Aspiration pneumonia

1. Aspiration pneumonia
Case presentation from female side
HDU medical Ward rotation .
Presented by : Walaa Aljuaid
Manal Alosaimi

2. Outlines :
•the case .
•What is the Aspiration pneumonia :
•Definition
•Causes
•Incidence and Prevalence
•Diagnosis
•Complication
•Treatment
• Intervention

3. THE CASE :
G. is a 92 years old female come to the
ER loss of consciousness , lack ability
of breathing, from ER transfer direct to
ICU then after approximately one week
she transmitted into FSHDU.
DATE OF ADMISSION : 29-5-1438

4. History of present illness:
Medical history :
She has a history of: old CVA, DVT, HTN, DM,
Stroke, secondary epilepsy and bedridden .
Family history :
her sister has a HTN , DM.
Allergy :
No Kind of Allergy .
Medication history :
Amlor 5mg P.O, Keppra 500 mg P.O, Aspirin 81
mg P.O, Omeprazole 20 mg P.O and Atrovastatin
20mg P.O .

5. Review of Systems :
Eyes: Bilateral Cataracts
Mental status: Unconscious, comatose,
GCS = 3/15 .
CNS: could not assess
Lymph nodes: could not assess
Respiratory system: Bilateral Crackles
Cardiovascular system: S1+S2
chest wall & breast: No any diseases
Abdomen: soft and lax .
Extremities : No any diseases.

6. Vital sign on admission :
11;00 am :
Temperatu
re
PR BP O2 % RR
36.5 125 80/45 66 18
after mechanical ventilation applying:
Temperatu
re
PR BP O2 % RR
36.5 94 120/60 99 18
Normal vital sign
Temperatu
re
PR BP O2 % RR
36-37 60-100 120/80 > 96% 16-20

7. Final Diagnosis
ASPIRATION
PNEUMONIA

8. What is Aspiration
pneumonia ?

9. - Pneumonia :is a breathing condition
in which there is swelling or an
infection of the lungs or large
airways.
- Aspiration pneumonia occurs when
food, saliva or liquids, enter into the
lungs or airways leading to the lungs,
instead of being swallowed into the
esophagus and stomach.
Aspiration pneumonia:

10. - Chemical such as gastric contents
- Obstruction: large volumes of
aspirated material may lead to
obstruction of the respiratory tract.
- Bacterial infection.
- NOTE: Risk to get Aspiration
pneumonia increase according the Age
( > 60 ) and Presence A history of
stroke
What causes aspiration
pneumonia?

11. - every year there are 141 clinically
suspected pneumonia cases , 76 of the
cases (53.9%) confirm positive by
microbiological tests.
- More than 94 % of the confirm cases
are in the age group >50 years, and
56.6 % of the cases are men.
- This incidence is high compared to
other country due to Hajj season
Incidence and Prevalence in
KSA :

12. - 1-Arterial blood gas
- 2-Blood culture
- 3-Bronchoscopy
- 4-Chest x-ray
- 5-Complete blood count (CBC)
- 6-CT scan of the chest
- 7-Sputum culture
- 8-Swallowing tests
How is aspiration pneumonia
diagnosed?

13. - 1-Lung abscess
- 2-Shock
- 3-Spread of infection to the
bloodstream (bacteremia)
- 4-Spread of infection to other areas
of the body
- 5-Respiratory failure
- 6-Death
Complications

14. - The major therapeutic approach is to
support pulmonary function.
- Using of Mechanical ventilation
- Using of Antimicrobial agents
according to the causative organism
- in case of severe illness , the empiric
use of antibiotics is reasonable.
However, if no infiltrates develop after
48 to 72 hours, it is appropriate to
stop antibiotics.
Treatment :

15. - 1- Musher D. Overview of pneumonia. In: Goldman L, Schafer AI,
eds. Goldman's Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier
Saunders; 2016: chap 97.
- 2-Atif H. Asghar, Ahmad M. Ashshi,* Esam I. Azhar,** Syed Z. Bukhari,+
Tariq A. Zafar,# and Aiman M. Momenah , Profile of bacterial
pneumonia durin hajj , Indian J Med Res. 2011 May; 133(5): 510–
513.
- 3-Lanspa MJ, Peyrani P, Wiemken T, et al; Characteristics associated
with clinician diagnosis of aspiration pneumonia: a descriptive
study of afflicted patients and their outcomes. J Hosp Med. 2015
Feb 10(2):90-6. doi: 10.1002/jhm.2280. Epub 2014 Nov 1.
- 4-John G Bartlett, Daniel J Sexton, Anna R Thorner, Aspiration
pneumonia in adults , uptodate ,Oct 2013.
References of this part :

