Aspiration syndromes

Aspiration Syndromes
Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric department
Khorfakkan Hospital
Sharjah ,UAE
saadsalani@yahoo.com

Introduction
“ Aspiration includes a wide clinical
spectrum from:
An asymptomatic condition
to
Acute life-threatening events „
5/27/2013
Aspiration syndrome Prof.Dr.Saad S Al Ani
Khorfakkan Hospital Sharjah UAE

Cont.
“Acute life-threatening events, such as
occur with:
i. Massive aspiration of gastric contents
or
ii. Hydrocarbon products „
5/27/2013

Cont.
“ Occult aspiration of nasopharyngeal
secretions into the lower respiratory
tract is a normal event in healthy people,
usually without apparent clinical
significance „
5/27/2013

Aspiration of gastric contents
“ Large-volume aspiration of gastric
contents usually occurs in the context of
vomiting „
5/27/2013

Cont.
“ It is an infrequent complication of
* General anesthesia
* Gastroenteritis
* Altered level of consciousness „
5/27/2013

Cont.
“ Increased clinical severity is noted with
volumes greater than approximately 0.8
mL/kg and/or pH <2.5 „
5/27/2013

Cont.
“After massive aspiration, the followings
occur rapidly :
i. Hypoxemia
ii. Hemorrhagic pneumonitis
iii. Atelectasis
iv. Intravascular fluid shifts, and
Pulmonary edema „
5/27/2013

Cont.
“ Most clinical changes are present within
minutes to 1-2 hr after the aspiration
event „
5/27/2013

Cont.
“In the next 24-48 hr, there is :
1. Marked increase in lung parenchymal
neutrophil infiltrations
2. Mucosal sloughing
3. Alveolar consolidation
That often correlates with increasing
infiltrates on chest radiographs „
5/27/2013

Cont.
“Infection usually does not have a role in
initial lung injury after aspiration of gastric
contents „
“Aspiration may impair pulmonary defenses,
predisposing the patient to secondary
bacterial pneumonia „
5/27/2013

Cont.
“In the patient who has shown clinical
improvement but then demonstrates
clinical worsening, especially with fever
and leukocytosis , secondary bacterial
pneumonia should be suspected „
5/27/2013

Treatment
“If large-volume or highly toxic substance
aspiration occurs in a patient who already
has an artificial airway in place, it is
important to perform immediate suctioning
of the airway „
5/27/2013

Cont.
“Attempts at acid neutralization are not
warranted because acid is rapidly
neutralized by the respiratory epithelium „
5/27/2013

Cont.
“ Patients in whom large volume or toxic
aspiration is suspected should:
i. Be observed
ii. Undergo oxygenation measurement by
oximetry or blood gas analysis
iii. Undergo a chest radiograph, even if
they are asymptomatic „
5/27/2013

Cont.
“ If the chest radiograph findings and
oxygen saturation are normal, and the
patient remains asymptomatic , home
observation, after a period of observation
in the hospital or office, is adequate „
5/27/2013

Cont.
“For patients who present with abnormal
findings or in whom such findings develop
during observation, oxygen therapy is
given to correct hypoxemia„
“Endotracheal intubation and mechanical
ventilation are often necessary for more
severe cases „
5/27/2013

Cont.
“Bronchodilators may be tried, although
they are usually of limited benefit„
“Prophylactic antibiotics are not indicated,
although in the patient with very limited
reserve, early antibiotic coverage may be
appropriate„
5/27/2013

Cont.
“If used, antibiotics should be selected that
cover for anaerobic microbes „
“If the aspiration event occurs in a
hospitalized or chronically ill patient,
coverage of Pseudomonas and enteric
gram-negative organisms should also be
considered. „
5/27/2013

Cont.
“A mortality rate of ≤5% is seen if 3 or
fewer lobes are involved„
“Unless complications develop, such as
infection or barotrauma, most patients
recover in 2-3 wk, although prolonged lung
damage may persist, with scarring,
bronchiolitis obliterans, and bronchiectasis„
5/27/2013

Prevention
“ Prevention of aspiration should always be
the goal when airway manipulation is
necessary for intubation or other invasive
procedures. „
5/27/2013

Cont.
“ 1.Feeding with enteral tubes passed beyond
the pylorus
2. Elevating the head of the bed 30-45 in
mechanically ventilated patients
3. Oral decontamination have been shown
to reduce the incidence of aspiration
complications in the intensive care unit „
5/27/2013

Cont.
“ 1.Minimizing use of sedation
2.Monitoring for gastric residuals
3.Gastric acid suppression
may all help prevent aspiration. „
5/27/2013

