PNEUMOTORAKS
REFERAT
Oleh: Aissyiyah Nur An Nisa
0610710006
Amaylia Fitria Dewi
0610710009
Ardhan Pr Prahara Pu Putra
0610710017
Fahima Hidayatullah P.
0610710044
Marina Yunita
0610710079
Pembimbing : dr. Soebagjo, Sp.B(K)TKV
LABORATORIUM/SMF ILMU BEDAH FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA RUMAH SAKIT UMUM DR.SAIFUL ANWAR MALANG 2011
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iii
HALAMAN PENGESAHAN
REFERAT
PNEUMOTORAKS
Oleh : Aissyiyah Nur An Nisa
0610710006
Amaylia Fitria Dewi
0610710009
Ardhan Prahara Putra
0610710017
Fahima Hidayatullah P.
0610710044
Marina Yunita
0610710079
Menyetujui :
Pembimbing I
dr. Astrid Jessica
Pembimbing II
dr. Soebagjo, Sp.B-(K)TKV Sp.B-(K) TKV
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iv
DAFTAR ISI
Halaman Judu Judull ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ........ ........ ........ ........ ....
i
Hala Halaman man Peng Pengesa esahan han.... ....... ....... ....... ...... ....... ....... ....... ....... ....... ....... ....... ....... ....... ........ ....... ....... ........ ....... ....... ....... ...... ...
ii
Dafta Daftarr Isi ..... ......... ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ........ ......... ......... ........ ........ ......... .....
iiiiii
BAB BAB I: PENDA PENDAHU HULU LUAN AN ....... .......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...
1
1.1 1.1 Lata Latarr Bela Belaka kang ng ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... ..
1
1.2 Rumu Rumusa san n Masa Masala lah h ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ....... ...
1
1.3 Tuju Tujuan an Penel Penelit itia ian n ....... .......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ....... ...
2
BAB BAB II: II: TINJ TINJAU AUAN AN PUS PUSTA TAKA KA ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ....
3
.................................... ........................ .................................................. ...................................... 2.1 Definisi........................
3
2.2 2.2 Epid Epidem emol olog ogii ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ... 2.3 2.3 Klas Klasif ifik ikas asii Pneu Pneumo moto tora raks ks Ber Berda dasa sark rkan an Mek Mekas asni nism sme e Keja Kejadi dian an .
4 5
2.3. 2.3.1 1 Pneu Pneumo moto tora raks ks Spon Sponta tan n .... ...... .... .... .... .... .... .... .... .... ..... ...... ..... ..... ...... ..... ..... ...... ...... ..... .... ..
5
2.3. 2.3.1. 1.1 1 Pneu Pneumo moto tora raks ks Spon Sponta tan n Prime Primer. r... .... .... .... ..... ...... ..... ..... ...... ...... ..... ....
5
2.3. 2.3.1. 1.2 2 Pneu Pneumo moto tora raks ks Spon Sponta tan n Seku Sekund nder er ………… …………… …... ......
9
2.3. 2.3.2 2 Pneu Pneumo moto tora raks ks Trau Trauma matitikk ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ...... ..
10
2.3. 2.3.2. 2.1 1 Pneu Pneumo moto tora raks ks Tra Traum umat atik ik Lat Latro roge geni nik. k... ..... ...... ...... ...... ...... ..... ..
10
2.3. 2.3.2. 2.2 2 Pne Pneum umot otor orak akss Trau Trauma mati tikk Non Non Latr Latrog ogen enik ik... ...... ..... ..... ..... ..
10
2.4 Klasifikasi Pneumotoraks Berdasarkan Berdasarkan jenis jenis Fistu Fistula lanya nya...... ........... ........ ....... ....... ....... ....... ....... ........ ....... ....... ........ ....... ....... ....... ...... ....... ....... ....... ....... .....
11
2.4. 2.4.1 1 Pne Pneum umot otor orak akss Tertu Tertutu tup. p.... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ....... ....... ........ ...... ..
