Aspiration Pneumonia and Dysphagia Joseph Murray, PhD VA Ann Arbor Healthcare System

Speech Pathology Most Frequent Solicitation • Determine presence of aspiration • Determine if PO intake of food and/or medications is possible • Based on assumption • Nothing enters the mouth • Nothing can enter the lungs

• There is no pass/fail!

Aspiration and Dysphagia • Conventional wisdom • Aspiration of food and liquid causes pneumonia • Assumption • Controlling aspiration controls pneumonia

• 95% increase in diagnostic coding of aspiration pneumonia • Suspected “upcoding” of Diagnosis Related Group • Greater reimbursement for DRG 79/80 • “aspiration pneumonia”

• Lower reimbursement for DRG 89/90 • “pneumonia organism unspecified”

Langmore et al. 1998 • Odds Ratios for Aspiration Pneumonia • • • •

Dependent for feeding Dependent for oral care Number of decayed teeth Tube feeding

• Dysphagia was an important risk for aspiration pneumonia • but generally not sufficient to cause pneumonia unless other risk factors were present

Dental Plaque • One cubic millimeter of dental plaque contains about 100 million bacteria • Oral bacterial load increases during intubation • Higher dental plaque scores predict risk of pneumonia • Munro CL, Grap MJ, Elswick RK Jr (2006). Oral health status and development of ventilator-associated pneumonia: a descriptive study. : 453–460.

Full diversity of oral flora is unknown • Maybe unknowable

Secretory Immunoglobulins • Heavy plasma proteins • • • •

Recognize pathogens Bind with protiens in the pathogen Kill it directly Block and bundle toxins

Mucins • “Slimy“ stuff in mouth • • • • •

Proteins coats many epithelial surfaces Secreted into saliva Serves as a diffusion barrier against contact with noxious substances Lubricates to minimize shear stresses • Super lubricant!

El-Solh, A et al. Colonization of Dental Plaques*: A Resevoir of Respiratory Pathogens for Hospital-Acquired Pneumonia in Institutionalized Elders Chest; November 2004 Vol 126(5) pp 1575-1582

• Association between dental plaque colonization and lower respiratory infection in elderly using molecular genotyping • 49 Critically ill LTC residents requiring ICU • Plaque index scores • Quantitative cultures • BAL on 14 patients who developed pneumonia • Respiratory pathogens compared genetically to plaques by pulse gel electrophoresis

El-Sohl et al. cont • 28/49 (57%) had colonization of plaque with aerobic pathogens • Staphylococcus aureus (45%) • Gram-negative bacilli (42%) • Pseudomonas aeruginosa (13%)

• Isolates from BAL fluid • 9/13 matched genetically those recovered from corresponding dental plaques of 8 patients

Association Between Oral Biofilms and Periodontitis with Pneumonia • Brown, JS, (2007) Oral biofilms, periodontitis and pulmonary infections. Oral Diseases 13 (6), 513-514. • Pathogens causing nosocomial pneumonia are present in oral biofilms • Increased bacterial contamination of oral biofilms and severity of periodontitis are associated with an increased incidence of pneumonia • Interventions to decrease the amount of pathogenic bacteria found in oral biofilms and the severity of periodontitis result in a lower incidence of pneumonia

• Systemic Infection Post Stroke

GOMES-FILHO, I., PASSOS, J., SEIXAS DA CRUZ, S.. Respiratory disease and the role of oral bacteria. Journal of Oral Microbiology, North America, 2, dec. 2010.

