Download Aspiration Risk Pneumonia

ASPIRATION PNEUMONITIS AND
ASPIRATION PNEUMONIA
Paul E. Marik, M.B., B.CH
N Engl J Med, Vol. 344, No. 9 ·March 1, 2001
“Aspiration pneumonia develops after the
inhalation of colonized oropharyngeal
material. Aspiration of colonized secretions
from the oropharynx is the primary
mechanism by which bacteria
gain entrance to the lungs.”
Marik PE, N Engl J Med, Vol. 344, No. 9 ·March 1, 2001
Defining HAP and HCAP
Hospital-Acquired
Pneumonia (HAP)
Not on Vent and Positive
Respiratory culture after
2 days from admission.
Kollef MH, et al., Chest. Dec 2005;128(6):3854-62.
Health Care-Associated
Pneumonia (HCAP)
Positive respiratory culture
within 2 days of admission and
any of the following:
1. Transferred from
another facility.
2. Long-term dialysis.
3. Prior Hospitalization within
30 days who do not meet
VAP definition.
Patients At Risk
• Those suffering from neurologic dysphagia,
stroke, COPD, malignancy, renal disease,
dementia, liver disease, enteral feeding,
suppressed immune systems, emergency
room admission and more.1,2
1. Marik PE, N Engl J Med. 2001;344(9):665-71. 2. Kozlow JH, et al., Crit Care Med. 2003;31(7):1930-7
Predictors of Aspiration Pneumonia:
How Important Is Dysphagia?*
Susan E. Langmore, PhD
Dysphagia 13:69–81 (1998)
“Aspiration pneumonia is a major problem
for the elderly, leading to hospitalization,
costly care, and at times death. It accounts
for anywhere from 13% to 48% of all
infections in nursing home residents and is
the second most common type of
nosocomial infection in hospitalized
patients, after urinary tract infections.”
Susan E. Langmore, PhD Dysphagia 13:69–81 (1998)
High Mortality, Longer Stays,
Increased Costs
HCAP
HAP
VAP
Mortality
19.8%
18.8%
29.3%
Length
of Stay
8.8 days
15.2 days
23 days
Mean Hospital
Charges
$27,647
$65,292
$150,841
Kollef MH, et al., Chest. Dec 2005;128(6):3854-62.
Biofilm as a Risk Factor
for Pneumonia
Staphylococcus aureus biofilm on an indwelling catheter.
Biofilm Defined
• A thin, usually resistant layer of
microorganisms (as bacteria) that form on
and coat various surfaces.
Biofilm. (n.d.). Merriam-Webster's Medical Dictionary. Retrieved July 03, 2007, from Dictionary.com website: http://dictionary.reference.com/browse/Biofilm
Biofilms and Infectious Diseases
• Biofilms have been found to be involved
in a wide variety of microbial infections
in the body– by one estimate, 80% of
all infections.
Immunology of Biofilms. Immunology and Immunotherapy Program, Center for Integrative Biology and Infectious Diseases,
National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 2004.
Biofilms and Infectious Diseases
• Infectious processes in which biofilms
have been implicated include common
problems such as urinary tract infections,
catheter infections, middle-ear infections,
formation of dental plaque and gingivitis.
Immunology of Biofilms. Immunology and Immunotherapy Program, Center for Integrative Biology and Infectious Diseases,
National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 2004.
http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm
How They Form
http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Structure-Function/default.htm
Formation of Biofilm
Biofilm forming over 12 hours
http://www.tumoutou.net/702_05123/it_jamilah.htm
Plaque as a Biofilm
http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm
Biofilm Dispersing
http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Structure-Function/default.htm
Biofilm Entering into Alveoli
http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm
Biofilm Growing and Strengthening
http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm
Biofilm Calcifies
http://www.erc.montana.edu/Res-Lib99-SW/Image_Library/Medical%20&%20Health/default.htm
How Do We
Combat Biofilms?
Mechanical Cleansing
with Antiseptic Agent
Oral Health Care Drug Products for Over-the-Counter Human Use;Antigingivitis / Antiplaque Drug Products;Establishment of a Monograph;Federal
Register,68(103):32232-87 (available atwww.fda.gov/cder/otcmonographs/Oral_Health_Care/gingivitis_&_plaque_PR_20030529.pdf).2
Oral Debridement
Oral Health Care Drug Products for Over-the-Counter HumanUse;Tentative Final Monograph;Federal Register,53(17):2436-61 (available at
www.fda.gov/cder/otcmonographs/Oral_Health_Care/oral_health_care_TF_PR_19880127.pdf).
With q12º brushing and q2º-q4º swabbing, we
should stop the development of biofilms.
http://www.tumoutou.net/702_05123/it_jamilah.htm
Recap
Mechanical Cleansing
with an oral antiseptic
helps to kill and remove
biofilms.
Oral Debridement
helps lift and remove
inactive biofilms that
are left behind.
Listen to the Experts
CDC Guidelines for Preventing Health Care-Associated Pneumonia
“...Develop and implement a comprehensive
oral-hygiene program (that might include use
of an antiseptic agent) for patients in acutecare settings or residents in long-term--care
facilities who are at risk for health-care-associated pneumonia (II).”*,1
*In addition to other interventions.
ACCN Practice Alert
• Expected Practice:
• Develop and implement a comprehensive oral
hygiene program for patients in critical care and
acute care settings who are at high risk for
healthcare-associated pneumonia.
Brush teeth, gums and tongue at least
twice a day using a soft pediatric or adult
toothbrush.
In addition to brushing, provide oral
moisturizing to oral mucosa and lips every
2 to 4 hours.
AACN Practice Alert - Oral Care in the Critically Ill - Aug 2006.
Oral Care Reduces Pneumonia in
Older Patients in Nursing Homes
Yoneyama et al. J Am Ger Soc 50:2002
• 11 nursing homes in Japan.
• 417 patients randomly assigned to “oral
care” or “no oral care.”
• Oral care provided by nurses or caregivers.
• Pneumonia, febrile days, death from
pneumonia decreased significantly in
patients with oral care.
Yoneyama et al. J Am Ger Soc 50:2002.
Oral Care for Everyone
Evidence Based Protocols
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Assessment
Cleaning
Debriding
Suctioning
Moisturizing
Support
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Educational Website
Protocols
Implementation plan
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