ASPIRATION PNEUMONIA[19] [20] Gastro-oesophageal reflux (GOR) is a common problem in paediatrics (see Ch. 54 ).

Laxity of the lower oesophageal sphincter combined with overexpansion of the lungs predisposes to reflux, and children with neuromuscular disorders, developmental delay or cerebral palsy may have immature swallowing mechanisms. The use of nasogastric tubes for feeding sick children also predisposes to GOR. The combination of GOR and incoordination of laryngeal closure can result in chronic aspiration of milk or gastric acid into the lungs, causing recurrent pneumonia or apnoea. The affected lobe depends on the childs posture, the upper lobes being more common in infants who spend more time supine than in the older child who sits upright. Barium studies or feeding studies can be specifically directed to assessing GOR, laryngeal inco-ordination or aspiration[21] . Oesophageal 24-hour pH monitoring is considered as the gold standard for detecting GOR. Radionuclide radiology milk scan

Figure 31B-9 H-type tracheo-oesophageal fistula associated with recurrent pneumonia. H-type fistula (black arrow) running obliquely (backwards and upwards) between the trachea (white arrow) and the oesophagus (black arrowhead); these fistulas are usually smaller and often difficult to visualize using contrast studies. (Courtesy of Dr C. Ngoma, Grimsby.)

648 using 99 m Tc sulphur colloid[22] [23] is useful in documenting aspiration during feeding, GOR or aspiration when lying supine after feeding. Milk scans and pH monitoring will not exclude structural disease in the oesophagus or bowel as a predisposing cause of GOR. Achalasia is a very rare cause of recurrent aspiration in children.

Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed. 2001 By Ronald G. Grainger (Editor), David Allison (Editor), Andreas Adam (Editor), Adrian K. Dixon (Editor), Helen Carty (Editor), Alan Sprigg (Editor), Elian A. Zerhouni, Holger Pettersson By Churchill Livingstone Aspiration Pneumonia Aspiration pneumonia is usually a mixed bacterial infection caused by aspiration of foreign material into the bronchial tree. The causes are numerous and range from aspiration of vomitus by a postsurgical or semicomatose patient to aspiration as a result of paresis or paralysis of the pharyngeal muscles. Tracheoesophageal fistula, gastroesophageal reflux, and various other esophageal lesions can also cause aspiration pneumonitis. Gram-negative organisms included in the aspirate may produce pneumonia followed by necrosis and abscess formation. This complication is discussed in the section on lung abscess. The radiographic findings vary with the extent of disease and its location. The right lower and middle lobes are most frequently affected, but involvement of the left lower lobe is not unusual. Irregular, poorly defined areas of increased density are seen and may be extensive (Fig. 24-4). Early in the disease these densities are focal, but later they may become conglomerate. In some instances the disease is acute and clears rapidly as the patient recovers from the condition that produced the aspiration. In other instances the pneumonia results from a chronic disease, and repeated aspiration leads to chronic basal pneumonitis, which causes patchy or linear basal opacity (Fig. 24-5 and Fig. 24-6). Aspiration of acidcontaining gastric contents (Mendelsons syndrome), can produce a chemical pneumonitis causing pulmonary edema, often in a dependent portion of one or both lungs. The appearance is similar to basal pulmonary edema of other causes. The roentgen findings are therefore varied, and it may not be possible to differentiate this basal inflammatory disease from other nonspecific basal pneumonia or from the chronic pneumonia associated with bronchiectasis. However, correlation of the history with clinical and roentgen findings usually leads to the proper diagnosis.

FIG. 24-4. Aspiration pneumonia. Note the scattered patchy opacities in the lower half of the left lung and a similar but less extensive change at the right base. This was an acute process that cleared quickly on treatment.

FIG. 24-5. Chronic aspiration pneumonia. The pneumonia in the parahilar areas and at the right base is somewhat more clearly defined and stringy than the acute process shown in FIG. 24-4. This patient had partial esophageal obstruction and had aspirated intermittently for several months.

FIG. 24-6. A and B: Computed tomographic findings in a patient with chronic recurrent aspiration. Multifocal, patchy air-space disease is present bilaterally with a tree-in-bud pattern seen in the periphery of the lungs where aspirated material has become inspissated in bronchioles. Note also the dilated esophagus with retained contrast material within the lumen. Essentials of Radiologic Imaging, 7th Ed.

Case 29. This elderly male patient had recent loss of weight and bone pains. What is the most obvious CXR abnormality (Fig. 29.1)? Name the differential diagnoses? CASE 29INCREASED BONY DENSITIES DUE TO INTERPRETING CHEST X-RAYS OSTEOSCLEROTIC METASTASES The bones show patchy increased density due to metastases from carcinoma of the prostate. The di?erential diagnoses are Pagets disease and Fluorosis. Cancer of breast or lymphoma may also cause the same appearance. The CXR also shows right lower lobe infiltrates, suggesting aspiration pneumonia, common in the last stages of patients debilitated with cancer.

