Aspiration pneumonia occurs when a large volume of oropharyngeal or gastric contents are aspirated into the lungs, depositing a large bacterial inoculum. This can overwhelm normal lung defenses and cause pneumonia. Risk factors include dysphagia, altered mental status, vomiting, enteral feeding, and oropharyngeal colonization with more virulent bacteria. Aspiration is common but often does not cause pneumonia due to protective mechanisms; however, large volume macroaspiration can lead to aspiration pneumonia.
Pneumonia is an inflammation of the lung tissue that is commonly caused by a microbial infection. It can be classified based on its causative agent such as bacteria, viruses, or fungi. Common symptoms include cough, fever, shortness of breath, and chest pain. Diagnosis involves physical examination, sputum culture, chest x-ray, and other tests. Treatment focuses on relieving symptoms, using antibiotics if caused by bacteria, and preventing complications through rest and fluid intake.
This document discusses the management of severe viral pneumonia in the ICU. It begins with an introduction that outlines the major concerns of viral pneumonia for intensivists due to high mortality and morbidity rates. It then discusses the various viruses that can cause respiratory infections in the ICU such as influenza, RSV, adenovirus, SARS-CoV, and others. The pathophysiology, clinical presentation, diagnostic tools including imaging and labs, and treatment approaches including antiviral therapy, corticosteroids, oxygenation and ventilation are summarized. Non-invasive ventilation is discussed as a first-line treatment for acute respiratory failure but criteria for NIV failure requiring intubation are also provided.
Health care-associated pneumonia: Pathogenesis Diagnosis and Preventionsiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
hospital acquired pneumonia from preventive med prospectivefawziahroublah1
This document discusses hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). It defines HAP and VAP, examines their epidemiology in the US, Asia, and Saudi Arabia, and explores their impacts including increased morbidity, mortality, and healthcare costs. The document also reviews the causes and risk factors for HAP, such as bacterial/viral infections, weakened immune systems, extended hospital stays, and use of ventilators. Finally, it outlines several methods for preventing HAP, including proper hand hygiene, use of personal protective equipment, staff education, surveillance programs, vaccination, proper disinfection/sterilization, restricted antibiotic use, respiratory hygiene, and oral care.
Pneumonia is an inflammatory condition of the lungs that is usually caused by a bacterial or viral infection. Globally, pneumonia affects around 450 million people per year and causes about 4 million deaths, mostly in developing countries. Symptoms include cough, chest pain, fever, and difficulty breathing. Diagnosis is usually based on symptoms and chest x-ray findings. Treatment involves antibiotics, antivirals, fluids, and rest. Prevention strategies include staff education, infection control measures, and vaccination.
Pneumonia is an inflammatory lung condition caused by infection. It can be caused by viruses, bacteria, or fungi. The document discusses pneumonia in detail, including defining it, risk factors, classification, etiology, pathophysiology, clinical manifestations, diagnosis, and management. Pneumonia has a high incidence rate in children under 5 years old and is a leading cause of child mortality worldwide. Treatment depends on the severity and cause of the pneumonia.
This document discusses definitions, pathophysiology, risk factors, and prevention strategies for hospital-acquired infections (HAIs) like hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). It focuses on prevention bundles, which group multiple interventions together to potentially increase their effectiveness by exploiting synergies. Effective bundle elements include proper hand hygiene, oral care with chlorhexidine, maintaining endotracheal tube cuff pressure, and early mobility. Bundles provide a practical way to enhance care and reduce infection rates.
1) Aspiration, defined as the inhalation of oropharyngeal or gastric contents into the lower respiratory tract, can lead to a range of diseases from infectious pneumonia to respiratory distress syndrome and is associated with significant morbidity and mortality.
2) The reported incidence of aspiration during anesthesia varies between 3-10 per 10,000 operations, with higher rates in obstetric and pediatric anesthesia as well as certain surgical procedures like tracheostomy.
3) Patients are most at risk during induction and emergence from anesthesia, particularly in emergency situations. The likelihood of aspiration can be reduced by preoperative fasting, pharmacological prevention, and rapid sequence induction techniques.
Pneumonia is an inflammation of the lung tissue that is commonly caused by a microbial infection. It can be classified based on its causative agent such as bacteria, viruses, or fungi. Common symptoms include cough, fever, shortness of breath, and chest pain. Diagnosis involves physical examination, sputum culture, chest x-ray, and other tests. Treatment focuses on relieving symptoms, using antibiotics if caused by bacteria, and preventing complications through rest and fluid intake.
This document discusses the management of severe viral pneumonia in the ICU. It begins with an introduction that outlines the major concerns of viral pneumonia for intensivists due to high mortality and morbidity rates. It then discusses the various viruses that can cause respiratory infections in the ICU such as influenza, RSV, adenovirus, SARS-CoV, and others. The pathophysiology, clinical presentation, diagnostic tools including imaging and labs, and treatment approaches including antiviral therapy, corticosteroids, oxygenation and ventilation are summarized. Non-invasive ventilation is discussed as a first-line treatment for acute respiratory failure but criteria for NIV failure requiring intubation are also provided.
Health care-associated pneumonia: Pathogenesis Diagnosis and Preventionsiosrphr_editor
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
hospital acquired pneumonia from preventive med prospectivefawziahroublah1
This document discusses hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). It defines HAP and VAP, examines their epidemiology in the US, Asia, and Saudi Arabia, and explores their impacts including increased morbidity, mortality, and healthcare costs. The document also reviews the causes and risk factors for HAP, such as bacterial/viral infections, weakened immune systems, extended hospital stays, and use of ventilators. Finally, it outlines several methods for preventing HAP, including proper hand hygiene, use of personal protective equipment, staff education, surveillance programs, vaccination, proper disinfection/sterilization, restricted antibiotic use, respiratory hygiene, and oral care.
Pneumonia is an inflammatory condition of the lungs that is usually caused by a bacterial or viral infection. Globally, pneumonia affects around 450 million people per year and causes about 4 million deaths, mostly in developing countries. Symptoms include cough, chest pain, fever, and difficulty breathing. Diagnosis is usually based on symptoms and chest x-ray findings. Treatment involves antibiotics, antivirals, fluids, and rest. Prevention strategies include staff education, infection control measures, and vaccination.
Pneumonia is an inflammatory lung condition caused by infection. It can be caused by viruses, bacteria, or fungi. The document discusses pneumonia in detail, including defining it, risk factors, classification, etiology, pathophysiology, clinical manifestations, diagnosis, and management. Pneumonia has a high incidence rate in children under 5 years old and is a leading cause of child mortality worldwide. Treatment depends on the severity and cause of the pneumonia.
This document discusses definitions, pathophysiology, risk factors, and prevention strategies for hospital-acquired infections (HAIs) like hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP). It focuses on prevention bundles, which group multiple interventions together to potentially increase their effectiveness by exploiting synergies. Effective bundle elements include proper hand hygiene, oral care with chlorhexidine, maintaining endotracheal tube cuff pressure, and early mobility. Bundles provide a practical way to enhance care and reduce infection rates.
1) Aspiration, defined as the inhalation of oropharyngeal or gastric contents into the lower respiratory tract, can lead to a range of diseases from infectious pneumonia to respiratory distress syndrome and is associated with significant morbidity and mortality.
2) The reported incidence of aspiration during anesthesia varies between 3-10 per 10,000 operations, with higher rates in obstetric and pediatric anesthesia as well as certain surgical procedures like tracheostomy.
