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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2780_Библиотеки_им_академика_М_И_Перельмана
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lung eld density, enlarged cardiac shadow,
and enhanced pulmonary vascular shadow.
Therefore, it is important to know the degree
of insufation. In the deep inspiratory position, the right diaphragm is usually located in
the sixth or seventh anterior intercostal space,
and the left diaphragm is located 1–1.5 intercostal spaces below it.
7.3 Basics ofImage Reading
It is important to conrm that the images are
taken in the correct position and orientation.
When reading images, it is advisable to determine the order of observation to avoid oversight. In general, the images should be read
from the outside to the inside. It is advisable to
compare the densities of the lung elds at the
same height on both sides to avoid the effects of
gravity.
The key points are the cardiothoracic ratio, the
pulmonary blood ow distribution, and the presence of enlarged mediastinal shadow.
Although pneumonia is often seen as a common disease, in the supine position, pleural effusions may be mistaken for pneumonia because of
increased radiopacity of lung eld due to over-
lapping. In pneumonia, the contrast of the pulmonary blood vessels is lost, and the contrast of the
bronchi appears as a translucent tract because of
the accumulation of exudate in the alveoli around
the blood vessels (Fig.5.4). Aspiration pneumonia occurs more frequently on the dorsal side of
the lower lobe of the right lung, because the right
main bronchial bifurcation is shallower and aspirated contents tend to move to the “right,”
“lower,” and “dorsal” side due to the effect of
gravity in the upright or supine position. In aspiration pneumonia, a high opacity is often seen
close to the right heart border. However, because
the lesion located dorsal, normal lung tissue is
present near the right heart border, and the right
heart (right atrium) border remains clear. The
depth of the lesion can be inferred from the frontal view alone (Fig.5.5).
For the dentists, it is necessary to note the following: aspiration and accidental ingestion of
foreign bodies, subcutaneous emphysema mainly
in the neck caused by air tools, anaphylaxis
caused by dental anesthetics, and pulmonary
edema secondary to anaphylaxis. In general, foreign bodies can be identied by plain radiographs
because many of them are high absorbers of
X-rays, but it should be noted that some materials
may be difcult to identify by X-rays (Fig.5.6).
Fig. 5.4 Bacterial
pneumonia. The bilateral
middle lung elds show
an increase in density
(inltrative shadow)
with indistinct margins.
In the same area, the
border of the pulmonary
vascular shadow is
unclear, indicating
intrapulmonary
involvement
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Y. Yajima et al.
Fig. 5.5 Aspiration pneumonia. An inltrative shadow
with air bronchogram is seen on the dorsal aspect of the
right lower lobe. The bronchial translucency is an indication of an intrapulmonary lesion, as is the blurring of pulmonary vascular margins. In this case, the right atrium
Fig. 5.6 Foreign body
in esophagus (accidental
ingestion of foreign
body). This is a case of
accidental ingestion of a
healing abutment. A
dense foreign body was
found in the lower
esophagus. Since there
is no lung structure in
this part, it can be
judged as accidental
ingestion rather than
aspiration
In addition, acute pulmonary edema associated
with acute respiratory distress syndrome (ARDS),
a condition related to anaphylaxis, should be
noted. A bilateral inltrating shadow at the lung
hilum is a typical nding, and buttery pulmo-
was clearly contoured, indicating that the lesion was not
adjacent to the right atrium and was therefore located dorsally. Based on this information, the aspiration pneumonia
is strongly suspected
nary opacities or a batwing sign can be seen
(Fig. 5.7). If a patient complains of respiratory
symptoms after dental treatment, it is important
to keep this syndrome in mind and not to overlook the imaging ndings.
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Fig. 5.7 Acute pulmonary edema. A typical buttery pulmonary opacities is that an inltrative shadow that extends
around the bilateral hilum is shown. Acute pulmonary
edema can be caused by a variety of factors, but when it is
caused by anaphylaxis, it is more likely to have an acute
References
1. Kanda J, et al. Relationship between blood sodium
concentration and severity of heat stroke and muscle
symptoms in heat stroke. KANTO J Jpn Assoc Acute
Med. 2010;31:132–3. (in Japanese).
2. Ieko M.Clinical aspects of thrombohaemostasis—for
residents I. 2. Differential diagnosis of bleeding tendency. Jpn J Thromb Hemost. 2007;18(6):555–8. (in
Japanese).
3. Tomiyama Y. Clinical aspects of thrombohaemostasis—for residents I. 3. Classication and causes of
outcome and requires an emergency response. In the dental eld, dental anesthesia is a potential cause of pulmonary edema, and acute pulmonary edema should be
considered when patients complain of dyspnea
purpura. Jpn J Thromb Hemost. 2007;18(6):559–62.
