Pulmonary aspiration

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Pulmonary Aspiration
Upper respiratory tract.jpg
Diagram of the upper respiratory tract.
Specialty Emergency Medicine, Anesthesiology, Neurology, Pulmonology
Symptoms Wheezing, Coughing, Shortness of Breath
Complications Aspiration pneumonia, Chemical pneumonitis, Death

Pulmonary aspiration is the entry of solid or liquid material such as pharyngeal secretions, food, drink, or stomach contents from the oropharynx or gastrointestinal tract, into the trachea and lungs [1] . When pulmonary aspiration occurs during eating and drinking, the aspirated material is often colloquially referred to as "going down the wrong pipe".

Contents

Consequences of pulmonary aspiration include no injury at all, chemical pneumonitis, pneumonia, or even death from asphyxiation. These consequences depend on the volume, chemical composition, particle size, and presence of infectious agents in the aspirated material, and on the underlying health status of the person.

In healthy people, aspiration of small quantities of material is common and rarely results in disease or injury. People with significant underlying disease or injury are at greater risk for developing respiratory complications following pulmonary aspiration, especially hospitalized patients, because of certain factors such as depressed level of consciousness and impaired airway defenses (gag reflex and respiratory tract antimicrobial defense system). About 3.6 million cases of pulmonary aspiration or foreign body in the airway occurred in 2013. [2]

Causes and Risk Factors

Neurologic Impairment

Any condition that results in depressed level of consciousness (such as traumatic brain injury, alcohol intoxication, drug overdose, medical sedation, stroke, and general anesthesia) can result in pulmonary aspiration of pharyngeal secretions. [3] Neurologic conditions that affect muscle coordination and posture (such as cerebral palsy, Parkinson's disease, muscular dystrophies, etc.) can also increase risk of aspiration.

Pulmonary Disease

Patients with a poor ability to clear their airway of secretions are at an increased risk of pulmonary aspiration. [4] This includes patients with pulmonary disease resulting in a weak cough, or poor forced expiratory volume. Any condition requiring mechanical ventilation is also at risk for aspiration.

Oropharyngeal Disorders

Conditions which disrupt coordination of swallowing above the glottis put a patient at increased risk for aspiration. This is referred to as oropharyngeal dysphagia and can be a result of structural abnormalities (strictures, stenosis, mediastinal and neck masses, etc.), connective tissue diseases, neuropathy, or other central nervous system-related disorders (stroke, head injury, ALS, Guillain-Barre, etc.). [5]

Medications

Drugs can increase a person's risk of aspiration through multiple mechanisms. [6] Medications including sedatives, hypnotics, and antipsychotics can result in decreased level of consciousness and loss of cough and swallow reflexes. [7] Long-term use of proton pump inhibitors can lead to overgrowth of gastric bacteria and increase risk of aspiration. [8] Antihistamines and antidepressants can cause xerostomia (decreased oral secretions) which can also lead to aspiration. [9]

Foreign-Body Aspiration

Particularly common in children, foreign-body aspiration occurs when an object is inhaled from the mouth into the airway. Objects commonly include food, coins, toys and balloons. [10] Age and developmental delays are therefore also considered risk factors for aspiration. The lumen of the right main bronchus is more vertical and slightly wider than that of the left, so aspirated objects are more likely to end up in this bronchus or one of its subsequent bifurcations. [11]

Presentation

Uncomplicated aspiration events commonly present with symptoms including wheezing and coughing. Signs and symptoms that aspiration is complicated can include dyspnea (shortness of breath), hypoxemia (low oxygen in the blood), tachycardia (high heart rate), fever, and crackles or wheezes on lung exam.

Evaluation

Evaluation and diagnosis of aspiration and aspiration-related complications may include imaging or laboratory studies.

Imaging

Radiologic studies may be done to image the chest wall, lungs, and airway to evaluate and diagnose conditions that may be contributing to aspiration, and also to diagnose complications of previous aspiration.

Chest X-rays can be useful in the diagnosis of aspiration pneumonia but may be negative early in the course. [12] Chest CT Scan can identify the presence of a pneumonia as well, and can also assist in characterizing abscesses, foreign objects, or pleural disease.

Aspiration seen on barium swallow study. Aspiration on barium swallow.jpg
Aspiration seen on barium swallow study.

