia. Bronkiolitis. In: Buku Ajar Respirologi Anak. Cetakan
pertama. Jakarta: IDAI;2008.p. 333-47
15. WHO. Buku saku pelayanan kesehatan di rumah sakit : pedoman bagi rumah sakit
rujukan tingkat pertama di kabupaten/kota. Jakarta:WHO Indonesia:2008