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

719737, 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 difcult to dene because of its relatively low occurrence and difculty in diagnosis. The gastric volume predisposing to aspiration is larger than 30 ml. Fasting times for uids 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 bre-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 uids; chemoprophylaxis; cricoid pressure; rapid sequence induction; bre-optic intubation.

The rst 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 reux and regurgitation do not detect aspiration, as not all episodes of reux 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.: 1-503-494-7641; Fax: 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.

720 C. P. H. Kalinowski and J. R. Kirsch

often limited by the heterogeneity of patient populations and anaesthetic technique, so it may be difcult to evaluate the impact of a particular intervention on outcome.3 The single most important means of treating aspiration of gastric contents is in its prevention. 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. Preoperative assessment and identication of patients at risk for aspiration allows the anaesthetist to institute preoperative fasting, medication administration and appropriate anaesthetic techniques to minimize the risk of pulmonary aspiration. The treatment of pulmonary aspiration is primarily supportive, and may range from observation, respiratory support and physiotherapy to management of septic shock and severe lung injury.

DEFINITIONS The North American Summit on aspiration in critically ill patients has dened the vocabulary to standardize the terms related to aspiration conditions4: reux: 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, choking, shortness of breath or respiratory distress aspiration pneumonitis: a non-infectious acute inammatory reaction to aspirated material characterized by an inltration on chest radiograph aspiration pneumonia: a parenchymal inammatory reaction to aspirated material mediated by an infectious agent, characterized by an inltrate on chest radiograph. Aspiration may be a witnessed regurgitation/aspiration event at the bedside accompanied by choking/coughing and expectoration of material. Upon examination, the anaesthetists may observe foreign material in the larynx below the true vocal cords. Aspiration may also be diagnosed by radiographically demonstrating contrast material in the lungs that was previously administered by mouth or radioisotope by scintigraphy. Aspiration may cause acute lung injury, which is characterized by increased alveolarcapillary membrane permeability associated with a constellation of clinical, radiological and physiological ndings that are not the result of left atrial or pulmonary capillary hypertension. Acute lung injury is characterized by impaired arterial oxygenation with a PaO2/FiO2 ratio , 300irrespective of the level of positive end expiratory pressure (PEEP)and no evidence of left atrial hypertension. In extreme situations acute lung injury may progress to adult respiratory distress syndrome (ARDS). With ARDS there is worsening arterial hypoxia, characterized by a PaO2/FiO2 ratio , 200 (regardless of PEEP), bilateral inltrates on chest radiograph and no evidence of left atrial hypertension.

Prophylaxis and treatment for aspiration 721

CLINICAL SEQUELAE OF PULMONARY ASPIRATION Mendelson described two syndromes involving the aspiration of gastric contents.2 The rst, an obstructive picture, results from aspiration of solid gastric material; the symptoms and signs include cyanosis, wheezing, coughing, tachypnoea, hypotension and evidence of mediastinal shift and consolidation. Classically, Mendelsons syndrome results from acid aspiration and presents with bronchospasm, tachypnoea, wheezing, cyanosis and fever. Radiographic observation of a right middle lobe inltrate is consistent with aspiration pneumonia. Chest radiographic ndings in paediatric cases of silent aspiration may be normal in 14% and have diffuse severe involvement in 68%, 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.6 The measurement of glucose content in tracheal aspirates in tube-fed patients correlates with serum glucose concentrations rather than with evidence of aspiration.7 Invasive techniques to conrm pulmonary aspiration include bre-optic bronchoscopy, broncheoalveolar lavage, percutaneous needle biopsy and open lung biopsy.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.9 The true incidence of perioperative aspiration pneumonitis is difcult to determine. Most reports are based on retrospective observational studies of perioperative databases, without consistent denitions of aspiration, failure to detect aspiration outside of the operating room and inaccurate documentation. For example, Tiret et al reported 27 aspirations occurring on induction or during maintenance and recovery from anaesthesia, giving a rate of 1 per 7337.10 There were four deaths (mortality rate of 1 in 49 525). Likewise, 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 46 340.11 In this analysis risk factors included extremes of age, emergency procedures, time of day (18:00 06:00 hours, sixfold higher than during the day), caesarean section, upper gastrointestinal tract procedures and obesity. Pulmonary aspiration is much more common in patients under general anaesthesia as compared to neuraxial or regional anaesthesia. Although regurgitation and aspiration are most common during induction of anaesthesia (41 of 87 aspirations), they also occur during maintenance (10 of 87 aspirations) and on emergence (17 of 87 aspirations) of anaesthesia. Difculty with the airway or intubation occurred in 58 of 87 patients experiencing aspiration. Warner et al reviewed 172 334 adult patients who underwent 215 488 general anaesthetics in all specialties between 1985 and 1991.12 There were 67 aspirations with a rate of 1 in 3216 anaesthetics and three deaths (mortality rate of 1 in 71 829). Approximately 50% of patients had no predisposing risk factors for aspiration. The aspiration rate for emergency procedures was 1 in 895 (11/10 000), while that for elective procedures was 1 in 3886 (2.6/10 000). Aspiration events occurred on induction/laryngoscopy in 26 of 67 patients and on extubation on 24 of 67 patients. Age, gender, pregnancy, body mass index . 35, comorbid illness,

