High incidence of silent aspiration in elderly patients with community-acquired pneumonia

Pneumonia risk and use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

Background

Recent studies have shown that use of angiotensin-converting enzyme (ACE) inhibitors may decrease pneumonia risk in various populations. We investigated the effect of ACE inhibitors and angiotensin II receptor blockers (ARBs) on pneumonia hospitalization in the general population of Taiwan.

Methods

We conducted a case-crossover study using the Taiwan Longitudinal Health Insurance Database for the year 2005. Data from patients hospitalized for the first time for pneumonia during 1997–2007 were analyzed. The case period was defined as the 30 days before admission; the periods 90 to 120 days and 180 to 210 days before admission were used as control periods. Prescribing status of ACE inhibitors and ARBs during the 3 periods was assessed for each patient. Conditional logistic regression was used to estimate the odds ratio (OR) for pneumonia associated with use of ACE inhibitors and ARBs.

Results

We identified 10 990 cases of hospitalization for new pneumonia. After adjustment for time-variant confounding factors, pneumonia was not associated with use of ACEI or ARBS: the ORs were 0.99 (95% CI, 0.81–1.21) and 0.96 (0.72–1.28), respectively. No association was seen for cumulative defined daily doses (DDDs), as compared with nonusers, for 0 to 30, 31 to 60, or more than 60 DDDs. The results were found to be robust in sensitivity analysis.

Conclusions

Neither the use nor cumulative dose of ACE inhibitors or ARBs was associated with pneumonia among the Taiwanese general population.

[Relationship between comprehensive quality of life and factors related to chewing and swallowing function among community-dwelling elderly individuals]

AIM

The purpose of the present study was to examine the relationship between comprehensive quality of life (QOL) and some factors regarding chewing and swallowing function among community-dwelling elderly individuals.

METHODS

The subjects were 675 independent elderly persons residing in the northern area of Miyazaki Prefecture, and we obtained the self-administered questionnaires from 545 elderly people. We used "active scale for the elderly (ASE)" and "dysphagia risk assessment for the community-dwelling elderly (DRACE)" to evaluate their comprehensive QOL and function of chewing and swallowing, respectively. Furthermore, we examined some factors such as age, gender, subjective satisfaction with diet and verbal communication.

RESULTS

The score of ASE showed a significant decline with age (p<0.01) while the DRACE score increased significantly with age (p<0.01). Pearson's correlation coefficients revealed that the ASE score was significantly related to all of the factors regarding regulation of food intake. Partial correlation coefficients adjusted for age also revealed the same tendency. From the multiple regression analysis, subjective satisfaction with verbal communication, DRACE score, age and appetite were extracted as factors influencing ASE score (adjusted R(2)=0.43, p<0.01).

CONCLUSION

Among independent elderly persons residing in the community, the comprehensive QOL was significantly related to factors such as subjective satisfaction with verbal communication, dysphagia risk, age, and appetite.

[An elderly case of post-gastrectomy aspiration pneumonia following an influenza virus A infection]

A 85-year-old female was admitted to our hospital because of a fever and unconsciousness. Three days prior to admission, she had been diagnosed to have influenza A, and oseltamivir was therefore prescribed. The symptoms due to the influenza infection, including the fever, thereafter rapidly resolved. She regularly took 10 mg zopiclone for insomnia before sleeping. On the day of admission, she was drowsy with fever. Chest radiography showed bilateral massive infiltration of the lungs. Chest CT images revealed multilobar and nodular infiltration on both lungs. She underwent the partial gastrectomy 10 years ago due to the gastrointestinal bleeding. After that, gastro-esophageal reflux syndrome was occurred in the patient. A bronchoscope was easily inserted into the trachea without anesthesia. Aspirated saliva was found in trachea. Based on her post-gastrectomy state, post-gastrectomy aspiration pneumonia was diagnosed. Sulbactam/ampicillin (SBT/ABPC) (6 g) was administered daily, which led to reduced inflammatory responses and lung infiltration. Although influenza itself is sometimes critical for the elderly, careful attention should be paid to subsequent bacterial infections in patients who are at risk for developing aspiration pneumonia.

