Aspiration pneumonia in older people

Ayman Morish, M.D. Internal medicine, Critical care Medicine and Geriatrics Fellow.

.

.

Contents

Epidemiology

Causes of aspiration pneumoniaIssues of older ageManagement

Prevention

.

.

Case 1: admission Jan 26

CHIEF COMPLAINT(S): weakness and feeling unwell

HPI: 90-year-old gentleman. Came from an assisted living facility feeling weak for the past 4 days.

PMH: ESRD on HD, AFib, COPD, CHF, HTN, CAD.

SHx: Assisted living facility. Independent in most of his ADLs and need moderate support with transfer and mobilities.

.

.

P/E VITALS: tachycardia 121,

others unremarkable.

CVS: S1+S2, Irregularly irregular, holo-systolic murmur. No JVD.

Chest: reduced air entry, nwheezing or crackles.

o

Abd: + BS, soft, non-tender, no masses.

Neuro: AAOX3, grossly intact, able to move UE and LE

Extremity: No pitting edema, normal pulses.

.

.

Lab and Imagining

WBC 6.93Na 138 K 3.9BUN 19Creat 2.9BNP 2687

CXR: Left LL infiltrate / atelectasis. Hyperinflated lung suggesting COPD.

.

.

What do you think is going on?

Hold your thoughts for now ..

.

.

Case 2: Admission Feb 14 CHIEF COMPLAINT(S): Weakness, cough, nausea and vomiting. HPI: 90-year-old gentleman. Came from an assisted living facility

complaining of vomiting 3-4 times, chocking and coughing with eating.

Had a recent history of pneumonia 3 weeks ago and was treated with antibiotics. PMH: ESRD on HD, AFib, COPD, CHF, HTN, CAD.

SHx: Assisted living facility. Independent in most of his ADLs and need moderate support with transfer and mobilities.

.

.

P/E

VITALS: stable

Gen: cachectic and ill appearing

Mouth: dry oral mucosa

CVS: S1+S2, Irregularly irregular, 3/6 murmur in the mitral area.

Chest: b/l crackles , left>right

Abd: + BS, soft, non-tender, no rigidity

Neuro: AAOX3, No gross motor or sensory deficit

Extremities: pitting edema, normal pulses.

.

.

Lab and Imagining

WBC 7.76 K 6.2 BUN 71 Cr 5.7 BNP 4357

CXR: interstitial prominence, left lower lobe airspace opacity consistent with atelectasis or consolidation. Left pleural effusion.

.

.

What do you think is going on?

Hold your thoughts for now ..

.

.

Definitions and mechanisms

Aspiration is the misdirection of oropharyngeal or gastric contents into the larynx and lower respiratory tract

Aspiration Pneumonitis is a chemical injury by inhalation of gastric contents.

Aspiration pneumonia is an infection caused by inhalation of bacteria colonized oropharyngeal contents

.

.

Epidemiology

Adults age 65 years and older account for >50 percent of all pneumonia

Incidence of pneumonia increases with aging and frailty

Hospitalisations per year for pneumonia1.1 /1000 young adults12 /1000 old adults 32 /1000 nursing home residents

https://www.uptodate.com

.

.

Epidemiology: cont..

Rate of bacteremia: 1/1000 between age 35-44. 25/1000 at age > 75

Rate of nosocomial pneumonia:<2/1000 between 30-40 17/1000 at age > 70

*Kaplan et al. Arch Intern Med 163:317, 2003, ** Johnstone et al. Medicine 87: 329, 2008

.

.

Bacteriology:

anaerobic bacteria is less common than previously thought. Hard to distinct. Aspiration pneumonia represents a distinct entity from typical

pneumonia? Pneumonia occurs from micro aspiration of oropharyngeal

contents. Similar microbiology and clinical course as aspiration

pneumonia

.

.

Bacteriology: cont...

CAPYoung adult S. pneumoniae; Mycoplasma; Chlamydia

Older adultS. pneumoniae; H. influenza; Chlamydia; S. aureus; Gram-negative rods

.

.

Bacteriology: cont...

NHS. pneumoniaeGram-negative rods S. Aureus

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

.

.

Work up:

https://www.uptodate.com/contents/image?imageKey=RADIOL%2F100988&topicKey=ID%2F7024&source=outline_link

.

.

Indications for extensive workup .

.

Diagnosis:

new hypoxemia pulmonary infiltrates on imaging, particularly in gravity-

dependent lung regions on chest imagingposterior-segments of the upper lobes, basilar segments of the lower lobes

fever leukocytosis tachypnea

.

.

LimitLimitatatiionons:s:

Diagnosis is made in <50% of cases

Insufficient sample.

Gram-negative pathogens and Staph aureus are common.

Strep pneumoniae remains the most common pathogen.

