chapter 3 tracheos+pnemo 2

8/9/2019 chapter 3 tracheos+pnemo 2

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3.3. Pnemonia in Traumatic Brain Injury

Pneumonia is an important cause of morbidity following severe traumatic

brain injury (TBI).

Adult respiratory distress syndrome develops in up to 2! of

patients wit" severe "ead injury.

T"is complicates t"e treatment of "ead#injured patients because lung#

protective strategies suc" as "ig" positive end#e$piratory pressure (P%%P) and

permissive "ypercapnia may increase intracranial pressure (I&P) and reduce cerebral

perfusion pressure. T"e use of "ig"#fre'uency percussive ventilation (P*) is an

alternate mode of ventilation t"at may improve o$ygenation for "ead#injured patients

w"ile also lowering I&P.

Definitions

Pneumonia is an inflammatory condition of t"e lung.+,- It is often

c"aracteried as including inflammation of t"eparenc"ymaof t"e lung (t"at is/ t"e

alveoli) and abnormal alveolar filling wit" fluid (consolidation and e$udation).+2-

Classification

Pneumonias can be classified in several ways. T"e primary system of

classification is t"e combined clinical classification/ w"ic" combines factors suc" as

age/ ris0 factors for certain microorganisms/ t"e presence of underlying lung disease

or systemic disease/ and w"et"er t"e person "as recently been "ospitalied. 1t"er

classifications include according to t"e anatomic c"anges t"at can be found in t"e

lungs during autopsies/ based on t"e microbial cause/ and a radiological

classification.

1.Clinical

Traditionally/ clinicians "ave classified pneumonia by clinical c"aracteristics/

dividing t"em into acute (less t"an t"ree wee0s duration) and c"ronic
http://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Parenchymahttp://en.wikipedia.org/wiki/Alveolushttp://en.wikipedia.org/wiki/Consolidation_(medicine)http://en.wikipedia.org/wiki/Exudationhttp://en.wikipedia.org/wiki/Anatomyhttp://en.wikipedia.org/wiki/Autopsyhttp://en.wikipedia.org/wiki/Microbialhttp://en.wikipedia.org/wiki/Radiologyhttp://en.wikipedia.org/wiki/Inflammationhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Parenchymahttp://en.wikipedia.org/wiki/Alveolushttp://en.wikipedia.org/wiki/Consolidation_(medicine)http://en.wikipedia.org/wiki/Exudationhttp://en.wikipedia.org/wiki/Anatomyhttp://en.wikipedia.org/wiki/Autopsyhttp://en.wikipedia.org/wiki/Microbialhttp://en.wikipedia.org/wiki/Radiology


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pneumonias. T"is is useful because c"ronic pneumonias tend to be eit"er non#

infectious/ or mycobacterial/ fungal/ or mi$ed bacterial infections caused by airway

obstruction. Acute pneumonias are furt"er divided into t"e classic bacterial

bronc"opneumonias (suc" as Streptococcus pneumoniae)/ t"e atypical pneumonias

(suc" as t"e interstitial pneumonitis of Mycoplasma pneumoniae or Chlamydia

pneumoniae)/ and t"e aspiration pneumonia syndromes.

&"ronic pneumonias/ on t"e ot"er "and/ mainly include t"ose of Nocardia/

ActinomycesandBlastomyces dermatitidis/as well as t"e granulomatous pneumonias

(Mycobacterium tuberculosis and atypical mycobacteria/ Histoplasma capsulatumand Coccidioides immitis).+3-

T"e combined clinical classification/ now t"e most commonly used

classification sc"eme/ attempts to identify a person4s ris0 factors w"en "e or s"e first

comes to medical attention. T"e advantage of t"is classification sc"eme over previous

systems is t"at it can "elp guide t"e selection of appropriate initial treatments even

before t"e microbiologic cause of t"e pneumonia is 0nown. T"ere are two broad

categories of pneumonia in t"is sc"eme5 community#ac'uired pneumonia and

"ospital#ac'uired pneumonia. A recently introduced type of "ealt"care#associated

pneumonia(in patients living outside t"e "ospital w"o "ave recently been in close

contact wit" t"e "ealt" care system) lies between t"ese two categories.

