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Complication rates greater among patients with aspiration pneumonia
Patients with aspiration pneumonia had more complications, greater length of stay and 30-day readmission rates and higher hospital costs compared with patients who had nonaspiration pneumonia, according to recent research.
“In children with [neurologic impairment (NI)], pneumonia is one of the most common reasons for hospitalization, admission to an ICU, and death,” Joanna Thomson, MD, MPH, from the division of hospital medicine, Cincinnati Children’s Hospital Medical Center, and colleagues wrote. “In our clinical experience, pneumonia in children with NI, compared with otherwise healthy children, can be challenging to diagnose and treat because no validated clinical practice guidelines exist for pneumonia in children with NI.”
Thomson and colleagues retrospectively identified 27,455 patients with NI aged 1 to 18 years who were diagnosed with pneumonia from 2007 to 2012 across 40 children’s hospitals. The researchers recorded whether the patients had aspiration (9.7%) or nonaspiration pneumonia and examined the records for outcomes such as length of stay, 30-day readmission and acute respiratory failure.
They found that 34% of patients with aspiration pneumonia had complications vs. 15.2% of those who had nonaspiration pneumonia (adjusted OR = 1.2; 95% CI, 1.1-1.3). Patients with aspiration pneumonia stayed in the hospital a median of 5 days compared with 3 days in patients with nonaspiration pneumonia (ratio of means = 1.2; 95% CI, 1.2-1.3).
In addition, patients with aspiration pneumonia also had more transfers in the ICU (4.3% vs. 1.5%; aOR = 1.4; 95% CI, 1.1-1.9, more 30-day readmissions (17.4% vs. 6.8%; aOR = 1.3; 95% CI, 1.2-1.5) and increased median hospital costs ($11,594 vs. $5,162; ratio of means = 1.2; 95% CI, 1.2-1.3), according to the study.
“These findings highlight the serious health consequences of pneumonia that occur in children with NI,” Thomson and colleagues wrote. “It is important that these consequences are discussed with families of children with NI, especially the high rates of complications (34%) and 30-day hospital readmission (18%) in children diagnosed with aspiration pneumonia.
“Yet there remains a need to understand how to accurately distinguish pneumonia type; which antibiotics are most effective; and how bronchodilators, steroids, and other respiratory treatments can be leveraged to maximize pulmonary function.” – by Jeff Craven
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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This detailed analysis of a large national pediatric inpatient data set strongly validates our clinical intuition. Thomson and colleagues demonstrate that among hospitalized children with neurologic impairments and pneumonia, those with aspiration pneumonia have more complications and use more hospital resources than those with nonaspiration pneumonia. Aspiration is significantly associated with chronic conditions, technology dependencies and epilepsy.
What do we do with these findings, other than smugly nod in agreement? These results remind us to anticipate needs. Children with neurologic impairments, multiple chronic conditions, technology dependencies, aspiration pneumonia — these children are those that we now recognize as children with medical complexity (CMC), who account for about 1% of the pediatric population. They are children with the highest of medical complexity, medical fragility, psychosocial complexity and technology dependency. And although they are often the highest utilizers of pediatric health care resources, they are also the children in the poorest of health and recipients of the most fragmented care.
Despite our available approaches to manage gastroesophageal reflux, impaired airway protection and clearance mechanisms, restrictive and chronic lung disease and neuromuscular scoliosis that are common to CMC, we cannot prevent aspiration. Therefore, parents of CMC need anticipatory guidance and opportunities to define advanced care plans for their children, based on thoughtful discussions, shared decision-making and goal of care.
With trusted providers in longitudinal relationships, parents can make decisions regarding therapeutic feedings for quality of life, and state preferences for hospital or home-based care for acute events. While we continue to do all we can to prevent aspirations in CMC, we need to also do all we can to anticipate events. CMC and their parents deserve an evidence-based plan, and Thomson and colleagues offer us the evidence.
Perspective
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This is an interesting and well-designed study that highlights important differences in outcomes and resource utilization among children with neurologic impairment who are hospitalized with aspiration vs. nonaspiration pneumonia.
While the results may be partially confounded by the lack of a gold standard for aspiration pneumonia, those with aspiration pneumonia suffered more complications, more intensive care transfers, and longer hospitalizations than those with nonaspiration pneumonia. Those with aspiration pneumonia also represented a population of children with a larger degree of medical complexity, including more severe neurologic impairment and more comorbidities; however, differences remained after controlling for these and other factors.
Although reasons for the observed differences are unclear, this study highlights an important and understudied problem in a vulnerable population of children. Efforts to improve the diagnosis and treatment of aspiration pneumonia as well as effective measures to reduce the risk for aspiration and subsequent hospitalization in children with neurologic impairment are needed.