Aspira tio n pne umo nia in o lde r pe o ple Ayman Mo rish, M.D. I - - PowerPoint PPT Presentation

Aspira tio n pne umo nia in

• lde r pe o ple

Ayman Mo rish, M.D.

I nte rna l me dic ine , Critic a l c a re Me dic ine a nd Ge ria tric s F e llo w.

Conte nts

E

pide mio lo g y

Ca use s o f a spira tio n pne umo nia I

ssue s o f o lde r a g e

Ma na g e me nt Pre ve ntio n

Ca se 1: a dmissio n Ja n 26

 CHI

E F COMPL AI NT (S): we a kne ss a nd fe e ling unwe ll

 HPI: 90-ye a r-o ld g e ntle ma n. Ca me fro m a n a ssiste d living

fa c ility fe e ling we a k fo r the pa st 4 da ys.

 PMH: E

SRD o n HD, AF ib , COPD, CHF , HT N, CAD.

 SHx: Assiste d living fa c ility. I

nde pe nde nt in mo st o f his ADL s a nd ne e d mo de ra te suppo rt with tra nsfe r a nd mo b ilitie s.

P/ E

 VI

T AL S: ta c hyc a rdia 121,

• the rs unre ma rka b le .

 CVS: S1+S2, I

rre g ula rly irre g ula r, ho lo -systo lic

• murmur. No JVD.

 Che st: re duc e d a ir e ntry, n

whe e zing o r c ra c kle s.

•  Ab d: + BS, so ft, no n-te nde r,

no ma sse s.

 Ne uro : AAOX3, g ro ssly inta c t,

a b le to mo ve UE a nd L E

 E

xtre mity: No pitting e de ma , no rma l pulse s.

L a b a nd I ma g ining

WBC 6.93 Na 138 K 3.9 BUN 19 Cre a t 2.9 BNP 2687 CXR: L e ft L L infiltra te / a te le c ta sis. Hype rinfla te d lung sug g e sting COPD.

Wha t do yo u think is g o ing o n?

 Ho ld yo ur tho ug hts fo r no w ..

Ca se 2: Admissio n F e b 14

 CHI

E F COMPL AI NT (S): We a kne ss, c o ug h, na use a a nd vo miting .

 HPI

: 90-ye a r-o ld g e ntle ma n. Ca me fro m a n a ssiste d living fa c ility c o mpla ining o f vo miting 3-4 time s, c ho c king a nd c o ug hing with e a ting . Ha d a re c e nt histo ry o f pne umo nia 3 we e ks a g o a nd wa s tre a te d with a ntib io tic s.

 PMH: E

SRD o n HD, AF ib , COPD, CHF , HT N, CAD.

 SHx: Assiste d living fa c ility. I

nde pe nde nt in mo st o f his ADL s a nd ne e d mo de ra te suppo rt with tra nsfe r a nd mo b ilitie s.

P/ E

 VI

T AL S: sta b le

 Ge n: c a c he c tic a nd ill

a ppe a ring

 Mo uth: dry o ra l muc o sa  CVS: S1+S2, I

rre g ula rly irre g ula r, 3/ 6 murmur in the mitra l a re a .

 Che st: b / l c ra c kle s , le ft>rig ht  Ab d: + BS, so ft, no n-te nde r, no

rig idity

 Ne uro : AAOX3, No g ro ss mo to r o r

se nso ry de fic it

 E

xtre mitie s: pitting e de ma , no rma l pulse s.

L a b a nd I ma g ining

 WBC 7.76  K

6.2

 BUN 71  Cr 5.7  BNP 4357  CXR: inte rstitia l pro mine nc e , le ft lo we r lo b e a irspa c e

• pa c ity c o nsiste nt with a te le c ta sis o r c o nso lida tio n. L

e ft ple ura l e ffusio n.

Wha t do yo u think is g o ing o n?

 Ho ld yo ur tho ug hts fo r no w ..

De finitio ns a nd me c ha nisms

 Aspir

ation is the misdire c tio n o f o ro pha ryng e a l o r g a stric

c o nte nts into the la rynx a nd lo we r re spira to ry tra c t

 Aspir

ation Pne umonitis is a c he mic a l injury b y inha la tio n o f

g a stric c o nte nts.

 Aspir

ation pne umonia is a n infe c tio n c a use d b y inha la tio n o f

b a c te ria c o lo nize d o ro pha ryng e a l c o nte nts

E pide mio lo g y

Adults a g e 65 ye a rs a nd o lde r a c c o unt fo r >50

pe rc e nt o f a ll pne umo nia

I

nc ide nc e o f pne umo nia inc re a se s with a g ing a nd fra ilty

Ho spita lisa tio ns pe r ye a r fo r pne umo nia

1.1 / 1000 yo ung a dults 12 / 1000 o ld a dults 32 / 1000 nursing ho me re side nts

https:/ / www.upto da te .c o m

E pide mio lo g y:

c o nt..

