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Best Practice & Research Clinical Anaesthesiology Vol. 18, No. 4, pp.

719–737, 2004
doi:10.1016/j.bpa.2004.05.008 available online at http://www.sciencedirect.com

12 Strategies for prophylaxis and treatment for aspiration
Christopher Peter Henry Kalinowski*
Assistant Professor
MB, ChB, FANZCA

Jeffery Robert Kirsch
Professor and Chairman

MD

The Department of Anesthesia and Peri-Operative Medicine, 3181 SW Sam Jackson Park Road, Oregon Health and Sciences University, Portland, OR 97239, USA

The absolute incidence of aspiration is difficult to define because of its relatively low occurrence and difficulty in diagnosis. The gastric volume predisposing to aspiration is larger than 30 ml. Fasting times for fluids have reduced; however, a large meal may require 9 hours of preoperative fasting. Preoperative carbohydrate-enriched beverages may attenuate postoperative catabolism. Aspiration occurs most frequently during induction and laryngoscopy. Awake fibre-optic intubation may be a suitable alternative in high-risk cases for aspiration. The role of cricoid pressure in anaesthesia needs re-evaluation as radiological and clinical evidence suggest that it may be ineffective and may impede intubation and ventilation. Chemoprophylaxis does not reduce the severity of aspiration pneumonitis as gastric bile is unaffected by these agents and induces a worse pneumonitis than gastric acid. Patients may be discharged home 2 hours after aspirating provided they are clinically unaffected and have postoperative surveillance. Key words: aspiration; preoperative fasting; carbohydrate-enriched fluids; chemoprophylaxis; cricoid pressure; rapid sequence induction; fibre-optic intubation.

The first recorded anaesthetic death, that of Hannah Greer, was believed by James Simpson in 1848 to be attributable to the pulmonary aspiration of brandy.1 Subsequently, Mendelson described two syndromes involving aspiration of gastric contents.2 Many studies of aspiration risk use intermediate or surrogate endpoints such as pH and volume of gastric contents. The use of pharyngeal detectors of reflux and regurgitation do not detect aspiration, as not all episodes of reflux and regurgitation result in aspiration. Assessment of the incidence of aspiration in anaesthetic practice has been generally derived from large-scale studies using a computerized database. Multivariate analysis may be used to identify certain risk factors, but this type of study is
* Corresponding author. Tel.: þ 1-503-494-7641; Fax: þ 1-503-494-3092. E-mail address: kalinows@ohsu.edu (C.P.H. Kalinowski). 1521-6896/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved.

With ARDS there is worsening arterial hypoxia. The American Society of Anesthesiologists (ASA) Closed Claims database demonstrates a reduction in aspiration-related deaths that is probably due to changes in management in this patient population. shortness of breath or respiratory distress † aspiration pneumonitis: a non-infectious acute inflammatory reaction to aspirated material characterized by an infiltration on chest radiograph † aspiration pneumonia: a parenchymal inflammatory reaction to aspirated material mediated by an infectious agent. DEFINITIONS The North American Summit on aspiration in critically ill patients has defined the vocabulary to standardize the terms related to aspiration conditions4: † reflux: single passage of gastric contents into the oesophagus † regurgitation: effortless passage of gastric contents into the oropharynx † vomiting: passage of gastric contents into the oropharynx associated with retrograde peristalsis and abdominal muscle contractions † aspiration: inhalation of material into the airway below the level of the true vocal cords † silent aspiration: asymptomatic aspiration † symptomatic aspiration: aspiration accompanied by coughing. so it may be difficult to evaluate the impact of a particular intervention on outcome.720 C. bilateral infiltrates on chest radiograph and no evidence of left atrial hypertension. radiological and physiological findings that are not the result of left atrial or pulmonary capillary hypertension. R. Preoperative assessment and identification of patients at risk for aspiration allows the anaesthetist to institute preoperative fasting. Aspiration may also be diagnosed by radiographically demonstrating contrast material in the lungs that was previously administered by mouth or radioisotope by scintigraphy. Kalinowski and J. Aspiration may cause acute lung injury. Kirsch often limited by the heterogeneity of patient populations and anaesthetic technique. H. P. In extreme situations acute lung injury may progress to adult respiratory distress syndrome (ARDS). characterized by an infiltrate on chest radiograph. 300—irrespective of the level of positive end expiratory pressure (PEEP)—and no evidence of left atrial hypertension. characterized by a PaO2/FiO2 ratio . medication administration and appropriate anaesthetic techniques to minimize the risk of pulmonary aspiration. respiratory support and physiotherapy to management of septic shock and severe lung injury. which is characterized by increased alveolarcapillary membrane permeability associated with a constellation of clinical. Acute lung injury is characterized by impaired arterial oxygenation with a PaO2/FiO2 ratio . choking. 200 (regardless of PEEP).3 The single most important means of treating aspiration of gastric contents is in its prevention. The treatment of pulmonary aspiration is primarily supportive. and may range from observation. . Aspiration may be a witnessed regurgitation/aspiration event at the bedside accompanied by choking/coughing and expectoration of material. the anaesthetists may observe foreign material in the larynx below the true vocal cords. Upon examination.

