Management of Aspiration Pneumonia

1. Management of Aspiration Pneumonia Dr Leon Lai, Dr TK Wu, Dr YSK Yeung

2. Introduction • Definition • inflammation of the lungs and bronchial tubes due to breathing in a foreign material, e.g. food, stomach content • CAP, HAP, VAP • Diagnosis • History, physical exam, blood count, imaging • Definitive diagnosis: translaryngeal aspiration • account for 6% to 9% of all cases of community-acquired pneumonia in US [1,2] [1] Rev Infect Dis 1989;11(4):586-99 [2] Am J Respir Crit Care Med 1995;152(4 Pt 1):1309-15

3. Risk factors • Decreased level of consciousness • acute and chronic alcohol abuse • drug overdose • stroke • seizure; head trauma • anesthesia • Dysphagia • Vomiting • Reflux disease

4. Risk factors • Bronchial obstruction due to neoplasm or foreign body • Neurologic disease • Stroke • amyotrophic lateral sclerosis • myasthenia gravis • multiple sclerosis • Parkinson's disease • Iatrogenic • OGD • ERCP • nasogastric feeding tube

5. Clinical Approach • History • Cough, sputum, SOB, wheeze, fatigue • Risk factors • Smoking history • Physical examination • Temp, SaO2 • RR, Reduced chest expansion / AE, dull on percussion, crackles • Blood tests • CBP • liver functions • U&E • Microbiology • Deep cough sputum gram stain, culture, sensitivity spectrum • Sensitivity < 50% • NPA for virology, sputum for AFP if suspicious • Radiology • CXR

6. Typical CXR • Right middle and lower lung lobes are the most common sites of infiltrate formation • Because right main bronchus has larger caliber and more vertical

7. Multidiscipline Approach • Speech therapist • Swallowing test, use of thickener • Physiotherapist • Microbiologist • ENT Surgeon • FEEST • Clinicians

8. Management option • Antimicrobial treatment • Prevention • Treatment of complications

9. Antimicrobial Treatment • Antibiotic therapy • prophylactic antibiotics are not recommended • common organisms: • anaerobic organisms like Bacteroides, Peptostreptococcus, and Fusobacterium species • gram-negative enteric bacilli and Staphylococcus aureus in patient receiving taking antacid / H2blocker / PPI [Chest 1987;91(6):901-9 ] • Duration of antibiotic: No controlled studies. 7-10 days • Adjunctive corticosteroids have no proven value in the treatment of aspiration pneumonia and may be deleterious [1,2] [1] Evaluation of corticosteroid treatment in aspiration of gastric contents: a controlled clinical trial. Mt Sinai J Med 1980;47(4):335-40 [2] Effects of corticosteroids in the treatment of patients with gastric aspiration. Am J Med 1977;63(5):719-22

10. Hospitalised CAP • mild to moderate infection • Without DRSP risk • β-lactam /β-lactamase inhibitor ± Macrolide, or • Fluoroquinolone • With DRSP risk • Augmentin/Unasyn ± Macrolide, or • Cefotaxime/Ceftriaxone ± Macrolide • Severe infection • Without pseudomonas risk: • Cefotaxime/Ceftriaxone ± Macrolide, or • Piperacillin/Tazobactam ± Macrolide • With pseudomonas risk • 2 antipseudomonal agents ± Macrolide, or • Fluoroquinolone + antipseudomonal agents

11. HAP • early-onset pneumonia (≤4 days admission), not received prior antimicrobial treatment • 3rd generation cephalosporin OR • β-lactam/β-lactamase inhibitor (Amoxycillinclavulanate/Ampicillin-sulbactam) • early-onset pneumonia (≤4 days admission), received prior antimicrobial treatment or late-onset pneumonia (>4 days admission), not received prior antimicrobial treatment • Antipseudomonal β-lactam/β-lactam inhibitor OR • 3rd generation antipseudomonal cephalosporin OR • 4th generation cephalosporin • ± aminoglycoside OR fluoroquinolone • late-onset pneumonia (>4 days admission), and received prior antimicrobial treatment • Antipseudomonal β-lactam/β-lactam inhibitor OR • 3rd generation antipseudomonal cephalosporin OR • 4th generation cephalosporin OR • Imipenem/Meropenem • ± aminoglycoside OR fluoroquinolone • (± Vancomycin after careful assessment of indication)

12. Prevention • Non-surgical method • Positioning of patient • Elevation of the head of the bed • Feeding patient in the sitting position and not placed supine until 1 to 2 hours after meals • Periodic checking for residual stomach amount • recommend 100 cc or less as the acceptable residual if a gastrostomy tube is used and 200 cc if a nasogastric tube is used • Tube feeding: Gastrostomy/jejunostomy • Thickener

