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Semin Respir Crit Care Med 2024; 45(02): 237-245
DOI: 10.1055/s-0043-1777772
Review Article

Aspiration Pneumonia

Di Pan
1   Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
,
Samuel Chung
1   Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
,
Erik Nielsen
1   Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
,
Michael S. Niederman
1   Division of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medical College, New York, New York
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Abstract

Aspiration pneumonia is a lower respiratory tract infection that results from inhalation of foreign material, often gastric and oropharyngeal contents. It is important to distinguish this from a similar entity, aspiration with chemical pneumonitis, as treatment approaches may differ. An evolving understanding of the human microbiome has shed light on the pathogenesis of aspiration pneumonia, suggesting that dysbiosis, repetitive injury, and inflammatory responses play a role in its development. Risk factors for aspiration events involve a complex interplay of anatomical and physiological dysfunctions in the nervous, gastrointestinal, and pulmonary systems. Current treatment strategies have shifted away from anaerobic organisms as leading pathogens. Prevention of aspiration pneumonia primarily involves addressing oropharyngeal dysphagia, a significant risk factor for aspiration pneumonia, particularly among elderly individuals and those with cognitive and neurodegenerative disorders.

Keywords

aspiration pneumonia - aspiration pneumonitis - chemical pneumonitis


Publication History

Article published online:
11 January 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001; 344 (09) 665-671
    Google Scholar
  • 2 Mandell LA, Niederman MS. Aspiration pneumonia. N Engl J Med 2019; 380 (07) 651-663
    Google Scholar
  • 3 Almirall J, Rofes L, Serra-Prat M. et al. Oropharyngeal dysphagia is a risk factor for community-acquired pneumonia in the elderly. Eur Respir J 2013; 41 (04) 923-928
    Google Scholar
  • 4 Taylor JK, Fleming GB, Singanayagam A, Hill AT, Chalmers JD. Risk factors for aspiration in community-acquired pneumonia: analysis of a hospitalized UK cohort. Am J Med 2013; 126 (11) 995-1001
    Google Scholar
  • 5 Wilkinson JM, Halland M. Esophageal motility disorders. Am Fam Physician 2020; 102 (05) 291-296
    Google Scholar
  • 6 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; 39 (01) 39-45
    Google Scholar
  • 7 Gipsman AI, Lapinel NC, Mayer OH. Airway clearance in patients with neuromuscular disease. Paediatr Respir Rev 2023; 47: 33-40
    Google Scholar
  • 8 Niedermeyer S, Murn M, Choi PJ. respiratory failure in amyotrophic lateral sclerosis. Chest 2019; 155 (02) 401-408
    Google Scholar
  • 9 Troche MS, Brandimore AE, Okun MS, Davenport PW, Hegland KW. Decreased cough sensitivity and aspiration in Parkinson disease. Chest 2014; 146 (05) 1294-1299
    Google Scholar
  • 10 Koopman WJ, Wiebe S, Colton-Hudson A. et al. Prediction of aspiration in myasthenia gravis. Muscle Nerve 2004; 29 (02) 256-260
    Google Scholar
  • 11 Suttrup I, Warnecke T. Dysphagia in Parkinson's disease. Dysphagia 2016; 31 (01) 24-32
    Google Scholar
  • 12 Orlikowski D, Prigent H, Sharshar T, Lofaso F, Raphael JC. Respiratory dysfunction in Guillain-Barré Syndrome. Neurocrit Care 2004; 1 (04) 415-422
    Google Scholar
  • 13 Armstrong JR, Mosher BD. Aspiration pneumonia after stroke: intervention and prevention. Neurohospitalist 2011; 1 (02) 85-93
    Google Scholar
