Aspiration pneumonia

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Aspiration pneumonia
Aspiration pneumonia (2).jpg
Microscopic image of aspiration pneumonia in an elderly person with a neurologic illness. Note foreign-body giant cell reaction.
Specialty Emergency medicine, pulmonology
Symptoms Fever, cough [1]
Complications Lung abscess [1]
Usual onsetElderly [2]
Risk factors Decreased level of consciousness, problems with swallowing, alcoholism, tube feeding, poor oral health [1]
Diagnostic method Based on presenting history, symptoms, chest X-ray, sputum culture [2] [1]
Differential diagnosis Chemical pneumonitis, tuberculosis [1] [2]
Medication Clindamycin, meropenem, ampicillin/sulbactam, moxifloxacin [1]
Frequency~10% of pneumonia cases requiring hospitalization [1]

Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. [1] Signs and symptoms often include fever and cough of relatively rapid onset. [1] Complications may include lung abscess, acute respiratory distress syndrome, empyema, and parapneumonic effusion. [3] [1] Some include chemical induced inflammation of the lungs as a subtype, which occurs from acidic but non-infectious stomach contents entering the lungs. [1] [2]

Contents

Infection can be due to a variety of bacteria. [2] Risk factors include decreased level of consciousness, problems with swallowing, alcoholism, tube feeding, and poor oral health. [1] Diagnosis is typically based on the presenting history, symptoms, chest X-ray, and sputum culture. [1] [2] Differentiating from other types of pneumonia may be difficult. [1]

Treatment is typically with antibiotics such as clindamycin, meropenem, ampicillin/sulbactam, or moxifloxacin. [1] For those with only chemical pneumonitis, antibiotics are not typically required. [2] Among people hospitalized with pneumonia, about 10% are due to aspiration. [1] It occurs more often in older people, especially those in nursing homes. [2] Both sexes are equally affected. [2]

Signs and symptoms

The person may have an insidious course with increased respiratory rate, foul-smelling sputum, hemoptysis, and fever. Complications may occur, such as exudative pleural effusion, empyema, and lung abscesses. [4] If left untreated, aspiration pneumonia can progress to form a lung abscess. [5] Another possible complication is an empyema, in which pus collects inside the lungs. [6] If continual aspiration occurs, the chronic inflammation can cause compensatory thickening of the insides of the lungs, resulting in bronchiectasis. [6]

Causes

Most aspiration events occur in patients with a defective swallowing mechanism, such as a neurological disease or as the result of an injury that directly impairs swallowing or interferes with consciousness. [7] Impaired consciousness can be intentional, such as the use of general anesthesia for surgery. For many types of surgical operations, people preparing for surgery are therefore instructed to take nothing by mouth (nil per os, abbreviated as NPO) for at least four hours before surgery. These conditions enable the entry of bacteria into the lungs, thus allowing the development of an infection.[ citation needed ]

Risk factors

Bacteria

Bacteria involved in aspiration pneumonia may be either aerobic or anaerobic. [12] Common aerobic bacteria involved include:

Anaerobic bacteria also play a key role in the pathogenesis of aspiration pneumonia. [14] They make up the majority of normal oral flora and the presence of putrid fluid in the lungs is highly suggestive of aspiration pneumonia secondary to an anaerobic organism. [14] While it is difficult to confirm the presence of anaerobes through cultures, the treatment of aspiration pneumonia typically includes anaerobic coverage regardless. [14] Potential anaerobic bacteria are as follows:

Pathophysiology

Aspiration is defined as inhalation of oropharyngeal or gastric contents into the pulmonary tree. Depending on the composition of the aspirate, three complications have been described: [4]

Location

The location is often gravity dependent, and depends on the person's position. Generally, the right middle and lower lung lobes are the most common sites affected, due to the larger caliber and more vertical orientation of the right mainstem bronchus. People who aspirate while standing can have bilateral lower lung lobe infiltrates. The right upper lobe is a common area of consolidation, where liquids accumulate in a particular region of the lung, in alcoholics who aspirate in the supine position. [15]

Diagnosis

Aspiration pneumonia in a ventilated person with a central line and nasogastric tube AspirationPneumonia.png
Aspiration pneumonia in a ventilated person with a central line and nasogastric tube