11
2.4. 2.4.2 2 Pneu Pneumo moto tora raks ks Terb Terbuk uka. a.... ...... ...... ...... ...... ...... ...... ....... ........ ........ ........ ........ ........ ........ ...... ..
12
2.4. 2.4.3 3 Pneu Pneumo moto tora raks ks Venti Ventil. l.... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... ..
12
2.5 2.5 Pato Patofifisi siol olog ogii Pneu Pneumo moto tora raks ks ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ........ ........ ......
13
2.6 2.6 Diag Diagno nosi siss Pneu Pneumo moto tora raks ks... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ....
16
2.6. 2.6.1 1 Kelu Keluha han n Suby Subyek ektitif. f.... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...
16
2.6. 2.6.2 2 Pem Pemer erik iksa saan an Fisi Fisik. k.... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ........ ........ ........ ...... ..
17
2.6. 2.6.3 3 Pemer Pemerik iksa saan an Pen Penun unja jang ng
17
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v
2.7. 2.7.2 2 Pena Penata tala laks ksan anaa aan n Pneu Pneumo moto tora raks ks Tert Tertut utup up.. .... .... .... .... .... .... .... .... .... .... .... .
18
2.7. 2.7.3 3 Penat Penatal alak aksa sana naan an Pneu Pneumo moto tora raks ks Terb Terbuk uka… a…........ ......... ...... ...... ...... .....
19
2.7. 2.7.4 4 Pena Penata tala laks ksan anaa aan n Tens Tensio ion n Pneu Pneumo moto tora raks ks.... ........ ....... ....... ........ ......... .....
19
2.7. 2.7.4. 4.1 1 Need Needle le Theo Theora raco cost stom omy. y.... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ....... ..... ..
19
2.7. 2.7.4. 4.2 2 Pema Pemasa sang ngan an Ches Chestt Tube. Tube... .... .... .... ..... ..... ..... ...... ...... ..... ..... ...... ..... ..... .....
20
2.8 2.8 Komp Komplilika kasi si Pneu Pneumo moto tora raks ks ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ........ ........ ....
20
BAB BAB III: III: PEN PENUT UTUP UP…… ………. ….... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ........ ........ ........ ........ ....... ...
22
3.1 3.1 Kesi Kesimp mpul ulan an... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... ..
22
DAFT DAFTAR AR PUST PUSTAK AKA A ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ....... ........ ........ ....... ...... ...
23
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vi
BAB I PENDAHULUAN
1.1.
Latar Belakang
Pneumotor Pneumotoraks aks didefinis didefinisikan ikan sebagai sebagai adanya adanya udara udara atau gas dalam dalam rongga pleura, yaitu, di ruang potensial antara pleura viseral dan parietal paruparu. Hasilnya adalah kolaps dari paru-paru pada sisi yang terkena. Udara bisa masuk ruang intrapleural melalui komunikasi dari dinding dada (yaitu, trauma) atau melalui parenkim paru-paru di pleura viceralis. Hasil dari terapi pada 480 penderita dengan fraktur multiple costa dan dihubungkan pada trauma dada yang telah dianalisa. Berdasarkan dari trauma; 55 (25,5% (25,5%)) pasien pasien pneumo pneumotor toraks aks yang yang berkem berkemban bang g menja menjadi di 71 (32,8% (32,8%))hemathorax, 90(41,7%)-hemopneumotoraks 90(41,7%)-hemopneumotoraks.. Terapi konservatif dari pneumo dan hemotorak hemotorakss dalam dalam beberapa beberapa kasus kasus kebanyak kebanyakan an (biasany (biasanya a dilakuk dilakukan an tusukan tusukan pada pada rongga rongga pleura, pleura, jarang jarang dilak dilakuka ukan n draina drainage ge). ).
