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 o 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  Ab d: + BS, so ft, no n-te nde r, T AL S: ta c hyc a rdia 121, o the rs unre ma rka b le . no ma sse s.  CVS: S1+S2, I  Ne uro : AAOX3, g ro ssly inta c t, rre g ula rly irre g ula r, ho lo -systo lic a b le to mo ve UE a nd L E murmur. No JVD.  Che st: re duc e d a ir e ntry, n o  E xtre mity: No pitting e de ma , whe e zing o r c ra c kle s. 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  Che st: b / l c ra c kle s , le ft>rig ht T AL S: sta b le  Ge n: c a c he c tic a nd ill  Ab d: + BS, so ft, no n-te nde r, no a ppe a ring rig idity  Mo uth: dry o ra l muc o sa  Ne uro : AAOX3, No g ro ss mo to r o r se nso ry de fic it  CVS: S1+S2, I rre g ula rly irre g ula r,  E 3/ 6 murmur in the mitra l a re a . 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 o 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 Older adult Young adult S. pneumoniae; S. pneumoniae; H. influenza; Mycoplasma; Chlamydia; Chlamydia S. aureus; Gram-negative rods .

. Ba c te rio lo g y: c o nt... NH Aspiration Pneumonia S. pneumoniae Same as NH with anaerobes it was Gram-negative rods isolated from patients with long- S. Aureus 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 imita t a ti io n o ns: s: L imit  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 o 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 ! I nc re ase d o ral vulne rab ility • Re duc e d c o nsc io usne ss le ve l • Dyspha g ia • I mpa ire d ha nd / a rm func tio n • Nil b y mo uth (NPO) • Drug s (PPI a nd a ntiH2) Can’ t ask fo r o ral hyg ie ne ! • Nutritio na l sta tus • Co mmunic a tio n b a rrie rs  Dyspha sia  De lirium  De me ntia .

.  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 or 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 y) alone : mo xiflo xa c in, luor oquinolone (r e spir ator le vo flo xa c in, o r Ge miflo xa c in  or Mac r olide 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 olide : do xyc yc line . native to a Mac r  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 or va 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 . .