Increased expression levels of integrin α9β1 and CD11b on circulating neutrophils and elevated serum IL-17A in elderly aspiration pneumonia

BACKGROUND

Repeated aspiration pneumonia is a serious problem in the elderly. In aspiration pneumonia, neutrophils play an important role in acute lung injury, while CD18-independent neutrophil transmigration pathways have also been reported in acid-aspiration pneumonia animal models. However, the involvement of IL-17A and β1 integrin still remains unclear. The β1 integrin subfamily integrin α9β1 has been shown to be expressed on human neutrophils and to mediate adhesion to extracellular matrix proteins including the vascular cell adhesion molecule-1.

OBJECTIVES

To elucidate the possible involvement of β1 integrin subfamily and IL-17A in aspiration pneumonia.

METHODS

We analyzed the expression levels of CD11b, CD18 and integrin α9β1 in circulating neutrophils and serum concentration of IL-17A, IL-22 and IL-23 in elderly aspiration pneumonia patients (n = 32, 14 males and 18 females, 78.8 ± 3.9 years old) at 2 time points (on the day of admission before starting antibiotics and the day after finishing antibiotics) and compared the results with those of a control group (n = 30, 13 males and 17 females, 76.1 ± 3.4 years old).

RESULTS

Recombinant IL-17A stimulated integrin α9β1 and CD11b expression levels in healthy human neutrophils in vitro. The expression levels of integrin α9β1 and CD11b in circulating neutrophils were significantly higher in pneumonia patients compared with the controls. In addition, serum IL-17A concentration was significantly increased in pneumonia patients. Integrin α9β1 levels positively correlated with serum IL-17A and CD18 expression levels.

CONCLUSIONS

These findings suggest a potential role of integrin α9β1 expressed in neutrophils and elevated serum IL-17A in extravasation of neutrophils in cases of aspiration pneumonia.

Severe brain atrophy in the elderly as a risk factor for lower respiratory tract infection

BACKGROUND

The purpose of this study is to determine whether elderly subjects with severe brain atrophy, which is associated with neurodegeneration and difficulty swallowing (dysphagia), are more susceptible to lower respiratory tract infections (LRTI), including pneumonia.

METHODS

The severity of brain atrophy was assessed by computed tomography in 51 nursing home residents aged 60-96 years. The incidence of LRTI, defined by body temperature ≥ 38.0°C, presence of two or more respiratory symptoms, and use of antibiotics, was determined over 4 years. The incidence of LRTI was compared according to the severity and type of brain atrophy.

RESULTS

The incidence rate ratio of LRTI was significantly higher (odds ratio 4.60, 95% confidence interval 1.18-17.93, fully adjusted P = 0.028) and the time to the first episode of LRTI was significantly shorter (log-rank test, P = 0.019) in subjects with severe brain atrophy in any lobe. Frontal and parietal lobe atrophy was associated with a significantly increased risk of LRTI, while temporal lobe atrophy, ventricular dilatation, and diffuse white matter lesions did not influence the risk of LRTI.

CONCLUSION

Elderly subjects with severe brain atrophy are more susceptible to LRTI, possibly as a result of neurodegeneration causing dysphagia and silent aspiration. Assessing the severity of brain atrophy might be useful to identify subjects at increased risk of respiratory infections in a prospective manner.

Aging-related geniohyoid muscle atrophy is related to aspiration status in healthy older adults

BACKGROUND

Age-related muscle weakness due to atrophy and fatty infiltration in orofacial muscles may be related to swallowing deficits in older adults. An important component of safe swallowing is the geniohyoid (GH) muscle, which helps elevate and stabilize the hyoid bone, thus protecting the airway. This study aimed to explore whether aging and aspiration in older adults were related to GH muscle atrophy and fatty infiltration.

