2 severe respiratory infections in the icu

Islam M. Ibrahim, M.D., FACP, FCCP,
Pulmonary and critical care medicine,
Clinical associate Professor,
University of California San Diego, USA.
Severe pneumonia
management
challenges
in the ICU

Major concern
Mortality
ARDS 50%.
Morbidity

Severe pneumonia in (ICU)
CAP
HCAP
HAPVAP
NV-
ICUAP

Organism
Anaerobes.
poor dental
hygiene
Aspiration
Mycoplasma
pneumoniae.
Young
adults
Skin rashes,
bullous
myringitis
Legionella
species
Water
source
community-
acquired or
health care–
associated
Moraxella
catarrhalis.
lung
disease;
elderly
immunity
Pneumocystis
jiroveci.
AIDS,
immunosuppre
ssed

Organism
S. pneumoniae
H. influenzae.
Chronic
CP
disease
Follows
UTI
S.
aureus
NURSING
HOME
influenza
IV drug
Klebsiella
pneumoniae
Alcohol
DM
HAP
E. coli
HCAP
Rarely
CAP
P. aeruginosa
cystic
fibrosis,
bronchiect
asis
HAP

• A 17-year-old adolescent male presents to the ER with a temperature of 101.0°F
(38.3°C), a deep nonproductive cough, and generalized malaise for 3 days. He
doesn't recall being around any particular sick contacts but is around many people
in his after-school job in sales and at school. A chest x-ray reveals bilateral, diffuse
infiltrates on chest x-ray. Sputum G. stain shows many WBCs, but no organisms
• Which of the following is the most likely cause of his pneumonia ?
1. A. S pneumonia
2. B. P. jiroveci
3. C. Legionella pneumophila
4. D. M pneumonia
5. E. H influenza

atypical
Mycoplasma Legionella
diarrhea.

• A 35-year-old woman patient returns to clinic with a temperature of 104.0°F,
night sweats, chills, shortness of breath, and cough productive of yellowish-
green sputum. She was seen 2 weeks ago for headache, fever of 102.0°F,
nonproductive cough, and myalgias. She was prescribed a dose of oseltamavir
for 10 days. She felt better after taking the medication but now feels she is
getting worse. Which of the following is the best treatment for this patient?
1. A. 14-day trial of oseltamavir
2. B. Erythromycin
3. C. Penicillin
4. D. Cefuroxine
5. E. No treatment needed

• A 76-year-old widowed man presents with increasing SOB and chest
pain at rest for the past 2 weeks.His cough is productive of dark
brown foul sputum. He has had chronic hypertension and CAD for
20 years. Two years ago he suffered a CVA to the brainstem. He now
has dysphagia and is noted to cough frequently at night. He has no
cough at present. Which of the following is the best next step?
1. A. Upper endoscopy
1. C. Nitroglycerine patch
2. D. Chest radiograph

• A 35-year-old female patient, who is
being treated for cutaneous
chickenpox presents with high fever,
myalgia, headache, sore throat, and
harsh cough with burning
retrosternal chest pain, is followed
by increasing dyspnea.
• Physical findings include pharyngitis, crackles and wheezes in all lung fields,
tachypnea, and cyanosis. The patient developed acute respiratory failure with
severe hypoxemia , required intubation and mechanical ventilation.
• Lab work is pending.

Viral Pneumonia
(RSV) or (CMV)
debilitated
/elderly
/immunocompro
mised
Varicella zoster
virus
healthy adults
CHICKENPOX
Epstein-Barr virus
nonimmunocompr
omised adults
/infectious
mononucleosis
Adenovirus
young adults in
close contact
influenza viruses A
and B.
flu season
nonimmunized
/elderly
/underlying
disease.

ICU-Acquired Pneumonia
Risk Factors
Age
coma
prior broad spectrum antibiotics.
•Burn
•trauma
•ARDS
•pulmonary contusion
•duration on mech. ventilation
peaks
day 5
plateaus
15 days
then
declines

ICU-Acquired Pneumonia
Pathophysiology
Aspiration
inhalation
hematogenous
spread.
“Early” organisms
<72 hours)
S. aureus
S.
pneumoniae
other
Streptococci
H.
influenzae
“late”
pathogens
Pseudomonas
aeruginosa,
MRSA,
Acinetobacter
baumannii.