16. BACK TO THE CASE

17. First Day :
patient was on the IV fluid and mechanical ventilation
left lung collapse and the ECG was abnormal
MEDICATION :
Drug name Dose frequency Route of
administration
Enoxaparin 4000 IU BID S.C
Dextrose 100 ml OD IV
NaCL Sterile Sol. 100 ml - IV
omeprazole 40 mg OD IV
Cefepime 500 mg OD IV
Levofloxacin 250 mg OD IV
Regular insulin 10U initial Immediatly IV
Levetiracetam 500 mg BID N.G.T
Atrovastatin 20 mg OD N.G.T

18. WBC
10^3/uL
RBC
10^6/uL
Hb g/dL
24 3,93 10.2
CBC and Differential :
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
248 6.12 153 110 2.7 2.1 3.5
Chemistry:
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
70-119 3.5-5.3 135-153 98-110 2.7-4.5 1.7-2.55 3.5-5.2
NORMAL
NORMAL

19. PH PCO2 mmHg PO2 mmHg
7.26 41.9 32.4
Blood Gases:
PH PCO2 mmHg PO2 mmHg
7.35-7.45 32-48 83-108
NORMAL

20. Assessment :
• Doing cultures ( nasal Swab And sputum,
blood and Urine) and start Empiric
Antibiotic medication .
• keep patient on the mechanical ventilator.
• do CT scan for brain to see if there were
any stroke ( because the patient had 4
time stroke before According her medical
history ) .

21. Second - fourth day:
patient still on the IV fluid and mechanical ventilation
left lung collapse
Drug name Dose frequency Route of
administration
Enoxaparin 4000 IU BID S.C
NaCL Sterile Sol. 60 ml - IV
Dextrose 60 ml OD IV
omeprazole 40 mg OD IV
Cefepime 1 g OD IV
Levofloxacin 250 mg OD IV
Regular insulin 1U initial Q 6 h IV
Levetiracetam 500 mg BID N.G.T
Atrovastatin 20 mg OD N.G.T
Human Albumin 100 ml BID IV
fusidic acid 1 apply Q 6 h local
k cl 40 mEq OD IV
Mg sulphate 2 g Immediately IV
MEDICATION
add on 4th day
on 4th day
add on 3rd
day
on 3rd
day
on 4th day
into 50 ml

22. WBC
10^3/uL
RBC
10^6/uL
Hb g/dL
8.9 3.8 9.6
CBC and Differential :
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
120 2.64 149 110 2.7 1.6 2.5
Chemistry:
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
70-119 3.5-5.3 135-153 98-110 2.7-4.5 1.7-2.55 3.5-5.2
NORMAL
NORMAL

23. PH PCO2 mmHg PO2 mmHg
7.40 42 68
Blood Gases:
PH PCO2 mmHg PO2 mmHg
7.35-7.45 32-48 83-108
NORMAL
Temperatu
re
PR BP O2 % RR
36-37 60-100 120/80 > 96% 16-20
Vital sign :
NORMAL
Temperatu
re
PR BP O2 % RR
36.8 86 125/60 100% 17

24. Assessment :
• cultures ( nasal Swab +ve MRSA on third day , Urine Culture
+ve leukocyte and microorganism on second day
(microrganism type dose not mention) and the Blood
Culture was -ve
• CT scan -ve .
• MRSA start treated with Fusidic acid locally
• keep electrolyte in balance , K by adding Kcl on 4th day
and Mg by adding Mg Sulphate .
• increase the cefipime dose ( until sputum culture results
appear ) , and add human Albumin due to decrease in
albumin because infection .
• patient still on the mechanical Ventilation .

25. Fifth - seventh day:
patient still on the IV fluid and mechanical ventilation no
new evidence except she transfer into FSHDU
left lung collapse .
Drug name Dose frequency Route of
administration
Enoxaparin 4000 IU BID S.C
NaCL Sterile Sol. 60 ml - IV
Dextrose 60 ml OD IV
omeprazole 40 mg OD IV
Tigacycline 100 mg OD IV infusion
Colistin 1000000 IU BID IV
Regular insulin 1U initial Q 6 h IV
Levetiracetam 500 mg BID N.G.T
Atrovastatin 20 mg OD N.G.T
Human Albumin 100 ml BID IV
fusidic acid 1 apply Q 6 h local
k cl 50 mEq OD IV
Mg sulphate 2 g OD IV
K phosphate 21 mmol Immediately IV
MEDICATION
instead of
cefepime and
levofluxacine
on 5th day
add on 5th day
add on 6th day

