Nonaspiration Pneumonia Research Articles

Computed tomography findings of 50 patients diagnosed with aspiration pneumonia: A case series

AbstractThe effect of neglecting imaging in aspiration pneumonia diagnosis is not well understood. In this study, the computed tomography images of 50 patients diagnosed with aspiration pneumonia were retrospectively analyzed by three radiologists at a different hospital. Among these cases, 32%–42% were not classified as aspiration pneumonia based on imaging. Thus, imaging features may not have been adequately considered for diagnosing aspiration pneumonia. Although not all patients with aspiration pneumonia can be diagnosed based on imaging, aspiration pneumonia should be considered in the diagnosis as cases that are clearly nonaspiration pneumonia can be misdiagnosed as aspiration pneumonia.

Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty?

Key summary pointsAimThe aim of this study was to investigate the impact of aspiration pneumonia and other prognostic factors that affect long-term and functional outcomes in older patients with pneumonia.FindingsMortality was significantly higher in aspiration pneumonia than non-aspiration pneumonia during admission and at 1 year. However, independent risk factors for poor prognosis were old age, frailty and cardio-respiratory comorbidities and not the initial diagnosis of aspiration pneumonia.MessageThe management of older adults with pneumonia must be based on frailty and overall condition rather than the potentially futile labelling of aspiration pneumonia or non-aspiration pneumonia.

In-hospital mortality for aspiration pneumonia in a tertiary teaching hospital: A retrospective cohort review from 2008 to 2018

BackgroundAspiration pneumonia is a preventable condition that has higher rates of recurrence and mortality compared to non-aspiration pneumonia. The primary objective of the study was to examine independent patient factors that are associated with mortality in those requiring acute admission for aspiration pneumonia at a tertiary institution. Secondary goals of the study were to review whether factors such as mechanical ventilation and speech language pathology intervention can impact patient mortality, length of stay (LOS), and costs relating to hospitalization.MethodsPatients older than 18 years of age who were admitted with a primary diagnosis of aspiration pneumonia from January 1, 2008 to December 31, 2018 at Unity Health Toronto-St. Michael’s hospital in Toronto, Canada, were included in the study. Descriptive analyses were performed on patient characteristics using age as a continuous variable as well as a dichotomous variable with age 65 as a cut-off. Multivariable logistic regression was used to identify independent factors that contributed to in-hospital mortality and Cox proportional-hazard regression was used to identify independent factors that affected LOS.ResultsA total of 634 patients were included in this study. 134 (21.1%) patients died during hospitalization with an average age of 80.3 ± 13.4. The in-hospital mortality did not change significantly over the ten-year period (p = 0.718). Patients who died had longer LOS with a median length of 10.5 days (p = 0.012). Age [Odds Ratio (OR) 1.72, 95% Confidence Interval (95% CI) 1.47–2.02, p < 0.05] and invasive mechanical ventilation (OR 2.57, 95% CI 1.54–4.31, p < 0.05) were independent predictors of mortality while female gender was found to be a protective factor (OR 0.60, 95% CI 0.38–0.92, p = 0.02). Elderly patients had five times higher risk of dying during their hospital course when compared to younger patients [Hazard Ratio (HR) 5.25, 95% CI 2.99–9.23, p < 0.05).ConclusionElderly patients are a high-risk population for developing aspiration pneumonia and are at higher risk of death when hospitalized for this condition. This warrants improved preventative strategies in the community. Further studies involving other institutions and creating a Canada-wide database are required.Graphical

Diagnosis of COVID-19 in a geriatric patient hospitalised for fall with initial misinterpreted aspiration pneumonia

