[Pneumonia Severity Index (PSI), CURB-65, and mortality in hospitalized elderly patients with aspiration pneumonia]

Predictive Value of the Pneumonia Severity Score on Mortality due to Aspiration Pneumonia

Objective: Designing an efficient management strategy for aspiration is of high priority in our aging society because of its high incidence. We evaluated the prognostic value of both the A-DROP (age, dehydration, respiratory, disorientation, and pressure) and the modified A-DROP scoring systems (adding respiratory rate and comorbidity to A-DROP) in patients with aspiration pneumonia.Design: This is a retrospective study using electronic medical records at Saitama Medical University (SMU) hospital.Setting: A 965-bed university tertiary medical center in Japan.Participants: Data were extracted from the electronic medical records of patients from SMU hospital.Methods: In-hospital mortality was compared between two groups: (1) those with a 'severe' to 'advanced severe' A-DROP score; and (2) those with a 'low' to 'middle' A-DROP score. Area under the curve (AUC) for mortality for both the A-DROP and modified A-DROP scoring systems were compared.Results: The in-hospital mortality rates for patients with a high and a low A-DROP score were 28.6% and 9.0%, respectively. The mortality rates in the high modified A-DROP score group and in the low modified A-DROP score group were 28.2% and 9.9%, respectively. These differences in the mortality rates between the two groups were statistically significant for both the A-DROP and the modified A-DROP scoring systems. The AUC of the receiver operating characteristics curve for the A-DROP (0.700; 95% confidence interval, 0.608-0.779) was statistically significant.Conclusion: The A-DROP and modified A-DROP scoring systems are associated with in-hospital mortality in patients with aspiration pneumonia. The A-DROP scoring system is easy to use and may be a clinically valuable tool in the management of aspiration pneumonia.

Variation in the Diagnosis of Aspiration Pneumonia and Association with Hospital Pneumonia Outcomes

RATIONALE

National efforts to compare hospital outcomes for patients with pneumonia may be biased by hospital differences in diagnosis and coding of aspiration pneumonia, a condition that has traditionally been excluded from pneumonia outcome measures.

OBJECTIVES

To evaluate the rationale and impact of including patients with aspiration pneumonia in hospital mortality and readmission measures.

METHODS

Using Medicare fee-for-service claims for patients 65 years and older from July 2012 to June 2015, we characterized the proportion of hospitals' patients with pneumonia diagnosed with aspiration pneumonia, calculated hospital-specific risk-standardized rates of 30-day mortality and readmission for patients with pneumonia, analyzed the association between aspiration pneumonia coding frequency and these rates, and recalculated these rates including patients with aspiration pneumonia.

RESULTS

A total of 1,101,892 patients from 4,263 hospitals were included in the mortality measure analysis, including 192,814 with aspiration pneumonia. The median proportion of hospitals' patients with pneumonia diagnosed with aspiration pneumonia was 13.6% (10th-90th percentile, 4.2-26%). Hospitals with a higher proportion of patients with aspiration pneumonia had lower risk-standardized mortality rates in the traditional pneumonia measure (12.0% in the lowest coding and 11.0% in the highest coding quintiles) and were far more likely to be categorized as performing better than the national mortality rate; expanding the measure to include patients with aspiration pneumonia attenuated the association between aspiration pneumonia coding rate and hospital mortality. These findings were less pronounced for hospital readmission rates.

CONCLUSIONS

Expanding the pneumonia cohorts to include patients with a principal diagnosis of aspiration pneumonia can overcome bias related to variation in hospital coding.

