Síndromes Aspirativas


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Síndromes Aspirativas

  1. 1. doi: 10.1111/j.1742-1241.2007.01300.x REVIEW ARTICLE Aspiration syndromes: 10 clinical pearls every physician should know H. S. Paintal, W. G. KuschnerDivision of Pulmonary and SUMMARYCritical Care Medicine, Stanford Review Criteria Aspiration syndromes are clinically and pathologically classified into three sets ofUniversity School of Medicine, • Articles were identified by searching PubMedPalo Alto; and U.S. Department disorders: (i) large airway mechanical obstruction caused by foreign bodies; (ii) (1960 – December 2006) using the followingof Veterans Affairs Palo Alto aspiration pneumonitis; and (iii) aspiration pneumonia. In this article, we discuss search terms: aspiration pneumonia, aspirationHealth Care System, Palo Alto, the common clinical presentations, risk factors, radiographic features and methods pneumonitis, tracheo-bronchial foreign bodyCA, USA of management of these disorders. We highlight recent recommendations and con- aspiration, ventilator associated pneumonia,Correspondence to: troversies surrounding the prevention of aspiration pneumonia in the critically ill healthcare-associated pneumonia, HeimlichDr Ware G. Kuschner, patient. Finally, we review ethical dilemmas surrounding feeding and aspiration risk manoeuvre and swallow evaluation. We carried outVeterans Affairs Palo Alto concerns in debilitated and demented patients. a complementary search on Google Scholar. WeHealth Care System, 3801 reviewed evidence-based clinical practice guidelinesMiranda Avenue, Pulmonary on airway management produced by: (i) theSection, Mail Stop 111 P, American Society of Anesthesiologists; (ii) thePalo Alto, CA 94304, USA American College of Chest Physicians; and (iii) theTel.: + 1 650 493 5000 American Heart Association. We reviewed evidence-(ext. 63544) based clinical practice guidelines for theFax: + 1 650 852 3276 management of healthcare-associated pneumoniaEmail: kuschner@stanford.edu produced by the United States Centers for DiseaseDisclosures Control and Prevention. We also reviewedThe authors have no financial evidence-based clinical practice guidelines fordisclosures or conflicts of nutritional support of high aspiration risk patientsinterest to report. produced by the Canadian Critical Care Society and the Canadian Society for Clinical Nutrition, and Dietitians of Canada and evidence-based clinical practice guidelines on enteral nutrition produced by the European Society for Clinical Nutrition and Metabolism. facial trauma, loose teeth and dental appliances are Pearl no. 1 commonly aspirated foreign bodies. In 2001, an estimated 17,537 children in the USA Infants, toddlers and adults with decreased under the age of 14 years were treated in emergency sensorium are at highest risk of foreign body departments for choking-related episodes, with 160 aspiration resulting in tracheo-bronchial reported deaths. Rates were highest for infants aged mechanical obstruction and asphyxiation. < 1 year and decreased with increasing age. Food The cough, gag and swallowing reflexes protect the was implicated in almost 60% of cases (hard candy respiratory tract in most children and adults. How- and gum were most common); 13% were associated ever, infant and toddler exploratory behaviour that with coins (1). A typical presentation of tracheo- includes placing small objects in the mouth increases bronchial obstruction resulting from aspiration the risk of a catastrophic aspiration event in this age includes a history of eating or swallowing followed group. Tracheo-bronchial foreign body aspiration by abrupt onset of difficulty speaking or breathing. leads to varying degrees of obstruction of airflow Common signs and symptoms of foreign body aspir- depending on the size of the object and the calibre ation include tachypnoea, tachycardia, wheezing, of the airway. In young children, the most common cough and cyanosis. objects aspirated are food, coins and toys. In adults ´ The term ‘cafe coronary’ stems from the presenta- with decreased sensorium or in the setting of cranio- tion of a person suddenly choking on food (in a ª 2007 The Authors846 Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, May 2007, 61, 5, 846–852
