Aspiration syndromes

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Aspiration syndromes

  1. 1. Aspiration SyndromesProf. Dr. Saad S Al AniSenior Pediatric ConsultantHead of Pediatric departmentKhorfakkan HospitalSharjah ,UAEsaadsalani@yahoo.com
  2. 2. Introduction“ Aspiration includes a wide clinicalspectrum from:An asymptomatic conditiontoAcute life-threatening events „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  3. 3. Cont.“Acute life-threatening events, such asoccur with:i. Massive aspiration of gastric contentsorii. Hydrocarbon products „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  4. 4. Cont.“ Occult aspiration of nasopharyngealsecretions into the lower respiratorytract is a normal event in healthy people,usually without apparent clinicalsignificance „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  5. 5. Aspiration of gastric contents“ Large-volume aspiration of gastriccontents usually occurs in the context ofvomiting „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  6. 6. Cont.“ It is an infrequent complication of* General anesthesia* Gastroenteritis* Altered level of consciousness „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  7. 7. Cont.“ Increased clinical severity is noted withvolumes greater than approximately 0.8mL/kg and/or pH <2.5 „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  8. 8. Cont.“After massive aspiration, the followingsoccur rapidly :i. Hypoxemiaii. Hemorrhagic pneumonitisiii. Atelectasisiv. Intravascular fluid shifts, andPulmonary edema „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  9. 9. Cont.“ Most clinical changes are present withinminutes to 1-2 hr after the aspirationevent „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  10. 10. Cont.“In the next 24-48 hr, there is :1. Marked increase in lung parenchymalneutrophil infiltrations2. Mucosal sloughing3. Alveolar consolidationThat often correlates with increasinginfiltrates on chest radiographs „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  11. 11. Cont.“Infection usually does not have a role ininitial lung injury after aspiration of gastriccontents „“Aspiration may impair pulmonary defenses,predisposing the patient to secondarybacterial pneumonia „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  12. 12. Cont.“In the patient who has shown clinicalimprovement but then demonstratesclinical worsening, especially with feverand leukocytosis , secondary bacterialpneumonia should be suspected „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  13. 13. Treatment“If large-volume or highly toxic substanceaspiration occurs in a patient who alreadyhas an artificial airway in place, it isimportant to perform immediate suctioningof the airway „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  14. 14. Cont.“Attempts at acid neutralization are notwarranted because acid is rapidlyneutralized by the respiratory epithelium „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  15. 15. Cont.“ Patients in whom large volume or toxicaspiration is suspected should:i. Be observedii. Undergo oxygenation measurement byoximetry or blood gas analysisiii. Undergo a chest radiograph, even ifthey are asymptomatic „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  16. 16. Cont.“ If the chest radiograph findings andoxygen saturation are normal, and thepatient remains asymptomatic , homeobservation, after a period of observationin the hospital or office, is adequate „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  17. 17. Cont.“For patients who present with abnormalfindings or in whom such findings developduring observation, oxygen therapy isgiven to correct hypoxemia„“Endotracheal intubation and mechanicalventilation are often necessary for moresevere cases „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  18. 18. Cont.“Bronchodilators may be tried, althoughthey are usually of limited benefit„“Prophylactic antibiotics are not indicated,although in the patient with very limitedreserve, early antibiotic coverage may beappropriate„5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  19. 19. Cont.“If used, antibiotics should be selected thatcover for anaerobic microbes „“If the aspiration event occurs in ahospitalized or chronically ill patient,coverage of Pseudomonas and entericgram-negative organisms should also beconsidered. „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  20. 20. Cont.“A mortality rate of ≤5% is seen if 3 orfewer lobes are involved„“Unless complications develop, such asinfection or barotrauma, most patientsrecover in 2-3 wk, although prolonged lungdamage may persist, with scarring,bronchiolitis obliterans, and bronchiectasis„5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  21. 21. Prevention“ Prevention of aspiration should always bethe goal when airway manipulation isnecessary for intubation or other invasiveprocedures. „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  22. 22. Cont.