Aspiration pneumonia medical therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
(Created page with "__NOTOC__ {{Aspiration pneumonia}} {{CMG}}; {{AE}} ==Overview== There is no treatment for [disease name]; the mainstay of therapy is supportive care. OR Supportive therapy...")
 
No edit summary
Line 4: Line 4:


==Overview==
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
==Medical Therapy==
Management of patients with swallowing dysfunction is highly individualized based on the cause of the dysfunction and other patient characteristics identified by the multidisciplinary evaluation outlined above.
 
If there are primary anatomical abnormalities that predispose to aspiration, these should be surgically corrected, if possible. Total parenteral nutrition or nasogastric tube feeding may be necessary to safely meet caloric requirements during the recovery period after corrective surgery. The same methods for nutritional support should be considered when the patient's swallowing dysfunction is secondary to a transient disease, such as a critical illness.
 
'''Feeding decisions'''


OR
The goals of therapy are safe and efficient nutrition that preserves stable respiratory function and appropriate growth. Oral feeding, while always desirable, is not always the most reasonable goal for patients with severe swallowing dysfunction because the risks of oral feeding may outweigh the psychosocial benefits to the patient and family [6,37,38]. On the other hand, for some patients with severe static encephalopathy or global delays, the family may choose to maintain oral feeds for pleasure despite the known risks of aspiration and pulmonary injury. These considerations require a clear and detailed discussion of goals and risks between the family and clinicians [39].


Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
'''Techniques to enhance oral feeding'''


OR
In children with functional abnormalities, treatment is often led by speech and occupational therapists that specialize in swallowing. The specialist selects specific techniques to improve swallowing function based on individual patient characteristics:


The majority of cases of [disease name] are self-limited and require only supportive care.
●In infants, change in the flow of liquids may significantly improve swallowing. These changes can be made by changing to a slow flow nipple.


OR
●Other feeding techniques include changes in the infant or child's position and posture during feeding, modification of bolus size, and alterations of consistency, shape, texture, and temperature of food. These techniques should be selected based on the result of the videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) (image 1) [3,40].


[Disease name] is a medical emergency and requires prompt treatment.
●In children with delayed maturation, swallowing function may improve over time. In the interim, the techniques outlined above are used to support adequate nutrition and avoid aspiration. The type of feeding is then gradually advanced as the infant or child matures. Advances in feeding may be directed by repeat swallowing evaluation, including clinical assessment of feeding, with or without VFSS or FEES.


OR
'''Gastrostomy feeds'''


The mainstay of treatment for [disease name] is [therapy].
Percutaneous gastrostomy tube placement should be considered for patients who are unable to safely consume enough calories by mouth. Some patients will require gastrostomy tubes to meet part or all of their nutritional needs. Oral-motor and swallowing therapy should be continued in patients in whom swallowing function is expected to improve, and gastrostomy tubes may be removed when no longer necessary.


OR
Parents may initially be reluctant to have a gastrostomy tube placed because of concerns about losing pleasure of eating, discomfort, or cosmesis. The importance of preventing pulmonary aspiration, long-term benefits of improved nutrition, and reversibility of this procedure should be emphasized. In addition, gastrostomy tubes can be useful for administering medication and fluid, when needed.
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.


OR
General considerations about gastrostomy placement and enteral feeding are discussed in a separate topic review.


[Therapy] is recommended among all patients who develop [disease name].
'''Management of salivary aspiration'''


OR
Management techniques for patients with suspected salivary aspiration include:


Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
●Providing small quantities ("tastes") of liquid or food, to assist purposeful swallowing and reduce the risk of aspiration from pooled saliva.


OR
●Administration of anticholinergic agents, such as glycopyrrolate or scopolamine patches to inhibit salivation. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)


Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
●Botulinum toxin injections to decrease salivation. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)


OR
●Surgical removal of salivary glands or salivary duct ligation has had a beneficial effect in some individuals, although these surgeries are not without risk. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)


Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
●In very rare instances, laryngotracheal separation with a permanent tracheostomy may be indicated.


