Based on the provided information, the most likely diagnosis is gastroesophageal reflux disease (GERD) causing recurrent aspiration and subsequent apneic episodes. Key clues include: - Persistent vomiting and chronic cough, suggesting recurrent aspiration - Apneic attacks occurring after being discharged from the hospital - Improvement of symptoms with thickened feeding formula and upright positioning, treatments for GERD The upper GI contrast study and 24-hour pH probe study supported the diagnosis of GERD by demonstrating gastric reflux into the esophagus. Recurrent aspiration from GERD was causing the apneic episodes in this infant. Proper management of the GERD resolved the symptoms.

1. Aspiration syndrome

2. Aspiration syndromes include all conditions in
which foreign substances are inhaled into the
lower airway such as gastric content or
hydrocarbons .

3. Pathophysiology
•
The act of swallowing is divided into the following 4 discrete
phases: oral preparatory, oral propulsive, pharyngeal, and
esophageal.
1) The oral preparatory phase begins when foods and liquids are placed into the
mouth, mixed with saliva, and formed into a bolus.
2) The oral propulsive phase consists of moving the bolus into the pharynx,
triggering the reflex swallow.
3) The pharyngeal phase, the larynx elevates and closes at the level of the
epiglottis, aryepiglottic folds, vocal cords.
4) The esophageal phase is initiated when the bolus passes through the relaxed
cricopharyngeal muscle and enters the esophagus.

5. •Aspiration may occur when foreign substances enter
the hypopharynx, either before relaxation of the
cricopharyngeal muscle or before closing of the
laryngeal sphincters
. Direct aspiration is the aspiration of a foreign particle
while swallowing.
. Indirect aspiration is the reflux of food from the
stomach into the esophagus and pulmonary system
.

7. Causes
1-Acute :
a-gastric content as in anaesthesia , gastroenteritis,
disturbed conscious level.
Accidental.:b-hydrocarbons
C-food particle as Poor feeding technique
2-recurrent :
•a-Anatomical and mechanical disorders:
•b-Neurological disorders
•C-miscellaneous .

8. Gastric content
Cause:
A-anaesthesia
B-gastroenteritis,
C-disturbed conscious level
The effect depend on :
1-Ph of the aspirate :more severe with ph<2.5
2-amount ,volume :more severe with >0.8 ml/kg

9. Pathophysiology
1-Most clinical changes are present within
minutes to 1–2 hr after the aspiration event :
Hypoxemia, hemorrhagic pneumonitis, atelectasis,
pulmonary edema, intravascular fluid shifts occur rapidly
after massive aspiration.
2- In the next 24–48 hr :
there is a marked increase in lung parenchymal neutrophil
infiltrations, mucosal sloughing and alveolar consolidation
that often correlates with increasing infiltrates on chest
radiographs.
3-Impair pulmonary defense mechanism so predispose to
secondary bacterial infection

10. Presentation
1-Choking or coughing while feeding
2-acute onset of cough and dyspnea.
3-respiratory distress as retraction ,grunting and
cyanosis
4-aspiration may be silent with no overt signs or
symptoms.

11. Investigation
1-CXR:radiographic changes in 2-8 hrs up to 48-
72hrs
Such as
a- infiltrate
b-pleural effusion
c-pneumatocele
2-ABG: hypoxia
3-ECG:arrythmia
4-pulmonary function test: persistent abnormal
test may present many years after ingestion

13. Prevention
1-preoperative patients:restrict feeding 2-6 hrs
before anaesthesia
2-in disturbed conscious level :
a-feeding with enteral tubes passing beyond
pylorus
b-elevate head 30-45 degree
c-oral decontamination
d-minimize use for sedation
e-monitor for gastric residual
•f-gastric acid supression

14. Management
1-patient on artificial airway : Immediate suctioning
of airway
2-oxygenation measurement as ABG, pulse oximeter
3-CXR :even if patient asymptomaic
4-in respiratory failure :endotrachael intubation and
mechanical ventilation
5-bronchodilator is of limited use
6-coticosteroid benefit only when given simultaneously
with aspiration but if given later on ,it
increase risk of secondary bacterial infection
7-observation for:respiratory symptoms and fever

15. 8- Antibiotic
A-Indication
1-Prophylactic in
a-in critically ill patients,
b-possible colonization of the stomach (e.g., patients taking proton pump
inhibitors, H2-antagonists, or antacids where the stomach pH is less
acidic).
2-therapeutic - patients with aspiration pneumonitis that fails to resolve
within 48 hours after aspiration.
B-choice
1-empirical but it must cover :
a-anaerobic: pseudomonas
b-staph aureus, enteric gram negative organisms in (hospitalized,chronically ill
patients)
2-according to culture :BAL

