This patient developed septic shock secondary to pneumonia (rhonchi on lung examination and radiographic lung opacities).  His history of dementia and stroke with residual hemiparesis and evidence of vocal cord paralysis (soft, breathy voice) is highly suggestive of aspiration pneumonia due to inhalation of oral secretions.  The superior regions of the lower lobes and posterior regions of the upper lobes are the most dependent locations in the lungs of supine individuals; infiltrates in these locations are further evidence of aspiration pneumonia.

Although early studies indicated that anaerobic organisms were largely responsible for aspiration pneumonia, newer data indicate that aerobic upper respiratory organisms are primarily involved.  Therefore, first-line empiric treatment targets typical community-acquired pneumonia pathogens.  Anaerobic coverage is only required when lung abscess or empyema are present.

(Choice A)  Enteral feeding, specifically oral intake, increases the risk of aspiration in patients with dysphagia.

(Choices B and D)  Reduced intercostal muscle strength can result in atelectasis and hypoxia.  Extended immobility can produce atelectasis in the posterior lungs if the patient remains in a supine position.  These conditions can also predispose to the development of pneumonia if pulmonary hygiene is inadequate.  However, aspiration pneumonia is less likely in such patients as long as swallow and cough reflexes are intact.

(Choice C)  Impaired cellular immunity can increase the risk of pneumonia.  However, affected patients usually have a history of recurrent viral and fungal infections.

Educational objective:
Patients with dementia or hemiparesis may have dysphagia, which is a risk factor for aspiration pneumonia.  Dependent lung consolidation is commonly seen in aspiration pneumonia.