Seminars in respiratory and critical care medicine最新文献

Aspiration pneumonia is a clinical entity with important ethical considerations. It is imperative for clinicians to understand these considerations to best provide counsel to patients and their families, allowing them to make fully informed decisions. Given that aspiration pneumonia is frequently associated with end of life, there are palliative medicine principles that may help in the treatment of this disease.

Aspiration represents the passage of oropharyngeal content to the lower respiratory tract. The interplay between the host and the aspirate proprieties determines the subsequent aspiration syndrome. A low pH, typical of gastric aspirate, favors chemical pneumonitis, whereas an increased bacterial inoculum causes aspiration pneumonia. About a quarter of patients with aspiration pneumonitis will develop a bacterial superinfection during the course of recovery. While antibiotic therapy is indicated for aspiration pneumonia, supportive care remains the cornerstone of treatment in aspiration pneumonitis. However, the overlapping clinical features of these syndromes lead to initiation of antimicrobial therapy in most cases of aspiration. Bronchoscopy can aid in clinical decision-making by direct airway visualization and also by providing access to a series of emerging biomarkers. Invasive microbiological studies increase diagnostic yield and enable a tailored antibiotic treatment. In conjunction with stewardship programs, invasive sampling and novel molecular diagnostics can decrease the amount of inappropriate antibiotic therapy. In the context of foreign body aspiration, bronchoscopy represents both diagnostic and treatment gold standard.

Therapeutic considerations for aspiration pneumonia prioritize the risk of multidrug-resistant organisms. This involves integrating microbiological insights with each patient's unique risk profile, including the location at the time of aspiration, and whether it occurred in or out of the hospital. Our understanding of the microbiology of aspiration pneumonia has also evolved, leading to a reassessment of anaerobic bacteria as the primary pathogens. Emerging research shows a predominance of aerobic pathogens, in both community and hospital-acquired cases. This shift challenges the routine use of broad-spectrum antibiotics targeting anaerobes, which can contribute to antibiotic resistance and complications such as Clostridium difficile infections-concerns that are especially relevant given the growing issue of antimicrobial resistance. Adopting a comprehensive, patient-specific approach that incorporates these insights can optimize antibiotic selection, improve treatment outcomes, and reduce the risk of resistance and adverse effects.

Aspiration pneumonia refers to the process of alveolar inflammation induced by the inhalation of oropharyngeal secretions into the lower respiratory tract. Predisposing factors comprise swallowing dysfunction, impaired cough reflex, and degenerative neurological diseases. Accumulating evidence projects a fading contribution of anaerobic bacteria in aspiration pneumonia at the expense of Gram-negative bacilli, with Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa, becoming the predominant organisms recovered from respiratory specimens. Aspiration of oropharyngeal secretions colonized with respiratory pathogens induces a profound disequilibrium of the lung microbiota resulting in a state of dysbiosis. Understanding this complex temporal variability between microbiome-host associations was only made possible with the introduction of metagenomic sequencing. In this narrative review, we summarize existing knowledge and elaborate on the evolving microbiology of aspiration pneumonia including the link between oral microbiome and pulmonary aspiration. We also highlight the progress and challenges in instituting microbiome-targeted strategies for preventing and treating the sequelae of aspiration pneumonia.

Aspiration following anesthesia is a major patient issue and a difficulty for anesthesiologists. Aspiration syndromes are more common than anticipated, and the condition is frequently undetected. Clinical signs are often dictated by the characteristics of aspiration, such as the infectivity of the material, its volume, and the severity of the underlying clinical condition. Pulmonary aspiration can cause an acute or persistent inflammatory response in the lungs and upper airways that can be complicated by tracheobronchitis, aspiration pneumonia, aspiration pneumonitis, acute respiratory distress syndrome, and subsequent bacterial infection due to particle, acid, and bacteria-related processes. Aspiration during anesthesia, while relatively rare, poses significant risks for patient morbidity and mortality. Chemical and bacterial aspiration provide distinct diagnostic and management issues. Preventive strategies such as a complete preoperative risk assessment, adherence to fasting rules, proper patient positioning, and the use of protective airway devices are critical in reducing aspiration risk. In addition, drugs such as proton pump inhibitors can help lower stomach acidity and volume. Innovations in monitoring techniques, better training, and awareness activities are critical to enhancing aspiration event management. Given the importance of this entity, this narrative review sought to make an updated overview of the management of aspiration after anesthesia: chemical versus bacterial, differential diagnosis, management, and prevention.