OR
Surgical approaches should be approached with caution because it is often difficult to predict whether or not these procedures will improve pulmonary symptoms.


Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
'''Management of gastroesophageal reflux'''


==Medical Therapy==
Patients with swallowing dysfunction, especially those with neurologic impairment, may have increased frequency and volume of gastroesophageal reflux (GER).  
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
 
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
Most patients with mild GER can be effectively managed without fundoplication, using dietary modification and positioning to reduce the frequency of GER, pharmacotherapy for acid suppression, and occasionally prokinetic agents.
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
 
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
'''Fundoplication'''
===Disease Name===
 
Fundoplication is a surgical procedure to reduce the risk of GER. It should be considered only in patients with GER that is strongly suspected to be contributing to pulmonary disease. When evaluating the severity of GER, a gastroenterologist classically focuses on the percent of time that gastric contents spend in the esophagus, which correlate with the risk for peptic esophagitis. From a pulmonary point of view, the number and duration of episodes may be less important than whether the reflux occurs during sleep, when the patient is horizontal and less likely to protect the larynx. Clinical judgment must be applied to individual patients when judging whether they are likely to benefit from fundoplication. Complications after fundoplication include retching, esophageal obstruction, intrathoracic herniation, and recurrence of GER due to breakdown of the wrap. Complications of fundoplication are most common in patients with neurologic impairment [42,43]. Failure rates (variously defined) of antireflux surgery range from 2 to 50 percent and are generally higher in children with neurological impairment [44].  


* '''1 Stage 1 - Name of stage'''
'''Jejunal feeds'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. ''''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
For patients with GER who are dependent on enteral feeds, an alternate strategy to reduce GER and the associated risks of aspiration is to place the feeding tube in the jejunum rather than in the stomach; this tends to reduce but not eliminate GER. Disadvantages of jejunal feeds include intolerance of rapid feeding infusions (such that continuous rather than bolus feeds must be used), and a tendency for accidental displacement (except with permanent, surgically placed jejunal tubes). A retrospective study in a group of children with neurological impairment found that the rates of aspiration pneumonia and mortality were similar among those treated with jejunal feeding as compared with those treated with fundoplication [45].
** 2.1 '''Specific Organ system involved 1 '''
**
**: '''Note (1):'''
*****  
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Revision as of 17:31, 24 March 2018

Aspiration pneumonia Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Aspiration Pneumonia from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Aspiration pneumonia medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Aspiration pneumonia medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Aspiration pneumonia medical therapy

CDC onAspiration pneumonia medical therapy

Aspiration pneumonia medical therapy in the news

Blogs on Aspiration pneumonia medical therapy

Directions to Hospitals Treating Pneumonia

Risk calculators and risk factors for Aspiration pneumonia medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Medical Therapy

Management of patients with swallowing dysfunction is highly individualized based on the cause of the dysfunction and other patient characteristics identified by the multidisciplinary evaluation outlined above.

If there are primary anatomical abnormalities that predispose to aspiration, these should be surgically corrected, if possible. Total parenteral nutrition or nasogastric tube feeding may be necessary to safely meet caloric requirements during the recovery period after corrective surgery. The same methods for nutritional support should be considered when the patient's swallowing dysfunction is secondary to a transient disease, such as a critical illness.

Feeding decisions

The goals of therapy are safe and efficient nutrition that preserves stable respiratory function and appropriate growth. Oral feeding, while always desirable, is not always the most reasonable goal for patients with severe swallowing dysfunction because the risks of oral feeding may outweigh the psychosocial benefits to the patient and family [6,37,38]. On the other hand, for some patients with severe static encephalopathy or global delays, the family may choose to maintain oral feeds for pleasure despite the known risks of aspiration and pulmonary injury. These considerations require a clear and detailed discussion of goals and risks between the family and clinicians [39].

Techniques to enhance oral feeding

In children with functional abnormalities, treatment is often led by speech and occupational therapists that specialize in swallowing. The specialist selects specific techniques to improve swallowing function based on individual patient characteristics:

●In infants, change in the flow of liquids may significantly improve swallowing. These changes can be made by changing to a slow flow nipple.

