Management of Aspiration Pneumonia Dr Leon Lai, Dr TK Wu, Dr

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Management of Aspiration Pneumonia

• Dr Leon Lai, Dr TK Wu, Dr YSK Yeung

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Introduction

• Definition
• inflammation of the lungs and bronchial tubes due
  to breathing in a foreign material, e.g. food,
  stomach content
• CAP, HAP, VAP
• Diagnosis
• History, physical exam, blood count, imaging
• Definitive diagnosis translaryngeal aspiration
• account for 6 to 9 of all cases of
  community-acquired pneumonia in US 1,2
• 1 Rev Infect Dis 198911(4)586-99
• 2 Am J Respir Crit Care Med 1995152(4 Pt
  1)1309-15

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Risk factors

• Decreased level of consciousness
• acute and chronic alcohol abuse
• drug overdose
• stroke
• seizure head trauma
• anesthesia
• Dysphagia
• Vomiting
• Reflux disease

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Risk factors

• Bronchial obstruction due to neoplasm or foreign
  body
• Neurologic disease
• Stroke
• amyotrophic lateral sclerosis
• myasthenia gravis
• multiple sclerosis
• Parkinson's disease
• Iatrogenic
• OGD
• ERCP
• nasogastric feeding tube

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Clinical Approach

• History
• Cough, sputum, SOB, wheeze, fatigue
• Risk factors
• Smoking history
• Physical examination
• Temp, SaO2
• RR, Reduced chest expansion / AE, dull on
  percussion, crackles
• Blood tests
• CBP
• liver functions
• UE
• Microbiology
• Deep cough sputum gram stain, culture,
  sensitivity spectrum
• Sensitivity lt 50
• NPA for virology, sputum for AFP if suspicious
• Radiology
• CXR

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Typical CXR

• Right middle and lower lung lobes are the most
  common sites of infiltrate formation
• Because right main bronchus has larger caliber
  and more vertical

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Multidiscipline Approach

• Speech therapist
• Swallowing test, use of thickener
• Physiotherapist
• Microbiologist
• ENT Surgeon
• FEEST
• Clinicians

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Management option

• Antimicrobial treatment
• Prevention
• Treatment of complications

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Antimicrobial Treatment

• Antibiotic therapy
• prophylactic antibiotics are not recommended
• common organisms
• anaerobic organisms like Bacteroides,
  Peptostreptococcus, and Fusobacterium species
• gram-negative enteric bacilli and Staphylococcus
  aureus in patient receiving taking antacid /
  H2blocker / PPI Chest 198791(6)901-9
• Duration of antibiotic No controlled studies.
  7-10 days
• Adjunctive corticosteroids have no proven value
  in the treatment of aspiration pneumonia and may
  be deleterious 1,2

1 Evaluation of corticosteroid treatment in
aspiration of gastric contents a controlled
clinical trial. Mt Sinai J Med 198047(4)335-40
2 Effects of corticosteroids in the treatment
of patients with gastric aspiration. Am J Med
197763(5)719-22
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Hospitalised CAP

• mild to moderate infection
• Without DRSP risk
• ß-lactam /ß-lactamase inhibitor Macrolide, or
• Fluoroquinolone
• With DRSP risk
• Augmentin/Unasyn Macrolide, or
• Cefotaxime/Ceftriaxone Macrolide
• Severe infection
• Without pseudomonas risk
• Cefotaxime/Ceftriaxone Macrolide, or
• Piperacillin/Tazobactam Macrolide
• With pseudomonas risk
• 2 antipseudomonal agents Macrolide, or
• Fluoroquinolone antipseudomonal agents

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HAP

• early-onset pneumonia (4 days admission), not
  received prior antimicrobial treatment
• 3rd generation cephalosporin OR
• ß-lactam/ß-lactamase inhibitor (Amoxycillinclavula
  nate/Ampicillin-sulbactam)
• early-onset pneumonia (4 days admission),
  received prior antimicrobial treatment or
  late-onset pneumonia (gt4 days admission), not
  received prior antimicrobial treatment
• Antipseudomonal ß-lactam/ß-lactam inhibitor OR
• 3rd generation antipseudomonal cephalosporin OR
• 4th generation cephalosporin
• aminoglycoside OR fluoroquinolone
• late-onset pneumonia (gt4 days admission), and
  received prior antimicrobial treatment
• Antipseudomonal ß-lactam/ß-lactam inhibitor OR
• 3rd generation antipseudomonal cephalosporin OR
• 4th generation cephalosporin OR
• Imipenem/Meropenem
• aminoglycoside OR fluoroquinolone
• ( Vancomycin after careful assessment of
  indication)

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Prevention

• Non-surgical method
• Positioning of patient
• Elevation of the head of the bed
• Feeding patient in the sitting position and not
  placed supine until 1 to 2 hours after meals
• Periodic checking for residual stomach amount
• recommend 100 cc or less as the acceptable
  residual if a gastrostomy tube is used and 200 cc
  if a nasogastric tube is used
• Tube feeding Gastrostomy/jejunostomy
• Thickener