METHOD

Eighty computed tomography scans of the head and neck from 40 healthy older (average age 78 years) and 40 younger adults (average age 32 years) were analyzed. Twenty aspirators and 20 nonaspirators from the 40 older adults had been identified previously. Two-dimensional views in the sagittal and coronal planes were used to measure the GH cross-sectional area and fatty infiltration.

RESULTS

GH cross-sectional area was larger in men than in women (p < .05). Decreased cross-sectional area was associated with aging (p < .05), and cross-sectional area was significantly smaller in aspirators compared with nonaspirators, but only among the older men (p < .01). Increasing fatty infiltration was associated with aging in the middle (p < .05) and posterior (p < .01) portions of the GH muscle. There was no significant difference in fatty infiltration of the GH muscle among aspirators and nonaspirators.

CONCLUSION

GH muscle atrophy was associated with aging and aspiration. Fatty infiltration in the GH muscle was increased with aging but not related to aspiration status. These findings suggest that GH muscle atrophy may be a component of decreased swallowing safety and aspiration in older adults and warrants further investigation.

The effect of bedside exercise program on stroke patients with Dysphagia

Objective

To examine the effects of a bedside exercise program on the recovery of swallowing after a stroke.

Method

Fifty stroke patients with dysphagia (<6 months post-stroke) were enrolled and classified into two groups, the experimental (25 subjects) and control groups (25 subjects). The control group was treated with conventional swallowing therapy. The experimental group received additional bedside exercise training, which consisted of oral, pharyngeal, laryngeal, and respiratory exercises, 1 hour per day for 2 months, and they were instructed regarding this program through the nursing intervention. All patients were assessed for their swallowing function by Videofluoroscopic Swallowing Study (VFSS), using the New VFSS scale, the level of functional oral intake, the frequency of dysphagia complications, the presence (or not) of tube feeding, the mood state and quality of life before the treatment and at 2 months after the treatment.

Results

After 2 months of treatment, the experimental group showed a significant improvement in the swallowing function at the oral phase in the New VFSS Scale than that of the control group (p<0.05). Further, they also showed less depressive mood and better quality of life than the control group. However, there was no significant change in the incidence of dysphagia complication and the presence (or not) of tube feeding between the two groups.

Conclusion

Bedside exercise program showed an improvement of swallowing function and exhibited a positive secondary effect, such as mood state and quality of life, on subacute stroke patients with dysphagia. For improvement of rehabilitation results on subacute stroke patients with dysphagia, this study suggests that additional intensive bedside exercise would be necessary.

Review Series: Old age: Pneumonia in old age

At the end of the 19th century William Osler noted key differences in the presentation of pneumonia in the elderly. His observational perspicuity has withstood the passage of time. The following article pays deference to this Canadian physician, summarizing not only differences in clinical presentation but also including an update on epidemiology, aetiology and management.

Nicergoline improves dysphagia by upregulating substance P in the elderly

Dysphagia induces silent aspiration, which is a known risk factor for aspiration pneumonia in the elderly. Dysphagia is associated with impaired substance P secretion. Because nicergoline was recently reported to enhance substance P secretion, it may improve dysphagia by upregulating substance P; however, roles for nicergoline in this process have not been demonstrated. We therefore compared the effects of nicergoline on serum substance P and dysphagia with the effects of imidapril, an angiotensin-converting enzyme (ACE) inhibitor whose efficacy in improving dysphagia and preventing pneumonia has been previously demonstrated.We randomly assigned 60 elderly patients with both dysphagia and a previous history of pneumonia to receive either imidapril (5 mg/d; n = 30) or nicergoline (15 mg/d; n = 30) for 6 months. Primary outcomes were the effects of these drugs on the substance P level and dysphagia 4 weeks after the start of treatment. Secondary outcome was the effect of these drugs on pneumonia recurrence during the 6 months of treatment.Significant elevations of serum substance P were obtained by both medications after 4 weeks of treatment. Patients whose dysphagia was improved showed significantly increased serum levels of substance P. There was no statistically significant difference in the overall proportion of patients who showed improvements in dysphagia and pneumonia recurrence with imidapril or nicergoline treatment. Nicergoline, but not imidapril, seemed to be more effective at improving dysphagia and elevating serum substance P in patients with dementia.In conclusion, nicergoline has a comparable effect to ACE inhibitors for improving dysphagia. Nicergoline might be a novel regimen for the treatment of dysphagia in the elderly who are not treatable with ACE inhibitors.

