Disclosure. What are pneumonitis and pneumonia? J. Coyle, Ph.D. April 2016; WVSHA Conference 04/06/2016

Transcription

1 Pneumonia & Common Pulmonary Diseases in Adults West Virginia Speech Language and Hearing Association Annual Conference, Bridgeport WV April, 2016 James L. Coyle, Ph.D., CCC SLP, BCS S University of Pittsburgh 1 Disclosure University of Pittsburgh (salary) WVSHA honorarium NIH RO 1 (25% effort) No products Lots of biases favoring my patients 2 What are pneumonitis and pneumonia? 3 attributed 1

2 Pneumonitis: lung inflammation Inhaled or aspirated sources Chemical Irritants, Allergens Radiation Therapy Medications Irritant traumatizes lung Inflammation 4 Pneumonia: lung infection Inhaled or aspirated sources Bacterial With or without other debris Viral Resolution Pathogen Colonizes lung Systemic Spread Pneumonia (Infection and Pneumonitis) Infection causes inflammation: pneumonia = infection + inflammation Pathogens and their waste are irritants Sepsis, Multi organ Failure, Shock 5 What is Pneumonia? Infectious pneumonitis Caused by a pathogen (problem 1) Produces inflammation (problem 2) 6 attributed 2

3 Pneumonia Most frequent infectious cause of death* 40% higher incidence in elderly ** #2 nosocomial infection (UTI) in hospitals*** High case fatality rate 55% (elderly) Leading cause of mortality in children under 5**** Marston, et al., 1997*; National Center for Health Statistics, 2003**; ***Niederman, et al., 2002; ****Baine et al., 2001; Almirall, et al., What is Pneumonia? 1. Inoculation, infection O2 enters alveoli, diffuses to blood CO2 diffuses to alveoli, is exhaled Pathogen enters alveoli Pathogen adheres to epithelium, produces waste, reproduces. Waste products are irritants C Inflammation: alveoli become thick, noncompliant. C C C Capillary RBC, WBC 8 2. Inflammation, RBC leakage Inflammation traumatizes respiratory membrane making it excessively permeable. Red blood cells leak into alveoli. C Volume of debris in alveoli increases C C C Capillary RBC, WBC 9 attributed 3

4 3. WBC plasma leakage, respiratory distress Immunological response, macrophages and other cells accumulate Volume of debris increases, forming a growing infiltrate (obstructs respiration). C Alveoli become more noncompliant Surface area for respiration shrinks, Reduced oxygen diffusion to blood (Hypoxemia) C Reduced CO2 diffusion to alveoli (Hypercapnea CO2 retention) C capillary C 10 Infiltrates Clear alveoli Thickened epithelium Resolution Inflammation subsiding; compliance improves Infiltrate volume has decreased, RBC eliminated Infiltrate clears Bacterial debris eliminated WBC eliminated, inflammation ends C C Respiratory surface area restored gas exchange normalizes C C capillary 12 attributed 4

5 What is aspiration and how do lungs respond to aspiration? 13 Pneumonia/Pneumonitis Setting in which it began Pathogenic origin Mechanism Aspiration Dysphagia related Non dysphagia related Hematogenous Iatrogenic: Direct Inoculation vs. Ventilator associated Health care workers vs. sterilization errors 14 Pneumonia classification By setting Community acquired pneumonia Aspiration, influenza, bug of the month Health care associated pneumonia Aspiration, ventilator associated, HCW, contaminated equipment 15 attributed 5

6 Pneumonia classification By pathogen causing infection Bacterial Streptococcal, staphylococcal, etc. Viral Influenza, etc. Fungal, etc. 16 Pneumonia classification By anatomy Bronchopneumonia Lobar pneumonia Multilobar Diffuse, focal 17 Pneumonia classification By mechanism Indirect HCW inoculation Direct equipment contamination Hematogenous Lung infected through circulatory system (sepsis) Aspiration Dysphagia related Non dysphagia related 18 attributed 6

7 Pneumonia 100% Inhaled Pathogen Typical Atypical CAP Aspirated Pathogen Aspiration Pneumonia 15.5% >Oropharyngeal >Gastric Hospital Acquired Pneumonia Inhaled Pathogen VAP DAP Non DAP Non VAP Baine et al., 2001 PEOPLE CAN ASPIRATE ANYWHERE: AP IS NOT SETTING SPECIFIC! 19 Aspiration Solid or liquid matter Not airborne, inhaled pathogen Courses by gravity, to its destination Crosses plane of true vocal folds 20 Aspiration destination Entrance of liquid or solid matter into the respiratory system, below the vocal folds Not airborne Aspirated material is gravity dependent Airborne is not R L R L 21 attributed 7