Ra te o f b a c te re mia :

 1/ 1000 b e twe e n a g e 35-44.  25/ 1000 a t a g e > 75

Ra te o f no so c o mia l pne umo nia :

<2/ 1000 b e twe e n 30-40 17/ 1000 a t a g e > 70

*K a pla n e t a l. Arc h I nte rn Me d 163:317, 2003, ** Jo hnsto ne e t a l. Me dic ine 87: 329, 2008

Ba c te rio lo g y:

 anaerobic bacteria is less common than previously thought.  Hard to distinct.  Aspiration pneumonia represents a distinct entity from typical pneumonia?  Pneumonia occurs from micro aspiration of oropharyngeal contents.  Similar microbiology and clinical course as aspiration pneumonia

Ba c te rio lo g y:

c o nt...

CAP

Young adult

• S. pneumoniae;

Mycoplasma; Chlamydia Older adult

• S. pneumoniae;
• H. influenza;

Chlamydia;

• S. aureus;

Gram-negative rods

Ba c te rio lo g y:

c o nt...

NH

• S. pneumoniae

Gram-negative rods

• S. Aureus

Aspiration Pneumonia

Same as NH with anaerobes it was isolated from patients with long- standing processes such as lung abscess; and it is unclear what role they play in early infection

Wo rk up:

https:/ / www.upto d a te .c o m/ c o nte nts/ ima g e ? ima g e K e y=RADI OL %2F 100988&to pic K e y=I D%2F 7024&so urc e =o utline _link

I ndic a tio ns fo r e xte nsive wo rkup

Dia g no sis:

 ne w hypo xe mia  pulmo na ry infiltra te s o n ima g ing , pa rtic ula rly in g ra vity-

de pe nde nt lung re g io ns o n c he st ima g ing

po ste rio r-se g me nts o f the uppe r lo b e s, b a sila r se g me nts o f the lo we r lo b e s  fe ve r  le uko c yto sis  ta c hypne a

L imit L imita t a ti io n

• ns:

s:

 Diagnosis is made in <50% of cases  Insufficient sample.  Gram-negative pathogens and Staph aureus are common.  Strep pneumoniae remains the most common pathogen.

Risk fa c to rs – a spira tio n pne umo nia in

• lde r pe o ple

 a lte re d me nta l sta tus  Dyspha g ia in re side nts o f lo ng -te rm c a re fa c ilitie s Diffic ulty swa llo wing fo o d (OR 2.0) a nd me dic a tio n (OR 8.3) Swa llo wing dysfunc tio n, e .g . in pa tie nts with COPD o r a fte r

stro ke .

 pro lo ng e d supine po sitio n  Ga stro pa re sis a nd hig h re sidua l g a stric vo lume s  Aspira tio ns: 71% o f pa tie nts with CAP c o mpa re d to 10% in

c o ntro ls

He a lthy a g ing a nd the swa llo w

 Olde r pe o ple swa llo w mo re slo wly L

a ryng e a l c lo sure is de la ye d

Uppe r o e so pha g e a l sphinc te r o pe ning de la ye d Ora l b o lus tra nspo rt time pro lo ng e d  Sa fe ty o f o ro pha ryng e a l swa llo wing is no t c o mpro mise d T

he re is no inc re a se in a spira tio n c o mpa ring to yo ung e r a dults in ra dio g ra phic studie s

Dyspha g ia

 50% o f a c ute stro ke pa tie nts ha ve c linic a l

dyspha g ia

 Mo st (80%) re so lve in the first 7-10 da ys  Asso c ia te d with b ig stro ke s a nd a pha sia  De me ntia  Pa rkinso n dise a se  Multiple sc le ro sis

Ma nn e t a l, Stro ke 1999; 30:744

Po o r o ra l he a lth + o ro pha ryng e a l b a c te ria l c o lo niza tio n

Can’ t do o ral hyg ie ne !

• Re duc e d c o nsc io usne ss le ve l
• I

mpa ire d ha nd / a rm func tio n Can’ t ask fo r o ral hyg ie ne !

• Co mmunic a tio n b a rrie rs

Dyspha sia De lirium De me ntia

I nc re ase d o ral vulne rab ility

• Dyspha g ia
• Nil b y mo uth (NPO)
• Drug s (PPI

a nd a ntiH2)

• Nutritio na l sta tus

Ba c k to o ur pa tie nts Did the y me e t the c rite ria fo r dia g no sis o f

a spira tio n pne umo nia ?

Wha t a re the ir risk fa c to rs

F

irst c a se wa s tre a te d with Una syn (Ampic illin / Sulb a c ta m)

Se c o nd c a se tre a te d with c e ftria xo ne

Whe n to tre a t?

