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Aspiration Pneumonia Pathway

Preventative steps for patients at high risk of Aspiration Pneumonia

Aspiration pneumonia accounts for about 10% of patients admitted to hospital with pneumonia and is usually diagnosed as pneumonia in the presence of risk factors for aspiration. It is caused by food, fluid or even saliva entering the lungs and causing a severe infection.

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, bronchos-copy, upper endoscopy, and nasogastric feeding Pharyngeal anesthesia, and miscellaneous conditions such as protracted vomiting, large volume tube feedings, feeding gastrostomy, and the recumbent position.

Common signs of Aspiration

  • Coughing while eating and/or drinking
  • Choking while eating and/or drinking
  • Throat clearing while eating and/or drinking
  • Wet/gurgly voice at any time but particularly while eating and/or drinking
  • Changes in respiration while eating and/or drinking
  • Chest infections (either acute or recurrent) particularly ones affecting the right side of the lungs
  • Reduced movement of oral musculature (e.g. lips, tongue, cheeks) leading to difficulty maintaining the bolus orally or difficulty chewing
  • Significant drooling of saliva

Ensure patient nil by mouth

Perform Swallowing Assessment

A water swallow test is often used to identify aspiration risk. The patient is given teaspoonfuls of water and the initiation of the swallow and any occurrence of coughing or alteration in voice quality are observed. If there are no adverse signs, the patient is given a larger quantity to drink from a glass. This test has a reported sensitivity of >70% and a specificity of 22-66% for prediction of aspiration and has been found to be a useful and reasonably sensitive screening test.

Refer to senior

Complete standard admission documents

  • All patients should undergo venous thromboembolism (VTE) risk assessment upon admission and for a second time, within 24 hours of initial assessment
  • The initial dementia risk assessment should be completed within 72 hours of admission
  • Use the admission document and nursing assessment document to ensure that all other standard assessments are completed.

Oxygenation management

Oxygen therapy:

  • all patients should receive appropriate oxygen therapy with monitoring of oxygen saturations and inspired oxygen concentrations with the aim to maintain arterial oxygen tension (PaO2) at greater than 8kPa and oxygen saturation (SpO2) between 94-98%
  • high concentrations of oxygen can safely be given in patients who are not at risk of hypercapnic respiratory failure
  • oxygen therapy in patients at risk of hypercapnic respiratory failure complicated by ventilatory failure should be guided by repeated arterial blood gas measurements

Antibiotic management

Administer antibiotics in all patients as soon as diagnosis of Aspiration pneumonia (HAP) has been confirmed, ie:

  • before they leave the initial assessment area
  • within 4 hours of presentation to hospital for the majority of patients

Antimicrobial Therapy for Aspiration Pneumonia (for full guidance see formulary)

Admission <5 days

First Line: Amoxicillin 1g q8h IV plus Metronidazole 500mg q8h IV

OR Clindamycin 600mg q6h IV if Penicillin allergy for 5 days

Second Line: Discuss with Microbiologist

 

Admission >5 days - Treat as Hospital Acquired Pneumonia

Non-Severe—Early Onset (2-5d of hospital admission)

First Line: Amoxicillin 2g q8h IV Plus Gentamicin 5mg/kg IV One Stat dose. for 7 days

Second Line: Discuss with Microbiologist

 

Non-Severe—Late Onset (>5d of hospital admission) OR Severe—No Previous Antibiotics

First Line: Co-amoxiclav 1.2g q8h IV for 7 days

Second Line: Discuss with Microbiologist

 

Severe—Previous Antibiotic with high risk of CDI

First Line: Piperacillin-tazobactam 4.5g q8h IV for 7 days

Second Line: Discuss with Microbiologist

General management including smoking assessment

The following aspects of general management are recommended for all patients with aspiration pneumonia:

  • assess the patient for volume depletion they may require intravenous (IV) fluids
  • consider prophylaxis for venous thromboembolism (VTE) for all patients who are not fully mobile
  • consider patient mobility condition permitting, the patient should:
    • sit out of bed for at least 20 minutes within first 24 hours; and
    • increase mobility each subsequent day of hospitalisation where possible
  • administer analgesia for pleuritic chest pain
  • provide nutritional support in prolonged illness

Airway clearance techniques:

  • are not recommended routinely in patients with uncomplicated pneumonia; but
  • should be considered if the patient has either of the following:
    • difficulty with expectoration
    • a pre-existing lung condition

Request microbiologial investigations

Consider patient for amber care bundle

Identification: is the patient AMBER?

  • 1. Is the patient deteriorating, clinically unstable, and with limited reversibility?
  • 2. Is the patient at risk of dying within the next 1-2 months?

Monitor and re-assess

Monitor and record the following at least three times daily:

  • temperature
  • respiratory rate
  • pulse
  • blood pressure (BP)
  • mental status
  • oxygen saturation (SpO2)
  • inspired oxygen concentration

Vital signs may be captured by an early warning score and can be used to trigger escalation or de-escalation of management.

Reassess all patients deemed to be at high risk of death at least every 12 hours until shown to be improving:

  • reassess disease severity regularly - the "post take" round provides an early opportunity for this
  • reassess the choice of antibiotic and route of administration on the "post take" round, and daily thereafter

Average time to clinical stability for the following factors is 2-3 days:

  • temperature
  • pulse rate
  • respiratory rate
  • oxygen saturation (SpO2)

Repeat chest radiograph for patients who are not progressing satisfactorily after 3 days of treatment.