  • 14 Kakavas S, Mongardon N, Cariou A, Gulati A, Xanthos T. Early-onset pneumonia after out-of-hospital cardiac arrest. J Infect 2015; 70 (06) 553-562
    Google Scholar
  • 15 Aylward A, Abdelaziz S, Hunt JP. et al. Rates of dysphagia-related diagnoses in long-term survivors of head and neck cancers. Otolaryngol Head Neck Surg 2019; 161 (04) 643-651
    Google Scholar
  • 16 Nativ-Zeltzer N, Nachalon Y, Kaufman MW. et al. Predictors of aspiration pneumonia and mortality in patients with dysphagia. Laryngoscope 2022; 132 (06) 1172-1176
    Google Scholar
  • 17 Patil V, Noronha V, Shrirangwar S. et al. Aspiration pneumonia in head and neck cancer patients undergoing concurrent chemoradiation from India: findings from a post hoc analysis of a phase 3 study. Cancer Med 2021; 10 (19) 6725-6735
    Google Scholar
  • 18 Cvejic L, Bardin PG. Swallow and aspiration in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2018; 198 (09) 1122-1129
    Google Scholar
  • 19 Bustamante-Marin XM, Ostrowski LE. Cilia and mucociliary clearance. Cold Spring Harb Perspect Biol 2017; 9 (04) a028241
    Google Scholar
  • 20 Raju SV, Solomon GM, Dransfield MT, Rowe SM. Acquired cystic fibrosis transmembrane conductance regulator dysfunction in chronic bronchitis and other diseases of mucus clearance. Clin Chest Med 2016; 37 (01) 147-158
    Google Scholar
  • 21 Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946; 52: 191-205
    Google Scholar
  • 22 Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993; 78 (01) 56-62
    Google Scholar
  • 23 DePaso WJ. Aspiration pneumonia. Clin Chest Med 1991; 12 (02) 269-284
    Google Scholar
  • 24 Gajic O, Dabbagh O, Park PK. et al; U.S. Critical Illness and Injury Trials Group: Lung Injury Prevention Study Investigators (USCIITG-LIPS). Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. Am J Respir Crit Care Med 2011; 183 (04) 462-470
    Google Scholar
  • 25 James CF, Modell JH, Gibbs CP, Kuck EJ, Ruiz BC. Pulmonary aspiration–effects of volume and pH in the rat. Anesth Analg 1984; 63 (07) 665-668
    Google Scholar
  • 26 Wu YC, Hsu PK, Su KC. et al. Bile acid aspiration in suspected ventilator-associated pneumonia. Chest 2009; 136 (01) 118-124
    Google Scholar
  • 27 Garvey BM, McCambley JA, Tuxen DV. Effects of gastric alkalization on bacterial colonization in critically ill patients. Crit Care Med 1989; 17 (03) 211-216
    Google Scholar
  • 28 Bonten MJ, Gaillard CA, van der Geest S. et al. The role of intragastric acidity and stress ulcus prophylaxis on colonization and infection in mechanically ventilated ICU patients. A stratified, randomized, double-blind study of sucralfate versus antacids. Am J Respir Crit Care Med 1995; 152 (6 Pt 1): 1825-1834
    Google Scholar
  • 29 Phillips S, Liang SS, Formaz-Preston A, Stewart PA. High-risk residual gastric content in fasted patients undergoing gastrointestinal endoscopy: a prospective cohort study of prevalence and predictors. Anaesth Intensive Care 2015; 43 (06) 728-733
    Google Scholar
  • 30 Fisk RL, Symes JF, Aldridge LL, Couves CM. The pathophysiology and experimental therapy of acid pneumonitis in ex vivo lungs. Chest 1970; 57 (04) 364-370
    Google Scholar
  • 31 Teabeaut II JR. Aspiration of gastric contents; an experimental study. Am J Pathol 1952; 28 (01) 51-67
    Google Scholar
  • 32 Cameron JL, Caldini P, Toung JK, Zuidema GD. Aspiration pneumonia: physiologic data following experimental aspiration. Surgery 1972; 72 (02) 238-245
    Google Scholar
  • 33 Reeves EP, Lu H, Jacobs HL. et al. Killing activity of neutrophils is mediated through activation of proteases by K+ flux. Nature 2002; 416 (6878) 291-297