BACKGROUND SARS-CoV-2 is a virus which is more aggressive in aged patients with associated chronic age-related diseases. Although it is known that clinical picture of COVID-19 is already multifaceted, very little is still known about the infectious syndrome in aged patients. We present a case of an aged patient hospitalized for fall affected from Covid19 pneumonia, initially misinterpreted for an aspiration pneumonia. CASE PRESENTATION We describe the case of a 92 years patient with chronic heart diseases, hospitalized for fall complicated by head trauma. She was diagnosed with an aspiration pneumonia due to the fall so that she was put under antibiotics treatment. Despite four days of antibiotics treatment, the patient presented high fever and dry cough motivating in an epidemic period the nasopharyngeal PCR test for the research of SARS-CoV-2 which resulted positive. DISCUSSION AND CONCLUSION Aspiration pneumonia resulting from a fall is a common finding in geriatric patients, that’s why the diagnosis of COVID-19 was delayed. The geriatric population often have an altered clinical presentation of diseases, in particular regarding infectious diseases. The correct interpretation of some suspicious findings such as regular blood tests would have led more quickly to a diagnosis of non-aspiration pneumonia. Inflammatory markers and white blood cell count resulted within the normal range. Moreover, lymphopenia, considered as one of the biological features of COVID-19, was the only tract that appeared once the patient started to have symptoms. The presence of confusion as a sign of persisting infection in an older patient should not be underestimated, expression of a possible involvement of nervous system in SARS-CoV-2 infection. The common diagnosis of aspiration pneumonia in the geriatric field, the aspecific signs and symptoms of COVID-19 disease, the complex picture of our patient, prove that in geriatrics an apparently simple diagnosis could instead be insidious and complex.

Bronchoalveolar lavage (BAL) amylase and pepsin levels as potential biomarkers of aspiration pneumonia

Background and objectiveThere are currently no established markers for aspiration pneumonia. We hypothesized that bronchoalveolar lavage (BAL) amylase and pepsin might be candidate biomarkers for aspiration pneumonia. MethodsThis cross-sectional study reviewed consenting adults who underwent clinically-indicated bronchoscopy at Aizu Medical Center. BAL samples were obtained using standardized methods. Amylase levels were measured in our clinical laboratory, and pepsin levels were assessed by ELISA. ResultsAspiration pneumonia was clinically diagnosed based on the guidelines of the Japanese Respiratory Society in 48 of the 327 participants. Median BAL salivary amylase and pepsin levels in this group were 702.0 U/L and 12.7 ng/ml respectively, which were significantly higher than in non-aspiration pneumonia patients. BAL amylase ≥204 U/L had 77.1% sensitivity and 84.2% specificity as a diagnostic index, and the area under the receiver operating characteristic (ROC) curve was 0.859 (95% confidence interval (CI), 0.803-0.915). Similarly, BAL pepsin levels of ≥7.45 ng/ml had 87.2% sensitivity and 59.9% specificity for identifying aspiration, and the area under the ROC curve was 0.757 (95% CI, 0.688-0.826). Multivariate regression demonstrated that BAL amylase ≥204 U/L and BAL pepsin ≥7.45 ng/ml were associated with significantly higher odds for aspiration pneumonia (odds ratio (OR) 10.0, 95% CI, 4.51-22.2, and OR 8.81 95% CI, 3.32-23.4, respectively). There were no significant associations between risk factors for aspiration pneumonia and BAL amylase and pepsin levels. ConclusionBAL amylase and pepsin might be useful biomarkers for suggesting aspiration pneumonia, and could be objective markers without relying on known risk factors for aspiration.

Proportion of Aspiration Pneumonia Cases Among Patients With Community-Acquired Pneumonia: A Single-Center Study in Korea.

ObjectiveTo investigate the proportion of aspiration pneumonia cases among patients with community-acquired pneumonia in Korea.MethodsThis retrospective study included patients with community-acquired pneumonia who had been admitted to the emergency department of a university-affiliated tertiary hospital in Gyeonggi Province, Korea between January 1, 2016 and December 31, 2016. Among these patients, those with aspiration pneumonia were identified using ICD-10 codes (J69.*). Patients with recurrent pneumonia were excluded, as were those who were immunocompromised. The proportion of cases of aspiration pneumonia was calculated, and the characteristics and clinical outcomes of patients with aspiration pneumonia and non-aspiration pneumonia were compared.ResultsThe proportion of aspiration pneumonia cases among patients with community-acquired pneumonia was 14.2%. Patients with aspiration pneumonia were significantly more likely to be older (p<0.001) and male (p<0.001), and to have a higher confusion, uremia, respiratory rate, blood pressure, and age ≥65 years (CURB-65) score (p<0.001) as compared to patients with non-aspiration pneumonia. They were also more likely to require admission to the intensive care unit (p<0.001) and a longer hospital stay (p<0.001).ConclusionAspiration pneumonia accounts for 14.2% of all cases of community-acquired pneumonia in Korea. These data may contribute to the establishment of healthcare strategies for managing aspiration pneumonia among Korean adults.