Figure 3-44 Right upper lobe pneumonia. On the posteroanterior chest x-ray (A), note that the right cardiac border is well seen. The alveolar infiltrate is seen in the right midlung. Localization is quite easy on the lateral view (B) by noting where the major and minor fissures should be. The infiltrate (arrows) can be seen above the minor fissure, indicating that it is in the upper lobe.

Figure 3-48 Aspiration pneumonia. A chest x-ray obtained immediately after aspiration may be quite normal (A). The chemical pneumonia takes 6 or 12 hours (B) to cause an alveolar infiltrate (arrow).

ESSENTIALS of RADIOLO

Buka juga Pediatric Radiology

Third Edition 23. A 60-year-old man with a history of COPD and old TB is seen with mild hemoptysis and chronic cough. He is HIV negative and has been ill for about 2 wk. Vital signs: pulse 110 bpm; temperature 101F; respirations 24/min; blood pressure 108/70 mm Hg. No skin lesions are noted. Laboratory data: Hb 14 g/dL; HCA 42%; WBCs 8.7/L; BUN 24 mg/dL; creatinine 0.8 mg/dL; sodium 131 mEq/L; potassium 4.3 mEq/L. ABGs on RA: pH CO 43 mm Hg; PO 87 mm Hg. Sputum tests reveal numerous AFB7.37; P 22 positive organisms on smear. Spirometry shows an obstructive ventilatory impairment with marginal reversibility. CXR is shown in Fig. 14. Among the choices listed, the most likely diagnosis is

Items 3839 A 27-year-old man is seen with a history of chronic sinus and pulmonary infections. He works as a salesperson in a retail outlet and denies any specific occupational exposure. He lives with his wife of 4 years and has no children. Family and travel history is noncontributory. On examination, he is in no acute distress. Lung exam reveals crackles in both lower lung zones and extremities show no clubbing. CXR is shown below in Fig. 22.

59. The answer is c. Aspiration pneumonia can occur in any patient

with swallowing difficulty. It frequently presents with a nonspecific diffuse airspace infiltrate on the CXR. Pneumonia usually results from aspiration of infected material from the oral pharynx and esophagus into the respiratory tract. This is usually seen in debilitated or unconscious patients and in individuals with neuromuscular disease or esophageal disease with reflux. The posterior segment of the right upper lobe or the superior segment of the right lower lobe is commonly affected. Bilateral lower lobe basilar infiltrates also suggest aspiration pneumonia. Continuous low-grade aspiration may produce diffuse infiltrates as seen in this patient. Although 90% of the time anaerobic bacteria are found, infection is usually polymicrobial.

Items 6062 A 56-year-old male smoker is admitted with shortness of breath, rightsided chest wall pain, and productive cough. He has a past history of seizure disorder and is on anticonvulsants. Dilantin level is within therapeutic range. On examination, there is dullness to percussion in the right upper zone with decreased breath sounds. Sputum for AFB and fungi are negative on initial smear and cultures are pending. CXR is shown in Fig. 35. Items 6768 A 26-year-old woman with a past history of seizure disorder is admitted to the medical ICU with status epilepticus. Due to continued seizures, she is placed in a barbiturate coma. As part of supportive measures, she is intubated, placed on a mechanical ventilator, and given IV fluids through a

central line. She remains stable overnight. In the morning, however, the respiratory therapist reports that she has had excessive mucopurulent secretions throughout the night and that her peak and plateau airway pressures have risen 20 cm. She is febrile with a temperature of 100.2F the next morning. CXR is shown in Fig. 38. General Discussion The classical radiological signs of pneumonia include a nonhomogenous opacity that has air bronchograms and that may have segmental or lobar distribution. Various silhouette signs (i.e., loss of diaphragm margin for lower lobes and loss of heart border for anteriorly placed middle lobe or lingula) are used to determine which lobes are involved. The spine sign on a lateral film indicates lower lobe involvement and is especially useful in determining the involvement of the superior segment of the lower lobe. Signs of cavities or breakdown suggest necrotizing gram-negative/mixed/ anaerobic infection. Pneumonia occasionally may present as a round density. A nonresolving infiltrate after 4 to 6 wk usually suggests underlying pathology such as an endobronchial lesion. In approximately 50% of patients with community-acquired pneumonia (CAP), an etiologic diagnosis cannot be made. The common known causes of CAP are bacteria, viruses, and atypical pathogens. The ATS guidelines recommend treatment of patients based on severity of disease and comorbid conditions. Streptococcus pneumoniae is the most likely pathogen for all groups, and treatment must include coverage for that organism in all

