Risk Factors for Early Onset Pneumonia in Trauma Patients

doi:10.1378/chest.105.1.224

Chest

Volume 105, Issue 1, January 1994, Pages 224-228

https://doi.org/10.1378/chest.105.1.224 Get rights and content

Study objectives

The aim of the study was to identify risk factors for early onset pneumonia (EOP) in trauma patients, in order to seek possible intervention strategies.

Study population

Participants included 124 consecutive trauma patients admitted to a general intensive care unit (ICU) of a university hospital from December 1990 to February 1992 inclusive.

Data collection

The following data were prospectively collected for each patient: demographics, severity of trauma according to the abbreviated injury scale (AIS), severity of coma according to the Glasgow coma scale (GCS), presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and mechanical ventilation. All patients were monitored daily during the ICU stay for the onset of pneumonia, sepsis syndrome, septic shock, and adult respiratory distress syndrome (ARDS). Criteria for the diagnosis of pneumonia were: core temperature of greater than 38.3°C, a WBC count of 10,000 cells/mm³, purulent tracheobronchial secretions, a worsening of pulmonary gas exchange, and persistent pulmonary infiltrates. All patients with suspected pneumonia underwent quantitative bronchoalveolar lavage (BAL) as well as blood cultures; BAL cultures were considered positive when they showed bacterial growth greater than 1 × 10⁵ colony-forming unit (cfu)/ml, or less than 10⁵, but with the same microorganism isolated in blood cultures. Pneumonia occurring within the first 96 h after trauma was considered EOP.

Data analysis

A stepwise logistic regression analysis was carried out in order to identify factors independently associated with an increased risk of EOP and late onset pneumonia (LOP).

Results

Overall mortality was 43.5 percent: mortality increased by age and AIS score. Forty one patients (33.1 percent) developed pneumonia: 26 (63.4 percent) were EOP and 15 (36.6 percent) were LOP. In the univariate analysis, an age greater than 40 years, the presence of pulmonary contusion, AIS of more than 4 for thorax and of more than 9 for abdomen, and the absence of mechanical ventilation (MV) during the first 4 days of hospitalization or MV lasting less than 24 h were significantly associated with an increased risk of acquiring EOP. Logistic regression analysis showed that the strongest risk factor for EOP was a combined severe abdominal and thoracic trauma, which increased the risk of EOP by 11 times; an age of more than 40 years and MV of less than 24 h during the first 4 days of hospitalization were also independent risk factors for EOP. Factors associated with LOP were an AIS score of more than 4 for abdomen and a length of MV of more than 5 days. Conclusion: In a trauma population, a combined severe abdominal and thoracic trauma represents a major risk factor for EOP. Mechanical ventilation administered during the first days after trauma seems to reduce the risk of EOP. As reported in previous studies, mechanical ventilatory support lasting more than 5 days is associated with an increased risk of LOP.

Section snippets

Study Population and Data Collection

One hundred twenty four consecutive multiple trauma patients admitted to a our general ICU were prospectively enrolled from December 1990 to February 1992 inclusive.

Data Recorded

The following information was collected for each patient: demographics, severity of trauma according to the abbreviated injury scale (AIS),¹⁶ severity of coma according to the Glasgow coma scale (GCS),¹⁷ presence of pneumothorax, pulmonary contusion, rib fractures, hemothorax, and MV. During ICU stay, patients were monitored daily

Results

One hundred twenty four patients were admitted for trauma to the ICU during the study period. These patients mainly consisted of young men who were transferred from other hospitals after receiving first aid and were admitted to the ICU for multiple trauma (Table 1); 83.9 percent of the patients were admitted within the first 24 h after trauma.

