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  REPORT OF PBL

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“MODUL 2 – BREATHLESS”

RESPIRATORY SYSTEM

TUTOR : dr. Yani Sodiqah

GROUP 14:

NURUL SALSABILAH MUSTAJAR : 110 2014 0035

MUHAMMAD ALGHIFARI SULKAF : 110 2014 003

INDAH KURNIA RAMADHANI! M : 110 2014 00"#

MUHAMMAD $UHAL DAR%IS : 110 2014 00&5

ADE NO'ITA SAM : 110 2014 00#3NUR A$I$AH ALFIYAH! A : 110 2014 00#4

FENNY PUTRIANA SALIM : 110 2014 010

%IDYA KEMALASARI : 110 2014 011#

SITTI MUTMAINNAH : 110 2014 0134

SESARIH FATIMAH NUR!B : 110 2014 0143

MEDICAL FACULTY 

MUSLIM UNIVERSITY OF INDONESIA

MAKASSAR

2015

Case 2

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A 7 years old girl was a!en o he hos"ial e#ergen$y roo# %y her "arens

$o#"laining o& shorness o& %reah sin$e 4 ho'rs ago. Tha $hild had %een s'&&ering &ro#

shorness o& %reah 2 years ago. This $o#"lain is so#ei#es a$$o#"anied %y a $o'gh and

&e(er. On "hysi$al e)a#inaion he $hild loo!s $yanosis* res"iraory rae 4+ i#es wih $hes

wall rera$ion. The sa#e hisory in %oh "arens is denied.

,i&&i$'l -ords :

1. Cyanosis : is a %l'ish s!in d'e o e)$essi(e a#o'n o& deo)y% in %lood (essels o& s!in*

  es"e$ially $a"illaries

2. Rera$ion : wihdrawal lower $hes wall when %reahing in $on/'n$ion wih in$reased

Res"iraory rae

0. Shorness o& %reah : ,ys"nea is s'%/e$i(e sy#"o#s s'$h as "eo"le wih a desire o

n$rease e&&ors o o%ain %reahing air 

eywords :

• 7 years old girl

• Shorness o& %reah sin$e 4 ho'rs ago

• A$$o#"anied %y $o'gh 3 &e(er 

• ad %een s'&&ering &ro# shorness o& %reah 2 years ago

• oo!s $yanosis* res"iraory rae 4+ i#e wih $hes wall rera$ion

• Sa#e hisory in %oh "arens denied

5'esions :

1. -ha is he "ao"hysiology o& dys"ne' %ased on s$enario6

2. -ha is he relaion %eween dys"ne' and &e(er6

0. -ha is he Anao#y o& Res"iraory Tra$6

4. -hy he $hild loo!s $yanosis6

. -hy he res"iraory rae is 4+ i#e on "hysi$al e)a#inaion6

8. -hy is he $hes wall rera$ion on "hysi$al e)a#inaion6

7. -ha is he #os $a'se o& dys"ne' in $hildren6

9. -ha is he di&&erenial diagnosis o& he $ase6

. -ha is he way o diagnose6

1+. -ha is he hera"y %ased on he di&&erenial diagnose in he $ase6

Answers :

1. -ha is he "ao"hysiology o& dys"ne' %ased on s$enario6 

;e$hanis# o& dys"nea

Si#ilarly* re&le) $he#osi#'laion %y CO2 $a'ses dys"nea* e(en in he "resen$e o& 

res"iraory #'s$le "aralysis or $ord ranse$ion* indi$aing ha re&le) $he#ore$e"or 

3

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si#'laion "er se is dys"nogeni$. Sensory a&&erens in he (ag's ner(es ha(e %een $onsidered

o %e $losely asso$iaed wih dys"nea.1

,ys"nea is asso$iaed wih a$i(aion o& he li#%i$ syse#* es"e$ially he ins'lar area.

