Shinji Teramoto

Clinical Practice Guidelines for Nursing- and Healthcare-associated Pneumonia (NHCAP) [Complete translation]

Shigeru Kohno, Yoshifumi Imamura, Yuichiro Shindo, Masafumi Seki, Tadashi Ishida, Shinji Teramoto, Junichi Kadota, Kazunori Tomono, Akira Watanabe Unit of Molecular Microbiology and Immunology, Nagasaki University, Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501 Japan Institute for Advanced Research, Nagoya University, and Department of Respiratory Medicine, Nagoya University, Graduate School of Medicine, Japan Division of Infection Control and Prevention, Osaka University Hospital, Japan Department of Respiratory Medicine, Kurashiki Central Hospital, Japan Hitachinaka Medical Education and Research Center, University of Tsukuba, Japan Department of Internal Medicine II, Oita University Faculty of Medicine, Japan Division of Anti-Infective Agents, Institute of Development, Aging and Cancer, Tohoku University, Japan

Risk Factors for Aspiration Pneumonia in Older Adults.

Backgrounds Aspiration pneumonia is a dominant form of community-acquired and healthcare-associated pneumonia, and a leading cause of death among ageing populations. However, the risk factors for developing aspiration pneumonia in older adults have not been fully evaluated. The purpose of the present study was to determine the risk factors for aspiration pneumonia among the elderly. Methodology and Principal Findings We conducted an observational study using data from a nationwide survey of geriatric medical and nursing center in Japan. The study subjects included 9930 patients (median age: 86 years, women: 76%) who were divided into two groups: those who had experienced an episode of aspiration pneumonia in the previous 3 months and those who had not. Data on demographics, clinical status, activities of daily living (ADL), and major illnesses were compared between subjects with and without aspiration pneumonia. Two hundred and fifty-nine subjects (2.6% of the total sample) were in the aspiration pneumonia group. In the univariate analysis, older age was not found to be a risk factor for aspiration pneumonia, but the following were: sputum suctioning (odds ratio [OR] = 17.25, 95% confidence interval [CI]: 13.16–22.62, p < 0.001), daily oxygen therapy (OR = 8.29, 95% CI: 4.39–15.65), feeding support dependency (OR = 8.10, 95% CI: 6.27–10.48, p < 0.001), and urinary catheterization (OR = 4.08, 95% CI: 2.81–5.91, p < 0.001). In the multiple logistic regression analysis, the risk factors associated with aspiration pneumonia after propensity-adjustment (258 subjects each) were sputum suctioning (OR = 3.276, 95% CI: 1.910–5.619), deterioration of swallowing function in the past 3 months (OR = 3.584, 95% CI: 1.948–6.952), dehydration (OR = 8.019, 95% CI: 2.720–23.643), and dementia (OR = 1.618, 95% CI: 1.031–2.539). Conclusion The risk factors for aspiration pneumonia were sputum suctioning, deterioration of swallowing function, dehydration, and dementia. These results could help improve clinical management for preventing repetitive aspiration pneumonia.

Update on the pathogenesis and management of pneumonia in the elderly-roles of aspiration pneumonia

Pneumonia in the elderly results in the highest mortality among cases of community-acquired pneumonia (CAP). The pathophysiology of pneumonia in the elderly is primarily due to aspiration pneumonia (ASP). ASP comprises two pathological conditions: airspace infiltration with bacterial pathogens and dysphagia-associated miss-swallowing. The first-line therapy for the treatment of bacterial pneumonia in the elderly is a narrow spectrum of antibiotics, including sulbactam/ampicillin, which are effective against major lower respiratory infection pathogens and anaerobes. The bacterial pathogens of ASP cases of pneumonia in the elderly are similar to those associated with adult CAP. In addition to an appropriate course of antibiotics, pharmacologic and non-pharmacologic approaches for dysphagia and upper airway management are necessary for the treatment and prevention of pneumonia. Swallowing rehabilitation, oral health care, pneumococcal vaccination, gastroesophageal reflux management, and a head-up position during the night are necessary for the treatment and prevention of repeated episodes of pneumonia in elderly patients. In addition, tuberculosis should always be considered for the differential diagnosis of pneumonia in this patient population.