A fluoroscopic swallow study can be done in cases where dysphagia or motility disorders are thought to be the source of aspiration. Food and drink are mixed with barium contrast and monitored using x-ray to evaluate swallowing. Aspiration can be diagnosed if contrast is seen coursing below the vocal cords into the trachea. [13]

Laboratory Studies

Microbiologic studies may be obtained in the case of suspected aspiration-related pulmonary infection. Labs may include infectious cultures of patient blood, sputum, or pleural fluid depending on the patient case and clinical judgement of the treatment team.

Complications

Aspiration pneumonia Aspiration pneumonia201711-3264.jpg
Aspiration pneumonia

Aspiration Pneumonia

Aspiration pneumonia is when bacteria is carried into the respiratory tract via aspiration and subsequently causes an infection of the lung. Any substance or object that is aspirated into the airway has the potential of carrying infectious agents with it into the respiratory tract. It primarily affects older adults and can be especially severe in patients with learning disabilities, or disorders of abnormal swallowing. [14]

Aspiration Pneumonitis

Aspiration pneumonitis (Mendelson's syndrome) is chemical injury of lung tissue secondary to aspiration of regurtitated gastric acid. [15] The syndrome was first described among pregnant patients [16] after the administration of anesthesia, though it can occur in any scenario where gastric contents are aspirated. [17]

Death

Histopathology of aspiration, taken from an autopsy, showing plant-like cells in a bronchiole. However, alveoli were clear, indicating a finding secondary to cardiopulmonary resuscitation rather than a primary cause of death. Histopathology of aspiration.jpg
Histopathology of aspiration, taken from an autopsy, showing plant-like cells in a bronchiole. However, alveoli were clear, indicating a finding secondary to cardiopulmonary resuscitation rather than a primary cause of death.

Aspiration can result in patient death through a variety of mechanisms. It is important to recognize and diagnose early in order to improve patient outcomes. Death from aspiration and aspiration-related syndromes is most common in elderly patients with known baseline risk factors, though it frequently goes unrecognized. [18]

Prevention

The lungs are normally protected against aspiration by a series of protective reflexes such as coughing and swallowing. Significant aspiration can only occur if the protective reflexes are absent or severely diminished (in neurological disease, coma, drug overdose, sedation or general anesthesia). In intensive care, sitting patients upright reduces the risk of pulmonary aspiration and ventilator-associated pneumonia.

Measures to prevent aspiration depend on the situation and the patient. In patients at imminent risk of aspiration, tracheal intubation by a trained health professional provides the best protection. A simpler intervention that can be implemented is to lay the patient on their side in the recovery position (as taught in first aid and CPR classes), so that any vomitus produced by the patient will drain out their mouth instead of back down their pharynx. Some anesthetists will use sodium citrate to neutralize the stomach's low pH and metoclopramide or domperidone (pro-kinetic agents) to empty the stomach. In veterinary settings, emetics may be used to empty the stomach prior to sedation.

One strategy for prevention of aspiration in hospitalized patients with neurological disorders that impact swallowing is to place patients on a thickened fluids diet after swallowing assessment by a speech-language pathologist. However, the impact of diet-alteration is debated and may have an impact on patient quality of life. [19] Also, pharyngeal residue is more common with very thickened fluids: this may subsequently be aspirated and lead to a more severe pneumonia. [20]

Management

See also: Choking § Treatment, Basic Life Support, Advanced Cardiovascular Life Support

Treatment of foreign body aspiration is determined by the age of the patient and the severity of obstruction of the airway involved. [21]

Basic management

An airway obstruction can be partial or complete. In partial obstruction, the patient can usually clear the foreign body with coughing. [21] In complete obstruction, acute intervention is required to remove the foreign body. [21]

If foreign body aspiration is suspected, finger sweeping in the mouth is not recommended due to the increased risk of displacing the foreign object further into the airway. [21]

For choking children less than 1 year of age, the child should be placed face down over the rescuer's arm. [21] Back blows should be delivered with the heel of the hand, then the patient should be turned face-up and chest thrusts should be administered. [21] The rescuer should alternate five back blows followed by five chest thrusts until the object is cleared. [21] The Heimlich maneuver should be used in choking patients older than 1 year of age to dislodge a foreign body. [21] If the patient becomes unresponsive during physical intervention, cardiopulmonary resuscitation (CPR) should be started. [21]

