Update

Tatalaksana Batuk Kronik Berulang

pada Anak

Dwikisworo Setyowireni
Departemen IKA FK KMK UGM
RSUP Dr. Sardjito
 Mengeluarkan Benda
ANUGERAH Asing JANGAN
DITEKAN
< 2 MINGGU*

AKUT
AKUT < 4 minggu **
KRONIK > 4 minggu**
BATUK
KRONIK BERULANG
> 2 MINGGU*
*Rekomendasi IDAI. 2017;
BS 2018 **Alsubaie H, et al.. Int J Ped Adoles Med.2015;2:38-43; Chang AB. UpToDate.2019; ACCP; TSANZ
BS 2018
 > 2 minggu

KRONIK? > 3 minggu

MEMBANDEL
> 4 minggu

3 X/ 3 Bulan*
Berturut

BERULANG? ≥ 2 x/tahun**
LRTI
≥ 6 x/tahun**
URTI

BS 2018 *Rekomendasi IDAI 2017; **Ozdemir B, et al. Indian J Pediatr. 2016;83(8):777-82

BS 2018
 PENUNJANG

DIAGNOSIS GEJALA LAIN

TIPE BATUK

LAMANYA BATUK

USIA
BS 2018
 MENURUT UMUR
>5
Bayi 1 - 5 tahun tahun

Asthma
Congenital malformation Post viral Infection
Infection
(Laryngotracheomalacia, Gastroesophageal reflux
Protracted bacterial
tracheoesophageal fistula, Asthma
bronchitis
cleft, etc) Protracted bacterial
Passive smoking
Gastroesophageal reflux bronchitis
Bronchiectasis
Pertussis Passive smoking
Psychogenic cough
Foreign body inhalation Foreign body inhalation

Alsubaie H, et al.. Int J Ped Adoles Med.2015;2:38-43

Secondary to acute respiratory
tract infection, bronchial
hyperreactivity, increased
secretions, etc. Generally dry cough, of
unknown origin and as
an isolated symptom
BATUK
BATUK NON
NORMAL SPESIFIK
(expected cough)
Secondary to a
BATUK
determined
SPESIFIK etiology

Chang AB. Chest. 2006;129(1):260S-283S

 Gejala saluran napas

Onset dan pencetus

SPESIFIK GEJALA JELAS Kondisi terkait

BATUK KRONIK

Pemeriksaan fisik
Pemeriksaan
penunjang

NON GEJALA LAIN Kering

SPESIFIK TIDAK ADA/JELAS tidak ada kelainan

Bialy L, et al. Cochrane Rev J 2006;1:736-42; Chang AB, et al. Respir Res. 2005;6:3; Chang AB. UpToDate.2019
BATUK KRONIK BERULANG ACCP Guideline
No

Ro thorax & spirometry Yes BATUK SPESIFIK

abnormal
No
Batuk karakteristik
No
BATUK NON SPESIFIK
• Post infeksi virus atau bronchitis
akut BATUK
Evaluasi 1-2 minggu
• Inhalasi benda asing (jarang), PERSISTEN
asma, upper airway disorder,
ESO, gangguan fungsi,
pertussis, mycopolasma, GERD,
masalah telinga
SEMBUH
 BATUK SPESIFIK ACCP Guideline

Reversible airway
obstruction
Yes No

ASTHMA Assess risk factors for

BRONCHIECTASIS/ ILD
REC PNEUMONIA
AIRWAY ABN

ASPIRATION CARDIAC

CHRONIC INF OTHERS

Chang AB, Glomb WB. Chest. 2006;129(1):260S-283S
 FAKTOR RISIKO
Chang AB, Glomb WB. Chest. 2006;129(1):260S-283S

Br ectasis Chronic
Rec pneumonia Aspiration infection ILD

CF,
SweatCD,test,
sev Neuro
Ba abn,
swallow,
pneumonia,
Bronchoscopy, imm altered swallow,
Bronchoscopy, TB, test,
Mantoux Rheumatoid
Autoimmnue dis,
Ciliadef,
biopsy, weak cough
BAL refl, Bronchoscopy,
non TB, Cytotoxics,
marker,
Immune
airway lesion Fluoroscopy,dis,
neuromusc BAL,
mycoses, HRCT chest
drugs,
workup,
Cong anom pH monitor,
laryng abn, tonsil HRCT chest Lung biopsy
parasites, radiations
Foreignchest,
HRCT body adenoidscan
Lung hyper,
Ba swallow
TEF sev GERD
 FAKTOR RISIKO
Chang AB, Glomb WB. Chest. 2006;129(1):260S-283S