• Biological mechanisms involved between oral conditions and respiratory diseases • Four possible mechanisms • Oral pathogens directly aspirated into the lungs • Salivary enzymes associated with periodontal disease modify respiratory tract mucosal surfaces • Enzymes from periodontopathic bacteria destroy salivary film that protects against pathogenic bacteria • Cytokines

Oral pathogens directly aspirated into the lungs • Pseudomonas aeruginosa

• Opportunistic pathogen with ability to develop resistance to antibiotics

• Ventilator acquired pneumonia with P. aeruginosa • higher mortality compared with other pathogens

• Chastre J, Fragon J-Y. Ventilator-associated pneumonia. Am J Respir Crit Care Med 2002;165:867–903. • Increased colonization of the oropharynx of patients with nasogastric tubes • Leibovitz A, Dan M, Zinger J, Carmeli Y, Habot B, Segal R. Pseudomonas aeruginosa and the oropharyngeal ecosystem of tube-fed patients. Emerg Infect Dis 2003;9:956–959

Lung injury • Direct destructive effects of the organism on the lung parenchyma • Apoptosis of bronchial epithelial cells • Exuberant host immune responses • Grassme H, Kirschnek S, Riethmueller J, Riehle A, von Kurthy G, Lang F, Weller M, Gulbins E. CD95/CD95 ligand interactions on epithelial cells in host defense to Pseudomonas aeruginosa. Science 2000;290:527–530

Lung Injury • Salivary enzymes modify respiratory tract mucosal surfaces • Promote adhesion and colonization by respiratory pathogens • modification of the mucosal epithelium • loss and removal of surface fibronectin by hydrolytic enzymes • protein that covers the mucosa • results in de-masking of surface receptors

• release of cytokines

• Worse oral hygiene leads to higher enzymatic activity • Greater the possibility of mucosal changes • Increasing the adhesion and colonization by respiratory pathogens

Enzymes from periodontopathic bacteria destroy salivary film that protects against pathogenic bacteria • reduce the ability of mucins to adhere to pathogens • Pathogens are then free to adhere to mucosal receptors in the respiratory tract • Fewer non-specific host defense mechanisms in high-risk individuals

Cytokines continually released from periodontal tissues • Alters the respiratory epithelium • Promotes colonization by respiratory pathogens • Dysregulation of adhesion receptor expression on the mucosal surfaces • Results in infection

Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ. Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13:2: 69-81, 1998.

• Odds Ratios for Aspiration Pneumonia • • • • •

Dependent for feeding Dependent for oral care Number of decayed teeth Tube feeding Dysphagia was an important risk for aspiration pneumonia • but generally not sufficient to cause pneumonia unless other risk factors were present

Oral Care and Aspiration Pneumonia • Oral and dental bacterial colonization • The major source of bacteria in aspiration pneumonia • Paju, S & Scannapieco, FA (2007) Oral biofilms, periodontitis, and pulmonary infections.Oral Diseases 13 (6), 508-512. • Azarpazhooh A, Leake JL (2006). Systematic review of the association between respiratory diseases and oral health. : 1465–1482. • Garcia R (2005). A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia: underappreciated risk and a call for interventions. : 527–541.

Dental Plaque • One cubic millimeter of dental plaque contains about 100 million bacteria • Oral bacterial load increases during intubation • Higher dental plaque scores predict risk of pneumonia • Munro CL, Grap MJ, Elswick RK Jr (2006). Oral health status and development of ventilator-associated pneumonia: a descriptive study. : 453–460.

Yoneyama T, Yoshida M, Ohrui T, Okamoto H, Hishiba K et al. (2002) Oral care reduces pneumonia in older patients in nursing homes Journal of the American Geriatrics Society,50 3 430

•

417 patients randomly assigned to one of two groups • •

Oral care group No oral care group

Yoneyama et al. (2003) • Oral Care Group • Nurses or caregivers cleaned the patients' teeth by toothbrush after each meal. • Swabbing with iodine was additionally used in some cases. • Dentists or dental hygienists provided professional care once a week.

