[Dysphagia] Re: how much water?

[eripley at yahoo.com (Irene Campbell-Taylor)]

There seems to be continuing confusion over the etiology and nature of pneumonias. May I suggest reading the following:

 

 

 

 

NEJM Volume 344:665-671



March 1, 2001



Number 9




 





Aspiration Pneumonitis and Aspiration Pneumonia

Paul E. Marik,

AND

Medscape Respiratory Care

Aspiration Pneumonia: Current Concepts and Approach to Management

Author: Hugh A. Cassiere, MD, Winthrop University Hospital

 

 Abstract

Aspiration of pathogens from a previously colonized oropharynx is the primary route by which organisms gain entrance to the lungs. Like other respiratory tract infections, aspiration pneumonia most commonly manifests in patients with underlying disease that predisposes to host defense impairment. Conditions which compromise host immunity to aspirates include diabetes mellitus, congestive heart failure, COPD, malnutrition, renal failure, and malignancy. The clinical response to aspirated material is dependent on the interplay between the characteristics of the aspirate and those of the host. (In other words, What, How much, Over how long and How good is the patient?s defense system?)

AND

 

Tomás Franquet, MD, Ana Giménez, MD, Nuria Rosón, MD, Sofía Torrubia, MD, José M. Sabaté, MD and Carmen Pérez, MD Aspiration Diseases: Findings, Pitfalls, and Differential Diagnosis Radiographics. 2000;20:673-685

The aspiration of different substances into the airways and lungs may cause a variety of pulmonary complications. These disease entities most commonly involve the posterior segment of the upper lobes and the superior segment of the lower lobes. Esophagography and computed tomography (CT) are especially useful in the evaluation of aspiration disease related to tracheoesophageal or tracheopulmonary fistula. Foreign body aspiration typically occurs in children and manifests as obstructive lobar or segmental overinflation or atelectasis. An extensive, patchy bronchopneumonic pattern may be observed in patients following massive aspiration of gastric acid or water. CT is the modality of choice in establishing the diagnosis of exogenous lipoid pneumonia, which can result from aspiration of hydrocarbons or of mineral oil or a related substance. Aspiration of infectious material manifests as necrotizing consolidation and abscess formation. The relatively low diagnostic accuracy of chest
 radiography in aspiration diseases can be improved with CT and by being familiar with the clinical settings in which specific complications are likely to occur. Recognition of the varied clinical and radiologic manifestations of these disease entities is imperative for prompt, accurate diagnosis, resulting in decreased morbidity and mortality rates. In this article, we discuss and illustrate the spectrum of radiologic manifestations, diagnostic pitfalls, and differential diagnoses associated with a variety of aspiration diseases. These include diseases associated with tracheoesophageal or tracheopulmonary fistula; diseases caused by aspiration of foreign bodies, liquids, or infectious material; and other aspiration diseases (lentil aspiration pneumonia, aspiration bronchiolitis, obliterative bronchiolitis).

 Aspiration of Liquids
Gastric Acid Aspiration (Mendelson Syndrome)
Vomiting with massive aspiration of gastric contents is a very frequent phenomenon and is probably one of the most common causes of aspiration diseases

Near Drowning
The acute aspiration of massive amounts of water produces a pulmonary edema that is radiographically indistinguishable from pulmonary edema from other causes (18,19). The clinical significance of near drowning depends more on the volume of water aspirated than on whether the aspirate is fresh water or salt water Pneumonia may be a complication of the aspiration of either fresh or salt water, and, depending on the water source, may be caused by a variety of microorganisms including bacteria, fungi, and mycobacteria.

Barium Aspiration
The aspiration of barium is a well-recognized complication that occurs during imaging of the gastrointestinal tract (24). Several factors may predispose to barium aspiration, including swallowing disorders and recent esophageal surgery. As with massive aspiration of gastric acid, the overall mortality rate associated with massive barium aspiration is approximately 30% and exceeds 50% in patients with initial shock or apnea, secondary pneumonia, or adult respiratory distress syndrome.

(Please note that the aspiration must be massive and in an already debilitated patient. What happens to all of the thousands of patients who have aspirated small amounts of bariunm during VFSS ? Do they get sick? Not in my experience.)