3) Patients are most at risk during induction and emergence from anesthesia, particularly in emergency situations. The likelihood of aspiration can be reduced by preoperative fasting, pharmacological prevention, and rapid sequence induction techniques.
Pulmonary aspiration complicates between 1 in
900 to 1 in 10 000 general anaesthetics,1 dependent
on risk factors. All novice anaesthetists
in the UK are taught to consider the risk of aspiration
and to modify their anaesthetic technique
accordingly. The prevention of aspiration
remains a cornerstone of anaesthetic practice.
The recent Royal College of Anaesthetists
4th National Audit Project2 (NAP4) collected
data on the incidence and causes of major
airway complications in the UK. Over 50%
of airway-related deaths in anaesthesia were
as a consequence of aspiration, outweighing
the much feared can’t intubate can’t ventilate
(CICV) scenario. In addition, 23% of all cases
reported to NAP4 involved aspiration as either
the primary or secondary event. Cases not resulting
in death commonly resulted in significant
morbidity and prolonged stay on intensive care.
Despite the awareness among anaesthetists of
the need to minimize the risks of aspiration and
advances in anaesthetic practices, NAP4 provided
evidence that aspiration often occurred as
a consequence of incomplete assessment of aspiration
risk or a failure to modify anaesthetic
technique. This review aims to highlight the key
findings from NAP4 with regard to aspiration
and evaluates the literature on aspiration risk assessment
and decision-making.
Definition
Pulmonary aspiration is defined by the inhalation
of oro-pharyngeal or gastric contents into the
larynx and the respiratory tract. Mendelson3
described the potential consequences of abolished
airway reflexes under anaesthesia and
the subsequent aspiration of gastric contents,
which became synonymous with Mendelson’s
syndrome.
Aspiration of solid matter can cause hypoxia
by physical obstruction, whereas aspiration of
acidic gastric fluid can cause a pneumonitis with
the syndrome of progressive dyspnoea, hypoxia,
bronchial wheeze and patchy collapse, consolidation
on chest X-ray or all. The risk of mortality
and serious morbidity increases with bronchial
exposure to greater volumes and acidity of aspirated
material.
This document discusses various types of lower respiratory problems including acute bronchitis, pertussis, pneumonia, and tuberculosis. It provides information on the pathogenesis, clinical manifestations, risk factors, diagnostic testing, and nursing management of each condition. Key learning outcomes focus on comparing and contrasting the different problems, prioritizing nursing care, and describing collaborative treatment approaches.
Bacterial Pneumonia in dogs and cats_2020.pdfcuencamvz24
This document discusses bacterial pneumonia in dogs and cats. It begins by classifying bacterial pneumonia into categories such as aspiration pneumonia, infectious pneumonia, and foreign body pneumonia. It then discusses the pathogens and risk factors associated with each category. For aspiration pneumonia, risk factors include gastrointestinal disease, anesthesia, and neurological disorders. Infectious pneumonia in dogs is often preceded by viral infection of the upper respiratory tract. The document also provides brief overviews of the pathophysiology and management of bacterial pneumonia in dogs and cats.
This document provides information about pneumonia, including its diagnosis and treatment. It discusses:
1. Community-acquired pneumonia is a common disorder that can range from mild to fatal in severity. Mortality rates are under 1% for outpatients but 10-12% for hospitalized patients.
2. Diagnosis involves assessing symptoms like fever, cough, dyspnea, and signs of lung consolidation on exam and chest x-ray. Risk stratification tools like CURB-65 are used to determine need for hospitalization.
3. Treatment depends on severity and involves antibiotics, oxygen supplementation, and management of complications. Goals are to eradicate the pathogen and minimize morbidity.
management of Aspiration pneumonitits in stroke ptNeurologyKota
Dr. Sunil Kumar Sharma provides an overview of aspiration pneumonia. There are two main types: chemical pneumonitis caused by inhalation of large volumes of gastric contents, and aspiration pneumonia caused by bacteria normally residing in the oral cavity. Aspiration pneumonia is more common in individuals with impaired airway protection mechanisms. Common predisposing conditions include altered consciousness, neurological impairment, and dysphagia. Clinical presentation varies from mild to critical illness depending on the volume and pathogens involved. Diagnosis involves assessing risk factors and radiographic evidence of lung infiltrates.
1) Aspiration pneumonitis is a chemical injury caused by inhalation of sterile gastric contents, while aspiration pneumonia is an infectious process caused by inhalation of oropharyngeal secretions colonized by bacteria.
2) Risk factors for aspiration pneumonia include neurological dysphagia, gastroesophageal reflux, poor oral hygiene, and silent aspiration which is common in stroke patients.
3) Treatment of aspiration pneumonitis includes suctioning the airway after witnessed aspiration and possible intubation. Antibiotics are not routinely recommended but may be used if infection develops. Corticosteroids are not proven to provide clear benefits.
This document discusses different types of pneumonia including definitions, classifications, symptoms, investigations, management, and complications. It covers community acquired pneumonia, hospital acquired pneumonia, pneumonia in immunocompromised patients, and specific types like lobar pneumonia, bronchopneumonia, suppurative pneumonia, and aspiration pneumonia. Pneumonia is defined as acute lung inflammation seen on imaging and is classified by location and cause of acquisition. Signs, testing, treatment, and prognosis vary depending on the type and severity of pneumonia.
Ventilator-associated pneumonia (VAP) is a common infection in mechanically ventilated patients. The risk of developing VAP increases the longer a patient requires ventilation. Early-onset VAP is usually caused by bacteria that normally inhabit the mouth and throat, while late-onset VAP is often caused by more resistant bacteria. Diagnosis of VAP requires evaluating clinical signs along with testing lower respiratory tract secretions. Prevention strategies aim to reduce bacterial contamination and aspiration, including oral care, elevation of the head, and careful management of tubes.
This document provides information on pneumonia and lung abscess from a seminar presentation. It begins with an introduction to pneumonia, defining it as an infection of the lungs. It then discusses the incidence of pneumonia globally and in various countries. Etiology, risk factors, pathophysiology, classification, signs and symptoms, complications, diagnosis, and management of pneumonia are explained. It also provides detail on lung abscess including definition, risk factors, pathophysiology, signs and symptoms, complications, diagnosis, and management. Surgical interventions for complications like empyema are also mentioned.
Pneumonia is an infection of the lungs caused by bacteria, viruses or other pathogens. It is commonly transmitted when germs are inhaled into the lungs. Risk factors include impaired immunity, smoking, neurological conditions that impact swallowing, and chronic lung diseases. Diagnosis involves chest x-ray, sputum culture, blood tests and assessment of severity using CURB65 score. Treatment focuses on antibiotics, oxygen supplementation, hydration and symptom relief. Complications can include respiratory failure and sepsis.
Pneumonia is an infection of the lungs caused by bacteria, viruses or other pathogens. It is commonly transmitted when germs are inhaled into the lungs. Risk factors include impaired immunity, smoking, neurological conditions that impact swallowing, and chronic lung diseases. Diagnosis involves chest x-ray, sputum culture, blood tests and assessment of severity using CURB65 score. Treatment focuses on antibiotics, oxygen supplementation, hydration and symptom relief. Complications can include respiratory failure and sepsis.
Clinical presentation and diagnosis of ventilator associated pneumoniaChristian Wilhelm
This document discusses the clinical presentation, diagnosis, and differential diagnosis of ventilator-associated pneumonia (VAP). VAP is suspected in patients on mechanical ventilation who develop new or worsening pulmonary infiltrates accompanied by fever, leukocytosis, and purulent secretions. Diagnosis requires radiographic evidence of infiltrates plus microbiologic confirmation via lower respiratory tract sampling and culture. Bronchoscopic techniques may allow for narrower antibiotic treatment but do not significantly impact patient outcomes compared to nonbronchoscopic sampling. Diagnosis is challenging given numerous potential alternative causes for pulmonary signs and symptoms in critically ill patients.