These &indings "er#i a $learer 'ndersanding o& he #e$hanis#s o& dys"nea: A&&eren

in&or#aion &ro# re&le) si#'laion o& he "eri"heral sensors o he

sensori#oor $ore) and res'ls in he sensaion o& dys"nea. 1

2. -ha is he relaion %eween dys"ne' and &e(er 6

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?e(er : ;i$rooganis# r'ns o he %lood and will %e "hago$ye %y #a$r"hages and

ly#"ho$ye wih gran'lar and re#o(ed a&er ha @1 will %e realesed à  PG e2

wor! in hi"ohala#'s à &e(er rea$ion

y"erse$reion o& #'$o's gland a$'#'laed in res"iraory ra$< Go%le $ell> à The

ariway %e$o#e o%sr'$ion

Allergens à Release

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Airway Tra$

- 7+8 (+,

- P+)9(

- L+)9(

- T)+*+- 7+86+, 6-)+,

- P-

- B)-(,

R*,;)+6-)9 M,*,

ns"iraion

• ,ia"hrag#a

• ner$osal e)erna

• Pe$oralis #a/or 

• S$alene's

•

Serno$leido#asoide's

• Serra's anerior 

B)"iraion

• ner$osal inerna

• Re$'s a%do#inis

• Trans(ers's a%do#inis

• O%liq's a%do#inis in e e)8

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4. -hy he $hild loo!s $yanosis6

Cyanosis er# #eans %l'ish s!in. Cyanosis is a "hysi$al sign o& he $hara$erisi$s o& 

he #'$o's #e#%ranes* nail %eds* and %l'e s!in. The $a'se is he#oglo%in ha does no

$onain e)$essi(e a#o'ns o& o)ygen in he %lood (essels o& he s!in* es"e$ially in he

$a"illaries. o)ygenaed he#oglo%in ha does no ha(e a dar! %l'e@"'r"le $olor ha is (isi%le

hro'gh he s!in. in general* $yanosis a""ears when he arerial %lood $onains #ore han gra#s o& he#oglo%in ha $onains no o)ygen in e(ery 1++ #l o& %lood.7

Paiens wih dys"nea is one o& he $a'ses o& res"iraory gas a%nor#aliy in %ody &l'ids*

es"e$ially hy"er$a"nia and hy"o)ia. Too lile o& o)ygen in he air and oo lile he#oglo%in

ha $a'sed %y hi"o!sia #a!es he $hild loo!s $yanosis.7

. -hy he res"iraory rae is 4+ i#e on "hysi$al e)a#inaion6

n general shorness o& %reah o$$'rs d'e o in&la##aion o& he res"iraory ra$

$a'sed %y in&e$ion or irriaion o& he res"iraory ra$. Shorness o& %reah #ay o$$'r &ro# a

(ariey o& #e$hanis#s s'$h as i& he s"a$e "hysiology in$reases will %e $a'ses he disr'"ion

in e)$hange %eween O2  and CO2  $a'sing (enilaion req'ire#en in$reased. Ca'sing

shorness o& %reah in nor#al "eo"le dead s"a$e hese are &ew and no (ery i#"oran* %' in

 "eo"le in a sae o& "ahologi$al ra$ res"iraory he dead s"a$e will in$rease.2

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Si#ilarly* i& an in$rease in he e)$hange o& "risonerd airway will also %e a&&e$ed and

#ay also $a'se shorness.2

Tighness #ay also o$$'r in "eo"le who de$lined o "'l#onary $o#"lian$e* he lower 

he a%iliy o& he l'ng $o#"lian$e* he greaer he rans#'ral "ress're gradien whi$h $an

$'r(e &or ins"iraion o "rod'$e nor#al l'ng de(elo"#en. Ca'ses o& de$line in l'ng

$o#"lian$e $an (ary one o& whi$h was he re"la$e#en o& l'ng iss'e wih &i%ro's $onne$ed

iss'ed d'e o inhalaion o& irrians as%son or si#ilar.2

8. -hy is he $hes wall rera$ion on "hysi$al e)a#inaion6

On "hysi$al e)a#inaion o& he ash#a %ron$hial* here are no generally a%nor#aliies

when "aiens do no e)"erien$e an aa$!. -hen he aa$!* $an %e &o'nd shorness o& %reah*

$hes hy"erin&laion* $hes indrawing * e)"iraion lenghwise wih a'di%le wheeDe.

Rera$ion indi$ae a &or$ed %reahing. n$reasing %reahing wor! in ash#ai$s res'led in he

ne$! and iner$osals #'s$les .0*4

7. -ha is he #os $a'se o& dys"ne' in $hildren6

The $a'se o& dis"nea on $hild.

@ B)"os're o en(iron#enal $ondiions &or $erain #edi$aion:

1.> Allergen* s'$h as "ollen* &'ng's or $he#i$als res'ling in a $o#"lain &or#

 %ron$hos"as# wih shorness o& %reah.

2.> ,'s* s#o!e* $igaree s#o!e* and oher $he#i$al $an $a'se irriaions o& he airway

ha $a'se o& %ron$hos"as#.