 Pro phyla c tic a ntib io tic s a re no t re c o mme nde d  Antib io tic s a re disc o ura g e d sho rtly a fte r a spira tio n e ve n with

fe ve r, le uko c yto sis o r pulmo na ry infiltra te .

 Re c o mme nd a ntib io tic s in:

1. Aspira tio n in hig h risk pa tie nts with c o lo nize d g a stric c o nte nts 2. Aspira tio n pne umo nitis tha t fa ils to re so lve within 48 hrs 3. Unsta b le pa tie nt with witne sse d a spira tio n

T re a tme nt:

F

• r

nur sing home r e side nts, patie nts with antibiotic s use in the last 3 months or patie nts with c omor biditie s:

 F

luor

• quinolone (r

e spir ator y) alone : mo xiflo xa c in,

le vo flo xa c in, o r Ge miflo xa c in

 or Mac r

• lide s (Azithro myc in, c la rithro myc in, o r e rythro myc in)

plus β- lac tams (a mo xic illin (hig h do se ) o r a mo xic illin-

c la vula na te a c id)

 Alternative β- lac tams: c e ftria xo ne , c e fpo do xime o r

c e furo xime . Alte r

native to a Mac r

• lide: do xyc yc line .

 Amo xic illin-c la vula na te a c id if ne e d a na e ro b ic b a c te ria l

c o ve ra g e .

T re a tme nt:

c o nt..

Nursing - home or Hospita l- a c quire d Pne umonia Re quiring Pa re nte ra l T re a tme nt:

 Antipse udomona l c e pha losporin (c e fe pime o r c e fta zidime ) or

Antipse udomona l c a rba pe ne m (imipe ne m o r me ro pe ne m) or ß- la c ta m/ ß- la c ta ma se inhibitor(pipe ra c illin-ta zo b a c ta m) plus

 Antipse udomona l fluoroquinolone (c ipro flo xa c in o r le vo flo xa c in) or

Aminog lyc oside (a mika c in, g e nta mic in, o r to b ra myc in) plus

 MRSA L

ine zo lid orva nc o myc in

 Ampic illin-sulb a c ta m if ne e d a na e ro b ic b a c te ria l c o ve ra g e .

Dur ation of T r e atme nt:

A minimum o f 5 da ys plus no fe ve r fo r 48 h a nd sho uld

ha ve no CAP a sso c ia te d sig n o f c linic a l insta b ility:

HR >100 b pm Re spira to ry ra te 225/ min SBP 00 mmHg 02 sa tura tio n <90% o r Pa 02 mmHg Ab ility to ma inta in o ra l inta ke a b no rma l me nta l sta tus

Ma inta in the ra py:

 Switc h fro m pa re nte ra l to o ra l a ntib io tic s whe n pa tie nt is

he mo dyna mic a lly sta b le , sho ws c linic a l impro ve me nt, is a fe b rile fo r 16 h, a nd c a n to le ra te o ra l me dic a tio ns;

 Ave ra g e dura tio n o f 7—14 d de pe nding o n c linic a l

re spo nse .

 L

• ng -te rm c a re fa c ility—usua lly 10—14 d

Re c o mme nda tio ns:

 Sta rt e a rly (<4hrs) in c ritic a lly ill.  T

a rg e t the c a usa tive o rg a nism.

 I

f no infiltra te s de ve lo p 48 to 72 ho urs a fte r a n a spira tio n, it is a ppro pria te to sto p a ntib io tic s.

Ma na g e me nt stra te g ie s to re duc e the risk o f a spira tio n pne umo nia

 Assista nc e with re g ula r o ra l hyg ie ne  Sc re e ning / inve stig a tio n fo r dyspha g ia

 Hig h risk sub g ro ups e .g . stro ke , de me ntia , pne umo nia , witne sse d

a spira tio n

 Nil-b y-mo uth during hig h risk pe rio ds  Po stura l inte rve ntio ns.  Ha nd-fe e ding  Sma ll a mo unts fre q ue ntly  Mo difie d die t / thic ke ne d fluids / fo o d supple me nts

Swa llo wing a sse ssme nt a fte r a stro ke :

Ro utine asse ssme nt

 L

• o k in the mo uth!

No impaire d c o nsc io usne ss

 Wa te r swa llo w te st  Be dside swa llo w a sse ssme nt

Se le c te d patie nts

 Na so sc o pe  Mo difie d Ba rium swa llo w

(vide o -fluo ro sc o py)

Co nc lusio ns

 Aspira tio n is the ma in c a use o f pne umo nia in la te r life  T

he risk inc re a se d with;

dyspha g ia with o ro pha ryng e a l b a c te ria l c o lo nisa tio n  F

ra ilty, c o g nitive impa irme nt a nd multi-mo rb idity

 AP ha s no n-spe c ific pre se nta tio n  Po te ntia l fo r pre ve ntio n o f AP multi-mo da l / multi-disc iplina ry stra te g ie s

T ha nk yo u