16. Complication
•1-respiratory failure
•2-worsening after clinical improvement in
form of fever, leukocytosis suspect secondary
•bacterial infection<pneumonia,lung abscess>
•3-prolonged lung damage as atlectasis ,
bronchiectasis

17. Prognosis
1-mortality<5% is seen if 3 or less lobes
invloved
2-most patients recover in 2-3 weeks unless
complications(infection,barotrauma)develop

18. Hydrocarbon Aspiration
•Effect depend on :
•1-Volatility:. The higher the volatility, the easier the
compound is to inhale. Simple petroleum distillates
such as kerosene, mineral oil, gasoline, and furniture
polish are examples of such substances that are easily
aspirated
•2-volume: >30 ml increase risk of severe pneumonitis
•3-frequency of exposure : repeated exposure to low
concentration of (,chlorine,mercury
vapour,beryllium)lead to interstitial pneumonia and
granuloma formation

19. Presentation
•1-acute onset of cough, dyspnea
2-fever
3-respiratory distress as retraction, grunting
4-other system affected as
CNS,: lethargy, headache,, and coma may follow. Seizures
are uncommon and are believed to be due to hypoxia
Liver: Hepatotoxicity
•Git; Abdominal pain and nausea are common complaints.
Vomiting increases the likelihood of pulmonary aspiration

20. Management
•1-Gastric emptying is contraindicated because of
further risk of aspiration
•2-Supportive therapy
•a-IV fluid
•b-oxygen or ventilatory support
•3-Observation :if asymptomatic with normal CXR
•4-Corticosteroid may decrease development of
fibrosis and improve pulmonary function test.

21. Recurrent aspiration
•Causes:
•1-Anatomical And Mechanical :
•-Gastroesophageal reflx disease -Tracheoesophageal fitula
--Cleft palate
--Achalasia
-Endotracheal tube
-Collagen vascular disease (scleroderma, dermatomyositises)

22. •2- Neuromuscular :
•-Altered consciousness
-Cerebral palsy - -
Myasthenia gravis
-Guillain-Barré syndrome
-Spinal muscular atrophy
vocal cord paralysis -
-Cerebral vascular accident
-Immaturity of swallowing/Prematurity
-

23. •3- Miscellaneous :-
•Poor oral hygiene
-Gingivitis
-Prolonged hospitalization
--

24. GERD
•Gastroesophageal reflux (GER) is defined as the
involuntary retrograde passage of gastric contents into
the esophagus with or without regurgitation or
vomiting.
•It is a frequently experienced physiologic condition
occurring several times a day, mostly postprandial and
causes no symptoms.
•GER disease (GERD) occurs when reflux of the gastric
contents causes symptoms that affect the quality of life
or pathologic complications.

25. GERDGER
Regurgitation with poor weight gainRegurgitation with normal weight
gain
Persistent irritability; pain in infants
Lower chest pain
Hematemesis and iron deficiency
anemia
No signs or symptoms of esophagitis
Apnea and cyanosis in infants
Wheezing
Aspiration or recurrent pneumonia
CHRONIC COUGH
Stridor
No significant respiratory symptoms

26. Pathophysiology of GERD
•1-Transient lower esophageal sphincter
relaxations allowing the gastric refluxate to return into
the esophagus.
•2-Delayed gastric emptying that predisposes
them to gastric distension, increased acid secretion, and
esophagitis.
•3-Gravitational and positional factors may
exacerbate GER and increase the risk of GERD by
allowing reflux to occur in a supine position.

27. Presentation of recurrent
aspiration•
Repeated aspiration of even small quantities of gastric, nasal,
or oral contents can lead to
•a-recurrent bronchitis or bronchiolitis<recurrent wheezes>
b-recurrent pneumonia
•c-chronic cough
d- apnea and/or laryngospasm
•e-failure to thrive,
•f-choking on feeds or secretions
G- IN GERD :
Water brash
-Sandifer syndrome (ie, posturing with opisthotonus or
torticollis)
•Typical or atypical crying and/or irritability
Vomiting

28. Differential diagnosis
•1-causes of chronic wheezes
•1-bronchial asthma
•2-bronchitis
•3-bronchiolitis
•4-foreign body
•

29. •2-causes of chronic cough
•1-bronchial asthma
•2-sinusitis
•3-foreign body
•4-whooping cough