Community-acquired pneumonia in the elderly

BACKGROUND

Community-acquired pneumonia (CAP) is a frequent cause of hospitalization and death among the elderly.

OBJECTIVE

This article reviews information on CAP among the elderly, including age-related changes, predisposing risk factors, causes, treatment strategies, and prevention.

METHODS

Searches of MEDLINE (January 1990-November 2009), International Pharmaceutical Abstracts (January 1990-November 2009), and Google Scholar were conducted using the terms community-acquired pneumonia, pneumonia, treatment guidelines, and elderly. Additional publications were found by searching the reference lists of the identified articles. Studies that reported diagnostic criteria as well as the treatment outcomes achieved in adult patients with CAP were selected for this review.

RESULTS

Three practice guidelines, 5 reviews, and 43 studies on CAP in the elderly were identified in the literature search. Based on those publications, risk factors that predispose the elderly to pneumonia include comorbid conditions, poor functional and nutritional status, consumption of alcohol, and smoking. The clinical presentation of pneumonia in the elderly (>/=65 years of age) may be subtle, lacking the typical acute symptoms (fever, cough, dyspnea, and purulent sputum) observed in younger adults. Pneumonia should be suspected in all elderly patients who have fever, altered mental status, or a sudden decline in functional status, with or without lower respiratory tract symptoms such as cough, purulent sputum, and dyspnea. Treatment of CAP in the elderly should be guided by the latest recommendations of the Infectious Diseases Society of America and the American Thoracic Society (IDSA/ATS), along with consideration of local rates and patterns of antimicrobial resistance, as well as individual patient risk factors for acquiring less common or more resistant pathogens. Recommended empiric antimicrobial regimens generally consist of either a beta-lactam plus a macrolide or a respiratory fluoroquinolone alone. Adherence to the IDSA/ATS guidelines has been found to improve in-hospital mortality (adherence vs nonadherence, 8%; 95% CI, 7%-10% vs 17%; 95% CI, 14%-20%; P< 0.01), length of hospital stay (8 days; interquartile range [IQR], 5-15 vs 10 days; IQR, 6-24 days, respectively; P < 0.01), and time to clinical stability in elderly patients with CAP (percentage of stable patients by day 7, 71%; 95% CI, 68%-74% vs 57%; 95% CI, 53%-61%, respectively; P < 0.01). All elderly patients should be vaccinated against pneumococcal disease and influenza based on recommendations from the Centers for Disease Control and Prevention. Lifestyle modifications and nutritional support are also important elements in the prevention of pneumonia in the elderly.

CONCLUSION

Adherence to established guidelines, along with customization of antimicrobial therapy based on local rates and patterns of resistance and patient-specific risk factors, likely will improve the treatment outcome of elderly patients with CAP.

[Follow-up of dysphagia in the elderly--clinical survey of deglutition disorder at a private ENT office]

In a one-year-plus follow-up study in 17 of 26 cases involving apparent liquid aspiration during videoendoscopic screening, subjects were instructed in swallowing using video images and in choosing food, utensils, and posture. The amount of sputum decreased in 10 case (59%), and sputum sticking in the throat disappeared in 4 (18%). Body weight also increased in 4 (24%). Choking coughs noted in 11 during initial videoendoscopy disappeared in 2 (18%). We thus, concluded that detecting dysphagia symptoms early and providing follow-up could help prevent aspiration pneumonia.

