Professional Documents
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Management of Aspiration
Pneumonia
Renee (Pik Shan) Fung
Dietetic Intern
ARAMARK Healthcare
Distance Learning Dietetic Internship
Maple Grove Hospital
Disease Description
Definitions
Aspiration- the inhalation of oropharyngeal
or gastric contents into the larynx and lower
respiratory tract
Aspiration Pneumonitis- Chemical injury
caused by the inhalation of sterile gastric
contents
Aspiration Pneumonia- Infectious process
caused by the inhalation of oropharyngeal
secretions that are colonized by pathogenic
bacteria
Aspiration
Aspiration can cause serious illnesses and even
death.
Four common problems of aspiration:
1. Failure to distinguish aspiration pneumonitis from
aspiration pneumonia
2. Tendency to consider all pulmonary complications
of aspiration as infectious
3. The failure to identify the spectrum of pathogens in
patients with infectious complications
4. Misconception that aspiration must be witnessed
for it to be dx.
Etiology
Half of all healthy adults aspirate.
The human body is capable of removing
foreign objects by coughing
Individuals who have problem with removing
foreign objects properly are at risk of
developing aspiration pneumonia/
pneumonitis
Pathophysiology
Common cause of aspiration pneumonia is
the inhalation of Haemophilus influenza and
Streptococcus Pneumonia.
They are colonized in the nasopharynx or
oropharynex before they are aspirated.
Pathophysiology
Since aspiration pneumonitis is the
inhalation of sterile gastric contents,
bacterial infection does not play an
important role at early stage.
At a later stage of aspiration pneumonitis,
bacterial colonization may occur if the
individual has gastroparesis, small-bowel
obstruction, receives enteral feedings, or has
higher pH gastric acids. In this case, the
individual has aspiration pneumonia.
Aspiration Pneumonia
Diagnosis
Signs/symptoms: (signs of aspiration)
Persistent cough and fever. However, many
times silent aspiration can develop. In
aspiration pneumonia, the episode of
aspiration is generally not witnessed.
Swallowing evaluation by an SLP
CT scan- radiographic evidence of foreign
material infiltrating in patients lungs (some
may be undetectable)
Co-morbidity
Increased LOS
Increased cost
Increased morbidity and mortality
CT scan
Participants:
128 Bedridden PEG participants
Age: Average 80 years old
Gender: 60 of the participants were male.
Method:
60 subjects were assigned to elemental diet group
67 subjects were assigned to the standard liquid diet
group.
Record subjects who experienced aspiration and
aspiration pneumonia
Result:
The number of patients who had diet
aspirated from the trachea or who developed
new aspiration pneumonias in the elemental
group was significantly less than the
standard liquid diet group.
Result:
Elemental diets were associated with more
rapid gastric empting.
Possibly due to:
Fatty diet takes longer time to empty and is
associated with gastroesophageal
regurgitation. Standard liquid diet has higher
fat content than elemental diet.
Limitation:
Study 1 had increased risk of bias because it
was neither randomized nor blinded
Study 2 could not prove the hypothesis by itself
Participants in study 1 included those who had
pervious experience of aspiration which
suggested that they can be generalized.
Study 2 might have carry-over issues between
treatments.
Jiyoung J, et al (2013) - Effect of gastric versus postpyloric feeding on the incidence of pneumonia in
critically ill patients: observations from traditional
and Bayesian random-effects meta-analysis.
Result:
The incidences of pneumonia were 16.3% in the postpyloric feeding group and 26.1% in the gastric feeding
group (P = 0.001).
There was no significant differences in the beneficial
effect of the post-pyloric feed location (duodenum
(P=0.03) versus jejunum (P= 0.07).
there was no significant difference between post-pyloric
feeding group and gastric feeding group in the amount of
aspiration (P= 0.55) and vomiting (P = 0.56) incidence.
Limitation
Not all outcomes in the selected studies were reported.
Many of the studies were not good qualities.
For example, potential biases may exist in the selected
studies, clinical heterogeneity in the studies that may
account for the statistical heterogeneity that were found in
this study which could have affected the result, and not all
studies reported adequate concealment, blinding of
participants, and outcome assessment.
Case Presentation
Case Presentation
58 yrs old F
Lives at group home
Aspiration noted by group home manager.
Patient had continuous coughing and
developed a fever. Patient was admitted to
the ER the next day
DNR status
Lab Results
Component Valu Nor Date
Rationale
e
mal
SODIUM
M mg/dL
CHLORIDE 106
mEq/L
CALCIUMSE 7.6*
RUM mg/dL
BUNUREAN 19*
RO
CREATININE 1.15
mg/dL
3
95- 9/27/2013 Check for fluid/ acid-base imbalances
105
9-11 9/27/2013 Low serum calcium; Corrected Ca: 8.4*
9/27/2013 Malnutrition
Short-term goal:
(Achieved) Short-term goal: Maximize nutrient intake:
Patient receives more than 75% of recommended
nutritional needs via PO or nutrition support.
(Not Achieved) Patient maintain current weight.
Long-term goal:
(Not Achieved) Patient will be able to meet more than
75% of recommended nutritional needs via PO intake or
long-term tube placement in place for feeding.
(Not Achieved) Patient reduces aspiration incidence.
Evidence-based recommendation
implemented on this case
30-45 degrees head of bed position
Enteral nutrition support to decrease risk of
aspiration
Jejunal feeds rather than gastric feeds
Elemental formula was used
Conclusion
The current recommendation for Aspiration
Pneumonia care is to feed patients who are receiving
tube feeding in a 30-45 degree elevation of head of
bed position. Promotility agents are also encouraged
to use. There are controversial in whether or not
jejunal feeding is more beneficial over gastric feeding;
More research need to be done to confirm this finding.
Further more, research suggest that elemental
formula may be a better choice than standard
formula, however, elemental formulas are more
expensive and many insurance do not cover it.
References
1. Horiuchi A, Nakayama Y, Sakai R, Suzuki M, Kajiyama M, Tanaka N. Elemental diets
may reduce the risk of aspiration pneumonia in bedridden gastrostomy-fed
patients. Am J Gastroenterol. 2013; 108: 804-810.
2. Jiyong J, Tiancha H, Huiqin W, Jingfen J. Effect of gastric versus post-pyloric feeding
on the incidence of pneumonia in critically ill patients: observations from traditional
and Bayesian random-effects meta-analysis. Clin Nutr. 2013; 32: 8-15.
3. Echevarria IM, Schwoebel A. Development of an intervention model for the
prevention of aspiration pneumonia in high-risk patients on a medical-surgical unit.
Medsurg Nurs.2012; 21 (5): 303-308.
4. Marik P. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;
344(9): 665-671.
5. Komiya K, Ishii H, Umeji K, et al. Impact of aspiration pneumonia in patients with
community-acquired pneumonia and healthcare-associated pneumonia: A
multicenter retrospective cohort study. Respirology.2013; 18 :514-521.
6. Garcia J, CCC, Chambers E. Managing dysphagia through diet modifications. Am J
Nurs. 2010; 110(11): 26-33
7. Recommendations Summary CIU: Optimizing Enteral Nutrition Delivery. Academy of
Nutrition and Dietetics Evidence Analysis Library Web site.
http://andevidencelibrary.com/template.cfm?key=3256.Accessed December 14,
2013
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