Pneumonia and Risk of Serious Adverse Outcomes in Hospitalized Strokes in Thailand

Background: The impact of stroke associated pneumonia (SAP) on stroke complications is not well understood; we aimed to study the association between SAP and adverse outcomes including in-hospital mortality, prolonged length of stay and the risk of developing common serious complications (sepsis, respiratory failure, and convulsions). Methods: We retrospectively analyzed data from a cohort of 610,668 stroke patients drawn from the Universal Coverage Health Security Scheme (a national insurance database) in Thailand which covers ∼80% of the Thai population. Patients were hospitalized between October 2004 and January 2013. Results: Pneumonia was present in 9.6 % (n = 58,586) of patients. Aspiration pneumonia was present in 6.2% (n = 38,060) and nonaspiration pneumonia in 3.4% (n = 20,526). After adjusting for age, sex, stroke type, and comorbidities, patients with SAP had significantly higher odds of in-hospital mortality (odds ratio [OR] 2.90: 2.83-2.96), long length of stay (OR 13.11: 12.83-13.40), sepsis (OR 8.49: 8.22-8.76), respiratory failure (OR 4.37: 4.27-4.48), and convulsions (OR 2.09: 2.00-2.17). On subanalysis, patients with nonaspiration pneumonia were found to have higher odds of adverse outcomes compared to aspiration pneumonia; the corresponding ORs (95% confidence interval) for above outcomes were 1.25 (1.21-1.30), 2.40 (2.32-2.49), 1.34 (1.28-1.40), 1.80 (1.73-1.88), and 1.19 (1.11-1.28), respectively. Conclusions: SAP is associated with higher odds of inpatient mortality, long length of stay, and risk of developing serious stroke complications. Nonaspiration pneumonia is associated with significantly higher likelihood of adverse outcomes compared to aspiration pneumonia in this patient population. Early identification and treatment of SAP is vital in reducing adverse outcomes in acute stroke.

Clinical Importance of Peak Cough Flow in Dysphagia Evaluation of Patients Diagnosed With Ischemic Stroke.

ObjectiveTo investigate the relationship between peak cough flow (PCF), pulmonary function tests (PFT), and severity of dysphagia in patients with ischemic stroke.MethodsThis study included patients diagnosed with ischemic stroke, who underwent videofluoroscopic swallowing study (VFSS), PCF and PFT from March 2016 to February 2017. The dysphagia severity was assessed using the videofluoroscopic dysphagia scale (VDS). Correlation analysis of VDS, PFT and PCF was performed. Patients were divided into three groups based on VDS score. One-way ANOVA of VDS was performed to analyze PCF, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and age among the different groups.ResultsThe correlation coefficients of VDS and PCF, VDS and FVC, and VDS and FEV1 were -0.836, -0.508, and -0.430, respectively, all of which were statistically significant at the level of p<0.001. The one-way ANOVA indicated statistically significant differences in PCF, FVC, FEV1, and age among the VDS groups. Statistically significant differences in VDS and age were observed between aspiration pneumoia and non-aspiration pneumonia groups.ConclusionCoughing is a useful factor in evaluating the risk of aspiration in dysphagia patients. Evaluation of respiratory and coughing function should be conducted during the swallowing assessment of patients with ischemic stroke.

Low estimated glomerular filtration rate and pneumonia in stroke patients: findings from a prospective stroke registry in the East of England.

PurposeLow estimated glomerular filtration rate (eGFR) (<60 mL/min/1.73 m2) is a recognized risk factor for pneumonia in general population. While pneumonia is common after stroke, the association between levels of eGFR and pneumonia in stroke patient population has not yet been examined thoroughly.Patients and methodsUsing data of 10,329 patients from the Norfolk and Norwich Stroke Registry between January 2003 and April 2015, we examined the association of poststroke pneumonia (in-hospital and after discharge) with low eGFR and when eGFR is divided into the complete spectrum of clinically relevant categories; (≥90) (ref.), 60–89, 45–59, 30–44, 15–30, and <15 mL/min/1.73 m2).ResultsIn all, 1,519 (14.7%) developed in-hospital pneumonia and 1,037 (12.9%) developed pneumonia after hospital discharge. In age- and sex-adjusted model, low eGFR was associated with in-hospital pneumonia (subdistribution hazard ratio (sHR): 1.13; 95% CI: 1.01–1.25) and pneumonia after discharge (sHR: 1.20; 95% CI: 1.07–1.38). In fully adjusted model, association remained significant for pneumonia after hospital discharge. When eGFR was categorized in all clinically relevant categories, association with in-hospital pneumonia tended to be “U” shaped (eg, compared to eGFR ≥90, sHR for 60–89 was 0.78; 95% CI: 0.62–0.99 and for <15 was 1.06; 95% CI: 0.71–1.60) and association with pneumonia after discharge tended to increase with decline in eGFR level such that risk was almost two fold higher at eGFR <15 (sHR: 1.85; 95% CI: 1.01–3.51). Association for in-hospital pneumonia was driven mainly by aspiration pneumonia, whereas association in stroke survivors was predominantly for nonaspiration pneumonia.ConclusionIn stroke patients, low eGFR at admission was associated with pneumonia, particularly severely reduced eGFR with nonaspiration pneumonia after hospital discharge. eGFR could form the basis for identifying patients at high risk of poststroke pneumonia.