failure to detect aspiration outside of the operating room and inaccurate documentation. Ollsen et al reviewed computer-based records of anaesthetics administered between 1967 –1970 and 1975– 1983 and found an incidence of 1 in 2131 anaesthetics and a mortality rate of 1 in 46 340. Mendelson’s syndrome results from acid aspiration and presents with bronchospasm. percutaneous needle biopsy and open lung biopsy. The aspiration rate for emergency procedures was 1 in 895 (11/10 000). coughing.7 Invasive techniques to confirm pulmonary aspiration include fibre-optic bronchoscopy. without consistent definitions of aspiration.12 There were 67 aspirations with a rate of 1 in 3216 anaesthetics and three deaths (mortality rate of 1 in 71 829).6/10 000). results from aspiration of solid gastric material.8 INCIDENCE AND RISK FACTORS In one study asymptomatic aspiration occurred in 9/20 normal subjects (45%) during sleep and 70% of patients with depressed levels of consciousness. wheezing. Although regurgitation and aspiration are most common during induction of anaesthesia (41 of 87 aspirations).6 The measurement of glucose content in tracheal aspirates in tube-fed patients correlates with serum glucose concentrations rather than with evidence of aspiration. Classically. tachypnoea. Radiographic observation of a right middle lobe infiltrate is consistent with aspiration pneumonia. an obstructive picture.Prophylaxis and treatment for aspiration 721 CLINICAL SEQUELAE OF PULMONARY ASPIRATION Mendelson described two syndromes involving the aspiration of gastric contents. tachypnoea. hypotension and evidence of mediastinal shift and consolidation. Chest radiographic findings in paediatric cases of silent aspiration may be normal in 14% and have diffuse severe involvement in 68%.2 The first. broncheoalveolar lavage. . Warner et al reviewed 172 334 adult patients who underwent 215 488 general anaesthetics in all specialties between 1985 and 1991.10 There were four deaths (mortality rate of 1 in 49 525). caesarean section. wheezing.11 In this analysis risk factors included extremes of age. cyanosis and fever. sixfold higher than during the day). Tiret et al reported 27 aspirations occurring on induction or during maintenance and recovery from anaesthesia. For example. the symptoms and signs include cyanosis. time of day (18:00– 06:00 hours. body mass index . Age. Pulmonary aspiration is much more common in patients under general anaesthesia as compared to neuraxial or regional anaesthesia. upper gastrointestinal tract procedures and obesity. gender.9 The true incidence of perioperative aspiration pneumonitis is difficult to determine. Aspiration events occurred on induction/laryngoscopy in 26 of 67 patients and on extubation on 24 of 67 patients. they also occur during maintenance (10 of 87 aspirations) and on emergence (17 of 87 aspirations) of anaesthesia. pregnancy. Difficulty with the airway or intubation occurred in 58 of 87 patients experiencing aspiration. Approximately 50% of patients had no predisposing risk factors for aspiration. most commonly in the upper lobes and posterior areas of the lower lobes.5 Radiographic changes may be visible within a few hours and show improvement over the next 48 –72 hours. Most reports are based on retrospective observational studies of perioperative databases. Likewise. emergency procedures. while that for elective procedures was 1 in 3886 (2. 35. comorbid illness. giving a rate of 1 per 7337.

and the laryngeal mask may not have been in widespread use in the USA. In the ASA Closed Claims Project Database aspiration was either the primary or the secondary mechanism of injury in 158 claims (of a total of 4459 claims) (Table 2). Kirsch Table 1. Aspiration occurred during induction in 67/158 (42%) of the cases and 17/67 had cricoid pressure applied. regurgitation or aspiration resulted in death. Obstetric-related aspiration occurred in 33/157 (21%). but then remained about the same in the 1990s as in the 1980s. There were no claims in which a laryngeal mask was involved. The top 10 predisposing factors for aspiration.722 C. Care was deemed appropriate in 9/17 claims. Factors associated with aspiration-related claims. Results were similar in other large non-randomized studies in adult13 – 15 and paediatric16 patients.17 1 2 3 4 5 6 7 8 9 1 Emergency Inadequate anaesthesia Abdominal pathology Obesity Opioid medication Neurological deficit Lithotomy Difficult intubation/airway Reflux Hiatus hernia Aspiration n ¼ 133: 21 18 17 15 13 10 8 8 7 6 experience.18 Associated factors in 158 aspiration-related claims Phase of anaesthesia Induction Maintenance Emergence/PACU Obstetrical-related Difficult intubation Cricoid pressure History of reflux n ¼ 158 67 28 17 33 20 17 4 % 42 18 11 21 13 11 3 . and aspiration occurred in some patients despite properly applied cricoid pressure. In the Australian Anaesthethetic Incident Monitoring Study (AIMS: an anonymous self-reporting database) Kluger et al found that five of 244 reported incidents of vomiting. Table 2. The percentage of aspiration-related claims for severe outcomes (death or brain damage) decreased from the 1970s to the 1980s.18There were 11/158 (7%) claims for aspiration during regional anaesthesia or sedation. P. However. Kalinowski and J. H.17 Factors that increased the incidence of aspiration are similar to those observed in the American experience (Table 1). R. anaesthesia and surgical provider were not independent risk factors. the latest claim was in 1994.