26. WBC
10^3/uL
RBC
10^6/uL
Hb g/dL
8.9 3.9 8.2
CBC and Differential :
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
120 3.2 147 110 0.81 2 2.5
Chemistry:
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
70-119 3.5-5.3 135-153 98-110 2.7-4.5 1.7-2.55 3.5-5.2
NORMAL
NORMAL

27. PH PCO2 mmHg PO2 mmHg
7.39 39.9 127
Blood Gases:
PH PCO2 mmHg PO2 mmHg
7.35-7.45 32-48 83-108
NORMAL
Temperatu
re
PR BP O2 % RR
36-37 60-100 120/80 > 96% 16-20
Vital sign :
NORMAL
Temperatu
re
PR BP O2 % RR
37 74 152/53 99% 17

28. Assessment :
• cultures sputum culture +VE Acentobactar Sensitive to
Colisitin and tigacyclin and resistance to cefepime and
intermediate resistance to levofluxacin according the
sensitivity test So , stop the empiric therapy and start
Colisitin and tigacyclin
• Tigacyclin start with 100 mg then keep patient on the 50
mg BID .
• MRSA start treated with Fusidic acid locally
• keep electrolyte in balance K by increasing the dose of Kcl
on 5th day and K phosphate to get benefit to ( k and
phosphate ).
• patient still on the mechanical Ventilation .

29. 8th - 12th day:
patient still on the IV fluid and
mechanical ventilation .
Drug name Dose frequency Route of
administration
Enoxaparin 4000 IU BID S.C
NaCL Sterile Sol. 60 ml - IV
Dextrose 60 ml OD IV
omeprazole 40 mg OD IV
Tigacycline 100 mg OD IV infusion
Colistin 1000000 IU BID IV
Regular insulin 1U initial Q 6 h IV
Levetiracetam 500 mg BID N.G.T
Atrovastatin 20 mg OD N.G.T
Human Albumin 100 ml BID IV
fusidic acid 1 apply Q 6 h local
k cl 50 mEq OD IV
Mg sulphate 2 g OD IV
K phosphate 21 mmol OD IV
Amlor 5 mg OD N.G.T
MEDICATION
stop on 10th day
add on 10th day

30. WBC
10^3/uL
RBC
10^6/uL
Hb g/dL
15.8 then 8.3 3.55 9
CBC and Differential :
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
120 4.9 150 110 3.8 2.5 3.1
Chemistry:
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
70-119 3.5-5.3 135-153 98-110 2.7-4.5 1.7-2.55 3.5-5.2
NORMAL
NORMAL
8th day
9th day

31. PH PCO2 mmHg PO2 mmHg
7.45 32 121
Blood Gases:
PH PCO2 mmHg PO2 mmHg
7.35-7.45 32-48 83-108
NORMAL
Temperatu
re
PR BP O2 % RR
36-37 60-100 120/80 > 96% 16-20
Vital sign :
NORMAL
Temperatu
re
PR BP O2 % RR
37 79 146/59 100% 17
165/73
207/97
8d
9d
10d

32. Assessment :
• keep using antibiotic for 10 days
• adding Amilodipine 5m due to highly
increase in blood pressure target BP for
patient under 140/60 .
• keep electrolyte in balance by stop mg
sulphate .
• patient still on the mechanical Ventilation
• lung collapse open in day 9 ( improve with
antibiotic therapy ).

33. 13th - 14th day:
patient still on the IV fluid and mechanical ventilation they
found blood on the Nasogastric tube
Patient develop bilateral limp edema on 14 th day .
Drug name Dose frequency Route of
administration
Enoxaparin 4000 IU BID S.C
NaCL Sterile Sol. 60 ml - IV
Dextrose 60 OD IV
omeprazole 40 mg OD IV
Tigacycline 100 mg OD IV infusion
Colistin 1000000 IU BID IV
Regular insulin 1U initial Q 6 h IV
Levetiracetam 500 mg BID N.G.T
Atrovastatin 20 mg OD N.G.T
Human Albumin 100 ml BID IV
fusidic acid 1 apply Q 6 h local
k cl 50 mEq OD IV
K phosphate 21 mmol OD IV
Amlor 5 mg OD N.G.T
MEDICATION
stop d 13
stop d 13
stop d 14
PTT= 15.5
normal = 10 -12.8