Analysis of prevalence rate and risk factors for aspiration pneumonia in elderly inpatients

Objective To analyze the prevalence rate and risk factors for aspiration pneumonia in elderly inpatients, and to identify a high-risk population for aspiration pneumonia. Methods Totally 398 inpatients aged ≥60 years in Beijing Hospital from April 2014 to April 2015 were selected.A questionnaire survey was performed for aspiration risk factors, including gender, age, smoking and drinking history, swallowing function, basal diseases, medication history, activities of daily living(ADL), occurrence of aspiration pneumonia over the past year.The patients were divided into aspiration pneumonia group and non-aspiration pneumonia group, and the prevalence rate and risk factors for aspiration pneumonia were studied. Results 364 cases with complete data were collected, and 14.3%(52/364)were identified definitively as aspiration pneumonia over the past year.The ADL score was(77.0±33.9)scales in aspiration pneumonia group, and(88.0±22.2)scales in non-aspiration pneumonia group, with statistically significant difference(P<0.05). The incidence rate of aspiration pneumonia was increased along with the increase of the age of patients.Risk factors for aspiration pneumonia were different in different age group.The proportion of patients aged 60-69, 70-79 and over 80 years were 23.1%(12 cases), 36.5%(19 cases), 40.4%(23 cases)in the aspiration pneumonia group, respectively.Under the condition of a propensity score-matched case-control pair design on 104 subjects with versus without aspiration pneumonia, the logistic regression analysis showed that smoking history, coronary heart disease, Parkinson’s disease, dementia, chronic obstructive pulmonary disease(COPD), gastro-esophageal reflux disease(GERD), long-term uses of theophylline, calcium antagonists, nitrates, diazepam, antidepressants, anti-Parkinson drugs were the risk factors for aspiration pneumonia in elderly(all P<0.05). Conclusions Smoking history, basal diseases and medication history are associated with the incidence rate of aspiration pneumonia in elderly.Assessment of these risk factors for aspiration pneumonia should be emphasized, and preventive measures should be considered conscientiously to lower the incidence rate of aspiration pneumonia in elderly. Key words: Pneumonia, aspiration; Risk factors

Aspiration and Non-Aspiration Pneumonia in Hospitalized Children With Neurologic Impairment.

Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumonia, including aspiration pneumonia. We sought to compare hospital management and outcomes of children with NI diagnosed with aspiration versus nonaspiration pneumonia. A retrospective study of 27 455 hospitalized children aged 1 to 18 years with NI diagnosed with pneumonia from 2007 to 2012 at 40 children's hospitals in the Pediatric Health Information System database. The primary exposure was pneumonia type, classified as aspiration or nonaspiration. Outcomes were complications (eg, acute respiratory failure) and hospital utilization (eg, length of stay, 30-day readmission). Multivariable regression was used to assess the association between pneumonia type and outcomes, adjusting for NI type, comorbid conditions, and other characteristics. In multivariable analysis, the 9.7% of children diagnosed with aspiration pneumonia experienced more complications than children with nonaspiration pneumonia (34.0% vs 15.2%, adjusted odds ratio [aOR] 1.2 (95% confidence interval [CI] 1.1-1.3). Children with aspiration pneumonia had significantly longer length of stay (median 5 vs 3 days; ratio of means 1.2; 95% CI 1.2-1.3); more ICU transfers (4.3% vs 1.5%; aOR 1.4; 95% CI 1.1-1.9); greater hospitalization costs (median $11 594 vs $5162; ratio of means 1.2; 95% CI 1.2-1.3); and more 30-day readmissions (17.4% vs 6.8%; aOR 1.3; 95% CI 1.2-1.5). Hospitalized children with NI diagnosed with aspiration pneumonia have more complications and use more hospital resources than when diagnosed with nonaspiration pneumonia. Additional investigation is needed to understand the reasons for these differences.

