Rehabilitative management for aspiration pneumonia in elderly patients

Aspiration Pneumonia

Aspiration pneumonia is a lower respiratory tract infection that results from inhalation of foreign material, often gastric and oropharyngeal contents. It is important to distinguish this from a similar entity, aspiration with chemical pneumonitis, as treatment approaches may differ. An evolving understanding of the human microbiome has shed light on the pathogenesis of aspiration pneumonia, suggesting that dysbiosis, repetitive injury, and inflammatory responses play a role in its development. Risk factors for aspiration events involve a complex interplay of anatomical and physiological dysfunctions in the nervous, gastrointestinal, and pulmonary systems. Current treatment strategies have shifted away from anaerobic organisms as leading pathogens. Prevention of aspiration pneumonia primarily involves addressing oropharyngeal dysphagia, a significant risk factor for aspiration pneumonia, particularly among elderly individuals and those with cognitive and neurodegenerative disorders.

Lymphatic flow mapping using near-infrared fluorescence imaging with indocyanine green helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer not treated with neoadjuvant chemotherapy

BACKGROUND

Lymphatic flow mapping using near-infrared fluorescence (NIR) imaging with indocyanine green (ICG) has been used for the intraoperative prediction of lymph node metastasis in esophageal or esophagogastric junction cancer. However, a consistent method that yields sufficient diagnostic quality is yet to be confirmed. This study explored the diagnostic utility of our newly established lymphatic flow mapping protocol for predicting lymph node metastasis in patients with esophageal or esophagogastric junction cancer.

METHODS

We injected 0.5 mL of ICG (500 μg/mL) into the submucosal layer at four peritumoral points on the day before surgery for 54 patients. We performed lymphatic flow mapping intraoperatively using NIR imaging. After determining the NIR status and presence of metastases, evaluable lymph node stations on in vivo imaging and all resected lymph nodes were divided into four categories: ICG+meta+ (true positive), ICG+meta- (false positive), ICG-meta+ (false negative), and ICG-meta- (true negative).

RESULTS

The distribution of ICG+ and meta+ lymph node stations differed according to the primary tumor site. Sensitivity and specificity for predicting meta+ lymph nodes among ICG+ ones were 50% (95% CI 41-59%) and 75% (73-76%), respectively. Predicting meta+ lymph node stations among ICG+ stations improved these values to 66% (54-77%) and 77% (74-79%), respectively. Undergoing neoadjuvant chemotherapy was an independent risk factor for having meta+ lymph nodes with false-negative diagnoses (odds ratio 4.82; 95% CI 1.28-18.19). The sensitivity of our technique for predicting meta+ lymph nodes and meta+ lymph node stations in patients who did not undergo neoadjuvant chemotherapy was 79% (63-90%) and 83% (61-94%), respectively.

CONCLUSION

Our protocol potentially helps to predict lymph node metastasis intraoperatively in patients with esophageal or esophagogastric junction cancer undergoing esophagectomy who did not undergo neoadjuvant chemotherapy.

Comparison of the thickness of the erector spinae muscles between aspiration pneumonia and bacterial pneumonia patients

BACKGROUND AND AIMS

Aspiration pneumonia is generally associated with deterioration of skeletal muscle mass, which is usually evaluated by the erector spinae muscle cross-sectional area (ESMCSA); however, no report has assessed ESMCSA in patients with aspiration pneumonia. Furthermore, erector spinae muscle thickness (ESMT) was developed to be easier to measure than ESMCSA. Therefore, this study investigated the relationship between ESMT and ESMCSA in aspiration pneumonia patients compared to bacterial pneumonia patients.

METHODS

We retrospectively collected data for 164 patients with aspiration pneumonia and 480 patients with bacterial pneumonia who were hospitalized at Fukujuji Hospital between September 2018 and May 2022. We assessed the correlations between ESMCSA and ESMT and compared the data between the two groups.

RESULTS

ESMT had a strong, proportional relationship with ESMCSA in all patients (r = 0.908, p < 0.001) and those with aspiration pneumonia (r = 0.896, p < 0.001). ESMCSA (median 671.8 mm2 [range 164.0-1636.7] vs. median 1057.0 mm2 [range 161.3-2412.5], p < 0.001) and ESMT (median 17.1 mm [range 6.95-34.4] vs. median 23.8 mm [range 6.95-43.7], p < 0.001) were significantly lower in patients with aspiration pneumonia. A multivariate analysis of aspiration pneumonia diagnosis showed significant independent differences from bacterial pneumonia in ESMCSA (odds ratio 0.998 [95% CI: 0.996-0.999], p = 0.001) and ESMT (odds ratio 0.90 [95% CI: 0.84-0.96], p = 0.002).

CONCLUSION

This study demonstrates a strong correlation between ESMCSA and ESMT. ESMT can be more easily used to evaluate skeletal muscle mass and can help in diagnosing aspiration pneumonia.

