J. Coyle, Ph.D. April 2016; 04/06/2016 WVSHA …c.ymcdn.com/.../2016SpeakerHandouts/Coyle_WVSHA_topic_2_pneumoni.pdfApr 06, 2016 · J. Coyle, Ph.D. April 2016; WVSHA Conference 04/06/2016

J. Coyle, Ph.D. April 2016; WVSHA Conference

04/06/2016

(c) 2016 James L Coyle except as otherwise attributed 1

Pneumonia & Common Pulmonary Diseases in Adults

James L. Coyle, Ph.D., CCC‐SLP, BCS‐S

University of Pittsburgh 1

West Virginia Speech Language and Hearing Association Annual Conference, Bridgeport WV April, 2016

Disclosure

• University of Pittsburgh (salary)

• WVSHA honorarium

• NIH RO‐1 (25% effort)

• No products

• Lots of biases favoring my patients

2

What are pneumonitis and pneumonia?

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Pneumonitis: lung inflammation

Inflammation

ChemicalMedications

Irritanttraumatizes lung

Irritants,Allergens

RadiationTherapy

Inhaled or aspirated sources

4

Pneumonia: lung infection

Pneumonia (Infection andPneumonitis)

PathogenColonizes lung

Bacterial

Inhaled or aspirated sources

SystemicSpread

Resolution

Sepsis, Multi‐organ

Failure,Shock

ViralWith or withoutother debris

5

Infection causes inflammation: pneumonia = infection + inflammationPathogens and their waste are irritants

What is Pneumonia?

• Infectious pneumonitis• Caused by a pathogen (problem 1)

• Produces inflammation (problem 2)

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Pneumonia

• Most frequent infectious cause of death*

• 40% higher incidence in elderly ** • #2 nosocomial infection (UTI) in hospitals***

• High case fatality rate• 55% (elderly)• Leading cause of mortality in children under 5****

Marston, et al., 1997*; National Center for Health Statistics, 2003**; ***Niederman, et al., 2002;****Baine et al., 2001; Almirall, et al., 2000 7

What is Pneumonia?

Capillary – RBC, WBC

O2

O2

O2

O2

O2O2

O2

CO2

CO2

CO2

CO2

O2 enters alveoli, diffuses to blood

CO2 diffuses to alveoli, is exhaled

Pathogen enters alveoli

Pathogen adheres to epithelium,produces waste, reproduces. Wasteproducts are irritants

Inflammation: alveoli become thick,noncompliant.

1. Inoculation, infection

8

Capillary – RBC, WBC

O2

O2

O2

O2

O2

O2

O2

CO2

CO2

CO2

CO2

Inflammation traumatizes respiratorymembrane making it excessively permeable.

Red blood cells leak into alveoli.

Volume of debris in alveoli increases

2. Inflammation, RBC leakage

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capillary

O2O2

O2

O2

O2

O2

O2

CO2

CO2

CO2

CO2

Alveoli become more noncompliant

Immunological response, macrophages and other cells accumulate

Volume of debris increases, forming a growing infiltrate (obstructs respiration).

Surface area for respiration shrinks,

Reduced oxygen diffusion to blood (Hypoxemia)

Reduced CO2 diffusion to alveoli(Hypercapnea‐CO2 retention)

3. WBC plasma leakage, respiratory distress

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Clear alveoli

Thickened epithelium

Infiltrates

11

capillary

O2

O2

O2

O2

O2

O2

O2

CO2

CO2

CO2

CO2

Infiltrate volume has decreased,RBC eliminated

Inflammation subsiding; compliance improves

Respiratory surface area restoredgas exchange normalizes

WBC eliminated, inflammation ends

Infiltrate clears

4. Resolution

Bacterial debris eliminated

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What is aspiration and how do lungs respond to aspiration?

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Pneumonia/Pneumonitis

• Setting in which it began

• Pathogenic origin

• Mechanism• Aspiration

• Dysphagia‐related

• Non dysphagia‐related

• Hematogenous

• Iatrogenic: Direct Inoculation vs. Ventilator associated• Health care workers vs. sterilization errors

14

Pneumonia classification

• By setting• Community acquired pneumonia

• Aspiration, influenza, bug of the month

• Health care associated pneumonia• Aspiration, ventilator associated, HCW, contaminated equipment

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• By pathogen causing infection• Bacterial

• Streptococcal, staphylococcal, etc.

• Viral• Influenza, etc.

• Fungal, etc.

