Aspiration Pneumonia

Dr. Abdul Rohman, SpPDr. Abdul Rohman, SpP

K-B

Definition Aspiration Pneumonia: refers to an

infectious process of the lung parenchyma due to the introduction of pathogenic organism into the lower respiratory tract.

Aspiration Pneumonitis: The

inflammatory response that occurs in the lungs following aspiration injury

Mendelson’s syndrome: the chemical injury of the lungs secondary to aspiration of gastric contents.

KEY POINTS: ASPIRATION SYNDROMES1. Aspiration pneumonitis: acute inflammation

• Early response within 1 – 2 hours• Late response 4 – 6 hours

2. Aspiration pneumonia: an infectious process

EPIDEMIOLOGY

Normal deep sleep micro aspirations : 45 %

Aspiration post-stroke: 80 % aspiration pneumonia: 40 %

Elderly patient with CAP 71 % aspiration pneumonia

Pathophysiology of Aspiration

A. Aspirated material1. Type

a.Fluids : - toxic (bile, acid, HC)- Inert (mucous , water)b.Solids : - tiny

-large balus of food

2. Volume-Small - large

3. Distribution-1 segment localized damage-All segment ARDS

4. pH-< 2,5 ( asam ) severe lung injury-Neutral or non acidic minimal

damage

Pathophysiology of Aspiration

B. Associated pathogens

1. Predominant :

Oropharyngeal flora

1 : 10

(10 million aerobes :

100 million anaerobes)

2. Distal airway & lung

parenchyma : sterile

Predisposing Factors in Aspiration Pneumonia

Disease states

1.Decreased level of consciousness

Cerebrovascular accident (stroke, hemorrhage)

Head trauma (suburdural hematoma)

Seizures

Drug overdose

Alcohol intoxication

Sepsis

Hypothermia

Malignant hyperthermia

Other causes predisposing to coma

2. CNS disorders of esophageal motility

Myasthenia gravis

Guillain-Barre’ syndrome

Multiple sclerosis

Other conditions causing problems with gag

reflex

3. Disorders of esophageal motility

Achalasia

Scleroderma

Hiatal hernia

Cardiospasm

4. Communication between trachea & esophagus

Congenital esophageal atresia with

tracheoesophageal fistula

Neoplastic communication between trachea

and esophagus

5. Disorders of gastric and intestinal motility

Gastric dilation secondary to autonomic

dysfunction

Electrolyte imbalance or recent surgery

Adynamic ileus

Intestinal obstruction

6. Miscellaneous causes

Upper gastrointestinal hemorrhageLabor and deliveryTrauma

7. Iatrogenic factors ( > 60% )

General anesthesiaCardiopulmonary resuscitationAttempting emergency intubationTracheostomyNasogastric feeding tamponadeEsophageal ballon tamponadeRecent neurosurgery

CLINICAL SETTINGS FAVORING ASPIRATION PNEUMONIA

Depresed Levels of consciousness and a

decreased cough reflect :1. Neurologic and seizure disorders,

2. Drug overdose

3. Alcoholism

4. CBA

5. General anasthesia

Iatrogenic Causes 1. Trachestomy tube

Interferes normal laryngeal movement

Secretions collect above the cuff

2. Cardiopulmonary rescucitation:

compression of the sternum intra

abdominal pressure stomach content into the

pharynx.

ETIOLOGI

1. PAK (Pneumonia Aspirasi Komuniti)Anaerob obligat ( 41 – 46 % ) (Sekitar gigi – ludah)-Peptococcus +

Klebsiella pn Bacteriodes melStaphylococ PeptostreptococFusobacterium nucleatum

2. PAN (Pneumon Aspirasi NosokomialKolonisasi Ku anaerob, Gram neg., Pseudomonas, Proteus, Serratia & Staphylococcus aureus

