Aspiration Pneumonia & Oral Infection Control PDF

11/7/2024 Aspiration Pneumonia & Oral Infection Control CSCD 6306 9 Nov 2024 1 9/11/2024 2 9/11/2024 3 ...

11/7/2024 Aspiration Pneumonia & Oral Infection Control CSCD 6306 9 Nov 2024 1 9/11/2024 2 9/11/2024 3  11/7/2024 What is aspiration? In the context of dysphagia, aspiration means the entry of food, liquid, saliva, nasal secretion or gastric content into the airway below the level of the VF Laryngeal aspiration, pulmonary aspiration used interchangeably 9/11/2024 4 Aspiration Can be followed by overt signs Can be silent (no overt signs) Can occur before, during or after the swallow 9/11/2024 5 Overt Signs of Aspiration Cough Multiple swallows Wheeze Desaturations or apnea Stridor during feeding Frequent throat clearing Wet/gurgly voice Gagging Labored breathing during feeds Nasal regurgitation (Weir et al, 2011) (Weir et al, 2011) 9/11/2024 6  11/7/2024 Overt signs of aspiration in infants Change in respiratory pattern Choking Gagging Change in skin color Change in vocal quality Nasal flaring Apnea with bradycardia Eye watering/eye blinking Cyanosis Frowning Stridor Disorganized activity Coughing 7 Prandial aspiration refers to aspiration that occurs during swallow Events Leading to Aspiration 1. Oropharyngeal dysphagia: prandial aspiration 2. Insufficient management of nasal/oral secretions: antegrade aspiration 3. Esophageal content in congenital malformation (e.g. TEF) 4. Gastroesophageal reflux (GER): post prandial, retrograde aspiration of gastric content (vomit, ingested food, gastric secretion) Events may coexist 9/11/2024 8 Aspiration A cause of or a result from pulmonary disease Aspiration can lead to respiratory disease, irreversible lung damage and death Pathologic changes in the lungs include: degeneration of bronchiolar epithelium, pulmonary edema, acute inflammatory cell infiltrate and fibrosis (Tutor, 2020) 9/11/2024 9  11/7/2024 Aspiration Chronic pulmonary aspiration can lead to recurrent wheezing, recurrent pneumonias, pulmonary scarring, empyema, bronchiectasis, and severe impairment of pulmonary function (Tutor, 2020) Children with a Hx of early lower respiratory illnesses (LRIs) have diminished lung function that can persist to adulthood (Chan et al, 2015) 9/11/2024 10 What is pneumonia? Acute infection of the lung tissue 9/11/2024 11 Pneumonias Aspiration pneumonia (AP) Community acquired pneumonia (CAP) Hospital acquired pneumonia (HAP) Pneumonitis Ventilator-Associated Pneumonia (VAP) 9/11/2024 12  11/7/2024 Pneumonia: The lung microbiome The stability of the lung microbiome is probably maintained by a balance of immigration and elimination of bacteria and by feedback loops. Immigration involves bacterial movement from the oropharynx to the lung primarily by means of microaspiration, and elimination mainly occurs through ciliary clearance and coughing. 9/11/2024 13 Irritant Inflammation  Infection An inflammatory event may lead to epithelial and endothelial injury, creating a signal that can promote inflammation, disrupt bacterial homeostasis, and increase susceptibility to infection. 9/11/2024 14 A macroaspiration event, particularly in a patient with risk factors for impaired bacterial elimination could then overwhelm the elimination side of the immigration–elimination balance, further disrupting bacterial homeostasis and triggering signals leading to acute infection 9/11/2024 15  11/7/2024 Virulence The relative capacity of a microorganism to cause damage to a host. Infection is not simply the result of bacterial replication or of bacterial gene products; it is also a consequence of the host response, resultant inflammation, and tissue damage. Mandell et al, 2019 9/11/2024 16 Where can bacteria colonize? Various sites in the human oral cavity, e.g. the gingiva, dental plaque, and tongue Pathogenic bacteria, including gram-negative species that are not seen in the normal host: seen in the elderly, patients in nursing homes or hospitals, those with nasogastric & gastric tubes, those with acute illness 9/11/2024 17 Dental Issues in G-Tube (GT) Special Need (SN) Children (Jawadi et al, 2004) Compared 2 groups of SN children w/ & w/out GT (total 54) Matched in age, gender, major Med Dx, 1 type of Meds (CNS) GT group more likely to: Pneumonia, vomiting, constipation, dysphagia, 3 additional meds https://dental.tufts.edu (respiratory & GI) 9/11/2024 18  11/7/2024 Results (Jawadi et al, 2004) More dental issues in GT More of one AP-associated organism in GT group despite similar oral hygiene behaviors Significantly higher calculus score in GT w/AP compared w/ controls Drosenbach. Wikipedia. GT