This suggests that strategies for aspiration prophylaxis in the obstetric patient were having clinical effects in the 1980s.25 GASTRIC EMPTYING Gastric emptying of liquids is controlled by the proximal part of the stomach.Prophylaxis and treatment for aspiration 723 and there was a notable downward trend over time.20 This goal appears to be commonly achieved using traditional fasting guidelines in patients. extremes of age. Several anaesthesia societies suggest shorter fasting times with regards to liquids in fit healthy patients. gastric contents may also have elements of bile which. up to 45% of medications may be inadvertently omitted preoperatively with traditional fasting practices.22 Over the past decade. gastrointestinal and abdominal procedures.21 However. In addition. The rational was to minimize gastric volume.23 Preoperative fasting may cause a dry mouth.24 In addition.19 The goal of having a gastric volume of less than 25 ml was extrapolated from animal studies which assumed that the entire gastric content would be aspirated under the least ideal conditions. although not adding to the acidity. unless there is concurrent . may cause worse lung injury than that observed with acid aspiration. thirst and increased risk of postoperative nausea and vomiting (PONV) and hypovolaemia. impaired consciousness. one must remember that gastric pH is also an important determinant of lung injury following aspiration. obesity and lithotomy position † the phase of anaesthesia at which aspiration occurs most frequently is on induction and laryngoscopy Research agenda † elucidate the baseline level of reflux and regurgitation in the normal population † assessment and clarification of risk factors in gastric aspiration PREOPERATIVE FASTING The routine request to fast patients prior to surgery has evolved with time to emptying the stomach prior to induction of anaesthesia without differentiating between solids and liquids. Practice points † aspiration incidence is between 1 per 2000 –3000 adult anaesthetics and 1 per 2600 paediatric anaesthetics † aspiration incidence is between 1 per 600– 800 adult emergency anaesthetics and 1 per 400 emergency paediatric anaesthetics † aspiration incidence is between 1 per 430– 900 for caesarean section and 1 per 6000 for vaginal assisted anaesthesia † aspiration incidence for regional anaesthesia appears to be less than 1 per 30 000 † associated factors for aspiration included after-hours procedures. It is directly related to the gastroduodenal pressure gradient. acidity and particles so as to minimize the effects of aspiration pneumonitis. the rationale for traditional fasting practices has been re-examined.

28 Clear fluids are water. In addition. R.724 C. initial emptying is delayed and then follows a non-linear function. At least 4 hours is necessary for emptying of particles from the stomach after a light meal (e.36 However. Kalinowski and J. P.34 Several studies have demonstrated that carbohydrate-enriched water empties from the stomach at approximately the same rate as non-fortified water.75 hours for glucose. Patients who are allowed the luxury of drinking these fluids until 2 hours before surgery are less hungry and have less anxiety than patients exposed to a traditional preoperative fast. Gastric emptying times of human breast milk and low-fat milk was 2. fat-free and protein-free liquids. there is some evidence that patients allowed a preoperative carbohydrate-containing beverage may have a reduced length of hospital stay. fasted animals have less reserve to cope with the stress of hypovolaemia and endotoxaemia.19 Much less controversy exists regarding the appropriateness of providing patients with solid food before surgery. displayed improved muscle strength and demonstrated less bacterial translocation compared to animals in the fasted state. carbonated drinks. Milk has gastric emptying characteristics similar to those of solids because of the casein it contains. H.5%.28 Healthy children drinking unrestricted amounts of fluid volumes up to 2 hours preoperatively had no difference in gastric volumes or pH as compared to those limited to 10 ml/kg.g. Larger non-digestible particles ( . If the intragastric pressure is caloric.26 Gastric fluid volumes are variable at the time of induction in fasting healthy children. Kirsch pyloric pathology or surgical disruption. a large heavy meal can take more than 9 hours to empty from the stomach. 285 mosmols/kg) before colorectal and hip replacement surgery. In animal studies. pulp-free fruit juice.30 The result concurs with a study of 179 healthy adults between 18 and 70 years of age.27 The oral intake of clear fluids does not increase gastric fluid volumes or acidity. and reflects the time to reduce food particle size.75 hours compared with 1. 1 mm in size) are emptied during fasting.29 Residual gastric volumes in 152 healthy adolescents allowed unrestricted fluid for up to 3 hours preoperatively did not differ from those who were fasted for a longer period of time.31 Formula and milk substitutes have different gastric emptying times depending on their fat and protein composition. Patients treated with a high-dose glucose infusion (5 mg/kg/min) overnight had a dramatic reduction in postoperative insulin resistance as compared with patients fasted overnight after upper abdominal surgery.32 Fed animals responded to trauma with a lower concentration of endocrine markers of stress. slice of toast with jam. Gastric emptying depends upon the amount and nature of the food ingested. clear tea and black coffee. the rate decreasing as intragastric pressure and volume decrease. a glass of pulp-free orange juice and black coffee). The migrating motor complex begins in the proximal part of the stomach after the digestible contents are emptied and migrates distally through the small intestine.37 . and it took 4 hours for 10 polyvinyl capsules (indigestible particles) to empty from the stomach.35 In addition. The half-life of gastric emptying in 50 subjects was 59 minutes for two eggs (digestible particles). fed animals metabolized glucose in a more anabolic way. Most importantly. Non-caloric liquids empty in a mono-exponential function.33 Similar effects have been demonstrated in patients provided with a carbohydrate drink (12. there have been no complications reported in more than 600 patients in several studies following the consumption of a preoperative carbohydrate-enriched drink. Little work has been done to determine the potential detrimental effects of fasting. The lag period occurs between ingestion of food and duodenal activity. acidic or non-isotonic.