34. WBC
10^3/uL
RBC
10^6/uL
Hb g/dL
10.32 3.9 9
CBC and Differential :
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
120 4.1 146 110 3.8 1.8 4.05
Chemistry:
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
70-119 3.5-5.3 135-153 98-110 2.7-4.5 1.7-2.55 3.5-5.2
NORMAL
NORMAL

35. PH PCO2 mmHg PO2 mmHg
7.45 40 112
Blood Gases:
PH PCO2 mmHg PO2 mmHg
7.35-7.45 32-48 83-108
NORMAL
Temperatu
re
PR BP O2 % RR
36-37 60-100 120/80 > 96% 16-20
Vital sign :
NORMAL
Temperatu
re
PR BP O2 % RR
37 74 109/53 93% 17

36. Assessment :
• nasal swab culture result was -ve MRSA so
they stopped fusidic acid
• the patient’s electrolyte in balance
• Bleeding happen so stops Enoxaparin
• stop human Albumin because Albumin
reach the normal levels .

37. 15th day:
patient still on the IV fluid and mechanical ventilation
Patient develop new infection according Chest X-ray .
Drug name Dose frequency Route of
administration
NaCL Sterile Sol. 60 ml - IV
Dextrose 60 ml OD IV
omeprazole 40 mg OD IV
Tigacycline 100 mg OD IV infusion
Colistin 1000000 IU BID IV
Regular insulin 1U initial Q 6 h IV
Levetiracetam 500 mg BID N.G.T
Atrovastatin 20 mg OD N.G.T
Salbutamol 2,5 mcg Q 8 h with inhalation
Hydrocortisone 100 ml Immediately IV
Furosemide 20 mg Immediately I.V
K phosphate 21 mmol OD IV
k cl 50 mEq OD IV
Amlor 5 mg OD N.G.T
MEDICATION
add on 15th
day

38. WBC
10^3/uL
RBC
10^6/uL
Hb g/dL
12.28 4.28 8.9
CBC and Differential :
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
118 4.1 144 110 3.8 2 4.06
Chemistry:
WBC
10^9/uL
RBC
10^12/uL
Hb g/dL
4-10 x10^9/L 4,5 -5,5 X10^12/L 12-16
glucose
mg/dl
K
mmol/L
Na
mmol/L
Cl
mmol/L
PO4
mg/dL
Mg
mg/dL
Albumin
70-119 3.5-5.3 135-153 98-110 2.7-4.5 1.7-2.55 3.5-5.2
NORMAL
NORMAL

39. PH PCO2 mmHg PO2 mmHg
7.30 41.5 112
Blood Gases:
PH PCO2 mmHg PO2 mmHg
7.35-7.45 32-48 83-108
NORMAL
Temperatu
re
PR BP O2 % RR
36-37 60-100 120/80 > 96% 16-20
Vital sign :
NORMAL
Temperatu
re
PR BP O2 % RR
37 74 98/52 96% 17

40. Assessment :
• do Culture Again to know the New microorganism
• the patient’s still electrolyte in balance
• PPT=13.3 , bleeding stop after changing the tube
• continue using antibiotic until the culture results done .
• Salbutamol and Hydrocortisone to help patient breathing
• Furosemide Added to relive edema .
Treat Pneumonia
again

41. INTERVENTION

42. 1-Anemia
Patient’s Hb was low all the time , according
to the OLD file patient before 29 - 5 she was
diagnosed of chronic Iron deficiency
anemia , so we could not give her iron
( IV ) due to it is chronic ( iron will just
accumulate in her body without benefit )
and the bacterial infection because the
Pathogenic microorganisms, including
bacteria, fungi, and protozoa, require iron
for growth and proliferation.
BLOOD TRANSFUSION
IS The SOLUTION

43. 2-Using Of
Hydrocortisone
using of Hydrocortisone IV it is not
necessary because there are no data
to support the use of systemic
steroids as a standard of care in
pneumonia, neither in mild-to-
moderate and severe, nor in
bacterial and viral infection.

44. References of this part :
[1] Schaible UE, Kaufmann SH. Iron
and microbial infection. Nat Rev
Microbiol. 2004;2:946-953.
[2] Póvoa P1, Salluh JI , What is the
role of steroids in pneumonia
therapy, 2012 Apr;25(2):199-204.

45. –Albert Schweitzer.
“ Success is not the key to happiness.
Happiness is the key to success. If
you love what you are doing, you
will be successful’’.

46. Thank You .