Aspiration syndromes: aspiration pneumonia and pneumonitis

Aspiration pneumonia and pneumonitis are common clinical syndromes that occur in hospitalized patients. Aspiration pneumonia occurs in patients with dysphagia and usually presents as a community-acquired pneumonia with a focal infiltrate in a dependent bronchopulmonary segment. Patients with aspiration pneumonia require treatment with broad-spectrum antibiotics and management of the underlying dysphagia. Aspiration pneumonitis follows the aspiration of gastric contents, usually in patients with a marked decreased level of consciousness. Treatment of aspiration pneumonitis is essentially supportive; however, corticosteroids and other immunomodulating agents may have a role in these patients.

Tazobactam/piperacillin for moderate-to-severe pneumonia in patients with risk for aspiration: comparison with imipenem/cilastatin

BACKGROUND

Treatment of aspiration pneumonia is becoming an important issue due to aging of populations worldwide. Effectiveness of tazobactam/piperacillin (TAZ/PIPC) in aspiration pneumonia is not clear.

PURPOSE

To compare clinical efficacy between TAZ/PIPC (1:4 compound) and imipenem/cilastatin (IPM/CS) in patients with moderate-to-severe aspiration pneumonia.

PATIENTS AND METHODS

In this open-label, randomized study either TAZ/PIPC 5 g or IPM/CS 1 g was intravenously administered every 12 h to patients with moderate-to-severe community-acquired aspiration pneumonia or nursing home-acquired pneumonia with risk for aspiration pneumonia for average 11 days. The primary outcome was clinical response rate at the end of treatment (EOT) in validated per-protocol (VPP) population. Secondary outcomes were clinical response during treatment (days 4 and 7) and at the end of study (EOS) in VPP population, and survival at day 30 in modified intention-to-treat (MITT) population.

RESULTS

There was no difference between the groups in primary or secondary outcome. However, significantly faster improvement as measured by axillary temperature (p < 0.05) and WBC count (p = 0.01) was observed under TAZ/PIPC treatment. In patients with gram-positive bacterial infection, TAZ/PIPC was more effective at EOT in VPP population (p = 0.03).

CONCLUSION

TAZ/PIPC is as effective and safe as IPM/CS in the treatment of moderate- to-severe aspiration pneumonia.

The pathogenesis of acute pulmonary viral and bacterial infections: investigations in animal models

Acute viral and bacterial infections in the lower respiratory tract are major causes of morbidity and mortality worldwide. The proper study of pulmonary infections requires interdisciplinary collaboration among physicians and biomedical scientists to develop rational hypotheses based on clinical studies and to test these hypotheses in relevant animal models. Animal models for common lung infections are essential to understand pathogenic mechanisms and to clarify general mechanisms for host protection in pulmonary infections, as well as to develop vaccines and therapeutics. Animal models for uncommon pulmonary infections, such as those that can be caused by category A biothreat agents, are also very important because the infrequency of these infections in humans limits in-depth clinical studies. This review summarizes our understanding of innate and adaptive immune mechanisms in the lower respiratory tract and discusses how animal models for selected pulmonary pathogens can contribute to our understanding of the pathogenesis of lung infections and to the search for new vaccines and therapies.

Aspiration pneumonia

Aspiration pneumonia is diagnosed upon confirmation of inflammatory findings in the lungs and overt aspiration (apparent aspiration) or a condition in which aspiration is strongly suspected (abnormal swallowing function and dysphagia). In hospital-acquired pneumonia, this occurs as one consequence of frequent silent aspiration. In the diagnosis of aspiration pneumonia, evaluation of the risk of silent aspiration during the night and evaluation of swallowing function are important. The causative microorganisms in aspiration pneumonia, similar to community-acquired pneumonia, are basically thought to be bacteria residing in the oral cavity, such as pneumococcus, Haemophilus influenzae, Staphylococcus aureus and anaerobes. Hospital-acquired aspiration pneumonia often occurs with no distinction between apparent and silent aspiration, and in many cases, aspiration of foreign substances is serious when dysphagia itself is severe. In the treatment of aspiration pneumonia, use of antimicrobials for the pneumonia itself and early measures to prevent aspiration are important.