Computed tomography findings of aspiration pneumonia in 53 patients.

Aim:u2003 No large case series has so far shown the chest computed tomography (CT) features in patients with aspiration pneumonia, despite the fact that aspiration pneumonia is the most common pulmonary disease in the elderly and is regarded as gravity‐dependent pneumonia. The aim of the present study was to elucidate the CT features based on the patients status in patients with dysphagia‐associated aspiration pneumonia.

Diagnostic utility of C-reactive Protein combined with brain natriuretic peptide in acute pulmonary edema: a cross sectional study

Introduction Discriminating acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) from cardiogenic pulmonary edema (CPE) using the plasma level of brain natriuretic peptide (BNP) alone remains controversial. The aim of this study was to determine the diagnostic utility of combination measurements of BNP and C-reactive protein (CRP) in critically ill patients with pulmonary edema.MethodsThis was a cross-sectional study. BNP and CRP data from 147 patients who presented to the emergency department due to acute respiratory failure with bilateral pulmonary infiltrates were analyzed.ResultsThere were 53 patients with ALI/ARDS, 71 with CPE, and 23 with mixed edema. Median BNP and CRP levels were 202 (interquartile range 95-439) pg/mL and 119 (62-165) mg/L in ALI/ARDS, and 691 (416-1,194) pg/mL (p < 0.001) and 8 (2-42) mg/L (p < 0.001) in CPE. BNP or CRP alone offered good discriminatory performance (C-statistics 0.831 and 0.887), but the combination offered greater one [C-statistics 0.931 (p < 0.001 versus BNP) (p = 0.030 versus CRP)]. In multiple logistic-regression, BNP and CRP were independent predictors for the diagnosis after adjusting for other variables.ConclusionsMeasurement of CRP is useful as well as that of BNP for distinguishing ALI/ARDS from CPE. Furthermore, a combination of BNP and CRP can provide higher accuracy for the diagnosis.

Plasma C-reactive protein levels are associated with mortality in elderly with acute lung injury

PURPOSEnThe plasma C-reactive protein (CRP) level is considered to be a predictor of severity in both hospital- and community-acquired pneumonias, whereas recent reports have shown that higher CRP levels lead to better outcomes in patients with acute lung injury (ALI). To explain this discrepancy, we evaluated the relationship among plasma CRP levels, etiology, affectors of CRP production, and mortality in patients with ALI.nnnMATERIALS AND METHODSnThis was a case-control study of 76 consecutive patients with ALI. The plasma CRP levels had been measured in all of the patients within 1 hour of visiting an emergency department. The associations between the plasma CRP levels and 60-day mortality were analyzed after adjusting for the causes of ALI, disease severity, the patients age, use of corticosteroids, and presence of hepatic failure.nnnRESULTSnThe CRP levels and patients ages were strongly related to the mortality (adjusted hazard ratio, 1.005 [P = .007] and 1.059 [P = .011], respectively), whereas the etiology of ALI did not affect the mortality (adjusted hazard ratio, 0.789 [P = .530]) in the Cox proportional hazard models.nnnCONCLUSIONSnThe plasma CRP level may be a predictor of mortality in elderly patients with ALI.

Influence of pneumonia complications on the prognosis of patients with autopsy-confirmed Alzheimer's disease, dementia with Lewy bodies, and vascular dementia

Pneumonia is a major, complicated disease in patients with dementia. However, the influence of pneumonia on the prognosis of patients with varying types of dementia has not been fully evaluated.

Nine pulmonary aspiration syndrome cases of atypical clinical presentation, in which the final diagnosis was obtained by histological examinations.