patients. In elderly and chronically ill patients, those with COPD, and even smokers without COPD, coverage must include gram-negative bacteria. Aspiration pneumonia should be considered in those with impaired consciousness or altered swallowing reflexes. About 5% of patients with CAP have Pseudomonas aeruginosa identified in their respiratory tract. In the United States, 5% to 35% of pneumococci are now penicillin resistant. Most are intermediate-level resistant and are seen more in immunecompromised and/or chronically ill patients, especially if these patients have received a -lactam antibiotic in the preceding 3 mo. Mortality rates in severe community-acquired pneumococcal pneumonia exceed 15% but are related to patient host factors and not bacterial resistance. Legionella remains an underestimated and often unidentified pathogen with a high mortality. Staphylococcal pneumonia is frequently seen in older or debilitated patients, not infrequently occurring as a complication of influenza. The disease is commonly bilateral, starting as patchy multilobar infiltrates. Volume 83. A 41-year-old man is admitted with severe shortness of breath. He complains of a 25-lb weight loss over the last 2 mo and occasional vomiting after meals. On physical examination, vital signs are: pulse 110 bpm; temperature 98F; respirations 24/min; blood pressure 110/70 mm Hg. Pertinent findings: dullness to percussion on the left posterior chest with decreased breath sounds. A patchy area of egophony is heard over the left upper lung field posteriorly. PPD is 15 mm. CXR is shown in Fig. 47. The most likely diagnosis is

Chest Radiology PreTest Self-Assessment and Review 1. A. Pneumonia b. Atalectasis c. Cavity d. Pleural effusion / Hemothorax / Empyema e. Congestive heart failure f. Chronic interstitial lung disease g. Nodule/mass Clinical Radiology made ridiculously simple

Airway and Lung Anatomy The lungs themselves are divided into five lobes, each supplied by a bronchus with the same name as the lobe. On the right, there are three lobes: the upper, middle and lower, while on the left there are two: the upper and lower. The upper and middle lobes of the right lung sit anteriorly and are separated from each other by the minor fissure. The minor fissure runs horizontal from the hilum and is usually seen well on the frontal radiograph. Figure 1.17 illustrates this fissure. In both lungs the lower lobes sit posteriorly, behind the major fissure. On the right, both the upper and middle lobes sit in front of the major fissure, while on the left there is only and upper lobe (which includes the lingula) to sit in front of the major fissure. The major fissures are not seen on the frontal radiograph, but both can be seen on

the lateral radiograph. The major fissures run obliquely, parallel to the lateral rib shadows, as shown in Figure 1.18. It is not always possible to tell the left from right major fissure because in the normal individual they overlie each other on the lateral radiograph. In some cases the minor fissure will also be visible on the lateral radiograph, running anterior to the major fissure. These relationships are shown in Figure 1.18. stem bronchi can be well seen through the mediastinum because they represent air-filled structures surrounded by soft tissue density. Figures 1.15 and 1.16 illustrate the anatomy of the central airways on the frontal and lateral chest radiographs respectively. The Medical Student's Guide to the Plain Chest Film

ASPIRATION PNEUMONIA Patients whose anatomic defense mechanisms are impaired are at risk of aspiration pneumonia (Table 182). Acute disease is commonly caused by bacteria present in the mouth (especially gram-negative anaerobes). Chronic aspiration often causes recurrent bouts of acute febrile pneumonia. It may also lead to chronic focal infiltrates, atelectasis, illness resembling asthma or interstitial lung disease, or failure to thrive.

Table 18-2. Risk factors for aspiration pneumonia.

Clinical Findings A. SYMPTOMS AND SIGNS

Acute onset of fever, cough, respiratory distress, or hypoxemia in a patient at risk suggests aspiration pneumonia. Chest physical findings, such as rales, rhonchi, or decreased breath sounds, may initially be limited to the lung region into which aspiration occurred. Although any region may be affected, the right sideespecially the right upper lobe in the supine patientis commonly affected. In patients with chronic aspiration, diffuse wheezing may occur. Generalized rales may also be present. Such patients may not develop acute febrile pneumonias. B. LABORATORY FINDINGS AND IMAGING

Chest x-rays may reveal lobar consolidation or atelectasis and focal or generalized alveolar or interstitial infiltrates. In some patients with chronic aspiration, perihilar infiltrates with or without bilateral air trapping may be seen. In severely ill patients with acute febrile illnesses, a bacteriologic diagnosis should be made. In addition to blood cultures, cultures of tracheobronchial secretions and bronchoalveolar lavage or lung puncture specimens may be desirable (see Culture of Material from the Respiratory Tract section, above). In patients with chronic aspiration pneumonitis, solid documentation of aspiration as the cause of illness may be elusive. Barium contrast studies may provide evidence of suck-swallow dysfunction, laryngeal cleft, occult tracheoesophageal fistula, or gastroesophageal reflux. Overnight or 24-hour esophageal pH probe studies may also help establish the latter. Although radionuclide scans are commonly used, the yield from such studies is disappointingly low. Rigid bronchoscopy in infants or flexible bronchoscopy in older children can be useful in more definitively excluding tracheoesophageal fistula and obtaining bronchoalveolar lavage specimens to search for lipid-laden macrophages, which can suggest chronic aspiration.