Calculus AP? 9/11/2024 19 Aspiration pneumonia vs Aspiration pneumonitis Aspiration Pneumonia Chemical Pneumonitis A noninfectious, inflammatory response of the airways and pulmonary parenchyma to acidic Aspiration pneumonia is an gastric contents or bile acid infection caused by specific oral microorganisms Only if aspirated large volume Characterized by a sudden onset of dyspnea, hypoxemia, tachycardia, and diffuse wheezes or crackles on examination 9/11/2024 20 Predisposing factors to develop Aspiration Pneumonia Mandell et al, 2019, Pg. 653 9/11/2024 21  11/7/2024 Clinical Features Aspiration pneumonia is usually acute, with symptoms developing within hours to a few days after a sentinel event Aspiration pneumonia is associated with higher mortality than other forms of pneumonia Neither chemical pneumonitis nor aspiration pneumonia occurs with tube feedings or aspirated blood, since the aspirate pH is usually high and uncontaminated by bacteria 9/11/2024 22 Clinical Features These radiographic findings include infiltrates in gravity- dependent lung segments (superior lower-lobe or posterior https://www.wikidoc.org/index. upper-lobe segments, if the php/Aspiration_pneumonia_x- patient is in a supine) ray A chest radiograph may be negative early in the course of aspiration pneumonia. 9/11/2024 23 Diagnosing Aspiration Pneumonia (Kim, 2018) Depends on the presence of both subjective and objective signs/symptoms: Subjective symptoms: fever, cough, and sputum production Objective signs: coarse lung sounds, presence of lung infiltration on chest X-ray, systemic inflammation based on laboratory findings such as white blood cell counts and C- reactive protein levels, lung-lavage cultures 9/11/2024 24  11/7/2024 Prevention of Aspiration Pneumonia Swallowing therapy Oral hygiene Mandell et al, 2019, Pg 659 9/11/2024 25 Respiratory Factors Associated with Aspiration Steele & Cichero (2014) 9/11/2024 26 Respiratory Factors Associated with Aspiration Abnormalities in respiratory rate and oxygen saturation Inconsistency in swallow-respiratory pattern between two swallows 9/11/2024 27  11/7/2024 Tongue Factors Associated with Aspiration Reduced tongue–palate pressures 9/11/2024 28 Hyoid Factors Associated with Aspiration Reduced hyoid excursion 9/11/2024 29 Laryngeal Factors Associated with Aspiration An absent or diminished laryngeal adductor reflex during Flexible Endoscopic Examination of Swallowing with Sensory Testing (FEEST) Impaired laryngeal sensation in combination with reduced pharyngeal contraction on a pharyngeal squeeze maneuver Reduced movement of the larynx Reduced duration of laryngeal closure in combination with delayed swallow response and prolonged pharyngeal transit time 9/11/2024 30  11/7/2024 Prevention of aspiration pneumonia (AP) with oral care Tada & Miura (2012) 9/11/2024 31 Predictors of Aspiration Pneumonia: How Important Is Dysphagia? Langmore et al (1998) 9/11/2024 32 Questions What are the predictors for Aspiration Pneumonia in the elderly? Is dysphagia sufficient to predict aspiration pneumonia? 9/11/2024 33  11/7/2024 References Ashford, J. R. (n.d.). Three Pillars of Pneumonia. Retrieved October 31, 2020, from https://www.sasspllc.com/three-pillars-pneumonia/. Kim, G., Sung, I., Ko, E., Choi, K., & Kim, J. (2018) Comparison of videofluoroscopic swallowing study and radionuclide salivagram for aspiration pneumonia in children with swallowing difficulty. Ann Rehabil Med, 42 (1):52-58. Jawadi, A., Casamassimo, P., Griffen, A. Enrile, B., Marcone, M. (2004). Comparison of oral findings in special needs children with and without gastrostomy. Pediatr Dent, 26 (3):283-8. Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298–307. https://doi.org/10.1007/s00455-002-0072-5 Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia?. Dysphagia, 13(2), 69-81. https://doi.org/10.1007/pl00009559 9/11/2024 34 References Mandell, L. A., & Niederman, M. S. (2019). Aspiration Pneumonia. NEJM, 380 (7), 651–663. doi:10.1056/nejmra1714562 Steele, C. & Cicher, J. (2014) Physiological factors related to aspiration risk: A systematic review. Dysphagia, 29:295–304. doi: 10.1007/s00455-014- 9516-y Tada, A., & Miura, H. (2012). Prevention of aspiration pneumonia (AP) with oral care. Archives of Gerontology and Geriatrics, 55(1), 16–21. doi:10.1016/j.archger.2011.06.029 Tutor, J. (2020) Dysphagia and chronic pulmonary aspiration in children. Pediatrics in Review, 41 (5): 236-244. DOI: 10.1542/pir.2018-0124 Weir, K. , McMahon, S, Taylor, S., & Chang, A. (2011) Oropharyngeal aspiration and silent aspiration in children. CHEST, 140; 589-597. doi: 10.1378/chest.10-1618 9/11/2024 35