8 Lung response to aspiration: water Inside alveolus H2O H2O H2O Alveolar membrane Capillary membrane Water H2O Respiratory Membrane RBC s From (R) heart WBC s Plasma containing water inside capillary Toward (L) heart Effros, et al., Lung response to aspiration: pathogens and particulate matter Inside alveolus infiltrate Chemical irritant Alveolar membrane Capillary membrane Respiratory Membrane RBC s From (R) heart WBC s H2O H2O plasma H2O Plasma containing water inside capillary Toward (L) heart Chemical pneumonitis 23 Dysphagia related Aspiration Destinations (R) Basilar infiltrates (R) Upper lobe infiltrates Aspiration produces pneumonitis or pneumonia in gravity dependent portions of lung(s). Dependence depends on posture when aspiration occurs, density & volume aspirated. 24 Marik, 2001 attributed 8

9 What is aspiration pneumonia? and what other types of pneumonia are there? 25 Aspiration Pneumonias Dysphagia related AP (DAP) Pathogen in solid or liquid matter Courses by gravity, to its destination Not airborne, inhaled pathogen Incidence: 11%; 15.5%, 22% (*) Dysphagia! Oral pathogens typically Colonization of oral cavity Robbins et al., 2008; Baine et al., 2001; Langmore et al., Other Aspiration Pneumonias Non dysphagia related AP (NDAP) Aspiration pneumonia NOT FROM THE MOUTH Colonized emesis Gastroesophageal esophagopharyngeal reflux Esophageal motility disorder Oral pathogens that survive in stomach Or from esophagus 27 attributed 9

10 Community Acquired Pneumonia (CAP) Pneumonia not acquired in a health care facility Mechanism: aspiration or other 4 5 million cases per year* ** 600,000 hospitalizations, 45,000 deaths** Incidence** 12 per 1000 persons 20 per 1000 elderly persons (60% greater) Common pathogens Typical: Streptococcus, Klebsciella pneumoniae Atypical *: H. influenzae, RSV, Legionella, E. coli, Staph. aureus, others *Niederman, 2002; **Mandell & Wunderink, Other Types of Pneumonia Ventilator Associated Pneumonia Exposure to mechanical ventilation Contaminated respiratory circuits Contaminated suction, bronchoscopic equipment Aspiration of oral secretions while sedated Gastroesophageal reflux common in ventilation Early, late onset Early: typically CAP pathogens Late: MRSA, other drug resistant pathogens 29 Other Types of Pneumonia Respiratory Syncitial virus (RSV) Viral, common in children (day care) Legionella pneumonia Hematogenous pneumonia: sepsis AKA SIRS Systemic inflammatory response syndrome Lung infected by bloodborne pathogen 30 attributed 10

11 Sepsis Infection and sepsis Infection Pathogenic Organism Organism that causes disease in host organ enters and occupies host organ/tissue draws nutrients from host and damages tissue reproduces and generates metabolic waste organism, offspring, waste, are all IRRITANTS blood organ barrier disrupted organism enters circulatory system = SEPSIS process repeats in other organs Depending on organ effects of infection??? 32 Infection and sepsis Sepsis = septicemia = bacteremia (if bacterial) Pathogen Damage to vascular structures, organs Leakage of fluid from blood vessels Hypotension Organs need adequate blood pressure to function Organ metabolic failure Hypotensive shock Multi organ hypotensive failure (high mortality) Organism infecting other organs Example: UTI sepsis hematogenous pneumonia 33 attributed 11

12 Infection and sepsis Typical scenarios 1. Urinary tract infection Bladder ureters kidneys blood spread 2. Pneumonia Airway alveoli pulmonary capillaries spread 3. Wound infection Local wound tissue capillaries blood spread Progression Typically insidious in first days Patient may not develop sudden signs 34 Infection and sepsis Effects of sepsis Depends on organs affected: Examples Brain and CNS Progressive lethargy reduced oral intake dehydration more lethargy more reduced intake more dehydration Urinary system Impaired filtration accumulated [organ] metabolic waste impaired nervous system and other organ function Metabolic acidosis Example to illustrate E. coli, pneumococcus in blood culture 35 Sepsis The challenge in sepsis Acute mental status changes affect sensorimotor function Patient is impaired SLP examines patient Patient performs poorly; diagnoses dysphagia Pulmonary infection now presumed to be ASPIRATION RELATED Association sticks and becomes a permanent part of the record Patient has permanent history of aspiration pneumonia 36 attributed 12