Differential Diagnosis In the acutely ill patient, bacterial and viral pneumonias should be considered. In the chronically ill patient, the differential diagnosis may include disorders causing recurrent pneumonia (eg, immunodeficiencies, ciliary dysfunction, foreign body), chronic wheezing, or interstitial lung disorders (see Interstitial Lung Disease section, below), depending on the presentation. Complications Empyema or lung abscess may result from acute aspiration pneumonia. Chronic disease may result in bronchiectasis. Treatment Antimicrobial therapy for acute aspiration pneumonia includes coverage for gram-negative anaerobic organisms. In general, clindamycin is appropriate initial coverage. However, in some hospital-acquired infections, additional coverage for multiply resistant P aeruginosa, streptococci, and other organisms may be required. Treatment of recurrent and chronic aspiration pneumonia may include the following: surgical correction of anatomic abnormalities; improved oral hygiene; improved hydration; and inhaled bronchodilators, chest physical therapy, and suctioning. In patients with compromise of the CNS, exclusive feeding by gastrostomy and (in some) tracheostomy may be required to control airway secretions. Gastroesophageal reflux, often requiring surgical correction, is commonly present in such patients. Prognosis The outlook is directly related to the disorder causing aspiration. Current Pediatric Diagnosis & Treatment 16th Ed: William W. Hay Jr, et al By McGraw-Hill Education - Europe 2002

Aspiration Pneumonia Background

Pneumonia is an inflammation of the lung tissue that may follow either a noninfectious or infectious insult, often involving the pathogens entering directly down the respiratory tract. The common infectious causes of pneumonia are discussed in Chapter 84. Although the pathophysiology of these pneumonias may directly involve aspiration of various pathogens, the term aspiration pneumonia has become commonly associated with the consequences of inhalation of oropharyngeal or stomach contents. In contrast to episodic pneumonia in an otherwise healthy child, aspiration pneumonia is most common in children with debilitation, altered consciousness, and CNS disorders that impair normal swallowing or protective airway reflexes. Other important causes of aspiration pneumonia are disorders of esophageal motility or problems with gastric emptying, and obstructive lesions such as tracheoesophageal fistula or, rarely, duodenal stenosis. Institutionalized children are often afflicted with this disorder. However, aspiration pneumonia can also occur in healthy children who have full stomachs when undergoing emergency procedures, in otherwise healthy children following seizures, or in children with decreased intestinal motility caused by pain, trauma, or analgesic administration. Pathophysiology Wynee and Modell have comprehensively reviewed the pathophysiology of aspiration pneumonias, which may be classified in two groups, based on the pH of the aspirate. A critical pH (2.5), below which severe lung damage is likely to occur, has been described. Acid Aspiration Aspirations in humans are considered acidic if the pH of the aspirate is less than 2.5. Experimentally, as the pH decreases below this level, the severity of lung injury increases. The volume and distribution of the aspirate are also important: large, poorly localized aspirates are most damaging. Likewise, aspirates with high bacterial content, such as those in patients with bowel obstruction, are associated with high morbidity. Acid aspiration causes a severe chemical pneumonitis with direct injury to alveolar-capillary membranes. A hemorrhagic, granulocytic, necrotizing reaction generally follows. Hypoxia from multiple causes can occur within minutes of acid aspiration. These causes include reflex airway closure; destruction of surfactant, resulting in atelectasis; interstitial and alveolar edema after exudation of

fluid and protein across damaged membranes; and alveolar hemorrhage and consolidation. Nonacid Aspiration Nonacid aspirates (pH greater than 2.5), such as from the oropharynx or with mixed aspiration, can cause either transient or sustained pulmonary damage. Many of the early effects seen after acid aspiration may also result from nonacid aspiration. Pulmonary edema, endothelial cell alteration, and peribronchial neutrophilic infiltration have all been described. However, alveolar neutrophilic infiltration and necrosis are minimal. The exact nature and extent of lung damage from nonacid aspirates depend greatly on the composition of the aspirate. In contrast to the rapid resolution of nonacid, clear liquid (saline, water) aspiration, a prolonged pathologic response follows aspiration of partially digested meat, vegetable, or dairy products in which small food particles may be present. Unlike the neutrophilic response to acid aspiration, a widespread mononuclear and granulomatous reaction is seen in these cases. When repeated aspirations of irritating food particles occur over an extended period, roentgenograms may show granuloma formation similar to that of miliary tuberculosis. Infection The role of infection in the pathogenesis of aspiration pneumonia is unclear. Most physicians agree that infection plays little or no role in the initial pulmonary complications as a result of aspiration. However, following acid aspiration, the injured lung is potentially vulnerable to bacterial infection. Bacterial pulmonary infection is a complication in up to half of these cases. Why most patients do not develop pulmonary infection is not well understood. Although normal gastric contents contain few, if any, bacteria, oropharyngeal secretions may contain up to 108 bacteria/cm3. It is conceivable that bacteria in oropharyngeal secretions either do not always gain access to susceptible areas or are diluted by the aspirate to concentrations that can be cleared by local defense mechanisms. Two distinct patterns of infection are seen in patients who aspirate. A localized necrotizing bacterial pneumonia, abscess, or empyema may result from a heavily infected inoculum. In nonhospitalized children, anaerobic organisms are generally responsible for these infections; in hospitalized patients, facultative anaerobes and aerobic organisms are more common. The second pattern of infection is that which follows large aspirates, usually of the acid type. Aerobic, rather than anaerobic, organisms predominate

