RESUMO
Pneumonia is the most frequent cause of hospitalization, resulting in a high risk of mortality. Diabetic patients are at high risk of aquatinting pneumococcal infections with their consequent complications. Despite the fact that glycemic control of the patients reduces the risk of diabetic complications and enhances their immunity, pneumococcal vaccination should still be given irrespective of the patients' glycemic control. The purpose of this review is to address the present situation of pneumococcal disease prevention in diabetic patients in the Kingdom of Saudi Arabia (KSA) and to gather professional recommendations to overcome the vaccination-related barriers. Onsite insights of scientific leaders in family medicine, endocrinology, and internal medicine in Riyadh and Jeddah were gathered and linked with the available literature to tackle the current practice of pneumococcal disease prevention in diabetic patients in the Kingdom of Saudi Arabia. Pneumococcal vaccination importance is still not well recognized among endocrinologists across the Kingdom of Saudi Arabia, despite the availability of established local recommendations and the National Immunization Program. The prevention of serious and fatal pneumococcal diseases should be one of the treatment pillars for diabetic patients, and it is not less important than controlling other risk factors.
RESUMO
We discuss a case of severe pneumonia with pneumatoceles in a 2-month old infant. Despite peak and plateau airway pressures kept below 30 and 25 cmH(2)O, respectively, the infant developed bilateral pneumothorax and pneumomediastinum caused by pneumatocele rupture, necessitating bilateral intercostal drainage. Application of positive end-expiratory pressure (PEEP) of 10 cmH(2)O at FIO(2) of 0.7 worsened oxygenation, and transthoracic echocardiography showed right-to-left shunting of blood through the patent foramen ovale. Therefore, PEEP had to be tapered to 6 cmH(2)O, and ventilation carried out at FIO(2) of 1 until the lung condition improved. The open lung strategy of higher increments of PEEP and lower FIO(2) for lung protective ventilation actually proved deleterious to our patient. We conclude that a subset of patients with acute respiratory distress syndrome with refractory hypoxaemia may have right-to-left shunting of blood through a patent foramen ovale. This can be detected by echocardiography, and these patients may benefit from a ventilation strategy aimed at lowering pulmonary vascular resistance.