Aspirasyon Pnömonisi ile Yoğun Bakım Ünitesine Yatan Geriatrik Hastalarda Erken Mortalite Belirteçleri

Amaç Geriatrik grupta aspirasyon pnömonisi en sık Yoğun Bakıma yatış nedenlerinden biridir. Sistemik hastalıklarla ilişkili çoklu komorbiditelerin yanı sıra demans, kırılganlık ve yutma veya hava yolunu koruma güçlüğü geriatrik yaşta aspirasyon pnömonisinin oluşumuna katkıda bulunabilir. Ayrıca, diğer birçok değişken bu hasta grubunun sonucunu etkileyebilir. Bu çalışmada yoğun bakım mortalitesine etkisi olabilecek parametrelerin belirlenmesi amaçlanmıştır. Materyal ve Metod Aspirasyon pnömonisi tanısı ile üçüncü basamak yoğun bakım ünitesine yatırılan 80 yaş ve üzeri 221 hasta retrospektif olarak incelendi. 28 günlük sonuçlara göre iki gruba ayrıldılar (hayatta kalanlar ve hayatta kalmayanlar). Arteriyel kan Ph ve pCO2 ve laktat, kan üre, kreatinin, potasyum (K) ve sodyum (Na) seviyeleri, APACHE II, Glaskow Koma Ölçeği (GCS), modifiye şok indeksi (MSI) ve aspirasyon pnömonisinin kaynağı ( toplum kökenli aspirasyon pnömonisi (CA-AP) veya sağlık hizmeti ile ilişkili aspirasyon pnömonisi (HCA-AP)) kaydedildi. Bu değişkenlerin 28 günlük mortalite üzerindeki etkileri analiz edildi. Bulgular HCA-AP, GCS ve APACHEII skorlarının varlığı iki grup arasında anlamlı olarak ilişkili bulundu. Bu değişkenler için ROC analizi yapıldı ve kesme noktaları hesaplandı. Lojistik regresyon analizi, APACHEII(>22.5, AUC:0.812,P=0.00) ve GCS'nin (<9, AUC:0.730, P=0.00) HCA-AP varlığı ilebirlikte mortalitenin en belirgin bağımlı belirleyicileri olduğunu gösterdi (p<0.05, olasılık oranı 7.68 , 3,23 sırasıyla). Sonuç Aspirasyon pnömonisi olan geriatrik hastaların yoğun bakım ünitesine yatışlarında ilk 28 günlük mortaliteyi öngörmede birçok değişken anlamlı olmakla birlikte, HCA-AP varlığı, yüksek yatış APACHE II skoru ve düşük GCS skoru anlamlı bağımsız değişkenlerdi.

Anahtar Kelimeler:

aspirasyon pnömonisi, geriatri, mortalite öngörücüleri, yoğun bakım üniteleri, sağlık hizmeti ilişkili aspirasyon pnömonisi

The Predictors of Early Mortality in Geriatric Patients who Hospitalized to the Intensive Care Unit with Aspiration Pneumonia

Aim In the geriatric group, aspiration pneumonia is one of the most common causes of Intensive Care Unit admission. Multiple comorbidities related with systemic diseases, as well as dementia, fraility and difficulty in swallowing or protecting the airway may all contribute the development of the AP in the geriatric age. Furthermore, many other variables may influence the outcome of this patient group. In this study, it is aimed to determine the parameters that may have an effect on the intensive care mortality. Materials and Methods 221 patients aged ≥ 80 years who were admitted to the third level ICU with the diagnosis of aspiration pneumonia were retrospectively analyzed. They were divided into two groups according to the 28-day outcome (survived-nonsurvived). The admission levels of arterial blood Ph and pCO2 and lactate , blood urea, creatinine, potassium (K) and sodium (Na) levels, APACHE II, Glaskow Coma Scale (GCS), modified shock index (MSI) and the aspiration pneumonia's source ( community-acquired aspiration pneumonia (CA-AP) or healthcare-associated aspiration pneumonia (HCA-AP) )were recorded.The effects of these variables on 28-day mortality were analyzed. Results The presence of HCA-AP, GCS and APACHEII scores were found to be significantly correlated between the two groups. ROC analysis were done for those variables and cutoff points werecalculated. Logistic regression analysis indicated that APACHEII (>22.5,AUC:0.812,P=0.00) and GCS (<9, AUC:0.730, P=0.00) as the most prominentin dependent predictors of mortality (p<0,05, odds ratio 7.68, 3.23 respectively) with the presence of HCA-AP. Conclusion Although many variables are significant in predicting the first 28 days of mortality in ICU admission of geriatric patients with aspiration pneumonia, the presence of HCA-AP, high hospitalization APACHE II score and low GCS score were significant independent variables.

Keywords:

aspiration pneumonia, geriatrics, mortality predictors, intensive care units, healthcare-associated aspiration pneumonia,