Overall mortality was 43.5 percent; mortality increased by age (32.9 percent less than 40 years, 60 percent for the 41- to 65-year age group, and 75

Discussion

Trauma patients have been shown to be at high risk for pneumonia,¹⁹ but no clear distinction has been made between EOP and LOP. Our study confirms that pneumonia is a commonly occurring complication in multiple trauma patients and shows that most cases are EOP, occurring within 4 days after trauma. Similar findings also have been described among general intensive care populations.7, 16, 17

Early and late onset pneumonia probably result from different underlying causal models; therefore,

ACKNOWLEDGMENTS

The authors are grateful to Drs. Maria Segneri and Luca Severi and to Luigi Riccioni for their assistance in collecting and delineating the data of this article.

References (20)

WeigeltJ.A.
Risk of wound infections in trauma patients
Am J Surg
(1985)
LedinghamI. et al.
Influence of sedation on mortality in critically ill multiple trauma patients
Lancet
(1983)
CravenD.E. et al.
Nosocomial pneumonia in the intubated patients: new concepts on pathogenesis and prevention
Surg Clin North Am
(1989)
TeasdaleG. et al.
Assessment of coma and impaired consciousness: a practical scale
Lancet
(1974)
LaForceF.M.
Lower respiratory tract infections
GreenG.M. et al.
Defense mechanism of the respiratory membrane
Am Rev Respir Dis
(1977)
DanieleR.P.
Immunodefenses of lung.
BerghemL. et al.
Role of phagocitic cells in host defense in relation to trauma: a brief review
Acta Chir Scand
(1979)
HowardR.J. et al.
Acquired immunologic deficiencies after trauma and surgical procedure
Surg Gynec Obstet
(1974)
HolchN. et al.
Posttraumatisches/post-operatives Immunodefektsyndrom: Vortrag Lahres-versannlung
Schweiz Ges Intensiv Med Zurich
(1987)

There are more references available in the full text version of this article.

Cited by (171)