  2. 2. Aspiration syndromes 847 ´cafe/restaurant) with sudden cyanosis, chest pressure patient. Rigid bronchoscopy must be performed Message for theor fainting that mimics an acute coronary syndrome. under general anaesthesia. Corticosteroids have a ClinicIn one of the first case series in the early 1960s, Hau- limited role to reduce airway inflammation, and anti- • Aspiration syndromesgen reported nine cases, giving details of four cases. biotics are indicated only if the patient develops a are an important causeThe author noted that acute alcoholism, poor denti- postobstructive pneumonia. Imaging studies, inclu- of morbidity in chronically debilitatedtion and atrocious table manners were precipitating ding plain radiographs and computed tomographs, and critically ill patientsfactors for this emergency, and opined that the only can localise the site of the aspirated object in some, and among persons ateffective means of treatment was on the scene trache- but not all cases. the extremes of life.otomy (2). Aspiration events are In a recent Australian retrospective study of aut- typically attributable to: Pearl no. 3 (i) the loss of protectiveopsy files from 1993 to 2002, 44 cases of food airway reflexes in the ´asphyxiation/cafe coronary were identified. Fifty- setting of alteredseven per cent of victims were between 71 and Aspiration in adults is attributable to two consciousness and/or;90 years of age. Deaths occurred in nursing homes factors: (i) loss of protective reflexes in the (ii) swallowing(N ¼ 22), at home (N ¼ 11) and in restaurants setting of altered consciousness; and (ii) dysfunction. Mechanical obstruction of a large(N ¼ 4). Twenty-seven of the victims (61%) had his- impaired neuromuscular function airway caused bytories of neurological or psychiatric disorders such as Altered consciousness resulting in diminished pro- aspiration of a soliddementia, schizophrenia, Alzheimer’s and Parkinson tective airway reflexes is common in the elderly (10). object can be adisease. Twenty-seven cases (61%) were edentulous Factors that contribute to altered sensorium include catastrophic eventor had significant numbers of teeth missing. Toxico- dementia, sedating prescription drugs, illicit drugs, requiring emergent intervention. Aspirationlogical evaluation of blood revealed alcohol and a alcohol use, metabolic disorders, stroke, traumatic pneumonitis is a non-variety of psychotropic prescription medications in brain injury and seizures. Other risk factors for aspir- infectious inflammatory19 cases (3). In another recent autopsy-based, retro- ation include dependence on custodial care for feed- condition, often self-spective study conducted in Austria, there was signi- ing, dependence for oral care, number of decayed limited, that does notficantly higher food-related asphyxiation in the teeth, tube feeding, more than one medical diagnosis, require antimicrobial therapy, but may resultelderly (age > 64 years) related to semi-solid foods number of medications and smoking (11). Important in mild to severeand impaired dentition. This was in contrast to the oesophageal diseases that may cause dysphagia and respiratory dysfunction,younger individuals (adults aged 64 years or increase the risk for aspiration include collagen vas- including respiratoryyounger) who choked significantly more often on cular disorders, cancer, achalasia, oesophageal dys- failure. Aspirationlarge pieces of solid food and, on average, had a motility, hiatal hernia, gastroesophageal reflux and pneumonia requires empiric antimicrobialhigher blood alcohol concentration (4). gastroparesis. treatment for Gram- Other risk factors for aspiration include invasive negative bacilli and diagnostic and therapeutic procedures involving the Gram-positive cocci.Pearl no. 2 oesophagus or upper thorax; i.e. laryngeal or oeso- Recent reports suggest phageal cancer resection, neck or thoracic radiation that aerobic bacteria are a more common causeManagement of catastrophic foreign body for head, neck, lung, breast and mediastinal of aspiration pneumoniaaspiration requires emergent clearance of the tumours, and gastric cancers with new anastamosis. than anaerobicairway that may include the Heimlich Aspiration is also associated with mechanical inter- infections. A spectrummanoeuvre or extraction of the foreign body ruption of glottic closure or the cardiac sphincter of interventions showby bronchoscopy because of tracheostomy and endotracheal tubes. some promise in reducing aspirationComplete obstruction of the trachea is life threaten- Aspiration may result from procedures such as events in high-risking. If airway patency is not restored within bronchoscopy, upper gastrointestinal endoscopy, individuals.3–5 min, death or irreversible ischaemic damage to and nasogastric tube insertion