Pada Pada 47 penderit penderita a yang yang
berkaitan dengan trauma yang dengan forced position (posisi setengah duduk), Bertujuan untuk kateterisasi pada cavum pleura dengan menggunakan stiletto trocar melengkung dibawah sudut 60 derajat. Pada terapi clotting hematothoraks digun digunaka akan n strept streptoki okinas nase e yang yang tercat tercatat at berefe berefekk positi positiff pada pada 6 dari dari 7 pasie pasien. n. Indika Indikasi si untuk untuk torako torakotom tomii dibata dibatasi si pada pada pasie pasien n dengan dengan trauma trauma dada dada yang yang berhubungan dengan shock dan kehilangan darah akut (Rebecca B, 2011). 1.2.
Rumusan Masalah
1. Apa etiologi pneumotoraks?
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vii
4. Apa saja saja saja komplikasi komplikasi yang dapat dapat terjadi pada pada pneumotoraks? pneumotoraks? 1. 3
Tujuan Penelitian 1. Untuk mengetahui etiologi pneumotoraks 2. Untuk dapat menegakkan menegakkan diagnosa pneumotoraks
penetalaksanaan pneumotoraks 3. Untuk mengetahui penetalaksanaan 4. Untuk tuk
mengetah tahui
pneumotoraks
komplikasi
yang
dapat
terjadi
pada
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viii
BAB II TINJAUAN PUSTAKA
2.1 Definisi
Pneumotoraks adalah penumpukan udara yang bebas dalam dada diluar paru yang menyebabkan paru kolaps. Pneumotoraks merupakan suatu kondisi dimana terdapat udara pada kavum pleura. Pada kondisi normal, rongga pleura tidak terisi udara sehingga paru-par paru-paru u dapat dapat leluasa leluasa mengemba mengembang ng terhadap terhadap rongga rongga dada. dada. Udara Udara dalam dalam kavum pleura ini dapat ditimbulkan oleh : 1. Robekn Robeknya ya pleur pleura a visera viseralis lis sehing sehingga ga saat saat inspir inspirasi asi udara udara yang yang berasal dari alveolus akan memasuki kavum pleura. Pneumotoraks jenis ini disebut sebagai closed pneumotoraks. Apabila kebocoran pleura viseralis berfungsi sebagai katup, maka udara yang masuk saat inspirasi tak akan dapat keluar dari kavum pleura pada saat eksp ekspir iras asi. i. Akib Akibat atny nya, a, udar udara a sema semaki kin n lama lama sema semaki kin n bany banyak ak sehin sehingga gga mendo mendoron rong g media mediasti stinu num m kearah kearah kontra kontralat latera erall dan dan menyebabkan menyebabkan terjadinya tension pneumotoraks. 2. Robeknya Robeknya dinding dinding dada dan pleura pleura parietal parietalis is sehingga sehingga terdapat terdapat
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ix
akibatnya udara dari kavum pleura keluar melalui lubang tersebut. Kondisi ini disebut sebagai open pneumotoraks (Berck, 2010). 2.2 Epidemiologi
Pneumoto Pneumotoraks raks dapat dapat diklasifi diklasifikasi kasikan kan menjadi menjadi pneumotor pneumotoraks aks spontan dan traumatik. Pneumotoraks spontan merupakan pneumotoraks yang yang terja terjadi di tiba-t tiba-tiba iba tanpa tanpa atau atau dengan dengan adanya adanya penyak penyakitit paru paru yang yang mendasar mendasari.i. Pneumotor Pneumotoraks aks jenis jenis ini dibagi dibagi lagi menjadi menjadi pneumotor pneumotoraks aks primer (tanpa adanya riwayat penyakit paru yang mendasari) maupun sekunder (terdapat riwayat penyakit paru sebelumnya). Insidensinya sama antara pneumotoraks primer dan sekunder, namun pria lebih banyak terkena dibanding wanita dengan perbandingan 6:1. 6:1. Pada Pada pria, pria, resiko resiko pneum pneumoto otorak rakss sponta spontan n akan akan mening meningkat kat pada pada perokok perokok berat berat dibandin dibanding g non perokok. perokok. Pneumoto Pneumotoraks raks spontan spontan sering sering terjadi pada usia muda, dengan insidensi puncak pada dekade ketiga kehidupan kehidupan (20-40 tahun). Sementara itu, pneumotoraks traumatik dapat disebabkan oleh trau trauma ma lang langsu sung ng maup maupun un tida tidakk lang langsu sung ng pada pada dind dindin ing g dada dada,, dan dan diklasifikasikan diklasifikasikan menjadi iatrogenik maupun non-iatrogenik. Pneumotoraks iatro iatroge genik nik merup merupaka akan n tipe tipe pneum pneumoto otorak rakss yang yang sangat sangat sering sering terjad terjadii (Berck, 2010).