0.> ,r'gs $ons'#"ion=in/e$ion $an $a'se hy"ersensii(iy.9

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9. -ha is he di&&erenial diagnosis o& he $ase6

Sy#"o#s ,ys"ne' Co'gh ?e(er -heeDin

g

Rera

$ion

Cyanos

is

a% Rad

Ash#aron$hial

E E E=@ E E E GA F@Ray

ron$hiis

Chroni$

E E E E=@ E E e'$o$ye F@Ray

ron$hial ash#a

ron$hial ash#a is an in&la##aory airway disorder ha in(ol(es a lo o& 

in&la##aory $ells and #ediaors . Ash#a $an %e #ild and do no iner&ere wih he a$i(iy *

 %' here is also he na're o& he hea(y and disr'"i(e a$i(iy .

Ash#a is !nown %y hisory o& res"iraory sy#"o#s s'$h as wheeDing * shorness o& 

 %reah * $hes disress and $o'gh ha (ary o(er i#e and in inensiy * along wih e)"iraory

air&low li#iaion .

7(+ ,9;6-,

1. $o'ghing '" "hleg# worsened in he #orning and e(ening.

2. shorness

0. wheeDing on a's$'laion

4. a hea(y aa$! 'sed a %reahing #'s$les < rera$ions s'"ra$la(i$'la * iner$osal * and

e"igasri$ >

T* ;)-;*)6*, -. 69;+ ,9;6-, -. +,6+

1. sy#"o#s o$$'r re"eaedly < e"isodi$ >

2. e#%ossed i#e = "ari$'lar season < "eriodi$ >

0. hea(y@ligh di&&eren sy#"o#s < (aria%le >

4. $an re$o(er = disa""ear s"onaneo'sly or wih #edi$aion < re(ersi%le >

. here is a hisory o& ash#a = allergy ohers < ao"y > in "aiens or heir &a#ilies

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8. here are (ario's &a$ors < rigger>

P)*;6+6(< .+6-),

1. allergens < ho'se d's * ani#al dander >

 2. &ood < s"i$es * &la(orings * "reser(ai(es >

 0. Res"iraory ra$ in&e$ions

 4. Changes in he weaher 

 . Che#i$als and "har#a$e'i$als

 8. e)$essi(e a$i(iy

 7. irrians

 9. The s#ell ha si#'laes

 . e#oion

ron$hiis $hroni$ is a res"iraory disease ha is o&en a$q'ired in he $o##'niy.

The disease is a "'%li$ healh "ro%le# %e$a'se i is $hroni$* "ersisen and "rogressi(e.

Res"iraory in&e$ions are a $o##on $lini$al "ro%le# in "aiens wih $hroni$ %ron$hiis

whi$h #ay aggra(ae he disease. A$'e e)a$er%aion o& $hroni$ %ron$hiis in&e$ions whi$h

#ay aggra(ae he disease. B)a$er%aion o& a$'e in&e$ion will a$$elerae he da#age ha

has o$$'rred* in addiion o he ger#s ha $a'se e)a$er%aion also a&&e$s he #or%idiy o& 

his disease. The illness lass longer han a$'e %ron$hiis* whi$h lass &or one year wih a

&req'en$y o& "rod'$i(e $o'gh &req'en$y 0 #onhs &or 2 years in a row.1+

A. Bhiolgy

S#o!ing or e)"os're o "oll'ion is a #a/or $a'se $hroni$ o& %ron$hiis. Paiens wih

$hroni$ %ron$hiis are #ore s's$e"i%le o re$'rren$e o& lower res"iraory ra$ in&e$ion. The

range o& (iral in&e$ions* %a$eria* and %road #i!ro"las#a $an $a'se e"isodes o& a$'e

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 %ron$hiis. B)a$er%aion o& $hroni$ %ron$hiis is al#os $erainly he $ase d'ring he winer.

reahing $old air $an $a'se %ron$hos"as# &or he ('lnera%le.11

There are se(eral &a$ors ha he eiology o& $hroni$ %ron$hiis* na#ely:

1. Cigarees

There is a $lose relaionshi" %eween s#o!ing and a de$rease in BP

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n'#%er* he &'n$ion o& $ilia de$reases* and #ore #'$'s is "rod'$ed. As a res'l* he

 %ron$hioles %e$o#e narrowed and $logged.12

Sr'$'ral $hanges in he l'ngs $a'sing "hysiologi$al $hanges whi$h are

$hara$erisi$s o& $hroni$ %ron$hiis li!e $hroni$ $o'gh* s"''# "rod'$ion* airway

o%sr'$ion*disr'"ion o& gas e)$hange* "'l#onary hy"erension and $or@"'l#onale.12

,'e o he $hangeo& %ron$hial and al(eolar an inerr'"ion o$$'rs in gas e)$hange.

