Severe burns are one of the most devastating forms of trauma. In South Africa, burn injuries are the third commonest external cause of fatal injuries up to the age of 15 years and the main cause under the age of 4 years. In the Cape Town region, at least six out of 10 000 children are seriously burnt every year, and as many as 15 out of 10 000 toddlers and infants.1,2
A number of advances have been made in recent times with regard to fluid resuscitation protocols, dressings, infection control strategies and antimicrobials, surgical techniques, intensive care, and nutrition. There is now widespread recognition that specialist burns units or centres deliver the best care for these patients. As a result of these measures, mortality and morbidity rates have declined significantly over the last few decades.3,4
Significant thermal injuries induce a state of immunosuppression; three-quarters of all severe burn related deaths are consequence of infection, most notably burn wound infections, sepsis, pneumonia and urinary tract infections, many of which are nosocomial.4-8
There are a number of mechanisms for the development of pneumonia in the severely burnt. Pulmonary complications are common with inhalational injury, but burnt patients have more pulmonary complications even without direct lung injury. Atelectasis and hypostatic pneumonia are common due to altered ventilation and reduced lung expansion that may occur in patients with chest or abdominal burns. These patients may also have a high risk of aspirating, and respiratory physiotherapy with regular airway suctioning of upper airway secretions and expectoration of sputum may be critical to maintaining pulmonary function.5,9
Patients who require prolonged ventilation are also at risk of developing ventilator-associated pneumonia (VAP). Prior to 2007, VAP could only be diagnosed after 48 h of mechanical ventilation. No minimum time of ventilation is now required to make the diagnosis.10
Despite this change in definition, there may still be some utility in considering patients in early or late groups, because causative organisms and their resistance patterns vary in relation to this.
In the paediatric intensive care setting, VAP is responsible for significant morbidity and mortality, and ranks as the second commonest hospital acquired infection. In fact, a large European trial in a variety of paediatric settings showed that VAP accounted for over half of hospital acquired infections in the PICU.11
The prevalence of nosocomial pneumonia in the ICU ranges from 10 to 65% and mortality rates exceed 25%. Those who develop VAP are twice as likely to die compared to those without VAP, and spend longer in intensive care. The nosocomial bacteria that cause VAP tend to be more resistant.11-15
There is a paucity of literature on VAP in children, particularly within the context of major paediatric burns. International guidelines for the prevention and management of VAP have largely been extrapolated from adult experience with VAP. Burns patients, and particularly paediatric patients with burns, are a special group, with peculiar demands and predispositions, and should be managed by burns surgeons, anaesthetists, specialist nursing staff, paediatric intensivists, physiotherapists and occupational therapists with special interest and experience.