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x
Incidens pada usia tertentu: 7,4-18 kasus per 100.000 orang per tahun pada laki-laki 1,2-6 kasus per 100.000 orang per tahun pada perempuan
•
Pneumotoraks spontan sekunder
Umur : Puncak kejadian di usia 60-65 tahun insidensi 6,3 kasus per 100.000 orang per tahun pada laki-laki 2,0 kasus per 100.000 orang per tahun pada perempuan 26 per 100.000 pasien dengan penyakit paru obstruktif kronik per tahun (McCool FD, 2008)
•
Kejadian pneumotoraks spontan primer adalah 18 per 100.000 orang per tahun dan 6 per 100.000 perempuan per tahunnya.
•
Hal ini terjadi terjadi paling paling sering di usia 20-an, 20-an, dan pneumotora pneumotoraks ks spontan spontan primer jarang terjadi di atas usia 40.
•
Pneumotoraks spontan sekunder biasanya terjadi antara usia 60 dan 65.
•
Antara Antara Tahun Tahun 1991 1991 dan 1995 tingkat tingkat MRS di UK Hospital Hospitalbaik baik untuk untuk pneumotor pneumotoraks aks spontan spontan primer primer dan sekunder sekunder adalah 16,7 per 100.000 100.000 orang per tahun dan 5,8 per 100.000 perempuan per tahun.
•
Rekurensiakan terjadi pada sekitar 30% dari 45% primer dan sekunder
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xi
Pneumotoraks ini merupakan pneumotoraks yang terjadi pada paruparu yang sehat dan tidak ada pengaruh dari penyakit yang mendasari. Angka kejadian pneumotoraks spontan primer (PSP) sekitar 18-28 per 100.000 pria pertahun dan 1,2-6 per 100.000 wanita pertahun (Mackenzie and Gray, 2007). Umumnya, kejadian ini terjadi pada orang bertubuh tinggi, kurus, dan berusia antara 18-40 tahun. Mekanisme yang diduga mendasari terjadinya PSP adalah ruptur bleb subpleura pada apeks paru-paru (Heffner and Huggins, 2004). Udara yang terdapat di ruang intrapleura tidak didahului oleh trauma, tanpa disertai kelainan klinis dan radiologis. Namun banyak pasien yang dinyatakan mengalai PSP mempunyai penyakit paru-paru subklinis. Riwayat keluarga dengan kejadian serupa dan kebiasaan merokok meningkatkan resiko terjadinya pneumotoraks ini (Heffner and Huggins, 2004). Faktor Faktor yang yang saat saat ini ini didug diduga a berper berperan an dalam dalam patom patomeka ekanis nisme me PSP adalah adalah terdapat terdapat sebagian sebagian parenkim parenkim paru-paru paru-paru yang meningka meningkatt porosita porositasnya snya.. Peningkatan Peningkatan porositas menyebabkan kebocoran udara viseral dengan atau tanpa peru peruba baha han n
emfi emfise sema mato tous us
paru paru-p -par aru. u.
Hubu Hubung ngan an
ting tinggi gi
bada badan n
deng dengan an
penin peningka gkatan tan resiko resiko terja terjadin dinya ya PSP adala adalah h karena karena gradi gradien en tekan tekanan an pleur pleura a meningkat dari dasar ke apeks paru. Akibatnya, alveoli pada apeks paru-paru orang orang bertub bertubuh uh tinggi tinggi rentan rentan terha terhadap dap mening meningkat katnya nya tekana tekanan n yang yang dapat dapat mendahului mendahului proses pembentukan kista subpleura (Mackenzie and Gray, 2007).