(in Japanese).
4. Nakagawa Y.Atlas of oral mucosal diseases. (Kouku
Nenmaku Shikkan Atlas). 2nd ed. Tokyo: Quintessence
Publishing; 2018. (in Japanese).
5. Tomita Y, supervisor. Standard textbook of dermatology (Hyoujun Hifuka-gaku). 10th ed. Tokyo: Igaku
Shoin; 2017. p.42–51, 158–185. (in Japanese).
6. Klippel JH, Stone JH, Crofford LJ, White P, editors.
Primer on the rheumatic diseases. Germany: Springer;
2008.
Part II
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Diseases
Respiratory Diseases
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NorihikoFunaguchi, NoritakaOhga,
YoshimasaKitagawa, TakujiKiryu,
TadahideNoguchi, YoshiyukiMori,
TakeshiTerashima, HitoshiMiyashita,
TetsuTakahashi, YasuhiroGon, TetsuoShimizu,
YuOhashi, KeisukeHosokawa, ShigeruSakurai,
KazuroSatoh, ToshimiChiba, andAtsushiOgawa
6
N. Funaguchi · T. Kiryu
Department of Radiology, Asahi University Hospital,
Gifu, Japan
N. Ohga · Y. Kitagawa
Hokkaido University Faculty of Dental Medicine,
Sapporo, Hokkaido, Japan
T. Noguchi
Department of Dentistry, Oral and Maxillofacial
Surgery, School of Medicine, Jichi Medical
University, Shimotsuke, Tochigi, Japan
Y. Mori
Department of Dentistry, Oral and Maxillofacial
Surgery, Saitama Medical Center, Jichi Medical
University, Saitama, Japan
T. Terashima (*)
Department of Respiratory Medicine, Tokyo Dental
College, Ichikawa General Hospital, Ichikawa, Chiba,
Japan
e-mail: terasima@tdc.ac.jp
H. Miyashita
Department of Dentistry and Oral Surgery, Tohoku
Medical and Pharmaceutical University Hospital,
Sendai, Miyagi, Japan
T. Takahashi
Southern Tohoku Fukushima Hospital, Fukushima,
Japan
Y. Gon · T. Shimizu
Division of Respiratory Medicine, Department of
Internal Medicine, Nihon University School of
Medicine, Itabashi-ku, Tokyo, Japan
Y. Ohashi
Division of Oral and Maxillofacial Surgery,
Department of Oral and Maxillofacial Reconstructive
Surgery, School of Dentistry, Iwate Medical
University, Yahaba, Iwate, Japan
K. Hosokawa · S. Sakurai
Division of Behavioral Sleep Medicine and Sleep
Disorders Center, Iwate Medical University, Morioka,
Iwate, Japan
K. Satoh
Division of Internal Medicine of Dentistry,
Department of Oral Medicine, Iwate Medical
University, Morioka, Iwate, Japan
Division of Orthodontics, Department of
Developmental Oral Health Science, School of
Dentistry, Iwate Medical University, Morioka, Iwate,
Japan
T. Chiba
Division of Internal Medicine of Dentistry,
Department of Oral Medicine, Iwate Medical
University, Morioka, Iwate, Japan
A. Ogawa
Division of Oral and Maxillofacial Surgery,
Department of Oral and Maxillofacial Reconstructive
Surgery, School of Dentistry, Iwate Medical
University, Morioka, Iwate, Japan
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
T. Chiba, H. Yamada (eds.), Internal Medicine for Dental Treatments,
https://doi.org/10.1007/978-981-99-3296-2_6
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N. Funaguchi et al.
Acronyms
classied separately since 2017, pneumonia has
been ranked fth and aspiration pneumonia
AIDS Acquired immunodeciency
syndrome
CAP Community-acquired pneumonia
sixth in 2019 statistics. More than 95% of pneumonia deaths were among people aged 65years
or older.