Swallowing is a complex process that involves over 50 muscles and nerves and has two critical roles: passing food from the oral cavity through the pharynx and into the esophagus and preventing contents from entering the airway. If a patient's swallowing physiology or airway protective mechanisms are disturbed, the airways and the lungs have innate defense systems to protect against injury and infection. However, critically ill patients are more likely to develop dysphagia, which is an impairment or malfunction in any aspect of the swallowing mechanism, due to the numerous interventions they undergo. When airway reflexes fail, commonly in the presence of dysphagia, aspiration can occur, which is the entry of a fluid or solid below the level of the true vocal cords. If left unmanaged, dysphagia has been associated with aspiration pneumonia, pneumonitis, airway obstruction, delayed enteral nutrition, prolonged length of intensive care unit (ICU) and hospital stay, reduced quality of life, and even death; in some cases, dysphagia is an independent risk factor for mortality. It is important to routinely assess dysphagia in all critically ill patients using a multimodal approach, including systematic assessments, scoring indices, trained specialists, and ICU nurses. Several interventions are crucial for preventing and managing dysphagia and its associated problems. Further research is necessary to help determine the best ways to prevent and manage pulmonary aspiration in critically ill patients. Several interventions are essential in preventing and managing dysphagia and the sequelae of swallowing dysfunction. Further research is needed to help elucidate the best way to avoid and manage pulmonary aspiration in critically ill patients.

Aspiration pneumonia (AP) remains a critical health issue, especially among older and hospitalized patients. This review focuses on understanding the epidemiology and pathogenesis of AP, exploring key risk factors, and proposing diagnostic strategies. Aspiration pneumonia is commonly associated with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), where pathogens introduced into the lungs from gastric aspiration cause infection. Several factors, such as oropharyngeal dysphagia, silent aspiration, and poor oral health, contribute to increased risk, especially in frail elderly populations with chronic comorbidities. Diagnostic criteria for AP are not well-defined, complicating accurate diagnosis. Radiographic evidence of pulmonary infiltrates, history of aspiration, and clinical symptoms, such as cough and fever, guide diagnosis, but the absence of specific biomarkers remains a challenge. Furthermore, the microbiome of the lung, which shares characteristics with the oropharyngeal flora, plays a pivotal role in the development of infection. The incidence of AP is likely to increase given the growing elderly population with factors predisposing them to aspiration. It is one of the most common types of pneumonia in older adults, with its prevalence estimated to range from 5% to 24% in cases of CAP admissions. This revision highlights the growing need for comprehensive diagnostic tools and treatment protocols for AP, especially in high-risk populations such as the elderly and those in long-term care. Understanding the underlying mechanisms and the role of silent aspiration can improve prevention strategies and reduce morbidity and mortality in these vulnerable groups.

Aspiration pneumonia results from the abnormal entry of fluids into the respiratory tract. We present a review of drugs known to affect the risk of aspiration. Drugs that increase the risk of aspiration pneumonia can be broadly divided into those that affect protective reflexes (like cough and swallowing) due to direct or indirect mechanisms, and drugs that facilitate gastric dysbiosis or affect esophageal and intestinal motility. Chief among the first group are benzodiazepines and antipsychotics, while proton pump inhibitors are the most well-studied in the latter group. Pill esophagitis may also exacerbate swallowing dysfunction. On the other hand, some research has also focused on pharmaceutical modulation of the risk of aspiration pneumonia. Angiotensin-converting enzyme inhibitors have been demonstrated to be associated with a decrease in the hazard of aspiration pneumonia in high-risk patients of Chinese or Japanese origin. Drugs like amantadine, nicergoline, or folic acid have shown some promising results in stroke patients, although the available evidence is thus far not enough to allow for any meaningful conclusions. Importantly, antimicrobial prophylaxis has been proven to be ineffective. Focusing on modifiable risk factors for aspiration pneumonia is relevant since this may help to reduce the incidence of this often severe problem. Among these, several commonly used drug classes have been shown to increase the risk of aspiration pneumonia. These drugs should be withheld in the high-risk population whenever possible, alongside general measures, such as the semirecumbent position during sleep and feeding.

Patients with aspiration pneumonia often develop this lung infection due to poor oral health or because the contents of the digestive tract or upper airway enter the lower airway traversing the larynx through different mechanisms. Prevention of this condition is directed at the mechanism by which it occurs. The elderly are the most likely to suffer from aspiration pneumonia, occasionally due to issues related to poor dental health, but more frequently due to abnormal swallowing, which may appear after a stroke, a functional impairment related to aging, or may be part of a specific disease such as Parkinson's disease or some other nervous system condition. People with dysphagia complicated by pneumonia have limited feeding and become debilitated, and aspiration pneumonia in these individuals has a high mortality rate at 90 days. Dietary modifications, assistance with feeding, use of postures that facilitate a normal deglutition, rehabilitation, and use of medications to improve swallowing defects are the tools of medicine to overcome the obstacles to swallowing normally and prevent the development of aspiration pneumonia and its consequences.