2.Community-acquired

Community-acquired pneumonia (&AP) is infectious pneumonia in a

person w"o "as not recently been "ospitalied. &AP is t"e most common type of

pneumonia. T"e most common causes of &AP vary depending on a person4s age/ but

t"ey include Streptococcus pneumoniae/ viruses/ t"e atypical bacteria/ and

Haemophilus influenzae. 1verall/ Streptococcus pneumoniae is t"e most common

cause of community#ac'uired pneumonia worldwide. Gram-neati!e "acteriacause
http://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Mycoplasma_pneumoniaehttp://en.wikipedia.org/wiki/Chlamydia_pneumoniaehttp://en.wikipedia.org/wiki/Chlamydia_pneumoniaehttp://en.wikipedia.org/wiki/Nocardiahttp://en.wikipedia.org/wiki/Actinomyceshttp://en.wikipedia.org/wiki/Blastomyces_dermatitidishttp://en.wikipedia.org/wiki/Blastomyces_dermatitidishttp://en.wikipedia.org/wiki/Mycobacterium_tuberculosishttp://en.wikipedia.org/wiki/Atypical_mycobacteriahttp://en.wikipedia.org/wiki/Histoplasma_capsulatumhttp://en.wikipedia.org/wiki/Coccidioides_immitishttp://en.wikipedia.org/wiki/Healthcare-associated_pneumoniahttp://en.wikipedia.org/wiki/Healthcare-associated_pneumoniahttp://en.wikipedia.org/wiki/Community-acquired_pneumoniahttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Gram-negative_bacteriahttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Mycoplasma_pneumoniaehttp://en.wikipedia.org/wiki/Chlamydia_pneumoniaehttp://en.wikipedia.org/wiki/Chlamydia_pneumoniaehttp://en.wikipedia.org/wiki/Nocardiahttp://en.wikipedia.org/wiki/Actinomyceshttp://en.wikipedia.org/wiki/Blastomyces_dermatitidishttp://en.wikipedia.org/wiki/Mycobacterium_tuberculosishttp://en.wikipedia.org/wiki/Atypical_mycobacteriahttp://en.wikipedia.org/wiki/Histoplasma_capsulatumhttp://en.wikipedia.org/wiki/Coccidioides_immitishttp://en.wikipedia.org/wiki/Healthcare-associated_pneumoniahttp://en.wikipedia.org/wiki/Healthcare-associated_pneumoniahttp://en.wikipedia.org/wiki/Community-acquired_pneumoniahttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Gram-negative_bacteria


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&AP in certain at#ris0 populations. &AP is t"e fourt" most common cause of deat" in

t"e #nited $indom and t"e si$t" in t"e #nited %tates. T"e term wal0ing

pneumonia "as been used to describe a type of community#ac'uired pneumonia of

less severity (because t"e sufferer can continue to wal0 rat"er t"an re'uire

"ospitaliation).&'( 6al0ing pneumonia is usually caused by t"e atypical bacterium/

Mycoplasma pneumoniae.&)(

3.*ospital-acquired

ospital#ac'uired pneumonia/ also called nosocomial pneumonia/ is

pneumonia ac'uired during or after "ospitaliation for anot"er illness or procedure

wit" onset at least 72 "rs after admission. T"e causes/ microbiology/ treatment and

prognosis are different from t"ose of community#ac'uired pneumonia. 8p to 9! of

patients admitted to a "ospital for ot"er causes subse'uently develop pneumonia.

ospitalied patients may "ave many ris0 factors for pneumonia/ including

mec+anical !entilation/ prolonged malnutrition/ underlying +eart and lun

diseases/ decreased amounts of stomac" acid/ and immune disturbances. Additionally/

t"e microorganisms a person is e$posed to in a "ospital are often different from t"ose

at "ome. ospital#ac'uired microorganisms may include resistant bacteria suc" as

,%/ Pseudomonas/ Enterobacter/ and Serratia. Because individuals wit"

"ospital#ac'uired pneumonia usually "ave underlying illnesses and are e$posed to

more dangerous bacteria/ it tends to be more deadly t"an community#ac'uired

pneumonia. /entilator-associated pneumonia(*AP) is a subset of "ospital#ac'uired

pneumonia. *AP is pneumonia w"ic" occurs after at least 3: "ours of intu"ationand

mec+anical !entilation.

