2.11.08 aspiration pna gabbard
TRANSCRIPT
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Aspiration Pneumonia
Scott Gabbard, MD
2/11/2008
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Aspiration Pneumonia
Definition
Misdirection of gastric contents into the
larynx resulting from alteration in lowerairway defenses such as glottic closureand the cough reflex
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Incidence
Half of all adults aspirate small amounts oforopharyngeal contents in their sleep
Aspiration pneumonia may occur in up to10% of nursing home residents annually
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Predisposing Factors
Decreased consciousness
Alcohol
Drugs
Hepatic failure
CVA
Anesthesia
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Predisposing Factors
Esophageal disorders
GERD
Stricture
Tracheoesophageal fistula
Incompetent cardiac sphincter
Protracted vomiting
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Predisposing Factors
Disruption of glottic closure
Endotracheal intubation
NG tube
Endoscopy/bronchoscopy
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Predisposing Factors
Neuromuscular disorders
Multiple sclerosis
Parkinsons
Myasthenia gravis
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Chemical Pneumonitis
Mendelson first described aspirationpneumonitis in 1946
61 OB patients aspirated gastric contentsafter ether anesthesia
All patients had recovery within 2 days
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Chemical Pneumonitis
Pathophysiology
Animal models demonstrate that clinically
significant pneumonitis results fromaspirating at least 1ml/kg of pH2.5
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Chemical Pneumonitis
Clinical features
Abrupt onset of dyspnea
Low grade fever
Pink frothy sputum
Diffuse crackles on exam
CXR: diffuse infiltrates
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Chemical Pneumonitis
Xray of chemicalpneumonitis 2 hours afteraspiration event
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Chemical Pneumonitis
Treatment
Ventilatory support may be necessary
Corticosteriods: beneficial in animalmodels, unsuccessful in humans
Antibiotics
Up to 25% of patients have bacterialsuperinfection (Dines et al)
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Bacterial Pneumonitis
Clinical features
Much more insidious onset than chemical
pneumonitis (days to weeks) Cough
Fever
Purulent sputum CXR: Infiltrate frequently in dependent
segments
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Bacterial Pneumonitis
Xray of bacterialaspiration pneumonia
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Bacterial Pneumonitis
Microbiology
Anaerobes
Peptostreptococcus Fusobacterium
Bacteroides
Gram negative bacilli
Klebsiella in alcoholics
E coli, serratia, proteus
Gram positive bacteria
Staph, Hemophilus, streptococcus
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Bacterial Pneumonitis
Treatment Usual treatment 1-2 weeks (6-12 weeks for
abscess) Clindamycin
Superior response rates to PCN
Augmentin
Flagyl (dont use as single agent)
Moxifloxacin over other quinolones Cefotaxime/ceftriaxone over other cephalosporins
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Solid Particle Aspiration
Large particles
Sudden respiratory distress, cyanosis,
aphonia Heimlich!
Small particles
Irritative cough, unilateral wheezing Remember: bacterial superinfection is
common
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Assessment of Dysphagia
Clinical signs of dysphagia
Drooling
Coughing before, during, or after swallow
Multiple swallows per mouthful
Unusual head posturing while swallowing
Clinical exam for diagnosis Sensitivity 80%, Specificity 70%
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Assessment of Dysphagia
Modified barium swallow (MBS)
Patients swallow small amounts of different texturedbarium and evaluated by flouroscopy
One study demonstrated that MBS did not change thesensitivity of clinical exam, but did make the evaluationmore specific
Laryngoscopy
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Modified Barium Swallow
Stasis of contrast at the level of the pyriform sinuses (bluearrows) with subsequent aspiration (yellow arrows)
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Tube Feeding
Short term dysphagia
In moderately disabled CVA patients with
dysphagia, tube feeding has been shownto be associated with less pneumoniathan oral feeds (54% vs. 13%, p
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Tube Feeding
Long term dysphagia
No data exists to suggest that tube
feeding decreases pneumonia or prolongssurvival in patients with advanceddementia
102 patients with severe dementia: 58%
aspiration pneumonia in FT patients vs. 17%in those not receiving FT (Peck)
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Prevention
HOB elevated 30-45 degrees
Oral decontamination with chlorhexidine
Chin down - helps to narrow the airway Head tilt to stronger side when swallowing
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Prevention
Substance P
Believed to play a major role in the cough
and swallow pathwaysACE inhibitors prevent breakdown of
substance P
576 elderly patients with HTN: 3%pneumonia in those treated with ACEI vs.9% in those treated with Ca channelblocker (Arai)
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References
Haruka Tohara, Eiichi Saitoh, Keith A. Mays, Keith Kuhlemeier andJeffrey B. Palmer; Three Tests for Predicting Aspiration withoutVideofluorography; Dysphagia. 2003 Spring;18(2):126-34
Li, I. Feeding tubes in patients with severe dementia. AmericanFamily Physician. 2002 Apr 15;65(8):1605-10, 1515
Marek, PE. Aspiration pneumonia and dysphagia in the elderly.Chest. 2003 Jul;124(1):328-36
Paintal, HS. Kuschner, WG. Aspiration syndromes: 10 clinical pearls
every physician should know. Int J Clinical Practice.2007May;61(5):846-52.
Uptodate
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