and feeding. It isthe heart, brain and other vital organs will result. therefore important that the above-mentioned pro-The Heimlich manoeuvre is an easily performed pro- cedures be performed by, or under the supervisioncedure that can be lifesaving. An illustrated descrip- of, experienced clinicians. Some risks factors fortion of the technique may be found on the ref. (5). aspiration in the intensive care unit (ICU) include In the case of partial airway obstruction, more endotracheal intubation, feeding the patient in thetime is available to transport the patient for appro- recumbent position, gastric and intestinal dysmotil-priate hospital-based care. Treatment options include ity related to critical illness or postsurgical causes,extraction of the foreign body with either a flexible large volume tube feedings and feeding gastrostomyfibreoptic or a rigid bronchoscope. Success rates are tubes (12–19). Patients with any of the aforemen-higher with rigid bronchoscopy and with an experi- tioned characteristics and/or illnesses should beenced operator (6–9). Flexible bronchoscopy can be viewed as having a high risk for aspiration. Man-carried out on an awake, spontaneously ventilating agement strategies should aim to reduce the riskª 2007 The AuthorsJournal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, May 2007, 61, 5, 846–852
  3. 3. 848 Aspiration syndromes for a major aspiration event in these high-risk signs and symptoms of lower respiratory tract infec- populations (for additional details, see Pearl no. tion into aspiration pneumonitis, aspiration event, 9). pneumonia and bronchitis based on whether patients had a witnessed aspiration event and radiographic absence vs. presence of an infiltrate (unilateral/bilat- Pearl no. 4 eral, dependent lung zones). The authors defined aspiration pneumonitis as a patient presenting with Aspiration pneumonitis is a non-infectious signs and symptoms of lower respiratory tract infec- inflammatory response to aspiration that may tion of < 24 h duration and a positive chest X ray. cause mild to severe respiratory dysfunction, The authors tested their management algorithm pro- but does not require antimicrobial therapy spectively (26). The investigators concluded that it is Aspiration pneumonitis, also referred to as chemical appropriate to observe patients with an aspiration pneumonitis, is an inflammatory response typically event or aspiration pneumonitis with symptom dur- caused by aspiration of gastric acid, but may also ation of < 24 h without initiation of antibiotics. occur with aspiration of milk products, mineral oils, They speculate that this approach may lead to acids, fat or other fluids. The resulting injury from shorter hospital stays, lessen chances of adverse the acidic or alkaline agent damages the bronchial events and delay the development of antibiotic resis- and alveolar surface epithelial cell lining (20–22). tance patterns highly relevant in an institutionalised Experimental data from rats demonstrated a biphasic debilitated patient. Antibiotics should however be pattern of injury following aspiration of acidic con- instituted if the patient’s clinical status deteriorates tents, the initial phase within 1 h thought to be due needing higher level of monitoring, if the patient fails to the physiochemical reaction to the acidic aspirate, to improve despite symptomatic treatment, or the and the second phase within the next 2–3 h thought development of a pulmonary opacity on radiological to be due to neutrophils resulting in an inflamma- imaging suggestive of pneumonia. tory reaction (23). This results in atelectasis, release of inflammatory cytokines and migration of poly- Pearl no. 5 morphonuclear cells, alveolar macrophages and dis- ruption of the normal alveolar–capillary membrane. Patients maybe asymptomatic or may present with Aspiration pneumonia is a common cause of abrupt onset of dyspnoea, low-grade fever, bilateral respiratory morbidity and mortality in elderly rales and bilateral infiltrates on the chest radiograph. and debilitated patients Respiratory injury may be mild to severe and can Aspiration pneumonia accounts for approximately progress to non-cardiogenic pulmonary oedema, 10% of community-acquired pneumonia. Studies hypoxemia and respiratory failure. have also suggested an aspiration pneumonia inci- Initial management and treatment includes careful dence of approximately 30% in the nursing home monitoring of oxygenation and ventilation for at population (24,27,28). Clinical manifestations include