%in and symptoms

People wit" infectious pneumonia often "ave a coug" producing greenis" or

yellow sputum/ or p"legmand a "ig" fever t"at may be accompanied by s"a0ing
http://en.wikipedia.org/wiki/United_Kingdomhttp://en.wikipedia.org/wiki/United_Stateshttp://en.wikipedia.org/wiki/Mycoplasma_pneumoniaehttp://en.wikipedia.org/wiki/Nosocomial_infectionhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Malnutritionhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Methicillin-resistant_Staphylococcus_aureushttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Enterobacterhttp://en.wikipedia.org/wiki/Serratiahttp://en.wikipedia.org/wiki/Serratiahttp://en.wikipedia.org/wiki/Ventilator-associated_pneumoniahttp://en.wikipedia.org/wiki/Intubationhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Phlegmhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Rigorshttp://en.wikipedia.org/wiki/United_Kingdomhttp://en.wikipedia.org/wiki/United_Stateshttp://en.wikipedia.org/wiki/Mycoplasma_pneumoniaehttp://en.wikipedia.org/wiki/Nosocomial_infectionhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Malnutritionhttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Methicillin-resistant_Staphylococcus_aureushttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Enterobacterhttp://en.wikipedia.org/wiki/Serratiahttp://en.wikipedia.org/wiki/Ventilator-associated_pneumoniahttp://en.wikipedia.org/wiki/Intubationhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Sputumhttp://en.wikipedia.org/wiki/Phlegmhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Rigors


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c"ills. ;"ortness of breat" is also common/ as is pleuritic c"est pain/ a s"arp or

stabbing pain/ eit"er e$perienced during deep breat"s or coug"s or worsened by t"em.

People wit" pneumonia may coug" up blood/ e$perience "eadac"es/ or develop

sweaty and clammy s0in. 1t"er possible symptoms are loss of appetite/ fatigue/

blueness of t"e s0in/ nausea/vomiting/ mood swings/ andjoint painsor muscle ac"es.


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Pneumonia fills t"e lung4s alveoliwit" fluid/ 0eeping o$ygen from reac"ing

t"e bloodstream. T"e alveolus on t"e left is normal/ w"ile t"e alveolus on t"e rig"t is

full of fluid from pneumonia.

;ymptoms of pneumonia need immediate medical evaluation. P"ysical

e$amination by a "ealt" care provider may reveal fever or sometimes low body

temperature/ an increased respiratory rate/ low blood pressure/ a "ig" "eart rate/ or a

lowo$ygen saturation/ w"ic" is t"e amount of o$ygen in t"e blood as indicated by

eit"erpulse o$imetry or blood gas analysis. People w"o are struggling to breat"e/

w"o are confused/ or w"o "ave cyanosis (blue#tinged s0in) re'uire immediate

attention.

indings from p"ysical e$amination of t"e lungs may be normal/ but often

s"ow decreased e$pansion of t"e c"est on t"e affected side/ bronc"ialbreat"ing on

auscultation wit" a stet"oscope("ars"er sounds from t"e larger airways transmitted

t"roug" t"e inflamed and consolidated lung)/ and rales(or crac0les) "eard over t"e

affected area during inspiration. Percussion may be dulled over t"e affected lung/ but

increased rat"er t"an decreased vocal resonance(w"ic" distinguis"es it from apleural

effusion).+>-6"ile t"ese signs are relevant/ t"ey are insufficient to diagnose or rule

out a pneumonia= moreover/ in studies it "as been s"own t"at two doctors can arrive

at different findings on t"e same patient.

+,-+,,-

Dianosis

If pneumonia is suspected on t"e basis of a patient4s symptomsand findings

from p+ysical e0amination/ furt"er investigations are needed to confirm t"e
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diagnosis. Information from a c+est -rayand "lood testsare "elpful/ and sputum

culturesin some cases. T"e c"est ?#ray is typically used for diagnosis in "ospitals

and some clinics wit" ?#ray facilities. owever/ in a community setting ( eneral

practice)/ pneumonia is usually diagnosed based on symptoms and p"ysical

e$amination alone. @iagnosing pneumonia can be difficult in some people/ especially

t"ose w"o "ave ot"er illnesses. 1ccasionally a c"est CT scanor ot"er tests may be

needed to distinguis" pneumonia from ot"er illnesses.

Treatment

Antibioticsimprove outcomes in t"ose wit" bacterial pneumonia.