49 With a reduced function in protective airway reflexes. probably secondary to diabetic autonomic neuropathy and not HbA1c.39 In addition.51 Consistent with this hypothesis. In addition. passive regurgitation in patients with an impaired level of consciousness may frequently result in pulmonary aspiration.50 Kollef et al has attributed a higher rate of ventilator-associated pneumonia in patients requiring transportation out of the ICU to the practice of transporting patients in the supine position. pulmonary aspiration is commonly observed in patients with impaired consciousness who were left in the supine position. gender.43 Renal failure delays gastric emptying in both haemodialysed and continuous ambulatory peritoneal dialysis patients. body mass index or presence of dyspepsia.44 Likewise. gastrointestinal symptoms do not correlate with gastric emptying function. Orozco-Levi et al demonstrated that a semi-recumbent position reduces the chance of pulmonary aspiration of gastric contents in patients with nasogastric tubes.55 H2-receptor antagonists bind competitively to receptors on the basal parietal cell membrane. preprandial blood glucose or age. However. When administered 90– 120 minutes before surgery. In addition.56 but there have been no randomized trials in patients that prove their efficacy in decreasing frequency of pulmonary aspiration in high-risk patients. Indeed. However. presence of peritoneal dialysis fluid in the abdomen45 or the need for haemodialysis46 did not independently effect gastric emptying time. pregnancy has hormonal effects that impair the function of the gastro-oesophogeal sphincter. However. there is no question that gastric emptying is significantly impaired during labour. A reduced level of consciousness interferes with protective upper airway reflexes47 and is also associated with impaired function of the lower oesophageal sphincter48 and delayed gastric emptying. gastric emptying is further delayed in patients who are both diabetic and have chronic renal failure.41. 3.54 Sucralfate binds bile and gastric acid and is effective in reducing the incidence of gastric stress bleeding in at-risk patients.53 Non-particulate buffered salts of citric acid (Bicitra.52 Pharmacotherapy Both the degree of acidity and the presence of particulate matter in gastric fluid have a significant impact on the severity of lung injury following pulmonary aspiration. For example. the gravid uterus may cause physical impairment of gastric emptying and significant changes in the position of the gastro-oesophogeal sphincter in the chest.42 Gastric emptying of liquids and solids is delayed in 40– 50% of both Type I and Type II diabetic patients. recent literature supports the hypothesis that subacute tolerance (in patients on these medications for several days) can develop to H2-receptor . in patients with renal failure there was no independent effect on gastric emptying due to age. aspiration of sucralfate will produce acute pneumonitis and pulmonary haemorrhage.38 Nonetheless. these agents reduce gastric volume and increase pH. epidural opiates during labour have been shown to delay gastric emptying. Shohl’s solution) increase gastric pH . However.40 Type I diabetes is associated with reduced gastric emptying.8 for at least 7 hours compared with sodium citrate.Prophylaxis and treatment for aspiration 725 Conditions causing reduced gastric emptying There are several different conditions in our patients that may have a significant impact on gastric emptying times. In addition. one study demonstrated that after 6 hours of fasting there was no difference in the rate of gastric emptying in the nonpregnant control group and any of the three-trimester pregnancy groups.