CRP C-reactive protein
HAP Hospital-acquired pneumonia
HIV Human immunodeciency virus
1.3 Cause andClassication
NHCAP Nursing and healthcare-associated
pneumonia
There are three types of pneumonia: communityacquired pneumonia (CAP), which occurs in people with no or minimal underlying disease;
hospital-acquired pneumonia (HAP), which occurs
1 Pneumonia [1]
in patients hospitalized for any disease (after 48h
of hospitalization); and healthcare- associated
NorihikoFunaguchi
1.1 Concept
Pneumonia is an acute inammation of the lung
parenchyma (alveolus) caused by infection with
a variety of pathogenic microorganisms. Bacterial
pneumonia is the most frequent.
pneumonia (NHCAP), which occurs mainly in
elderly people receiving medical care or nursing
care. Streptococcus pneumoniae, Haemophilus
inuenzae, Moraxella catarrhalis, and Legionella
are the causative organisms of bacterial pneumonia
in CAP.The most important causative organisms of
atypical pneumonia in CAP are Mycoplasma pneu-
moniae and Chlamydophila pneumonia (chla-
mydia). It is important to differentiate between
1.2 Epidemiology
Since 2011, pneumonia has been the third leading cause of death in Japan, but since pneumonia and aspiration pneumonia have been
bacterial pneumonia and atypical pneumonia, since
the effective antimicrobial agents are different for
each pneumonia (Fig. 6.1). The frequency of
Staphylococcus aureus and Pseudomonas aeruginosa, including MRSA, is higher in HAP.
Fig. 6.1 Differentiation
between bacterial
pneumonia and atypical
pneumonia
1. under 60 years of age
2. no or mild underlying disease
3. have a persistent cough
4. lack of findings on chest auscultation
5. no sputum or no causative organism proved by rapid diagnostic method
6. white blood cell count of less than 10,000 µL
Differential criteria
Out of 5 items from 1 to 5
Out of 6 items from 1 to 6
Suspected atypical
pneumonia
3 or more items
4 or more items
Suspected bacterial
pneumonia
Less than 2 items
Less than 3 items
ab
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In NHCAP, aspiration pneumonia is more frequent, and oral Streptococcus and anaerobic bacteria should be considered. For Legionella, it is
important to ask about the history of travel to hot
springs and use of circulatory bathtubs. If there is
a history of long-term use of steroids or immunosuppressive drugs, it is necessary to differentiate
between fungus, Mycobacterium tuberculosis,
and cytomegalovirus as opportunistic infections.
1.4 Symptoms
Symptoms such as fever, cough, sputum, chest
pain, and dyspnea are often observed. Bacterial
pneumonia is often accompanied by purulent
sputum. Mycoplasma pneumonia is characterized by a persistent dry cough without sputum. In
addition, malaise, anorexia, and disturbance of
consciousness may be observed.
1.5 Clinical Examination
pneumoniae and Legionella pneumophila and the
mycoplasma antigen test using pharyngeal swabs
are useful for rapid diagnosis.
Chest roentgenogram shows inltrative shadows, slit-glass shadows, and other shadows.
Chest CT ndings are broadly divided into alveolar pneumonia (lobar pneumonia) and bronchopneumonia. In the former, non-distracting
inltrative shadows and slit-glass shadows with
bronchial translucency are seen (Fig.6.2a), and
Streptococcus pneumoniae and Legionella
pneumophila are the most common causative
organisms that induce severe pneumonia. In the
latter case, inltrative shadows with regional
distribution, lobular central granular shadows,
branched shadows, and bronchial wall thickening are seen (Fig. 6.2b), and most bacterial
pneumonias including atypical pathogens such
as Mycoplasma and Haemophilus inuenzae
show this pattern.
1.6 Treatment
The number of leukocytes in the peripheral blood
is increased in pneumonia caused by general bacteria, but in atypical pneumonia such as mycoplasma pneumonia, the number of leukocytes is
often not increased. Sputum Gram’s stain and
culture and blood culture should be performed
before starting treatment with antimicrobial
agents. The urine antigen test for Streptococcus
It is evaluated that the presence of sepsis and
severity of CAP determines the method of treatment (Fig.6.3); the NHCAP and HAP determine
the risk of aspiration pneumonia and whether the
patient is terminal stage of disease or senility and
further evaluate the presence of sepsis and severity of pneumonia and the risk of bacterial
resistance.
Fig. 6.2 (a) Alveolar pneumonia (lobar pneumonia)
caused by Streptococcus pneumoniae. An inltrative
shadow with bronchopleural translucent area is seen in the
right lower lobe. An inltrative shadow is also seen in a
part of the right upper lobe. (b) Bronchopneumonia
caused by Haemophilus inuenzae. Regional granular
shadow in the right upper lobe, light inltrative shadow,
and bronchial wall thickening are seen
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ICU Admission
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N. Funaguchi et al.
Fig. 6.3 Classication
of severity of
community-acquired
pneumonia. (Created
based on [1])
01 or
Minor illness
*But if there′s shock, even one item is very serious.