least 8–12 h after presentation while ensuring that altered mental status, dyspnoea, low blood pressure, the patient is not given any food (or medicine that tachypnoea, dyspnoea, fever and elevated white count needs to be swallowed). The patient’s symptoms and without a definite focus of infection. Physical exam- clinical condition should dictate the initial level of ination findings include poor dentition, coarse rales monitoring. Aggressive airway clearance with oro- or rhonchi in the lower lung fields, and hypoxemia. pharyngeal and tracheal suctioning (with an oral or The chest radiograph on initial presentation may be nasopharyngeal suction catheter) should be per- normal or may show airspace opacities in the formed, as indicated. If the patient’s clinical condi- dependent lung zones. This commonly progresses to tion deteriorates as seen by either hypoxemia or airspace consolidation, and may progress to the acute hypercapnia on an arterial blood gas, respiratory respiratory distress syndrome. support should be provided with non-invasive or Microscopic examination of sputum commonly invasive ventilation. The absence of purulent secre- shows many polymorphonuclear cells with Gram- tions, fever and leucocytosis suggests a non-infectious negative rods and Gram-positive cocci. Sputum cul- syndrome and, in the setting of mild respiratory tures usually show a predominance of aerobic insufficiency and limited clinical–radiographic find- Gram-negative enteric bacteria such as Escherichia ings, supports a management plan of watchful wait- coli, Klebsiella, Serratia, Proteus and Pseudomonal ing without antimicrobial therapy (24). species, followed less commonly by aerobic Gram- Mylotte et al. (25,26) have shown that it is poss- positive bacteria such as Staphylococcus, Hemophilus ible to stratify nursing home patients presenting with and Streptococcal species. Recent analyses show that ª 2007 The Authors Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, May 2007, 61, 5, 846–852
  4. 4. Aspiration syndromes 849anaerobic bacteria such as Bacteroides, Prevotella, lung because of the almost straight axis between theFusobacterium and Peptostreptococcus are rarely trachea and the right main stem bronchus. The mostfound in cultures (24,29). Klebsiella species has been common lobes involved include the superior segmentcommonly implicated as a cause of pneumonia in of the right lower lobe and the posterior segment ofalcoholics (30). A study that examined pharyngeal the right upper lobe, because of the dependency offlora of ambulatory alcoholic patients, 59% of the these lobes in the supine position. However, aspirationalcoholic patients had Gram-negative bacilli in their can occur into any part of the lung depending on thepharyngeal flora, compared with 14% in the control position of the patient at the time of the inciting event.group. Seventy-six per cent of the isolates belonged Chest radiographs usually lag a few days behindto the Klebsiella–Enterobacter group, Klebsiella pneu- the inciting event and the initiation of injury, there-moniae being the most frequent isolate (40%) (31). fore patients may present immediately after the eventAlcohol causes molecular changes within the lung with a normal chest radiograph. However, in aspir-that predispose alcoholic patients to pneumonia ation pneumonitis, radiographic opacities maybecause of this organism (30,32). resolve rapidly if precipitating factors are controlled. This is in contrast to the radiographic opacities asso- ciated with aspiration pneumonia which can takePearl no. 6 weeks to resolve.Chest radiographs in aspiration syndromes Pearl no. 7show characteristic, but non-specificabnormalitiesThe radiological picture after aspiration of the foreign Antibiotic coverage of Gram-negative bacillibody depends upon the density of the aspirated object. and Gram-positive cocci are indicated in theSolids such as metallic nails, coins, and toys, peanuts, treatment of aspiration pneumoniabones can be visualised on X rays, however soft objects As most causes of aspiration pneumonia are causedsuch as meat, vegetables are difficult to visualise. by aspiration of oral or upper gastrointestinal tractObstruction of the involved airway presents as either flora, the lungs are exposed to aerobic as well asas atelectasis or hyperinflation of the lung distal to the anaerobic polymicrobes. Important predisposing fac-area of blockage. In a study of lung volume, dynamic tors include periodontal disease and gingivitis, alco-lung compliance and blood gases