The Functional Dysphagia Scale Is a Useful Tool for Predicting Aspiration Pneumonia in Patients With Parkinson Disease.

ObjectiveTo describe the correlation between the functional dysphagia scale and aspiration pneumonia and which characteristics influence the occurrence of aspiration pneumonia in patients with idiopathic Parkinson disease.MethodsFifty-three patients with idiopathic Parkinson disease were prospectively evaluated in this study. Disease severity and functional status were measured by modified Hoehn and Yahr (H&Y) staging, Schwab and England activities of daily living (S-E ADL) scale and Korean version of Mini-Mental State Examination (K-MMSE). Swallowing function was evaluated by the functional dysphagia scale (FDS) and the penetration-aspiration scale (PAS) based on a videofluoroscopic swallowing study. The patients were followed up for 3 months and divided into two groups according to the occurrence of aspiration pneumonia. The correlation between the variables and aspiration pneumonia was analyzed.ResultsEight patients of the 53 patients were allocated to the aspiration pneumonia group and 45 patients to the non-aspiration pneumonia group. The patients in the aspiration pneumonia group had significantly higher H&Y staging, and scored lower on S-E ADL scale and K-MMSE. The patients in the aspiration pneumonia group had significantly higher scores on FDS and PAS. A multiple logistic regression analysis showed that the S-E ADL scale and the FDS were associated with the occurrence of aspiration pneumonia in the patients with Parkinson disease.ConclusionGiven that the FDS can quantitatively assess the functional problems associated with dysphagia, it can be clinically effective in predicting the occurrence of aspiration pneumonia, and the FDS and the S-E ADL scale could be predictive variables for aspiration pneumonia in patients with Parkinson disease.

Characteristics associated with clinician diagnosis of aspiration pneumonia: a descriptive study of afflicted patients and their outcomes.

Aspiration pneumonia is a common disease, although less well characterized than other pneumonia syndromes. We analyzed patient-level covariates associated with clinician-defined aspiration pneumonia. We used the Community-Acquired Pneumonia Organization database, a multicenter, international population of patients with community-acquired pneumonia, using data from 2001 to 2012. Aspiration pneumonia was determined by the treating clinician. We analyzed covariates associated with clinician-defined diagnosis of aspiration pneumonia using logistic regression. We compared aspiration pneumonia patients to propensity-matched cases with nonaspiration pneumonia. We studied 5185 patients. Four hundred fifty-one of these patients had aspiration pneumonia. Patients with aspiration pneumonia were older, had greater disease severity, and more comorbidities than patients with nonaspiration pneumonia. They were more likely cared for in the intensive care unit (19% vs 13%, P = 0.002), had longer unadjusted hospital length of stay (9 vs 7 days, P < 0.001), and took longer to achieve clinical stability (unadjusted 8 vs 4 days, P < 0.001). Confusion, nursing home residence, and cerebrovascular disease were most associated with clinician diagnosis of aspiration pneumonia (odds ratio: 4.4, 2.9, 2.3, respectively). Unadjusted inpatient mortality was higher (23% vs 9%, P < 0.001). Aspiration pneumonia conferred a 2.3 odds ratio for inpatient mortality after adjusting for age, disease severity, and comorbidities. Among pneumonia patients, confusion, nursing home residence, and cerebrovascular disease are associated with a clinician diagnosis of aspiration. Aspiration pneumonia is associated with greater mortality among patients with community-acquired pneumonia, which is not explained by older age, measured indices of severity, or comorbidities.

Clinical features and outcomes of aspiration pneumonia compared with non-aspiration pneumonia: a retrospective cohort study.

