Bankstown Hospital - Grand Rounds - Further Reading

Welcome to the Grand Rounds Further Reading List, Respiratory edition, brought to you by the Clinical Library, on Level 4, next to the Auditorium.

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Byun, S.-E., et al. (2019). "Risk factors and prognostic implications of aspiration pneumonia in older hip fracture patients: A multicenter retrospective analysis." Geriatrics & Gerontology International 19(2): 119-123  https://onlinelibrary.wiley.com/doi/abs/10.1111/ggi.13559

    Aim The present study aimed to investigate the risk factors and prognostic implications of aspiration pneumonia in older hip fracture patients. Methods A total of 394 female and 125 male hip fracture patients aged ≥60 years who underwent surgery between 2015 and 2018 were retrospectively analyzed. To identify risk factors of aspiration pneumonia, demographic factors, the American Society of Anesthesiologists classification, past medical history, known risk factors of aspiration and factors associated with surgery were compared between the aspiration pneumonia group and the control group. Regression analysis was also carried out. To assess the prognostic implications of aspiration pneumonia, hospital stay, frequency of the intensive care unit admission and in-hospital mortality rates were compared between groups. Results Aspiration pneumonia was diagnosed in 8.8% of the hip fracture patients. Increased age, low body mass index, malnutrition, longer duration of surgery and delayed surgery were identified as risk factors of aspiration pneumonia. Regarding prognostic implications, hospital stay, the frequency of intensive care unit care and in-hospital mortality rates were significantly higher in the aspiration pneumonia group (P < 0.001, <0.001 and 0.001, respectively). Conclusions Older hip fracture patients with aspiration pneumonia showed worse prognostic outcome compared with patients without aspiration pneumonia. Longer duration of surgery and delayed surgery, as well as patient characteristics including increased age, low body mass index and malnutrition were identified as risk factors for aspiration pneumonia. Therefore, surgeons should try to reduce the operation time and the time interval between injury and surgery when treating older patients for hip fractures. Geriatr Gerontol Int 2019; 19: 119–123.

Finegold, S. M. (1991). "Aspiration Pneumonia." Reviews of Infectious Diseases 13(Supplement_9): S737-S742  https://doi.org/10.1093/clinids/13.Supplement_9.S737 
    The primary problems that predispose to aspiration pneumonia include a reduced level of consciousness, dysphagia, periodontal disease, and mechanical interference that is related to the insertion of various tubes into the respiratory or gastrointestinal tracts. The bacterial flora involved include the indigenous oral flora (among which anaerobes predominate) and, in the hospital or a similar setting, nosocomially acquired pathogens such as Staphylococcus aureus and various aerobic and facultative gram-negative bacilli that may colonize patients. Specific etiologic diagnosis is difficult. The most useful materials for reliable anaerobic and aerobic culture are pleural fluid, transtracheal aspirates, and secretions obtained with a protected bronchial brush and during bronchoalveolar lavage. Special care must be taken to avoid normal and colonizing flora and to keep anaerobes viable. Aside from the drainage of empyemas, the primary therapy for aspiration pneumonia involves antimicrobial agents. A number of options are available; the most appropriate mode of therapy depends on the nature of the infecting flora and the severity of the illness.

Makhnevich, A., et al. (2019). "Aspiration Pneumonia in Older Adults." Journal of Hospital Medicine 14(7): 429-435  https://shmpublications.onlinelibrary.wiley.com/doi/abs/10.12788/jhm.3154 
    Aspiration pneumonia refers to an infection of the lung parenchyma in an individual that has inhaled a bolus of endogenous flora that overwhelms the natural defenses of the respiratory system. While there are not universally agreed upon criteria, the diagnosis can be made in patients with the appropriate risk factors and clinical scenario, in addition to a radiographic or an ultrasonographic image of pneumonia in the typical dependent lung segment. Treatment options for aspiration pneumonia vary based on the site of acquisition (community-acquired aspiration pneumonia [CAAP] versus healthcare-associated aspiration pneumonia [HCAAP]), the risk for multidrug-resistant (MDR) organisms, and severity of illness. Hospitalized CAAP patients without severe illness and with no risk for MDR organisms or Pseudomonas aeruginosa (PA) can be treated with standard inpatient community-acquired pneumonia therapy covering anaerobes. Patients with CAAP and either of the following—risk factors for MDR pathogens, septic shock, need for an intensive care unit (ICU) admission, or mechanical ventilation—can be considered for broader coverage against anaerobes, methicillin-resistant Staphylococcus aureus (MRSA), and PA. Severe aspiration pneumonia that originates in a long-term care facility or HCAAP with one or more risk factors for MDR organisms should be considered for similar treatment. HCAAP with one or more risk factors for MDR organisms or PA, plus septic shock, need for ICU admission or mechanical ventilation should receive double coverage for PA in addition to coverage for MRSA and anaerobes. Multiple gaps in current understanding and management of aspiration pneumonia require future research, with a particular focus on antibiotic stewardship.

Mandell, L. A. and M. S. Niederman (2019). "Aspiration Pneumonia." New England Journal of Medicine 380(7): 651-663  https://www.nejm.org/doi/full/10.1056/NEJMra1714562

Teramoto, S. (2022). "The current definition, epidemiology, animal models and a novel therapeutic strategy for aspiration pneumonia." Respiratory Investigation 60(1): 45-55  https://www.sciencedirect.com/science/article/pii/S2212534521001805 
    In the 21st century, aspiration pneumonia (ASP) is very common in older patients, and has a high mortality rate. ASP is diagnosed following confirmation of inflammatory findings in the lungs and overt aspiration or the existence of dysphagia. It is dominant in hospitalized community-acquired pneumonia (CAP), nursing and healthcare-associated pneumonia (NHCAP), and hospital-acquired pneumonia (HAP). The incidence of ASP is increasing every year. The human and experimental animal data revealed that micro-aspiration due to dysphagia during the night is the central mechanism of ASP. Therefore, the precise assessment of swallowing function is the key to diagnose ASP. From a therapeutic point of view, an appropriate administration of antibiotics, as well as a comprehensive approach for dysphagia plays a pivotal role in the prognosis and recovery from ASP. The non-pharmacologic approach, including swallowing rehabilitation and oral care, and a pharmacologic approach including ACE inhibitors and bronchodilators, are essential modalities for treatment and prevention of ASP. The clinical data of NHCAP provides us with a promising treatment strategy for ASP.

Therapeutic Guidelines -  Respiratory.

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BMJ Best Practice. Available via CIAP (login required for home use).