    Google Scholar
  • 34 Davidson BA, Knight PR, Helinski JD, Nader ND, Shanley TP, Johnson KJ. The role of tumor necrosis factor-alpha in the pathogenesis of aspiration pneumonitis in rats. Anesthesiology 1999; 91 (02) 486-499
    Google Scholar
  • 35 DiBardino DM, Wunderink RG. Aspiration pneumonia: a review of modern trends. J Crit Care 2015; 30 (01) 40-48
    Google Scholar
  • 36 Dickson RP, Erb-Downward JR, Huffnagle GB. Towards an ecology of the lung: new conceptual models of pulmonary microbiology and pneumonia pathogenesis. Lancet Respir Med 2014; 2 (03) 238-246
    Google Scholar
  • 37 Dickson RP, Erb-Downward JR, Martinez FJ, Huffnagle GB. The microbiome and the respiratory tract. Annu Rev Physiol 2016; 78: 481-504
    Google Scholar
  • 38 Wu BG, Segal LN. The lung microbiome and its role in pneumonia. Clin Chest Med 2018; 39 (04) 677-689
    Google Scholar
  • 39 Martin-Loeches I, Dickson R, Torres A. et al. The importance of airway and lung microbiome in the critically ill. Crit Care 2020; 24 (01) 537
    Google Scholar
  • 40 Bartlett JG, Gorbach SL. The triple threat of aspiration pneumonia. Chest 1975; 68 (04) 560-566
    Google Scholar
  • 41 Miyashita N, Kawai Y, Tanaka T. et al. Detection failure rate of chest radiography for the identification of nursing and healthcare-associated pneumonia. J Infect Chemother 2015; 21 (07) 492-496
    Google Scholar
  • 42 Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominguez BL, Loesche WJ. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001; 49 (05) 557-563
    Google Scholar
  • 43 Vieira Colombo AP, Magalhães CB, Hartenbach FA, Martins do Souto R, Maciel da Silva-Boghossian C. Periodontal-disease-associated biofilm: a reservoir for pathogens of medical importance. Microb Pathog 2016; 94: 27-34
    Google Scholar
  • 44 Pan D, Nielsen E, Chung S, Niederman MS. Management of pneumonia in the critically ill. Minerva Med 2023; 114 (05) 667-682
    Google Scholar
  • 45 Ramirez JA, Musher DM, Evans SE. et al. Treatment of community-acquired pneumonia in immunocompromised adults: a consensus statement regarding initial strategies. Chest 2020; 158 (05) 1896-1911
    Google Scholar
  • 46 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 (07) e45-e67
    Google Scholar
  • 47 Pan D, Niederman MS. Risk factors and algorithms for the empirical treatment of hospital-acquired pneumonia and ventilator-associated pneumonia. Semin Respir Crit Care Med 2022; 43 (02) 183-190
    Google Scholar
  • 48 Torres A, Niederman MS, Chastre J. et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J 2017; 50 (03) 1700582
    Google Scholar
  • 49 Kalil AC, Metersky ML, Klompas M. et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63 (05) e61-e111
    Google Scholar
  • 50 El-Solh AA, Vora H, Knight III PR, Porhomayon J. Diagnostic use of serum procalcitonin levels in pulmonary aspiration syndromes. Crit Care Med 2011; 39 (06) 1251-1256
    Google Scholar
  • 51 Labro G, Aptel F, Puyraveau M. et al; PROPASPI (PROcalcitonin Pneumonia/pneumonitis Associated with ASPIration) trial investigators. Impact on antimicrobial consumption of procalcitonin-guided antibiotic therapy for pneumonia/pneumonitis associated with aspiration in comatose mechanically ventilated patients: a multicenter, randomized controlled study. Ann Intensive Care 2021; 11 (01) 145
    Google Scholar
  • 52 Kutz A, Briel M, Christ-Crain M. et al. Prognostic value of procalcitonin in respiratory tract infections across clinical settings. Crit Care 2015; 19 (01) 74