This document discusses viral pneumonia. It begins by describing a case of a 54-year-old woman admitted to the ICU in respiratory distress following a febrile illness. Testing showed mild renal failure and normal blood counts. She was started on antivirals, antibiotics, and oxygen supplementation. She was intubated but improved and was extubated on day 7. The document then discusses viral pneumonia in more detail, covering causes, diagnosis, treatment and outcomes. It emphasizes the importance of viral pneumonia and discusses emerging viruses as a cause.
Case Study Of Pneumonia And Chronic Pulmonary DiseaseEvelyn Donaldson
This document discusses a case study of pneumonia and chronic pulmonary disease. It describes how pneumonia inflames the lungs and can range from mild to severe. It identifies both extrinsic and intrinsic risk factors for pneumonia, including exposure to irritants, smoking, alcohol abuse, and underlying medical conditions. It also discusses types of pneumonia, pneumonia severity index scoring, research on hospital-acquired pneumonia, and prevention of ventilator-associated pneumonia.
The document discusses the management of bacterial pneumonia. It covers the use of antibiotic therapy as the mainstay of treatment, with choices of first-line antibiotics depending on the causative bacteria. It also discusses determining the need for hospitalization, administering respiratory support and fluid resuscitation, and using empiric broad-spectrum antibiotic therapy for hospitalized patients. The document provides tables on first- and second-line antibiotic choices for specific organisms and guidelines on inpatient and outpatient empiric antibiotic regimens.
Bronchopneumonia is a type of pneumonia characterized by patchy lung inflammation and infection. It is often caused by aspiration of oropharyngeal bacteria. Community-acquired pneumonia is commonly seen in children and the elderly. Hospital-acquired pneumonia is a major complication for hospitalized patients, especially those on ventilators. Diagnosis involves clinical features, imaging, and microbiological testing of sputum or bronchial samples. Treatment focuses on oxygenation, fluid balance, and antibiotics tailored to likely causative organisms. Immunocompromised patients are at higher risk for opportunistic pathogens.
This document discusses the approach to a child with recurrent or persistent pneumonia. It begins by defining recurrent pneumonia as 2 or more episodes in a year or 3 or more episodes ever, with radiographic clearing between occurrences. Persistent pneumonia is defined as symptoms and radiological abnormalities persisting for over 1 month despite treatment. Potential underlying causes include congenital malformations, aspirations, defects in airway clearance, and disorders of local or systemic immunity. A detailed clinical history and preliminary investigations can provide clues to the underlying illness in many cases. The approach involves obtaining a thorough history, performing physical examinations and initial tests, and considering possible etiologies.
This document discusses the approach to a child with recurrent or persistent pneumonia. It begins by defining recurrent pneumonia as 2 or more episodes in a year or 3 or more episodes ever, with radiological clearing between occurrences. Persistent pneumonia is defined as symptoms and radiological abnormalities persisting for over 1 month despite treatment. Potential underlying causes include congenital malformations, aspirations, defects in airway clearance, and disorders of local or systemic immunity. A detailed clinical history and preliminary investigations can provide clues to the underlying illness in many cases. The approach involves obtaining a thorough history, performing physical examinations and initial tests, and considering possible etiologies.
Epidemiology treatment and_outcomes_of_sa_nosocomial_pneumonia_chest_2005-1Christian Wilhelm
This study examined outcomes of nosocomial bacteremic Staphylococcus aureus pneumonia (NBSAP) in 60 patients over 5 years. It found that NBSAP commonly developed late in a patient's hospital stay among critically ill patients on mechanical ventilation. NBSAP was associated with high mortality and infection-related mortality rates of 55.5% and 40%, respectively. While delayed appropriate antibiotic therapy did not predict worse outcomes compared to early therapy, the study was limited by small sample size. The findings suggest a need for new antibiotics with better activity against NBSAP.
1. Pneumonia remains a common cause of death in both children and adults, with mortality rates as high as 50%. It is caused by both viral and bacterial pathogens.
2. Pneumonia is categorized as community-acquired or hospital-acquired depending on where onset occurs. The most common causes are Streptococcus pneumoniae for bacterial and rhinovirus and influenza for viral.
3. Symptoms include fever, cough, difficulty breathing, and chest pain. Physical exam may reveal fast breathing, fast heart rate, and low oxygen levels. Chest x-ray and culture of sputum can help identify the pathogen.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Pulmonary aspiration complicates between 1 in
900 to 1 in 10 000 general anaesthetics,1 dependent
on risk factors. All novice anaesthetists
in the UK are taught to consider the risk of aspiration
and to modify their anaesthetic technique
accordingly. The prevention of aspiration
remains a cornerstone of anaesthetic practice.
The recent Royal College of Anaesthetists
4th National Audit Project2 (NAP4) collected
data on the incidence and causes of major
airway complications in the UK. Over 50%
of airway-related deaths in anaesthesia were
as a consequence of aspiration, outweighing
the much feared can’t intubate can’t ventilate
(CICV) scenario. In addition, 23% of all cases
reported to NAP4 involved aspiration as either
the primary or secondary event. Cases not resulting
in death commonly resulted in significant
morbidity and prolonged stay on intensive care.
Despite the awareness among anaesthetists of
the need to minimize the risks of aspiration and
advances in anaesthetic practices, NAP4 provided
evidence that aspiration often occurred as
a consequence of incomplete assessment of aspiration
risk or a failure to modify anaesthetic
technique. This review aims to highlight the key
findings from NAP4 with regard to aspiration
and evaluates the literature on aspiration risk assessment
and decision-making.
Definition
Pulmonary aspiration is defined by the inhalation
of oro-pharyngeal or gastric contents into the
larynx and the respiratory tract. Mendelson3
described the potential consequences of abolished
airway reflexes under anaesthesia and
the subsequent aspiration of gastric contents,
which became synonymous with Mendelson’s
syndrome.
Aspiration of solid matter can cause hypoxia
by physical obstruction, whereas aspiration of
acidic gastric fluid can cause a pneumonitis with
the syndrome of progressive dyspnoea, hypoxia,
bronchial wheeze and patchy collapse, consolidation
on chest X-ray or all. The risk of mortality
and serious morbidity increases with bronchial
exposure to greater volumes and acidity of aspirated
material.
This document discusses various types of lower respiratory problems including acute bronchitis, pertussis, pneumonia, and tuberculosis. It provides information on the pathogenesis, clinical manifestations, risk factors, diagnostic testing, and nursing management of each condition. Key learning outcomes focus on comparing and contrasting the different problems, prioritizing nursing care, and describing collaborative treatment approaches.
Bacterial Pneumonia in dogs and cats_2020.pdfcuencamvz24
This document discusses bacterial pneumonia in dogs and cats. It begins by classifying bacterial pneumonia into categories such as aspiration pneumonia, infectious pneumonia, and foreign body pneumonia. It then discusses the pathogens and risk factors associated with each category. For aspiration pneumonia, risk factors include gastrointestinal disease, anesthesia, and neurological disorders. Infectious pneumonia in dogs is often preceded by viral infection of the upper respiratory tract. The document also provides brief overviews of the pathophysiology and management of bacterial pneumonia in dogs and cats.