+23-

Initiallyantibiotic c"oice depends on t"e c"aracteristics of t"e person affected suc" as age/

underlying "ealt"/ and location t"e infection was ac'uired.

In t"e 8 empiric treatment is usually wit" amo$icillin/ eryt"romycin/ or

ait"romycinfor community#ac'uired pneumonia.+29- In ort" America/ w"ere t"e

atypical forms of community#ac'uired pneumonia are becoming more common/

macrolides (suc" as ait"romycin)/ and do$ycycline"ave displaced amo$icillin as

first#line outpatient treatment for community#ac'uired pneumonia.+,C-+2D-T"e use of

fluoro'uinolones in uncomplicated cases is discouraged due to concerns of side

effects and resistance.+,C-T"e duration of treatment "as traditionally been seven to ten

days/ but t"ere is increasing evidence t"at s"ort courses (t"ree to five days) are

e'uivalent.+27- Antibiotics recommended for "ospital#ac'uired pneumonia include

t"ird# and fourt"#generation cep"alosporins/ carbapenems/ fluoro'uinolones/

aminoglycosides/ and vancomycin.+2:-T"ese antibiotics are often given intravenously

and may be used in combination.

o specific treatments e$ist for most types of viral pneumonia including

;AE; coronavirus/ adenovirus/ "antavirus/ and parainfluena virus wit" t"e

e$ception of influena A and influena B. Influena A may be treated wit"

rimantadineoramantadinew"ile influena A or B may be treated wit" oseltamiviror

anamivir. T"ese are beneficial only if t"ey are started wit"in 3: "ours of t"e onset of
http://en.wikipedia.org/wiki/Chest_X-rayhttp://en.wikipedia.org/wiki/Blood_testhttp://en.wikipedia.org/wiki/Microbiological_culturehttp://en.wikipedia.org/wiki/General_practicehttp://en.wikipedia.org/wiki/General_practicehttp://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Empiric_therapyhttp://en.wikipedia.org/wiki/Amoxicillinhttp://en.wikipedia.org/wiki/Erythromycinhttp://en.wikipedia.org/wiki/Azithromycinhttp://en.wikipedia.org/wiki/North_Americahttp://en.wikipedia.org/wiki/North_Americahttp://en.wikipedia.org/wiki/Macrolidehttp://en.wikipedia.org/wiki/Azithromycinhttp://en.wikipedia.org/wiki/Doxycyclinehttp://en.wikipedia.org/wiki/Community-acquired_pneumoniahttp://en.wikipedia.org/wiki/Fluoroquinoloneshttp://en.wikipedia.org/wiki/Cephalosporinshttp://en.wikipedia.org/wiki/Carbapenemhttp://en.wikipedia.org/wiki/Fluoroquinolonehttp://en.wikipedia.org/wiki/Aminoglycosidehttp://en.wikipedia.org/wiki/Vancomycinhttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Viral_pneumoniahttp://en.wikipedia.org/wiki/SARShttp://en.wikipedia.org/wiki/Adenovirushttp://en.wikipedia.org/wiki/Hantavirushttp://en.wikipedia.org/wiki/Parainfluenzahttp://en.wikipedia.org/wiki/Influenza_Ahttp://en.wikipedia.org/wiki/Influenza_Ahttp://en.wikipedia.org/wiki/Influenza_Bhttp://en.wikipedia.org/wiki/Rimantadinehttp://en.wikipedia.org/wiki/Amantadinehttp://en.wikipedia.org/wiki/Amantadinehttp://en.wikipedia.org/wiki/Oseltamivirhttp://en.wikipedia.org/wiki/Zanamivirhttp://en.wikipedia.org/wiki/Chest_X-rayhttp://en.wikipedia.org/wiki/Blood_testhttp://en.wikipedia.org/wiki/Microbiological_culturehttp://en.wikipedia.org/wiki/General_practicehttp://en.wikipedia.org/wiki/General_practicehttp://en.wikipedia.org/wiki/CT_scanhttp://en.wikipedia.org/wiki/Antibiotichttp://en.wikipedia.org/wiki/Empiric_therapyhttp://en.wikipedia.org/wiki/Amoxicillinhttp://en.wikipedia.org/wiki/Erythromycinhttp://en.wikipedia.org/wiki/Azithromycinhttp://en.wikipedia.org/wiki/North_Americahttp://en.wikipedia.org/wiki/Macrolidehttp://en.wikipedia.org/wiki/Azithromycinhttp://en.wikipedia.org/wiki/Doxycyclinehttp://en.wikipedia.org/wiki/Community-acquired_pneumoniahttp://en.wikipedia.org/wiki/Fluoroquinoloneshttp://en.wikipedia.org/wiki/Cephalosporinshttp://en.wikipedia.org/wiki/Carbapenemhttp://en.wikipedia.org/wiki/Fluoroquinolonehttp://en.wikipedia.org/wiki/Aminoglycosidehttp://en.wikipedia.org/wiki/Vancomycinhttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Viral_pneumoniahttp://en.wikipedia.org/wiki/SARShttp://en.wikipedia.org/wiki/Adenovirushttp://en.wikipedia.org/wiki/Hantavirushttp://en.wikipedia.org/wiki/Parainfluenzahttp://en.wikipedia.org/wiki/Influenza_Ahttp://en.wikipedia.org/wiki/Influenza_Bhttp://en.wikipedia.org/wiki/Rimantadinehttp://en.wikipedia.org/wiki/Amantadinehttp://en.wikipedia.org/wiki/Oseltamivirhttp://en.wikipedia.org/wiki/Zanamivir