Pneumonia is a leading cause of death among elderly patients. Although aspiration pneumonia (AP) commonly occurs with aging, its clinical features and outcomes are still uncertain. The aims of this study were to describe the clinical features and outcomes of AP and to assess whether presence of AP affects clinical outcomes in patients with community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP). We retrospectively analyzed patients with CAP and HCAP hospitalized in our institution in Japan from October 2010 to March 2012. We compared clinical features and outcomes between AP and non-AP, and investigated risk factors for recurrence of pneumonia and death. Of 214 consecutive patients, 100 (46.7%) were diagnosed as having aspiration pneumonia. These patients were older and had lower body mass index, more comorbidities, and poorer Eastern Cooperative Oncology Group performance status (ECOG PS) than the patients with non-AP. Patients with AP had more severe disease, required longer hospital stays, and had a frequent recurrence rate of pneumonia and higher mortality. In multivariate analyses, AP, age, and ECOG PS were related to recurrence of pneumonia, and the prognostic factors were CURB-65 score and ECOG PS. AP was not a significant indicator for prognosis but was the strongest risk factor for recurrence of pneumonia. Clinical background and outcomes including recurrence and mortality of AP were obviously different from those of non-AP; therefore AP should be considered as a distinct subtype of pneumonia, and it is important to prevent the recurrence of pneumonia in the patients with AP.

Oropharyngeal Dysphagia is a Risk Factor for Readmission for Pneumonia in the Very Elderly Persons: Observational Prospective Study

To determine whether oropharyngeal dysphagia is a risk factor for readmission for pneumonia in elderly persons discharged from an acute geriatric unit. Observational prospective cohort study with data collection based on clinical databases and electronic clinical notes. All elderly individuals discharged from an acute geriatric unit from June 2002 to December 2009 were recruited and followed until death or December 31, 2010. All individuals were initially classified according to the presence of oropharyngeal dysphagia assessed by bedside clinical examination. Main outcome measure was readmission for pneumonia. Clinical notes were reviewed by an expert clinician to verify diagnosis and classify pneumonia as aspiration or nonaspiration pneumonia. A total of 2,359 patients (61.9% women, mean age 84.9 y) were recruited and followed for a mean of 24 months. Dysphagia was diagnosed in 47.5% of cases. Overall, 7.9% of individuals were readmitted for pneumonia during follow-up, 24.2% of these had aspiration pneumonia. The incidence rate of hospital readmission for pneumonia was 3.67 readmissions per 100 person-years (95% CI 3.0-4.4) in individuals without dysphagia and 6.7 (5.5-7.8) in those with dysphagia, with an attributable risk of 3.02 readmissions per 100 person-years (1.66-4.38) and a rate ratio of 1.82 (1.41-2.36). Multivariate Cox regression showed an independent effect of oropharyngeal dysphagia, with a hazard ratio of 1.6 (1.15-2.2) for hospitalization for pneumonia, 4.48 (2.01-10.0) for aspiration pneumonia, and 1.44 (1.02-2.03) for nonaspiration pneumonia. Oropharyngeal dysphagia is a very prevalent and relevant risk factor associated with hospital readmission for both aspiration and nonaspiration pneumonia in the very elderly persons.

Simplified Prediction Rule for Prognosis of Patients With Severe Community-Acquired Pneumonia in ICUs

To develop a simplified prognostic prediction rule for patients admitted to ICUs for severe community-acquired pneumonia (CAP). Six ICUs in the north of France. Five hundred five patients admitted to ICUs over a 9-year period (from 1987 to 1995) for severe CAP. Retrospective prognosis analysis and multivariate analysis using a credit scoring technique. The primary outcome measure was ICU mortality. Among the 505 patients, 472 were eligible for the prognosis study. The ICU mortality rate was 22.9%. Multivariate analysis identified, on the basis of the patient's medical history and initial examination on ICU admission, six independent predictors of mortality: age > or = 40 years, anticipated death within 5 years, nonaspiration pneumonia, chest radiograph involvement > 1 lobe, acute respiratory failure requiring mechanical ventilation, and septic shock. An initial risk score based on these factors classified patients into three risk classes of increasing mortality: 4% in class I, 25% in class II, and 60% in class III. Multivariate analysis of events occurring during ICU stay identified three independent predictors of mortality: hospital-acquired lower respiratory tract superinfections, nonspecific CAP-related complications, and sepsis-related complications. An adjustment risk score based on these factors was essential to accurately predict the final outcome of patients in the initial risk class II. As an aid to clinicians in stratifying the prognosis of patients with severe CAP, the simplified prediction rule used in this study could be useful for therapeutic decisions and appropriate care.

Epidemiological features and prognosis of severe community-acquired pneumococcal pneumonia.

