Aspiration pneumonia in older people

Transcription

1 Aspiration pneumonia in older people Ayman Morish, M.D. Internal medicine, Critical care Medicine and Geriatrics Fellow.

2 Contents Epidemiology Causes of aspiration pneumonia Issues of older age Management Prevention

3 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.

4 P/E VITALS: tachycardia 121, others unremarkable. Abd: + BS, soft, non-tender, no masses. CVS: S1+S2, Irregularly irregular, holo-systolic murmur. No JVD. Neuro: AAOX3, grossly intact, able to move UE and LE Chest: reduced air entry, no wheezing or crackles. Extremity: No pitting edema, normal pulses.

5 Lab and Imagining WBC 6.93 Na 138 K 3.9 BUN 19 Creat 2.9 BNP 2687 CXR: Left LL infiltrate / atelectasis. Hyperinflated lung suggesting COPD.

6 What do you think is going on? Hold your thoughts for now..

7 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.

8 P/E VITALS: stable Chest: b/l crackles, left>right Gen: cachectic and ill appearing Abd: + BS, soft, non-tender, no rigidity Mouth: dry oral mucosa CVS: S1+S2, Irregularly irregular, 3/6 murmur in the mitral area. Neuro: AAOX3, No gross motor or sensory deficit Extremities: pitting edema, normal pulses.

9 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.

10 What do you think is going on? Hold your thoughts for now..

11 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

12 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 pneumonia 1.1 /1000 young adults 12 /1000 old adults 32 /1000 nursing home residents

13 Epidemiology: cont.. Rate of bacteremia: 1/1000 between age /1000 at age > 75 Rate of nosocomial pneumonia: <2/1000 between /1000 at age > 70 *Kaplan et al. Arch Intern Med 163:317, 2003, ** Johnstone et al. Medicine 87: 329, 2008

14 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

15 Bacteriology: cont... CAP Young adult S. pneumoniae; Mycoplasma; Chlamydia Older adult S. pneumoniae; H. influenza; Chlamydia; S. aureus; Gram-negative rods

16 Bacteriology: cont... NH S. pneumoniae Gram-negative rods S. Aureus Aspiration Pneumonia Same as NH with anaerobes it was isolated from patients with longstanding processes such as lung abscess; and it is unclear what role they play in early infection

17 Work up:

18 Indications for extensive workup

19 Diagnosis: new hypoxemia pulmonary infiltrates on imaging, particularly in gravitydependent lung regions on chest imaging posterior-segments of the upper lobes, basilar segments of the lower lobes fever leukocytosis tachypnea

20 Limitations: Diagnosis is made in <50% of cases Insufficient sample. Gram-negative pathogens and Staph aureus are common. Strep pneumoniae remains the most common pathogen.

21 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 position Gastroparesis and high residual gastric volumes Aspirations: 71% of patients with CAP compared to 10% in controls

22 Healthy aging and the swallow Older people swallow more slowly Laryngeal closure is delayed Upper oesophageal sphincter opening delayed Oral bolus transport time prolonged Safety of oropharyngeal swallowing is not compromised There is no increase in aspiration comparing to younger adults in radiographic studies

23 Dysphagia 50% of acute stroke patients have clinical dysphagia Most (80%) resolve in the first 7-10 days Associated with big strokes and aphasia Dementia Parkinson disease Multiple sclerosis Mann et al, Stroke 1999; 30:744

24 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 Dysphasia Delirium Dementia Increased oral vulnerability Dysphagia Nil by mouth (NPO) Drugs (PPI and antih2) Nutritional status

25 Back to our patients Did they meet the criteria for diagnosis of aspiration pneumonia? What are their risk factors

26 First case was treated with Unasyn (Ampicillin / Sulbactam) Second case treated with ceftriaxone

27 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 contents 2. Aspiration pneumonitis that fails to resolve within 48 hrs 3. Unstable patient with witnessed aspiration

28 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 amoxicillinclavulanate acid) Alternative β-lactams: ceftriaxone, cefpodoxime or cefuroxime. Alternative to a Macrolide: doxycycline. Amoxicillin-clavulanate acid if need anaerobic bacterial coverage.

29 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/ßlactamase 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.

30 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 bpm Respiratory rate 225/min SBP 00 mmhg 02 saturation <90% or Pa02 mmhg Ability to maintain oral intake abnormal mental status

31 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 d

32 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.

33 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 frequently Modified diet / thickened fluids / food supplements

34 Swallowing assessment after a stroke: Routine assessment Look in the mouth! No impaired consciousness Water swallow test Bedside swallow assessment Selected patients Nasoscope Modified Barium swallow (video-fluoroscopy)

35 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

36 Thank you