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symptoms. Fany strains of 9,influena A/ also 0nown as avian influenaor bird

flu/ "ave s"own resistance to rimantadine and amantadine.

T"ere is no evidence to support t"e use of antibiotics in c"emical pneumonitis

wit"out bacterial superinfection. If infection is present in aspiration pneumonia/ t"e

c"oice of antibiotic will depend on several factors/ including t"e suspected causative

organism and w"et"er pneumonia was ac'uired in t"e community or developed in a

"ospital setting. &ommon options include clindamycin/ a combination of a beta#

lactam antibiotic and metronidaole/ or an aminoglycoside.+2>- &orticosteroids are

commonly used in aspiration pneumonia/ but t"ere is no evidence to support t"eir useeit"er.+2>-

Complications

;ometimes pneumonia can lead to additional complications. &omplications are more

fre'uently associated wit" bacterial pneumonia t"an wit" viral pneumonia. T"e most

important complications include5

espiratory and circulatory failure

Because pneumonia affects t"e lungs/ often people wit" pneumonia "ave

difficulty breat"ing/ and it may not be possible for t"em to breat"e well enoug" to

stay alive wit"out support. on#invasive breat"ing assistance may be "elpful/ suc" as

wit" a bi#level positive airway pressuremac"ine. In ot"er cases/ placement of an

endotrac"eal tube(breat"ing tube) may be necessary/ and a ventilatormay be used to

"elp t"e person breat"e.

Pneumonia can also cause respiratory failure by triggering acute respiratory

distress syndrome (AE@;)/ w"ic" results from a combination of infection and

inflammatory response. T"e lungs 'uic0ly fill wit" fluid and become very stiff. T"is
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stiffness/ combined wit" severe difficulties e$tracting o$ygen due to t"e alveolgar

fluid/ create a need for mec"anical ventilation.

Pleural effusion

&"est $#ray s"owing a pleural effusion. T"e A arrow indicates fluid layering

in t"e rig"t c"est. T"e B arrow indicates t"e widt" of t"e rig"t lung. T"e volume of

useful lung is reduced because of t"e collection of fluid around t"e lung.

;epsis and septic s"oc0 are potential complications of pneumonia. ;epsis occurs

w"en microorganisms enter t"e bloodstream and t"e immune system responds by

secreting cyto0ines. ;epsis most often occurs wit" bacterial pneumonia=

Streptococcus pneumoniae is t"e most common cause. Individuals wit" sepsis or

septic s"oc0 need "ospitaliation in an intensive care unit. T"ey often re'uire

intravenous fluidsand medications to "elp 0eep t"eir blood pressure from dropping

too low. ;epsis can cause liver/ 0idney/ and "eart damage/ among ot"er problems/ and

it often causes deat".

