Critical Care Aspects of Alcohol Abuse

Ibrahim Al-Sanouri MD; Matthew Dikin MD; Ayman O. Soubani MD

Disclosures

South Med J. 2005;98(3):372-381. 

In This Article

Respiratory Complications

Respiratory Infections

Alcohol has been observed to be a common comorbidity in MICU patients with pneumonia.[60] Interestingly, there is a 60% increase in the use of the MICU when an alcoholic has pneumonia compared with a nonalcoholic patient. Moreover, the length of stay is increased compared with a nonalcoholic patient.[61] The mortality rate of pneumonia with alcohol-related diagnoses was reported to be 10%; however, in the case of Klebsiella pneumoniae, there was a higher incidence of bacteremia, with mortality up to 66%.[62] In addition, the incidence of tuberculosis, pleurisy, bronchitis, and empyema are significantly higher among alcoholics compared with nonalcoholics.[63]

The pathophysiology of pneumonia in alcoholics is primarily due to depression of normal defense mechanisms. Alcohol is known to depress normal mucociliary function.[64] Furthermore, the ability of neutrophils and macrophages to fight against infection is hampered.[65,66] Other inhibited lower respiratory tract defenses include nonspecific antibacterial activity of surfactant, opsonization by immunoglobulin or complement, and intracellular killing by alveolar macrophages.[67] Aspiration of material from the mixed oropharyngeal flora may be due to a diminished cough or epiglottic reflex seen during alcoholic withdrawal seizures or a decrease in level of consciousness associated with heavy drinking.[67] Other contributors to an increased risk of development of pneumonia include poor nutrition, immunosuppression from alcohol-related liver disease, and smoking abuse.

The symptoms of pneumonia in alcoholics are similar to those with community-acquired pneumonia but may be more severe. The organisms most commonly isolated are Streptococcus pneumoniae, Haemophilus influenza, and K pneumoniae.[68] In addition, because of the frequent occurrence of poor oral dentition, seizures, and subsequent aspiration, alcoholics are susceptible to a variety of anaerobic pleuropulmonary diseases, including anaerobic pneumonitis, necrotizing pneumonia, primary lung abscess, and empyema.

Treatment of alcoholics with pneumonia in the MICU is challenging. Mechanical ventilation for pneumonia is often required in severe hypoxemia, significant aspiration, and/or acute alcohol-withdrawal seizure. Antibiotic therapy for severe pneumonia or suspected aspiration must be started as early as possible for better outcome. Treatment options include cefotaxime or certriaxone plus a macrolide or a fluoroquinolone. If aspiration is suspected, ampicillin/sulbactam, ticarcillin/clavulanate, or piperacillin/tazobactam may be used as monotherapy, or a fluoroquinolone plus clindamycin or metronidazole can be used as an alternative for penicillin allergy. Last, surgical intervention with decortication or chest thoracostomy for necrotizing aspiration pneumonia, lung abscesses, and empyema may be required. Supportive therapy with adequate hydration, bronchodilators, chest physiotherapy, and nutrition are also essential in the treatment of these patients.

Acute Respiratory Distress Syndrome

A history of chronic alcohol abuse significantly increases the risk of developing acute respiratory distress syndrome (ARDS) in critically ill patients, regardless of the inciting illness.[69] Risk factors of developing ARDS in chronic alcohol abuse include severe pancreatitis, hypertransfusion caused by gastrointestinal bleeding, aspiration pneumonia, hepatic failure, trauma, and sepsis.

The pathophysiology of alcoholic-related ARDS is complex. Alcohol may directly interact with the pathogenic cascade leading to ARDS. In vitro studies have shown an increase in neutrophil adherence, phagocytosis, and chemotaxis when alcohol levels consistent with intoxication are found in experimental animals. In addition, other in vivo studies have shown upregulation of CD 11b/CD 18 receptors, which recognize the intercellular adhesion molecule, ICAM-1, on endothelial cells, an important step in cell requirement at the site of inflammation. This would increase oxidative free radical production and enhance the inflammatory process seen with ARDS.

The management of ARDS in alcoholics in the MICU is similar to that of nonalcoholics. Treatment is directed at supportive care, mechanical ventilation, and treatment of the underlying illness. The outcome of alcoholic patients with ARDS appears to be worse than in nonalcoholics. In-hospital mortality rates may be as high as 65% in patients with a history of alcohol abuse, compared with 36% in those without a history of alcohol abuse.[70]

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