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Aspiration lung disorder

Presented by: M-kheyri, B-ghaderi

Fall 2003




Clinical entities

Aspiration pneumonia, a special type of pneumonia that may be seen

in critical care units, is a major cause of morbidity and mortality.
Aspiration has been recorded in as many as 38% of critically ill,
intubated patients receiving feeding through small-bore nasogastric
tubes, despite maintenance of the integrity of cuffed tracheal
tubes.Many of the risk factors leading to aspiration are present in
critical care patients (see the box below).

Assessment and Diagnosis

Nursing care
Nursing Diagnosis and


Impaired consciousness
Compromised glottal closure
Compromised cough reflex
Ileus or gastric dilation
Nasogastric feeding tubes (large or small bore)
Artificial airways
Disorders affecting pharyngeal and / or esophageal motility
Tracheoesophageal fistulas
General anesthesia
Cardiopulmonary resuscitation
Improper patient positioning during tube feeding
Esophageal strictures

The presence of abnormal substances in the airways and alveoli as a result of aspiration is
misleadingly called aspiration pneumonia .The title is misleadingly because the aspiration of
toxic substances into the lung may or may not involve bacterial infection. Aspiration lung
disorder would be a more meaningful title, because injury to the lung can result from chemical,
mechanical, and/ or bacterial characteristics of the aspirate. Each gives rise to a specific clinical
entity (see table 1).
Table 1 Clinical entities associated with aspiration lung disorder




bacterial infection

Clinical features

Acute dyspnea. Tachypnea,

sputum: pink,frothy;x-rayfilm:infiltrate in
one or both lower lobes


fluids, monitor
blood gas,
antibiotics for

Oropharyngeal Bacterial infection, Usually insidious

abscess,empyema sputum,leukocytosis;x-ray film: infiltrate
involving dependent pulmonary segment or
lobe cavitations
Acute dyspnea ,cyanosis
fluids(water, obstruction, reflex apnea,pulmonary edema, hypoxemia
suction during
airway closure
or immediately
Dependent on level of obstruction:range Extraction of
matter, foreign obstruction
from acute apnea and rapid death to
irritating chronic cough recurrent
matter via
antibiotics for


Characteristics of the aspirated material are crucial to the ultimate effects on lung tissue.
Generally, an aspirate with a low Ph spreading throughout the lung fields may quickly result in
adult respiratory distress syndrome. As seen in animal studies, the "critical pH" of less than 2.5
is thought to cause severe chemical lung injury. The coupling of a low pH and virulent
pathogens may quickly overwhelm normal defenses of the lung. Aspiration of material from the
oropharynx carries resident flora to the sterile lower respiratory tract. Elderly and hospitalized
patients show a prevalence of gram-negative bacteria in the oropharynx, which increases the
likelihood of gram-negative pneumonias associated with aspiration.
The outcome of an aspiration event depends on the amount and type of aspirate, the
distribution of aspirate in the lungs, and the patient's overall condition and defense
mechanisms. Aspiration of significant amounts can be readily noticed with respiratory distress,
dyspnea, wheezing, and coughing. However, aspiration of smaller amounts (silent aspiration)
can occur without recognition, especially in patients with altered level of consciousness.
Aspiration of gastric juices that have a pH of less than 2.5 results in a chemical burn to the
lung. If significant of acid are aspirated, extensive atelectasis can occur. Bronchospasm occurs
later and is followed by epithelial injury and disruption of the alveolar membrane. Changes in
the alveolar membrane result in fluids and cellular elements leaking into the interstitial space
and to the alveoli. The fluid decreases surfactant production, which results in atelectasis.
Aspiration of particular matter may have an immediate life-threatening result if large particles
mechanically block the major airways.

Assessment and Diagnosis

When aspiration of a significant volume or repeated aspiration of smaller volumes occurs, the
patient will develop increasing dyspnea, fever, tachypnea, and cyanosis.
If the cough reflex is intact, increased coughing occurs. Intubated patients may require more
frequent suctioning, and aspirated material may be present in secretions. Auscultation of the
lung fields demonstrates breath sounds in the affected area with associated wheezes.
Arterial blood gases reflect hypoxemia and a widened Aa Do2, while an increased FIO2 is
needed to maintain satisfactory oxygenation. Intubations followed by mechanical ventilation
may be required. If bacterial infection becomes established, the white blood cell count may
become elevated. A normal or decreased white blood cell count in the setting of infection
suggests overwhelming host invasion and a poor prognosis.
Chest x-ray changes appear 12 to 24 hours after the initial aspiration. The validity of the chest
x-ray in diagnosing aspiration lung disorder is related to the prior status of the patient. Patients
with underlying lung involvement, as commonly seen in critical care units, may already have
significant pulmonary infiltrates present on chest x-ray evaluation, clouding the interpretation.
In massive aspiration, diffuse bacterial infiltrates suggest pulmonary edema is present, whereas
lesser aspirations show atelectasis in early period. Later chest films show large, fluffy
Since most aspiration events are unwitnessed, a high degree of suspicion coupled with an
ability to recognize the at-risk patient is paramount to diagnosing aspiration lung disorder.
Purposeful data collection is followed to delineate the presence or absence of aspiration lung
disorder. Radiographic and bacteriological studies should be undertaken. Recognizing
aspiration lung disorder requires understanding of the clinical spectrum of events, recognition
of the factors that predispose to aspiration, chest x- ray and laboratory data, and the
identification of pathogens from the aspirated material or uncontaminated sputum specimens.