Pleural effusion empyema and a"scess

1ccasionally/ microorganisms infecting t"e lung will cause fluid (a pleural

effusion) to build up in t"e space t"at surrounds t"e lung (t"e pleural cavity). If t"e

microorganisms t"emselves are present in t"e pleural cavity/ t"e fluid collection is

called an empyema. 6"en pleural fluid is present in a person wit" pneumonia/ t"e
http://en.wikipedia.org/wiki/Sepsishttp://en.wikipedia.org/wiki/Septic_shockhttp://en.wikipedia.org/wiki/Immune_systemhttp://en.wikipedia.org/wiki/Cytokineshttp://en.wikipedia.org/wiki/Cytokineshttp://en.wikipedia.org/wiki/Bacterial_pneumoniahttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/Intravenous_fluidhttp://en.wikipedia.org/wiki/Pleural_effusionhttp://en.wikipedia.org/wiki/Pleural_effusionhttp://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Empyemahttp://en.wikipedia.org/wiki/File:Pleural_effusion.jpghttp://en.wikipedia.org/wiki/Sepsishttp://en.wikipedia.org/wiki/Septic_shockhttp://en.wikipedia.org/wiki/Immune_systemhttp://en.wikipedia.org/wiki/Cytokineshttp://en.wikipedia.org/wiki/Bacterial_pneumoniahttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/Intravenous_fluidhttp://en.wikipedia.org/wiki/Pleural_effusionhttp://en.wikipedia.org/wiki/Pleural_effusionhttp://en.wikipedia.org/wiki/Pleural_cavityhttp://en.wikipedia.org/wiki/Empyema


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fluid can often be collected wit" a needle (t"oracentesis) and e$amined. @epending

on t"e results of t"is e$amination/ complete drainage of t"e fluid may be necessary/

often re'uiring a c"est tube. In severe cases of empyema/ surgerymay be needed. If

t"e fluid is not drained/ t"e infection may persist/ because antibiotics do not penetrate

well into t"e pleural cavity.

Earely/ bacteria in t"e lung will form a poc0et of infected fluid called an

abscess.


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"ig"er rates of deat" from pneumonia. or t"ese reasons/ t"e majority of deat"s in

c"ildren under five due to pneumococcal disease occur in developing coutries.+CC-

Adenoviruscan cause severe necrotiing pneumonia in w"ic" all or part of a

lung "as increased translucency radiograp"ically/ w"ic" is called ;wyer#Games

;yndrome.+C3- ;evere adenovirus pneumonia also may result in bronc"iolitis

obliterans/ a subacute inflammatory process in w"ic" t"e small airwaysare replaced

by scar tissue/ resulting in a reduction in lung volumeand lung compliance.+C3-

/entilator ssosiated Pnemonia

&onsistent wit" previous studies (151!1"#/ t"e development of *AP

was associated wit" significant morbidity. T"e burden associated wit" *AP included

increased lengt" of mec"anical ventilation/ increased I&8 and "ospital lengt"s of

stay/ and increased re'uirement for trac"eostomy. T"ese results/ if proven to be

causally related in subse'uent wor0/ and t"e estimated attributable cost of H,,/:>7

($5# would define *AP as a critical "ealt" issue bot" to t"e patient wit" severe TBI

and t"e "ealt" care system c"arged wit" t"eir care.Patients w"o developed *AP e$perienced more nonneurological organ

dysfunction t"an t"ose w"o did not develop *AP. In addition to t"e recently identified

association wit" poor outcome following severe TBI ($%#/ F1@ "as been s"own to

be a major determinant of poor p"ysical "ealt" at D mont" follow#up of I&8 survivors

($!#. owever/ t"e majority of patients developed ma$imal nonneurological organ

dysfunction more t"an 3: "ours from t"e diagnosis of *AP. T"is suggests t"at

alt"oug" *AP li0ely contributes to t"e development of nonneurological organ

dysfunction/ it is not t"e sole mec"anism responsible.

It is important to note t"e observed *AP rate occurred a&ter t"e

implementation of a regional/ multidisciplinary *AP prevention program. T"is

program standardied diagnostic algorit"ms and significantly revised regional policy
http://en.wikipedia.org/wiki/Adenovirushttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchioleshttp://en.wikipedia.org/wiki/Fibrosishttp://en.wikipedia.org/wiki/Lung_volumehttp://en.wikipedia.org/wiki/Lung_compliancehttp://en.wikipedia.org/wiki/Adenovirushttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Swyer-James_Syndromehttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchiolitis_obliteranshttp://en.wikipedia.org/wiki/Bronchioleshttp://en.wikipedia.org/wiki/Fibrosishttp://en.wikipedia.org/wiki/Lung_volumehttp://en.wikipedia.org/wiki/Lung_compliance


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according to evidence#based recommendations for t"e prevention of *AP. T"ese

revisions included many of t"e interventions suggested recently by ollef ($"#.