Mortality NV- ICUAP
similar to VAP 36%

The list of SCAP challenges
Recognition
of the
severity.
Appropriate
triaging.
DIAGNOSIS
Delayed
identification of
microorganisms
Prevention
of HAP /
VAP
Complications;
ARDS.
Respiratory
failure.
Atypical
Non
resolving
pneumonia
Timely
administration
of the
appropriate
anti-microbials
. Ventilation Oxygenation

Clinical bundle for severe pneumonia
risk assessment
evaluation for ICU admission
prompt oxygenation
early fluid resuscitation
immediate combo antibiotic therapy

Our 1st challenge
identifying patients who need
aggressive management.
Recognize severity
Estimate mortality risk

Q
• Estimation of risk , admission and triaging
decisions should be based on objective data
only not the subjective physicians clinical
judgment.
1. True
2. False

IDSA / ATS CRITERIA
CURB-65 PSI
SCAP score

Estimation of mortality risk
• 60 yo F, Nursing home resident with
• PMH of DM2, HTN
• CC Fever, cough, chest pain, chills, SOB x 48 H
• O/E BP 100/60, HR 115, RR 25, T 38.5
• AOX3 O2 SAT. 92% Lungs RLL crackles, bronchial BS,
and eogophony, dry mouth.
• CXR RLL consolidation.
• ABG 7.36 35 65 19 Na 128, BUN 34, Glucose 220,
HCT 33

• Using PSI,
What is the estimated mortality for this patient?
1. < 50
2. 51-70
3. 71-90
4. 91-130
5. >130

• 60 yo F, Nursing home resident with PMH of
DM2, HTN
• CC Fever, cough, chest pain, chills, SOB x 48 H
• O/E BP 100/60, HR 115, RR 25, T 38.5
• AOX3 O2 SAT. 92% Lungs RLL crackles, bronchial
BS, and eogophony, dry mouth.
• CXR RLL consolidation.
• ABG 7.36 35 65 19, BUN 34, Glucose 220,
HCT 33, Na 128

• 45 yo male patient with a PMH of DM2
chronic renal failure on Lasix 20 mg daily, and
glucophage1000 mg bid, is seen in the ER for a
complaint of fever, productive cough, chest
pain, fatigue, and SOB that has progressed
over the past 3 days. On exam, T 39 HR 130
SR, RR 32,BP 95/60. The patient appears
confused and Ox1, LLL crackles, bronchial BS,
and eogophony, no cyanosis or edema, the
rest of the PE is unremarkable.

• CXR LLL infiltrate with moderate sized
effusion.
• Na 128, BUN 31, glucose 280, HCT 33,
• ABG 7.34 30 59 17

• Using PSI,
What is the estimated mortality for this patient?
205
1. < 50
2. 51-70
3. 71-90
4. 91-130
5. >130

45
10
20
20
10
30
20
20
10
10
10

clinical
bundles
risk assessment
prompt oxygenation

Triaging to ICU
CURB-
65
An easier,
faster scoring
system

CURB-65
• C onfusion ----------------------------- 1 Point
• U remia------------------------------------1 Point
• R R------------------------------------------1 Point
• B P------------------------------------------1 Point
• 65 < age-----------------------------------1 Point

Based on curb-65, criteria,
Which one of these patients needs not be admitted to ICU?
1. A 72-year-old male with CAP, who has a blood
pressure of 150/90 mmHg, heart rate 120 bpm,
respiratory rate 35 bpm, who appears disoriented,
and a BUN of 27.
2. A 55-year-old female with CAP, blood pressure 85/50
mmHg, sleepy, and disoriented, heart rate 55 bpm
respiratory rate 22, BUN 22,
3. 85-year-old female with CAP, alert, complains of
dyspnea, respiratory rate 25, blood pressure 110/65
mmHg, BUN 17,

predicting evolution
toward severe CAP
CURB-65 PSI
SCAP score ≥10
superior to

SCAP score
Major criteria:
• A pH <7.30 — 13 P
• SBP <90 mmHg 11 p
Minor criteria:
•Age ≥80 years — 5 points
•RR >30 — 9 points
•Altered mental status — 5 points
•PaO2/FIO2 <250 — 6 points
•BUN >30 mg/dL — 5 points
•Multilobar infiltrates — 5 points

Admission to intensive care
2007 IDSA/ATS consensus guidelines
superior to
PSI
CURB-65
SCAP
predicting
need for mechanical
ventilation
vasopressor support
ICU admission

Admission to intensive care
2007 IDSA/ATS consensus guidelines
major
criteria
septic shock
requiring
vasopressor
support
mechanical
ventilation
minor criteria: 3
respiratory rate ≥30 breaths/minute,
PaO2/FiO2 ratio ≤250,
multilobar infiltrates,
confusion,
blood urea nitrogen ≥20 mg/dL
leukopenia,
thrombocytopenia,
hypothermia,
hypotension requiring fluid support.

