Pneumonia Isn’t Always the
Result of Aspiration
MARY CAMPBELL
DEPT. OF COMMUNICATION SCIENCES &
DISORDERS
WAYNE STATE UNIVERSITY
Pneumonia Isn’t Always the Result of Aspiration
 What is Pneumonia?
 Identifying Varieties of Pneumonia.
 Determining Etiology.
 The Elderly, a Vulnerable Population.
 Identifying Aspiration Pneumonia.
 Conclusion
What is Pneumonia?
 According to the Mayo Clinic it is:
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Inflammation of the lungs caused by infection.
Can be caused by bacteria, viruses, fungi or parasites.
Can arise as a complication of another condition, such as the
flu.
Can range in seriousness from mild to life-threatening.
Identifying Varieties of Pneumonia
 Viral (Community Acquired) Pneumonia
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Most Common pneumonia in children under 5
1/3 of all cases of pneumonia
 Bacterial Community Acquired Pneumonia (CAP).
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Streptococcus pneumoniae is causative in 2/3 of all CAP.
Most common variety of pneumonia in older children and adults.
The most frequent cause of pneumonia in nursing home patients
(Lieberman et al., 1997).
Identifying Varieties of Pneumonia
 Pneumonias are typically named based on where the
infection was acquired, not the pathogen.
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Community Acquired Pneumonia (CAP)
Hospital Based Pneumonia
Nursing Home Acquired Pneumonia (NHAP)
 Etiology is often assumed based on setting.
 Community Acquired Pneumonia = airborne pathogen
 Nursing Home Acquired Pneumonia = aspiration
Identifying Varieties of Pneumonia
 Aspiration pneumonia:
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Right lower lobe is implicated.
Is assumed if the patient has increased risk factors for
aspiration (Tada et al., 2012)
Dysphagia due to neurological disease
 Gastroesophageal reflux disease.
 Dysphagia due to decreased oropharyngeal and gastroesophageal
motility.
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Determining Etiology of Pneumonia
 True etiology is difficult to determine.
 Even when actively investigated, the definitive cause only
found in 52-83% of the cases. (File, 2003)
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Typical pulmonary pathogens are often difficult to culture.
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Pneumonia can arise from more than one pathogen at the same time.
Treatment begins immediately without diagnosing etiology.
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Unethical to withhold treatment.
Knowing etiology not necessary to begin treatment.
Most people are treated and released.
Therapy started within 4 hours yields better outcomes.
The Elderly, More Prone to Pneumonia
 Normally healthy, independent elderly individuals
have the same susceptibility as the general populace.
 All people are more vulnerable to infection when
they have a compromised immune system.
 Many elderly individuals suffer from comorbid
conditions that weaken their immune system.
• Chronic Obstructive
Pulmonary Disease
• Neurologic disease.
• Renal insufficiency
• Diabetes
•
•
•
•
Malignancy
Stroke
Cardiac conditions
G.E.R.D.
The Elderly, More Prone to Pneumonia
 Aspiration pneumonia has been reported to be the
second most frequent principle diagnosis among
hospitalized Medicare patients (El-Solh et al., 2003,
Langmore et al., 2002).
 Also, the second most common cause of infection in
nursing home residents.
Identifying Aspiration Pneumonia
 Increased risk of aspiration pneumonia in hospitals
and nursing homes because:
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Altered level of consciousness.
The use of naso-gastric tubes and PEG tubes.
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The orophayngeal cavities of those not orally fed remain
undisturbed for long periods of time and allow large colonies of
bacteria to flourish.
Dysphagia resulting from illness or brain injury.
Natural bacteria that would compete for the environment are
eliminated with antibiotics, leaving the oral-pharyngeal cavity
vulnerable to “pathogenic bacterial colonization” (Langdon,
2009).
Identifying Aspiration Pneumonia
 Identifying bacteria responsible (El-Solh et al., 2003):
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Gram-negative enteric bacilli (49%)
Anaerobic bacteria (16%)
Staph aureaus (12%)
Anaerobes were found in combination with enteric gram negative
bacilli
 The Bates Study (Bates et al., 1992)
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Patients with community acquired and hospital acquired pneumonia
were included in the study
Detailed study with rigorous inclusion criteria.
Intensive testing done to identify responsible pathogens
Exact etiology could only be determined in 51% of cases.
A significant presence of gram -negative bacilli was found.
Conclusion
 Aspiration pneumonia is not the most common cause of
pneumonia, but is more common with certain populations (the
elderly, those with compromised immune systems, nursing home
residents).
 Because of limited diagnostic and etiologic information, aspiration
pneumonia is underestimated in community acquired pneumonia
and overestimated in nursing home acquired pneumonia.
 Bates study with rigorous testing methods found a large amount of
gram-negative and anaerobic bacterial pathogens. This would
implicate aspiration across populations, including community
acquired pneumonia.
 Younger people without compromised immune systems may
aspirate but are better able to combat infection.
References
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Bates, J. H., Campbell, G. D., Barron, A. L., McCracken, G. A., Morgan, P. N., Moses, E. B., &
Davis, C. M. (1992, April). Microbial etiology of acute pneumonia in hospitalized
patients. CHEST, 101(4), 1005-1012. doi:10.1378/chest101.41005
El-Solh, A. A., Pietrantoni, C., Bhat, A., Aquilina, A. T., Okada, M., Grover, V., & Gifford, N.
(2003, April 10). Microbiology of severe aspiration pneumonia in institutionalized
elderly. Am J Respir Crit Care Med, 167(12), 1650-1654.
Fein, A. M. (1999, April). Pneumonia in the elderly: Overview of diagnostic and therapeutic
approaches [Electronic version]. Clinical Infectious Diseases, 28(4), 726-729.
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File, T. M. (2003, December 13). Community-acquired pneumonia. The Lancet, 362(9400),
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Klapdor, B., Ewig, S., Schaberg, T., Rohde, G., Pletz, M. W., Schutte, H., & Weite, T. (2012,
July).
Presentation, etiology and outcome of pneumonia in younger nursing home
residents. Journal of Infection, 65(1), 32-38. doi:10.1016/j.jinf.2012.02.003
Langdon, P. C., Lee, A. H., & Binns, C. W. (2009, February). High incidence of respiratory
infections in 'nil by mouth' tube-fed acute ischemic stroke patients. Neuroepidemiology,
32(2), 107-113. doi: 10.1159/000177036
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002, December). Predictors of
aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307.
doi:10.1007/s00455-002-0072-1
References
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Lieberman, D., Lieberman, D., Schlaeffer, F., & Porath, A. (1997). Community-acquired
pneumonia in old age: a prospective study of 91 patients admitted from home. Age and
Aging, 26(2), 69-75. doi: 10.1093/ageing/26.2.69
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Etiology of community-acquired pneumonia treated in an ambulatory setting
[Electronic version]. Respiratory Medicine, 99(1), 60-65.
Mylotte , J.M., (2002). Nursing Home-Acquired Pneumonia. Clinical Infectious Diseases,
35(10),1205-1211. doi: 10.1086/344281.
Pneumonia. (n.d.). In Mayo Clinic. Retrieved May 10, 2011, from www.mayoclinic.com.
Tada, A., & Miura, H. (2012, July). Prevention of aspiration pneumonia (AP) with oral care
[Electronic version]. Archives of Gerontology and Geriatrics, 55(1), 16-21.
doi:10.1016/j.archger.2011.06.029
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July 20, 2012, from http://www.nhlbi.nih.gov
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from http://www.lung.org