here; Gram-negative organisms such as Pseudomonas aeruginosa and Gram-positive organisms such as staphylococci are often isolated. Of particular risk are children with bowel obstruction who develop aspiration syndromes. Clinical Manifestations. Aspiration pneumonia should be suspected in any at-risk child who has signs of respiratory distress. The actual aspiration is often witnessed or vomitus is present in the immediate vicinity, suggesting the possibility of aspiration. The clinical manifestations of pneumonia are discussed in Chapter 84. Most often, after the aspiration of gastric contents, a brief latent period occurs before the onset of respiratory signs and symptoms. More than 90% of patients are symptomatic within 1 hour, and almost all patients have symptoms within 2 hours. Fever, tachypnea, and cough are usually seen. Hypoxia is common. Apnea and hypotensive shock are less common. Sputum production is usually minimal. The physical findings in patients with aspiration pneumonia are not dissimilar from those in patients with pulmonary infections resulting from either bacterial or viral causes. Diffuse crackles and wheezing are common; cyanosis appears with progression of the diseases. Chest roentgenograms (Fig. 95.5A and Fig. 95.5B) may show either localized or diffuse infiltrates, which are often bilateral. The chest roentgenogram of a patient who has aspirated stomach contents may evolve suddenly from normal to complete bilateral opacification within 8 to 24 hours.

FIGURE 95.5. A. Blood aspiration. A 3-year-old boy with tachypnea 1 day after surgery for enlarged adenoids/tonsils. Chest film shows an infiltrate in the right upper lobe and left lower lobe. B. Blood aspiration (see A). The chest film 2 days later shows clearing of the infiltrate in the right upper lobe and left lower lobe.

Management. The suspicion of aspiration should be confirmed with a chest radiograph. Children with a significant aspiration pneumonia (lobar infiltrates, moderate to severe respiratory distress) require admission to the hospital. Table 95.6 outlines therapeutic modalities that may be useful. Some children who aspirate may have radiographs that are significantly abnormal in the face of minimal clinical symptoms. A common example is that of mild hydrocarbon aspiration.

Table 95.6. Initial Treatment of Aspiration Pneumonia

In the acute-care setting, children who aspirate stomach contents require primarily supportive care. Specifically, prevention of further aspiration by adequate oropharyngeal suctioning and proper positioning should be the rule. The pulmonary signs and symptoms associated with aspiration of stomach contents may resolve quickly with supportive care or progress to respiratory failure, with the subsequent development of bacterial superinfection over a period of days. Intubation of the trachea is indicated if the airway reflexes are inadequate or if respiratory failure ensues. Supplemental oxygen should be administered, as determined by pulse oximetry or direct measurement of oxygenation with an ABG. The management of subsequent bacterial infection is addressed in the following section. The use of corticosteroids in the treatment of aspiration pneumonia is controversial. Because experimental evidence indicates at best minimal benefit from steroids in acid aspirations and because these drugs may be

contributing factors in the development of secondary bacterial pneumonia, their administration is not indicated in the ED. Another consideration in the therapy of aspiration pneumonias is the role of prophylactic antibiotic administration. Because fever, purulent sputum, leukocytosis, and pulmonary infiltrates all may result from chemical pneumonitis alone and because no strong data exist that support the use of prophylactic antibiotics in children who acutely aspirate stomach contents, a reasonable initial approach is to defer antibiotic treatment in favor of careful observation. Assuming that prophylaxis is not given following the aspiration of stomach contents, and clear signs of infection later develop, the choice of antibiotics can be guided by both the clinical setting and the results of properly obtained specimens for culture. Community-acquired pneumonias generally involve anaerobes and are adequately treated with penicillin, whereas nosocomial infections require antibiotics effective against both aerobes (including Staphylococcus aureus and Gram-negative bacilli) and anaerobes. A combination such as clindamycin and gentamicin is often used. In neurologically impaired children, with either aspiration or tracheostomy-associated pneumonia, antibiotics effective against penicillinresistant anaerobic bacteria (i.e., clindamycin or ticarcillin-clavulanate) have been shown to produce clinical and microbiologic responses superior to those associated with agents less effective against these organisms. Textbook of Pediatric Emergency Medicine 4th edition (January 15, 2000): by Gary R. Fleisher (Editor), Stephen Ludwig (Editor), Silverman, Fred M. Henretig By Lippincott, Williams & Wilkins