• Significant decrease in: • Pneumonia • febrile days • death from pneumonia

Scannapieco, Paju and Bush Annals of Periodontology, Vol 8, Number 1, 54-69 December 2003

• Review of periodontal disease and nosocomial pneumonia • 21 case control and cohort studies • 9 RTCs

• Oral colonization is associated with nosocomial pneumonia • Oral interventions improving hygiene reduced incidence of nosocomial pneumonia by an average of 40%

Terpenning M, Taylor GW, Lopatin DE, et al. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001; 49:557-563

• 134 Geriatric patients • Dentate patients with pneumonia • 27% of inpatients • 19% of LTC

• Edentulous patients with pneumonia • 5%

Hand Dexterity and Oral Hygiene • Padilha DMP, Hugo FN, Hilgert JB . Hand function and oral hygiene in Brazilian institutionalized elderly. J Am Geriatr Soc 2007;:1333–1338. • 49 institutionalized participants • 29 dentate • 36 one complete denture • Poor hand function (Purdue Test of Dominant Hand Function) • Dentate • Correlated with significantly more dental plaque

• Complete denture wearers • Correlated with significantly more denture plaque

Who Should Do It? • Kenneth Shay, DDS, MS. (2007) Who Is Responsible for a Nursing Home Resident's Daily Oral Care?. Journal of the American Geriatrics Society :9, 1470–1471 • Costs are also high for: • Bathing • Toileting • Feeding

What About Aggressive Oral Hygiene? • Simons D, Kidds EA, Beighton D. Oral health of elderly occupants in residential homes [letter]. Lancet 1999; 353:1761

• Health-care providers in residential homes give little assistance with tooth and denture cleaning • Simons D, Baker P, Jones B, et al. An evaluation of oral health training programme for carers of the elderly in residential homes. Br Dent J 2000; 188:206-210

• Even if training and education are provided!

Hassan, A. E., Chaudhry, S. A., Zacharatos, H., Khatri, R., Akbar, U., Suri, M. F. K., & Qureshi, A. I. (2012). Increased rate of aspiration pneumonia and poor discharge outcome among acute ischemic stroke patients following intubation for endovascular treatment. Neurocritical care, 16(2), 246-250.

Methods

• Logistic regression model was used to assess contribution of intubation and aspiration pneumonia on poor outcome after adjusting for potential confounders. • Results • 136 acute ischemic stroke patients • received endovascular treatment • •

83 local sedation without intubation 53 with intubation

• Aspiration pneumonia • Not intubated (14%) • Intubated (23%)

Hassan et al. (2012) cont. • Poor outcomes • • • •

Non-intubated (55%) Intubated (83%) Poor outcome at discharge (OR 2.9, 95% CI 1.2–7.4) (P = 0.0243) In-hospital mortality (OR 4.5, 95% CI 1.5–12.5) (P = 0. 0.0046)

• After adjusting for pneumonia • Effect of intubation on poor outcome at discharge (OR 2.7, CI 1.1–7.1) (P = 0.0006) • In-hospital mortality (OR 4.4, CI 1.6–12.5) (P = 0.00051)

• Conclusions • Rate of death and disability appears to be high for intubated patients receiving endovascular treatment • This increased rate is not explained by higher rates of subsequent aspiration pneumonia

Mortensen, H. R., Jensen, K., & Grau, C. (2013). Aspiration pneumonia in patients treated with radiotherapy for head and neck cancer. Acta Oncologica, 52(2), 270-276.

• High incidence of aspiration pneumonia in head and neck cancer populations treated with chemo-radiotherapy • Investigated incidence and mortality of aspiration pneumonia • 324 consecutive patients treated with curative intended radiotherapy

• Data collection • Patient, tumor, treatment characteristics obtained from DAHANCA database • Hospital admissions obtained from National Patient Registry • National Registry of Causes of Death

Mortensen et al. (2013) cont. • Results • Severe dysphagia in 32% of the 324 patients • 18 patients developed aspiration pneumonia in first year after radiotherapy • incidence rate of 29 (95% CI 17–46) per 1000 person-years • incidence proportion of 5.3% (95% CI 3.1–8.3%)

• Significant risk factors • • • • •

tube feeding clinical stage severity of dysphagia response to treatment 3/18 died of aspiration pneumonia

• Conclusion. • Dysphagia-related aspiration pneumonia is serious and potentially fatal • Occur less frequently that previously reported

Lanspa, M. J., Jones, B. E., Brown, S. M., & Dean, N. C. (2013) Mortality, morbidity, and disease severity of patients with aspiration pneumonia. Journal of Hospital Medicine, 8(2), 83-90.

