Pulmonary Complications

Pulmonary complications are frequent in patients with SAH and represent a significant cause of morbidity and mortality. Among the most common are nosocomial and aspiration pneumonia, pulmonary edema (neurogenic and cardiogenic), and pulmonary embolism (21,63). Older patients with worse Hunt and Hess grade and lower Glasgow Coma Scale score on admission are at higher risk for developing pulmonary complications (63 ).

Patients with pulmonary complications were shown to have a greater incidence of symptomatic vasospasm.

Most cases of pneumonia are seen in patients who require mechanical ventilation. Extu-bation should be performed as early as clinically possible. Care must be taken to prevent accidental extubation. Nasally placed endotracheal tubes should be avoided to diminish risk of sinusitis. All mechanically ventilated patients should be maintained in semirecumbent position to prevent aspiration. Adequate enteral nutrition is crucial; however, large gastric volumes should be avoided (64).

Neurogenic pulmonary edema may be seen acutely, within hours of the initial ictus, or a few days after the onset of aneurysmal rupture. Clinical features are nonspecific and similar to those of cardiogenic pulmonary edema with respiratory distress, tachycardia, and hypotension. Treatment is generally supportive and includes the administration of both supplemental oxygen, to maintain adequate tissue oxygenation, and diuretics; patients with severe hypoxemia require ventilatory support with high positive end-expiratory pressure. Insertion of a pulmonary artery catheter may be warranted, especially if hemodynamic therapy for vasospasm is required. Neurogenic pulmonary edema is often reversible within 48 to 72 hrs.

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