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• By anatomy• Bronchopneumonia• Lobar pneumonia

• Multilobar

• Diffuse, focal

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• By mechanism• Indirect ‐ HCW inoculation• Direct ‐ equipment contamination

• Hematogenous• Lung infected through circulatory system (sepsis)

• Aspiration• Dysphagia‐related• Non‐dysphagia‐related

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Aspiration Pneumonia 15.5%

>Oropharyngeal>Gastric

DAPNon‐DAP

Typical

Pneumonia100%

CAPHospital Acquired

Pneumonia

VAPAtypical

Inhaled Pathogen

AspiratedPathogen

Non‐VAP

Inhaled Pathogen

19PEOPLE CAN ASPIRATE ANYWHERE: AP IS NOT SETTING SPECIFIC!Baine et al., 2001

Aspiration

• Solid or liquid matter• Not airborne, inhaled pathogen

• Courses by gravity, to its destination

• Crosses plane of true vocal folds

20

Aspiration‐destination• Entrance of liquid or solid matter into the respiratory system, below the vocal folds• Not airborne

• Aspirated material is gravity dependent

• Airborne is not

R L

RL

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Lung response to aspiration: water

Inside alveolus

Plasma containing water inside capillary

RespiratoryMembrane

Water

H2O

H2O

H2O

H2O

RBC’s

WBC’s

Toward (L) heartFrom (R) heart

Capillary membrane

Alveolar membrane

Effros, et al., 2000 22

Inside alveolus

RespiratoryMembrane

Chemical irritant

Lung response to aspiration: pathogens and particulate matter

RBC’s

WBC’s

Plasma containing water inside capillary

Toward (L) heartFrom (R) heart

H2O H2O plasma H2O

Capillary membrane

Alveolar membrane

infiltrate

Chemical pneumonitis 23

Dysphagia‐related Aspiration Destinations

Aspiration produces pneumonitis or pneumonia in gravity dependent portions of lung(s).“Dependence” depends on posture when aspiration occurs, density & volume aspirated.

(R) Basilar infiltrates (R) Upper lobe infiltrates

24Marik, 2001


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What is aspiration pneumonia?

• …and what other types of pneumonia are there?

25

Aspiration Pneumonias

• Dysphagia‐related AP (DAP)• Pathogen in solid or liquid matter• Courses by gravity, to its destination• Not airborne, inhaled pathogen• Incidence: 11%; 15.5%, 22% (*)• Dysphagia!• Oral pathogens typically

• Colonization of oral cavity

26Robbins et al., 2008; Baine et al., 2001; Langmore et al., 1998

Other Aspiration Pneumonias

• Non‐dysphagia related AP (NDAP)• Aspiration pneumonia NOT FROM THE MOUTH

• Colonized emesis

• Gastroesophageal esophagopharyngeal reflux

• Esophageal motility disorder

• Oral pathogens • that survive in stomach

• Or from esophagus

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Community Acquired Pneumonia (CAP)

• Pneumonia not acquired in a health care facility• Mechanism: aspiration or other

• 4‐5 million cases per year* **• 600,000 hospitalizations, 45,000 deaths**

• Incidence**• 12 per 1000 persons• 20 per 1000 elderly persons (60% greater)

• Common pathogens• Typical: Streptococcus, Klebsciella pneumoniae

• Atypical *: H. influenzae, RSV, Legionella, E. coli, Staph. aureus, others

*Niederman, 2002; **Mandell & Wunderink, 200728

Other Types of Pneumonia• Ventilator Associated Pneumonia

• Exposure to mechanical ventilation• Contaminated respiratory circuits

• Contaminated suction, bronchoscopic equipment

• Aspiration of oral secretions while sedated

• Gastroesophageal reflux common in ventilation• Early, late onset

• Early: typically CAP pathogens• Late: MRSA, other drug‐resistant pathogens

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Other Types of Pneumonia

• Respiratory Syncitial virus (RSV)• Viral, common in children (day care)

• Legionella pneumonia

• Hematogenous pneumonia: sepsis• AKA SIRS

• Systemic inflammatory response syndrome

• Lung infected by bloodborne pathogen

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Sepsis

Infection and sepsis

• Infection• Pathogenic Organism…

• Organism that causes disease in host organ

• … enters and occupies host organ/tissue …

• … draws nutrients from host and damages tissue …

• … reproduces and generates metabolic waste …

• … organism, offspring, waste, are all IRRITANTS …

• … blood organ barrier disrupted …

• … organism enters circulatory system = SEPSIS

• … process repeats in other organs …

• Depending on organ … effects of infection … ???

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• Sepsis = septicemia = bacteremia (if bacterial)• Pathogen Damage to vascular structures, organs

• Leakage of fluid from blood vessels

• Hypotension • Organs need adequate blood pressure to function

• Organ metabolic failure

• Hypotensive shock• Multi‐organ hypotensive failure (high mortality)

• Organism infecting other organs• Example: UTI sepsis hematogenous pneumonia

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• Typical scenarios• 1. Urinary tract infection

• Bladder ureters kidneys blood spread

• 2. Pneumonia• Airway alveoli pulmonary capillaries spread

• 3. Wound infection• Local wound tissue capillaries blood spread

• Progression• Typically insidious in first days

• Patient may not develop sudden signs

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• Effects of sepsis• Depends on organs affected: Examples …• Brain and CNS

• Progressive lethargy reduced oral intake dehydration more lethargy more reduced intake more dehydration …

• Urinary system• Impaired filtration accumulated [organ] metabolic waste impaired nervous system and other organ function• Metabolic acidosis