during the first three holism, prolonged hospitalisation and nursing homepostnatal days in infants with meconium aspiration patients. The usual presentation consists of older agesyndrome, six of the 12 infants with aspiration had patients with moderate grade temperature, leucocyto-radiological evidence of hyperinflation, while in sis and weight loss associated with cough with puru-another retrospective study of 150 infants who lent sputum, and dyspnoea. The disease severity canpresented with wheezing and radiological hyperinfla- vary from a segmental pneumonia to lung abscess totion, 40% were found to have meconium aspiration empyema. Aerobic Gram-negative enteric bacteria(33,34). such as E. coli, Klebsiella, Serratia, Proteus, Pseudo- In a recent series of children with suspected monas and aerobic Gram-positive bacteria such asforeign body aspiration, virtual bronchoscopy and Staphylococcus, Hemophilus and Streptococcus arelow-dose multidetector computed tomography were commonly grown in sputum cultures from theseshown to be effective diagnostic imaging modalities. patients. Anaerobic bacteria such as Bacteroides,Obstructive pathology was found in 16 (43%) of 37 Prevotella, Fusobacterium and Peptostreptococcus arepatients using these imaging techniques. In 13 of found much less commonly.these patients, foreign bodies were detected and The antibiotics that have traditionally been usedremoved via conventional bronchoscopy. In 21 include piperacillin–tazobactam, penicillins with met-patients in whom no obstructive pathology was ronidazole, clindamycin, imipenem for 2–6 weeksdetected by virtual bronchoscopy and computed depending upon the severity of the underlying dis-tomography, conventional bronchoscopy was not ease (10,24,29). However, the rationale behind theirperformed. These patients were followed for use has been the provision of anaerobic coverage.5–-20 months without any recurrent obstructive Given the more recent data on the higher prevalencesymptomatology (35). of aerobic bacteria in patients with aspiration pneu- The most common radiographic finding of aspir- monia, more studies are needed to establish the cor-ation pneumonitis and pneumonia is patchy bilateral rect antibiotic regimens that treat the underlyingairspace consolidation with a perihilar or basilar distri- infection, minimise multidrug resistance patterns andbution. Aspiration commonly occurs into the right establish cost-effectiveness.ª 2007 The AuthorsJournal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, May 2007, 61, 5, 846–852
  5. 5. 850 Aspiration syndromes There has been a significant interest in preventing Pearl no. 8 aspiration in the critically ill population, especially mechanically ventilated patients, with ongoing clin- Bedside evaluation and imaging techniques can ical research in this area. Interventions that have be utilised to assess the risk of aspiration shown promising in preventing or reducing aspir- Attempting to feed patients with definite risk factors ation in the critically ill patients, but have not been for aspiration without a complete safety evaluation proven in large multicentre prospective clinical trials, exposes them to serious and avoidable risks (10). All include (10,12,17,22,24,39–52): patients suspected of having any risk factor must • a chin down position while feeding patients with undergo a thorough evaluation before feeding is altered swallowing ability (39); attempted. This includes a complete neurological • percutaneous endoscopic gastrostomy tube or per- evaluation with assessment of cortical functions, cutaneous endoscopic jejunostomy tube for feeding assessment of bulbar muscles, gag and cough reflex, in chronically debilitated patients (10,39); presence of dentition and dental hygiene. If any • feeding by hand compared with insertion of feed- doubt persists, then a formal swallow evaluation gen- ing tube in the geriatric population (10,39); erally performed by a speech pathologist should be • soft mechanical diet and thickened liquids (39); requested. Details about the performance of a swal- • suction of subglottic secretions in the mechanically low evaluation may be found on ref. (36). ventilated patient (42,43); Flexible endoscopic evaluation of swallowing with • gastric acid suppression by drugs (12,44–47); or without sensory testing can usually be performed • minimise use of sedating drugs (10,48,49); at the bedside with an initial assessment of cough • use of amantadine, angiotensin converting enzyme after swallowing water or a thick liquid. Speech