The challenge of
Microbiological
Diagnosis
Who is the enemy?

The challenge of microbiological Diagnosis
obtaining LRT samples.

Question.
• The literature did not show diagnostic
advantage for the bronchoscopic sampling of
the LRT over blind tracheal aspiration.
1. True
2. false.

Question.
• The literature did not show diagnostic advantage
for the bronchoscopic BAL sampling of the LRT
over blind tracheal aspiration.
1. True
2. false.

Question.
• Bronchoscopic sampling of LRT has the
diagnostic advantage of obtaining protected
brushing samples for quantitative cultures.
1. True
2. false.

Immunocompromised with SCAP
fiber optic bronchoscopy with BAL
aspergillosis,
Pneumocystis
jiroveci

Biomarkers?
Are there any more tests to
help identify the organism?

Question.
• Which one of the following biomarkers is
suggestive of pneumonia diagnosis in addition
to history and physical?
1. C. reactive protein
2. Sedimentation rate.
3. Procalcitonin.
4. Tumor necrosis factor

length of
antimicrobial
therapy.
Procalcitonin
(PCT)

Question which one of these
statements is true ?
1. High levels of pro-calcitonin can be seen with
viral infections.
2. It does not helps distinguish bacterial from
nonbacterial pulmonary inflammation.
3. High pro-calcitonin level is a clear indication
to start antibiotic combination.
4. A sharp drop in pro-calcitonin level could be
used as a marker to discontinue antibiotics
earlier with signs of clinical stability.

Procalcitonin
Viral
nonspecific
inflammatory
conditions
Elevated
in severe
bacterial
conditions
Reduced
antibiotic
use

Urinary
antigen
S.
pneumoniae
specificity of
96%
sensitivity of
71%
L.
pneumophila
specificity
(0.99)
sensitivity
(0.74)

PCR

PCRAdvantages
Rapid
Sensitive
Limit
Quantitative
cut-off
colonizing
bacteria
viruses
harmless
shedding,
costs

clinical bundles
risk assessment
prompt oxygenation

The challenge of
Complications management
ARF

predict NIV failure
– Severe central neurological disturbances
– unstable hemodynamic
– inability to protect the airway or clear respiratory
secretions
– gastrointestinal bleeding
– inability to fit the interface
– Undrained pneumothorax.
– Failure to maintain PaO2 : FiO2 ratio above 100
– persistence of dyspnea and tachypnea

septic shock
improved
outcome
resuscitation /6h
s. lactates
control of hypotension
early antibiotic
administration
low-dose steroids
glucose control
inspiratory plateau
pressure<30cmH2O
The challenge of
Complications management

ALI/ARDS
bilateral infiltrates on chest X-ray
pO2/FiO2 ratio ≤ 200 mmHg (≤ 300 mmHg for ALI)
lung protective ventilation strategy
• tidal volume of 4–8 ml/kg of ideal body weight (IBW)
• plateau pressure < 30cmH2O
• higher PEEP (around 15cmH2O) values were
associated with improved survival rate (P = 0.03)
• conservative fluid strategies and
• early use of short term neuromuscular blocking
agents are being associated with improved outcome.

