[Dysphagia] RE: how much water

[acellucc at bidmc.harvard.edu (acellucc@bidmc.harvard.edu)]

Along the lines of these postings, I have a question with regards to a pt we recently were asked to see, whose first two chest films have reportedly been negative for evidence of pna, they are planning to run more films to follow this, but was admitted with fever, productive cough, dyspnea, sat @88% on RA, requiring O2, who had 2 sputum cultures (+) for oropharyngeal flora, RLL rhonchi, r/o for the flu, but the working dx thus far is pna (per MD team, not me, mind you). She does not have any oropharyngeal dysphagia based on exams at the bedside and under fluoroscopy (though there is evidence of a hiatal hernia - but if there was reflux occurring occultly - would the sputum have oropharyngeal flora in it?). PMH includes: aortic stenosis, s/p AVR/Pacer, afib, iron deficiency anemia, s/p L CEA, s/p L MCA CVA '00 w/ h/o seizure, temporal arteritis, depression, diverticulae, hemorrhoids, essential tremor, cervical stenosis, h/o GIB, h/o scarlet fever, s/p hysterectomy, s/p kidney removal. Also had a dropping hematocrit recently requiring 1u PRBC. 

So my question is, in this pt who is not presenting with any difficulty taking po's, is the presence of "copious amounts of oropharyngeal flora (per MD)" potentially due to aspiration while sleeping?? Any thoughts would be greatly appreciated, as I am just curious about this pt, mind you we are not restricting her po's on our end in any way, I am just wondering how this could have come about in a pt who is not significantly immunocompromised, ambulatory, living at home (with some assistance, but certainly not dependent for her care). 

Any thoughts?

alex

Message: 2
Date: Mon, 14 Mar 2005 05:56:11 -0800 (PST)
From: Irene Campbell-Taylor <eripley@yahoo.com>
Subject: RE: [Dysphagia] Re:  how much water?
To: Jai Gupta <GuptaJ@SESAHS.NSW.GOV.AU>, Dysphagia@b9.com
Message-ID: <20050314135611.47138.qmail@web14023.mail.yahoo.com>
Content-Type: text/plain; charset=us-ascii



Jai Gupta <GuptaJ@SESAHS.NSW.GOV.AU> wrote:

Hi all, I am really worried when people make a generalist comment that "each patient receives his or her requisite amount of water every day"..

*** That was the OPPOSITE of a general comment - please note "his or her requisite amount" - individualized and we DO have methods of determining how mucha given individual needs. Please read the medical, nursiing and physiological literature on hydration.

..we don't have evidence do we? I have come across so many elderly citizens who do not drink a sip of water but live on tea or cordial some on bear .

*** And are chronically dehydrated as all of the above are DIURETIC.

....but these are rare cases ..

*** These are COMMON cases .

and there are obvious signs of asp pneu 

*** Aspiration pneumonia is one of the most difficult diagnoses to make in a living person.Please note the following from, arguably, the world's expert on aspiration pneumonia and aspiration pneumonitis:



Aspiration pneumonia

 

 

John G Bartlett, MD
Co-Editor-in-Chief - Infectious Diseases
Professor of Medicine
Johns Hopkins University School of Medicine

INTRODUCTION - Aspiration is a common event even in healthy individuals and usually resolves without detectable sequelae. Markers placed in the stomach can often be detected in the lungs of healthy persons using scintigraphic methods. 

[Berson, W, Adiani, J. "Silent" regurgitation and aspiration of gastric contents during anesthesia. Anesthesiology 1954; 15:644.]

Aspiration pneumonia refers to the pulmonary consequences resulting from the abnormal entry of fluid, particulate exogenous substances, or endogenous secretions into the lower airways. There are usually two requirements to produce aspiration pneumonia:

   Compromise in the usual defenses that protect the lower airways including glottic closure, cough reflex, and other clearing mechanisms

   An inoculum deleterious to the lower airways by a direct toxic effect, stimulation of an inflammatory process from a large enough bacterial inoculum, or obstruction due to a sufficient volume of material or particulate matter

Most pneumonia arises following the "aspiration" of microorganisms from the oral cavity or nasopharynx. The term aspiration pneumonia should be reserved for pneumonitis resulting from the altered clearance defenses noted above. The pathogens which commonly produce pneumonia, such as Streptococcus pneumoniae, Haemophilus influenzae, Gram negative bacilli, and Staphylococcus aureus, are relatively virulent bacteria so that only a small inoculum is required and the aspiration is usually subtle.

 A true aspiration pneumonia, by convention, usually refers to an infection caused by less virulent bacteria, primarily anaerobes, which are common constituents of the normal flora in a susceptible host prone to aspiration.

The predisposing conditions, clinical syndromes, diagnosis, and treatment of aspiration pneumonia will be reviewed here. Community-acquired pneumonia, nosocomial pneumonia, pneumonia due to specific pathogens, empyema, and lung abscess are discussed separately. (See related topic reviews).

PREDISPOSING CONDITIONS - Conditions that predispose to aspiration pneumonia include:

   Reduced consciousness, resulting in a compromise of the cough reflex and glottic closure 
   Dysphagia from neurologic deficits 
   Disorders of the upper gastrointestinal tract including esophageal disease, surgery involving the upper airways or esophagus, and gastric reflux 
   Mechanical disruption of the glottic closure or cardiac sphincter due to tracheostomy, endotracheal intubation, bronchoscopy, upper endoscopy, and nasogastric feeding 
   Pharyngeal anesthesia, and miscellaneous conditions such as protracted vomiting, large volume tube feedings, feeding gastrostomy, and the recumbent position

These conditions all share properties of frequent or large volume aspiration which increase the probability of developing aspiration pneumonitis . A number of interventions (eg, positioning, dietary changes, drugs, oral hygiene, tube feeding) have been proposed to prevent aspiration, especially in elderly patients. However, a systematic review of such measures found insufficient data to assess effectiveness


Interventions to prevent aspiration pneumonia in older adults: a systematic review. 
Loeb MB; Becker M; Eady A; Walker-Dilks C 

 J Am Geriatr Soc 2003 Jul;51(7):1018-22. 

A systematic review was conducted to assess the effectiveness of the following interventions for prevention of aspiration pneumonia (AP) in older adults: compensatory strategy/positioning changes, dietary interventions, pharmacologic therapies, oral hygiene, and tube feeding. Data sources included a key word search of the MEDLINE, EMBASE, Cochrane Library, CINAHL, and HealthSTAR databases and hand searches of six journals. Reference lists of relevant primary and review articles were searched. Studies included were randomized, controlled trials (RCTs) enrolling adults aged 65 and older at risk of and assessed for AP. Two investigators extracted data on population, intervention, outcomes, and methodological quality. Of the 17 identified RCTs, eight met the selection criteria, two addressed dietary management or compensatory swallowing, two assessed pharmacological therapies, one assessed oral hygiene, and three assessed tube feeding. None of the eight trials reported use of blinding,
 and allocation concealment was unclear in five. Use of amantadine prevented pneumonia in one trial of nursing home residents. The antithrombotic agent cilostazol prevented AP in another trial but resulted in excessive bleeding. Insufficient data exist to determine the effectiveness of positioning strategies, modified diets, oral hygiene, feeding tube placement, or delivery of food in preventing AP. Considering how common the problem of AP is in older adults, larger, high-quality RCTs on the effectiveness of preventive interventions are warranted. 

AD - Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.


 




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

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End of Dysphagia Digest, Vol 16, Issue 14
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