[Dysphagia] pneumonia vs pneumonitis

[eripley at yahoo.com (Irene Campbell-Taylor)]

--- Allison Bartlett
<allison_bartlett@health.qld.gov.au> wrote:
 It seems
> that the doctors where I work label most lung
> changes as aspiration pneumonia, I have never seen
> pneumonitis written in a chart.
>
*** Well, that's the problem. By not paying attention
to the Hx, they miss the signs/symptoms that make it
clear that what has occurred is aspiration of stomach
contens - pneumonitis - not bacterial pneumonia. Even
if they do know the difference, they still tend to
call it pneumonia as if the terms were synonymous and
they are most decidedly not! This is what has led to
the hysteria over aspiration and the assumption that
even alittle water is aspirated will be lethal PLEASE
read- and send to your docs - these:

http://jnnp.bmjjournals.com/cgi/content/full/64/5/569

http://www.australianprescriber.com/index.php?content=/magazines/vol26no1/14_17_pneumonia.htm
http://medicine.ucsf.edu/housestaff/handbook/HospH2002_C4.htm#Aspiration
ASPIRATION PNEUMONITIS AND PNEUMONIA
 
1.     The evidence (forget what you?ve learned!):
·       Aspiration pneumonitis can present with a
fever, infiltrate, cough, elevated WBC.  However,
aspiration pneumonitis does not require treatment with
antibiotics initially.  Use the guidelines below to
differentiate from aspiration pneumonia.  Symptoms
usually resolve within 24-48 hours.
·       Aspiration pneumonia is not caused by
anaerobes (for the most part).  It?s mostly caused by
gram negative rods, so make sure you cover with a
broad spectrum antibiotic.  Don?t use
penicillin/clindamycin as this will not cover gram
negatives!
·       Percutaneous gastrostomy (PEG) tubes don?t
prevent aspiration pneumonia and are not superior to
nasogastric (NG) tubes. 
  
2.     Aspiration pneumonia: 
·       Patients at risk are those with dysphagia and
gastric dysmotility.
·       Usually affects elderly patients and usually
is not witnessed.  
·       Results from aspiration of colonized
oropharyngeal material and is therefore not sterile. 
·       Pathogens: mainly gram-negative rods and
gram-positive cocci. Rarely due to anaerobic bacteria.
·       Clinically presents as typical pneumonia with
tachypnea, fever, cough.     
 
3.     Aspiration pneumonitis: 
·       Patients at risk are those with a depressed
level of consciousness.
·       Usually affects younger patients who are
intoxicated, sedated, or have head injury/pathology
and is usually witnessed.
·       Results from aspiration of sterile gastric
contents; acute lung injury results from acitidy and
particulate material and not bacteria though
superinfection later is always possible.
·       Clnically can present with no symptoms, mild
symptoms, or severe acute lung injury or ARDS with
hypotension.   
 
4.     Management: 
·       Suction the upper airway after a witnessed
aspiration event and if the patient can?t protect
airway, intubate.
·       Don?t blindly use prophylactic antibiotics for
aspiration pneumonitis (this will simply select for
more resistant bugs causing superinfection).
·       Aspiration pneumonitis:
-        If symptoms > 48 hours: treat with
levofloxacin or ceftriaxone.
-        If the patient is at risk for colonization of
gastric contents (small bowel obstruction or on
antacid therapy): use ceftriaxone, zosyn, or
ceftazidime.
·       Aspiration pneumonia:
-        Community acquired: levofloxacin or
ceftriaxone.
-        Residence in long term care facility: zosyn
or ceftazidime.
-        Severe periodontal disease, putrid sputum,
alcoholism, CXR with lung abscess: treat for anaerobes
with zosyn, imipenem, or 2 drug therapy (levofloxacin
or ceftriaxone plus clindamycin or metronidazole).
 
 
Marik PE. Aspiration pneumonitis and aspiration
pneumonia. N Engl J Med 2001; 344:665-71.
http://www.google.ca/search?q=cache:widTEmVB1xIJ:scalpel.stanford.edu/articles/aspiration--NEJM.pdf+Marik+PE++aspiration+&hl=en
 

http://www.postgradmed.com/issues/2003/03_03/j_johnson.htm

http://www.emedicine.com/ped/topic2622.htm
http://www.google.ca/search?q=cache:cHuI3KRQ5mAJ:www.healthsystem.virginia.edu/internet/digestive-health/Apr03OpillaArticle.pdf+Marik+PE++aspiration+&hl=en


=====
Dr I Campbell-Taylor
Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com