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xii
dilakukan pada pasien PSP antara lain observasi, drainase interkostal dengan video-assisted isted thoracosc thoracoscopic opic surgery surgery (VATS) atau atau tanpa tanpa pleuro pleurode desis sis,, dan dan video-ass
(Heffner and Huggins, 2004). Panduan terapi untuk PSP dikeluarkan oleh British Thoracic Society (BTS) dan American College of Chest Physician (ACCP). Terdapat perbedaan untuk besar-kecilnya pneumotoraks dan jenis terapi untuk PSP kecil simtomatik dan PSP simtomatik yang stabil di antara keduanya(Mackenzie keduanya(Mackenzie and Gray, 2007). Berikut adalah ringkasan gabungan panduan terapi menurut BTS dan ACCP (Mackenzie and Gray, 2007). a. Clinically Clinically stable small pneumotoraks pneumotoraks
Kedua Kedua panduan panduan menyatakan menyatakan terapi terapi untuk untuk pasien pasien stabil stabil dengan dengan pneu pneumo moto tora raks ks keci kecill (<2 (<2 cm, cm, BT BTS; S; <3 cm, cm, ACCP ACCP)) dan dan geja gejala la minimal minimal adalah adalah dengan dengan melakuka melakukan n observas observasii dan di-KRS-k di-KRS-kan. an. Panduan ACCP menyarankan dilakukannya observasi sekitar 3-6 jam, foto rontgen paru-paru, diKRSkan dengan instruksi lengkap, dan pasien diminta untuk kontrol dalam dua hari berikutnya. b. Large pneumotoraks and symptomatic small pneumotoraks
Pasien yang tergolong dalam PSP ini membutuhkan intervensi. BTS merekomen merekomendasi dasikan kan aspirasi aspirasi sederhan sederhana a sebagai sebagai terapi terapi lini pertama pada PSP luas dengan kondisi stabil dan pneumotoraks
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xiii
Pada pasien yang termasuk dalam kategori ini sebaiknya dilakukan pemasangan drain interkostal dan di-MRS-kan. Paru-paru harus dapat mengembang sepenuhnya 24 jam sebelum drain dilepas. CXR dilakukan setiap 24 jam. d. Surg Surgic ical al inte interv rven enti tion on
Terapi Terapi pembe pembedah dahan an harus harus mulai mulai dipiki dipikirka rkan n apabi apabila la terda terdapat pat kebocoran udara persisten atau paru-paru gagal melakukan reekspansi ekspansi setelah setelah 3-5 hari.Indi hari.Indikasi kasi dilakuka dilakukannya nnya operasi operasi meliputi meliputi terjadin terjadinya ya pneumotor pneumotoraks aks ipsilate ipsilateral ral yang kedua, kedua, pneumoto pneumotoraks raks kontralateral yang pertama, dan adanya reiko pekerjaan seperti penyelam penyelam atau pilot. pilot. Pasien Pasien dengan dengan profesi profesi tersebut tersebut sebaikny sebaiknya a menjalan menjalanii tindakan tindakan operasi operasi bilateral bilateral.. Pili Pilihan han terapi terapi pembeda pembedahan han yang dapat dilakukan seperti VATS, pleural abrasion, surgical talc pleurodesis, pleurodesis, pleurectomy , dan open thoracostomy (Mackenzie and Gray, 2007)
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xiv
keberhasilan keberhasilan atau penurunan penurunan resiko r esiko rekurensi. Indikasi klem drain adalah apabila terda terdapat pat keboco kebocoran ran udara udara terus terus meneru meneruss karen karena a berpot berpotens ensii menyeb menyebab abkan kan tension pneumotoraks pneumotoraks.