Association between the amount of rehabilitation and the outcomes in patients with aspiration pneumonia

The appropriate amount of rehabilitation for aspiration pneumonia remains unknown. We conducted a historical cohort study to investigate the association between the amount of rehabilitation provided and the outcome of patients with aspiration pneumonia. A total of 4148 patients with aspiration pneumonia recruited from a database created by JMDC were categorized into three groups based on daily rehabilitation units: none or <1 unit (low-volume group), 1-2 units (medium-volume group), and more than 2 units (high-volume group). The main outcome measures were death in the hospital, discharge home, and length of hospital stay. The results showed that the middle-volume and high-volume groups had significantly fewer in-hospital deaths [middle-volume group, odds ratio (OR) 0.62; 95% confidence interval (CI), 0.46-0.83; high-volume group, OR 0.66; 95% CI, 0.45-0.97], more patients were discharged home (middle-volume group, OR 1.29; 95% CI, 1.03-1.62; high-volume group, OR 2.00; 95% CI, 1.48-2.71), and shorter hospital stay (middle-volume group, coefficient -3.30; 95% CI, -6.42 to -0.19; high-volume group, coefficient -4.54; 95% CI, -8.69 to -0.40) compared with the low-volume group. In conclusion, higher rehabilitation units per day provided to patients with aspiration pneumonia were associated with fewer deaths, more home discharges, and shorter hospital stays.

The role of transcranial direct current stimulation in diminishing the risk of pneumonia in patients with dysphagia: A double-blinded randomized clinical trial

Background: Dysphagia can be a life-threatening issue for post-stroke patients, with aspiration pneumonia (AP) being a common risk. However, there is hope through the potential combination of transcranial direct current stimulation (tDCS) and classical behavior therapy. Our study aims to investigate the effectiveness of this combination in diminishing the risk of AP in patients with dysphagia who suffered from stroke. Methods: In this randomized, parallel-group, blinded clinical trial, 48 patients were allocated into the sham group (speech therapy + 30 seconds of tDCS) and the real group (speech therapy + 20 minutes of tDCS). We used the Mann Assessment of Swallowing Ability (MASA) as an assessment tool. We assessed patients at baseline, one day after treatment, and at a one-month follow-up. Results: Groups showed no significant difference at baseline. After treatment, the real group showed a significant difference in the severity risk of AP (P = 0.02); the same was for the follow-up (P = 0.04). The number of patients showing severe risk of AP was higher in the sham group after treatment (n = 13, 54.20%) and at follow-up (n = 4, 18.20%) than the real group (n = 4, 16.70%; n = 1, 4.50%, respectively). None of the patients reported the history of AP at any stage of assessment. Conclusion: Although the results were more promising in the real group than the sham group in reducing the risk of AP, both techniques can prevent AP. Therefore, we recommend early dysphagia management to prevent AP regardless of the treatment protocol.

Mortality from Aspiration Pneumonia: Incidence, Trends, and Risk Factors

Aspiration pneumonia is a potentially preventable, aggressive type of pneumonia. Little is understood on the burden in mortality from aspiration pneumonia. Our objectives were to first examine the burden of mortality from aspiration pneumonia in the United States and second investigate comorbidities associated with aspiration pneumonia to understand risk factors. We conducted a case-control study of individuals who died of aspiration pneumonia matched to those who died of other causes. We analyzed all deaths in the United States using the Multiple Cause of Death Dataset from 1999 to 2017. Cases were matched with controls based on age, sex, and race. We calculated age-adjusted mortality rates, annual percentage changes in aspiration pneumonia mortality, and matched odds ratio comparisons. We identified a total of 1,112,944 deaths related to aspiration pneumonia from 1999 to 2017 or an average of 58,576 per year (age-adjusted mortality rate, 21.85 per 100,000 population; 95% confidence interval (CI) 21.78-21.92). Aspiration pneumonia was reported as the underlying cause of death in 334,712 deaths or an average of 17,616 deaths per year (30.1% of the total aspiration pneumonia-associated deaths). Individuals 75 years old or older accounted for 76.0% of aspiration pneumonia deaths and the age adjusted rate ratio was 161.0 (CI 160.5-161.5). Neurologic, upper gastrointestinal, and pulmonary conditions as well as conditions associated with sedative substances were more often associated with aspiration pneumonia-associated deaths. Aspiration pneumonia is the underlying cause or a cofactor in tens of thousands of deaths each year in the United States. Aspiration pneumonia-associated deaths are highly prevalent with advanced age and are associated with neurologic, upper gastrointestinal and pulmonary conditions.

Relationship Between Start of Feeding and Functional Outcome in Aspiration Pneumonia: A Retrospective Cohort Study

INTRODUCTION

Aspiration pneumonia is the predominant form of pneumonia in the elderly. Low oral intake levels and malnutrition have been reported to be associated with increased mortality and loss of function in aspiration pneumonia. However, the relationship between start of feeding and readmission, which is associated with malnutrition and low oral intake levels, has not been reported. The purpose of this study was to clarify the relationship between start of feeding and functional prognosis in aspiration pneumonia.

METHODS

Patients' basic information, comorbidities, severity of pneumonia, swallowing function, time from admission to the start of feeding, geriatric nutritional risk index (GNRI), readmission, and Barthel index (BI) were evaluated in 160 patients. The patients were divided into two groups-a readmission group and a non-readmission group-and statistical verification was performed.