“Do You Need a Doctor's Note?” Factors Leading to Delayed Return to Work after Blunt Chest Trauma
2021, Journal of Surgical Research
Blunt chest trauma is associated with significant morbidity, but the long-term functional status for these patients is less well-known. Return to work (RTW) is a benchmark for functional recovery in trauma patients, but minimal data exist regarding RTW following blunt chest trauma.
Patients ≥ 18 y old admitted to a Level 1 trauma center following blunt chest trauma with ≥ 3 rib fractures and length of stay (LOS) ≥ 3 d were included. An electronic survey assessing RTW was administered to patients after discharge. Patients were stratified as having delayed RTW (> 3 mo after discharge) or self-reported worse activities-of-daily-living (ADL) function after injury. Patient demographics, outcomes, and injury characteristics were compared between groups.
Median time to RTW was 3 mo (IQR 2,5). Patients with delayed RTW had higher odds of having more rib fractures than those with RTW ≤ 3 mo (median 10 versus 7; OR:1.24, 95%CI:1.04,1.48) as well as a longer LOS (median 13 versus 7 d; OR:1.15, 95% CI:1.04,1.30). Patients with stable ADL after trauma returned to work earlier than those reporting worse ADL (median 2 versus 3.5 mo, P < 0.01). 23.6% of respondents took longer than 5 mo to return to independent functioning, and 50% of respondents’ report limitations in daily activities due to physical health after discharge.
The significant proportion of patients with poor physical health and functional status suggests ongoing burden of injury after discharge. Patients with longer LOS and greater number of rib fractures may be at highest risk for delayed RTW after injury.
Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardiopulmonary resuscitation: A substudy of the CAAM trial
2020, Resuscitation
Early-onset pneumonia (EOP) is a common in-hospital complication in survivors of out-of-hospital cardiac arrest. In this substudy of the CAAM trial, we aimed to compare whether bag mask ventilation (BMV) compared to endotracheal intubation (ETI) performed during cardiopulmonary resuscitation increases the risk of developing EOP.
Adult patients from the CAAM trial that survived beyond 12 h of hospitalization were included. Information about in-hospital management and outcome of study subjects was systematically collected. Our primary aim was to compare the incidence of EOP in the BMV and ETI group using a series of bivariate analysis adjusting for one variable at a time and a logistic regression controlled for survival beyond 96 h, age, gender, catecholamine administration, no flow time, and initial shockable rhythm.
Of 627 patients from the CAAM trial that survived to hospital admission, 409 patients were hospitalized beyond 12 h and thus included (202 randomized to BMV and 20 7 randomized to ETI). Patients in the BMV group had a significantly longer period of unsecured airway during prehospital cardiopulmonary resuscitation (BMV (median): 33 min; ETI (median): 17 min, p < 0.0001). No significant difference in the development of EOP according to airway management was identified on univariate analysis (BMV: 53%, ETI: 53%, Odds Ratio 1.0 [0.7–1.5], p = 1.0). We found no difference in the development of EOP according to airway management in the series of bivariate analyses or in the multivariable regression analysis either.
In this substudy of the CAAM trial, development of early-onset pneumonia in out-of-hospital cardiac arrest survivors did not depend on airway management technique during CPR.
Chest Trauma Scoring Systems for Predicting Respiratory Complications in Isolated Rib Fracture
2019, Journal of Surgical Research
We retrospectively compared chest trauma scoring systems in patients with rib fractures without major extrathoracic injury for predicting respiratory complications. We also evaluated the predictive power according to the presence or absence of pulmonary contusion.
Data from 177 patients with isolated rib fractures were included (December 2013 to April 2018). The primary outcome was respiratory complications (pneumonia, respiratory failure, or empyema). The Abbreviated Injury Scale (AIS), Thoracic Trauma Severity Score (TTSS), Chest Trauma Score (CTS), Rib Fracture Score (RFS), and RibScore were evaluated using univariate and receiver operating characteristic (ROC) analyses to determine their predictive value for pulmonary complications. We divided patients into two groups according to the presence or absence of pulmonary contusion, and constructed ROC curves for both groups.
Twenty-eight patients (15.8%) had ≥1 respiratory complication, with significantly higher numbers of standard, segmental, and displaced rib fractures as well as significantly higher TTSS, CTS, RFS, and AIS scores. In all patients, the TTSS (0.723, 95% confidence interval [CI] 0.651-0.788) showed the highest area under the ROC curve (AUROC), followed by the CTS, RFS, AIS, and RibScore. In patients with pulmonary contusion, TTSS also showed the highest AUROC (0.704, 95% CI 0.613-0.784). In patients without pulmonary contusion, RFS showed the highest AUROC (0.759, 95% CI 0.630-0.861).
TTSS was the most useful system for predicting respiratory complications in isolated rib fracture patients with pulmonary contusion. By contrast, RFS was the most useful in patients without pulmonary contusion.
Time in Collars and Collar-Related Complications in Older Patients
2019, World Neurosurgery
Citation Excerpt :
Nonetheless, we suggest that the duration for all types of collars should be minimized for this population. Furthermore, previous studies have indicated that chest trauma is associated with the development of pneumonia, although it was not associated with the composite outcome in our study.48,49 It is possible that specific chest injuries, such as rib fractures, hemothorax, pneumothorax, or management with a thoracostomy may be associated with adverse events and remain topics for further research.50