Evaluation of aspiration is generally performed with a video fluoroscopic swallowing study involving radiologic evaluation of the swallowing mechanism via challenges with liquid and solid food consistencies. These studies allow for evaluation of penetration to the vocal folds and below but are not a sensitive and specific marker for aspiration. [16] Additionally, it is difficult to distinguish between aspiration pneumonia and aspiration pneumonitis. [17]

Aspiration pneumonia is typically diagnosed by a combination of clinical circumstances (people with risk factors for aspiration) and radiologic findings (an infiltrate in the proper location). [1] A chest x-ray is typically performed in cases where any pneumonia is suspected, including aspiration pneumonia. [18] Findings on chest x-ray supportive of aspiration pneumonia include localized consolidation depending on the patient's position when the aspiration occurred. [18] For example, people that are supine when they aspirate often develop consolidation in the right lower lobe of the lung. [18] Sputum cultures are not used for diagnosing aspiration pneumonia because of the high risk of contamination. [19] Clinical symptoms may also increase suspicion of aspiration pneumonia, including new difficulty breathing and fever after an aspiration event. [6] Likewise, physical exam findings such as altered breath sounds heard in the affected lung fields may also be suggestive of aspiration pneumonia. [6] Some cases of aspiration pneumonia are caused by aspiration of food particles or other particulate substances like pill fragments; these can be diagnosed by pathologists on lung biopsy specimens. [20]

While aspiration pneumonia and chemical pneumonitis may appear similar, it is important to differentiate between the two due to major differences in management of these conditions. Chemical pneumonitis is caused by damage to the inner layer of lung tissue, which triggers an influx of fluid. [19] The inflammation caused by this reaction can rapidly cause similar findings seen in aspiration pneumonia, such as an elevated WBC (white blood cell) count, radiologic findings, and fever. [19] However, it is important to note that the findings of chemical pneumonitis are triggered by inflammation not caused by infection, as seen in aspiration pneumonia. Inflammation is the body's immune response to any perceived threat to the body. Thus, treatment of chemical pneumonitis typically involves removal of the inflammatory fluid and supportive measures, notably excluding antibiotics. [21] The use of antimicrobials is reserved for chemical pneumonitis complicated by secondary bacterial infection. [19]

Prevention

There have been several practices associated with decreased incidence and decreased severity of aspiration pneumonia as detailed below.

Oral hygiene

Studies showed that the net reduction of oral bacteria was associated with a decrease in both incidence of aspiration pneumonia as well as mortality from aspiration pneumonia. [22] One broad method of decreasing the number of bacteria in the mouth involves the use of antimicrobials, ranging from topical antibiotics to intravenous antibiotic use. [22] Whereas the use of antibiotics focuses on destroying and hindering the growth of bacteria, mechanical removal of oral bacteria by a dental professional also plays a key role in reducing the bacterial burden. [22] By reducing the amount of bacteria in the mouth, the likelihood of infection when aspiration occurs is reduced as well. [22] For people who are critically ill that require a feeding tube, there is evidence suggesting that the risk of aspiration pneumonia may be reduced by inserting the feeding tube into the duodenum or the jejunum (post-pyloric feeding), when compared to inserting the feeding tube into the stomach. [10]

Enhanced swallow

Many people at risk for aspiration pneumonia have an impaired swallowing mechanism, which may increase the chance of aspiration of food particles with meals. [22] There is some evidence to indicate that training of various parts of the body involved in the act of swallowing, including the tongue and lips, may reduce episodes of aspiration and aspiration pneumonia; however, further research is required to confirm this benefit. [22] Other simple actions during feeding can improve the swallowing capability of a person and thus reduce the risk of aspiration, including changes in position and feeding assistance. [23]

After surgery

Many instances of aspiration occur during surgical operations, especially during anesthesia induction. [24] The administration of anesthesia causes suppression of protective reflexes, most importantly the gag reflex. As a result, stomach particles can easily enter the lungs. Certain risk factors predispose individuals to aspiration, especially conditions causing dysfunction of the upper gastrointestinal system. [24] Identifying these conditions before the operation begins is essential for proper preparation during the procedure. [24] It is recommended that patients fast prior to procedures as well. [24] Other practices that may be beneficial but have not been well-studied include medication that reduce the acidity of gastric contents and rapid sequence induction. [24] On the other hand, regarding reducing acidity of the stomach, an acid environment is needed to kill the organisms that colonize the gastrointestinal tract; agents, such as proton pump inhibitors, that decrease the acidity of the stomach, may favor the growth of bacteria and increase the risk of pneumonia. [4]