ALI/ARDS
prone position with ARDS
• redistribution of ventilation and perfusion matching
• alveolar recruitment
• avoidance of heart compression upon the lungs.
reduced mortality
• recent meta-analysis of (RCTs)
• PaO2/FiO2 below 100

ALI/ARDS
High-frequency
oscillatory
ventilation (HFOV)
Oxygenation
fixed mPaw
FiO2
CO2 elimination.
pressure
amplitude of
oscillation
respiratory
frequency

ALI/ARDS
Inhaled nitric
oxide (iNO)
improve
oxygenation
lack of evidence
to mortality
benefits
a rescue
intervention

ALI/ARDS
(ECMO)
CESAR trial
180 severe ARF patients
(60% severe pneumonia)
lower mortality
(47 vs. 63%;
P = 0.03).
cohort study
H1N1 ARDS
lower mortality
(23.7 and 32 vs. 52.5%;
P = 0.006)

combination
beta-lactam
macrolide Respiratory
fluoroquinolone
Rx of SCAP in ICU
Canadian and American guidelines
fluoroquinolone
-clindamycin
allergy
b-lactams
ceftriaxone
cefotaxime
ampicillin/
sulbactam,
piperacillin/
tazobactam

aminoglycoside
Rx of SCAP in ICU
Canadian and American guidelines
aminoglicosyde fluoroquinolone
Pseudomonas
suspected
COPD
cystic fibrosis,
bronchiectasis
previous ATB
/steroids
anti-
pseudomonas
beta-lactam
(piperacillin/tazobactam,
carbapenems,
cefepime)
anti-
pseudomonas
fluoroquinolone

Question.
• Which group of patients with CPAP would not
benefit from a combination of beta lactam plus a
macrolide vs. beta-lactam monotherapy?
1. Low severity, CAP.
2. Moderate severity, CAP.
3. High severity CAP.
4. Bacteremic pneumococcal CAP.

Challenge - management
Evaluate the management this patient
• A 75-year-old male patient , nursing home
resident, PMH of liver cirrhosis, ascites, chronic
renal failure, on hemodialysis, hypertension, and
diabetes, type II, admitted with pneumonia.
• On physical examination, T 39.5°C, HR 135, SR, RR
33, BP 110/70 mmHg, AOX3 He had reproducible
tenderness over the anterior chest wall, reduced
air entry with audible crackles over both lower
lobes of lungs, with bronchial breath sounds,
eogophony, and dullness to percussion.

• Chest x-ray showed bilateral lower lobe infiltrates, with
moderate right-sided pl. effusion.
• EKG NO ischemic changes,
• Sodium 127, creatinine 1.5, BUN 32, hematocrit 35,
potassium 5.5. ABG pH 7.33, PaCO2 32, PaO2 59,
bicarbonate16. The patient was admitted to telemetry,
started on IV ceftriaxone after blood and sputum cultures
have been sent off,, and O2 via nasal cannula at 4 L per
minute.
• 12 hours after admission, the patient’s respiratory status
worsened, BP 85/55 the patient was started on IV fluids, was
placed on BiPAP with 10 L of oxygen. A repeat chest x-ray was
ordered, 20 minutes later, the patient developed
cardiopulmonary arrest, ACLS protocol was applied, the
patient was intubated during the code, which lasted 20
minutes, Unfortunately, the patient expired.

Evaluate the management this patient
• A 75-year-old male patient , nursing home
resident, PMH of liver cirrhosis, ascites, chronic
renal failure, on hemodialysis, hypertension, and
diabetes, type II, admitted with pneumonia.
• On physical examination, T 39.5°C, HR 135, SR,
• RR 33, BP 110/70 mmHg, AOX3 He had
reproducible tenderness over the anterior chest
wall, reduced air entry with audible crackles over
both lower lobes of lungs, with bronchial breath
sounds, eogophony, and dullness to percussion.

Question.
• The triaging decision for this patient was,
1. Appropriate.
2. Inappropriate.

Question.
• The antibiotic choice for this patient was
1. adequate.
2. Inadequate

Question.
• The appropriate choice of antibiotics for this
patient should have been ,
1. Imipenem intravenously.
2. Meropenem intravenously.
3. Pipracillin/tazobactam plus levofloxacin.
4. Vancomycin plus azithromycin.

Question.
• The appropriate choice of antibiotics for this
patient should have been calm.
1. Imipenem intravenously.
2. Meropenem intravenously.
3. Pipracillin/tazobactam plus levofloxacin.
4. Vancomycin plus azithromycin.

Which of these management errors
occurred?
1. Triaging
2. ATB coverage.
3. ARF management
4. Reassessment for ICU transfer
5. BIPAP.
6. Hemodynamic management
7. All of the above

Question.
• With the following is incorrect regarding the
potential benefit of steroids as adjunctive therapy
in patients with CAP ?
1. Decreased mortality.
2. Reduced hospital length of stay.
3. Reduced incidence of the delayed shock.
4. Reduced resistance of chest x-ray abnormalities.