Can continuous pump feeding reduce the incidence of pneumonia in nasogastric tube-fed patients? A randomized controlled trial

BACKGROUND & AIMS

Continuous pump feeding is often used to reduce aspiration risk in older patients on tube feeding, but its effectiveness in preventing aspiration pneumonia is unproven. A randomized controlled trial was therefore performed to examine the effectiveness of continuous pump feeding in decreasing the incidence of pneumonia in tube-fed older hospital patients.

METHODS

One hundred and seventy eight elderly patients from three convalescence hospitals and one infirmary, on nasogastric tube feeding, were randomly assigned to have intermittent bolus (bolus) or continuous pump (pump) feeding for 4weeks. The primary outcome was the incidence of pneumonia. The secondary outcome was mortality.

RESULTS

Eighty five subjects were randomized into the pump group and 93 in the bolus group. The groups were comparable in age, nutritional and functional status, co-morbidities and history of pneumonia, except that there were more women in the pump group. Within 4weeks, 15 subjects (17.6%) in the pump group and 18 (19.4%) in the bolus group developed pneumonia. Seven subjects (8.2%) in pump group and 13 subjects (14.0%) in bolus group died. There was no significant difference in either pneumonia or death rates between the two groups.

CONCLUSION

Continuous pump feeding did not significantly affect the rates of pneumonia or mortality in tube-fed older hospital patients when compared with intermittent bolus feeding.

Novel preventive and therapuetic strategy for post-stroke pneumonia

Pneumonia is a significant complication of ischemic stroke that increases mortality. Post-stroke pneumonia is defined as newly developed pneumonia following stroke onset. Clinically and chronologically, post-stroke pneumonia is divided into two types of aspiration pneumonia. First, acute-onset post-stroke pneumonia occurs within 1 month after stroke. Second, insidious or chronic-onset post-stroke pneumonia occurs 1 month after the stroke. The mechanisms of pneumonia are apparent aspiration and dysphagia-associated microaspiration. Stroke and the post-stroke state are the most significant risk factors for aspiration pneumonia. The preventive and therapeutic strategies have been developed thoroughly and appropriate antibiotic use, and both pharmacological and nonpharmacological approaches for the treatment of post-stroke pneumonia have been studied rigorously. Increases in substance P levels, oral care, and swallowing rehabilitation are necessary to improve swallowing function in post-stroke patients, resulting in a reduction in the incidence of post-stroke pneumonia in a chronic stage. The stroke must be a cause of aspiration pneumonia.

Trappin-2 promotes early clearance of Pseudomonas aeruginosa through CD14-dependent macrophage activation and neutrophil recruitment

Microaspiration of Pseudomonas aeruginosa contributes to the pathogenesis of nosocomial pneumonia. Trappin-2 is a host defense peptide that assists with the clearance of P. aeruginosa through undefined mechanisms. A model of macrophage interactions with replicating P. aeruginosa (strain PA01) in serum-free conditions was developed, and the influence of subantimicrobial concentrations of trappin-2 was subsequently studied. PA01 that was pre-incubated with trappin-2 (at concentrations that have no direct antimicrobial effects), but not control PA01, was cleared by alveolar and bone marrow-derived macrophages. However, trappin-2-enhanced clearance of PA01 was completely abrogated by CD14- null macrophages. Fluorescence microscopy demonstrated the presence of trappin-2 on the bacterial cell surface of trappin-2-treated PA01. In a murine model of early lung infection, trappin-2-treated PA01 was cleared more efficiently than control PA01 2 hours of intratracheal instillation. Furthermore, trappin-2-treated PA01 up-regulated the murine chemokine CXCL1/KC after 2 hours with a corresponding increase in neutrophil recruitment 1 hour later. These in vivo trappin-2-treated PA01 effects were absent in CD14-deficient mice. Trappin-2 appears to opsonize P. aeruginosa for more efficient, CD14-dependent clearance by macrophages and contributes to the induction of chemokines that promote neutrophil recruitment. Trappin-2 may therefore play an important role in innate recognition and clearance of pathogens during the very earliest stages of pulmonary infection.