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Prevention

• 2. Surgical method
• Vocal fold medialization thyroplasty /-
  arytenoid adduction
• Tracheoesophageal diversion
• Total laryngectomy

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Medialization thyroplasty

• 1st described by Isshiki in 1974 1
• Indication
• aspiration secondary to unilateral paralysis or
  atrophy of the vocal folds
• Method
• Open method placement of a silastic
  subperichondrial implant to medialize the vocal
  fold
• Endoscopic method injection of varying
  substances to stiffen and/or medialize the vocal
  fold (e.g. Telfon, Gelfoam)

1 Isshiki N, Morita H, Okamura H, Hiramoto M
Thyroplasty as a new phonosurgical technique.
Acta Otolaryngol 1974 Nov-Dec 78(5-6) 451-7
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Medialization thyroplasty
Superior and inferior subplatysmal flaps are then
elevated and the strap muscles are separated in
the midline and retracted laterally to expose the
thyroid cartilage
With the entire thyroid lamina exposed, the
fenestra template is placed with the long axis in
the horizontal dimension. The superior aspect of
the fenestra is at the vocal fold level
approximately 0.8 to 1.0 cm posterior to the
anterior margin of the thyroid cartilage
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A drill is then used with a 3-4 mm cutting bur to
create the window in the thyroid lamina being
careful not to penetrate the inner perichondrium
The inner perichondrium is elevated off the
thyroid lamina using the perichondrium elevator
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A trial instrument is then selected and
introduced into the fenestra by inserting the
large end first in an anterior to posterior
fashion. The trial is then positioned
perpendicular to the fenestra.
Completely retract the knob on the handle of the
implant inserter. Secure the implant into the
inserter. Insert the implant into the fenestra.
Insert the large end first in an anterior to
posterior fashion. Position the implant in the
previously determined optimal position. Push the
knob on the handle of the inserter forward and
release the implant.
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Complications

• Extrusion/Displacement
• Misplacement most often superior
• Infection
• Undercorrection

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Limitation

• Poor closure of posterior glottic gap

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Arytenoid Adduction

• First described by Isshiki with modifications by
  Zeitels and others
• Pulling arytenoid into adducted position

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• N. Isshiki, M. Tanabe and M. Sawada. Arytenoid
  adduction for unilateral vocal cord paralysis.
  Arch Otolaryngol Head Neck Surg
• Vol. 104 No. 10, October 1978
• The arytenoid adduction technique was devised and
  performed under local anesthesia on five patients
  with unilateral vocal cord paralysis
• The muscle process is pulled by two 3-0 nylon
  sutures in simulation of the functions of the
  lateral cricoarytenoid muscle and the lateral
  thyroarytenoid muscle
• Improvement of voice after surgery was dramatic
  in all of the patients who were operated on

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Efficacy of medialization thyroplasty

• Pou AM, Carrau RL, Eibling DE, Murry T. Laryngeal
  framework surgery for the management of
  aspiration in high vagal lesions.Am J
  Otolaryngol. 1998 Jan-Feb19(1)1-7.
• METHODS
• A retrospective chart review was performed on
  each patient presenting with a high vagal lesion
  who was treated with laryngeal framework surgery
  from June 1992 to April 1996 at a university
  medical center
• RESULTS
• 35 patients underwent MTs.
• 95 experienced aspiration improved
• 90 noted to have subjective improvement in voice
  postoperatively.
• CONCLUSION
• Laryngeal framework surgery improves airway,
  deglutition, and voice in individuals suffering
  from high vagal lesions, and facilitates the
  rehabilitation of these patients.

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Efficacy of medialization thyroplasty

• Thevasagayam MS, Willson K, Jennings C, Pracy P.
  Bilateral
• medialization thyroplasty an effective approach
  to severe, chronic aspiration. J Laryngol Otol.
  2006 Aug120(8)698-701. Epub 2006 Jun 2.
• MATERIALS AND METHODS
• Three cases that underwent bilateral
  medialization thyroplasty are described. The
  technique used was the standard medialization
  thyroplasty described by Isshiki as a unilateral
  procedure.
• RESULTS
• All patients stopped aspirating following
  surgery. One patient returned to a normal diet
  and one patient returned to a solid diet. All
  patients required a permanent tracheostomy
• CONCLUSION
• Bilateral medialization thyroplasty offers an
  effective surgical option in the treatment of
  severe, chronic aspiration. It maintains good
  voice, with a possible return to oral diet.

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Tracheoesophageal diversion
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Active treatment

• Stabilizing the patient's airway, breathing, and
  circulation (ABC)
• Airway
• suctioning of the upper airway
• Intubation considered in any patient who is
  unable to protect his or her airway
• Breathing
• Oxygen supplementation
• Circulation
• Cardiac monitoring and pulse oximetry
• Intravenous catheter placement and intravenous
  fluids as indicated

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Treatment of complications

• Complications
• lung abscess
• Empyema
• Management
• Adequate duration of appropriate antibiotic (4-8
  weeks)
• Adequate drainage

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• Thank you.