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Aging and Disease    2015, Vol. 6 Issue (1) : 27-37     DOI: 10.14336/AD.2014.0127
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Healthcare-associated Pneumonia and Aspiration Pneumonia
Kosaku Komiya1, 2, Hiroshi Ishii3, Jun-ichi Kadota1
1Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Yufu, Japan
2Clinical Research Center of Respiratory Medicine, Tenshindo Hetsugi Hospital, Oita, Japan
3Department of Respiratory Medicine, Fukuoka University Hospital, Jonan-ku, Fukuoka, Japan
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Abstract  

Healthcare-associated pneumonia (HCAP) is a new concept of pneumonia proposed by the American Thoracic Society/Infectious Diseases Society of America in 2005. This category is located between community-acquired pneumonia and hospital-acquired pneumonia with respect to the characteristics of the causative pathogens and mortality, and primarily targets elderly patients in healthcare facilities. Aspiration among such patients is recognized to be a primary mechanism for the development of pneumonia, particularly since the HCAP guidelines were published. However, it is difficult to manage patients with aspiration pneumonia because the definition of the condition is unclear, and the treatment is associated with ethical aspects. This review focused on the definition, prevalence and role of aspiration pneumonia as a prognostic factor in published studies of HCAP and attempted to identify problems associated with the concept of aspiration pneumonia.

Keywords healthcare-associated pneumonia      aspiration pneumonia      elderly      diagnosis     
Corresponding Authors: Kosaku Komiya   
Online First Date: 23 November 2014    Issue Date: 02 February 2015
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Kosaku Komiya
Hiroshi Ishii
Jun-ichi Kadota
Cite this article:   
Kosaku Komiya,Hiroshi Ishii,Jun-ichi Kadota. Healthcare-associated Pneumonia and Aspiration Pneumonia[J]. Aging and Disease, 2015, 6(1): 27-37.
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http://www.aginganddisease.org/EN/10.14336/AD.2014.0127     OR     http://www.aginganddisease.org/EN/Y2015/V6/I1/27
Figure 1.  Risk factors associated with aspiration pneumonia.

Abbreviations: CNS= central nervous system

Figure 2.  Diagnostic procedures and types of intervention for dysphagia and aspiration pneumonia.
StudyCountryDesignPatientsDefinition of aspiration pneumonia or risk factors for aspiration pneumonia
Carratalà J, et al. 200748SpainprospectiveCAP/HCAPPatients with risk factors such as compromised consciousness, altered gag reflex, dysphagia, severe periodontal disease, putrid sputum and radiographic evidence of involvement of a dependent pulmonary segment or necrotizing pneumonia.
Garcia-Vidal C, et al. 201123SpainprospectiveCAP/HCAPSame as Carratalà J, et al. 2007.
Simonetti A, et al. 201222SpainprospectiveCAP/HCAPSame as Garcia-Vidal C, et al. 2011.
Giannella M, et al. 201221SpainprospectiveCAP/HCAP/HAPAltered consciousness, altered gag reflex, dysphagia, severe periodontal disease or putrid sputum.
Falcone M, et al. 201210ItalyprospectiveHCAPPatients with risk factors such as compromised consciousness, altered gag reflex, dysphagia, severe periodontal disease, putrid sputum or necrotizing pneumonia in absence of positive respiratory specimen cultures.
Fukuyama H, et al. 201320JapanprospectiveCAP/NHCAPPatients with apparent aspiration, a condition in which aspiration is strongly expected or the existence of an abnormal swallowing function or dysphagia. Suspected patients were assessed using water swallowing tests or VE for the purpose of evaluating the swallowing function.
Shindo Y, et al. 200949JapanretrospectiveCAP/HCAPProbable aspiration was defined as any witnessed aspiration before hospital admission or aspiration confirmed by fluid-drinking test on hospital admission.
Miyashita N, et al. 201230JapanretrospectiveCAP/NHCAPPneumonia in a patient with a predisposition to aspiration because of dysphagia or a swallowing disorder. The swallowing function was assessed using the water-swallowing test, repetitive saliva-swallowing test, simple swallowing provocation test and VF. When the swallowing function was not assessed using these examinations, the presence of overt symptoms of dysphagia or a medical history of aspiration was determined to a swallowing disorder in the patient.
Ishida T, et al. 201227JapanretrospectiveCAP/NHCAPTrained nurses checked the following factors three times: a past history of aspiration, the occurrence of a choking sensation with a wet cough during meals and the presence of massive fur on the tongue. If at least one factor was identified, the patient was judged to have a risk of aspiration and the swallowing function was assessed using the water swallowing test, repetitive saliva swallowing test, VE and VF.
Miyashita N, et al. 201326JapanretrospectiveNHCAPSame as Miyashita N, et al. 2012.
Oshitani Y, et al. 201325JapanretrospectiveCAP/NHCAPInvolvement of aspiration was defined as dysphagia or aspiration confirmed or strongly suspected.
Komiya K, et al. 20138JapanretrospectiveCAP/HCAPPatients with both risk factors for aspiration and evidence of gravity-dependent opacity on chest CT.
Nakagawa N, et al. 201324JapanretrospectiveCAP/NHCAPAspiration was recorded when witnessed by a patient’s family member or care staff member before the onset of pneumonia and confirmed by a water swallowing test or swallowing test using a laryngoscope.
Table 1.  Definition of aspiration pneumonia among studies of healthcare-associated pneumonia
StudyRatio in CAP/(N)HCAPRatio in CAPRatio in (N)HCAPCrude mortality or adjusted OR or HR
Carratalà J, et al. 20074844/727 (6.1%)18/601 (18%)26/126 (20.6%)n.a.
Garcia-Vidal C, et al. 201123162/2153 (7.5%)91/1668 (5.5%)71/485 (14.6%)n.a.
Simonetti A, et al. 201222123/1593 (7.7%)68/1274 (5.3%)55/319 (17.2%)no significance?
Giannella M, et al. 201221262/898 (29.2%)108/591 (18.3%)154/307 (50.2%)OR 0.87 (0.48–1.57) p=0.66 for in-hospital mortality
Falcone M, et al. 201210n.a.n.a.55/217 (25.3%)OR 4.94 (1.71–14.27) as in-hospital mortality with significance
Fukuyama H, et al. 201320129/306 (42.2%)7/114 (6.1%)122/192 (63.5%)14.8% vs 4.3% 30 day-mortality
Shindo Y, et al. 200949124/371 (33.4%)42/230 (18.3%)82/141 (58.2%)n.a.
Miyashita N, et al. 201230492/1385 (35.5%)122/786 (15.5%)370/599 (61.8%)no significance?
Ishida T, et al. 201227376/893 (42.1%)96/451 (21.3%)280/442 (63.3%)n.a.
Miyashita N, et al. 201326n.a.n.a.370/599 (61%)n.a.
Oshitani Y, et al. 201325382/718 (53.2%)24/241 (10%)358/477 (75.1%)no significance in NHCAP
Komiya K, et al. 20138116/637 (18.2%)n.a.n.a.HR 5.690 (2.306–14.040) <0.001 at 30 days
Nakagawa N, et al. 201324484/960 (50.4%)46/373 (12.3%)438/587 (74.6%)72/484 (14.9%) vs 28/476 (5.9%) during hospitalization
Table 2.  Prevalence and role of aspiration pneumonia as a prognostic factor among studies defining aspiration pneumonia in patients with CAP and (N)HCAP
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