722 C. P. H. Kalinowski and J. R. Kirsch

Table 1. The top 10 predisposing factors for aspiration.17 1 2 3 4 5 6 7 8 9 1 Emergency Inadequate anaesthesia Abdominal pathology Obesity Opioid medication Neurological decit Lithotomy Difcult intubation/airway Reux Hiatus hernia Aspiration n 133: 21 18 17 15 13 10 8 8 7 6

experience; anaesthesia and surgical provider were not independent risk factors. Results were similar in other large non-randomized studies in adult13 15 and paediatric16 patients. In the Australian Anaesthethetic Incident Monitoring Study (AIMS: an anonymous self-reporting database) Kluger et al found that ve of 244 reported incidents of vomiting, regurgitation or aspiration resulted in death.17 Factors that increased the incidence of aspiration are similar to those observed in the American experience (Table 1). 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).18There were 11/158 (7%) claims for aspiration during regional anaesthesia or sedation. Aspiration occurred during induction in 67/158 (42%) of the cases and 17/67 had cricoid pressure applied. Care was deemed appropriate in 9/17 claims, and aspiration occurred in some patients despite properly applied cricoid pressure. The percentage of aspiration-related claims for severe outcomes (death or brain damage) decreased from the 1970s to the 1980s, but then remained about the same in the 1990s as in the 1980s. There were no claims in which a laryngeal mask was involved. However, the latest claim was in 1994, and the laryngeal mask may not have been in widespread use in the USA. Obstetric-related aspiration occurred in 33/157 (21%),

Table 2. Factors associated with aspiration-related claims.18 Associated factors in 158 aspiration-related claims Phase of anaesthesia Induction Maintenance Emergence/PACU Obstetrical-related Difcult intubation Cricoid pressure History of reux n 158 67 28 17 33 20 17 4 % 42 18 11 21 13 11 3

Prophylaxis and treatment for aspiration 723

and there was a notable downward trend over time. This suggests that strategies for aspiration prophylaxis in the obstetric patient were having clinical effects in the 1980s.

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, extremes of age, gastrointestinal and abdominal procedures, impaired consciousness, 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 reux and regurgitation in the normal population assessment and clarication 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. The rational was to minimize gastric volume, acidity and particles so as to minimize the effects of aspiration pneumonitis.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.20 This goal appears to be commonly achieved using traditional fasting guidelines in patients.21 However, one must remember that gastric pH is also an important determinant of lung injury following aspiration. In addition, gastric contents may also have elements of bile which, although not adding to the acidity, may cause worse lung injury than that observed with acid aspiration.22 Over the past decade, the rationale for traditional fasting practices has been re-examined. Several anaesthesia societies suggest shorter fasting times with regards to liquids in t healthy patients.23 Preoperative fasting may cause a dry mouth, thirst and increased risk of postoperative nausea and vomiting (PONV) and hypovolaemia.24 In addition, up to 45% of medications may be inadvertently omitted preoperatively with traditional fasting practices.25 GASTRIC EMPTYING Gastric emptying of liquids is controlled by the proximal part of the stomach. It is directly related to the gastroduodenal pressure gradient, unless there is concurrent