RESULTS

The readmission group was 62 cases (38.8%). Univariate analysis showed that the time from admission to the start of feeding was significantly longer in the readmission group (p < 0.001). Age was significantly higher and nutrition parameters were lower in the readmission group (p = 0.001, 0.006). Furthermore, according to logistic regression analysis, readmission was associated with age (odds ratio, 1.063; p =  0.007; 95% confidence interval (CI) 1.017-1.111) and time from admission to the start of feeding (odds ratio 1.080; p < 0.001; 95% CI 1.025-1.137).

CONCLUSION

The time from admission to the start of feeding was significantly longer in the readmitted patients. A comprehensive intervention with multidisciplinary collaboration should be performed from the early stage of hospitalization.

TRIAL REGISTRATION

This study is registered in the UMIN-Clinical Trials Registry (UMIN-CTR). UMIN-CTR meets the criteria of the International Committee of Medical Journal Editors (ICMJE). (Registration number: 000047141).

A Paradigm Shift in the Diagnosis of Aspiration Pneumonia in Older Adults

In older adults, community-acquired pneumonia (CAP) is often aspiration-related. However, as aspiration pneumonia (AP) lacks clear diagnostic criteria, the reported prevalence and clinical management vary greatly. We investigated what clinical factors appeared to influence the diagnosis of AP and non-AP in a clinical setting and reconsidered a more clinically relevant approach. Medical records of patients aged ≥75 years admitted with CAP were reviewed retrospectively. A total of 803 patients (134 APs and 669 non-APs) were included. The AP group had significantly higher rates of frailty, had higher SARC-F scores, resided in institutions, had neurologic conditions, previous pneumonia diagnoses, known dysphagia, and were more likely to present with vomiting or coughing on food. Nil by mouth orders, speech therapist referrals, and broad-spectrum antibiotics were significantly more common, while computed tomography scans and blood cultures were rarely performed; alternative diagnoses, such as cancer and pulmonary embolism, were detected significantly less. AP is diagnosed more commonly in frail patients, while aspiration is the underlying aetiology in most types of pneumonia. A presumptive diagnosis of AP may deny patients necessary investigation and management. We suggest a paradigm shift in the way we approach older patients with CAP; rather than trying to differentiate AP and non-AP, it would be more clinically relevant to recognise all pneumonia as just pneumonia, and assess their swallowing functions, causative organisms, and investigate alternative diagnoses or underlying causes of dysphagia. This will enable appropriate clinical management.

Risk for prolonged hospitalization and mortality in aged community acquired pneumonia patients: a retrospective study in Japan

The present study aimed to reveal; i) risk for prolonged hospitalization and mortality in aged community acquired pneumonia patients, and ii) whether swallowing ability was related to re-hospitalization. The present retrospective study included 92 patients older than 75 years hospitalized with community acquired pneumonia in Takagi Hospital between April 2017 and March 2018. The patients were classified into 3 groups; discharged within 17 days (group I): hospitalized more than 18 days (group II): died during the hospitalization (group III). Swallowing ability was evaluated if available. Univariate analysis indicated males and body mass index (BMI) in group I (n = 24) were higher than group II (n = 46). Group III (n = 22) had low serum albumin, low BMI, and severe disease progression compared with group I. Multivariate analysis demonstrated that group II BMI was lower than group I [odds ratio (OR) = 1.18, p = 0.042]. Group III had lower serum albumin level compared with group I (OR = 81.01, p = 0.025). Diabetes mellitus (p = 0.009), but not swallowing disability, was risk for readmission. Malnutrition represented by low albumin enhanced mortality rate in the pneumonia patients, and low BMI and diabetes mellitus might increase the pneumonia risk.

Rehabilitation nutrition in general and family medicine

Rehabilitation and nutrition are included in general and family medicine. Rehabilitation nutrition care process includes rehabilitation nutrition assessment and diagnostic reasoning, rehabilitation nutrition diagnosis, rehabilitation nutrition goal setting, rehabilitation nutrition intervention, and rehabilitation nutrition monitoring. I expect that many general and family physicians are interested in rehabilitation nutrition, sarcopenia, and sarcopenic dysphagia and prevent iatrogenic sarcopenia.

Rehabilitative management for aspiration pneumonia in elderly patients

Aspiration pneumonia is a common disease that frequently occurs in elderly patients. Most patients with aspiration pneumonia have swallowing disability and develop hospital‐acquired disability. Frequently, patients have difficulty returning home, and they often require long‐term hospitalization. Recently, the effectiveness of rehabilitative management including physical, pulmonary, and dysphagia rehabilitation for aspiration pneumonia was reported. Several studies showed that early rehabilitation was associated with reduced mortality and early hospital discharge after aspiration pneumonia. Unnecessary “nil by mouth” directives associated with aspiration pneumonia at hospital admission resulted in adverse effects, including decline in swallowing ability and prolonged treatment duration. Rehabilitative management combined with appropriate nutrition is recommended to improve clinical outcomes, including physical and swallowing function in geriatric patients with aspiration pneumonia.