MANIFESTASI KLINIS

Dapat : - Bronkopneumonia - Pneumonia lobaris

- Pneumonia nekrotikans - Abses paru & Empiema

- Mendadak batuk & sesak n sesudah makan atau minum

- Awitan insidiousPdu datang 1-2 mi postaspirasi dgn :- Demam menggigil, nyeri pleuritik,

batuk, dahak purulen bau (50 %)- Nyeri perut, anoreksia, & BB turun

PEMERIKSAAN PENUNJANG

Darah : - lekositosis & LED meningkatSputum (Gram): banyak lekosit & kuman campuran X-ray : infiltrat segmen paru dependent disertai kavitas & efusi pleura Lokasi tersering lobus kanan tengah dan

atau lobus atasLain-2 : elektrolit, BUN, kreatinin, AGD &

kultur darah

DIAGNOSISA. CLINICAL PRESENTATION

determined by the nature and the quality of the aspirate

1. Massive aspiration (trauma victims seizure disorders) :

- Acute respir failure - Deep cyanosis- Marked stridor - Pulmonary edema

2.Small volumeAfter 1 - 2 hours : progressive shortness of breath, cough, wheezing, fever, tachypnea, and cyanosis.

3.Auscultation :- Rales and decrease breath sounds.

4.Arterial blood gases : - Hypoxia - Increasing alveolar-arterial PO2 gradient

- Hypotension- Decreased cardiac

output- Tachypnea- Dyspnea

B. Radiographic findings 12 – 24 hours after initial aspiration

1. a. Foreign body aspiration : • Upright position -- lower lobe • Supine - posterior segment of upper lobe

- superior segment of the lower lobe Adult : right side < 15 years : left side equal to the right side b. Gastric contents : patchy airspace consolidation,

bilateral & multi centric perihiler of basal region

2. a. Massive aspiration : diffuse bilateral infiltrates pulmonary edema

b. Sub massive aspiration Athelectasis (6 – 8 hours ) large, fluffy infiltrate

3. Uncommon : - Reticular infiltrates

- Pleural effusion - Lung abscess

C.Bacteriology

1. Lower resp. tract : Transtracheal aspiration and bronchoscopy

2. Secondary infection : anaerobic organism predominant.

3. Hospitalized acquired aspiration pneumonia : aerobic organism more commonly.

TERAPI Baring setengah duduk NGT disfagi & gangguan telan PAK – Anaerob : Penicilin/Sefalosporin G3 /Clindamisin PAN – Gram (-) + Stafilikokus aureus :

aminoglicosid + sefalosporin G3/4 atau

clindamisinLama Terapi : 2 mi Rő Th bersih atau stabil

WSD - empiema Bronkoskopi – abses paru ok sumbatan

atau bekuan mukus Bedah – abses bila respon Tx (-) & relaps

di tempat yang sama

Steroid – sebagai obat tambahan pd bronkokonstriksi reaktif

MANAGEMENTProtecting the airway and minimizing the extent of pulmonary damage.

Head down in the right lateral decubitus position.

Endotracheal suction immediately

Pulmonary lavage : 5 – 10 ml sterile saline

Hemodynamic support

Arterial blood gases : highly concentrated O2 or

mechanical ventilation

PEEP (Positive End-Expiratory Pressure)

Miscellaneous agents

- Steroids IV within 5 minutes of aspiration

- Bronchodilators bronchospasm

- Antibiotics : - Clindamycin – anaerobic infection

-Hospitalized-acquired aspiration

pneumonia – gram + ve and – ve aerobs

CLINICAL EVALUATIONBe observed for sign of clinical improvement :

o Resolution of fever, dyspnea and cough

o Decreasing WBC counts

o Resolution of lung infiltrates

o Absence of white cells on gram stain –ve sputum culture

KOMPLIKASI & PROGNOSIS

Komplikasi: - Gagal Napas Akut- Empiema

- Abses paru - Superinfeksi paru

Mortalitas : - PAK - 5 %- PAN - 20 %- Aspirasi masif dengan/tanpadisertai Sindroma Mendelson 70 %

PREVENTION

• An unconscious patients

– Foot of bed elevated tracheal pooling

aspiration less

– NG feeding + a cuffed ET

• Conscious patients

– NG feeding: head end of the bed 45° ---

regurgitation of stomach

• Patency of tube & residual gastric volume

• Constant infusion > a bolus of NG feeding

• Elective surgery – fasting of 6 – 8 hours: an empty

stomach

• Preoperative antacid of H2 – acceptor antagonists

with general anesthesia