Treatment

Adjusting the patient's posture should come first, then the oropharyngeal contents should be suctioned with the nasogastric tube in place. Humidified oxygen is given to patients who are not intubated, and the head end of the bed should be elevated by 45 degrees. It's crucial to keep a close eye on the patient's oxygen saturation, and if hypoxia is detected, urgent intubation with mechanical breathing should be given. Flexible bronchoscopy is often used to gather samples of bronchoalveolar lavage for quantitative bacteriological tests as well as high volume aspiration to clear the secretion. [25] In general practice The main treatment of aspiration pneumonia revolves around the use of antibiotics to remove the bacteria causing the infection. [1] Broad antibiotic coverage is required to account for the diverse types of bacteria possibly causing the infection. [1] Even though they are not necessary in cases with aspiration pneumonitis, antibiotics are typically started right away to stop the disease's development.[ citation needed ] Recommended antibiotics include clindamycin, meropenem, ertapenem, ampicillin/sulbactam, and moxifloxacin. [1] Treatment with piperacillin/tazobactam, cefepime, levofloxacin, imipenem, or meropenem is recommended in cases of potential antibiotic resistance. [26] The typical duration of antibiotic therapy is about 5 to 7 days. [26] If there is a large accumulation of fluid within the lungs, drainage of the fluid may also aid in the healing process. [14]

Prognosis

Dysphagia clinicians often recommend alteration of dietary regimens, altered head positioning, or removal of all oral intake. While studies have suggested that thickening liquids can decrease aspiration through slowed pharyngeal transit time, they have also demonstrated increased pharyngeal residues with risk for delayed aspiration. The ability of clinical interventions to reduce pneumonia incidence is relatively unknown. Dietary modifications or nothing-by-mouth status also have no effect on a patient's ability to handle their own secretions. A patient's individual vigor may impact the development of pulmonary infections more than aspiration. Also increased pneumonia risk exists in patients with esophageal dysphagia when compared to stroke patients because patients with stroke will improve as they recover from their acute injury, whereas esophageal dysphagia is likely to worsen with time. In one cohort of aspiration pneumonia patients, overall three-year mortality was 40%. [16]

Studies have shown that aspiration pneumonia has been associated with an overall increased in-hospital mortality as compared with other forms of pneumonia. [27] Further studies investigating differing time spans including 30-day mortality, 90-day mortality, and 1-year mortality. [27] Individuals diagnosed with aspiration pneumonia were also at increased risk of developing future episodes of pneumonia. In fact, these individuals were also found to be at higher risk for readmission after being discharged from the hospital. [27] Lastly, one study found that individuals diagnosed with aspiration pneumonia were more likely to fail treatment compared to other types of pneumonia. [27]

Elderly

Aging increases the risk of dysphagia. The prevalence of dysphagia in nursing homes is approximately 50%, and 30% of the elderly with dysphagia develop aspiration. For individuals older than 75, the risk of pneumonia due to dysphagia is six times greater than those 65. [28] Owing to multiple factors, such as frailty, impaired efficacy of swallowing, decreased cough reflex and neurological complications, dysphagia can be considered as a geriatric syndrome. [29] Atypical presentation is common in the elderly. Older patients may have impaired T cell function and hence, they may be unable to mount a febrile response. The mucociliary clearance of older people is also impaired, resulting in diminished sputum production and cough. Therefore, they can present non-specifically with different geriatric syndromes. [4]

Microaspirations

In the elderly, dysphagia is a significant risk factor for the development of aspiration pneumonia. Aspiration pneumonia most often develops due to micro-aspiration of saliva, or bacteria carried on food and liquids, in combination with impaired host immune function. [30] Chronic inflammation of the lungs is a key feature in aspiration pneumonia in elderly nursing home residents and presents as a sporadic fever (one day per week for several months). Radiological review shows chronic inflammation in the consolidated lung tissue, linking chronic micro-aspiration and chronic lung inflammation.