$a'sing wo serio's "ro%le#s* na#ely:

1. lood &low and air &low o he walls o& he al(eoli ha no a""ro"riae

.;os "la$es here is adeq'ae %lood &low %' (ery

lile &low2. air and "arly elsewhere insead. Per&or#an$e is de$lining &ro# he "'#"

res"iraion es"e$ially he #'s$les o& res"iraion res'ling in o(erin&lasi and

narrowing o& he airway* $a'sing hy"o(enilaion and ins'&&i$ien air o he

al(eoli $a'sing %lood CO2in$rease and O2 in he %lood de$rease.12

. -ha is he way o diagnose6

Se" o diagnose

isory Ta!ing

Physi$al B)a#inaion

a%oraory

Radiology

Ohers10

Ana#nesis

1. L-+6-(! -here is i6 ,oes i radiae6

2. =+69! -ha is i li!e6

0. =+(669 -) ,*8*)69! ow %ad is i6

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4. T( i sar6 ow long did i las6 ow o&en did i

$o#e6

. S*66(< ( > 6 -),!  n$l'de en(iron#enal &a$ors* "ersonal a$i(iies*

e#oional rea$ions* or oher $ir$'#san$es ha #ay ha(e $onri%'ed o he illness.

8. R*66(< -) *+*)/+6(< .+6-),! ,oes anyhing #a!e i %eer or worse6

7. A,,-+6*? +(.*,6+6-(,! a(e yo' noi$ed anyhing else ha a$$o#"anies i610

Physi$al B)a#inaion

SPBCTO :

- Sha"e and SiDe Thora$i$* i& hereHs any de&or#iy or no. ,e&or#iy o& $hes wall $an

$a'se "ro%le# o& %reahing

- S'r&a$e $hes

ner"reaion :

n$rease ol'#e : e#&ise#a* e&'si* "ne'#oora)

,e$rease ol'#e : aele$asis*&i%oro$is* S$hware 

- Res"iraory #'$le hel"* #eans we did &or$e ins"iraion

-Cosae and ner$osae* i& hereHs any &ra$'re or no- ?ossa I'g'laris* nra 3 S'"ra $la(i$'laris* o see in(ol(e#en o& hear in "ro%le# o& 

 %reahing

- Ty"e and &req'en$y o& res"iraory* o see i& iHs a$y"ne' or dys"ne'

PAPATO

- Posiion o& #ediasin'#: ra$hea* i$'s. ,e(iaion o& #ediasin'# $an %e a #ar!er o

ideni&y he disease

,e(iaion o a healhy side : &l'id* air* #assa

,e(iaion o $onralaeral side : &i%rosis* s$hware* aele$asis

- Thro%%ing (i%raion* '#"* ede#a* $re"i's- Tenderness

- o$al &re#i's* $o'ld %e de$rease or in$rease. n$rease ha""en in "ne'#onia* while

de$reasing ha""en in aele$asis* or "le'raHs e&&'sion

PBRCUSSO

n hora) area* in nor#al $ondiion will %e heard sonor so'nd in he l'ng

AUSCUTATO

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- reah So'nd

Ron$hi : is a shor dis$onin'e so'nd ha heard when ins"iraion. B) : o%sr'$ion

-heeDing: is a so'nd ha heard when hereHs a narrowing o& res"iraory ra$. B) :

ash#a* %ron$hiis

Sridor : is a "ahology so'nd ha o$$'r when hereHs o%sr'$ion in laryng or ra$hea

ron$ho(esi$'ler : is a nor#al %reahso'nd ha heard i& we "' sheos$o" near he

hill's o& he hora)

- -his"ering So'nd

 or#al : i& heard in laryng

Pahology : Consolidaion* aele$asis

Addiional B)a#inaion

S;)-*6)9

7(+ (?+6-(,

- To e(al'ae sy#"o#s* signs or a%nor#al es res'ls.

- Pro(ide o%/e$i(e* q'ani&ia%le #eas'res o& l'ng &'n$ion.

- B(al'ae and #onior disease.

- Assess e&&e$s o& en(iron#enal=o$$'"aional=dr'g e)"os'res %oh ad(erse and %ene&i$ial .

