Aspiration Pneumonia
Dr. Abdul Rohman, SpPDr. Abdul Rohman, SpP
K-B
Definition Aspiration Pneumonia: refers to an
infectious process of the lung parenchyma due to the introduction of pathogenic organism into the lower respiratory tract.
Aspiration Pneumonitis: The
inflammatory response that occurs in the lungs following aspiration injury
Mendelson’s syndrome: the chemical injury of the lungs secondary to aspiration of gastric contents.
KEY POINTS: ASPIRATION SYNDROMES1. Aspiration pneumonitis: acute inflammation
• Early response within 1 – 2 hours• Late response 4 – 6 hours
2. Aspiration pneumonia: an infectious process
EPIDEMIOLOGY
Normal deep sleep micro aspirations : 45 %
Aspiration post-stroke: 80 % aspiration pneumonia: 40 %
Elderly patient with CAP 71 % aspiration pneumonia
Pathophysiology of Aspiration
A. Aspirated material1. Type
a.Fluids : - toxic (bile, acid, HC)- Inert (mucous , water)b.Solids : - tiny
-large balus of food
2. Volume-Small - large
3. Distribution-1 segment localized damage-All segment ARDS
4. pH-< 2,5 ( asam ) severe lung injury-Neutral or non acidic minimal
damage
Pathophysiology of Aspiration
B. Associated pathogens
1. Predominant :
Oropharyngeal flora
1 : 10
(10 million aerobes :
100 million anaerobes)
2. Distal airway & lung
parenchyma : sterile
Predisposing Factors in Aspiration Pneumonia
Disease states
1.Decreased level of consciousness
Cerebrovascular accident (stroke, hemorrhage)
Head trauma (suburdural hematoma)
Seizures
Drug overdose
Alcohol intoxication
Sepsis
Hypothermia
Malignant hyperthermia
Other causes predisposing to coma
2. CNS disorders of esophageal motility
Myasthenia gravis
Guillain-Barre’ syndrome
Multiple sclerosis
Other conditions causing problems with gag
reflex
3. Disorders of esophageal motility
Achalasia
Scleroderma
Hiatal hernia
Cardiospasm
4. Communication between trachea & esophagus
Congenital esophageal atresia with
tracheoesophageal fistula
Neoplastic communication between trachea
and esophagus
5. Disorders of gastric and intestinal motility
Gastric dilation secondary to autonomic
dysfunction
Electrolyte imbalance or recent surgery
Adynamic ileus
Intestinal obstruction
6. Miscellaneous causes
Upper gastrointestinal hemorrhageLabor and deliveryTrauma
7. Iatrogenic factors ( > 60% )
General anesthesiaCardiopulmonary resuscitationAttempting emergency intubationTracheostomyNasogastric feeding tamponadeEsophageal ballon tamponadeRecent neurosurgery
CLINICAL SETTINGS FAVORING ASPIRATION PNEUMONIA
Depresed Levels of consciousness and a
decreased cough reflect :1. Neurologic and seizure disorders,
2. Drug overdose
3. Alcoholism
4. CBA
5. General anasthesia
Iatrogenic Causes 1. Trachestomy tube
Interferes normal laryngeal movement
Secretions collect above the cuff
2. Cardiopulmonary rescucitation:
compression of the sternum intra
abdominal pressure stomach content into the
pharynx.
ETIOLOGI
1. PAK (Pneumonia Aspirasi Komuniti)Anaerob obligat ( 41 – 46 % ) (Sekitar gigi – ludah)-Peptococcus +
Klebsiella pn Bacteriodes melStaphylococ PeptostreptococFusobacterium nucleatum
2. PAN (Pneumon Aspirasi NosokomialKolonisasi Ku anaerob, Gram neg., Pseudomonas, Proteus, Serratia & Staphylococcus aureus
MANIFESTASI KLINIS
Dapat : - Bronkopneumonia - Pneumonia lobaris
- Pneumonia nekrotikans - Abses paru & Empiema
- Mendadak batuk & sesak n sesudah makan atau minum
- Awitan insidiousPdu datang 1-2 mi postaspirasi dgn :- Demam menggigil, nyeri pleuritik,
batuk, dahak purulen bau (50 %)- Nyeri perut, anoreksia, & BB turun
PEMERIKSAAN PENUNJANG
Darah : - lekositosis & LED meningkatSputum (Gram): banyak lekosit & kuman campuran X-ray : infiltrat segmen paru dependent disertai kavitas & efusi pleura Lokasi tersering lobus kanan tengah dan
atau lobus atasLain-2 : elektrolit, BUN, kreatinin, AGD &
kultur darah
DIAGNOSISA. CLINICAL PRESENTATION
determined by the nature and the quality of the aspirate
1. Massive aspiration (trauma victims seizure disorders) :
- Acute respir failure - Deep cyanosis- Marked stridor - Pulmonary edema
2.Small volumeAfter 1 - 2 hours : progressive shortness of breath, cough, wheezing, fever, tachypnea, and cyanosis.