Management includes emergency treatment and follow up treatment. When aspiration is

witnessed, emergency treatment should be instituted to secure the airway and minimize
pulmonary damage. The patient should be placed in slight (6 to 8 inches head-down)
Trendelburg's positioned turned to right lateral decubitus position to aid drainage and avoid
involvement of other lung areas.Oropharyngeal suctioning should immediately follow. Direct
visualization by bronchoscopy is indicated when large particulate aspirate blocks airways.
Bronchial and pulmonary lavage is not recommended, because studies have demonstrated that
this practice disseminates aspirate in lungs and increases damage.
Following airway clearance, attention should be given to hemodynamic support, arterial blood
gas monitoring, and respiratory support. Hemodynamic changes result from fluid shifts
occurring in massive aspiration causing noncardiogenic pulmonary edema. Monitoring
intravascular volume is essential, and judicious amounts of replacement fluids should be
instituted to maintain adequate urinary output and vital signs. Other medical intervention
involves drug therapy. Bronchodilators may be useful in situations associated with
bronchospasm. Benefits of steroidal drugs remain unclear; they are frequently used in
aspiration, even though current studies do not support the use of steroids. Antibiotics should be
instituted according to positive Gram's stain or culture results.

Nursing care

During the course of caring for the critically ill patient, the nurse must implement measures
for preventing aspiration lung disorder. If the aspiration event occurred before the patient
admission to the critical care unit, the nurse must direct interventions toward (1) maintaining
the airway and supporting respiratory function, (2) early recognition and treatment of
complications of aspiration of lung disorder, and (3) preventing further aspiration events.
Unless contraindicated, the unconscious patient should be placed on the side in a slight
Trendelburg's position to promote drainage and discourage aspiration. Placement of
nasogastric tubes(NG) for gastric decompression requires careful consideration, as NG tubes
paradoxically increase the risk of aspiration and have been frequently shown to empty the
stomach incompletely. Patients receiving continuous or intermittent tube feeding should be
maintained in at least a 30-degree head elevation. If a recumbent or head down position is
necessary, feeding should be interrupted every 30 minutes to 1 hour before assuming a flat
position is preferred, because it aids passage of gastric contents through the pylorus. Also, in
this situation the choice of the type of feeding tubes takes on added importance. Most sources
recommended intestinal feedings via a small-bore weighted tube to reduce the risk of
aspiration. Frequent checking of tube location, as well as checking for gastrin retention of the
feeding, is necessary to prevent aspiration. The standard technique used to check retention may
be difficult in small-bore, pliable catheters, because drawing back can collapse the lumen.
Therefore abdominal girths should be monitored on a serial basis. An increase in abdominal
measurements of 8 to 10 cm above the baseline should be interpreted as a significant sign of
gastric retention, and feedings should temporarily be postponed. When the residual can be
checked by aspiration, amounts greater than 150 ml of a bolus feeding or greater than 10% to
20% of the hourly flow rate in continuous feeding indicates that feeding should be withheld
until emptying occurs.
Gastrointestinal motility should be assessed regularly by auscultation of bowel sounds.
Absence of bowel sounds (5 minutes without sounds), presence of persistent distention, or
nausea and vomiting indicates that feeding should be discontinued.
Monitoring nasogastric tube placement regularly is a necessary nursing task. Placement of any
tube should be initially verified by x-ray examination or whenever the possibility of
dislodgment is suspected. There have been several reports about small-bore tubes being
inadvertently placed or dislodged into the respiratory tract.
Frequent suctioning of the oropharynx should be performed in patients with artificial airways.
This prevents pooling of secretions on the cuff and subsequent aspiration to the lower
respiratory tract. Aspiration past a properly inflated, functioning cuffed tube has been seen in
58% to 87% of patients.

Nursing Diagnosis and Management Aspiration Lung

Impaired Gas Exchange related to ventilation-perfusion inequality
secondary to aspiration.
Potential for Aspiration risk factors: reduced level of consciousness,
depressed cough and gag reflexes, presence of tracheostomy or
endotracheal tube, gastrointestinal tube, enteral tube feedings,
decreased gastrointestinal motility, impaired swallowing,
facial/oral/neck surgery or trauma, situations hindering evaluation of
upper body.
Sensory-Perceptual Alteration related to sensory overload, sensory
deprivation, sleep pattern disturbance.
Anxiety related to threat to biological, psychological, and social
Definition of Aspiration
Aspiration: Removal of a sample of fluid and cells through a needle. Aspiration also refers to the
accidental sucking in of food particles or fluids into the lungs.
Common Misspellings: asperation