This document provides information about pneumonia, including its diagnosis and treatment. It discusses:
1. Community-acquired pneumonia is a common disorder that can range from mild to fatal in severity. Mortality rates are under 1% for outpatients but 10-12% for hospitalized patients.
2. Diagnosis involves assessing symptoms like fever, cough, dyspnea, and signs of lung consolidation on exam and chest x-ray. Risk stratification tools like CURB-65 are used to determine need for hospitalization.
3. Treatment depends on severity and involves antibiotics, oxygen supplementation, and management of complications. Goals are to eradicate the pathogen and minimize morbidity.
management of Aspiration pneumonitits in stroke ptNeurologyKota
Dr. Sunil Kumar Sharma provides an overview of aspiration pneumonia. There are two main types: chemical pneumonitis caused by inhalation of large volumes of gastric contents, and aspiration pneumonia caused by bacteria normally residing in the oral cavity. Aspiration pneumonia is more common in individuals with impaired airway protection mechanisms. Common predisposing conditions include altered consciousness, neurological impairment, and dysphagia. Clinical presentation varies from mild to critical illness depending on the volume and pathogens involved. Diagnosis involves assessing risk factors and radiographic evidence of lung infiltrates.
1) Aspiration pneumonitis is a chemical injury caused by inhalation of sterile gastric contents, while aspiration pneumonia is an infectious process caused by inhalation of oropharyngeal secretions colonized by bacteria.
2) Risk factors for aspiration pneumonia include neurological dysphagia, gastroesophageal reflux, poor oral hygiene, and silent aspiration which is common in stroke patients.
3) Treatment of aspiration pneumonitis includes suctioning the airway after witnessed aspiration and possible intubation. Antibiotics are not routinely recommended but may be used if infection develops. Corticosteroids are not proven to provide clear benefits.
This document discusses different types of pneumonia including definitions, classifications, symptoms, investigations, management, and complications. It covers community acquired pneumonia, hospital acquired pneumonia, pneumonia in immunocompromised patients, and specific types like lobar pneumonia, bronchopneumonia, suppurative pneumonia, and aspiration pneumonia. Pneumonia is defined as acute lung inflammation seen on imaging and is classified by location and cause of acquisition. Signs, testing, treatment, and prognosis vary depending on the type and severity of pneumonia.
Ventilator-associated pneumonia (VAP) is a common infection in mechanically ventilated patients. The risk of developing VAP increases the longer a patient requires ventilation. Early-onset VAP is usually caused by bacteria that normally inhabit the mouth and throat, while late-onset VAP is often caused by more resistant bacteria. Diagnosis of VAP requires evaluating clinical signs along with testing lower respiratory tract secretions. Prevention strategies aim to reduce bacterial contamination and aspiration, including oral care, elevation of the head, and careful management of tubes.
This document provides information on pneumonia and lung abscess from a seminar presentation. It begins with an introduction to pneumonia, defining it as an infection of the lungs. It then discusses the incidence of pneumonia globally and in various countries. Etiology, risk factors, pathophysiology, classification, signs and symptoms, complications, diagnosis, and management of pneumonia are explained. It also provides detail on lung abscess including definition, risk factors, pathophysiology, signs and symptoms, complications, diagnosis, and management. Surgical interventions for complications like empyema are also mentioned.
Pneumonia is an infection of the lungs caused by bacteria, viruses or other pathogens. It is commonly transmitted when germs are inhaled into the lungs. Risk factors include impaired immunity, smoking, neurological conditions that impact swallowing, and chronic lung diseases. Diagnosis involves chest x-ray, sputum culture, blood tests and assessment of severity using CURB65 score. Treatment focuses on antibiotics, oxygen supplementation, hydration and symptom relief. Complications can include respiratory failure and sepsis.
Pneumonia is an infection of the lungs caused by bacteria, viruses or other pathogens. It is commonly transmitted when germs are inhaled into the lungs. Risk factors include impaired immunity, smoking, neurological conditions that impact swallowing, and chronic lung diseases. Diagnosis involves chest x-ray, sputum culture, blood tests and assessment of severity using CURB65 score. Treatment focuses on antibiotics, oxygen supplementation, hydration and symptom relief. Complications can include respiratory failure and sepsis.
Clinical presentation and diagnosis of ventilator associated pneumoniaChristian Wilhelm
This document discusses the clinical presentation, diagnosis, and differential diagnosis of ventilator-associated pneumonia (VAP). VAP is suspected in patients on mechanical ventilation who develop new or worsening pulmonary infiltrates accompanied by fever, leukocytosis, and purulent secretions. Diagnosis requires radiographic evidence of infiltrates plus microbiologic confirmation via lower respiratory tract sampling and culture. Bronchoscopic techniques may allow for narrower antibiotic treatment but do not significantly impact patient outcomes compared to nonbronchoscopic sampling. Diagnosis is challenging given numerous potential alternative causes for pulmonary signs and symptoms in critically ill patients.
This document discusses viral pneumonia. It begins by describing a case of a 54-year-old woman admitted to the ICU in respiratory distress following a febrile illness. Testing showed mild renal failure and normal blood counts. She was started on antivirals, antibiotics, and oxygen supplementation. She was intubated but improved and was extubated on day 7. The document then discusses viral pneumonia in more detail, covering causes, diagnosis, treatment and outcomes. It emphasizes the importance of viral pneumonia and discusses emerging viruses as a cause.
Case Study Of Pneumonia And Chronic Pulmonary DiseaseEvelyn Donaldson
This document discusses a case study of pneumonia and chronic pulmonary disease. It describes how pneumonia inflames the lungs and can range from mild to severe. It identifies both extrinsic and intrinsic risk factors for pneumonia, including exposure to irritants, smoking, alcohol abuse, and underlying medical conditions. It also discusses types of pneumonia, pneumonia severity index scoring, research on hospital-acquired pneumonia, and prevention of ventilator-associated pneumonia.
The document discusses the management of bacterial pneumonia. It covers the use of antibiotic therapy as the mainstay of treatment, with choices of first-line antibiotics depending on the causative bacteria. It also discusses determining the need for hospitalization, administering respiratory support and fluid resuscitation, and using empiric broad-spectrum antibiotic therapy for hospitalized patients. The document provides tables on first- and second-line antibiotic choices for specific organisms and guidelines on inpatient and outpatient empiric antibiotic regimens.
Bronchopneumonia is a type of pneumonia characterized by patchy lung inflammation and infection. It is often caused by aspiration of oropharyngeal bacteria. Community-acquired pneumonia is commonly seen in children and the elderly. Hospital-acquired pneumonia is a major complication for hospitalized patients, especially those on ventilators. Diagnosis involves clinical features, imaging, and microbiological testing of sputum or bronchial samples. Treatment focuses on oxygenation, fluid balance, and antibiotics tailored to likely causative organisms. Immunocompromised patients are at higher risk for opportunistic pathogens.
This document discusses the approach to a child with recurrent or persistent pneumonia. It begins by defining recurrent pneumonia as 2 or more episodes in a year or 3 or more episodes ever, with radiographic clearing between occurrences. Persistent pneumonia is defined as symptoms and radiological abnormalities persisting for over 1 month despite treatment. Potential underlying causes include congenital malformations, aspirations, defects in airway clearance, and disorders of local or systemic immunity. A detailed clinical history and preliminary investigations can provide clues to the underlying illness in many cases. The approach involves obtaining a thorough history, performing physical examinations and initial tests, and considering possible etiologies.