Pneumonia in the elderly: a review of the epidemiology, pathogenesis, microbiology, and clinical features

Pneumonia is a common and important disease in the elderly. The incidence is expected to rise as the population ages, and, therefore, it will become an increasingly significant problem in hospitals and the community. A comprehensive literature review was performed in order to look at the characteristics of pneumonia in the elderly population. In particular, the epidemiology, etiology and pathogenesis--including risk factors, microbiology, and clinical features--were evaluated. While aging causes physiological changes which make elderly patients more susceptible to pneumonia, it was found that comorbidities, rather than age, are also an important risk factor. The most common micro-organism responsible for pneumonia is Streptococcus pneumoniae, but other organisms need to be considered, depending on the environment of presentation. Elderly patients are more likely than younger adults to present with an absence of fever and an altered mental state. Nursing home residents tend to present with more atypical and less characteristic symptoms.

Community-acquired pneumonia in elderly patients

Community-acquired pneumonia continues to have a significant impact on elderly individuals, who are affected more frequently and with more severe consequences than younger populations. As the population ages it is expected that the medical and economic impact of this disease will increase. Despite these concerns, little progress has been made in research specifically focusing on community-acquired pneumonia in the elderly. Data continue to show that a high index of suspicion, early antimicrobial therapy and appropriate medications to cover typical pathogens are extremely important in treating community-acquired pneumonia in older individuals. This review is designed to serve as an update to our previous work published in Aging Health in 2006, with specific emphasis on the most recent evidence published since that time.

Oropharyngeal dysphagia in long-term care: misperceptions of treatment efficacy

The assessment and management of patients in long-term care who have oropharyngeal dysphagia has developed into an apparently complex and distinct field of practice. It is unfortunate that it lacks an evidence base, the efficacy of treatment is not established, and many clinicians are unfamiliar with appropriate and effective interventions because of a lack of training. Some commonly used interventions are not only ineffective but potentially hazardous. Physicians must become more familiar with the assessment process and appropriate management.

Use of ACE inhibitors and risk of community-acquired pneumonia: a review

BACKGROUND

The administration of angiotensin-converting enzyme (ACE) inhibitors has been suggested as an alternative strategy for lowering the risk of community-acquired pneumonia (CAP) in the elderly, especially in patients with neurological and cerebrovascular comorbidity.

METHODS

We critically examined the relevant data from studies regarding the impact of ACE inhibitors in lowering the risk of CAP and/or mortality due to CAP in the elderly. We searched PubMed, Cochrane Database, and references of initially retrieved articles, and http://clinicaltrials.gov for ongoing trials.

RESULTS

We identified 285 evaluable studies. Fourteen studies met the inclusion criteria and were evaluated further, of which seven were prospective studies, two randomized controlled trials, and five retrospective studies. Eight of ten studies including patients of Asian origin demonstrated a statistical significance in favor of ACE inhibitors. On the contrary, only one of five studies including patients of non-Asian origin demonstrated results in favor of ACE inhibitors.

CONCLUSION

The available data suggest that ACE inhibitors may contribute to the reduction of the risk of CAP. Nevertheless, clinical data are scarce and mainly comprise studies including patients of Asian origin. As there seem to be differences regarding the genetic polymorphism of ACE among patients of different origins, future studies are needed that incorporate relevant genetics data that may help clarify the role, if any, of ACE inhibitors in preventing CAP.