Male: 70 years old and over, Female: 75 years old and over
•
BUN over 21mg/dL or dehydration
•
SpO2 90% or less (PaO2 60 torr or less)
•
There is a change in consciousness.
•
Blood pressure (systolic) 90 mmHg or less
•
Moderate disease
Outpatient or inpatient treatment
Empiric therapy is used to identify the causative organism based on the patient’s age, underlying medical condition, symptoms, and laboratory
ndings and to select an antimicrobial agent. It is
important to administer sufcient doses of antimicrobial agents at an early stage. When the causative organism and drug susceptibility are
determined by sputum culture, targeted therapy is
used to select a more appropriate antimicrobial
agent. For bacterial pneumonia, β-lactams such as
penicillins and cephems are effective. For atypical
pneumonia and Legionella pneumophila,
β-lactams are not effective, and macrolides, quinolones, and tetracyclines are effective.
1.7 Aspiration Pneumonia
1.7.1 Concept
Aspiration pneumonia is a general term for pneumonia caused by aspiration of oral and pharyngeal contents such as saliva containing bacteria,
food, and vomit containing gastric juice into the
respiratory tract. Aspiration pneumonia accounts
for more than 70% of pneumonia in the elderly.
1.7.2 Causes andClassication
Aspiration is caused by a decrease in the swallowing and coughing reexes due to aging or disease. There are two types of aspiration: overt
aspiration (aspiration of food or vomit) and silent
aspiration (aspiration of small amounts of saliva
Applicable number of items above*.
or 53
Serious illness
Inpatient treatment
Very Critical
during sleep or when unconscious). Many elderly
patients with recurrent pneumonia are suspected
of having aspiration pneumonia caused by silent
aspiration.
Risk factors for aspiration pneumonia include
cerebrovascular disease, neuromuscular disease
that may cause dysphagia, consciousness disorder, severe dementia, gastroesophageal reux,
and multiple antipsychotic medications.
1.7.3 Clinical Examination
Hypoxemia, increased peripheral blood leukocyte count, and elevated C-reactive protein are
observed. Chest CT shows a predominantly dorsal inferior lung eld with ground glass appearance or inltrative shadows.
1.7.4 Treatment
In the acute phase of severe aspiration pneumonia, patients are often forced to stop eating and
drinking, and uid replacement and tube feeding
are performed. When the patient’s condition
improves with treatment, swallowing function is
assessed and oral intake is considered. Evaluation
of swallowing function includes repeated saliva
swallowing tests, revised water swallowing tests,
swallowing contrast examination, and swallowing endoscopy. Bacteria that cause aspiration
pneumonia include anaerobes such as
Peptostreptococcus, Prevotella, and
Fusobacterium, as well as Staphylococcus aureus
and Gram-negative enteric bacteria.
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Antibacterial agents such as penicillins containing β-lactamase inhibitors, carbapenems, and
clindamycin are used for treatment.
To prevent aspiration, oral care and swallowing rehabilitation should be performed. It is
important to maintain a mildly elevated head
position after eating and at bedtime. To raise the
level of consciousness, sedative drugs and sleeppromoting drugs should be reduced or discontinued. ACE (angiotensin-converting enzyme)
inhibitors and cilostazol should be considered to
improve swallowing function. Patients with
severe dysphagia or repeated aspirations may
require a gastrostomy; however, gastrostomy
alone does not prevent silent aspiration, and aspiration pneumonia cannot be completely prevented, so it is important to take measures to
prevent aspiration.
1.8 Pneumonia
asanOpportunistic Infection
1.8.1 Pneumocystis Pneumonia
1. Etiology: The pathogen is Pneumocystis jir-
ovecii, a fungus, and it is an opportunistic
infection that occurs mainly when cellular
immunity is markedly impaired.
It is one of the most common AIDS-related
opportunistic infections, and HIV-positive
individuals are at increased risk if their peripheral blood CD4 lymphocyte count is less than
200/μL.In non-HIV-positive individuals, risk
factors include long-term use of steroids and
immunosuppressive drugs, use of biological
agents such as anti-TNF-alpha antibodies, and
various immunocompromised states such as
after bone marrow or organ transplantation.
2. Symptoms: Dry cough, fever, progressive
dyspnea, and general malaise.
3. Laboratory tests: Elevated LDH and CRP,
hypoxemia, and elevated β-D-glucan and
KL-6.
Chest X-rays show bilateral diffuse ground
glass appearances. In chest CT, bilateral diffuse ground glass appearances with shading
are typical. A normal area just below the
pleura is seen as a characteristic image.
The diagnosis is made by direct detection
of the organism in sputum examination or
bronchial lavage uid by bacterioscopy with
Giemsa or Grocott staining or by detection by
PCR.
