Aspiration pneumonia

aspitration pneumonia

1. ASPIRATION PNEUMONIA Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019 DR ANKIT GAJJAR

2. INTRODUCTION Aspiration pneumonia is an infection caused by specific microorganisms Chemical pneumonitis – an inflamatory reaction to irritative gastric contents Aspiration pneumonia – 5-15% of CAP Large volume aspiration of Colonized oropharyngeal & Upper GI contents is must Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

3. Microbiologic & Pathogenic concept Role of lung microbiome Concept of Immigration & elimination Any illness lead to change in lung microbiota ( dysbiosis ) Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

4. Microbiologic & Pathogenic concept Previously, anaerobes were more common than aerobes But nowadays, aerobes are more common in both CAP & HAP, anaerobes are recovered less frequently Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

5. CLINICAL FEATURES ASPIRATION PNEUMONIA CHEMICAL PNEUMONIA ONSET Hours to days Minutes to hours SYMPTOMS Fever, Cough, Shock Dyspnea , hypoxia, tachycardia, diffuse wheeze… Abn CXR, ARDS GASTRIC CONTENT Micro / Macroaspiration Ph <2.5, >0.3 ml/kg ( Macroaspiration ) Treatment Antibiotic Supportive Antibiotic may be for secondary pneumonia Steroids No role No role Outcome poor Good - Effects of PPI on Aspiration Pneumonia Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

6. DIAGNOSIS Clinical history, risk factors & CXR CXR is must CT Scan may be required PCT not helpful ET C/S should be sent in all patients

7. TREATMENT Change in pathogens from anaerobes to aerobes Anaerobes are common in lung abscess, necrotizing pneumonia & severe periodontal disease For anaerobes, clindamycin is better than metronidazole Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

8. TREATMENT Antibiotic selection depends on CAP, HAP or pt in long term care facility CAP – Ampicilin-sulbactem or - Carbapenem ( ertapenem ) or - FQ’s – Levo or Moxi Clinda if risk of anaerobic infection Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

9. TREATMENT HAP – Piperacillin-tazobactam - Cefepime - Carbapenem (except Ertapenem ) If risk of MDR is high - Aminogycoside / colistin ± vancomycin /linezolid

10. TREATMENT DURATION - 5-7 days if good clinical response - 10-14 days if lung abscess, necrotizing pneumonia or empyema No role of steroids Treatment can be modified or discontinued after culture reports Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

11. TREATMENT CHEMICAL PNEUMONITIS Initial ABC management No role of steroids or antibiotics Indication of Antibiotics - If pt is taking Acid suppressing medicines - If p t has small bowel obstruction - If pt is very serious Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

12. Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

13. PREVENTION Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

14. PREVENTION Antibiotics in emergency intubation - only 2 studies - ceftriaxone/cefuroxime 2 doses - does not affect late onset pneumonia Role of ACE inhibitors & Cilostazol Role of oral care with chlorhexidine Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

15. PREVENTION Stroke patients - Early mobilisation & swallowing exercise - Trial of soft diet - RTF in semirecumbent position - Post pyloric RT & monitoring of RT aspiration of gastric residual not effective Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

16. CONCLUSIONS Preventive measures in high risk patients Difficult to differentiate with CAP / HAP Diagnostic approach should be based on clinical findings, risk factors & radio imaging Treatment should be based on risk factors No role of steroids Lionel A Mandell , Michael Niederman NEJM 380;7 FEB 14, 2019

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