    Google Scholar
  • 53 Schuetz P, Wirz Y, Sager R. et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. Lancet Infect Dis 2018; 18 (01) 95-107
    Google Scholar
  • 54 Villar J, Ferrando C, Martínez D. et al; dexamethasone in ARDS network. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial. Lancet Respir Med 2020; 8 (03) 267-276
    Google Scholar
  • 55 Dragan V, Wei Y, Elligsen M, Kiss A, Walker SAN, Leis JA. Prophylactic antimicrobial therapy for acute aspiration pneumonitis. Clin Infect Dis 2018; 67 (04) 513-518
    Google Scholar
  • 56 Pugin J, Auckenthaler R, Mili N, Janssens JP, Lew PD, Suter PM. Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic and nonbronchoscopic “blind” bronchoalveolar lavage fluid. Am Rev Respir Dis 1991; 143 (5 Pt 1): 1121-1129
    Google Scholar
  • 57 Moussali A, Cauchois E, Carvelli J. et al. Salivary alpha amylase bronchial measure for early aspiration pneumonia diagnosis in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest. Front Med (Lausanne) 2022; 9: 880803
    Google Scholar
  • 58 Cesar L, Gonzalez C, Calia FM. Bacteriologic flora of aspiration-induced pulmonary infections. Arch Intern Med 1975; 135 (05) 711-714
    Google Scholar
  • 59 Lorber B, Swenson RM. Bacteriology of aspiration pneumonia. A prospective study of community- and hospital-acquired cases. Ann Intern Med 1974; 81 (03) 329-331
    Google Scholar
  • 60 Mier L, Dreyfuss D, Darchy B. et al. Is penicillin G an adequate initial treatment for aspiration pneumonia? A prospective evaluation using a protected specimen brush and quantitative cultures. Intensive Care Med 1993; 19 (05) 279-284
    Google Scholar
  • 61 El-Solh AA, Pietrantoni C, Bhat A. et al. Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med 2003; 167 (12) 1650-1654
    Google Scholar
  • 62 Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y. Etiology and outcome of community-acquired lung abscess. Respiration 2010; 80 (02) 98-105
    Google Scholar
  • 63 Polverino E, Dambrava P, Cillóniz C. et al. Nursing home-acquired pneumonia: a 10 year single-centre experience. Thorax 2010; 65 (04) 354-359
    Google Scholar
  • 64 Carratalà J, Mykietiuk A, Fernández-Sabé N. et al. Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes. Arch Intern Med 2007; 167 (13) 1393-1399
    Google Scholar
  • 65 Marik PE, Careau P. The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. Chest 1999; 115 (01) 178-183
    Google Scholar
  • 66 Shoar S, Musher DM. Etiology of community-acquired pneumonia in adults: a systematic review. Pneumonia 2020; 12 (01) 11
    Google Scholar
  • 67 Prina E, Ranzani OT, Polverino E. et al. Risk factors associated with potentially antibiotic-resistant pathogens in community-acquired pneumonia. Ann Am Thorac Soc 2015; 12 (02) 153-160
    Google Scholar
  • 68 Mandell LA, Wunderink RG, Anzueto A. et al; Infectious Diseases Society of America, American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 (Suppl. 02) S27-S72
    Google Scholar
  • 69 Arancibia F, Bauer TT, Ewig S. et al. Community-acquired pneumonia due to gram-negative bacteria and Pseudomonas aeruginosa: incidence, risk, and prognosis. Arch Intern Med 2002; 162 (16) 1849-1858
    Google Scholar
  • 70 Restrepo MI, Babu BL, Reyes LF. et al; GLIMP. Burden and risk factors for Pseudomonas aeruginosa community-acquired pneumonia: a multinational point prevalence study of hospitalised patients. Eur Respir J 2018; 52 (02) 1701190
    Google Scholar