Airway
abnormality Cardiac Others

Tr br malacia,
Bronchoscopy, Pediatric
Intra luminar Pulmonary Primary/
BAL, less cardiologist
(tumor),
CT chest, hypertension, secondary
Echo-cardiac,
ExtrMRI chest
compressive Cardiac edema
catheter tumor
lession
 BATUK PERSISTEN
BATUK NON SPESIFIK ACCP Guideline

PILIHAN: diskusikan dg orang tua

Evaluasi 2 minggu Terapi percobaan

Batuk Batuk
membaik Tidak membaik Batuk kering Batuk berdahak
ICS Budesonid 400µg Antibiotika 10 hari*

Batuk
Tidak membaik Evaluasi 2-3 minggu
Evaluasi BATUK
pastikan SPESIFIK Batuk membaik

*Rekomendasi IDAI. 2017: Amoxicillin/Amoxic-clav ASTHMA PROTR. BRONCHITIS

 BATUK SPESIFIK
Rekomendasi IDAI. 2017

RINO- LAR BR
ASMA TB SINUSITIS MALACIA

Wheezing, Morning FTT, stridor

episodic, Demam lama, sneeze, PND, inspirasi,
nocturnal, kontak TB, BB hidung pectus
reversible, turun, tersumbat,
pencetus, excavatum,
tuberculin (+) sinus pain
atopi. tracheal tug
 BATUK SPESIFIK
Rekomendasi IDAI. 2017

OSAS, CLD,
PERTUSIS PNEUMONIA GERD BE, CF, ILD,
ATIPIK BPD, OMSK,

Paroxysmal/
Preschool Muntah
whooping Gejala lain
age, Ro berulang, FTT,
cough, sesuai
pneumonia, sandifer
subconjunctiv penyakit
klinis ringan posisition
al bleeding
 TATALAKSANA BATUK KRONIS
(Rekomendasi IDAI, 2017)
Mukoaktif Bronkodilator
• Mukolitik: n-asetilsistein, • Bronkodilator efektif untuk
ambroksol, erdostein tatalaksana ASMA
• Mukokinetik: bronkodilator,
ambroksol
• Mukoregulator: antikolinergik
• Ekspektoran: guaifenesin
Mukoaktif dapat diberikan anak
> 2 tahun (batuk akut)
Guaifenesin tidak efektif
 TATALAKSANA BATUK KRONIS
(Rekomendasi IDAI, 2017)
Kortikosteroid Antihistamin
• Sistemik: serangan asma, • Generasi pertama: tindak
croup, dianjurkan
• Topikal: talaksana jangka • Generasi kedua/ketiga:
panjang asma, rhinitis hanya pada rhinitis alergi
alergi, rinosinusitis
 TATALAKSANA BATUK KRONIS
(Rekomendasi IDAI, 2017)
Antibiotika Over the counter medicine
• Harus diberikan pada: • Tidak direkomendasikan
pneumonia, faringitis
streptokokus, otitis media
bakterial
Kasus: bayi 8 bulan
• Batuk kambuhan dalam 2
bulan
• Memberat saat makan,
berbaring, menangis (serak)
• Usia 4 bulan bronkiolitis
• Dititipkan di TPA
• Imunisasi lengkap
• Tidak ada alergi
• Ibu asma, ayah perokok
(terutama di luar rumah)
• Tidak demam
• Frekuensi napas 24x/menit
• Denyut jantung 100x/menit
• SpO2 99% (tanpa suplemen)
• Mukosa hidung bengkak, tidak
ada mucus
• Dada normal
• Wheezing bilateral
• Jantung dan abdomen normal
• Tidak ada jari tabuh
Tatalaksana kasus bayi 8 bulan
Primary care approach
• TPA  RSV, influenza, rhinovirus
(akut)
• Serak, saat makan  GERD, TEF
• Riw bronkiolitis, mukosa hidung
bengkak, wheezing  reactive airway
disease
• Ro thorax
• Darah lengkap, eosinophil, IgG, IgA,
IgE
• Tx: bronkodilator inhalasi  bila
respon  kortikosteroid inhalasi
Specialist approach
• Susp Asma
• Inhalasi bronkodilator:
– respon parsial  kortikosteroid
oral/inhalasi, lanjut bronkodilator
– Respon baik  kortikosteroid
inhalasi 3 minggu  sembuh
Dx: ASMA
 Tatalaksana BKB
Resume
Anamnesis Pemeriksaan fisik & penunjang
• Usia • Status nutrisi, pertumbuhan
• Tipe dan lama batuk • Sal napas atas: telinga, hidung,
• Stridor, wheezing sinus
• Waktu, cuaca • Dada: diameter ant-post, suara
• Sputum: karakter paru, jantung
• Paparan infeksi • Jari tabuh, eksema
• Respon terhadap terapi • Ro thorax
• Riwayat keluarga: atopi, asma, • Sputum: cat gram, kultur
eksema, kistik fibrosis • Darah lengkap. eosinophil, IgG,
IgA, IgM, IgE, uji keringat
 PENUNJANG