60 The prokinetic agents improve gastric emptying in the presence of diabetic gastroparesis but do not normalize gastric emptying. In fact. Kalinowski and J. R. prucalopride and mosapride are 5HT4 receptor agonists. all of which increase gut peristalsis.62 Practice points † fasting time for clear fluids is 2 hours. They decrease acidity of gastric contents and are not known to be associated with tolerance. breast milk 4 hours. Metoclopramide has greatest antagonistic affinity for dopamine-2 (DA2) and serotonin-2 (5HT2) receptor subtypes. H. PPIs are most effective in two successive doses. Studies to determine the preoperative efficacy of the PPIs have been conducted in subjects who were not at high risk of aspiration. The prokinetic properties of metoclopramide are limited to the proximal part of the gut. Kirsch antagonists. a light meal and formula milk 6 hours and a heavy meal up to 9 hours † a preoperative isotonic carbohydrate-enriched drink attenuates the postoperative catabolic response † acid aspiration prophylaxis should be considered in at-risk patients † proton pump inhibitors may be necessary in those patients taking H2-receptor antagonists . they are quite effective in patients who have already developed tolerance to the H2-receptor antagonists.57 Prokinetic drugs. Proton pump inhibitors (PPIs) bind to the cysteine residue of Hþ/Kþ ATPase pump on the gastric luminal surface. decreasing their effectiveness at the time when patient may be at greatest risk for pulmonary aspiration.59 There are numerous studies demonstrating reduction of gastric volume and acidity after the administration of antacids. gastric and small bowel activity.58 Cisapride. may decrease the risk of aspiration by decreasing the volume of gastric contents. Extrapyrimidal side-effects are mediated via the DA1 receptor.726 C. a-2 and 5HT3 antagonist and 5HT1 and 5 HT4 partial agonist.8 However. increasing gastric motility.59 Enteral naloxone administered to ventilated ICU patients may improve oesophageal tone and reduce reflux. Cisapride has been withdrawn from general use due to episodes of prolonged QT syndrome caused by blockade of voltage-dependent potassium channels. H2-receptor blockers. they have not demonstrated a reduced frequency of aspiration or intensity of pulmonary injury in high-risk patients taking PPIs. Prucalopride is a potent prokinetic agent of the upper and lower gut. The drug has no effect on electrocardiac parameters and has not been reported to be dysrhythmogenic. tegaserod. The antibiotics erythromycin and clarithromycin stimulate the motilin receptor. The anti-emetic effects have been attributed to 5HT3 antagonism and prokinetic effects to 5HT4 agonism. Tegaserod has prominent prokinetic effects in increasing oesophageal clearance and accelerating gastric emptying.61 Tolerance to H2-receptor antagonists may occur and use of a proton pump inhibitor should be considered in those patients taking certain H2-receptor antagonists. The prokinetic effects are blocked with atropine (10 mg/kg) and reduced gastric emptying in the presence of opiates due to increase gastrointestinal wall tone. The routine administration of these drugs has not been recommended by the ASA. there is little to suggest improved outcome after aspiration in patients who have been treated with these medications. P. the most common of which is metoclopramide. Although these data demonstrate efficacy of PPIs in lowering gastric volume and increasing pH. stimulating oesophageal. PPIs and prokinetic drugs. but is also a DA1.

particulate and microbiological composition of the aspirate. Immediate airway obstruction causing asphyxia will lead to death.66 Bile aspiration with pH 7. could result in complete airway obstruction or obstruction of a large bronchus. There is loss of ciliated and non-ciliated cells within 6 hours. PPIs. The effects of the acid are evident within 5 seconds of contact and are noted from the trachea to the alveoli. or of an unexpected foreign body previously swallowed by the patient. B2 integrins and ICAM-1). subsequently Raidoo et al found that the LD50 (50% lethal dose: the dose at which 50% of the subjects die) for pulmonary aspiration was 1 ml/kg of gastric fluid. H2-receptor antagonists. There is upregulation of cell adhesion molecules (including E-. 2.63 Aspiration of 0.68 Nursing home and hospitalized patients are more likely to have respiratory tract pathogens.22 Although rare.6 ml/kg at pH 1 produced mild to moderate clinical signs and radiological changes in the rhesus monkey. prokinetics) decreases the frequency of aspiration and intensity of damage during anaesthesia in high-risk patients PATHOPHYSIOLOGY OF ASPIRATION The effects of aspiration pneumonitis may be attributed to the acid.24 in the porcine model. Endotracheal intubation is required in an attempt to prevent further contamination. 2.4 –0.4 ml/kg and pH . it is possible that aspiration of large particles from the stomach. adjusted to a pH of 1. Anaerobes were recovered in 62 –100% of patients with aspiration pneumonia.64 There is a release of pro-inflammatory cytokines such as TNF-a and interleukin-8 inducing neutrophil recruitment. and regeneration is evident after 3 days and complete in 7 days.g. P-selectins.Prophylaxis and treatment for aspiration 727 Research agenda † further research to optimize the preoperative metabolic state of the patient in order to minimize the postoperative catabolic effects † further research on drugs to improve gastric emptying † develop means to reduce gastric bile content † determine whether administration of pharmacotherapy (e. which cause increased thromboxane and oxygen radical release. This was extrapolated to humans.67 Aspiration pneumonias are generally polymicrobial. tracheal intubation facilitates bronchoscopy and removal of particulate matter. forceps and suction.5 on the basis of fluid directly instilled into the lung of the rhesus monkey.5 have since remained in medical literature.69 Hospitalized patients are . L-.19 produced worse physiological and histological changes than gastric acid pH 2. Oxygenation and ventilation must be initiated immediately to prevent further hypoxia.20 However. and the figures of 25 ml with pH . Aspiration of either fresh or salt water in near-drowning victims also produces an inflammatory picture similar to acid aspiration.65 The effects of osmolality and chemical composition need further evaluation. The effects of acid aspiration have both an immediate and a delayed onset. Roberts and Shirely (from unpublished work) arbitrarily defined the critical volume of 0. Aspirated particles need immediate removal with direct laryngoscopy. chemical. Although there are no definitive data regarding improved outcome after aspiration with long-term intubation in intensive care patients. but no deaths.