Remeasure C-reactive protein (CRP) in patients who are not progressing after 3 days of treatment:

  • CRP usually falls by 50% by day 3 of treatment
  • failure of CRP to fall by 50% is associated with:
  • increased 30-day mortality
  • increased need for mechanical ventilation and/or inotropic support
  • increased incidence of complicated pneumonia, eg empyema

Inadequate response or deteriotation

For patients who fail to improve as expected, there should be a careful review by an experienced clinician of:

  • clinical history
  • examination
  • prescription chart
  • results of all available investigations

In the light of clinical review, consider further investigations, including:

  • white cell count (WCC)
  • further specimens for microbiological testing

Repeat chest radiograph for patients who are not progressing satisfactorily after 3 days of treatment.

Remeasure C-reactive protein (CRP) in patients who are not progressing after 3 days of treatment:

  • CRP usually falls by 50% by day 3 of treatment.
  • failure of CRP to fall by 50% is associated with:
    • increased 30-day mortality
    • increased need for mechanical ventilation and/or inotropic support
    • increased incidence of complicated pneumonia, eg empyema

Consider care of the dieing patient plan if patient fits criterea

Reassess diagnosis and look for complications

Common causes of treatment failure include:

  • pulmonary embolism (PE) or infarction
  • pulmonary oedema
  • bronchial carcinoma
  • bronchiectasis
  • slow response in elderly patients
  • complications of pneumonia, eg:
    • empyema
    • abscess
    • pleural effusion
  • unrecognised immunocompromised status
  • resistant causative organism
  • poor absorption of oral antibiotic
  • nosocomial infections

Check results of microbiology for antibiotic resistance or atypical pathogen(s).

Consider referral to Thoracic Medicine

Symptoms Improving

Reconfirm by completing the swallowing assessment.

If on IV antibiotics consider switch to oral.

If the patient has been initially treated with intravenous (IV) antibiotics and there are no contraindications to oral therapy, consider switching to oral antibiotics:

  • Perform a swallowing assessment to reconfirm diagnosis
  • reassess the route of administration on the "post take" round, and daily thereafter

The antibiotic choices for the switch from IV to oral are straightforward where there are effective and equivalent oral and parenteral formulations:

  • if parenteral cephalosporins are being used, a switch to oral co-amoxiclav is recommended rather than to oral cephalosporins for those treated with parenteral benzylpenicillin and levofloxacin, oral levofloxacin with or without oral amoxicillin is recommended

The following features indicate a response to parenteral therapy permitting consideration of oral antibiotic substitution:

  • resolution of fever for longer than 24 hours
  • pulse rate less than 100 beats per minute
  • tachypnoea resolved
  • clinically hydrated and taking oral fluids
  • hypotension has resolved
  • absence of hypoxia
  • improving white cell count (WCC)
  • non-bacteraemic infection
  • no microbiological evidence of legionella, staphylococcal, or Gram-negative enteric bacilli infection
  • no concerns over gastrointestinal (GI) absorption

Discharge and advise on secondary prevention

Consider discharge:

  • patients should be reviewed within 24 hours of planned discharge home
  • those suitable for discharge should not have more than one of the following clinical instabilities:
    • temperature above 37.8°C
    • heart rate above 100 beats per minute
    • respiratory rate above 24 breaths per minute
    • systolic blood pressure (BP) less than 90mmHg
    • oxygen saturation (SpO2) less than 90%
    • inability to maintain oral intake
    • abnormal mental status

Advise on measures for secondary prevention of community-acquired pneumonia (CAP):

  • ensure immunisation is up to date, following Department of Health (DH) guidelines for the following vaccines:
    • influenza vaccine – recommended for those aged 65 years or older and for people of any age with underlying chronic disease, or living in long-stay residential care
    • pneumococcal vaccine (PPV) – should be given to all people over the age of 65 years, on a one-off basis
  • reinforce smoking cessation advice if relevant
  • Arrange a clinical review for all patients after 6 weeks, either with their GP or in a hospital clinic:
    • it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
    • at discharge or follow-up, patients should be offered written information about CAP

Reassess in outpatient clinic as appropriate

Arrange a clinical review after 6 weeks, as an outpatient in secondary care if appropriate:

  • it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
  • at discharge or follow-up, patients should be offered written information about community-acquired pneumonia (CAP)

Arrange a chest radiograph after 6 weeks for patients with:

  • persistence of symptoms
  • physical signs of illness
  • a high risk of underlying malignancy - this especially includes all those who smoke and are age 50 years or older

Arrange follow-up with GP

Arrange a clinical review after 6 weeks, with patient's GP if appropriate:

  • it is the responsibility of the hospital team to arrange the follow-up plan with the patient and GP
  • at discharge or follow-up, patients should be offered written information about community-acquired pneumonia (CAP)

Arrange a chest radiograph after 6 weeks for patients with:

  • persistence of symptoms
  • physical signs of illness
  • a high risk of underlying malignancy - this especially includes all those who smoke and are age 50 years or older