In some cases of severe pneumonia, the severe hypoxemia can only be adequately managed with oxygen administration and mechanical ventilation. Several therapeutic strategies, some of which are still under clinical investigation, have been suggested.
1. The administration of anti-inflammatory drugs such as aspirin or indomethacin may reverse the partial ablation of hypoxic pulmonary vasoconstriction that occurs in some cases of bacterial pneumonia owing to the local release of vasodilator substances such as prostacyclin. The administration of these drugs to improve hypoxemia in pneumonia is still under clinical investigation and remains controversial.
2. The aerosolization of prostacyclin (epoprostenol, prostaglandin I 2) may reduce pulmonary hypertension and shunt and improve arterial oxygenation in the absence of systemic effects in patients with severe pneumonia.
3. In cases of unilateral pneumonia, placing the patient in the lateral position (affected lung up) may increase PaO2 by an average of 10 to 15 mmHg by improving the ventilation-perfusion mismatch. Specifically, there is an increase of blood flow to the well-ventilated areas.
4. Similarly, placing patients with refractory hypoxemia in the prone position has been shown to improve their oxygenation.
5. The inhalation of small amounts of nitric oxide (5-20 ppm) causes a selective arterial pulmonary vasodilation diverting blood flow to well-ventilated areas. The effect of nitric oxide in arterial oxygenation has been proved effective in acute respiratory distress syndrome patients with pulmonary hypertension. However, the beneficial effect in severe pneumonia is not confirmed and is still under clinical investigation.
Campbell, G.D., et al. (1996). Hospital acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventive strategies. A consensus statement. American
Journal of Respiratory and Critical Care Medicine, 153, 1771-25.
Niederman, M.S., et al. (1993). Guidelines for the initial management of adults with community-acquired pneumonia: diagnosis, assessment of severity, and initial antimicrobial therapy. American
Review of Respiratory Disease, 148, 1418-26.
Torres, A. (ed.) (1996). Severe pulmonary infections I and II. Seminars in Respiratory Infections, 11, 1-127.
Wunderink, R.G. (ed.) (1995). Pneumonia in the intensive care unit. Clinics in Chest Medicine, 16, 1-223.
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