13 Sepsis Assessment considerations Stage of recovery Organs affected Pulmonary damage: alveolar noncompliance, debris from infiltrates ALL Increase respiratory rate Muscle damage weakness, increased respiratory rate Brain damage Cognitive impairments after sepsis Patient endurance Weakness Effects of prolonged mechanical ventilation Depends on what organs suffered what damage Aspiration Pneumonitis (chemical pneumonitis) Non Infectious chemical trauma Acute Lung Injury: caustic or particulate aspiration Inflammation of alveoli by effects of irritants No primary infection Inflammatory edema reduces surface area Gastric contents Sterile, acidic, caustic Damage to airways, alveoli 39 attributed 13

14 ARDS Normal acute resolution Ware & Matthay, Other Respiratory Diseases 41 Categories Obstructive Diseases Inspired air is obstructed from the respiratory membrane Obstructed gas exchange Respiratory pump works Restrictive Diseases Airflow or volume is mechanically restricted Gas exchange is intact Patient cannot inhale sufficient volume 42 attributed 14

15 Respiratory Disease obstructive Obstructive diseases air is obstructed from contact with respiratory membrane Chronic bronchitis Emphysema Reduced oxygen supply Hypoxemia CO2 retention Hypercapnea Acidosis Increased respiratory rate Overlap with swallow obstruction Alveolar membrane destroyed McNaught & Callender, Chronic Obstructive Pulmonary Disease Respiratory membrane surface area is destroyed emphysema Respiratory membrane surface area is obstructed Chronic bronchitis 44 Restrictive Pulmonary Disease Remember: factors that enable ventilation! Restrictive Diseases Limit amount of air that can be inhaled Mechanical Poor compliance Increased rate Reduced tidal volume McNaught & Callender, attributed 15

16 Mechanically restrictive Disable expansion of alveoli Pulmonary non compliance Pulmonary fibrosis Atelectasis Pneumothorax Reduced surfactant production Disable expansion of thoracic cavity Kyphosis Abnormally flexed thoracic spine, compressed thorax Tough, leathery segments tether adjacent segments Paralysis 46 Kyphosis 47 Pneumothorax Perforation of pleural membrane Destroys intrapleural vacuum that holds lung open Subatmospheric pressure Pleural cavity Atmospheric pressure 48 attributed 16

17 Pneumothorax Hellerhoff en:user:clinical Cases 49 Restrictive Pulmonary Disease Atelectasis Areas of collapsed alveoli Compressive, dependent, adhesive, obstructive 50 CHF Both obstructive Pulmonary edema Fluid leaks into alveoli due to pulmonary hypertension Obstructs respiratory membrane diffusion And restrictive components Pleural effusions Fluid surrounds lung, prevents inflation 51 attributed 17

18 Pleural effusion Fluid filling parts of pleural cavity Preventing lung expansion during inspiration Gravity dependent bag of water Pleural cavity 52 Pleural Effusion CHF (transudative), Inflammatory (exudative) 53 Pulmonary vascular congestion Incoming arterial flow obstructed Blood backs up casts shadow on image Pulm. artery Pulm. vein Pulmonary hypertension Obstructed flow 54 attributed 18

19 Pulmonary edema Pulmonary hypertension 55 Pulmonary Edema 56 Iatrogenic causes of respiratory conditions Iatrogenic condition: a disease cause by treatment of another disease Sedation (restrictive) CNS depression Disruption of pleural linkage (restrictive) Cardiothoracic surgery Phrenic nerve injury (restrictive) Cardiothoracic surgery Vagal injury (obstructive: vocal fold paralysis) 57 attributed 19

20 Summary Pulmonary disease affects swallow/breathing coordination Pulmonary disease can cause dysphagia Mainly characterized by disruption of swallowrespiratory coordination Pulmonary disease can be caused by dysphagia Pneumonia and dysphagia are related but not married! 58 Questions? Thank you! 59 attributed 20