  • 71 Schneider-Lindner V, Delaney JA, Dial S, Dascal A, Suissa S. Antimicrobial drugs and community-acquired methicillin-resistant Staphylococcus aureus, United Kingdom. Emerg Infect Dis 2007; 13 (07) 994-1000
    Google Scholar
  • 72 Hidron AI, Kourbatova EV, Halvosa JS. et al. Risk factors for colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to an urban hospital: emergence of community-associated MRSA nasal carriage. Clin Infect Dis 2005; 41 (02) 159-166
    Google Scholar
  • 73 Popovich KJ, Hota B, Aroutcheva A. et al. Community-associated methicillin-resistant Staphylococcus aureus colonization burden in HIV-infected patients. Clin Infect Dis 2013; 56 (08) 1067-1074
    Google Scholar
  • 74 Zervou FN, Zacharioudakis IM, Ziakas PD, Rich JD, Mylonakis E. Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus colonization in HIV infection: a meta-analysis. Clin Infect Dis 2014; 59 (09) 1302-1311
    Google Scholar
  • 75 Shorr AF. Epidemiology of staphylococcal resistance. Clin Infect Dis 2007; 45 (Suppl. 03) S171-S176
    Google Scholar
  • 76 Jackson KA, Bohm MK, Brooks JT. et al. Invasive methicillin-resistant Staphylococcus aureus infections among persons who inject drugs - six sites, 2005-2016. MMWR Morb Mortal Wkly Rep 2018; 67 (22) 625-628
    Google Scholar
  • 77 Centers for Disease Control and Prevention (CDC). Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients–United States, 2005. MMWR Morb Mortal Wkly Rep 2007; 56 (09) 197-199
    Google Scholar
  • 78 Martin-Loeches I, Torres A, Nagavci B. et al. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Eur Respir J 2023; 61 (04) 2200735
    Google Scholar
  • 79 Gupte T, Knack A, Cramer JD. Mortality from aspiration pneumonia: incidence, trends, and risk factors. Dysphagia 2022; 37 (06) 1493-1500
    Google Scholar
  • 80 Suzuki J, Ikeda R, Kato K. et al. Characteristics of aspiration pneumonia patients in acute care hospitals: a multicenter, retrospective survey in Northern Japan. PLoS One 2021; 16 (07) e0254261
    Google Scholar
  • 81 Bowerman TJ, Zhang J, Waite LM. Antibacterial treatment of aspiration pneumonia in older people: a systematic review. Clin Interv Aging 2018; 13: 2201-2213
    Google Scholar
  • 82 Kadowaki M, Demura Y, Mizuno S. et al. Reappraisal of clindamycin IV monotherapy for treatment of mild-to-moderate aspiration pneumonia in elderly patients. Chest 2005; 127 (04) 1276-1282
    Google Scholar
  • 83 Marumo S, Teranishi T, Higami Y, Koshimo Y, Kiyokawa H, Kato M. Effectiveness of azithromycin in aspiration pneumonia: a prospective observational study. BMC Infect Dis 2014; 14 (01) 685
    Google Scholar
  • 84 Hasegawa S, Shiraishi A, Yaegashi M, Hosokawa N, Morimoto K, Mori T. Ceftriaxone versus ampicillin/sulbactam for the treatment of aspiration-associated pneumonia in adults. J Comp Eff Res 2019; 8 (15) 1275-1284
    Google Scholar
  • 85 Sun T, Sun L, Wang R. et al. Clinical efficacy and safety of moxifloxacin versus levofloxacin plus metronidazole for community-acquired pneumonia with aspiration factors. Chin Med J (Engl) 2014; 127 (07) 1201-1205
    Google Scholar
  • 86 Levison ME, Mangura CT, Lorber B. et al. Clindamycin compared with penicillin for the treatment of anaerobic lung abscess. Ann Intern Med 1983; 98 (04) 466-471
    Google Scholar
  • 87 Gudiol F, Manresa F, Pallares R. et al. Clindamycin vs penicillin for anaerobic lung infections. High rate of penicillin failures associated with penicillin-resistant Bacteroides melaninogenicus. Arch Intern Med 1990; 150 (12) 2525-2529
    Google Scholar
  • 88 Stern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M. Corticosteroids for pneumonia. Cochrane Database Syst Rev 2017; 12 (12) CD007720