Kirsch commonly on gastric acid suppressants and are enterally fed. P. regurgitation and vomiting. and in premedicated as compared to non-premedicated patients. resulting in coughing. Klebsiella species and Escherichia coli are the most common gram-negative bacteria and Staphylococcus aureus the predominant gram-positive organism in nosocomial aspiration pneumonia. regardless of position. 25 ml.70 INDUCTION OF ANAESTHESIA AND INTUBATION OF THE TRACHEA Several studies indicate that a significant number of aspiration events occur during induction of anaesthesia and laryngoscopy.728 C.10 – 17 Placement of a cuffed endotracheal tube is currently the best method for isolating the airway from the gastrointestinal tract. which often results in colonization of the stomach by gram-negative bacteria. Presumed increased intra-abdominal pressure. However. Harter et al demonstrated that high volume. H.72 Once successful intubation of the trachea has occurred. 2. R. Hazards of a rapid sequence induction include inadequate depth of anaesthesia and inadequate muscle relaxation during laryngoscopy.71 Few studies have demonstrated the optimum position of the patient to reduce aspiration risk during induction of anaesthesia or during laryngoscopy. delayed gastric emptying and gastro-oesophageal reflux disease increases the risk of aspiration pneumonitis in the obese patient. in describing application of cricoid pressure. Sellick. For example. However. Kalinowski and J. pulmonary aspiration appears to be less frequent in patients placed in a 458 head-elevated position. coughing may be due to intermittent episodes of aspiration. high residual gastric volume. Ovassapian reviewed 129 awake oral and nasal fibre-optic intubations in 123 patients considered to be at high risk of aspiration of gastric contents and found no evidence of aspiration in any of his patients.68 Pseudomonas aeruginosa.74 Recent studies have questioned the validity of this dogma. suggests that the patient lie supine with a slight head-down tilt to assist gravitational drainage of gastric contents away from the airway should regurgitation occur. low pH (HVLP) gastric contents (.73 OBESITY Obesity appears to be a contributing factor in several studies for pulmonary aspiration of gastric contents. but cannot serve as an absolute preventive measure. low pH. there was no difference between obese and normal-size patients with regard to the resistance gradient between the stomach and gastro-oesophageal junction. In patients at risk for pulmonary aspiration.75 In addition. the endotracheal tube may be placed awake or after rapid sequence induction of anaesthesia and application of cricoid pressure.76 In patients with reflux. pH .5) were more frequent in thin. than in obese patients. particularly during sleep. These patients are also more likely to have oropharyngeal colonization with Staphylococcus aureus and gram-negative enteric bacilli. There are no well-controlled clinical trials comparing a rapid sequence induction with an awake intubation of the trachea for their ability to prevent tracheal aspiration. coughing may also be induced via an oesophageal-tracheobronchial reflex caused by distal oesophageal receptor .

cricoid pressure was suggested as a means of preventing gastric distension during ventilation of the lungs.18 Inadequate depth of anaesthesia at laryngoscopy may manifest as coughing. Vomiting can elevate intragastic pressure by 40 and 45 mmHg. when a patient begins to vomit their head should be turned to the side and consideration should be given to placing them in Trundelenberg position.77 Regardless of the exact mechanism of refluxinduced cough.85 Intragastric pressure can reach 35 mmHg with gastric distension and succinylcholine.82 There are two radiological studies demonstrating that the oesophagus lies lateral to the cricoid cartilage in 49 – 52% of children and adults. and 30 N force). respectively.86 However. Failed intubation after a rapid sequence induction requires ventilation of the lungs with cricoid pressure in situ. and then firmly applied when consciousness is lost. LARYNGOSCOPY Suboptimal conditions at laryngoscopy appear to contribute significantly to the risks of pulmonary aspiration of gastric contents.Prophylaxis and treatment for aspiration 729 stimulation by gastric contents. but does not seem to promote reflux in awake healthy individuals. application of cricoid pressure may also cause relaxation of the lower oesophageal sphincter.81. patients with this disease experience improved symptoms with antireflux therapy.79 Cricoid pressure of 44 N applied to the awake individual has been associated with laryngeal discomfort and retching.12 – 14. bucking. Induction of anaesthesia causes a reduction in lower oesophageal sphincter pressure to 7– 14 mmHg.84 Cricoid pressure should be sufficient to occlude the oesophagus and prevent aspiration without causing discomfort and occluding the airway.82 Other reports have suggested that cricoid pressure is ineffective and possibly hazardous in impeding airway patency and intubation. studies in cadavers suggest that ‘firm’ cricoid pressure is required to prevent regurgitation (oesophageal pressures of 75 mmHg. laryngospasm and vomiting. In addition. 25 mmHg prevents spontaneous regurgitation in conscious supine patients.81 There are several studies supporting the use of cricoid pressure in preventing gastric insufflation and reducing reflux in children and adults.81.87 Maintenance of cricoid pressure during active vomiting may result in severe complications related to rupture of the oesophagus.81 ENDOTRACHEAL TUBES It is important to realize that aspiration has been documented to occur perioperatively and in long-term ventilated patients in the ICU in the presence of both endotracheal .80 The use of cricoid pressure during anaesthetic induction is routine practice in patients considered at risk of aspiration of gastric contents. Facemask or laryngeal-mask-airway (LMA) ventilation may be difficult with cricoid pressure in situ.85 Paradoxically.17.81 Upper oesophageal pressure . and it should be gradually relaxed and removed if ventilation fails. Historically.83.78 Sellick suggested that it is lightly applied just prior to injection of the induction agent. These events clearly contribute to difficulty with laryngoscopy and may precipitate regurgitation and pulmonary aspiration of gastric contents.

