organisms. Occasionally, empiric therapy with a broad-spectrum antibiotic is indicated. Daily chest X-ray is important in intubated patients, and broncho-alveolar lavage is indicated in patients not responding to antibiotic therapy or spiking a fever while on antibiotic therapy.

Patients with high cervical spinal cord injury frequently develop acute respiratory failure because of the sudden loss of intercostal muscles. Thus it is not surprising that tracheal intubation and mechanical ventilation are frequently indicated in these patients. Other indications include: depressed level of consciousness, inability to maintain or protect airway, respiratory failure, pneumonia, sepsis and pulmonary edema. Unconscious or obtunded patients are at risk of aspiration and development of pneumonia and adult respiratory distress syndrome (ARDS). In addition, many patients may require intubation and ventilation for imaging or angiography procedures. Pulmonary edema can develop from fluid overload and/or cardiac failure. Neurogenic pulmonary edema can develop in patients with acute traumatic brain injury, SAH or acute cervical spinal cord injury, presumably on the basis of severe sympathetic stress, leading to pulmonary vasoconstriction, with increase in pulmonary vascular permeability and disrupted capillary endothelium. Some patients also develop acute ventricular dysfunction. Although diuretics may be helpful, improvement is mainly dependent on dissipation of the sympathetic stress, and recovery of cardiac function, with or without inotropic support. Placement of a pulmonary artery catheter and echocardiographic examination of the heart is indicated in these patients. Weaning off ventilatory support in neurological patients should be no different from that in other patients. When weaning parameters are met using standard criteria (tidal volume, rapid shallow-breathing index, negative inspiratory pressure), the patient should be extubated. There is no standard method of weaning in these patients, and either intermittent mandatory ventilation or spontaneous continuous positive airway pressure can be used. Extubation should not be delayed because of depressed level of consciousness; the delay results in increased rate of nosocomial pneumonia and prolongs hospital stay.

In patients fulfilling the diagnostic criteria of ARDS, protective lung strategy with small tidal

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