- Pre@o"erai(e assess#en.

- B#"loy#en=ins'ran$e assess#en.

- Barly dee$ion o& %ron$hioliis o%lierans in l'ng rans"lan "aiens.10

P+6*(6 ;)*;+)+6-(

1. B)"lain wha he es in(ol(es. ;os res"iraory e$hni$ians de#onsrae e$hniq'e o

ens're #a)i#al e&&or and $oo"eraion o& "aien.

2. Paien #'s &'lly inhale %e&ore es.

0. B)hale ino %reahing '%e. ;'s %e #a)i#al e&&or wih no hesiaion.

4. o $o'gh=gloal $los're in he &irs se$ond.

. Tes #'s las a leas 8s .

8. o e(iden$e o& air&low lea!=o%sr'$ion o& #o'h"ie$e.10

I(6*);)*6+6-(

A leas hree a$$e"a%le ra$ings sho'ld %e o%ained. B)a#ine ea$h ra$ing o ens're

adeq'ae e&&or #ade %y "aien* ha i is re"rod'$i%le* and ha here are no are&a$s.

?B=?C raio: nde) o& he "resen$e=a%sen$e o& air&low li#iaion.

  Yo'ng and #iddle aged healhy non@s#o!ers rae J7K.

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  Older nor#al "aiens raio 7+L7K.

?B=?C ,e$reased: O%sr'$i(e.

 Classi&y se(eriy 'sing ?B* e)"ressed as K o& "redi$ed (al'e* e.g.

COP,* ash#a.

?B=?C &la or in$reased : Resri$i(e %' need red'$ed TC o $on&ir#* e.g. l'ng &i%rosis*

$hes wall "ro%le#s* "'l#onary e&&'sion and oede#a.10

S;6 )-,-;9 @ 6)*,;6 96--

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- Staphylococcus aureus and Pseudomonas li!ely in %ron$hie$asis.

@ oso$o#ial in&e$ions:

 L Staphylococcus aureus.

 – Pseudomonas.

 – Klebsiella.

 – Bacteroides.

 – Gra# L(e enero%a$eria.

@ Adeno$ar$ino#a and s#all $ell l'ng $an$er diagnosi$.

@ Sq'a#o's $ell $ar$ino#a on $yology $an re&le$ "re#alignan $hange.10

R+?--

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Trea#en o& se(ere ash#a. n $ases o& inadeq'ae ash#a $onrol* an in$reased CS dose

o& '" o 9++ lg ,P eq'i(alen $an %e 'sed a he dis$reion o& he "res$ri%ing

 "hysi$ian. Paiens req'iring higher doses sho'ld %e re&erred o a s"e$ialis. The

e&&i$a$y=sa&ey raio o& ro'ine oral seroids (s high@dose CS generally &a(ors CS. Se(ere

ash#a #ay req'ire reg'lar rea#en wih an oral $ori$oseroid . Prior o rea#en* naional g'idelines on age@relaed indi$aions sho'ld %e re(iewed.

Ash#a $onrol and #ainenan$e hera"y #'s %e assessed reg'larly and s"e$ialis $are

sho'ld %e so'gh when low@dose CS "l's add@on #edi$aion

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se(eral s'dies ha(e re"ored ha 'se o& inhaled $ori$oseroids in early in&an$y has no e&&e$

on he na'ral hisory o& ash#a or de(elo"#en o& wheeDe laer in $hildhood.

 A,6+ 6)*+6*(6 ( ?)*( +

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inhaled AA in addiion o CS.

There is a "ossi%iliy o& de(elo"ing oleran$e o inhaled %2 agoniss 'sed on a reg'lar %asis

. n so#e "aiens* he $o#%inaion o& CS* TRA and inhaled AA #ay %e needed o

 "re(en e)er$ise@relaed sy#"o#s. "raro"i'# %ro#ide #ay %e ried a&er indi(id'al

assess#en* %' is 's'ally added o oher rea#ens. n $erain $ir$'#san$es TRA alone #ay %e ried* %' sho'ld %e $learly &ollowed '" &or 

assess#en o& rea#en e&&e$. oe ha la$! o& res"onse o rea#en #ay indi$ae

#isdiagnosis o& e)er$ise@ind'$ed ash#a and "aiens #ay req'ire reassess#en.

