Aspiration SyndromesProf. Dr. Saad S Al Ani

Senior Pediatric ConsultantHead of Pediatric department

Khorfakkan HospitalSharjah ,UAE

.saadsalani@yahoo com

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Introduction

“ Aspiration includes a wide clinical spectrum from:

An asymptomatic condition

to

Acute life-threatening events „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“Acute life-threatening events, such as occur with:

i. Massive aspiration of gastric contents

or

ii. Hydrocarbon products „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“ Occult aspiration of nasopharyngeal secretions into the lower respiratory

tract is a normal event in healthy people, usually without apparent clinical

significance „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Aspiration of gastric contents

“ Large-volume aspiration of gastric contents usually occurs in the context of vomiting „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“ It is an infrequent complication of * General anesthesia * Gastroenteritis * Altered level of consciousness „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“ Most clinical changes are present within minutes to 1-2 hr after the aspiration event „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“Attempts at acid neutralization are not warranted because acid is rapidly neutralized by the respiratory epithelium „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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„

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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. „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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„

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Prevention

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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“ 1.Minimizing use of sedation

2.Monitoring for gastric residuals

3.Gastric acid suppression

may all help prevent aspiration. „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“Any patient with altered consciousness, especially one who is receiving tube feedings, should be considered at high risk for aspiration „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“Ingestion of >30 mL (approximate volume of an adult swallow) of hydrocarbonis associated with an increased risk of severe pneumonitis „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“Pneumatoceles and pleural effusions may occur„

“Patients presenting with: cough, shortness of breath, or hypoxemia are at high risk for pneumonitis „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“The pneumonic CHAMP refers collectively to the following hydrocarbons: Camphor, Halogenated carbons , Aromatic hydrocarbons, and those associated with Metals and Pesticides „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

“Repeated exposure to low concentrations of these agents can lead to chronic lung disease, such as:

i. Interstitial pneumonitis

and

ii. Granuloma formation „

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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Cont.

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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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 showsairspace disease in the right

lower lobe „

http://www.learningradiology.com

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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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

04/12/2023Aspiration syndrome Prof.Dr.Saad S Al Ani Khorfakkan Hospital Sharjah UAE

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“Thank you„