4. Treatment: Sulfamethoxazole and trimethoprim combination is the rst choice, and
pentamidine and atovaquone are the other
therapeutic agents.
1.9 Notes fromDentistry
Perspective
YoshimasaKitagawa,NoritakaOhga
1.9.1 Oral Diseases andPrevention
ofPneumonia andAspiration
Pneumonia
Etiology andPathophysiology
When dysphagia occurs, nutritional disorder due
to impaired food intake and pneumonia due to
aspiration (inow of food into the respiratory tract)
become problems. The swallowing and coughing
reexes of healthy elderly people are similar to
those of young people in their 20s, but the swallowing and coughing reexes of elderly people
with aspiration pneumonia are clearly blunted.
The causes of aspiration pneumonia due to dysphagia are as follows: cerebral vascular disease
causing bulbar paralysis or pseudobulbar paralysis, postoperative oral cancer (with reconstructive
surgery using a pedicled or free ap at the resection site), heavy drinking of alcohol, admission to
a nursing home (bedridden state), total parenteral
nutrition due to inability of oral ingestion, abnormal occlusion due to denture incompatibility, oral
dryness, and poor oral hygiene.
Silent aspiration of saliva or regurgitated gastric contents into the respiratory tract while the
patient is asleep is one of the most common
causes of aspiration pneumonia. It is said that
most pneumonia in the elderly is caused by
aspiration due to the decline in swallowing
function caused by aging, and it is an urgent
need for measures of this problem in this superaged society.
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N. Funaguchi et al.
Clinical Symptoms
Bacterial aspiration pneumonia generally develops over a period of days or weeks rather than
hours. After a few days, the patient becomes sick
and often presents with a fever of 37.5 °C or
higher, malaise, and sputum production. Blood
tests often show abnormally high levels of
C-reactive protein (CRP) and peripheral blood
leukocyte counts of 9,000/μL or higher, even
though there are no obvious infection focuses in
the oral cavity. Some patients also show weight
loss and anemia, reecting a more chronic course.
Sputum often does not have a stench if the course
of the disease is at least 1week or less. Gram’s
stain of the sputum shows polymorphic leukocytes and multiple bacterial species. Sputum is
often unsuitable as a specimen for anaerobic culture, because it cannot be avoided to be contaminated by oral indigenous bacteria.
Diagnostic Imaging
On chest X-ray, consolidation is seen in the
inferior lung segment due to the effect of gravity. Consolidation may be seen in the basal segment of the inferior lobe if the patient aspirates
in the upright position and in the posterior segment of the superior lobe (usually right side) or
the segment of inferior lobe if the patient aspirates supine position. The diagnosis of alveolar
inltrates on CT imaging is also very important
(Fig. 6.4). In this case, the patient should be
treated in collaboration with a respiratory physician. Aspiration pneumonia may be complicated
by necrotizing pneumonia and pyothorax.
Prevention ofAspiration Pneumonia
andOral Care
The importance of oral care in the prevention of
aspiration pneumonia has been recognized in clinical practice over the past 20years and is becoming common knowledge among healthcare staffs.
To prevent aspiration pneumonia, it is important to
reduce the number of oral bacteria by continuous
oral care. Detailed oral care procedures are the
subject of a separate article, but the basic principle
is the mechanical cleaning of the teeth and oral
soft tissues with toothbrushes, sponge brushes,
and interdental brushes, combined with chemical
cleaning methods such as gargling agents to ensure
the prevention of oral infections.
Here, we would like to introduce a study conducted by Yoneyama etal. in Japan that pioneered
the evidence for the prevention of aspiration
pneumonia by oral care. In this study, the effects
of oral care on the prevention of pneumonia were
investigated over a 2-year period in 11 facilities
throughout Japan. Three-hundred sixty-six residents of the facilities were randomly divided into
two groups: an oral care group and a non-oral
care group. Of the 366 residents, 184 received
professional oral care over a 2-year period as the
oral care group, whereas 182 did not receive any
additional professional oral care. Of the 182
patients in the non-oral care group, 34 (19%)
developed new pneumonia, compared with 21
(11%) in the oral care group. Furthermore, 30
patients (16%) in the non-oral care group died of
pneumonia, compared with 14 patients (7%) in
the oral care group (Fig.6.5). This study of oral
care for the prevention of aspiration pneumonia
Fig. 6.4 CT image of aspiration pneumonia
19
％
11
5
0
Fig. 6.5 Comparison of the incidence of pneumonia
between the non-oral care group and the oral care group
％
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