A,6+ 6)*+6*(6 ( ?)*( + o"ions:

o Add AA a leas iner#ienly

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• ;ain hera"y

Ani%ioi$ hera"y in a$'e %ron$hiis is no re$o##ended 'nless a$$o#"anied %y &e(er and a

$o'gh ha lass #ore han 8 days* s's"i$ion he in(ol(e#en o& res"iraory ra$ %a$eria s'$has S. "ne'#oniae* . n&l'enDae ?or "ersisen $o'ghJ 1+ days s's"e$ed

;y$o%a$eri'# "ne'#oniae in(ol(e#en so ha he 'se o& ani%ioi$s re$o##ended. ?or 

$hildren wih $o'ghJ 4 wee!s sho'ld 'ndergo &'rher e)a#inaion o& he "ossi%iliy o& 

'%er$'losis* "er'ssis or sin'siis.

Clini$al Condiions Paogen Barly Thera"y

ron!hiis a$'e $o##only (ir's ini : wiho' ani%ioi!a

ini :A#o!sisilin*a#o!si@!la(*

#a!rolida

ron!hiis roni!   H.influenzae,

 Moraxella catarrhalis,

S. pneumoniae

ini : A#o!sisilin

ini : A#o!si@!la(*

aDiro#isin* !ori#o!saDol

ron!hiis roni! wih

$o#"li$aions

s.d.a* K. Pneumoniae,

 P. aeruinosa* Gra#

%aang lain

ini : Ce&aDidi#e* Ce&e"i#e

ron!hiis !roni! wih

 %a$eri in&e$ions

s.d.a. ini : ;ero"ene# aa'

Ce&aDidi#e=Ce&e"i#eECi"ro&lo!s

asin oral.

Ani%ioi$s ha $an %e 'sed see a%le .1* wih long hera"y @ 14 days whereas $hroni$

 %ron$hiis o"i#al &or 14 days Gi(ing ani(iral a#anadine #ay i#"a$ shoren

long illness i& gi(en wihin 49 ho'rs a&er in&e$ion wih in&l'enDa (ir's A.

• S'""oring Thera"y

20

8/16/2019 KLP 14 Modul 2

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Q So" s#o!ing* %e$a'se s#o!ing $an hwar #e$hanis# he %odys de&enses

Q ron!hodilasi 'sing sal%'a#ol* al%'erol.

Q analgesi$s or ani"yrei$s 'sing "ara$ea#ol*SA,s.

Q Ani'si(* $odeine or de)ro#eor&an o s'""ress $o'gh.

Q a"oriDer 

DAFTAR PUSTAKA

1.  a'sherwan . 'r!i* ;,* Ph,* ?CCP and '@Y'an ee* Ph,. ;e$hanis#e o&

dys"nea. 2+1+. www.n$%i.nl#.nih.go(

2. BliDa%eh. I. $orwin. '!' Sa!' Pao&isiologi. Bdisi re(isi 0. Ia!ara:BGC. 2++.

ala#an 41 L 44

0. Tano $hris e al. a"ia Sele!a edo!eran Bd 4. Iilid 1. Ia!ara: ;edia Aes$'la"i's

2+14. Page 184.

4. -. S'doyo Ar' e al. '!' A/ar l#' Penya!i ,ala#. Iilid . Bd . 2++. Ia!ara:

nerna P'%lishing. Page 21+.

.  Price, Syl!ia, "orraine M. #ilson. $%%& Patofisioloi Konsep Klinis Proses Penya'it *

ol. 2* Bd. 8* "". 790@72: Pener%i '!' edo!eran BGC* Ia!ara8. Sherwood* a'ralee. '#an Phisiology. Cell o syse# Bd.9 . BGC. Ia!ara. Page 499

7. G'yon and hall. '!' a/ar &isiologi !edo!eran. Singa"ore : Blse(ier. Bd. F. hal

9

9. -. S'doyo Ar' e all. '!' A/ar l#' Penya!i ,ala#. Iilid . Bd . 2++. Ia!ara:

nerna P'%lishing. Page 219.

. '!' A/ar l#' Penya!i ,ala#. BGC : Ia!ara.

1+. AnD'eo AR* S$ha%erg T. A$'e e)a$er%aion o& Chroni$ %ron$hiis. ondon. S$ien$e

Press d. 2++0

11. Pillee C* 5'adrhiri Y* Godding * aer#an IP* Si%ille Y. 'ng ;'$osal ##'niy :

##'noglo%'lin@A re(isied. B'r Res"ir I 2++1 19 : 71@99

21

http://www.ncbi.nlm.nih.gov/http://www.ncbi.nlm.nih.gov/

8/16/2019 KLP 14 Modul 2

22/22