90.5 Aspiration of Foreign Material (Fetal Aspiration Syndrome, Aspiration Pneumonia) During prolonged labor and difficult deliveries, infants often initiate vigorous respiratory movements in utero because of interference with the supply of oxygen through the placenta. Under such circumstances, the infant may aspirate amniotic fluid containing vernix caseosa, epithelial cells, meconium, or material from the birth canal, which may block the smallest airways and interfere with alveolar exchange of oxygen and carbon dioxide. Pathogenic bacteria may accompany the aspirated material, and pneumonia may ensue, but even in noninfected cases,

respiratory distress accompanied by roentgenographic evidence of aspiration is seen ( Fig. 906 ). Pulmonary aspiration may also occur in newborn infants as a result of tracheoesophageal fistula, esophageal and duodenal obstruction, gastroesophageal reflux, improper feeding practices, and administration of depressant medicines. The contents of the stomach should be aspirated through a soft catheter just before surgery or other procedures that require anesthesia or significantly disturb an infant. Once aspiration has occurred, treatment consists of general and respiratory

Figure 90.5-6 Fetal aspiration syndrome (aspiration pneumonia). Note the coarsely granular pattern with irregular aeration typical of fetal distress from the aspiration of material contained in amniotic fluid, such as vernix caseosa, epithelial cells, and meconium. support and treatment of pneumonia ( Chapters 90.3 and 38 Nelson Textbook of Pediatrics 17th edition (May 2003): by Richard E., Md. Behrman (Editor), Robert M., Md. Kliegman (Editor), Hal B., Md. Jenson (Editor) By W B Saunders ASPIRATION PNEUMONIA

Epidemiology Aspiration pneumonia is an infectious inflammatory condition that results from the inhalation of oral contents into the lungs. The oral contents can be food, vomitus, inedible objects (e.g., toys, screws, etc.), or oral secretions. One of the earliest recorded aspiration deaths was in 475 B.C. when the Greek poet Anacreon died as a result of aspirating a grape seed.1 Mendelson in 1946, described 66 obstetrical patients who developed respiratory failure as a result of aspiration of stomach contents during obstetric anesthesia.2 The pulmonary effects of aspiration are due to the presence of foreign bodies, chemical irritants, and bacterial pathogens in the material aspirated.3 The true incidence of pathologic aspiration into the lungs is difficult to determine. Small volumes of aspiration that do not lead to infection or pulmonary disease have been documented in approximately 50 percent of normal subjects during sleep.4 Such chronic debilitating conditions as stroke, dysphagia, tube feeding, and altered mental status with decreased level of consciousness place patients at increased risk for aspiration (Table 60-1). Of patients studied within 5 days after an acute stroke, 38 percent demonstrated evidence of aspiration.5 One-third of those who aspirated had silent aspiration without evidence of cough or gag. Risk factors and predictors for silent aspiration included dysphagia, dysarthria, voice change after swallow, and abnormal gag reflex (Table 60-2).

TABLE 60-1 Risk Factors for Aspiration Pneumonia and Lung Abscess

TABLE 60-2 Physical Findings in Patients at Risk for Aspiration

Patients discharged back to long-term care facilities are at persistent risk for aspiration. Patients who aspirate are at three times the risk of dying compared with patients who did not aspirate.6 Pathophysiology Risk factors for aspiration among emergency patients includes transient or permanent altered mental states with depressed glottic reflexes, anomalies of the esophagus, alcohol or illicit drug intoxication, seizure, tube feedings, anesthesia, advanced age, and supine position. It is not uncommon to see more than one of these risk factors in a single patient. For example, an elderly nursing home patient in a persistent vegetative state with a gastrostomy tube arrives for evaluation of fever. Caretakers may not appreciate aspiration, since the event may be occult secondary to the lack of gag or cough reflex at the time of aspiration. The severity of the symptoms is related to the volume of material aspirated, the amount of bacterial contamination, and the pH of the material aspirated. Liquids with a pH lower than 2.0 are associated with a much higher mortality rate than are liquids with a higher pH. Aspirated bacteria usually come from oropharyngeal contents, with anaerobic bacteria predominating. Patients in hospitals or long-term care facilities may become colonized by gram-negative bacilli, and these bacteria may make their way into the aspirated inoculum. Normal mechanisms that protect the airway include the sneeze, gag, and cough reflexes. Particles deposited in the distal nasal epithelium are removed by a sneeze. Lower airways are protected by mucus produced by cells that line the airways. This mucus traps airborne particles of 10-m diameter. Once trapped by the mucous coating, these larger particles are

swept proximally by the mucocillary escalator to the oropharynx, where they are expectorated or swallowed. Alveolar macrophages, polymorphonuclear leukocytes, or lymphocytes destroy infectious particles that are small enough to reach the alveoli. Many of the symptoms of aspiration pneumonia are elicited by the body's inflammatory response to the infectious or irritative material. Proinflammatory cytokines, which increase capillary permeability and are cytotactic, cause migration of fluids and inflammatory cells into the area of irritation.7 The inflammatory response is responsible for the symptoms of fever, productive cough, and radiographic findings. These findings may not be present when aspiration occurs in an immunocompromised patient who may not be able to mount the inflammatory responses. Solid material, such as sand, dirt, toys, and other small objects, can cause rapid asphyxiation secondary to mechanical blockage of the trachea. Patients with total or near-total obstruction of the glottis or trachea will be unable to cough or call for help because of the lack of air movement.