This document discusses the approach to a child with recurrent or persistent pneumonia. It begins by defining recurrent pneumonia as 2 or more episodes in a year or 3 or more episodes ever, with radiological clearing between occurrences. Persistent pneumonia is defined as symptoms and radiological abnormalities persisting for over 1 month despite treatment. Potential underlying causes include congenital malformations, aspirations, defects in airway clearance, and disorders of local or systemic immunity. A detailed clinical history and preliminary investigations can provide clues to the underlying illness in many cases. The approach involves obtaining a thorough history, performing physical examinations and initial tests, and considering possible etiologies.
Epidemiology treatment and_outcomes_of_sa_nosocomial_pneumonia_chest_2005-1Christian Wilhelm
This study examined outcomes of nosocomial bacteremic Staphylococcus aureus pneumonia (NBSAP) in 60 patients over 5 years. It found that NBSAP commonly developed late in a patient's hospital stay among critically ill patients on mechanical ventilation. NBSAP was associated with high mortality and infection-related mortality rates of 55.5% and 40%, respectively. While delayed appropriate antibiotic therapy did not predict worse outcomes compared to early therapy, the study was limited by small sample size. The findings suggest a need for new antibiotics with better activity against NBSAP.
1. Pneumonia remains a common cause of death in both children and adults, with mortality rates as high as 50%. It is caused by both viral and bacterial pathogens.
2. Pneumonia is categorized as community-acquired or hospital-acquired depending on where onset occurs. The most common causes are Streptococcus pneumoniae for bacterial and rhinovirus and influenza for viral.
3. Symptoms include fever, cough, difficulty breathing, and chest pain. Physical exam may reveal fast breathing, fast heart rate, and low oxygen levels. Chest x-ray and culture of sputum can help identify the pathogen.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
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Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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2. Given this broad use of the term aspiration, classifying the
majority
of bacterial pneumonias as a consequence of aspiration is
strictly
correct based on known pathophysiology of community-
acquired
(CAP) and hospital-acquired pneumonia (HAP) [2–5].
However, when
a clinician uses the term aspiration pneumonia, he or she is
typically
implying a subset of bacterial pneumonia that, although
sharing the
common pathophysiologic mechanism with most other
pneumonias,
represents a unique entity of a macroaspiration event resulting
in
3. It is important to understand that aspiration is a
common event
that may lie within the spectrum of normal
physiology. A large
proportion of healthy people with normal mental
status aspirate
during sleep based on the detection of radiolabeled
oral dyes in the
lungs of healthy volunteers
4. Therefore, one of
the most common consequences of aspiration is
actually to have no
consequence—the inoculum is cleared by the
normal airway and/or
parenchymal host defenses without overt clinical
syndromes.
5. Although occurring in otherwise healthy people,
several important
clinical consequences of aspiration can occur.
6.
7. Chemical Pneumonitis
Chemical pneumonitis is characterized by
macroaspiration of
noxious liquids with immediate hypoxemia, fever,
tachycardia, and
abnormal chest radiograph and lung examination
result. The most
common noxious fluid is sterile gastric contents,
although others such
as bile and other agents instilled into the stomach
may also result in
this syndrome.
8. Animal experiments helped differentiate the pathophysiology
of
chemical pneumonitis from subclinical aspiration based on the
pH
and volume of gastric material needed to stimulate an
immediate and
severe inflammatory reaction. Based on experiments using
human
gastric secretions and rabbit lungs, a pH less than 2.4 was
required to
cause vigorous inflammation. At higher pH, the reaction seen
microscopically was more similar to the changes caused by
the
instillation of water into the lungs [21]. In terms of quantity,
experiments inducing chemical pneumonitis in a dog model
required
2 mL of hydrochloric acid solution per kilogram to induce the
clinical
9. Bland aspiration
Not all noninfectious macroaspirations cause an inflammatory
response in the lung; and therefore, to label these as
pneumonitis
would be inappropriate. Probably the 2 most common
examples are
aspiration of blood as a complication of severe epistaxis or
hematemesis and the aspiration of enteral feedings. Twenty
percent
of patients undergoing esophagogastroduodenoscopy will
have an
infiltrate immediately after the procedure in the dependent lung
[24,25]. Most resolve without antibiotic changes. Most
episodes of
aspiration with enteral nutrition are also uncomplicated
10. Although bland aspiration may not initially be infectious, blood
and enteral feedings represent excellent culture media for
growth of
either resident bacteria or the small aliquot of bacteria
included in the
inoculum. Generally, mucociliary clearance and the resident
alveolar
macrophages can clear the inoculum within hours. The major
issue is
confusion with an infectious aspiration pneumonia, particularly
when
the large-volume aspiration is not observed. Prolonged
antibiotic
treatment is unlikely to prevent this secondary pneumonia but
may
select for more multidrug-resistant (MDR) pathogens
11. CAP & HAP
Microaspiration has long been known to be the dominant
pathophysiologic mechanism behind CAP. Supporting evidence
includes the finding that most common CAP-causing microorganisms
colonize the oropharynx or nasopharynx in nonhospitalized patients
[2,27,28]. Similarly, the pathophysiology underlying HAP, including
ventilator-associated pneumonia (VAP), has proved to be microaspiration
of oropharyngeal, upper gastrointestinal, or subglottic
contents [3,5,29–32]. The distinct microbiology of HAP stems from
microaspiration occurring after hospitalized patients become colonized
with the virulent organisms found in intensive care unit and
hospital environments [4,33–36].
Given the above evidence of aspiration as a common event,
development of a parenchymal lung infection depends largely on host
defense factors [12,37] and the virulence of the aspirated pathogen.
This interaction helps explain the phenomenon of subclinical
aspiration without subsequent pneumonia described mostly in
young healthy volunteers and surgical candidates
12. Aspiration Pneumonia
Current use of this term most commonly refers to an acute
lung
infection developing after a large-volume aspiration of
oropharyngeal
or upper gastrointestinal contents with a high enough pH to
avoid
chemical pneumonitis (likely pH much greater than 2.5). This
type of
aspiration deposits a large bacterial load of pathogens from
the oral
cavity or upper gastrointestinal tract into the lungs. The
possibility of
infection with these normally nonvirulent, predominantly
anaerobic
organisms is partly because of the large inoculum
[2,17,21,39–41].
Confusion surrounding this terminology and the exact
definition
13. Macroaspiration is the unique pathophysiologic
component of
what most clinicians call aspiration pneumonia. The
challenge in
specifically diagnosing aspiration pneumonia is that, for
many
patients in the community who are at risk for
macroaspiration, the
events in the days leading up to presentation with fever,
cough, and
chest radiograph infiltrate are unclear. A common risk for
macroaspiration
is decreased mental status, but this can be the result of
CAP
rather than the cause [43]. Because of this reality,
substantial
diagnostic overlap exists between aspiration, HAP, and
14. Aspiration pneumonia represents 5% to 15% of
pneumonias in the
hospitalized population. The ICD-9 code–based
reviews suggest an
increasing incidence, making it the second most
common diagnosis in
Medicare patients who are hospitalized [2,44].
However, higher
reimbursement rates for this ICD-9 code than for
CAP ICD-9 codes may
falsely increase the frequency in this population.
15. RFs for Aspiration Pneumonia
Specific predisposing factors for aspiration pneumonia focus
on
the risk for high frequency and/or large volume of aspiration.