Advanced management

In the event that the basic measures do not remove the foreign body, and adequate ventilation cannot be restored, need for treatment by trained personnel becomes necessary. [21] Laryngoscopy should be performed in unresponsive patients if non-invasive airway clearance techniques are unsuccessful. [22] Laryngoscopy involves placing a device in the mouth to visualize the back of the airway. [22] If the foreign body can be seen, it can be removed with forceps. [22] An endotracheal tube should then be placed in order to prevent airway compromise from resulting inflammation after the procedure. [22] If the foreign body cannot be visualized, intubation, tracheotomy, or needle cricothyrotomy can be done to restore an airway for patients who have become unresponsive due to airway compromise. [21]

If non-invasive measures do not dislodge the foreign body, and the patient can maintain adequate ventilation, rigid bronchoscopy under general anesthesia should be performed. [21] Supplemental oxygen, cardiac monitoring, and a pulse oximeter should be applied to the patient. [22] Efforts should be made to keep the patient calm and avoid agitating the patient to prevent further airway compromise. [22] Flexible rather than rigid bronchoscopy might be used when the diagnosis or object location are unclear. When flexible bronchoscope is used, rigid bronchoscope is typically on standby and readily available as this is the preferred approach for removal. [23] Rigid bronchoscopy allows good airway control, ready bleeding management, better visualization, and ability to manipulate the aspirated object with a variety of forceps. [23] Flexible bronchoscopy may be used for extraction when distal access is needed and the operator is experienced in this technique. [23] Potential advantages include avoidance of general anesthesia as well as the ability to reach subsegmental bronchi which are smaller in diameter and further down the respiratory tract than the main bronchi. [23] The main disadvantage of using a flexible scope is the risk of further dislodging the object and causing airway compromise. [23] Bronchoscopy is successful in removing the foreign body in approximately 95% of cases with a complication rate of only 1%. [23]

After the foreign body is removed, patients should receive nebulized beta-adrenergic medication and chest physiotherapy to further protect the airway. [21] Steroidal anti-inflammatories and antibiotics are not routinely administered except in certain scenarios. [21] These include situations such as when the foreign body is difficult or impossible to extract, when there is a documented respiratory tract infection, and when swelling within the airway occurs after removal of the object. [23] Glucocorticoids may be administered when the foreign body is surrounded by inflamed tissue and extraction is difficult or impossible. [23] In such cases, extraction may be delayed for a short course of glucocorticoids so that the inflammation may be reduced before subsequent attempts. [23] These patients should remain under observation in the hospital until successful extraction as this practice can result in dislodgement of the foreign body. [23] Antibiotics are appropriate when an infection has developed but should not delay extraction. [23] In fact, removal of the object may improve infection control by removing the infectious source as well as using cultures taken during the bronchoscopy to guide antibiotic choice. [23] When airway edema or swelling occur, the patient may have stridor. In these cases, glucocorticoids, aerosolized epinephrine, or helium oxygen therapy may be considered as part of the management plan. [23]

Patients who are clinically stable with no need for supplemental oxygen after extraction may be discharged from the hospital the same day as the procedure. [24] Routine imaging such as a follow-up chest x-ray are not needed unless symptoms persist or worsen, or if the patient had imaging abnormalities previously to verify return to normal. [24] Most children are discharged within 24 hours of the procedure. [25]

See also

Related Research Articles

<span class="mw-page-title-main">Pneumonia</span> Inflammation of the alveoli of the lungs

Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity of the condition is variable.

<span class="mw-page-title-main">Choking</span> Mechanical obstruction of the flow of air from the environment into the lungs

Choking, also known as foreign body airway obstruction (FBAO), is a phenomenon that occurs when breathing is impeded by a blockage inside of the respiratory tract. An obstruction that prevents oxygen from entering the lungs results in oxygen deprivation. Although oxygen stored in the blood and lungs can keep a person alive for several minutes after breathing stops, choking often leads to death.

<span class="mw-page-title-main">Hemoptysis</span> Medical symptom consisting of bloody mucus from coughing

Hemoptysis or haemoptysis is the discharge of blood or blood-stained mucus through the mouth coming from the bronchi, larynx, trachea, or lungs. It does not necessarily involve coughing. In other words, it is the airway bleeding. This can occur with lung cancer, infections such as tuberculosis, bronchitis, or pneumonia, and certain cardiovascular conditions. Hemoptysis is considered massive at 300 mL. In such cases, there are always severe injuries. The primary danger comes from choking, rather than blood loss.