Clinical Features The typical patient has had problems with oral secretions or coughing with meals, suggesting gastroesophageal reflux.8 Patients who require tube feedings are at risk for aspiration.8 In the elderly, localizing symptoms may be minimal, and the complaint may be a change in baseline mental status. There may be a specific witnessed episode of aspiration. Physical findings include those common to pneumonia: fever; cough; localized rales, wheezes, or rhonchi; tachycardia; and tachypnea. Cyanosis can develop quickly in patients with underlying lung disease or in patients with overwhelming pulmonary bacterial contamination. Aspiration of large volumes of fluid can also precipitate the rapid development of cyanosis. Chest radiographs may show an interstitial or alveolar pattern. The right lower lobe is the most common area for the development of aspiration pneumonia when aspiration occurs in an upright sitting posture because the right main stem bronchus has a more direct course from the trachea than does the left main stem bronchus (Fig. 60-1). Aspiration in a supine position may produce infection in any lobe, although the posterior pulmonary segments are more susceptible.

FIG. 60-1. Aspiration pneumonia of the right lower lobe.

Laboratory tests may demonstrate an elevated white blood cell count. In elderly patients the typical leukocytosis may be blunted. In these situations it is helpful to assess the differential and look for a left shift with an increased percentage of immature forms. An elevated C-reactive protein level is a nonspecific indicator of an inflammatory process and may be the only indication of an aerobic infectious pulmonary process resulting from an aspiration.9 Arterial blood gas measurements may reveal hypoxia if the aspiration or inflammatory process is large enough to significantly interfere with alveolar gas exchange. Oxygen content may be normal early in the course of the illness, but evidence of pulmonary injury can be found by detecting hyperventilation (decreased PaCO2) and ventilation-perfusion mismatching (elevated A-a gradient). Treatment Prevention of aspiration is particularly important for those patients at risk. Treatment of illicit drug use and alcohol addiction will significantly decrease the individual patient's chance of intoxication and subsequent aspiration. Feeding in an upright position will decrease the risk of aspiration in patients with dysphagia, on tube feedings through nasogastric or orogastric tubes, or with gastrostomy or jejunostomy tubes. Increasing the gastric pH by the

use of antacids (four times a day) or proton pump inhibitors (omeprazole 20 mg/d orally) will decrease the pulmonary damage from silent serial aspirators.10 Prokinetic agents that increase lower esophageal sphincter tone and stimulate gastric emptying are useful in treating gastroesophageal reflux disease and would be useful in preventing aspiration in patients at risk. These agents include bethanecol 25 mg qid, metoclopramide 10 mg before meals and at bedtime, and cisapride 10 mg before meals and at bedtime. These agents are useful in gastroesophageal reflux disease, but they have some troublesome side effects. The side effects of bethanecol are related to its cholinergic effects: abdominal cramps, salivation, urination, and blurred vision. Cisapride has been reported to cause Q-T interval prolongation and ventricular dysrhythmias, including torsade de pointes, in patients receiving other medication (e.g., ketoconazole and other antifungals). In addition to the desirable antiemetic central nervous system effects of metoclopramide, there are also undesirable effects: mild anxiety, nervousness, insomnia, depression, confusion, disorientation, and hallucinations. Other troublesome side effects of metoclopramide include the extrapyramidal effects of tremor; akathisia; tardive dyskinesia, a Parkinson-like syndrome; gynecomastia; and reversible amenorrhea.8 For patients who have experienced an acute, symptomatic aspiration, immediate removal of any airway obstruction and rapid assessment of ventilation is needed. Hypoxia should be corrected by oxygenation, ventilation, and intubation if necessary. Aerosolized bronchodilators are useful for aspiration-induced bronchospasm. For patients in shock, aggressive intravenous (IV) fluid administration and, if appropriate, vasopressors are used. Healthy patients who aspirate but who are not hypoxic and have no infiltrate on x-ray may be observed for development of signs of infection and may not require antibiotic treatment. Elderly or chronically ill patients who present with signs and symptoms of infection should have antibiotic therapy instituted. In general, appropriate cultures of blood, urine, and sputum (if available) should be obtained in the emergency department, and antibiotic therapy should be initiated. Anaerobes predominate in aspiration pneumonia, and antibiotics that are proven effective include clindamycin 450 to 900 mg IV every 8 h, cefoxitin 2.0g IV every 8 h, ticarcillinclavulanate 3.1 g IV every 6 h, or piperacillin-tazobactam 3.375 g IV every 6 h.