Some
risks may be more pertinent for the macroaspiration
characteristic of
aspiration pneumonitis or anaerobic pleuropneumonia than for
microaspiration. Additionally, factors that influence the resident
bacterial flora leading to colonization by more virulent
pathogens,
which are more likely to overwhelm the normal protective
mechanisms,
also play a role in development of clinical disease
16. RFs for Aspiration Pneumonia
Dysphagia/swallowing dysfunction
Dysphagia, typically from neurologic disease
(dementia, Parkinson
disease, multiple sclerosis, poststroke), is
considered the most
important risk factor for aspiration pneumonia, given
the abovedescribed
pathogenesis.
17. RFs for Aspiration Pneumonia
Dysphagia/swallowing dysfunction
It is important to remember that dysphagia itself is not
definitive
evidence of aspiration. Many high-risk patients will not
complain of
dysphagia but still aspirate based on advanced testing [51].
The
poststroke population certainly has a higher prevalence of
pneumonia
with or without symptomatic dysphagia [52,53]. A lag time of
more
than 5 seconds between noxious stimuli and cough, as well as
an
increasing stimuli needed to produce a cough, has been linked
to
pneumonia in poststroke patients regardless of dysphagia
18. RFs for Aspiration Pneumonia
Dysphagia/swallowing dysfunction
The swallowing mechanism can also be affected by
chest anatomy.
Swallowing dysfunction is very common in chronic
obstructive
pulmonary disease (COPD) patients with
hyperinflation
19. RFs for Aspiration Pneumonia
Dysphagia/swallowing dysfunction
Certain medications interfere with the swallow reflex
and may
potentially lead to aspiration [58]. Although sedatives
may suppress
the patient’s mental status sufficiently to lead to
aspiration,
antipsychotic medications may actually affect the
swallowing mechanism
by inhibiting dopamine and therefore lead to
aspiration.
Accordingly, these drugs have been linked to
pneumonia in a fairly
large retrospective study
20. RFs for Aspiration Pneumonia
Altered Mental Status
The association between acute altered mental status
(AMS) and
aspiration pneumonia has not been studied extensively
despite the
obvious connection
Most available case series focus on the association of
acute AMS with chemical pneumonitis in the setting of
sedation,
poisoning, and trauma In these populations, vomiting and
large-volume reflux of gastric contents may also increase
the risk of
aspiration pneumonia.
21. RFs for Aspiration Pneumonia
Altered Mental Status
Two specific types of AMS—acute alcohol abuse and
seizures—are
most likely to lead to the anaerobic pleuropneumonia
syndrome.
Probably the highest risk of aspiration pneumonia
occurs in the severe
alcohol abuse population. Acute alcohol ingestion
has multifactorial
risks for aspiration pneumonia including AMS,
increased risk of
vomiting, and direct effects of alcohol on normal
neutrophil function.
22. RFs for Aspiration Pneumonia
Esophogeal motility disorders/vomiting
Esophogeal motility disorders independent of GERD are also
associated with aspiration and an increased risk of
pneumonia.
Many are a component of an underlying systemic disease,
such as
scleroderma or polymyositis, which may also compromise the
host
immune response itself or secondary to immunosuppressive
treatment.
Primary esophageal disorders, such as achalasia and
esophageal
strictures, increase the risk of aspiration of not only liquids but
also
solids. The latter are a unique form of aspiration risk in which
bronchial impaction and postobstructive pneumonia result
from the
23. RFs for Aspiration Pneumonia
Esophogeal motility disorders/vomiting
Given the frequency of vomiting, the incidence of
aspiration
pneumonia/pneumonitis is actually very low.
Protective laryngeal
reflexes will prevent macroaspiration in the
overwhelming majority
of circumstances. Macroaspiration with vomiting
almost always
requires concomitant abnormal mental status, such
as anesthesia
induction, acute alcohol intoxication, or
narcotics/sedatives.
24. RFs for Aspiration Pneumonia
Esophogeal motility disorders/vomiting
Another unique syndrome is vomiting associated with
small bowel
obstruction. In this situation, the stomach is no longer
sterile but
instead is filled with fluid that has significant overgrowth
of bowel
flora. Narcotics and antiemetics may compromise mental
status at the
time of vomiting. The result is a fulminant aspiration
pneumonia due
to gram-negative bowel pathogens, rather than the
predominant
gram-positive/anaerobic oral flora.
25. RFs for Aspiration Pneumonia
Enteral feeding
The risk for aspiration pneumonia with enteral tube
feeding has
been extensively studied, especially in the more
critically ill. Smalland
large-bore nasogastric tubes, postpyloric tube feeds,
gastric tube
feeds, and jejunal tube feeds have all been
associated with aspiration
pneumonia in patients with and without endotracheal
and tracheostomy
tubes.
26. RFs for Aspiration Pneumonia
Enteral feeding
Exact risk is difficult to characterize given the wide
variety of incidences reported, small sample sizes,
and lack of
standard definitions regarding aspiration and
aspiration pneumonia
[65–75]. Regardless of the deficiencies in
epidemiologic data,
aspiration pneumonia is common enough in this
population that it
should be a consideration for all patients on tube
feeds.
27. RFs for Aspiration Pneumonia
Enteral feeding
Certain
patients appear to be at greater risk. Intuitively, GERD and
decreased
gastric motility are implicated when tube feeds are aspirated
Decreased gastric motility, typically defined by high gastric
residual volume, has also been suggested as a risk factor for
aspiration
in tube-fed patients [65,67]. However, the criteria for high
gastric
residual volume vary widely between studies from 50 to
greater than
500 mL at every 4-hour checks. A potentially independent risk
factor
is that patients with high gastric residuals may also be at
increased
risk of vomiting
28. RFs for Aspiration Pneumonia
Oropharyngeal colonization
Microbiologic factors also influence the risk of aspiration
pneumonia.
Pathophysiologically, risk of pneumonia relates to the
body’s
ability to combat the bacteria that routinely reach the
lower
respiratory tract. Unusual or more virulent microbes may
be more
difficult to eradicate by the normal host defenses. By far,
the most
important influence on alterations in normal
oropharyngeal flora is
use of systemic antibiotics.
29. RFs for Aspiration Pneumonia
Oropharyngeal colonization
An independent association of poor oral hygiene with
aspiration
pneumonia is also supported by the literature [56,77]. The
microbial
density is increased in patients with gingival disease even if
the
spectrum has not shifted, increasing the likelihood of
pneumonia
developing in association with an episode of aspiration due to
the
greater inoculum. This suggests that edentulous patients are
at lower
risk for aspiration pneumonia. In edentulous patients, the
tongue is
more important as a focal point for colonization. Abe et al [78]
associated tongue-coating scores in an edentulous elderly
30. RFs for Aspiration Pneumonia
Oropharyngeal colonization
Many of the studies of oral hygiene have also
demonstrated greater
colonization by more virulent organisms in patients
with poor oral
hygiene. This is especially true for the colonization of
gram negatives
and respiratory pathogens in the intensive care unit [
31. RFs for Aspiration Pneumonia
Other Risks
Other risks
General risk factors like male sex and smoking may
increase risk
for aspiration pneumonia based on case-controlled and
cohort studies
[48]. Diabetes mellitus has been repeatedly associated
with pneumonia
in patients who have had an acute stroke [48].
Much has been discussed regarding the increased risk of
pneumonia as a whole in patients being treated with
proton pump
inhibitors and/or histamine receptor–2 antagonists
[80,81].
32. RFs for Aspiration Pneumonia
Other Risks
Although
these medications may not increase the risk of aspiration, they
change
the gastrointestinal environment such that natural host
defenses,
which include gastric acid secretion, cannot reduce bacterial
burden. If
a subsequent aspiration event occurs, patients appear more
likely to
deliver an inoculum of bacteria high enough to cause clinical
infection.