.

.

Risk factors – aspiration pneumonia in older people altered mental status Dysphagia in residents of long-term care facilities

Difficulty swallowing food (OR 2.0) and medication (OR 8.3)Swallowing dysfunction, e.g. in patients with COPD or after

stroke. prolonged supine positionGastroparesis and high residual gastric volumes Aspirations: 71% of patients with CAP compared to 10% in

controls

.

.

Healthy aging and the swallow

Older people swallow more slowlyLaryngeal closure is delayedUpper oesophageal sphincter opening delayedOral bolus transport time prolonged

Safety of oropharyngeal swallowing is not compromisedThere is no increase in aspiration comparing to younger

adults in radiographic studies

.

.

Dysphagia

50% of acute stroke patients have clinical dysphagiaMost (80%) resolve in the first 7-10 days

Associated with big strokes and aphasia Dementia Parkinson diseaseMultiple sclerosis

Mann et al, Stroke 1999; 30:744

.

.

Poor oral health + oropharyngeal bacterial colonization

Can’t do oral hygiene!• Reduced consciousness level• Impaired hand / arm function

Can’t ask for oral hygiene!• Communication barriers

DysphasiaDeliriumDementia

Increased oral vulnerability• Dysphagia• Nil by mouth (NPO)• Drugs (PPI and antiH2)• Nutritional status

.

.

Back to our patients

Did they meet the criteria for diagnosis of aspiration pneumonia?

What are their risk factors

.

.

First case was treated with Unasyn(Ampicillin / Sulbactam)

Second case treated with ceftriaxone

.

.

When to treat?

Prophylactic antibiotics are not recommended Antibiotics are discouraged shortly after aspiration even with

fever, leukocytosis or pulmonary infiltrate. Recommend antibiotics in:1. Aspiration in high risk patients with colonized gastric contents2. Aspiration pneumonitis that fails to resolve within 48 hrs3. Unstable patient with witnessed aspiration

.

.

Treatment:

For nursing home residents, patients with antibiotics use in the last 3 months or patients with comorbidities: Fluoroquinolone (respiratory) alone : moxifloxacin,

levofloxacin, or Gemifloxacin or Macrolides (Azithromycin, clarithromycin, or erythromycin)

plus β-lactams (amoxicillin (high dose) or amoxicillin-clavulanate acid)

Alternative β-lactams: ceftriaxone, cefpodoxime or cefuroxime. Alternative to a Macrolide: doxycycline.

Amoxicillin-clavulanate acid if need anaerobic bacterial coverage.

.

.

Treatment: cont..

Nursing-home or Hospital-acquired Pneumonia Requiring Parenteral Treatment: Antipseudomonal cephalosporin (cefepime or ceftazidime) or

Antipseudomonal carbapenem (imipenem or meropenem) or ß-lactam/ß-lactamase inhibitor (piperacillin-tazobactam)

plus Antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) or

Aminoglycoside (amikacin, gentamicin, or tobramycin) plus MRSA Linezolid or vancomycin Ampicillin-sulbactam if need anaerobic bacterial coverage.

.

.

Duration of Treatment:A minimum of 5 days plus no fever for 48 h and should

have no CAP associated sign of clinical instability:

HR >100 bpmRespiratory rate 225/minSBP 00 mmHg02 saturation <90% or Pa02 mmHgAbility to maintain oral intakeabnormal mental status

.

.

Maintain therapy:

Switch from parenteral to oral antibiotics when patient is hemodynamically stable, shows clinical improvement, is afebrile for 16 h, and can tolerate oral medications;

Average duration of 7—14 d depending on clinical response.

Long-term care facility—usually 10—14 d

.

.

Recommendations:

Start early (<4hrs) in critically ill. Target the causative organism. If no infiltrates develop 48 to 72 hours after an aspiration,

it is appropriate to stop antibiotics.

.

.

Management strategies to reduce the risk of aspiration pneumonia

Assistance with regular oral hygiene Screening / investigation for dysphagia

High risk subgroups e.g. stroke, dementia, pneumonia, witnessed aspiration

Nil-by-mouth during high risk periods Postural interventions. Hand-feeding Small amounts frequentlyModified diet / thickened fluids / food supplements

.

.

Swallowing assessment after a stroke:

Routine assessment Look in the mouth!No impaired consciousnessWater swallow test Bedside swallow assessmentSelected patients NasoscopeModified Barium swallow

(video-fluoroscopy)

.

.

Conclusions

Aspiration is the main cause of pneumonia in later life The risk increased with;

dysphagia with oropharyngeal bacterial colonisation Frailty, cognitive impairment and multi-morbidity

AP has non-specific presentation Potential for prevention of AP

multi-modal / multi-disciplinary strategies

.

.

Thank you

.

.