Bronchoscopy may be indicated for patients who aspirate large objects that move into the distal airways. Patients with viscous materials or tenacious secretions may require direct bronchoalveolar lavage for removal. Patients who develop copious hemoptysis may require bronchoscopy for both diagnosis and treatment. Disposition Patients who have had a witnessed episode of aspiration and who are otherwise healthy and exhibit no signs of infection or respiratory compromise may be discharged home with instructions to follow up with their primary care physician in 1 to 2 days. They should be instructed to watch for shortness of breath, fever, chest pain, unusual fatigue, or the development of a cough and to return to the emergency department or see their primary care physician promptly if any of these symptoms develop. Patients who appear stable but have risk factors for worse or very aggressive disease (diabetes, old age, dialysis, recent stroke, chronic pulmonary disease, active cancer, HIV, etc.) should be admitted to either a hospital or an observation unit. Oxygen, fluids, and possibly antibiotics should be started and the patient followed carefully for 12 to 24 h. If stable after 12 to 24 h of treatment and observation, such patients can be sent home and instructed to follow up as described above and to return if any sign of deterioration develops. Patients with definite evidence of infection should be admitted and antibiotic treatment started. Patients who exhibit hemodynamic or respiratory instability require admission to an intensive care unit.

Emergency Medicine: A Comprehensive Study Guide 6th edition (October 14, 2003): by Judith E Tintinalli (Editor), Gabor D., Md. Kelen (Editor), J. Stephan Stapczynski (Editor) By McGraw-Hill Professional

ASPIRATION PNEUMONITIS/PNEUMONIA

Aspiration syndromes refer to the clinical and pathophysiologic effects resulting from the introduction of foreign objects or substances into

the lower respiratory tract. The most commonly involved areas those that are most dependent in the supine position are the posterior segments of the upper lobes and the superior segments of the lower lobes.

ETIOLOGY

The usual causes of aspiration pneumonia in the elderly are Enterobacteriaceae, S. aureus, S. pneumoniae, and H. influenzae.

EPIDEMIOLOGY

Aspiration syndromes include two distinct clinical entities. In aspiration pneumonitis, gastric contents (sterile as long as gastric acid is present) are aspirated into the lungs, with a consequent inflammatory response. Pneumonia results from the aspiration of oropharyngeal flora into the lungs, with consequent bacterial infection. The risk factors for aspiration include altered level of consciousness, incompetent gastroesophageal junction, elevated intragastric pressure or volume, and neuromuscular diseases that interfere with glottic closure.

The number of cases of aspiration pneumonia diagnosed in Medicare patients increased by 93.5% between 1991 and 1998. The mortality rate among patients with aspiration pneumonia was 23.1%, compared with 7.6% among those with pneumococcal pneumonia.

CLINICAL FEATURES

The manifestations of aspiration pneumonia vary with the volume and nature of the material aspirated. Gastric acid aspiration results in a chemical pneumonitis that can be very severe, requiring assisted

ventilation. A pH of <2.5 and a gastric aspirate volume of >0.3 mL/kg (20 to 25 mL in adults) are required for the development of aspiration pneumonitis. There is an acute onset of dyspnea, tachypnea, bronchospasm, and cyanosis, with a chest radiograph often showing diffuse opacities.

Many elderly patients are achlorhydric and so may not fit the typical presentation described above. Indeed, in many of these patients, aspiration pneumonitis is often indistinguishable from pneumonia. A history or a witnessed account of an aspiration event (one or more instances of vomiting, coughing while eating, displacement of a feeding tube, or vomitus or tube feeding on bedclothes or on the patient within 24 h of the diagnosis of pneumonia) is documented in only 40% of definite aspiration events among LTCF51 residents. Thus the diagnosis of aspiration pneumonitis/pneumonia requires a high index of suspicion. The location of the pneumonia depends on the position of the patient when aspiration occurred. An opacity involving the posterior segment of the upper lobes (especially the right upper lobe) is found in persons who have aspirated in the recumbent position, while aspiration in the upright or semirecumbent position results in involvement of the posterior basal segments of the lower lobes.

In the setting of aspiration of oropharyngeal contents and poor dental hygiene, anaerobic bacteria may be present, and lung abscess is not an uncommon complication. Particulate matter may be aspirated, with consequent mechanical obstruction of the airway.

TREATMENT Treatment for aspiration occurring in a community setting is outlined in Table 239-9.

PREVENTION

Good oral hygiene reduces the risk of aspiration pneumonia among patients with cerebrovascular disease and swallowing impairment. Patients at high risk for aspiration (e.g., those who have had a stroke) should be assessed for aspiration. This evaluation is easily done by having an alert patient sit up and take increasing amounts of water, starting with one spoonful. Water leaking out of the corners of the mouth, coughing, and shortness of breath are all suggestive of aspiration and indicate the need for further evaluation.

Harrison's Principles of Internal Medicine 16th Edition by Dennis L. Kasper, Eugene Braunwald, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson Publisher: McGraw-Hill Professional; 16 edition (July 23, 2004)