• Example to illustrate• E. coli, pneumococcus in blood culture

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Sepsis

• The challenge in sepsis…• Acute mental status changes affect sensorimotor function

• Patient is impaired

• SLP examines patient• Patient performs poorly; diagnoses “dysphagia”

• Pulmonary infection now presumed to be ASPIRATION‐RELATED

• Association sticks and becomes a permanent part of the record

• Patient has permanent “history of aspiration pneumonia”

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Sepsis• Assessment considerations

• Stage of recovery

• Organs affected

• Pulmonary damage: alveolar noncompliance, debris from infiltrates ALL • Increase respiratory rate

• Muscle damage• weakness, increased respiratory rate

• Brain damage• Cognitive impairments after sepsis

• Patient endurance

• Weakness

• Effects of prolonged mechanical ventilation

• Depends on what organs suffered what damage…

Aspiration Pneumonitis(chemical pneumonitis)

• Non‐Infectious‐chemical trauma• Acute Lung Injury: caustic or particulate aspiration

• Inflammation of alveoli by effects of irritants• No primary infection

• Inflammatory edema reduces surface area

• Gastric contents• Sterile, acidic, caustic• Damage to airways, alveoli

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ARDS

Ware & Matthay, 2000

Normal acute resolution

40

Other Respiratory Diseases

41

Categories

• Obstructive Diseases• Inspired air is obstructed from the respiratory membrane• Obstructed gas exchange• Respiratory pump works

• Restrictive Diseases• Airflow or volume is mechanically restricted• Gas exchange is intact• Patient cannot inhale sufficient volume

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Respiratory Disease‐obstructive

Obstructive diseases air is “obstructed” from contact with respiratory membrane Chronic bronchitis

Emphysema

Reduced oxygen supply Hypoxemia

CO2 retention HypercapneaAcidosis

Increased respiratory rate Overlap with swallow

obstruction

Alveolarmembranedestroyed

43©McNaught & Callender, 1973

Chronic Obstructive Pulmonary Disease

• Respiratory membrane surface area is obstructed• Chronic bronchitis

Respiratory membrane surface area is destroyed emphysema

44

Restrictive Pulmonary Disease

Remember: factors that enable ventilation!

Restrictive Diseases Limit amount of air that can be inhaled

Mechanical

Poor compliance

Increased rate Reduced tidal volume

45

©McNaught & Callender, 1973


04/06/2016


Mechanically restrictive

• Disable expansion of alveoli• Pulmonary non‐compliance

• Pulmonary fibrosis

• Atelectasis• Pneumothorax

• Reduced surfactant production

• Disable expansion of thoracic cavity• Kyphosis

• Abnormally flexed thoracic spine, compressed thorax

• Tough, leathery segments tether adjacent segments

• Paralysis

46

Kyphosis

47

Pneumothorax

• Perforation of pleural membrane• Destroys intrapleural vacuum that holds lung open

Subatmospheric pressure

Pleural cavity

Atmospheric pressure48


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Pneumothorax

© en:User:Clinical Cases

© Hellerhoff

49

Atelectasis Areas of collapsed alveoli Compressive, dependent, adhesive, obstructive

Restrictive Pulmonary Disease

50

CHF

• Both obstructive…• Pulmonary edema

• Fluid leaks into alveoli due to pulmonary hypertension

• Obstructs respiratory membrane diffusion

• And restrictive components• Pleural effusions• Fluid surrounds lung, prevents inflation

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Pleural effusion• Fluid filling parts of pleural cavity

• Preventing lung expansion during inspiration

• Gravity dependent “bag of water”

Pleural cavity

52

CHF (transudative), Inflammatory (exudative)53

Pleural Effusion

Pulmonary vascular congestion

• Incoming arterial flow obstructed

• Blood “backs up” – casts shadow on image

Pulmonary hypertension54

Pulm. artery Pulm. vein

Obstructed flow


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Pulmonary edema

Pulmonary hypertension55

Pulmonary Edema

56

Iatrogenic causes of respiratory conditions

• Iatrogenic condition: a disease cause by treatment of another disease• Sedation (restrictive)

• CNS depression

• Disruption of pleural linkage (restrictive)• Cardiothoracic surgery

• Phrenic nerve injury (restrictive)• Cardiothoracic surgery

• Vagal injury (obstructive: vocal fold paralysis)

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Summary

• Pulmonary disease affects swallow/breathing coordination

• Pulmonary disease can cause dysphagia• Mainly characterized by disruption of swallow‐respiratory coordination

• Pulmonary disease can be caused by dysphagia

• Pneumonia and dysphagia are related but not married!

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Questions?

Thank you!

Documents

J. Coyle, Ph.D. April 2016; 04/06/2016 WVSHA …c.ymcdn.com/.../2016SpeakerHandouts/Coyle_WVSHA_topic_2_pneumoni.pdfApr 06, 2016 · J. Coyle, Ph.D. April 2016; WVSHA Conference 04/06/2016