• METHODS • Retrospective population study over 10 years of medical records • International Classification of Diseases, 9th Revision code 507.x • Physician chart review excluded patients with aspiration pneumonitis

• Aspiration pneumonia compared to community-acquired pneumonia • Compared CURB-65 predicted mortality with actual 30-day mortality

Lanspa et al. (2013) cont. • RESULTS • Identified 628 patients with aspiration pneumonia • • • • • •

30-day mortality of 21% Aspiration pneumonia had more frequent inpatient admission (99% vs 58%) Intensive care unit admission (38% vs 14%), Higher Charlson comorbidity index (3 vs 1), Higher prevalence of do not resuscitate/intubate orders (24% vs 11%) CURB-65 predicted mortality poorly in aspiration pneumonia

• CONCLUSIONS • Patients with aspiration pneumonia are older, have more comorbidities and demonstrate higher mortality than CAP patients, •

Even after adjustment for age and comorbidities

Maeda, N., Yoshioka, T., Tanaka, A., Inoue, K., & Haruma, K. (2013). Sa1614 Endoscopic and Clinical Features of 304 Consecutive Patients With Percutaneous Endoscopic Gastrostomy: Advanced Atrophy of Gastric Mucosa Is a Risk Factor of Aspiration Pneumonia. Gastrointestinal Endoscopy, 77(5), AB268-AB268.

• Methods:

• Endoscopic images at PEG placement were reviewed in 304 consecutive patients

• Results:

• Age and aspiration pneumonia were correlated with advanced gastric atrophy • Age: (p 0.0005, OR 1.044) • Aspiration pneumonia: (p0.037, OR 1.692)

• Mortality 3 months post PEG

• Dementia (p 0.007, OR 16.94) • Aspiration pneumonia (p 0.011,OR 29.17) • Low serum albumin (p 0.036, OR 0.16)

• Conclusion:

• Patients with PEG and recurrent aspiration • Often have co-occuring advanced atrophy of gastric mucosa and mortality • Advanced atrophy of gastric mucosa possible risk factor of aspiration pneumonia in patients with PEG

Additional Articles of Interest Aspiration Pneumonia • Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, Dowell SF, File TM Jr, Musher DM, Niederman MS, Torres A, Whitney CG; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72. • Levy ML, Le Jeune I, Woodhead MA, Macfarlaned JT, Lim WS; British Thoracic Society Community Acquired Pneumonia in Adults Guideline Group.Prim Care Respir J. 2010 Mar;19(1):21-7. Erratum in: Prim Care Respir J. 2010 Jun;19(2):108.

Additional Articles of Interest Aspiration Pneumonia • Weiss, C. H., Moazed, F., DiBardino, D., Swaroop, M., & Wunderink, R. G. (2013). Bronchoalveolar Lavage Amylase Is Associated With Risk Factors for Aspiration and Predicts Bacterial Pneumonia. Critical care medicine, 41(3), 765-773. • Bosch, X., Formiga, F., Cuerpo, S., Torres, B., Rosón, B., & López-Soto, A. (2012). Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality. European Journal of Internal Medicine. • van der Maarel‐Wierink, C. D., Vanobbergen, J. N., Bronkhorst, E. M., Schols, J. M., & de Baat, C. (2012). Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology.

Aspiration Pneumonia • Ifejika-Jones, N. L., Harun, N., Peng, H., Noser, E. A., Grotta, J. C., & Francisco, G. E. (2012). The Interaction of Aspiration Pneumonia with Demographic and Cerebrovascular Disease Risk Factors is Predictive of Discharge Level of Care in the Acute Stroke Patient. American Journal of Physical Medicine & Rehabilitation, 91(2), 141-147.

Alternate Questions What is the:  Risk for poor outcome?  Ability to maintain nutrition/hydration via oral feeding?  Plan for management of safety and vitality?  Means for improving physiology?

Alternate Questions How can we: • Plan/manage decline and compensation? • Determine means for ensuring quality of life? • Literature Is Not Sufficiently Developed to Answer These Questions!