To describe risk factors of severe pneumococcal community-acquired pneumonia and to study variables influencing outcome. Retrospective (1987-1992) and prospective (1993-1995) study. Three participating ICUs from primary care hospitals. Five hundred and five patients (mean age: 63 +/- 17 years) with severe community-acquired pneumonia (CAP). Three groups of patients were defined: pneumococcal CAP (group 1), CAP with microbial diagnosis other than Streptococcus pneumoniae (group 2), CAP from group 2 and CAP without microbial diagnosis (group 3). Admission data and data on the disease's course were recorded. The mean Simplified Acute Physiologic Score (SAPS) was 12.5 +/- 5.4. On admission 288 (57 %) patients were mechanically ventilated (mv) and 82 (16.2 %) required inotropic support. A microbial diagnosis was established for 309 (61.2%) patients. S. pneumoniae was isolated in 137 (27.1%) patients. Severe pneumococcal CAP was independently associated with male sex (p = 0.01), lack of antibiotics use before admission (p = 0.0001), non-aspiration pneumonia (p = 0.01) and septic shock (p = 0.0001). The overall mortality rate was 27.5 % (29.2 % in group 1). In patients with severe pneumococcal CAP, multivariate analysis showed that leukopenia less than 3,500/mm3 (p = 0.0004), age over 65 years (p = 0.01), septic shock (p = 0.01), sepsis related complications (p = 0.0001), ICU complications (p = 0.001) and inadequacy of antimicrobial therapy (p = 0.002) worsened the prognosis. Few features facilitate the identification of pneumococcal CAP on ICU admission. The prognosis is mostly related to severity of illness (leukopenia, septic shock) while comorbidities do not seem to influence outcome. Sepsis-related disorders, ICU complications and adequate antimicrobial chemotherapy are the major variables affecting the outcome during an ICU stay.

A five-year study of severe community-acquired pneumonia with emphasis on prognosis in patients admitted to an intensive care unit.

To characterize the epidemiology and to determine the prognosis factors in severe community-acquired pneumonia among patients admitted to an intensive care unit. Retrospective clinical study. Intensive Care and Infectious Diseases Unit of a municipal general hospital of Lille University Medical School. 299 consecutive patients exhibiting severe community-acquired pneumonia. On admission to ICU, 149 patients required mechanical ventilation for acute respiratory failure and 44 exhibited septic shock. Pulmonary involvement was bilateral in 71 patients. There were 260 organisms isolated from 197 patients (65.9%), the most frequent being Streptococcus pneumoniae (n = 80), Staphylococcus spp. (n = 57) and Gram-negative bacilli (n = 81). Overall mortality was 28.5% (85 patients). According to univariate analysis, mortality was associated with age over 60 years, anticipated death within 5 years, immunosuppression, shock, mechanical ventilation, bilateral pulmonary involvement, bacteremia, neutrophil count < 3500/mm3, total serum protein level < 45 g/l, serum creatinine > 15 mg/l, non-aspiration pneumonia, ineffective initial therapy and complications. Multivariate analysis selected only 5 factors significantly associated with prognosis: anticipated death within 5 years, shock, bacteremia, non-pneumonia-related complications and ineffective initial therapy. The effectiveness of the initial therapy appears to be the most significant prognosis factor and, as the one and only related to the initial medical intervention, suggests a need for permanent optimization of our antimicrobial strategies.

The association of swallowing dysfunction and aspiration pneumonia.

The medical literature has emphasized that aspiration of gastric contents or oral bacteria is a common cause of aspiration pneumonia. Swallowing disorders have been implicated in this disease but not studied at the time that aspiration pneumonia was diagnosed. A significant difference was found in the incidence of videofluoroscopically confirmed oropharyngeal swallowing problems in a group of patients diagnosed with aspiration pneumonia (AP) when compared with patients with nonaspiration pneumonia (NAP). Six of the 9 patients in the AP group aspirated during the videofluoroscopic evaluation and 2 others were considered to be at risk for aspiration. None of the 7 NAP patients demonstrated swallowing problems or aspiration. A significant difference in oral transit time also occurred between the two groups. Liquid was found to have a significantly faster oral transit time than paste or a cookie. Pharyngeal transit times were not found to be significantly different. Although there were only a small number of patients who met the criteria for this pilot study, a strong association was found between swallowing dysfunction and aspiration pneumonia.