2.3.1.2 Pneumotoraks Spontan Sekunder Sekunder
PSS PS S merupa merupakan kan pneum pneumoto otorak rakss yang yang terjad terjadii pada pada pasien pasien dengan dengan penyakit paru yang mendasari. Umumnya PSS terjadi sebagai komplikasi COPD, fibrosis kistik, tuberkulosis, pneumocystits pneumonia, dan menstruasi. PSS juga dapat
ter terjadi
ada
penyakit
intersisiel
paru
seperti
sarcoidosis,
lymphangioleiomyomatosis, langerhans cell histiocytosis and tuberous sclerosis . Secara umum udara pada PSS memasuki rongga pleura melalui alveoli yang melebar melebar atau rusak. rusak. Perburuka Perburukan n klinis klinis dan sequelae sequelae biasanya biasanya terjadi terjadi akibat akibat adanya kondisi komorbid. Causa terbanyak PSS adalah COPD, khususnya COPD sedang-berat. Apabila pneumotoraks terjadi pasien COPD gejala sesak napas yang progresif
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xv
terakhir dan dilakukan pada pasien dengan kebocoran udara yang tidak teratasi dan mengalami pneumotoraks rekuren (Mackenzie and Gray, 2007).
2.3.2 Pneumotoraks Traumatik
2.3.2.1 Pneumotoraks Traumatik Iatrogenik
Pneumotoraks iatrogenikmerupakan pneumotoraks yang terjadi akibat pembukaan rongga paru secara paksa saat tidakan dianosis atau terapi invasif dilakukan . Tindakan seperti thoracocentesis, biopsi pleura, pemasangan kateter vena sentral, sentral, biopsi biopsi paru perkutan perkutan,, bronkos bronkoskopi kopi dengan dengan biopsi biopsi transbron transbronkial kial,, aspiasi aspiasi transtorac transtoracic, ic, dan ventilasi ventilasi tekanan tekanan positif positif dapat dapat menjadi menjadi etiologi etiologinya. nya. Akibatnya, pasien perlu lebih lama dirawat di rumah sakit (Yilmaz, et al, 2002). Penyeba Penyebab b utama utama terjadi terjadinya nya pneumoto pneumotoraks raks iatrogen iatrogenii adalah adalah aspirasi aspirasi jarm halus transthoracic. Dua faktor yang memegang perang penting adalah ukur ukuran an dan dan keda kedala lama man n lesi lesi.. Apa Apa bila bila lesi lesi keci kecill dan dan dala dalam m maka maka resi resiko ko pneumotor pneumotoraks aks meningka meningkat. t. Penyebab Penyebab kedua kedua terbanya terbanyakk adalah adalah pemasang pemasangan an
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xvi
Pada Pada trauma trauma tumpul tumpul pneumotor pneumotoraks aks terjadi terjadi apabila apabila pleura pleura viserali viseraliss terobek oleh fraktur atau dislokasi costa. Kompresi dada tiba-tiba menyebabkan peningkatan tekanan alveolar secara tajam dan kemudian terjadi ruptur alveoli. Saat alveoli ruptur udara masuk ke rongga intersisiel dan terjadi diseksi menuju pleura viseralis atau mediastinum. Pneumotoraks terjadi saat terjadi ruptur pada pleu pleura ra vise visera raliliss atau atau medi medias astitinu num m dan dan udar udara a masu masukk ke rong rongga ga pleu pleura ra.. Manifestasi klinisnya dapat berupa Fallen lung sign/peptic lung sign di mana hilus paru terletak lebih rendah dari normal atau terdapat pneumotoraks persisten dengan chest tube terpasang dan berfungsi dengan baik (Sharma, 2009). Pneum Pneumoto otorak rakss trauma traumatik tik noniat noniatrog rogen enik ik juga juga dapat dapat terja terjadi di akibat akibat barot barotrau rauma ma.. Pada Pada suhu suhu konsta konstan, n, volume volume massa massa udara udara berba berband nding ing terba terbalik lik dengan dengan tekananny tekanannya, a, sehingga sehingga apabila apabila ditempatk ditempatkan an pada ketinggia ketinggian n 3050 m, volume udara yang tersaturasi pada tubuh meningkat 1,5 kali lipat daripada saat di ketinggian permukaan laut. Pada peningkatan tekanan tersebut, udara yang terjebak dalam bleb dapat mengalami ruptur dan menyebabkan pneumotoraks.