DIAGNOSIS GEJALA LAIN

TIPE BATUK

LAMANYA BATUK

USIA
BS 2018
 Update
Hasil-hasil penelitian
 Bailey EJ, Chang AB. Paediatr Child Health. 2008;13(6): 512-4

• There is insufficient evidence available to make treatment recommendations,

and further high-quality research is clearly needed.
• Antibiotic treatment for younger (predominately preschool-aged) children
presenting with a prolonged moist cough has been shown to be of benefit in
resolving cough and preventing illness progression. (prevalence of underlying
protracted bacterial bronchitis)
• No specific treatments, including the use of antibiotics, can be recommended
for a prolonged dry or nonspecific cough in children
Chronic cough: lasting more than 4 weeks
RRI (recurrent respirator infection): 6 times URTI/year; 2 times LRTI/year (interval at least 7d
Results
• 29 RCT, 4344 pediatric patients (0-14 years old)  15 appropriate RCT  8 double
blind and placebo controlled
• 10 RCTs were published from Italy, Russia or Greece, and 19 RCTs were published
by Chinese groups
• Intervention: Pidotimod (PDT) 400 mg twice a day at acute phase (2-4 weeks), followed
bay 400 mg once a day, treatment duration 20 days to 3.5 months.

International Immunopharmacology. 2019; 67:35–45

Relapse of RTIs=0
(follow-up period 1-3 months
Results
PDT in a random-effect model
• treatment with PDT resulted in a
significant increase in the proportion
Relapse of RTIs< 1
(follow-up period 4-6 months
of participants who had lower RTIs
(RR 1.59; 95% CI 1.45-1.74, p <
0.00001) compared with the
conventional treatment

Relapse of RTIs< 2
(follow-up period 7-12 months

Total PDT 1912 C 1848

RR 1.59 (1.45, 1.74) International Immunopharmacology. 2019; 67:35–45
Results

PDT could significantly decrease the duration of cough (RR -1.59; 95% CI -2.53,-0.65,
p < 0.00001)
International Immunopharmacology. 2019; 67:35–45
PDT could significantly decrease the duration of fever (RR -1.68; 95% CI -2.12,-1.12,
p < 0.00001)
International Immunopharmacology. 2019; 67:35–45
The number of patients in using antibiotics was also remarkably decreased in the PDT
treatment group (RR 0,41; 95% CI 0.32,0.51, p < 0.00001)

International Immunopharmacology. 2019; 67:35–45

When the cough does not improve: a review on
Protracted Bacterial Bronchitis in children
Galluci M, et al. Frontiers in Pediatr. 2020;8(433):1-7

• Clinical diagnosis is enough to start an empiric antibiotic

Amoxicillin-clavulanic acid for 2 weeks
 Efficacy of fiberoptic bronchoscopy and
bronchoalveolar lavage in childhood‐onset,
complicated plastic bronchitis
Wang L, et al. Pediatr Pulmonol. 2020;55(11):3088-95

Early FOB and BAL were effective in alleviating clinical findings,

atelectasis, and airway obstruction. Serial FOB could be
performed in patients with recurrent symptoms
THANK YOU