Cont.
“Any patient with altered consciousness,
especially one who is receiving tube
feedings, should be considered at high risk
for aspiration „
5/27/2013

Hydrocarbon aspiration
“ The most dangerous consequence of acute
hydrocarbon ingestion is usually aspiration
and resulting pneumonitis „
“Significant pneumonitis occurs in <2% of
all hydrocarbon ingestions „
5/27/2013

Cont.
“Hydrocarbons with lower surface tensions
(gasoline, turpentine, naphthalene) have
more potential for aspiration toxicity than
heavier mineral or fuel oils „
5/27/2013

Cont.
“Ingestion of >30 mL (approximate volume
of an adult swallow) of hydrocarbonis
associated with an increased risk of severe
pneumonitis „
5/27/2013

Clinical findings
“Clinical findings such as chest retractions,
grunting, cough, and fever may occur as
soon as 30 min after aspiration or may be
delayed for several hours „
“Lung radiographic changes usually occur
within 2-8 hr, peaking in 48-72 hr „
5/27/2013

Cont.
“Pneumatoceles and pleural effusions may
occur„
“Patients presenting with: cough, shortness
of breath, or hypoxemia are at high risk for
pneumonitis „
5/27/2013

Cont.
“Other organ systems, especially the liver,
central nervous system, and heart, may
suffer serious injury „
“Cardiac dysrhythmias may occur and may
be exacerbated by: hypoxia and acid-base
or electrolyte disturbances „
5/27/2013

Treatment
“Gastric emptying is nearly always
contraindicated because the risk of
aspiration is greater than any systemic
toxicity „
“Treatment is generally supportive,
consisting of: oxygen, fluids, and
ventilatory support as necessary „
5/27/2013

Cont.
“ The child who has no symptoms and
normal chest radiograph findings should
be observed for 6-8 hr to ensure safe
discharge „
“Certain hydrocarbons have more inherent
systemic toxicity „
5/27/2013

Cont.
“The pneumonic CHAMP refers
collectively to the following hydrocarbons:
Camphor, Halogenated carbons , Aromatic
hydrocarbons, and those associated with
Metals and Pesticides „
5/27/2013

Cont.
“ Patients who ingest these compounds in
volumes >30 mL, such as might occur with
intentional overdose, may benefit from
gastric emptying „
5/27/2013

Cont.
“If a cuffed endotracheal tube can be placed
without inducing vomiting, this procedure
should be considered, especially in the
presence of altered mental status „
5/27/2013

Cont.
“Other substances that are particularly toxic
and cause significant lung injury when
aspirated or inhaled include: baby powder,
chlorine, shellac, beryllium, and mercury
vapors „
5/27/2013

Cont.
“Repeated exposure to low concentrations
of these agents can lead to chronic lung
disease, such as:
i. Interstitial pneumonitis
and
ii. Granuloma formation „
5/27/2013

Cont.
“Corticosteroids may:
i. Help reduce fibrosis development
ii. Improve pulmonary function
although the evidence for this benefit is
limited „
5/27/2013

Cont.
“Aspirated and a chest
radiograph the patient was
thought to have was obtained
immediately (upper
radiograph).The lungs are
clear. Another chest
radiograph was obtained two
hours later (lower
radiograph) and now shows
airspace disease in the right
lower lobe „
http://www.learningradiology.com
5/27/2013

Cont.
“Anteroposterior view of the chest
of 14-month-old boy 30 hours
after ingesting lamp oil. Note the
central right lower lobe infiltrate
obscuring the right heart border „
http://emedicine.medscape.com
5/27/2013

References
• Vale J, Kulig K: American Academy of Clinical Toxicology; European Association of Poisons
Centres and Clinical Toxicologists: Position paper: gastric lavage. J Toxicol Clin
Toxicol 2004; 42:933-943.
• Jöhr M: Anaesthesia for the child with a full stomach. Curr Opin Anaesthesiol 2007; 20:201-
203
• Colombo JL, Thomas HM: Aspiration syndromes. In: Taussig LM, Landau LI, ed. Pediatric
respiratory medicine, ed 2. Philadelphia: Mosby/Elsevier; 2008:337-345
• http://www.learningradiology.com
• http://emedicine.medscape.com
• Kliegman, Robert, Nelson, Waldo E.: Nelson textbook of pediatrics, 19th ed. Saunders,
Philadelphia, USA . 2011
5/27/2013

“Thank you„
5/27/2013

Aspiration syndromes

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