Management of the risk of bronchoaspiration in patients with oropharyngeal dysphagia

ABSTRACT Objective: to manage the risk of bronchoaspiration in patients with oropharyngeal dysphagia through signalizing plates in the hospital bed. Methods: a descriptive, quantitative study, developed in the medical clinic I (diagnostic investigation), medical clinic II (infectology / pneumology), surgical clinics and intensive care unit of the University Hospital of the Federal University of Sergipe, from February to August 2017. It was composed of patients in the age group ≥ 18 years of age, of both sexes, diagnosed with oropharyngeal dysphagia, based on the application of the adapted protocol of clinical evaluation in the hospital bed and instrumental examination of swallowing, when pertinent. Following the clinical evaluation and identification of the risk of bronchoaspiration due to oropharyngeal dysphagia, the signs were inserted at the hospital bed by the speech therapist. Results: the study included 43 patients at risk of bronchoaspiration due to oropharyngeal dysphagia, average age of 53.7 ± 3.53 years old, with 51.1% (n = 22) females and 48.9% (n = 21) males. A predominance of neuropathies (53.4%) and severe neurogenic oropharyngeal dysphagia (37.2%) was observed. The intensive care unit stood out with 44.18% (n = 19) of the application of signs of risk of bronchoaspiration. Conclusion: the management of bronchoaspiration risk has been shown to be a promising measure to reduce adverse events, which affect the patient's safety and consequently the quality of care in the hospital environment, as well as a possible strategy for measuring respiratory complications triggered by aspiration of oropharyngeal contents.

Muscle Mass Loss Is a Potential Predictor of 90-Day Mortality in Older Adults with Aspiration Pneumonia

OBJECTIVES

To investigate the association between loss of muscle mass and aspiration pneumonia (AP).

DESIGN

Prospective observational cohort.

SETTING

Acute geriatric hospital.

PARTICIPANTS

Individuals admitted to the hospital for AP (N = 151; mean age 85.9; 49.7% male).

MEASUREMENTS

Appendicular skeletal muscle index (ASMI; appendicular skeletal muscle mass divided by height squared) was used to evaluate muscle mass. Data on age, sex, body mass index, Mini Nutritional Assessment-Short Form score, Barthel Index score, Charlson Comorbidity Index score, and pneumonia severity (Japanese version of the CURB-65 (C (confusion), U (blood urea nitrogen ≥20 mg/dL), R (respiratory rate ≥30 breaths/min), B (systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg), 65 (aged ≥65) severity score (A-DROP)) were obtained. Outcomes included 30- and 90-day mortality.

RESULTS

Mild, moderate, severe, and extremely severe AP were observed in 1.3%, 70.2%, 25.8%, and 2.6% of participants, respectively. On Kaplan-Meier analysis, participants in the lowest ASMI quartile for each sex were more likely to die than those in the other quartiles (log-lank test P = .005). Multivariate logistic analyses showed that ASMI and A-DROP were independent predictors of 90-day mortality; only A-DROP was a significant predictor of 30-day mortality (P < .001). Cox regression analysis also showed that the first ASMI quartile was independently associated with mortality (hazard ratio = 2.19; 95% confidence interval = 1.06-4.52; P = .03).

CONCLUSION

Low muscle mass is a potential predictor of long-term mortality in individuals with AP. Prospectively preventing muscle mass deterioration may be beneficial for recovery from AP in older adults.

The effect of sociodemographic and clinical features on mortality in patients with diagnosis of aspiration pneumonia

OBJECTIVE

The aim of this study was to evaluate the sociodemographic and clinical chracteristics of patients hospitalized with aspiration pneumonia in internal medicine clinics, and to determine the incidence and parameters of mortality among these patients.

METHODS

Patients over the age of 18 years who were hospitalized in clinics of internal medicine between January 1, 2010 and January 1, 2013 (115 male, 89 female; mean age: 77±13 years; patients aged 65 years and over, 88.2%; average duration of hospitalization, 11±9 days) were evaluated retrospectively and consecutively. The incidence of mortality, nutritional status at admission, comorbidity frequency, haematological and biochemical data and their relationship with mortality were evaluated.

RESULTS

At admission, 85% of the patients were fed through oral route, while 15% of them were fed through PEG. There was no relation between nutritional status of the patients (oral, nasogastric tube or PEG) at admission, and development of aspiration pneumonia. Commonly seen comorbidities were dementia (49%), hypertension (43%), cerebrovascular accident (42%), and diabetes mellitus (31%) respectively. The mortality rate was 24.5% (in first three days, 56%). A correlation was found between mortality and increase in neutrophil/lymphocyte ratio (NLR) and increased uric acid rate (for both p<0.05).