Conversely, the frequent use of proton pump inhibitors or
histamine
receptor–2 antagonist, particularly in the hospitalized
population,
may be associated with a lower incidence of aspiration
pneumonitis
33. Diagnosis
In clinical practice, aspiration pneumonia is
most often coded as the diagnosis when a new chest
radiograph
infiltrate in a dependent pulmonary segment is found
in patients with
risk factors for aspiration. In a bed-bound patient, the
dependent
pulmonary segments are the posterior segments of
the upper lobes
and the superior segments of the lower lobes. In
ambulatory patients,
lower lobes are classically involved, especially the
right
34. Diagnosis
Clinical features can help distinguish aspiration pneumonia
from
chemical pneumonitis and other lung infections. As opposed to
chemical pneumonitis, the aspiration event in aspiration
pneumonia
is rarely witnessed [17]. The large volume of stomach contents
required to cause chemical pneumonitis usually makes it a
more
obvious event. Furthermore, the clinical course of chemical
pneumonitis
is hyperacute hypoxemia, occurring almost immediately (within
hours) and resulting in either devastating lung injury or
resolution
within 48 hours. These patients are likely to also have
bronchospasm,
frothy sputum, and chest radiographs with bilateral patchy
infiltrates
including nondependent areas
35. Diagnosis
Because of this difficulty, efforts have been made to
use biomarkers
to distinguish aspiration pneumonia from other
aspiration syndromes.
El-Solh et al [85] attempted to use procalcitonin to
distinguish aspiration pneumonitis from aspiration
pneumonia in
the intensive care unit setting, given data to suggest
that procalcitonin
is a helpful marker for bacterial causes of sepsis
36. Diagnosis
Unfortunately, no difference between procalcitonin
levels was demonstrated in
culture-negative and culture-positive patients.
37. Diagnosis
Biomarkers more specific to aspiration have also been
studied.
Pepsinogen in tracheal secretions or BAL was very suggestive
of
aspiration as part of the pathogenesis of posttransplant BO
and VAP.
Bronchoalveolar lavage amylase levels have been
demonstrated to
correlate with clinical risk factors for aspiration, as well as with
positive cultures [87–89]. This relationship may even be true in
patients with VAP [90]. Bronchoalveolar lavage amylase can
also
function as an end point for studies of interventions to
decrease risk of
aspiration in ventilated patients
38. Microbiology
The unique pathophysiology of aspiration
pneumoniamay lend itself
to unique pathogens. However, the microbiology,
and therefore the
treatment, has seen significant changes over the last
40 to 50 years.
39. The original teaching was that anaerobic bacteria
were by far the
most common pathogens in aspiration pneumonia
based on well-done
microbiology studies undertaken in patientswith
aspiration pneumonia
acquired in and out of the hospital fromthe 1960s to
1980s.*
40. These anaerobic infections
commonly included greater than one pathogen, with
Bacteroides
species, Prevotella, Fusbacterium species, and
peptostreptococci predominating
(Table 2). Most of these patients had the anaerobic
pleuropneumonia syndrome described above.
41.
42. As homogenous as these initial results appeared, evidence
accumulated
that aspiration pneumonia occurring after hospitalization had a
microbiologic
spectrum that included more Staphylococcus aureus, aerobes,
and gram-negative bacilli [17,84,92,94]. The pathogens that
dominate aspiration
pneumonia microbiology after a macroaspiration event after
hospitalization are similar to those of many nosocomial
infections.
Although very limited, data fromreliable cultures in
nonintubated patients
do suggest a higher frequency of anaerobes than in intubated
patients; but
the frequency is substantially lower than that of the prior
43. Recent studies reveal much different results even for
patients
presenting from the community. El-Solh et al [97]
reported a series of
patients with suspected aspiration pneumonia who
underwent
bronchial sampling after intubation. Of the 54
patients with a
bacterial diagnosis, 20% grew only anaerobes, with
an additional
11% that included anaerobes as part of mixed flora.
44. In contrast,
common causative organisms in this study were
Escherichia coli,
S aureus, and Klebsiella pneumoniae. Tokuyasu et al [98]
described this
trend further in a series of elderly Japanese patients with
clinically
diagnosed aspiration pneumonia. Of 111 organisms
isolated in 62
individuals, only 22 (20%) were anaerobes. Anaerobes
were heavily
outweighed by gram-negative bacilli (almost all enteric
gramnegatives),
found in 51.6% of patients
45. Even the etiology in patients with lung abscess has changed.
Takayanagi et al [99] reported bacterial etiologies in 122
patients
diagnosed with community-acquired lung abscess, likely a
result of
untreated aspiration. In this population, 74% grew aerobes
only, 12%
grew anaerobes only, and 14% grew mixed flora. Of the 107
aerobic
cases, 79% were Streptococcus species. In a very similar
study, Wang et
al [100] reported that only 40 (44%) of 90 community-acquired
lung
abscesses grew any anaerobes, with only 13% purely
anaerobic. Of the
remaining cases, 33% were caused by K pneumoniae (almost
all being
pure K pneumoniae isolates).
46. The latter finding suggests that
aspiration may not even play a role in some cases of
lung abscess,
but rather more virulent CAP pathogens. The
combination of lung
abscess and empyema has also been reported with
communityacquired
methicillin-resistant S aureus (MRSA) pneumonia
47. These 2 distinct bodies of literature, taken
chronologically, reveal a
fading importance of anaerobic bacteria in aspiration
pneumonia and even community-acquired lung abscess.
A second implication of this
etiologic shift is that the principles of typical nosocomial
microbiology
apply to patients with aspiration pneumonia if
macroaspiration
occurs after hospitalization. This etiologic overlap
between aspiration
pneumonia and HAP has been progressively evident
since the 1970s
48. Treatment
As one would expect, empirical treatment of aspiration
pneumonia
has evolved, given the above changes in the microbiology of
the
infection [102]. Intravenous penicillin was the drug of choice in
the
past, as anaerobes constituted the vast majority of infections
with few
penicillinase-producing bacterial strains [103,104]. A
randomized
controlled trial (RCT) of 39 patients with lung abscesses
compared
penicillin with clindamycin in the early 1980s [105]. Although a
small
group of patients, the treatment failure rate and cure rate were
much
better for clindamycin, with all 13 followed patients being cured
vs 8
49. The failure of penicillin to cure anaerobic
infections was better characterized several years
later in a Spanish
RCT of confirmed anaerobic lung infections [106]. In
this cohort of 37
patients, 47 anaerobes were isolated. Ten of these
47, all Bacteroides
species, were penicillin resistant, whereas none
were clindamycin
resistant. None of the 5 patients with penicillin-
resistant bacteria
randomized to penicillin responded to therapy.
50. Metronidazole has also been studied in anaerobic lungs
infections.
Sanders et al [107] described a poor cure rate in 13
patients with
pleuropulmonary (11 of 13 being lung abscesses)
infections with
confirmed anaerobic bacteria. Similarly, Perlino [108]
reported higher
cure rates with clindamycin when compared to
metronidazole in
cases of lung abscess and pneumonia with confirmed
anaerobic flora
in a small RCT of 13 patients.