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xvii
berubah menjadi negatif karena diserap oleh jaringan paru disekitarnya. Pada kondisi tersebut paru belum mengalami reekspansi, sehingga masih ada ada rong rongga ga pleu pleura ra,, mesk meskip ipun un teka tekana nan n di dala dalamn mnya ya suda sudah h kemb kembal alii negatif.Pada waktu terjadi gerakan pernapasan, tekanan udara di rongga pleura tetap negatif. Misal terdapat robekan pada pleura viseralis dan paru atau jalan nafas atau esofagus, sehingga masuk vakum pleura karena tekanan vakum pleura negatif (Alsagaff, 2009). (Open Pneumothorax ) 2.4.2 Pneumotoraks Terbuka (Open
Pneumoto Pneumotoraks raks terbuka terbuka yaitu pneumoto pneumotoraks raks dimana dimana terdapat terdapat hubungan hubungan antara rongga pleura dengan bronkus yang merupakan bagian dari dunia luar karena terdapat luka terbuka pada dada. Dalam keadaan ini tekanan intrapleura sama dengan tekanan udara luar. Pada pneumotoraks terbuka tekanan tekanan intraple intrapleura ura sekitar sekitar nol. Perubahan Perubahan tekanan tekanan ini sesuai sesuai dengan dengan perubahan tekanan yang disebabkan oleh gerakan pernapasan.Pada saat inspi inspi
i tek
jadi jadi
gatif gatif da
da
ktu ekspir ekspirasi asi tek
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xviii
pleura makin lama makin tinggi dan melebihi tekanan atmosfer.Udara yang terkumpul dalam rongga pleura ini dapat menekan paru sehingga sering menimbulkan gagal napas (Alsagaff, 2009). 2.5 Patofisiologi Pneumotoraks
Pneumotoraks diklasifikasikan atas pneumotoraks spontan, traumatik, iatrogeni iatrogenik. k. Pneumoto Pneumotoraks raks spontan spontan dibagi dibagi lagi menjadi menjadi pneumotor pneumotoraks aks spontan spontan primer dan sekunder. Pneumotoraks traumatik disebabkan oleh trauma pada organ paru dan pneumotoraks iatrogenik merupakan komplikasi dari intervensi diagnostic ataupun terapeutik. Pneumotor Pneumotoraks aks spontan spontan primer primer terjadi terjadi tanpa tanpa kelainan kelainan atau penyakit penyakit
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xix
Rongga pleura memiliki tekanan negatif, sehingga bila rongga ini terisi oleh udara akibat akibat rupturnya rupturnya bula subpleur subpleural, al, paru-paru paru-paru akan kolaps kolaps sampai sampai tercapainya keseimbangan tekanan tercapai atau bagian yang ruptur tersebut ditu ditutu tup. p. Paru Paru-p -par aru u
akan akan bert bertam amba bah h
keci kecill
deng dengan an bert bertam amba bah h
luas luasny nya a
pneum pneumoto otorak raks. s. Konsek Konsekuen uensi si dari dari proses proses ini adala adalah h timbu timbulny lnya a sesak sesak akiba akibatt berkurangnya berkurangnya kapasitas vital paru dan turunnya t urunnya PO2. Sebuah penelitian penelitian lain lain menunjukkan menunjukkan bahwa bahwa faktor genetik berperan dalam patogenesis terjadinya pneumotoraks spontan primer. Beberapa kasus pneumotoraks spontan primer ditemukan pada kelainan genetik tertentu, seperti: sindrom marfan, homosisteinuria, serta sindrom Birt-Hogg-Dube. Birt-Hogg-Dube.