“ 1.Feeding with enteral tubes passed beyondthe pylorus2. Elevating the head of the bed 30-45 inmechanically ventilated patients3. Oral decontamination have been shownto reduce the incidence of aspirationcomplications in the intensive care unit „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  23. 23. Cont.“ 1.Minimizing use of sedation2.Monitoring for gastric residuals3.Gastric acid suppressionmay all help prevent aspiration. „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  24. 24. Cont.“Any patient with altered consciousness,especially one who is receiving tubefeedings, should be considered at high riskfor aspiration „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  25. 25. Hydrocarbon aspiration“ The most dangerous consequence of acutehydrocarbon ingestion is usually aspirationand resulting pneumonitis „“Significant pneumonitis occurs in <2% ofall hydrocarbon ingestions „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  26. 26. Cont.“Hydrocarbons with lower surface tensions(gasoline, turpentine, naphthalene) havemore potential for aspiration toxicity thanheavier mineral or fuel oils „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  27. 27. Cont.“Ingestion of >30 mL (approximate volumeof an adult swallow) of hydrocarbonisassociated with an increased risk of severepneumonitis „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  28. 28. Clinical findings“Clinical findings such as chest retractions,grunting, cough, and fever may occur assoon as 30 min after aspiration or may bedelayed for several hours „“Lung radiographic changes usually occurwithin 2-8 hr, peaking in 48-72 hr „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  29. 29. Cont.“Pneumatoceles and pleural effusions mayoccur„“Patients presenting with: cough, shortnessof breath, or hypoxemia are at high risk forpneumonitis „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  30. 30. Cont.“Other organ systems, especially the liver,central nervous system, and heart, maysuffer serious injury „“Cardiac dysrhythmias may occur and maybe exacerbated by: hypoxia and acid-baseor electrolyte disturbances „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  31. 31. Treatment“Gastric emptying is nearly alwayscontraindicated because the risk ofaspiration is greater than any systemictoxicity „“Treatment is generally supportive,consisting of: oxygen, fluids, andventilatory support as necessary „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  32. 32. Cont.“ The child who has no symptoms andnormal chest radiograph findings shouldbe observed for 6-8 hr to ensure safedischarge „“Certain hydrocarbons have more inherentsystemic toxicity „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  33. 33. Cont.“The pneumonic CHAMP referscollectively to the following hydrocarbons:Camphor, Halogenated carbons , Aromatichydrocarbons, and those associated withMetals and Pesticides „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  34. 34. Cont.“ Patients who ingest these compounds involumes >30 mL, such as might occur withintentional overdose, may benefit fromgastric emptying „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  35. 35. Cont.“If a cuffed endotracheal tube can be placedwithout inducing vomiting, this procedureshould be considered, especially in thepresence of altered mental status „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  36. 36. Cont.“Other substances that are particularly toxicand cause significant lung injury whenaspirated or inhaled include: baby powder,chlorine, shellac, beryllium, and mercuryvapors „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  37. 37. Cont.“Repeated exposure to low concentrationsof these agents can lead to chronic lungdisease, such as:i. Interstitial pneumonitisandii. Granuloma formation „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  38. 38. Cont.“Corticosteroids may:i. Help reduce fibrosis developmentii. Improve pulmonary functionalthough the evidence for this benefit islimited „5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  39. 39. Cont.“Aspirated and a chestradiograph the patient wasthought to have was obtainedimmediately (upperradiograph).The lungs areclear. Another chestradiograph was obtained twohours later (lowerradiograph) and now showsairspace disease in the rightlower lobe „http://www.learningradiology.com5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  40. 40. Cont.“Anteroposterior view of the chestof 14-month-old boy 30 hoursafter ingesting lamp oil. Note thecentral right lower lobe infiltrateobscuring the right heart border „http://emedicine.medscape.com5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  41. 41. References• Vale J, Kulig K: American Academy of Clinical Toxicology; European Association of PoisonsCentres and Clinical Toxicologists: Position paper: gastric lavage. J Toxicol ClinToxicol 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. Pediatricrespiratory 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 . 20115/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE
  42. 42. “Thank you„5/27/2013Aspiration syndrome Prof.Dr.Saad S Al AniKhorfakkan Hospital Sharjah UAE

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