Periodontal Disease
The oral cavity is densely populated by site-specific flora. Patients with advanced periodontal disease are at particular risk for the development of aspiration pneumonitis


Chris and Claire Langdon <chris_claire@bigpond.com> wrote:Below are some other diagnostic criteria for aspiration pneumonia used in
studies in the literature - lots of differences, but, also, used on
different populations - ie. Giselle Mann's study was acute stroke, Susan
Langmore's was male veterans.

Diagnostic Criteria

Respiratory difficulty, moist rales on auscultation plus 2 of the
following: (Johnson 1993)

1.. Temperature above 100 ºF
2.. White blood cell count > 10,000
3.. Evidence of hypoxia

Three or more of the following signs: (De Pippo, 1994)

1.. Sustained febrile illness > 100 oF
2.. Presence of rales or rhonchi on chest auscultation
3.. Drop in arterial PO2 > 10 Torr compared with baseline values
4.. Sputum Gram's stain showing significant number of leucocytes
5.. Sputum culture showing respiratory pathogens
Three or more of the following signs: (Ding and Logemann 2000)


1.. Fever
2.. Positive ausculatory findings on chest examination
3.. Productive cough
4.. PaO2 below 70mmHg or a 10mmHg decrease from the patient's
baseline
5.. Purulent sputum
6.. Gram stain or pathogen isolated from sputum culture
7.. Positive chest x-ray.


All three criteria must be present: (Langmore 1998)


1.. Elevated white blood cell count (12,000 or above)
2.. Fever: temperature above 100.5 oF
3.. New infiltrate on chest x-ray.

Respiratory crackles with one of the following: (Evans, 2001)

1.. Purulent sputum,
2.. Pyrexia,
3.. Leucocytosis
4.. Positive chest radiograph



1.. Positive blood or pleural cultures for the same microorganism
identified in the tracheal aspirate (Moore, 2002)
2.. New or progressive pulmonary infiltrate
3.. Fever (> 38º C)
4.. Leucocytosis (> 10,000/mm3 )
5.. Gram stained sputum samples with > 10 polymorphonuclear cells
per high power field and
6.. No other source of infection but the lungs




----- Original Message -----
From: "Jai Gupta" 
To: "Irene Campbell-Taylor" ; 
Sent: Tuesday, March 15, 2005 10:09 AM
Subject: RE: [Dysphagia] Re: how much water?



Hi, I am aware of that literature referred to, so am I aware of literature
on hydration. Fundamental question is how much one should drink and in
reality what is happening? I am not aware if this simple research question?
.... I am just illustrating what is happening in real world ...these are
interview and observation from real world .... and I disagree...any of them
were diagnosed as dehydrated ...they live like that of years ...another
interesting case ..I have met a lady who was 92 yrs and never had water as
far as her memory could go ..she hated the taste of water ....loved light
tea (I know Tea is DIURETIC :-), she is still living and dehydration has
never been an issue with her.... it does not support the research something
is wrong some were?
About diagnosis ...This will help those who seek simple solution to Asp
Pneu... ..as SLP we have to aware of complexities..... and this info helps
me esp with stroke clients .. Identification of Aspiration Pneumonia*
Diagnosis based on three or more of the following variables

§ Fever (> 38° C)

§ Productive cough with purulent sputum

§ Abnormal respiratory examination (tachypnoea > 22 breaths/min,
tachycardia, inspiratory crackles, bronchial breathing)

§ Abnormal chest radiograph

§ Arterial hypoxaemia (PO2<9.3 kPa)

§ Isolation of a relevant pathogen (positive Gram stain or culture)

*Ref: Mann G, Dip PG, Hankey GJ, et al. Swallowing function after stroke.
Stroke 1999;30:744-8


Jai Gupta. M.Sc.(S.H.) CPSP MSPA
Manager, Speech Pathology Services.
The Sutherland Hospital
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email: guptaJ@sesahs.nsw.gov.au
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Webmaster: Evidence Based Practice in Speech Pathology






Dr I Campbell-Taylor
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