Choking

After falls, choking on food presents as the second highest cause of preventable death in aged care. [30] Although food choking risk is commonly associated with young children, data shows that individuals over 65 years of age have a choking incidence that is seven times higher than children aged 1–4 years. [30]

Parkinson's disease

The reported prevalence of dysphagia in patients with Parkinson's disease ranges from 20% to 100% due to variations in the methods of assessing the swallowing function. [31] Unlike some medical problems, such as stroke, dysphagia in Parkinson's Disease degenerates with disease progression. Aspiration pneumonia was the most common reason for the emergency admission of patients with Parkinson's Disease whose disease duration was >5 years and pneumonia was one of the main causes of death.

Dementia

The familiar model of care for people with advanced dementia and dysphagia is the revolving door of recurrent chest infections, frequently associated with aspiration and related readmissions. Many individuals with dementia resist or are indifferent to food and fail to manage the food bolus. There are also many contributory factors such as poor oral hygiene, high dependency levels for being positioned and fed, as well as the need for oral suctioning. While tube feeding might therefore be considered a safer option, tube feeding has not been shown to be beneficial in people with advanced dementia. The preferred option therefore is to continue eating and drinking orally despite the risk of developing chest infections. [28]

See also

Related Research Articles

<span class="mw-page-title-main">Pneumonia</span> Inflammation of the alveoli of the lungs

Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity of the condition is variable.

<span class="mw-page-title-main">Dysphagia</span> Difficulty in swallowing

Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right.

<span class="mw-page-title-main">Sputum</span> Mucus that is coughed up from the lower airways

Sputum is mucus that is coughed up from the lower airways. In medicine, sputum samples are usually used for a naked eye examination, microbiological investigation of respiratory infections and cytological investigations of respiratory systems. It is crucial that the specimen does not include any mucoid material from the nose or oral cavity.

<span class="mw-page-title-main">Bronchiectasis</span> Disease of the lungs

Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Symptoms typically include a chronic cough with mucus production. Other symptoms include shortness of breath, coughing up blood, and chest pain. Wheezing and nail clubbing may also occur. Those with the disease often get lung infections.

<span class="mw-page-title-main">Pulmonary aspiration</span> Entry of materials into the larynx (voice box) and lower respiratory tract

Pulmonary aspiration is the entry of material such as pharyngeal secretions, food or drink, or stomach contents from the oropharynx or gastrointestinal tract, into the larynx and lower respiratory tract, the portions of the respiratory system from the trachea (windpipe) to the lungs. A person may inhale the material, or it may be delivered into the tracheobronchial tree during positive pressure ventilation. When pulmonary aspiration occurs during eating and drinking, the aspirated material is often colloquially referred to as "going down the wrong pipe".

<i>Klebsiella pneumoniae</i> Species of bacterium

Klebsiella pneumoniae is a Gram-negative, non-motile, encapsulated, lactose-fermenting, facultative anaerobic, rod-shaped bacterium. It appears as a mucoid lactose fermenter on MacConkey agar.

<span class="mw-page-title-main">Pleural empyema</span> Medical condition

Pleural empyema is a collection of pus in the pleural cavity caused by microorganisms, usually bacteria. Often it happens in the context of a pneumonia, injury, or chest surgery. It is one of the various kinds of pleural effusion. There are three stages: exudative, when there is an increase in pleural fluid with or without the presence of pus; fibrinopurulent, when fibrous septa form localized pus pockets; and the final organizing stage, when there is scarring of the pleura membranes with possible inability of the lung to expand. Simple pleural effusions occur in up to 40% of bacterial pneumonias. They are usually small and resolve with appropriate antibiotic therapy. If however an empyema develops additional intervention is required.

<span class="mw-page-title-main">Lower respiratory tract infection</span> Medical term

Lower respiratory tract infection (LRTI) is a term often used as a synonym for pneumonia but can also be applied to other types of infection including lung abscess and acute bronchitis. Symptoms include shortness of breath, weakness, fever, coughing and fatigue. A routine chest X-ray is not always necessary for people who have symptoms of a lower respiratory tract infection.

<span class="mw-page-title-main">Bacterial pneumonia</span> Disease of the lungs

Bacterial pneumonia is a type of pneumonia caused by bacterial infection.

Chemical pneumonitis is inflammation of the lung caused by aspirating or inhaling irritants. It is sometimes called a "chemical pneumonia", though it is not infectious. There are two general types of chemical pneumonitis: acute and chronic.