endotracheal tubes with gills may also cause less direct injury to the trachea. as a function of whether the patient was ventilated via an endotracheal tube airway. vomiting in two patients and there was one patient who experienced aspiration of gastric contents. P.90 though use of gel may be associated with an increased risk for post-extubation pharyngitis. There was only one episode of regurgitation of gastric fluid. classic LMA or ProSeal LMA.95 Surgeons. there were only five cases of regurgitation. Intensity of gastric distention was compared in 209 patients (37 obese) undergoing laparoscopic gynaecological surgery under general anaesthesia. In comparison to cuffed endotracheal tubes. and there were no long-term sequelae. Only one patient regurgitated during surgery. H. a survey of 11 910 patients (no obstetric service) anaesthetized using an LMA for a variety of laparoscopic and intra-abdominal cases. Verghes prospectively audited 2359 patients undergoing anaesthesia with use of the LMA. For example. their use does not appear to increase the frequency of vomiting or pulmonary aspiration. high-volume low-pressure cuffs may have longitudinal folds that allow methylene blue to leak beyond the seal of the cuff. For example.94 and found that of the 41% patients of who underwent positive pressure ventilation.92 demonstrated that regurgitation occurred in four patients. More recently an endotracheal tube that uses ‘gills’ as a barrier. Kalinowski and J. blinded to treatment groups. Kirsch and tracheostomy tubes. were unable to discern differences in gastric distension.89 In addition. In a meta-analysis. Practice points † adequate depth of anaesthesia and paralysis should be attained before attempting laryngoscopy † a head-down position on regurgitation should divert gastric contents away from the larynx † head-up 308 position reduces gastric aspiration in ventilated ICU patients † double-handed cricoid pressure displaces the oesophagus laterally and impairs laryngoscopy and ventilation † gel lubrication of the endotracheal tube reduces peri-cuff aspiration . has been demonstrated to have excellent efficacy in preventing aspiration.88 Continuous subglottic aspiration of secretions has been demonstrated to delay and prevent onset of ventilator-associated pneumonia. R.730 C. rather than an inflatable cuff. there is some evidence that applying gel lubrication to tracheal tubes results in delayed aspiration.91 THE LMA Although the LMA and other supraglottic devices do not isolate the larynx from the gastrointestinal tract. three of which occurred in the recovery room after LMA removal.93 Likewise. incidence of aspiration with use of the LMA was two of 10 000 patients. which was observed in the drain tube of the ProSeal LMA group immediately before deflation of the pneumoperitoneum.

and securing the airway with an endotracheal tube (Table 3). cyanosis and tachycardia. sterility. intermittent positive pressure ventilation. Hypoxaemia may be relatively resistant to treatment with positive endexpiratory pressure (PEEP). . pH. Progressive fibroproliferation with increased interstitial collagenase activity results in deposition of inelastic Type I/III collagen. virulence of organisms and host response. indicating repair of pulmonary endothelial and epithelial cells. continuous positive airway pressure. Hypoxaemia and fluffy radiological infiltrates are associated with interstitial neutrophil aggregation. initially characterized by mild symptoms of respiratory distress associated with neutrophil sequestration. Chemical pneumonitis has two phases. The second phase involves development of acute lung injury (ALI) which may lead to frank respiratory distress syndrome. The work of breathing increases and worsening hypoxaemia necessitates ventilatory support.68 There is no evidence to suggest that any particular order of events is superior in managing the consequences of aspiration. Within minutes of pulmonary aspiration there is exudation of fluid that neutralizes the aspirate.Prophylaxis and treatment for aspiration 731 Research agenda † optimum patient position for a rapid sequence induction † evaluate the efficacy of cricoid pressure in a rapid sequence induction in preventing regurgitation † comparison of a rapid sequence induction and awake fibre-optic intubation in patients at high risk of gastric aspiration † evaluation of succinylcholine and rocuronium on the incidence of aspiration with a rapid sequence induction MANAGEMENT OF PULMONARY ASPIRATION The primary determinants in outcome following pulmonary aspiration of gastric contents include the volume. CPAP. There are four clinical phases. clearing the airway of debris with suctioning and Magill forceps. Aspiration often initially presents with bronchospasm. Once the endotracheal tube is Table 3. particulate nature. Initial management and adjunctive management after aspiration.17 Treatment modality Number of patients receiving therapy 30 3 20 21 10 5 8 IPPV CPAP Bronchodilators Antibiotics Steroids Inotropes Bronchoscopy IPPV. maintenance of cricoid pressure if feasible. Suggested initial management of aspiration during anaesthesia involves positioning the patient head-down.