Alt"oug" noncompliance wit" suc" evidence#based recommendations "as been

identified as a important issue ($'#/ one must consider t"at nonp"armacological

interventions may not ma0e a significant impact on *AP rates in t"ese "ig"#ris0

patients.

%arly trac"eal coloniation "as been identified as a ris0 factor for t"e

development of pneumonia in patients wit" TBI ()1#. ;irvent studied t"e

prop"ylactic intravenous cefuro$ime after intubation in patients wit" structural coma

and found benefit compared to controls in terms of I&8 and "ospital stay (*#.

Alt"oug" early e$posure to s"ort#term antibiotics may be protective against initial

trac"eal coloniation/ suc" use "as also been associated wit" an increased ris0 for

subse'uent coloniation wit" ramnegative enteric bacilli andPseudomonas species

()#.

T"us/ t"e impact of systemic prop"ylactic antibiotic in patients wit" severe

TBI for t"e prevention of *AP "as not been fully elucidated. An alternative to

systemic antibiotics is pat"ogen#targeted topical eradication. In t"is study and ot"ers/

S+ aureus is a leading cause of pneumonia in patients wit" severe TBI/ and nasal

carriage of t"is pat"ogen is a ris0 factor for development of pneumonia (15$#.

Alt"oug" topical t"erapy wit" mupirocin is "ig"ly effective for eradication of nasal

carriage/ it "as not yet been s"own to reduce rates of infection (#. T"is study

identifies polytrauma patients wit" severe TBI as an e$tremely "ig" ris0 subgroup

t"at potentially could benefit from topical eradication.


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3. Trac+eostomy

Advances and improvements in treatment of critical illness "as resulted in

more patients w"o re'uire prolonged airway and ventilatory support., Fany of t"ese

patients will benefit from prolonged support programs and will eventually be weaned

from mec"anical ventilation.

%arly trac"eostomy "as been s"own to be beneficial after trauma= "owever/

t"ere are few objective data to identify early in t"e recovery period w"ic" patients

will ultimately re'uire trac"eostomy after blunt "ead trauma.

DefinitionTrac"eostomy is a surgical procedure in w"ic" an opening is made into t"e

trac"ea and maintained wit" a tube in order to establis" direct communication wit"

t"e e$ternal environment. A trac"eostomy provides direct access to t"e trac"ea by

surgically ma0ing an opening in t"e nec0. 1nce an opening is made it needs to be

maintained w"ic" is by trac"eostomy tube/ of w"ic" t"ere are several types.

Indication

T"e advent of t"e antibiotic era coupled wit" great advances in anest"esia "ave

made trac"eotomy or trac"eostomy a commonly performed elective procedure.

To bypass obstruction

o &ongenital anomaly (eg/ laryngeal "ypoplasia/ vascular web)

o oreign body t"at cannot be dislodged wit" eimlic" and basic

cardiac life support (B&


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ec0 trauma t"at results in severe injury to t"e t"yroid or cricoid cartilages/

"yoid bone/ or great vessels.

;ubcutaneous emp"ysema

o Appears in face/ nec0/ or c"est

o Eeadily dissecting air/ especially t"roug" inflamed or traumatied

tissue planes/ leading to massive soft tissue edema

acial fractures t"at may lead to upper airway obstruction (eg/ comminuted

fractures of t"e midface and mandible)

%dema

o Trauma

o Burns

o Infection

o Anap"yla$is

To provide a long#term route for mec"anical ventilation in cases of respiratory

failure

To provide pulmonary toilet

o Inade'uate coug" due to c"ronic painor wea0ness

o Aspiration and t"e inability to "andle secretions (T"e cuffed tube

allows t"e trac"ea to be sealed off from t"e esop"agus and its

reflu$ing contents. T"us/ t"is intervention can prevent aspiration and

provide for t"e removal of any aspirated substances. owever/ some

would argue t"at t"e ris0 of aspiration is not actually lessened/ as

secretions can lea0 around t"e cuffed tube and reac" t"e lower airway.)