Professional Oral Health Care Reduces the Number of Oropharyngeal Bacteria

Silent aspiration of oropharyngeal pathogenic organisms is a significant risk factor causing pneumonia in the elderly. We hypothesized that regular oral hygiene care will affect the presence of oropharyngeal bacteria. Professional cleaning of the oral cavity and/or the gargling of a disinfectant liquid solution was performed over a five-month period in three facilities for the dependent elderly. Total oropharyngeal bacteria, streptococci, staphylococci, Candida, Pseudomonas, and black-pigmented Bacteroides species were monitored. The levels of these oropharyngeal bacteria decreased or disappeared after weekly professional oral health care, i.e., cleaning of teeth, dentures, tongue, and oral mucous membrane by dental hygienists. After lunch, gargling with povidone iodine was shown to be less effective than professional oral care. These findings indicate that weekly professional mechanical cleaning of the oral cavity, rather than a daily chemical disinfection of the mouth, can be an important strategy to prevent aspiration pneumonia in the dependent elderly.

Healthcare-associated pneumonia: principles and emerging concepts on management

Healthcare-associated pneumonia (HCAP) is a relatively new entity that includes pneumonia occurring in healthcare settings other than acute-care hospitals. Many patients with HCAP are at greater risk for colonization and infection with multi-drug resistant (MDR) bacteria such as Pseudomonas aeruginosa, Gram-negative bacilli-producing extended-spectrum beta-lactamases and methicillin-resistant Staphylococcus aureus. Infections with these MDR pathogens require different empiric antibiotic therapy. To avoid initiation of inappropriate antibiotic therapy that may result in poorer patient outcomes, new principles for HCAP management were outlined in the 2005 American Thoracic Society and Infectious Diseases Society of America guidelines. These guidelines were suggested for patients assessed in acute-care hospitals and clinics, and may not be applicable for all patients with suspected HCAP in nursing homes and other long-term care settings. This review article addresses HCAP management strategies in both clinical settings.

Mechanical ventilation and acute respiratory distress syndrome in older patients

As the population of the United States ages, an increasing number of elderly adults will be cared for in intensive care units. An understanding of how aging affects the respiratory system is important for patient care and ongoing research. The incidence rates of acute respiratory failure and of acute respiratory distress syndrome increase dramatically with age, and therefore understanding the relationship between age and ARDS is important. This article focuses on the age-specific changes in respiratory function. We present a discussion of the management of acute lung injury and acute respiratory distress syndrome with a focus on the role of mechanical ventilation. We conclude with what is known about age and its impact on mortality and functional outcomes after mechanical ventilation.

Improving outcomes of elderly patients with community-acquired pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people. However, respiratory viruses and 'atypical' organisms such as Chlamydia pneumoniae are being described with increasing frequency in old patients, and aspiration pneumonia should also be taken into consideration, particularly in very elderly subjects and those with dementia. Age >65 years is a well established risk factor for infection with drug-resistant S. pneumoniae. Clinicians should be aware of additional risk factors for acquiring less common pathogens or antibacterial-resistant organisms that may suggest that additions or modifications to the basic empirical regimen are warranted. In addition to administration of antibacterials, appropriate supportive therapy, covering management of severe sepsis and septic shock, respiratory failure, as well as management of any decompensated underlying disease, may be critical to improving outcomes in elderly patients with CAP. Immunization with pneumococcal and influenza vaccines has also been demonstrated to be beneficial in numerous large studies. There is good evidence that implementation of guidelines leads to improvement in clinical outcomes in elderly patients with CAP, including a reduction in mortality. Protocols should address a comprehensive set of elements in the process of care and should periodically be evaluated to measure their effects on clinically relevant outcomes. Assessment of functional clinical outcome variables, in addition to survival, is strongly recommended for this population.