<span class="mw-page-title-main">Granuloma</span> Aggregation of immune cells in response to chronic inflammation

A granuloma is an aggregation of macrophages that forms in response to chronic inflammation. This occurs when the immune system attempts to isolate foreign substances that it is otherwise unable to eliminate. Such substances include infectious organisms including bacteria and fungi, as well as other materials such as foreign objects, keratin, and suture fragments.

<span class="mw-page-title-main">Atelectasis</span> Partial collapse of a lung causing reduced gas exchange

Atelectasis is the partial collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often referred to informally as a collapsed lung, although more accurately it usually involves only a partial collapse, and that ambiguous term is also informally used for a fully collapsed lung caused by a pneumothorax.

<span class="mw-page-title-main">Aspiration pneumonia</span> Medical condition

Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may include lung abscess, acute respiratory distress syndrome, empyema, and parapneumonic effusion. Some include chemical induced inflammation of the lungs as a subtype, which occurs from acidic but non-infectious stomach contents entering the lungs.

Chemical pneumonitis is inflammation of the lung caused by aspirating or inhaling irritants. It is sometimes called a "chemical pneumonia", though it is not infectious. There are two general types of chemical pneumonitis: acute and chronic.

<span class="mw-page-title-main">Lung abscess</span> Accumulation of pus in the lungs

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection.

<span class="mw-page-title-main">Respiratory disease</span> Disease of the respiratory system

Respiratory diseases, or lung diseases, are pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, influenza, and pharyngitis to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, tuberculosis, acute asthma, lung cancer, and severe acute respiratory syndromes, such as COVID-19. Respiratory diseases can be classified in many different ways, including by the organ or tissue involved, by the type and pattern of associated signs and symptoms, or by the cause of the disease.

Bronchoalveolar lavage (BAL), also known as bronchoalveolar washing, is a diagnostic method of the lower respiratory system in which a bronchoscope is passed through the mouth or nose into an appropriate airway in the lungs, with a measured amount of fluid introduced and then collected for examination. This method is typically performed to diagnose pathogenic infections of the lower respiratory airways, though it also has been shown to have utility in diagnosing interstitial lung disease. Bronchoalveolar lavage can be a more sensitive method of detection than nasal swabs in respiratory molecular diagnostics, as has been the case with SARS-CoV-2 where bronchoalveolar lavage samples detect copies of viral RNA after negative nasal swab testing.

<span class="mw-page-title-main">Airway obstruction</span> Blockage in the respiratory system

Airway obstruction is a blockage of respiration in the airway that hinders the free flow of air. Airway obstructions can occur either in the upper airway (UPA) or lower airway (LOA). The upper airway consists of the nose, throat, and larynx. The lower airway comprises the trachea, bronchi, and bronchioles.

<span class="mw-page-title-main">Lipid pneumonia</span> Lung inflammation caused by lipids in the bronchial tree

Lipid pneumonia is a specific form of lung inflammation (pneumonia) that develops when lipids enter the bronchial tree. The disorder is sometimes called cholesterol pneumonia in cases where that lipid is a factor.

<span class="mw-page-title-main">Chest physiotherapy</span> Treatments to improve breathing by indirect removal of mucus from breathing passage

Chest physiotherapy (CPT) are treatments generally performed by physical therapists and respiratory therapists, whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient. Other terms include respiratory or cardio-thoracic physiotherapy.

Mendelson's syndrome, named in 1946 for American obstetrician and cardiologist Curtis Lester Mendelson, is a form of chemical pneumonitis or aspiration pneumonitis caused by aspiration of stomach contents during anaesthesia in childbirth. This complication of anaesthesia led, in part, to the longstanding nil per os recommendation for women in labour.

<span class="mw-page-title-main">Incentive spirometer</span> Handheld device to improve lung function

An incentive spirometer is a handheld medical device used to help patients improve the functioning of their lungs. By training patients to take slow and deep breaths, this simplified spirometer facilitates lung expansion and strengthening. Patients inhale through a mouthpiece, which causes a piston inside the device to rise. This visual feedback helps them monitor their inspiratory effort. Incentive spirometers are commonly used after surgery or certain illnesses to prevent pulmonary complications.