Cervical spine immobilization, including cervical collars, has been recommended in most trauma guidelines. However, cervical spine immobilization can be associated with harm, and an increasing body of evidence has demonstrated associated complications. We hypothesized that older trauma patients placed in cervical collars for >24 hours were at greater risk of developing collar-related complications compared with those placed in cervical collars for ≤24 hours.
We conducted a retrospective cohort study of injured patients without a fracture of the cervical vertebrae, aged ≥65 years, who had been placed in a cervical collar during the period from January 1, 2015 to December 31, 2015. The primary outcome was the composite of the in-hospital development of nosocomial pneumonia and collar-related pressure ulcers.
A total of 1154 patients had been treated with cervical collars during the study period, and 61 (5.1%) had developed collar-related complications. Male sex, a lower initial Glasgow Coma Scale score, a history of congestive heart failure, a history of chronic obstructive pulmonary disease or asthma, operative management, and longer hospital and intensive care unit lengths of stay demonstrated a univariable association with collar-related complications (P < 0.10), in addition to a duration in the collar for >24 hours. An independent association was found between collar duration >24 hours and the outcome of interest (adjusted odds ratio, 2.50; 95% confidence interval, 1.16–5.39; P = 0.02).
Among older patients without a cervical vertebral fracture, duration of cervical collar use for >24 hours was associated with the development of collar-related complications. We recommend attention to early collar clearance for older trauma patients.
Impact of blunt pulmonary contusion in polytrauma patients with rib fractures
2019, American Journal of Surgery
We investigated the impact of blunt pulmonary contusion (BPC) in patients with rib fractures.
Adult patients with rib fractures caused by blunt mechanisms were enrolled over 3 years at a Level 1 trauma center. BPC was defined according to percentage of lung affected as: moderate (1–19% contusion) or severe (≥20% contusion).
In total, 1448 of the 7238 admitted patients had rib fractures. Of these, 321 (22.2%) had BPC: 236 moderate and 85 severe. Patients with BPC were more likely to be admitted to the ICU (moderate: OR 1.55, 95% CI 1.10–2.19; severe: OR 2.74, 95% CI 1.41–5.32). Significantly increased rates of pneumonia (OR 2.52, 95% CI 1.43–4.90) and empyema (OR 4.80, 95% CI 1.07–21.54) were found for moderate and severe BPC, respectively.
ICU admission and infectious pulmonary complications were more likely with BPC. The presence of BPC on admission CT is also prognostic of increased resource utilization.
Forced vital capacity assessment for risk stratification of blunt chest trauma patients in emergency settings: A preliminary study
2018, Anaesthesia Critical Care and Pain Medicine
The aim of this study was to assess the performance of Forced Vital Capacity (FVC) for prediction of secondary respiratory complications in blunt chest trauma patients.
During a 15-month period, all consecutive blunt chest trauma patients admitted in our emergency intensive care unit with more than 3 rib fractures were eligible, unless they required mechanical ventilation in the prehospital or emergency settings. FVC was measured at admission and at emergency discharge after therapeutic interventions. The main outcome was the occurrence of secondary respiratory complications defined by hospital-acquired pulmonary infection, secondary admission in the intensive care unit or mechanical ventilation for respiratory failure or death. The performance of FVC for prediction of secondary respiratory complications was assessed by receiver operating characteristic (ROC) curve and multivariate analysis after logistic regression.
Sixty-two consecutive patients were included and 13 (21%) presented secondary respiratory complications. Only FVC measured at emergency discharge – not FCV at admission – was significantly lower in patients who developed secondary respiratory complications (44 ± 15 vs. 61 ± 20%, P = 0.002). The area under the ROC curves for FCV in predicting secondary pulmonary complications was 0.79 [95% CI: 0.66–0.88], P = 0.0001. An FVC at discharge ≤ 50% was independently associated with the occurrence of secondary complications with an OR at 7.9 [1.9–42.1], P = 0.004.
The non-improvement of FVC ≤ 50% at emergency discharge is associated with secondary respiratory complications and should prevent the under-triage of patients with no sign of respiratory failure at admission.

View all citing articles on Scopus

View full text

Chest

Clinical Investigations in Critical CareRisk Factors for Early Onset Pneumonia in Trauma Patients

Study objectives

Study population

Data collection

Data analysis

Results

Section snippets

Study Population and Data Collection

Data Recorded

Results

Discussion

ACKNOWLEDGMENTS

Am J Surg

Lancet

Surg Clin North Am

Lancet

Lower respiratory tract infections

Defense mechanism of the respiratory membrane

Am Rev Respir Dis

Immunodefenses of lung.

Role of phagocitic cells in host defense in relation to trauma: a brief review

Acta Chir Scand

Acquired immunologic deficiencies after trauma and surgical procedure

Surg Gynec Obstet

Posttraumatisches/post-operatives Immunodefektsyndrom: Vortrag Lahres-versannlung

Schweiz Ges Intensiv Med Zurich

Clinical Investigations in Critical Care
Risk Factors for Early Onset Pneumonia in Trauma Patients