Question.
• The use of statins as adjunctive therapy for the
treatment of patients with CAP was associated
with which are the following clinical outcomes?
1. Decrease risk of CAP and reduced mortality.
2. Decreased risk of CAP and increased mortality.
3. Increased risk of CAP and reduced mortality.
4. Increased risk of CAP, and increased mortality

Question.
• With the following VAP. Patient is most likely
associated with higher attributable mortality?
1. Medical ICU patient.
2. Surgical ICU. Patient.
3. Thank you score= 20.

Question.
• With the following maybe associated with the
use of extended or continuous infusion of
antimicrobial agents in patients with VAP?
1. Reduced Length of hospital stay.
2. Microbiological eradication
3. Lower Mortality.
4. Lower Cost.

ANY
ceftriaxone
Fluoroquinolones
ampicillin/sulbactam
ertapenem.
Early onset
(HAP) (VAP)
Without
MDR risk
S.
pneumoniae
H. influenzae
MSSA
Gram negative
enteric rods

aminoglycoside
MDR risk
suspected
ESBL +
P. aeruginosa
Klebsiella
pneumoniae
Acinetobacter
anti-
pseudomonas
beta-lactam
B Lactamase
(piperacillin/
tazobactam,
carbapenems
anti-
pseudomonas
fluoroquinolone
Late onset VAP and HAP

Question.
• The use of linezolid was shown to improve, which
of the following clinical outcomes, in Meta-
analysis. When compared to vancomycin ?
1. Length of hospital stay.
2. Microbiological eradication.
3. Mortality.
4. Clinical cure.

Question.
• The use of statins as adjunctive therapy for
the treatment of patients with VAP is
associated with which and the following
outcomes?
1. Increased 28 day mortality.
2. Increased Ventilator free days.
3. Increased Development of ARDS.
4. Increased Myocardial infarction or ischemia.

Prevention of VAP
head elevated 30-45º)
• Avoid deep sedation
• Swallowing eval.
• mouth care
• orogastric tube
• soft small-bore tube
• enteral nutrition
• esterile ndotracheal tube suctioning
• endotracheal cuff seal and pressure
• infection control program
• hand washing and use of gloves
Aspiration
risk

Question.
• With the following VAP, oral health care
preventive measures has the strongest level of
evidence to support its use and clinical
practice?
1. Toothbrushing.
2. Iodine.
3. Chlorhexidine.

Question.
• With the following VAP, oral health care
preventive measures has the strongest level of
evidence to support its use and clinical
practice?
1. Tooth brushing.
2. Iodine.
3. Chlorhexidine.

Question.
• Which is the following medicines regarding
feeding a patient receiving mechanical
ventilation is shown to prevent VAP?
1. Enteral feeding.
2. N.P.O.
3. Small bowel enteral feeding.
4. Gastric enteral feeding.

Initial Antimicrobial Therapy for Opportunistic Lung Infections in
Critically Ill Immunocompromised Patients
Pneumocystis
carinii pneumonia
Cotrimoxazole 5 mg/kg TMP and 25 mg/kg SMX IV q 6 h
or
clindamycin 600 mg IV q 8 h with primaquine 30 mg PO once daily
Nocardia asteroids,
pneumonia, or
abscess
Cotrimoxazole 2.5 mg/kg TMP and 12.5 mg/kg SMX IV q 6 h
or
imipenem 500 mg IV q 6 h ± amikacin 5 mg/kg IV q 8 h
Aspergillosis Voriconazole 6 mg/kg q 12 h x 2, then 4 mg/kg IV q 12 h
or
amphotericin B 0.6–1.0 mg/kg IV q 24 h
Candida
pneumonia
/candidemia
Amphotericin B 0.5–0.8 mg/kg IV q 24 h
or
fluconazole 400 mg IV q 24 h
CMV pneumonia Ganciclovir 2.5 mg/kg IV q 8 h and CMV immunoglobulin 400–500 mg/kg on alternate days (4–10
doses)
Varicella zoster,
disseminated, with
pneumonia
Acyclovir 10 mg/kg IV q 8 h

2 severe respiratory infections in the icu

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