PREVENTION
AND TREATMENT
Since
eradication of an established
pneumonia in the burn patient is very
difficult, prevention is of primary
importance.
Preventive
measures focus in four areas:
PREVENTION
- Improving
systemic defenses
- Improving
local lung defenses
- Minimizing
oropharyngeal
colonization
- Minimizing
tracheobronchial
aspiration
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BILATERAL
TRACHEOBRONCHITIS
Improving
Systemic Host Defenses:
- Adequate
oxygen delivery to all tissues
- Optimize
nutrition especially protein
Improving
Local Lung Defenses:
- Optimizing
secretion clearance
- Good
cough
- If
long term need for tube
- consider early
tracheotomy
- Maintains
chest wall muscles
- Continuous
postural drainage -
consider rotation bed to
45 degrees
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Maintaining
an adequate cough mechanism is of
utmost importance in the patient at
risk for pneumonia, particularly in
the absence of positive-pressure
support, since there is a greater risk
of hypoventilation and atelectasis.
Analgesics and sedation must be used
carefully. It is necessary to provide
adequate pain relief, especially if
splinting due to a chest wall burn in
present. In addition, adequate sleep
is required to maintain muscle
activity. Oversedation and analgesia
are, of course, counterproductive
unless mechanical ventilatory support
is being provided.
An
endotracheal tube, although adequate
for maintenance of a patent and
protected airway, impairs the ability
to clear thick secretions by coughing.
It is very difficult to propel
secretions the length of the tube. If
continued intubation is expected to be
necessary for many weeks, conversion
to a tracheostomy performed in the
first 7 to 10 days will greatly assist
the clearance of secretions. The
tracheostomy should not be placed
through burned tissue. If the neck is
burned, early excision and grafting of
the neck area is indicated, and the
subsequent tracheostomy can be
performed through the skin graft in 24
to 48 hours.
Chest
wall muscle mass must be maintained.
Adequate nutrition and oxygen delivery
are obvious requirements. Frequent
position changes, hyperinflation, and
postural drainage will be necessary to
move the small and moderate airway
secretions to the proximal airways so
that cough clearance can occur.
Ambulation is the ideal approach. The
intubated, ventilated patient with a
lung injury who cannot ambulate is
best managed using side-to-side
position change. The side-to-side
rotating bed is ideal for this purpose
because the need for pushing on the
painful burn areas to move the patient
is eliminated.
Sources
of Infection in Airway and Lung
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Minimize
Risk of Tracheobronchial Aspiration:
- Avoid
over-sedation
- Head
elevated
- Remove
tubes as soon as
possible
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Minimize
Oropharyngeal Colonization
- Compulsive
hand washing
- Surveillance
for possible bacterial
reservoirs
- Careful
use of antibiotics
- Vigorous
mouth care
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