<span class="mw-page-title-main">Bronchoscopy</span> Procedure allowing a physician to look at a patients airways

Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or inflammation. Specimens may be taken from inside the lungs. The construction of bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical fiber instruments with realtime video equipment.

Pulmonary hygiene, also referred to as pulmonary toilet, is a set of methods used to clear mucus and secretions from the airways. The word pulmonary refers to the lungs. The word toilet, related to the French toilette, refers to body care and hygiene; this root is used in words such as toiletry that also relate to cleansing.

<span class="mw-page-title-main">Foreign body aspiration</span> Medical condition

Foreign body aspiration occurs when a foreign body enters the airway which can cause difficulty breathing or choking. Objects may reach the respiratory tract and the digestive tract from the mouth and nose, but when an object enters the respiratory tract it is termed aspiration. The foreign body can then become lodged in the trachea or further down the respiratory tract such as in a bronchus. Regardless of the type of object, any aspiration can be a life-threatening situation and requires timely recognition and action to minimize risk of complications. While advances have been made in management of this condition leading to significantly improved clinical outcomes, there were still 2,700 deaths resulting from foreign body aspiration in 2018. Approximately one child dies every five days due to choking on food in the United States, highlighting the need for improvements in education and prevention.

Plastic bronchitis (PB) is a disorder in which branching casts of the airways are expectorated. PB is not a single disease with a defined mechanism that explains the cast formation in all conditions. Examples of diseases associated with expectoration of casts, and which sometimes are labeled PB include tuberculosis, atypical mycobacterial disease, allergic bronchopulmonary aspergillosis, and asthma.

<span class="mw-page-title-main">Mediastinal shift</span> Medical condition

Mediastinal shift is an abnormal movement of the mediastinal structures toward one side of the chest cavity. A shift indicates a severe imbalance of pressures inside the chest. Mediastinal shifts are generally caused by increased lung volume, decreased lung volume, or abnormalities in the pleural space. Additionally, masses inside the mediastinum or musculoskeletal abnormalities can also lead to abnormal mediastinal arrangement. Typically, these shifts are observed on x-ray but also on computed tomography (CT) or magnetic resonance imaging (MRI). On chest x-ray, tracheal deviation, or movement of the trachea away from its midline position can be used as a sign of a shift. Other structures, like the heart, can also be used as reference points. Below are examples of pathologies that can cause a mediastinal shift and their appearance.

References

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  2. ↑ Vos, Theo; Barber, Ryan M; Bell, Brad; Bertozzi-Villa, Amelia; Biryukov, Stan; Bolliger, Ian; Charlson, Fiona; Davis, Adrian; Degenhardt, Louisa; Dicker, Daniel; Duan, Leilei; Erskine, Holly; Feigin, Valery L; Ferrari, Alize J; Fitzmaurice, Christina; Fleming, Thomas; Graetz, Nicholas; Guinovart, Caterina; Haagsma, Juanita; Hansen, Gillian M; Hanson, Sarah Wulf; Heuton, Kyle R; Higashi, Hideki; Kassebaum, Nicholas; Kyu, Hmwe; Laurie, Evan; Liang, Xiofeng; Lofgren, Katherine; Lozano, Rafael; et al. (2015). "Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013". The Lancet. 386 (9995): 743–800. doi:10.1016/s0140-6736(15)60692-4. PMC   4561509 . PMID   26063472.
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  20. ↑ Robbins J, Gensler G, Hind J, Logemann JA, Lindblad AS, Brandt D, et al. Comparison of 2 interventions for fluid aspiration on pneumonia incidence: a randomised trial. Ann Intern Med. 2008;148:509–18.
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  22. 1 2 3 4 5 6 Lucia, Dominic (2017). Current Diagnosis & Treatment: Emergency Medicine, 8e, "Respiratory Distress". New York, NY: McGraw-Hill. ISBN   978-0071840613.
  23. 1 2 3 4 5 6 7 8 9 10 11 12 13 Sheperd, Wes (2019). Airway foreign bodies in adults. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA.
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  25. ↑ Rovin, J. D.; Rodgers, B. M. (1 March 2000). "Pediatric Foreign Body Aspiration". Pediatrics in Review. 21 (3): 86–90. doi:10.1542/pir.21-3-86. ISSN   0191-9601. PMID   10702322. S2CID   40614870.

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