CONCLUSION

In this study, the mortality rates among patients diagnosed with aspiration pneumonia was found to be increased. The high number of geriatric patients and comorbidities might have played a role in this situation. Neutrophil/lymphocyte ratio (NLR) and uric acid levels in patients with aspiration pneumonia might be evaluated as factors related to mortality.

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

BACKGROUND

Aspiration pneumonia is a common disease, although less well characterized than other pneumonia syndromes.

OBJECTIVE

We analyzed patient-level covariates associated with clinician-defined aspiration pneumonia.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

The management of community-acquired pneumonia in the elderly

Pneumonia is one of the main causes of morbidity and mortality in the elderly. The elderly population has exponentially increased in the last decades and the current epidemiological trends indicate that it is expected to further increase. Therefore, recognizing the special needs of older people is of paramount importance. In this review we address the main differences between elderly and adult patients with pneumonia. We focus on several aspects, including the atypical clinical presentation of pneumonia in the elderly, the methods to assess severity of illness, the appropriate setting of care, and the management of comorbidities. We also discuss how to approach the common complications of severe pneumonia, including acute respiratory failure and severe sepsis. Moreover, we debate whether or not elderly patients are at higher risk of infection due to multi-drug resistant pathogens and which risk factors should be considered when choosing the antibiotic therapy. We highlight the differences in the definition of clinical stability and treatment failure between adults and elderly patients. Finally, we review the main outcomes, preventive and supportive measures to be considered in elderly patients with pneumonia.

Hospital admission decision for patients with community-acquired pneumonia

Where to treat patients is probably the single most important decision in the management of community-acquired pneumonia (CAP), with a substantial impact on both patients' outcomes and health-care costs. Several factors can contribute to the decision of the site of care for CAP patients, including physicians' experience and clinical judgment and severity scores developed to predict mortality, as well as social and health-care-related issues. The recognition, both in the community and in the emergency department, of the presence of severe sepsis and acute respiratory failure and the coexistence with unstable comorbidities other than CAP are indications for hospital admission. In all the other cases, physician's choice to admit CAP patients should be validated against at least one objective tool of risk assessment, with a clear understanding of each score's limitations.

Mortality, morbidity, and disease severity of patients with aspiration pneumonia

BACKGROUND

Aspiration pneumonia is a common syndrome, although less well characterized than other pneumonia syndromes. We describe a large population of patients with aspiration pneumonia.

METHODS

In this retrospective population study, we queried the electronic medical records at a tertiary-care, university-affiliated hospital from 1996 to 2006. Patients were initially identified by International Classification of Diseases, 9th Revision code 507.x; subsequent physician chart review excluded patients with aspiration pneumonitis and those without a confirmatory radiograph. Patients with community-acquired aspiration pneumonia were compared to a contemporaneous population of community-acquired pneumonia (CAP) patients. We compared CURB-65 (a clinical prediction rule based on Confusion, Uremia, Respiratory rate, Blood Pressure, and age)-predicted mortality with actual 30-day mortality.

RESULTS

We identified 628 patients with aspiration pneumonia, of which 510 were community-acquired. Median age was 77 years, with 30-day mortality of 21%. Compared to CAP patients, patients with community-acquired aspiration pneumonia had more frequent inpatient admission (99% vs 58%) and intensive care unit admission (38% vs 14%), higher Charlson comorbidity index (3 vs 1), and higher prevalence of do not resuscitate/intubate orders (24% vs 11%). CURB-65 predicted mortality poorly in aspiration pneumonia patients (area under the curve, 0.66).

CONCLUSIONS

Patients with community-acquired aspiration pneumonia are older, have more comorbidities, and demonstrate higher mortality than CAP patients, even after adjustment for age and comorbidities. CURB-65 poorly predicts mortality in this population.