BACKGROUNDnWhile pulmonary aspiration syndrome (PAS) is primarily clinically diagnosed, atypical PAS cases can be misdiagnosed clinically and are more accurately diagnosed histologically. To elucidate clinicopathological features of these rare cases, we examined PAS cases determined by histological examination of transbronchial lung biopsy (TBLB) specimens.nnnMETHODSnOf 6105 TBLB cases investigated from 1990 to 2007, 11 were diagnosed as PAS based on histology. Of these, we examined 9 records in detail, as the medical records for 2 cases were unavailable.nnnRESULTSnHistopathological findings indicated 8 patients with aspiration pneumonia and 1 with diffuse aspiration bronchiolitis. However, the pre-bronchoscopy diagnoses included lung cancer, mycobacteriosis, organizing pneumonia, repetitive pneumonia, fungal infection, and interstitial pneumonia. PAS was not considered before TBLB. Only 4 of the 9 patients developed subjective symptoms including fever and cough with sputum production. Laboratory findings demonstrated elevation of white blood cell (WBC) count in only 1 patient and elevation of C reactive protein (CRP) level in 4 patients. Radiographic examination revealed abnormal findings in the dorsal right lower lobes, which was the most vulnerable site for aspiration pneumonia, and also in the upper and ventral portions of the lung. Although the characteristic findings of PAS were scarce, all patients had conditions predisposing to aspiration; i.e., gastrectomy, excessive alcohol drinking, post-cerebral infarction, and sinobronchial syndrome.nnnCONCLUSIONSnWe diagnosed 9 PAS patients on the basis of histological findings that were distinct from clinical findings. Despite presenting with variable symptoms and laboratory and radiographic findings, they all exhibited predisposing factors to aspiration.

Organizing Pneumonia as the First Clinical Manifestation of Early Stage Rheumatoid Arthritis Determined by Hand Joints Synovitis Using Magnetic Resonance Imaging

We report the case of a 50-year-old man who presented with organizing pneumonia (OP) as the first manifestation of rheumatoid arthritis (RA). He experienced repeated episodes of pneumonia, which did not respond to several antibiotics. The lymphocyte dominant cell increase in the bronchoalveolar lavage fluid on chest computerized tomography suggested OP. Although he did not present with articular symptoms, magnetic resonance imaging (MRI) revealed synovitis of the hand joints without joint erosion, suggesting that this was a case of early stage RA. The MRI may be a useful diagnostic tool in asymptomatic patients with early stage RA.

Old age may influence features of pleuroparenchymal fibroelastosis (PPFE): Lessons from a donkey model for PPFE

In a recent issue of “Respiratory Investigation”, Watanabe et al. reported that pleuroparenchymal fibroelastosis (PPFE) is characterized by severe mechanical restriction with a high residual volume to total lung capacity ratio (RV/TLC), which causes an increased PaCO2 and eventual hypercapnic respiratory failure [1]. Pleuroparenchymal fibroelastosis (PPFE) is a rare form of interstitial pneumonia, but is distinct from idiopathic pulmonary fibrosis (IPF)/usual interstitial pneumonia (UIP). In Japan, the recent data suggest that approximately 5.9% of interstitial pneumonia can be diagnosed as PPFE [2]. Watanabe et al. proposed physiological variables that may serve as useful adjuncts in the diagnosis of PPFE. Although their findings may be important for the clinical diagnosis and evaluation of PPFE, they did not discuss aging, which is another important aspect in the pathogenesis of PPFE. They presented nine PPFE patients with the median age of 61 years. Patients aged less than 60 years had different clinical profiles and prognoses than patients aged more than 60 years. The survival time of the younger patients (mean, 51.3716.9 months) was longer than that of older patients (mean, 17.172.3 months). There were also more smokers among the older patients. These variables indicate that age-associated noxious insults may affect the disease progression of PPFE. It was recently reported that the pathologic and imaging features of donkeys with pulmonary fibrosis (DPF) mimics those of humans with PPFE [3]. Interestingly, DPF is a spontaneous syndrome with a high prevalence (35%) in aged donkeys. In horses, progressive fibrosing interstitial lung disease is associated with equine herpes virus 5 infections [4]. In a North American study, herpes viruses were also implicated in acute fibrosing interstitial pneumonia in 11 donkeys [5]. However, a recent study demonstrated that asinine herpes virus was ubiquitously expressed in both control and DPF lung tissue [3] and no other etiologic factors were identified in the tissue of the aged animals [3].