<span class="mw-page-title-main">Lung abscess</span> Medical condition

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection.

<span class="mw-page-title-main">Pneumonitis</span> General inflammation of lung tissue

Pneumonitis describes general inflammation of lung tissue. Possible causative agents include radiation therapy of the chest, exposure to medications used during chemo-therapy, the inhalation of debris, aspiration, herbicides or fluorocarbons and some systemic diseases. If unresolved, continued inflammation can result in irreparable damage such as pulmonary fibrosis.

Tracheobronchitis is inflammation of the trachea and bronchi. It is characterised by a cough, fever, and purulent sputum and is therefore suggestive of pneumonia. It is classified as a respiratory tract infection.

Community-acquired pneumonia (CAP) refers to pneumonia contracted by a person outside of the healthcare system. In contrast, hospital-acquired pneumonia (HAP) is seen in patients who have recently visited a hospital or who live in long-term care facilities. CAP is common, affecting people of all ages, and its symptoms occur as a result of oxygen-absorbing areas of the lung (alveoli) filling with fluid. This inhibits lung function, causing dyspnea, fever, chest pains and cough.

Ventilator-associated pneumonia (VAP) is a type of lung infection that occurs in people who are on mechanical ventilation breathing machines in hospitals. As such, VAP typically affects critically ill persons that are in an intensive care unit (ICU) and have been on a mechanical ventilator for at least 48 hours. VAP is a major source of increased illness and death. Persons with VAP have increased lengths of ICU hospitalization and have up to a 20–30% death rate. The diagnosis of VAP varies among hospitals and providers but usually requires a new infiltrate on chest x-ray plus two or more other factors. These factors include temperatures of >38 °C or <36 °C, a white blood cell count of >12 × 109/ml, purulent secretions from the airways in the lung, and/or reduction in gas exchange.

<span class="mw-page-title-main">Respiratory disease</span> Disease of the respiratory system

Respiratory diseases, or lung diseases, are pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, influenza, and pharyngitis to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, tuberculosis, acute asthma, lung cancer, and severe acute respiratory syndromes, such as COVID-19. Respiratory diseases can be classified in many different ways, including by the organ or tissue involved, by the type and pattern of associated signs and symptoms, or by the cause of the disease.

<span class="mw-page-title-main">Hospital-acquired pneumonia</span> Pneumonia contracted by a hospital patient

Hospital-acquired pneumonia (HAP) or nosocomial pneumonia refers to any pneumonia contracted by a patient in a hospital at least 48–72 hours after being admitted. It is thus distinguished from community-acquired pneumonia. It is usually caused by a bacterial infection, rather than a virus.

<span class="mw-page-title-main">Acute exacerbation of chronic obstructive pulmonary disease</span> Medical condition

An acute exacerbation of chronic obstructive pulmonary disease, or acute exacerbations of chronic bronchitis (AECB), is a sudden worsening of chronic obstructive pulmonary disease (COPD) symptoms including shortness of breath, quantity and color of phlegm that typically lasts for several days.

<span class="mw-page-title-main">Alcoholic lung disease</span> Human disease

Alcoholic lung disease is disease of the lungs caused by excessive alcohol. The term 'alcoholic lung disease' is not a generally accepted medical diagnosis, and "the association between alcohol abuse and acute lung injury remains largely unrecognized, even by lung researchers".

<span class="mw-page-title-main">Classification of pneumonia</span> Medical condition

Pneumonia can be classified in several ways, most commonly by where it was acquired, but may also by the area of lung affected or by the causative organism. There is also a combined clinical classification, which combines factors such as age, risk factors for certain microorganisms, the presence of underlying lung disease or systemic disease and whether the person has recently been hospitalized.

References

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  30. 1 2 3 Cichero, Julie (2018). "Age-Related Changes to Eating and Swallowing Impact Frailty: Aspiration, Choking Risk, Modified Food Texture and Autonomy of Choice". Geriatrics. 3 (4): 69–79. doi: 10.3390/geriatrics3040069 . PMC   6371116 . PMID   31011104.
  31. ↑ Umemoto G, Furuya H (2019). "Management of Dysphagia in Patients with Parkinson's Disease and Related Disorders". Intern Med. 59 (1): 7–14. doi: 10.2169/internalmedicine.2373-18 . PMC   6995701 . PMID   30996170.

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