13. Prevention 2. Surgical method • Vocal fold medialization thyroplasty +/- arytenoid adduction • Tracheoesophageal diversion • Total laryngectomy

14. Medialization thyroplasty • 1st described by Isshiki in 1974 [1] • Indication: • aspiration secondary to unilateral paralysis or atrophy of the vocal folds • Method: • Open method: placement of a silastic subperichondrial implant to medialize the vocal fold • Endoscopic method: injection of varying substances to stiffen and/or medialize the vocal fold (e.g. Telfon, Gelfoam) [1] Isshiki N, Morita H, Okamura H, Hiramoto M: Thyroplasty as a new phonosurgical technique. Acta Otolaryngol 1974 Nov-Dec; 78(5-6): 451-7

15. Medialization thyroplasty Superior and inferior subplatysmal flaps are then elevated and the strap muscles are separated in the midline and retracted laterally to expose the thyroid cartilage With the entire thyroid lamina exposed, the fenestra template is placed with the long axis in the horizontal dimension. The superior aspect of the fenestra is at the vocal fold level approximately 0.8 to 1.0 cm posterior to the anterior margin of the thyroid cartilage

16. A drill is then used with a 3-4 mm cutting bur to create the window in the thyroid lamina being careful not to penetrate the inner perichondrium The inner perichondrium is elevated off the thyroid lamina using the perichondrium elevator

17. A trial instrument is then selected and introduced into the fenestra by inserting the large end first in an anterior to posterior fashion. The trial is then positioned perpendicular to the fenestra. Completely retract the knob on the handle of the implant inserter. Secure the implant into the inserter. Insert the implant into the fenestra. Insert the large end first in an anterior to posterior fashion. Position the implant in the previously determined optimal position. Push the knob on the handle of the inserter forward and release the implant.

19. Complications • Extrusion/Displacement • Misplacement – most often superior • Infection • Undercorrection

20. Limitation • Poor closure of posterior glottic gap

21. Arytenoid Adduction • First described by Isshiki with modifications by Zeitels and others • Pulling arytenoid into adducted position

23. N. Isshiki, M. Tanabe and M. Sawada. Arytenoid adduction for unilateral vocal cord paralysis. Arch Otolaryngol Head Neck Surg • Vol. 104 No. 10, October 1978 • The arytenoid adduction technique was devised and performed under local anesthesia on five patients with unilateral vocal cord paralysis • The muscle process is pulled by two 3-0 nylon sutures in simulation of the functions of the lateral cricoarytenoid muscle and the lateral thyroarytenoid muscle • Improvement of voice after surgery was dramatic in all of the patients who were operated on

24. Efficacy of medialization thyroplasty • Pou AM, Carrau RL, Eibling DE, Murry T. Laryngeal framework surgery for the management of aspiration in high vagal lesions.Am J Otolaryngol. 1998 Jan-Feb;19(1):1-7. • METHODS: • A retrospective chart review was performed on each patient presenting with a high vagal lesion who was treated with laryngeal framework surgery from June 1992 to April 1996 at a university medical center • RESULTS: • 35 patients underwent MTs. • 95% experienced aspiration improved • 90% noted to have subjective improvement in voice postoperatively. • CONCLUSION: • Laryngeal framework surgery improves airway, deglutition, and voice in individuals suffering from high vagal lesions, and facilitates the rehabilitation of these patients.

25. Efficacy of medialization thyroplasty • Thevasagayam MS, Willson K, Jennings C, Pracy P. Bilateral medialization thyroplasty: an effective approach to severe, chronic aspiration. J Laryngol Otol. 2006 Aug;120(8):698-701. Epub 2006 Jun 2. • MATERIALS AND METHODS: • Three cases that underwent bilateral medialization thyroplasty are described. The technique used was the standard medialization thyroplasty described by Isshiki as a unilateral procedure. • RESULTS: • All patients stopped aspirating following surgery. One patient returned to a normal diet and one patient returned to a solid diet. All patients required a permanent tracheostomy • CONCLUSION: • Bilateral medialization thyroplasty offers an effective surgical option in the treatment of severe, chronic aspiration. It maintains good voice, with a possible return to oral diet.

26. Tracheoesophageal diversion

27. Active treatment • Stabilizing the patient's airway, breathing, and circulation (ABC) • Airway: • suctioning of the upper airway • Intubation: considered in any patient who is unable to protect his or her airway • Breathing: • Oxygen supplementation • Circulation: • Cardiac monitoring and pulse oximetry • Intravenous catheter placement and intravenous fluids as indicated

28. Treatment of complications • Complications: • lung abscess • Empyema • Management: • Adequate duration of appropriate antibiotic (4-8 weeks) • Adequate drainage

29. Thank you.