30. •3-causes of recurrent pneumonia
•1-foreign body
•2-immunodeficiency
•3-tuberculosis
4-congenital heart <shunts>

31. •4-Causes OF APNEA
1- infections,
2-low blood sugar levels
3-electrolyte problems
4-abnormalities of the central nervous system:
convulsions due to congenital anomalies ,infections
.
”

32. Evaluation
•.1-History
•A-Age:
•Early: congenital anomalies
•Older infant :infection ,foreign body ,.
•B-history suggestive of aspiration :
•choking while eating
•C- family history of allergic manifestation
in bronchial asthma

33. .
d-Physical, Mental development
•e– Symptoms:
1-spitting, vomiting, arching, or
epigastric discomfort in an older child as in
GERD
•

34. •2-Examination
1-Oral cavity should be inspected for gross abnormalities and
stimulated to assess the gag reflex.
2-observation of feeding: Drooling or excessive accumulation
of secretions in the mouth
3-Chest examination
4-neurological examination
5-cardiovascular examinatin

35. 3-Investigation
•1- DIAGNOSIS
Somewhat invasive
Evaluates short time
interval
Current gold standard for
diagnosis of Acid
gastroesophageal reflx
The physiologic
significance of a pH < 4 lies
in the fact that pH must be
< 4 for mucosal damage to
occur
1-Esophageal pH
monitoring
Can be constructed as
screening test or
confimatory
2-Dye study

36. diagnosis of GERD
3-gastr
oesphageal scintography
Evaluates all phases of swallowing
Feeding recommendations made at time of
study
4-Video swallow study

37. 2-COMPLICATIONS
LimitationBenefitInvestigation
Insensitive to early subtle changeAssess lung injury as atlectasis,
hyperinflation,effusion
1-CXR
More radiation exposure than CXRDetect bronchiectasis,
bronchial thickening,
2-CT chest
DETECT MUCOSAL DAMAGE
AND ALLOW FOR BIOPSY
4-ENDOSCOPY
-

38. Management
•A- If chronic aspiration is associated with another underlying
medical condition, treatment should be directed toward that
problem
•B-Feeding:
•1-alter position of feeding :elevation head 45 degree
•2-use thicker food formula
•3-limiting quantity per feeding
•4-use of nasogastric tube
•5-Make infant is in an upright position for 30 minutes after being fed.
•6-Avoid eating right before they go to bed or lie down; let two or three
hours pass
•

39. •C-Medical :
•1-using anticholinergic as scopolamine in <excess salivation>
•2- In GERD:
•a-Histamine-2 receptor drugs—to decrease acid production
•b-Proton pump inhibitors—to heal the esophagus lining and
relieve symptoms)
.

40. D-Surgical :
•1-trachestomy
•although sometimes predisposing to aspiration,
may provide overall benefit from improved
bronchial hygiene and the ability to suction
aspirated material
•2-postpyloric feeding
•3-fundoplication with gastrostomy or
jejunostomy tube will decrease propability of
reflux
•4-salivary gland excision or duct ligation in severe
form of salivary aspiration

41. Case
•A 4-month-old boy with a normal perinatal history was brought to our
hospital with complaints of cyanosis and hypotonia.
•He was healthy on physical examination.except for underweight 4kg .
•
•During the 3-day admission period, he showed no symptoms or
attacks.
•Several test results, including complete blood cell count,, arterial blood
gas, chest X-ray, electrocardiogram, electrolyte, random blood glucose
,echocardiography, brain CT-scan, short-term electroencephalogram
(EEG) for 30 min,, revealed no abnormalities.
•.

42. •Three days after getting discharged from the hospital, he
experienced several apneic episodes at home, each lasting for
30–120 s.
•He was rehospitalized for further evaluation. He had several
paroxysmal apneic attacks in the ward, and the pulse oximetry
values abruptly decreased to 22–28%. Central cyanosis and
flaccidity of extremities were seen during each attack,.
Bradycardia followed by tachycardia was detected once in two or
three attacks.

43. •When asking mother about any other
complains ,she said that he suffered from
persistent vomiting with chronic cough .
•.
•Upper gastrointestinal (GI) contrast study
•And 24-h pH-probe study, was done

44. •1-what is DD?
•2-WHAT IS DIAGNOSIS?

45. DD OF APNEA
•1-congenital heart
•2- infections,
•3-low blood sugar levels
•4-electrolyte problems
•5-abnormalities of the central nervous system:
convulsions due to congenital anomalies
,infections
•6-gastroesophageal reflux disease (GERD).
•”