inhibitors and cilostazol (10,39,48,49); pathologists then use a flexible fibreoptic scope to • monitoring gastric residual volumes as a marker of detect the presence of food in the posterior pha- aspiration risk (50); rynx, vallecula, over the vocal cords, along with • placement of a postpyloric feeding tube assessment of vocal cord function. Modified barium (10,12,17,24,39,51,52). swallow is another kind of study that involves directing the patient to swallow barium under fluo- Pearl no. 10 roscopic imaging. Any passage or retention of this radio-opaque substance in the respiratory tract can be directly seen. Aspiration events are a common cause of morbidity and mortality among debilitated, terminally ill, and elderly patients, especially Pearl no. 9 when enteral artificial nutrition or hydration is administered. Challenging ethical dilemmas Simple interventions show some promise in often arise in this clinical context reducing aspiration events in high-risk In a recent Canadian prospective cohort study that individuals looked at 1946 adults admitted with pneumonia, Patients at increased risk of aspiration include those 10% of those with community-acquired pneumonia who have absent or diminished protective airway had aspirated, compared with 30% of those with reflexes as may occur in the setting of altered con- continuing care facility-acquired pneumonia (27). sciousness or impaired neuromuscular function (for Patients with aspiration pneumonia were younger, additional details, see Pearl no. 3). more likely to go to ICU, to require mechanical ven- There is some evidence that keeping the head of tilation and had a longer length of stay and a higher the patient’s bed higher than 30–45° reduces the mortality rate than those with non-aspiration-related incidence of nosocomial pneumonia caused by aspir- pneumonia. The mortality rate in the community ation, especially in the critically ill or mechanically was 19% for aspiration pneumonia vs. 7% for non- ventilated patients (12,17,37–39). All patients in the aspiration pneumonia. In the continuing care facility hospital with risk factors for aspiration should have patients, the mortality rate was 28% for aspiration the head of their bed raised unless contraindicated. pneumonia vs. 15% for non-aspiration pneumonia. Oral decontamination with antiseptic solutions (2% The predominant risks factors for those with com- chlorhexidine with and without colistin) in mechan- munity-acquired aspiration pneumonia were ically ventilated patient has recently been shown to impaired consciousness because of alcohol, drugs or be beneficial in preventing ventilator associated hepatic failure; 72% of continuing care facility pneumonia (12,40,41). patients with aspiration pneumonia had neurological ª 2007 The Authors Journal compilation ª 2007 Blackwell Publishing Ltd Int J Clin Pract, May 2007, 61, 5, 846–852
  6. 6. Aspiration syndromes 851disease that resulted in dysphagia. As highlighted in Referencesthe last pearl, a spectrum of simple intervention have 1 Centers for Disease Control and Prevention (CDC). Nonfatal cho-shown some promise in reducing the incidence of king-related episodes among children – United States, 2001.aspiration in the at risk population, however no sin- MMWR Morb Mortal Wkly Rep 2002; 51: 945–8.gle intervention or combination of interventions has ´ 2 Haugen RK. The cafe coronary: sudden deaths in restaurants. ´ JAMA 1963; 186: 142–3 (The original JAMA cafe coronary paper).been proven in large prospective randomised trials to ´ 3 Wick R, Gilbert JD, Byard RW. Cafe coronary syndrome – fataleliminate this hazard. The involved physician must choking on food: an autopsy approach. J Clin Forensic Med 2006;weigh all these risks with the anticipated benefits of 13: 135–8 (Epub 13 December 2005).attempting to feed chronically debilitated patients, 4 Berzlanovich AM, Fazeny-Dorner B, Waldhoer T, Fasching P. For- eign body asphyxia: a preventable cause of death in the elderly.have informed discussions with the patient or the Am J Prev Med 2005; 28: 65–9.family explaining these not so trivial ethical issues, 5 The Heimlich Institute. How to Do the Heimlich Maneuver. http://and then making appropriate decisions. The physi- www.heimlichinstitute.org/page.php?id=34 (accessed 23 Marchcian must therefore use his clinical judgment, by 2007). 6 Soysal O, Kuzucu A, Ulutas H. Tracheobronchial foreign bodyidentifying patients at risk for aspiration (Pearl no. aspiration: a continuing challenge. 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