    Google Scholar
  • 89 Dequin PF, Meziani F, Quenot JP. et al; CRICS-TriGGERSep Network. Hydrocortisone in severe community-acquired pneumonia. N Engl J Med 2023; 388 (21) 1931-1941
    Google Scholar
  • 90 Bouadma L, Luyt CE, Tubach F. et al; PRORATA trial group. Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial. Lancet 2010; 375 (9713) 463-474
    Google Scholar
  • 91 de Jong E, van Oers JA, Beishuizen A. et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis 2016; 16 (07) 819-827
    Google Scholar
  • 92 Kyriazopoulou E, Liaskou-Antoniou L, Adamis G. et al. Procalcitonin to reduce long-term infection-associated adverse events in sepsis. A randomized trial. Am J Respir Crit Care Med 2021; 203 (02) 202-210
    Google Scholar
  • 93 Momosaki R. Rehabilitative management for aspiration pneumonia in elderly patients. J Gen Fam Med 2017; 18 (01) 12-15
    Google Scholar
  • 94 Hongo T, Yamamoto R, Liu K. et al. Association between timing of speech and language therapy initiation and outcomes among post-extubation dysphagia patients: a multicenter retrospective cohort study. Crit Care 2022; 26 (01) 98
    Google Scholar
  • 95 Elsyaad MSA, Fayed AM, Megahed MMAS, Hamouda NH, Elmenshawy AM. Early assessment of aspiration risk in acute stroke by fiberoptic endoscopy in critically ill patients. Acute Crit Care 2022; 37 (03) 276-285
    Google Scholar
  • 96 Fox KA, Mularski RA, Sarfati MR. et al. Aspiration pneumonia following surgically placed feeding tubes. Am J Surg 1995; 170 (06) 564-566 , discussion 566–567
    Google Scholar
  • 97 Adnet F, Borron SW, Finot MA, Minadeo J, Baud FJ. Relation of body position at the time of discovery with suspected aspiration pneumonia in poisoned comatose patients. Crit Care Med 1999; 27 (04) 745-748
    Google Scholar
  • 98 Warusevitane A, Karunatilake D, Sim J, Lally F, Roffe C. Safety and effect of metoclopramide to prevent pneumonia in patients with stroke fed via nasogastric tubes trial. Stroke 2015; 46 (02) 454-460
    Google Scholar
  • 99 Shinohara Y, Origasa H. Post-stroke pneumonia prevention by angiotensin-converting enzyme inhibitors: results of a meta-analysis of five studies in Asians. Adv Ther 2012; 29 (10) 900-912
    Google Scholar
  • 100 Ohkubo T, Chapman N, Neal B, Woodward M, Omae T, Chalmers J. Perindopril Protection Against Recurrent Stroke Sutdy Collaborative Group. Effects of an angiotensin-converting enzyme inhibitor-based regimen on pneumonia risk. Am J Respir Crit Care Med 2004; 169 (09) 1041-1045
    Google Scholar
  • 101 Sirvent JM, Torres A, El-Ebiary M, Castro P, de Batlle J, Bonet A. Protective effect of intravenously administered cefuroxime against nosocomial pneumonia in patients with structural coma. Am J Respir Crit Care Med 1997; 155 (05) 1729-1734
    Google Scholar
  • 102 Vallés J, Peredo R, Burgueño MJ. et al. Efficacy of single-dose antibiotic against early-onset pneumonia in comatose patients who are ventilated. Chest 2013; 143 (05) 1219-1225
    Google Scholar
  • 103 Mylotte JM. Will maintenance of oral hygiene in nursing home residents prevent pneumonia?. J Am Geriatr Soc 2018; 66 (03) 590-594
    Google Scholar
  • 104 Klompas M, Speck K, Howell MD, Greene LR, Berenholtz SM. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis. JAMA Intern Med 2014; 174 (05) 751-761
    Google Scholar
  • 105 Deschepper M, Waegeman W, Eeckloo K, Vogelaers D, Blot S. Effects of chlorhexidine gluconate oral care on hospital mortality: a hospital-wide, observational cohort study. Intensive Care Med 2018; 44 (07) 1017-1026
    Google Scholar