When deciding whether to treat patients who have aspirated with antibiotics. Of the 18 patients who were same-day surgery patients.67 Approximately 50% of patients who had received a single dose of antibiotics before microbiological sampling had Pseudomonas aeruginosa.e. 10%. Oxygen supplementation and bronchodilator therapy should be initiated depending on clinical assessment. sputum production and return of normal physiological function indicate resolution of . Warner et al retrospectively reviewed the outcome in 66 patients who had aspirated. Staphylococcus aureus and gram-negative bacilli as causative agents for pneumonia. the decision to proceed with surgery is a clinical decision between the surgeon and anaesthetist and should take into consideration the underlying health of the patient. need for ICU monitoring) depends upon the clinical manifestation within the first 2 hours of pulmonary aspiration. it is crucial to make the differential diagnosis of pneumonitis from pneumonia.97 Over a period of one week. 16% anaerobic bacteria and 12% Staphylococcus aureus. often in association with anaerobic organisms. Kirsch in place. Kalinowski and J. Acinetobacter species. the patient should receive aggressive suctioning of the tracheobronchial tree before (if possible) using 100% O2 and allowing spontaneous or mechanical ventilation.96 Streptococcus pneumoniae and Haemophilus influenzae predominate in community-acquired pneumonia and enteric gram-negative bacilli in patients with gastrointestinal disorders who aspirated. Antibiotic administration before onset of pneumonia has been linked to an increased frequency of ventilator-associated pneumonia (VAP) caused by virulent organisms such as Pseudomonas aeruginosa and Acinobacter species. Eighteen of 24 patients with post-aspiration respiratory symptoms (e.732 C. leukocytosis. a drop in SpO2 of . the difficulties in establishing the diagnosis of pneumonia often results in empirical antibiotic administration. Gram-negative bacilli were the most common cause of pneumonia. Oral flora changes in the institutionalized elderly is attributable to poor oral hygiene promoting colonization with anaerobic and aerobic Gram-negative organisms.12 Forty-two of 66 patients were asymptomatic at 2 hours post-aspiration and required no postoperative respiratory intervention. H. There are no prospective studies guiding optimal duration of antibiotic treatment in patients with aspiration pneumonia. 12 were discharged home without problem. Bronchial sampling in cases of severe aspiration pneumonia in this population typically reveals 49% gram-negative bacilli. extent of aspiration and urgency of the procedure. Antibiotics Controlled studies examining outcome for empirical antibiotic treatment of aspiration are lacking. Haemophilus influenzea and Staphylococcus aureus— to antibiotic-resistant gram-negative bacteria—including Pseudomonas aeruginosa. R. Reduction in fever.67 All efforts should be made to avoid use of empirical antibiotics. radiological evidence of aspiration) within 2 hours were admitted to the intensive care unit for respiratory support.97 Unfortunately. and treatment should not be initiated until there is a clear diagnosis of pneumonia. Postoperative disposition (i. Enterobacter species and methicillin-resitant Staphylococcus aureus.67 After making the diagnosis of aspiration.g. Three of the six patients who required mechanical ventilation for more than 24 hours and who developed respiratory distress syndrome died. wheezing.8 Bronchoscopy may be useful to check for residual debris and remove larger aspirated particles. The microbiology of aspiration pneumonia depends upon the patient population. ventilated patients have a shift from normal flora— including Streptococcus pneumoniae. P.

persistent lung abscess or empyema. intermittent positive pressure ventilation (IPPV). Antibiotic resistance generally results in rapid deterioration of the patient. continuous positive airway pressure (CPAP). . 6 hours for a light meal and up to 9 hours for larger meals. cavitation and malnutrition. biphasic positive airway pressure (BIPAP). The optimum patient position on rapid sequence induction is unknown. although the 308 head-up position prolongs the period of adequate oxygen saturation in apnoeic.98 Practice points † † † † † † † head-down position to limit amount of pulmonary contamination clear airway of particles and fluid with forceps and suction oxygenate. multilobar involvement. treatment for 14 days or more is often required to be effective. and ventilator management in the ICU † long-term medical follow-up is suggested to exclude other respiratory diseases affecting outcome Research agenda † assess the effects of aspirated bile and osmolality on the lung † development of intratracheal medications to neutralize the effects of gastric aspiration † evidenced-based management protocol of gastric aspiration SUMMARY The aspiration rate is highest in high ASA emergency cases. necrotizing pneumonitis. ventilate and secure airway with endotracheal tube bronchoscope as necessary bronchodilators used as required antibiotics and steroids should not be routinely used unless clinically indicated day-of-surgery patients may be discharged if asymptomatic 2 hours postaspiration with follow-up medical care † patients ventilated for more than 48 hours post-aspiration have a 50% mortality rate † respiratory support includes supplementary oxygen on the ward.Prophylaxis and treatment for aspiration 733 pneumonia. Gastric contents contain bile which damages the lungs more than acid. A single low-risk pathogen may require treatment for 7 –10 days. The preoperative intake of a carbohydrate-enriched drink has been shown to have potential benefits in reducing postoperative insulin resistance and the catabolic response to surgery. 4 hours for breast milk. and should be limited to those patients at increased risk for aspiration. Treatment failure is usually due to incorrect empirical therapy. Antacids and prokinetic drugs have not been shown to improve outcome after aspiration. abdominal surgery. Fasting times are 2 hours for clear fluids. the obese and consciousness-impaired. In the presence of antibiotic-resistant organisms.

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