PDF

___

1. A Torres 1, J Serra-Batlles, A Ferrer, P Jiménez, R Celis, E Cobo, R Rodriguez-Roisin. Severe community-acquired pneumonia. Epidemiology and prognostic factors. Am Rev Respir Dis. 1991 Aug;144(2):312-8.
2. Teramoto S. Clinical Significance of Aspiration Pneumonia and Diffuse Aspiration Bronchiolitis in the Elderly. Journal of Gerontology & Geriatric Research (2013) 03(01).
3. James KH Luk, FHKCP, FHKAM (Medicine)1; Daniel KY Chan, MD, FACP2,3. Preventing aspiration pneumonia in older people: do we have the 'know-how'? Hong Kong Med J 2014 Oct;20(5):421–7 | Epub 4 Jul 2014.
4. Susan L. Mitchell, MD; Dan K. Kiely, MPH; Lewis A. Lipsitz, MD. The Risk Factors and Impact on Survival of Feeding Tube Placement in Nursing Home Residents With Severe Cognitive Impairment. Arch Intern Med. 1997;157(3):327-332. doi:10.1001/archinte.1997.00440240091014
5. Xin Ding 1, Hui Lian 2, Xiaoting Wang. Management of Very Old Patients in Intensive Care Units. Aging Dis. 2021 Apr 1;12(2):614-624.
6. Kosaku Komiya 1, Hiroshi Ishii 2, Jun-Ichi Kadota . Healthcare-associated Pneumonia and Aspiration Pneumonia. Aging Dis. 2014 Feb 8;6(1):27-37.
7. Lanspa MJ, Jones BE, Brown SM, Dean NC. Mortality, morbidity, and disease severity of patients with aspiration pneumonia. J Hosp Med. 2013;8(2):83–90.
8. Vladimir Kaplan 1, Derek C Angus, Martin F Griffin, Gilles Clermont, R Scott Watson, Walter T Linde-Zwirble. Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med. 2002 Mar 15;165(6):766-72. doi: 10.1164/ajrccm.165.6.2103038.
9. Cabre M, Serra-Prat M, Palomera E, Almirall J, Pallares R, Clavé P. Prevalence and prognostic implications of dysphagia in elderly patients with pneumonia. Age Ageing. 2010 Jan;39(1):39-45. doi: 10.1093/ageing/afp100.
10. Lode H. Microbiological and clinical aspects of aspiration pneumonia. J Antimicrob Chemother. 1988 Apr;21 Suppl C:83-90. doi: 10.1093/jac/21.suppl_c.83.
11. Ott SR, Lode H. [Diagnosis and therapy of aspiration pneumonia]. Dtsch Med Wochenschr. 2006 Mar 24;131(12):624-8. doi: 10.1055/s-2006-933707.
12. Hickling KG, Howard R. A retrospective survey of treatment and mortality in aspiration pneumonia. Intensive Care Med. 1988;14(6):617-22. doi: 10.1007/BF00256765.
13. Janda M, Scheeren TW, Nöldge-Schomburg GF. Management of pulmonary aspiration. Best Pract Res Clin Anaesthesiol. 2006 Sep;20(3):409-27. doi: 10.1016/j.bpa.2006.02.006.
14. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416.
15. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.
16. Komiya K, Ishii H, Kadota J. Healthcare-associated Pneumonia and Aspiration Pneumonia. Aging Dis. 2014 Feb 8;6(1):27-37. doi: 10.14336/AD.2014.0127.
17. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar 1;344(9):665-71. doi: 10.1056/NEJM200103013440908.
18. Pikus L, Levine MS, Yang YX, et al. Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia. Am J Roentgenol. 2003;180:1613–1616.
19. El-Solh AA, Pietrantoni C, Bhat A, Aquilina AT, Okada M, Grover V, Gifford N. Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med. 2003 Jun 15;167(12):1650-4.
20. Godinjak A, Iglica A, Rama A, Tančica I, et al. Predictive value of SAPS II and APACHE II scoring systems for patient outcome in a medical intensive care unit. Acta Med Acad. 2016 Nov;45(2):97-103.
21. Altas OF, Kizilkaya M. The Effects of Neutrophil-Lymphocyte Ratio, Platelet-Lymphocyte Ratio and Prognostic Markers in Determining the Mortality in Patients Diagnosed With Pneumonia in Intensive Care. Medeni Med J. 2021;36(2):130-137. doi: 10.5222/MMJ.2021.64160. Epub 2021 Jun 18.
22. Eizadi-Mood N, Saghaei M, Alfred S, Zargarzadeh AH, Huynh C, Gheshlaghi F, et al. Comparative evaluation of Glasgow coma score and gag reflex in predicting aspiration pneumonitis in acute poisoning. J Crit Care. 2009;24:470.e9–470.15. doi: 10.1016/j.jcrc.2008.08.008.
23. Montassier E, Le Conte P. Aspiration pneumonia and severe self-poisoning: about the necessity of early airway management. J Emerg Med. 2012;43:122–123. doi: 10.1016/j.jemermed.2011.07.036.
24. Abdallah A, Demaerschalk BM, Kimweri D, et al. A comparison of the Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) scores in predicting mortality among patients with reduced level of consciousness in Uganda. Neurocrit Care. 2020 Jun;32(3):734-741. doi: 10.1007/s12028-019-00806-4.
25. Jayaprakash N, Gajic O, Frank RD, Smischney N. Elevated modified shock index in early sepsis is associated with myocardial dysfunction and mortality. J Crit Care. 2018 Feb;43:30-35. doi: 10.1016/j.jcrc.2017.08.019.
26. Özgültekin A, Çiyiltepe F. Do shock index and modified shock index have any prognostic value in severely ill elderly, medical patients with multiple comorbidities? International Journal of Gerontology 2019 Vol.13 No.1 pp.76-80 ref.33.
27. Schlanger LE, Bailey JL, Sands JM. Electrolytes in the aging. Adv Chronic Kidney Dis. 2010 Jul;17(4):308-19. doi: 10.1053/j.ackd.2010.03.008.
28. Pinargote H, Ramos JM, Zurita A, Portilla J. Clinical features and outcomes of aspiration pneumonia and non-aspiration pneumonia in octogenarians and nonagenarians admitted in a General Internal Medicine Unit. Rev Esp Quimioter. 2015 Dec;28(6):310-3. PMID: 26621175