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360 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

dyspnoea, tachypnoea, pleural rub, inspiratory crackles impacts on patient outcome. In particular, the first dose
on auscultation, plus radiological evidence of infiltrates of antibiotics is required as soon as possible after the
or consolidation. Cough is the most common finding diagnosis of pneumonia has been made. Studies where
and is present in up to 80% of all patients with CAP. 6,9 the first dose of antibiotic therapy was delayed showed
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an increase in mortality. Antibiotic cover for pneumonia
COLLABORATIVE PRACTICE depends on the causative organism and sensitivity to
6
Early recognition of pneumonia and timely administra- drugs (see Table 14.6 ). Review of antibiotic prescribing
tion of antibiotic therapy are key aspects for patient man- practices in Australia and New Zealand has shown that
agement. The most important aspect of management in prescription of antibiotics in pneumonia is consistent
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VAP is prevention and this is a key emphasis in the care with current guidelines.
of all mechanically-ventilated patients. One approach in
encouraging the implementation of VAP prevention was SPECIAL CONSIDERATIONS
the combination of four aspects of patient management Pneumonia is a leading cause of maternal and fetal mor-
into one evidence based guideline, known as the Ventila- bidity and mortality. It also increases the likelihood of
tor Care Bundle: elevating the head of bed to 30–45 the complications of pneumonia, including requirement
degrees, daily sedation vacation and assessment of readi- for mechanical ventilation. Bacterial pneumonia is the
ness to extubate, peptic ulcer disease (PUD) prophylaxis most common type experienced in pregnancy although
27
and deep vein thrombosis (DVT) prophylaxis. Effective- diagnosis is often delayed as a result of the reluctance to
ness of this strategy and implementation issues have been obtain a chest X-ray. Management is similar to a non-
further evaluated, with some additional perspectives pregnant patient with antibiotic therapy adjusted to con-
offered. While it is apparent that daily spontaneous awak- sider the impact on the fetus. 6
ening and breathing trials are associated with early libera-
tion from mechanical ventilation and VAP reduction, the CAP is a major cause of morbidity and mortality in
strategies included for DVT and PUD prophylaxis do not elderly patients. Streptococcus pneumoniae is the most
directly affect VAP reduction. Semi-recumbent position- common causative organism, with an increase in drug-
ing has been associated with a significant reduction in resistance being reported more widely in the over-65 age
14
VAP but is difficult to maintain in ventilated patients. It group. Treatment of elderly patients with pneumonia is
has been suggested that other methods to reduce VAP, similar to younger patients, with emphasis on supportive
such as oral care and hygiene, chlorhexidine in the pos- care, prevention of sepsis and management of preexisting
terior pharynx and specialised endotracheal tubes (con- chronic conditions. Immunisation with pneumococcal
tinuous aspiration of sub-glottic secretions, silver-coated), and influenza vaccines is beneficial in the prevention of
should be considered for inclusion in a revised Ventilator pneumonia in elderly patients. 34
Bundle more specifically aimed at VAP prevention. 14
Development of VAP is attributed in part to aspiration of RESPIRATORY PANDEMICS
oral secretions that are colonised by a variety of bacteria. Serious outbreaks of respiratory infections that spread
Maintenance of oral hygiene is therefore a key element in rapidly on a global scale are termed pandemics. Their
the care of mechanically-ventilated patients. Oral mucosa spread is so rapid because the infection is usually associ-
6
and dental plaque may also be colonised with bacteria ated with emergence of a new virus where the majority
and the use of an oral antiseptic solution (e.g. Chlorhexi- of the population has no immunity. These infections are
dine) may further reduce the risk of developing VAP. 28 characterised by extremely rapid ‘transmission with con-
Supportive ventilation is a key focus for managing patients current outbreaks throughout the globe; the occurrence
with pneumonia. In some instances this may include of disease outside the usual seasonality, including during
increased oxygen delivery and positive end expiratory the summer months; high attack rates in all age groups,
pressure (PEEP) to maintain oxygenation and prevent with high levels of mortality particularly in healthy young
alveolar collapse. Chest physiotherapy assists in the adults; and multiple waves of disease immediately before
35
29
prevention of VAP and remains a key component of and after the main outbreak’. Several severe respiratory
management of all ventilated patients. However, its infections have progressed to become pandemics in
contribution towards improving mortality in patients recent years; these have been associated with the Corona-
30
with pneumonia is unclear. Upright positioning and virus and Influenza viruses. Prediction of the interval
early mobilisation are important elements of both between pandemics is difficult, but occurrence is likely to
prevention and management of pneumonia. The effec- continue and therefore requires that the health care com-
tiveness of additional strategies, such as use of beds with munity be well prepared.
a continuous lateral rotation or a vibration function to
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assist in the removal of secretions is yet to be shown. SEVERE ACUTE RESPIRATORY SYNDROME
See Chapter 15 for further discussion.
In 2002–03 an outbreak of a novel Coronavirus occurred
in China and rapidly spread throughout the world. The
Medications infection was highly virulent with over 8000 cases
Antibiotic administration is fundamental to a patient’s reported and a mortality rate of 11%. The infection was
clinical progress. As noted earlier, the importance of accu- called Severe Acute Respiratory Syndrome (SARS) due to
rate and timely administration of antibiotics directly the severity of the disease, characterised by diffuse