51. It is important to understand that these studies included
mainly
classic anaerobic pleuropneumonia syndrome with
anaerobes confirmed
on culture and that most were completed decades ago. In
the
currently uncommon patient with aspiration resulting in
classic
anaerobic pleuropneumonia, prior results and the likely
greater
incidence of penicillin resistance suggest that
clindamycin may be
the optimal agent
52. Recent studies have focused on pneumonia in patients with
risk
factors for aspiration. Kadowaki et al [109] randomly assigned
100
elderly Japanese patients with suspected aspiration
pneumonia to
clindamycin, a carbapenem (penipenem/betamiprom), low-
dose
ampicillin/sulbactam (1.5 g twice daily), or high-dose
ampicillin/
sulbactam (3 g twice daily). The investigators found little
variance in
efficacy (N75% cure rate in all groups) and adverse events.
Interestingly,
no anaerobes were actually cultured. Of note, clindamycin was
the
53. Another study of elderly Japanese
with aspiration pneumonia [98] demonstrated a clinical
efficacy rate of
61.3% with another carbapenem, meropenem. This lower
efficacy than
that found by Kadowaki et al [109] may be due to greater
severity of
illness in the study patients. Once again, nosocomial
pathogens rather
than anaerobes were the most common documented
etiologies; and 33
of these 62 patients had MRSA growing in their
postantibiotic sputum
culture.
54. A recent randomized German study compared high-dose
ampicillin/sulbactam (3 g thrice times daily) to the standard
CAP
antibiotic moxifloxacin for the treatment of aspiration
pneumonia and
lung abscess in 96 elderly patients [110]. Clinical response
rates were
identical at 66.7%, and adverse reaction rates were very
similar.
Microbiology was consistent with the more recent data
described
above, with less than 10% of bacteria cultured being
anaerobes. Of note,
higher (although not statistically significant) mortality was seen
in the
ampicillin/sulbactamgroup, with 14 patients dying compared to
6 in the
moxifloxacin group.
55. These recent data from Japan and Germany have
demonstrated
effective treatment strategies for aspiration
pneumonia in the face of new microbiology patterns.
Based on this limited evidence,
clindamycin, a carbapenem, ampicillin/sulbactam,
and moxifloxacin
all appear to be reasonable first-line therapies in
modern-day
community-acquired aspiration pneumonia
56. For patients with hospital-acquired macroaspiration
pneumonias,
use of broad-spectrum combination therapy is
recommended if MDR
risk factors are present. Probably the single most
important risk factor
for MDR pathogens is prior antibiotic treatment. If none,
the
antibiotics listed for community-acquired aspiration
pneumonia are
adequate. The longer the prior course and the broader
the spectrum of
agent, the greater the likelihood of MDR pathogens.
57. In nonventilated
patients, anaerobes may still play a role; and
cefepime should be
avoided. For ventilated patients, the high oxygen
tension is sufficient
to kill anaerobes; and any β-lactam should be
appropriate, although
changing β-lactam class may be prudent.
58. Prevention
Dietary Changes
Dietary interventions have been studied in patients with dysphagia.
In a small study involving patients with dysphagia secondary to
neurodegenerative disease (pseudobulbar dysphagia) [111], more
aspiration pneumonia occurred in those on a pureed diet compared
to
a mechanical soft diet with thickened liquids. However, the utility of
dietary intervention has been questioned. Depippo et al [112]
randomized 115 poststroke patients to 3 groups according to speech
therapist intervention: Group A was given advice based on swallow
testing, but the ultimate dietwas determined by the patient and
family;
Group B was prescribed a specific diet based on swallow testing;
and
Group C was prescribed a specific diet and directly observed for
compliance daily. No statistically significant differences between the
groups were found in any end point.
59. Prevention
Drugs to Protect the Airway
A number of small studies have reviewed
pharmacologic intervention
to protect the airway via the cough reflex. The most
interesting drugs studied are angiotensin-converting
enzyme inhibitors
(ACEIs) because of their role in degrading substance
P and
bradykinin, stimulants of the cough reflex. A
reduction in aspiration
pneumonia in patients on an ACEI has been
suggested in one casecontrol
study [113] in elderly Japanese patients
60. Prevention
Drugs to Protect the Airway
Further, investigators
have categorized an increased risk for pneumonia in
patients with
certain ACE gene polymorphisms that are
associated with higher ACE
levels: homozygous deletion of an alu repeat within
intron 16 (ACE
DD). The risk of pneumonia was markedly reduced
in a case-control
study of patients without this genotype who were
taking an ACEI,
whereas it was unaffected in patients with the
genotype
61. Prevention
Enteric Feeding Tubes
Because enteric tube feeding presents a risk for
aspiration, there has
been considerable effort to compare types of tube
feeds tominimize this
risk. The most important comparisons are between
gastric and
postpyloric feedings. Given the gastric dysmotility
caused by critical
illness, gastroparesis, and commonmedications,
postpyloric feeds have
been commonly postulated to be superior
62. Prevention
Enteric Feeding Tubes
Two small prospective
trials have found no difference [115,116] in
pneumonia rates. To the
contrary, a very small randomized trial, with almost
no cases of
aspiration pneumonia, and another prospective trial
found advantages
to jejunal feeds [117,118]. Comparisons have also
been made between
nasogastric tube and percutaneous endoscopic
gastrostomy tube feeds
in a variety of clinical settings.
63. Prevention
Enteric Feeding Tubes
Several randomized controlled trials have
failed in demonstrating a difference in pneumonia
complication rates
between the 2 feeding strategies. Percutaneous
endoscopic gastrostomy
tubes are more likely to achieve goal feeds but come
at a much higher
cost
64. Prevention
Enteric Feeding Residual Volumes
Many institutions monitor residual volumes from tube
feeds to
know when aspiration risk is increased. Residual
volumes of 500 mL are considered high enough to hold
tube feeds [65]. However, the
inaccuracy of this method has been well documented
[122].
Furthermore, results from a recent randomized clinical
trial suggest
that using strict residual volumes (250 mL) to understand
when to
hold nasogastric tube feeds does not affect the incidence
of VAP
65. Prevention
Oral Care
Oral care has been shown to assist in preventing
aspiration
pneumonia as expected given the evidenced
discussed above. Data are
again limited, but encouraging quality oral care offers
potential
benefit with almost no morbidity
66. Prevention
Prophylactic Antibiotics
For patients at risk of aspiration around the time of
endotracheal
intubation, several studies have shown that a short
course (≤24
hours) of “prophylactic” β-lactam antibiotics may
decrease the risk of
subsequent VAP [125,126]. An extremely elevated
BAL amylase may
better select patients for this intervention.
67. Prevention
Head Elevation
One very important preventative measure surrounds
preventing
aspiration in the hospitalized, critically ill patient.
Increased aspiration
in the supine position was evident after a Spanish study
that detected
enterically administered dye aspirated into the lungs of
mechanically
ventilated patients. Aspiration rates not only were higher
in patients
who were supine but were dependent on how much time
was spent
in the supine position
68. Prevention
Head Elevation
The same investigators then confirmed
the importance of this phenomenon by demonstrating
drastically
reduced rates of HAP in mechanically ventilated patients
in the
semirecumbent position compared to supine [128]. A
subsequent
study did not show a benefit of semirecumbant position
when
compared to elevation of as little as 10° from supine
[129]. However,
the risk benefit ratio of elevation of the head of the bed in
ventilated
patients is so favorable that it has become standard
practice
Bartlett and
Gorbach [17] and Bartlett et al [92] reported on 2 cohorts of patients:
one with aspiration pneumonia and a second with aspiration-induced
pulmonary infections including pleural. In the initial study, 50 (93%) of
54 patients had anaerobes (25 cultures grewonly anaerobes; 25were a
part of mixed flora). In the follow-up study, 61 (87%) of 70 patientswith
aspiration pneumonia had anaerobes in culture. Subsequent studies
[93–96] seemed to confirm these results.