Anesthesia Secrets:
Aspiration
Intern 張雅婷
Definition
The passage of material from the pharynx into
the trachea.
Material origin:
Mouth
Nose
Stomach
Esophagus
Aspiration
Incidence of significant aspiration:1/10,000 anesthetics.
(Children’s anesthetics: 2/10,000 anesthetics)
The average hospital stay after aspiration: 21 days, most
in intensive care unit.
Complications: bronchospasm, pneumonia, and acute
respiratory distress syndrome, lung abscess, and
empyema.
Average mortality rate is 5%.
Aspiration syndromes
Aspiration of gastric acid causes a chemical
pneumonitis which has also been called
Mendelson syndrome.
Aspiration of bacteria from oral and pharyngeal
areas causes aspiration pneumonia.
Aspiration of oil (eg. mineral oil or vegetable oil)
causes exogenous lipoid pneumonia, an unusual
form of pneumonia.
Aspiration of a foreign body may cause an acute
respiratory emergency.
Aspiration pneumonitis describes the initial
inflammatory response after aspiration.
Aspiration pneumonia describes the
consolidation along with the inflammation.
Risk factors
Extremes of age
Type of surgery(most common in cases of esophageal, upper
abdominal, or emergency laparotomy surgery)
Inappropriate recent meal
Delayed gastric emptying and/or decreased lower
esophageal sphincter tone (diabetes, gastric outlet
obstruction, hiatal hernia)
Medications (e.g., narcotics, anticholinergics)
Trauma
Risk factors
Pregnancy
Pain and stress
Depressed level of consciousness
Morbid obesity
Difficult airway
Neuromuscular disease (impaired ability to protect the
trachea)
Esophageal disease (e.g., scleroderma, achalasia,
diverticulum, Zenker diverticulum)
Precautions
Empty stomach before anesthetic induction:
1. Adequate fasting period.
2. Gastrokinetic medications such as metoclopramide have
been thought to be of benefit because they enhance
gastric emptying, but no good data support this belief.
Increase gastric pH:
1. Nonparticulate antacids: sodium citrate and histamine-2 (H2)
receptor antagonists, either of which decreases acid
production.
2. H2 antagonists: cimetidine, ranitidine, and famotidine.
3. To be effective at induction, H2 blockers must be
administered 2 to 3 hours before the procedure.
4. The use of proton pump inhibitors in place of, or in concert
with, H2 antagonists has not proven to be more efficacious.
H2 blocker
1. Cimetidine has significant side-effect: hypotension, heart
block, central nervous system dysfunction, decreased hepatic
blood flow, and significant retardation of the metabolism of
many drugs.
2. Ranitidine: a newer H2 antagonist, is much less likely to cause
side effects. Only a few cases of central nervous system
dysfunction and heart block have been reported.
3. Famotidine is equally as potent as cimetidine and ranitidine
and has no significant side effects.
Management of difficult
airway pt. and those at high
risk of aspiration
regional anesthetic
rapid sequence induction with cricoid pressure is preferred
when a general anesthetic is needed.
Patients with difficult airways may require awake
placement of an endotracheal tube to allow protection of
the airway from aspiration.
Patient comfort is aided by the judicious use of sedation
and topical local anesthetic. Oversedation and
topicalization of the airway may make the patient less able
to protect the airway.
Endotracheal intubation does not guarantee that no
aspiration will occur. Material may still slip past a deflated or
partially deflated cuff.
Rapid sequence induction
RSI is the preferred method of endotracheal tube intubation in
the emergency department.
Results in rapid unconsciousness (induction) and
neuromuscular blockade (paralysis).
This is important in patients who have not fasted and because
of this are at much greater risk for vomiting and aspiration.
The goal of RSI is to intubate the trachea without having to use
bag-valve-mask ventilation.
Acidic aspirates
pH less than 2.5 and volumes of more than 0.4 ml/kg
Alveolar-capillary breakdown, resulting in interstitial edema,
intraalveolar hemorrhage, atelectasis, and increased airway
resistance.
Hypoxia is common. Although such changes usually start
within minutes of the initiating event, they may worsen over
a period of hours.
The first phase of the response is direct reaction of the lung
to acid— hence the name chemical pneumonitis. The
second phase, which occurs hours later, is caused by a
leukocyte or inflammatory response to the original damage
and may lead to respiratory failure.
Aspiration of nonacidic fluid
Destroys surfactant, causing alveolar collapse and
atelectasis.
Hypoxia is common.
The destruction of lung architecture and the late
inflammatory response are not as great as in acid
aspiration.
Aspiration of particulate
food matter
Aspiration of particulate food matter causes both physical
obstruction of the airway and a later inflammatory response.
Alternating areas of atelectasis and hyperexpansion may
occur.
Patients may have hypoxia and hypercapnia caused by
physical obstruction of airflow.
If acid is mixed with the particulate matter, damage is often
greater and the clinical picture worse.
clinical signs and symptoms
after aspiration
Fever occurs in over 90% of aspiration cases, with tachypnea
and rales in at least 70%.
Cough, cyanosis, and wheezing occur in 30% to 40% of cases.
Aspiration may occur silently—without the anesthesiologist’s
knowledge—during anesthesia.
Radiographic changes may take hours to occur and may be
negative, especially if radiographic images are taken soon
after an event.
The patient who shows none of the previously mentioned signs
or symptoms and has no increased oxygen requirement at the
end of 2 hours should recover completely.
Treatment-
mostly supportive care
Chest radiograph and hours of observation.
Immediate suctioning
Supplemental oxygen and ventilatory support should be
initiated if respiratory failure is a problem.
Patients with respiratory failure often demonstrate atelectasis
with alveolar collapse and may respond to positive end-
expiratory pressure.
Patients with particulate aspirate may need bronchoscopy to
remove large obstructing pieces.
Antibiotics should not be administered unless there is a high
likelihood that gram-negative or anaerobic organisms have
been aspirated.
Corticosteroids have not been shown to be helpful in human
studies.
Lavaging the trachea with normal saline or sodium
bicarbonate after aspiration has not been shown to be helpful
and may actually worsen the patient’s status.
More aggressive treatments of severe aspiration usually occur
in the critical care setting. Surfactant installation, high-
frequency oscillatory ventilation, and prone positioning have
all shown some promise for certain patients with severe
aspirations.