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xx
•
o
Sarkoidosis
o
Fibrosis paru idiopatik
o
Granulomatosis Granulomatosis sel langerhans langerhans
o
Limfangioleimiomatous
o
Sklerosis tuberus
Penyakit jaringan penyambung o
Artritis rheumatoid
o
Spondilitis ankilosing ankilosing
o
Polimiositis dan dermatomiosis
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xxi
Pneumotoraks iatrogenik merupakan komplikasi dari prosedur medis atau bedah.Salah satu yang paling sering adalah akibat aspirasi transtorakik (transthoracic needle aspiration), torakosentesis, biopsy transbronkial, ventilasi mekani mekanikk tekan tekanan an positi positiff (posi (positiv tive e pressu pressure re mecha mechanic nical al ventil ventilati ation) on).An .Angka gka kejadian kasus pneumotoraks meningkat apabila dilakukan oleh klinisi yang tidak berpengalaman. Pneumotor Pneumotoraks aks ventil ventil (tension (tension pneumotor pneumotoraks) aks) terjadi terjadi akibat akibat cedera cedera pada parenkim paru atau bronkus yang berperan sebagai katup searah.Katup ini mengak mengakiba ibatka tkan n udara udara berge bergerak rak searah searah ke rongga rongga pleura pleura dan mengha menghala langi ngi adanya aliran balik dari udara tersebut.Pneumotoraks ventil biasa terjadi pada
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xxii
b)
Sesak Sesak,, dapat dapat samapai samapai berat, berat, kadang kadang bisa bisa hilang hilang dalam dalam 24 jam, jam, apabila sebagian paru yang kolaps sudah mengembang kembali
c)
Mudah lelah pada saat beraktifitas maupun beristirahat.
d) Warna kulit kulit yang kebiruan kebiruan disebabkan disebabkan karena karena kurangnya kurangnya oksigen oksigen (cyanosis) 2.6. 2.6.2 2
Peme Pemeri riks ksaa aan n Fis Fisik ik a) Inspeksi: dapat terjadi pencembungan dan pada waktu pergerakan
nafas, tertinggal pada sisi yang sakit b) Palpa Palpasi: si: Pada Pada sisi sisi yang yang sakit sakit ruang ruang sela sela iga dapat dapat normal normal atau atau
melebar, iktus jantung terdorong kesisi thoraks yang sehat. Fremitus
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xxiii
5. Bila Bila hebat hebat sekali sekali dapat dapat menyebab menyebabkan kan terjadin terjadinya ya perdoron perdorongan gan
pada jantung jantung misalnya pada pada pneumotoraks pneumotoraks ventil atau apa yang yang pneumothorax kita kenal sebagai tension pneumothorax 6. Juga Juga medi medias astitinu num m dan dan trak trakea ea dapa dapatt terd terdor oron ong g kesi kesisi si yang yang
berlawanan.
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xxiv
double line dengan terjadi terjadi perdarah perdarahan an masif masif dilakuka dilakukan n pemasang pemasangan an double dengan cairan cairan
kristaloid (Boon, 2008).
2.7.2 Penatalaksanaan Pneumotoraks Tertutup (Simple ( Simple Pneumothorax)
Kebanyakan
simp simple le
pneu pneumo moth thor orac aces es
akan akan
memb membut utuh uhka kan n
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xxv
2.7.4 Penatalaksanaan Penatalaksanaan Tension Pneumothorax 2.7.4.1 Needle Thoracostomy
Manajeme Manajemen n klasik klasik tension pneumothorax adalah adalah dekompre dekompresi si dada emergensi dengan needle toracostomy . Jarum ukuran 14-16 G ditusukkan pada
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xxvi
Pneumome Pneumomedias diastinum tinum jarang jarang menyebab menyebabkan kan komplik komplikasi asi klinis klinis yang signifik signifikan. an. Tetapi pada beberapa kasus, tension pneumomediastinum dapat menyebabkan penin peningka gkatan tan tekan tekanan an medias mediastin tinum um sehing sehingga ga terjad terjadii peneka penekanan nan langsu langsung ng terhadap jantung atau menurunkan aliran darah balik sehingga terjadi penurunan curah curah jantung. jantung. Pneumome Pneumomedias diastinum tinum dapat dapat berkemba berkembang ng menjadi menjadi emfiesem emfiesema a
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