3.Auscultation :- Rales and decrease breath sounds.
4.Arterial blood gases : - Hypoxia - Increasing alveolar-arterial PO2 gradient
- Hypotension- Decreased cardiac
output- Tachypnea- Dyspnea
B. Radiographic findings 12 – 24 hours after initial aspiration
1. a. Foreign body aspiration : • Upright position -- lower lobe • Supine - posterior segment of upper lobe
- superior segment of the lower lobe Adult : right side < 15 years : left side equal to the right side b. Gastric contents : patchy airspace consolidation,
bilateral & multi centric perihiler of basal region
2. a. Massive aspiration : diffuse bilateral infiltrates pulmonary edema
b. Sub massive aspiration Athelectasis (6 – 8 hours ) large, fluffy infiltrate
3. Uncommon : - Reticular infiltrates
- Pleural effusion - Lung abscess
C.Bacteriology
1. Lower resp. tract : Transtracheal aspiration and bronchoscopy
2. Secondary infection : anaerobic organism predominant.
3. Hospitalized acquired aspiration pneumonia : aerobic organism more commonly.
TERAPI Baring setengah duduk NGT disfagi & gangguan telan PAK – Anaerob : Penicilin/Sefalosporin G3 /Clindamisin PAN – Gram (-) + Stafilikokus aureus :
aminoglicosid + sefalosporin G3/4 atau
clindamisinLama Terapi : 2 mi Rő Th bersih atau stabil
WSD - empiema Bronkoskopi – abses paru ok sumbatan
atau bekuan mukus Bedah – abses bila respon Tx (-) & relaps
di tempat yang sama
Steroid – sebagai obat tambahan pd bronkokonstriksi reaktif
MANAGEMENTProtecting the airway and minimizing the extent of pulmonary damage.
Head down in the right lateral decubitus position.
Endotracheal suction immediately
Pulmonary lavage : 5 – 10 ml sterile saline
Hemodynamic support
Arterial blood gases : highly concentrated O2 or
mechanical ventilation
PEEP (Positive End-Expiratory Pressure)
Miscellaneous agents
- Steroids IV within 5 minutes of aspiration
- Bronchodilators bronchospasm
- Antibiotics : - Clindamycin – anaerobic infection
-Hospitalized-acquired aspiration
pneumonia – gram + ve and – ve aerobs
CLINICAL EVALUATIONBe observed for sign of clinical improvement :
o Resolution of fever, dyspnea and cough
o Decreasing WBC counts
o Resolution of lung infiltrates
o Absence of white cells on gram stain –ve sputum culture
KOMPLIKASI & PROGNOSIS
Komplikasi: - Gagal Napas Akut- Empiema
- Abses paru - Superinfeksi paru
Mortalitas : - PAK - 5 %- PAN - 20 %- Aspirasi masif dengan/tanpadisertai Sindroma Mendelson 70 %
PREVENTION
• An unconscious patients
– Foot of bed elevated tracheal pooling
aspiration less
– NG feeding + a cuffed ET
• Conscious patients
– NG feeding: head end of the bed 45° ---
regurgitation of stomach
• Patency of tube & residual gastric volume
• Constant infusion > a bolus of NG feeding
• Elective surgery – fasting of 6 – 8 hours: an empty
stomach
• Preoperative antacid of H2 – acceptor antagonists
with general anesthesia
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