Aspiration syndromes

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Aspiration Syndromes Prof. Dr. Saad S Al Ani Senior Pediatric Consultant Head of Pediatric department Khorfakkan Hospital Sharjah ,UAE [email protected]

description

Definition ,Causes ,presentation ,treatment ,prevention

Transcript of Aspiration syndromes

Page 1: Aspiration syndromes

Aspiration SyndromesProf. Dr. Saad S Al Ani

Senior Pediatric ConsultantHead of Pediatric department

Khorfakkan HospitalSharjah ,UAE

.saadsalani@yahoo com

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Introduction

“ Aspiration includes a wide clinical spectrum from:

An asymptomatic condition

to

Acute life-threatening events „

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Cont.

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

i. Massive aspiration of gastric contents

or

ii. Hydrocarbon products „

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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 „

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Aspiration of gastric contents

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

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Cont.

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

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Cont.

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

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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 „

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Cont.

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

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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 „

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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 „

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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 „

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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 „

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Cont.

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

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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 „

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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 „

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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 „

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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„

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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. „

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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„

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Prevention

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

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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 „

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Cont.

“ 1.Minimizing use of sedation

2.Monitoring for gastric residuals

3.Gastric acid suppression

may all help prevent aspiration. „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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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 „

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Cont.

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

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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

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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

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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

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“Thank you„