[Dysphagia] Re: Pneumonia and pneumonitis

[yorickw at att.net (Yorick)]

Wow, Irene. I have read your posts on the subject several times on this list
and am always extremely impressed with your command of the literature that
is out there! Do you have access to publications that talk about the
economic impact of pneumonia and/or pneumonitis?

Thanks, Yorick

Irene wrote: *** Well, that's the problem. By not paying attention to the
Hx, they miss the signs/symptoms that make it clear that what has occurred
is aspiration of stomach contens - pneumonitis - not bacterial pneumonia.
Even if they do know the difference, they still tend to call it pneumonia as
if the terms were synonymous and they are most decidedly not! This is what
has led to the hysteria over aspiration and the assumption that even alittle
water is aspirated will be lethal PLEASE
read- and send to your docs - these:

http://jnnp.bmjjournals.com/cgi/content/full/64/5/569

http://www.australianprescriber.com/index.php?content=/magazines/vol26no1/14
_17_pneumonia.htm
http://medicine.ucsf.edu/housestaff/handbook/HospH2002_C4.htm#Aspiration
ASPIRATION PNEUMONITIS AND PNEUMONIA
 
1.     The evidence (forget what youve learned!):
7       Aspiration pneumonitis can present with a
fever, infiltrate, cough, elevated WBC.  However, aspiration pneumonitis
does not require treatment with antibiotics initially.  Use the guidelines
below to differentiate from aspiration pneumonia.  Symptoms usually resolve
within 24-48 hours.
7       Aspiration pneumonia is not caused by
anaerobes (for the most part).  Its mostly caused by gram negative rods, so
make sure you cover with a broad spectrum antibiotic.  Dont use
penicillin/clindamycin as this will not cover gram negatives!
7       Percutaneous gastrostomy (PEG) tubes dont
prevent aspiration pneumonia and are not superior to nasogastric (NG) tubes.

  
2.     Aspiration pneumonia: 
7       Patients at risk are those with dysphagia and
gastric dysmotility.
7       Usually affects elderly patients and usually
is not witnessed.  
7       Results from aspiration of colonized
oropharyngeal material and is therefore not sterile. 
7       Pathogens: mainly gram-negative rods and
gram-positive cocci. Rarely due to anaerobic bacteria.
7       Clinically presents as typical pneumonia with
tachypnea, fever, cough.     
 
3.     Aspiration pneumonitis: 
7       Patients at risk are those with a depressed
level of consciousness.
7       Usually affects younger patients who are
intoxicated, sedated, or have head injury/pathology and is usually
witnessed.
7       Results from aspiration of sterile gastric
contents; acute lung injury results from acitidy and particulate material
and not bacteria though superinfection later is always possible.
7       Clnically can present with no symptoms, mild
symptoms, or severe acute lung injury or ARDS with
hypotension.   
 
4.     Management: 
7       Suction the upper airway after a witnessed
aspiration event and if the patient cant protect airway, intubate.
7       Dont blindly use prophylactic antibiotics for
aspiration pneumonitis (this will simply select for more resistant bugs
causing superinfection).
7       Aspiration pneumonitis:
-        If symptoms > 48 hours: treat with
levofloxacin or ceftriaxone.
-        If the patient is at risk for colonization of
gastric contents (small bowel obstruction or on antacid therapy): use
ceftriaxone, zosyn, or ceftazidime.
7       Aspiration pneumonia:
-        Community acquired: levofloxacin or
ceftriaxone.
-        Residence in long term care facility: zosyn
or ceftazidime.
-        Severe periodontal disease, putrid sputum,
alcoholism, CXR with lung abscess: treat for anaerobes with zosyn, imipenem,
or 2 drug therapy (levofloxacin or ceftriaxone plus clindamycin or
metronidazole).
 
 
Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med
2001; 344:665-71.
http://www.google.ca/search?q=cache:widTEmVB1xIJ:scalpel.stanford.edu/articl
es/aspiration--NEJM.pdf+Marik+PE++aspiration+&hl=en
 

http://www.postgradmed.com/issues/2003/03_03/j_johnson.htm

http://www.emedicine.com/ped/topic2622.htm
http://www.google.ca/search?q=cache:cHuI3KRQ5mAJ:www.healthsystem.virginia.e
du/internet/digestive-health/Apr03OpillaArticle.pdf+Marik+PE++aspiration+&hl
=en