Prop"yla$is (as in preparation for e$tensive "ead and nec0 procedures and t"econvalescent period)

;evere sleep apnea not amendable to continuous positive airway pressure

(&PAP) devices or ot"er/ less invasive surgery.

Procedure
http://emedicine.medscape.com/article/868375-overviewhttp://www.medscape.com/resource/traumahttp://emedicine.medscape.com/article/879183-overviewhttp://www.medscape.com/resource/painmgmthttp://emedicine.medscape.com/article/868375-overviewhttp://www.medscape.com/resource/traumahttp://emedicine.medscape.com/article/879183-overviewhttp://www.medscape.com/resource/painmgmt


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4utcomes and Pronosis

,.@uration of trac"eostomy5 A trac"eostomy can be used for days or/ wit" proper

care/ for years.

2.@ecision to decannulate5 T"e trac"eostomy tube s"ould be removed as soon as is

feasible and/ t"erefore/ s"ould be downsied as 'uic0ly as possible. T"is allows t"e

patient to resume breat"ing t"roug" t"e upper airway and reduces dependence

(psyc"ological and ot"erwise) on t"e lesser resistance of t"e trac"eostomy tube.

@ecannulation may be performed w"en t"e patient can tolerate plugging of t"e

trac"eostomy tube overnig"t w"ile asleep wit"out o$ygen desaturation. After t"e

tube is removed/ t"e s0in edges are taped s"ut/ t"e patient is encouraged to occludet"e defect w"ile spea0ing or coug"ing/ and t"e wound s"ould "eal wit"in 9#7 days.

C.In 2>/ Tobin proposed t"at t"e use of a trac"eostomy team may reduce morbidity

of t"is indwelling respiratory device.( Tobin A%. Trac"eostomy teams # filling a

void. Crit Care ,esusc. Far 2>=,,(,)5C#3. +Fedline-)

Contraindications

o absolute contraindications e$ist to trac"eostomy. A strong relative

contraindication to discrete surgical access to t"e airway is t"e anticipation t"at t"e

bloc0age is a laryngeal carcinoma. T"e definitive procedure (usually a laryngectomy)

is planned/ and prior manipulation of t"e tumor is avoided because it may lead to

increased incidence of stomal recurrence. Temporary trac"eostomy may be performed

just under t"e first trac"eal ring in anticipation of a laryngectomy at a later time.

%nd#of#life issues may also come to bear on t"e decision to perform a

trac"eostomy because it may represent furt"er mec"aniation of t"e patient4s care to

family members. In fact/ t"e performance of a trac"eostomy does not affect t"edecision to e$tend or to wit"draw care. ygiene is improved/ 'uality of life (spea0ing

and eating/ if relevant) is improved/ and placement in long#term care is facilitated in

some cases= "owever/ dependence on mec"anical ventilation may not be c"anged.

T"e patient is still being 0ept alive by mac"ines.
http://www.medscape.com/medline/abstract/19281436http://www.medscape.com/medline/abstract/19281436


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4utcomes and Pronosis

,.@uration of trac"eostomy5 A trac"eostomy can be used for days or/ wit" proper

care/ for years.

2.@ecision to decannulate5 T"e trac"eostomy tube s"ould be removed as soon as is

feasible and/ t"erefore/ s"ould be downsied as 'uic0ly as possible. T"is allows t"e

patient to resume breat"ing t"roug" t"e upper airway and reduces dependence

(psyc"ological and ot"erwise) on t"e lesser resistance of t"e trac"eostomy tube.

@ecannulation may be performed w"en t"e patient can tolerate plugging of t"e

trac"eostomy tube overnig"t w"ile asleep wit"out o$ygen desaturation. After t"e

tube is removed/ t"e s0in edges are taped s"ut/ t"e patient is encouraged to occlude

t"e defect w"ile spea0ing or coug"ing/ and t"e wound s"ould "eal wit"in 9#7 days.

C.In 2>/ Tobin proposed t"at t"e use of a trac"eostomy team may reduce morbidity

of t"is indwelling respiratory device.( Tobin A%. Trac"eostomy teams # filling a

void. Crit Care ,esusc. Far 2>=,,(,)5C#3. +Fedline-)
http://www.medscape.com/medline/abstract/19281436http://www.medscape.com/medline/abstract/19281436

chapter 3 tracheos+pnemo 2

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