●Other feeding techniques include changes in the infant or child's position and posture during feeding, modification of bolus size, and alterations of consistency, shape, texture, and temperature of food. These techniques should be selected based on the result of the videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) (image 1) [3,40].

●In children with delayed maturation, swallowing function may improve over time. In the interim, the techniques outlined above are used to support adequate nutrition and avoid aspiration. The type of feeding is then gradually advanced as the infant or child matures. Advances in feeding may be directed by repeat swallowing evaluation, including clinical assessment of feeding, with or without VFSS or FEES.

Gastrostomy feeds

Percutaneous gastrostomy tube placement should be considered for patients who are unable to safely consume enough calories by mouth. Some patients will require gastrostomy tubes to meet part or all of their nutritional needs. Oral-motor and swallowing therapy should be continued in patients in whom swallowing function is expected to improve, and gastrostomy tubes may be removed when no longer necessary.

Parents may initially be reluctant to have a gastrostomy tube placed because of concerns about losing pleasure of eating, discomfort, or cosmesis. The importance of preventing pulmonary aspiration, long-term benefits of improved nutrition, and reversibility of this procedure should be emphasized. In addition, gastrostomy tubes can be useful for administering medication and fluid, when needed.

General considerations about gastrostomy placement and enteral feeding are discussed in a separate topic review.

Management of salivary aspiration

Management techniques for patients with suspected salivary aspiration include:

●Providing small quantities ("tastes") of liquid or food, to assist purposeful swallowing and reduce the risk of aspiration from pooled saliva.

●Administration of anticholinergic agents, such as glycopyrrolate or scopolamine patches to inhibit salivation. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)

●Botulinum toxin injections to decrease salivation. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)

●Surgical removal of salivary glands or salivary duct ligation has had a beneficial effect in some individuals, although these surgeries are not without risk. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)

●In very rare instances, laryngotracheal separation with a permanent tracheostomy may be indicated.

Surgical approaches should be approached with caution because it is often difficult to predict whether or not these procedures will improve pulmonary symptoms.

Management of gastroesophageal reflux

Patients with swallowing dysfunction, especially those with neurologic impairment, may have increased frequency and volume of gastroesophageal reflux (GER).

Most patients with mild GER can be effectively managed without fundoplication, using dietary modification and positioning to reduce the frequency of GER, pharmacotherapy for acid suppression, and occasionally prokinetic agents.

Fundoplication

Fundoplication is a surgical procedure to reduce the risk of GER. It should be considered only in patients with GER that is strongly suspected to be contributing to pulmonary disease. When evaluating the severity of GER, a gastroenterologist classically focuses on the percent of time that gastric contents spend in the esophagus, which correlate with the risk for peptic esophagitis. From a pulmonary point of view, the number and duration of episodes may be less important than whether the reflux occurs during sleep, when the patient is horizontal and less likely to protect the larynx. Clinical judgment must be applied to individual patients when judging whether they are likely to benefit from fundoplication. Complications after fundoplication include retching, esophageal obstruction, intrathoracic herniation, and recurrence of GER due to breakdown of the wrap. Complications of fundoplication are most common in patients with neurologic impairment [42,43]. Failure rates (variously defined) of antireflux surgery range from 2 to 50 percent and are generally higher in children with neurological impairment [44].

Jejunal feeds

For patients with GER who are dependent on enteral feeds, an alternate strategy to reduce GER and the associated risks of aspiration is to place the feeding tube in the jejunum rather than in the stomach; this tends to reduce but not eliminate GER. Disadvantages of jejunal feeds include intolerance of rapid feeding infusions (such that continuous rather than bolus feeds must be used), and a tendency for accidental displacement (except with permanent, surgically placed jejunal tubes). A retrospective study in a group of children with neurological impairment found that the rates of aspiration pneumonia and mortality were similar among those treated with jejunal feeding as compared with those treated with fundoplication [45].

References

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Aspiration_pneumonia_medical_therapy&oldid=1456354"