724 C. P. H. Kalinowski and J. R. Kirsch

pyloric pathology or surgical disruption. Non-caloric liquids empty in a mono-exponential function, the rate decreasing as intragastric pressure and volume decrease. If the intragastric pressure is caloric, acidic or non-isotonic, initial emptying is delayed and then follows a non-linear function. The lag period occurs between ingestion of food and duodenal activity, and reects the time to reduce food particle size. Larger non-digestible particles ( . 1 mm in size) are emptied during fasting. 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.26 Gastric uid volumes are variable at the time of induction in fasting healthy children.27 The oral intake of clear uids does not increase gastric uid volumes or acidity.28 Healthy children drinking unrestricted amounts of uid volumes up to 2 hours preoperatively had no difference in gastric volumes or pH as compared to those limited to 10 ml/kg.29 Residual gastric volumes in 152 healthy adolescents allowed unrestricted uid for up to 3 hours preoperatively did not differ from those who were fasted for a longer period of time.30 The result concurs with a study of 179 healthy adults between 18 and 70 years of age.28 Clear uids are water, fat-free and protein-free liquids, pulp-free fruit juice, carbonated drinks, clear tea and black coffee. Milk has gastric emptying characteristics similar to those of solids because of the casein it contains. Gastric emptying times of human breast milk and low-fat milk was 2.75 hours compared with 1.75 hours for glucose.31 Formula and milk substitutes have different gastric emptying times depending on their fat and protein composition. Little work has been done to determine the potential detrimental effects of fasting. In animal studies, fasted animals have less reserve to cope with the stress of hypovolaemia and endotoxaemia.32 Fed animals responded to trauma with a lower concentration of endocrine markers of stress. In addition, fed animals metabolized glucose in a more anabolic way, displayed improved muscle strength and demonstrated less bacterial translocation compared to animals in the fasted state. 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.33 Similar effects have been demonstrated in patients provided with a carbohydrate drink (12.5%, 285 mosmols/kg) before colorectal and hip replacement surgery.34 Several studies have demonstrated that carbohydrate-enriched water empties from the stomach at approximately the same rate as non-fortied water. Patients who are allowed the luxury of drinking these uids until 2 hours before surgery are less hungry and have less anxiety than patients exposed to a traditional preoperative fast.35 In addition, there is some evidence that patients allowed a preoperative carbohydrate-containing beverage may have a reduced length of hospital stay. Most importantly, there have been no complications reported in more than 600 patients in several studies following the consumption of a preoperative carbohydrate-enriched drink.19 Much less controversy exists regarding the appropriateness of providing patients with solid food before surgery. Gastric emptying depends upon the amount and nature of the food ingested. At least 4 hours is necessary for emptying of particles from the stomach after a light meal (e.g. slice of toast with jam, a glass of pulp-free orange juice and black coffee). The half-life of gastric emptying in 50 subjects was 59 minutes for two eggs (digestible particles), and it took 4 hours for 10 polyvinyl capsules (indigestible particles) to empty from the stomach.36 However, a large heavy meal can take more than 9 hours to empty from the stomach.37

Prophylaxis and treatment for aspiration 725

Conditions causing reduced gastric emptying There are several different conditions in our patients that may have a signicant impact on gastric emptying times. For example, pregnancy has hormonal effects that impair the function of the gastro-oesophogeal sphincter. In addition, the gravid uterus may cause physical impairment of gastric emptying and signicant changes in the position of the gastro-oesophogeal sphincter in the chest. However, 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.38 Nonetheless, there is no question that gastric emptying is signicantly impaired during labour.39 In addition, epidural opiates during labour have been shown to delay gastric emptying.40 Type I diabetes is associated with reduced gastric emptying, probably secondary to diabetic autonomic neuropathy and not HbA1c, preprandial blood glucose or age.41,42 Gastric emptying of liquids and solids is delayed in 40 50% of both Type I and Type II diabetic patients. However, gastrointestinal symptoms do not correlate with gastric emptying function.43 Renal failure delays gastric emptying in both haemodialysed and continuous ambulatory peritoneal dialysis patients. In addition, gastric emptying is further delayed in patients who are both diabetic and have chronic renal failure. However, in patients with renal failure there was no independent effect on gastric emptying due to age, gender, body mass index or presence of dyspepsia.44 Likewise, presence of peritoneal dialysis uid in the abdomen45 or the need for haemodialysis46 did not independently effect gastric emptying time. A reduced level of consciousness interferes with protective upper airway reexes47 and is also associated with impaired function of the lower oesophageal sphincter48 and delayed gastric emptying.49 With a reduced function in protective airway reexes, passive regurgitation in patients with an impaired level of consciousness may frequently result in pulmonary aspiration. Indeed, pulmonary aspiration is commonly observed in patients with impaired consciousness who were left in the supine position.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.51 Consistent with this hypothesis, Orozco-Levi et al demonstrated that a semi-recumbent position reduces the chance of pulmonary aspiration of gastric contents in patients with nasogastric tubes.52 Pharmacotherapy Both the degree of acidity and the presence of particulate matter in gastric uid have a signicant impact on the severity of lung injury following pulmonary aspiration.53 Non-particulate buffered salts of citric acid (Bicitra, Shohls solution) increase gastric pH . 3.8 for at least 7 hours compared with sodium citrate.54 Sucralfate binds bile and gastric acid and is effective in reducing the incidence of gastric stress bleeding in at-risk patients. However, aspiration of sucralfate will produce acute pneumonitis and pulmonary haemorrhage.55 H2-receptor antagonists bind competitively to receptors on the basal parietal cell membrane. When administered 90 120 minutes before surgery, these agents reduce gastric volume and increase pH,56 but there have been no randomized trials in patients that prove their efcacy in decreasing frequency of pulmonary aspiration in high-risk patients. In addition, recent literature supports the hypothesis that subacute tolerance (in patients on these medications for several days) can develop to H2-receptor

726 C. P. H. Kalinowski and J. R. Kirsch

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

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.g. H2-receptor antagonists, PPIs, 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, chemical, particulate and microbiological composition of the aspirate. Roberts and Shirely (from unpublished work) arbitrarily dened the critical volume of 0.4 ml/kg and pH , 2.5 on the basis of uid directly instilled into the lung of the rhesus monkey. This was extrapolated to humans, and the gures of 25 ml with pH , 2.5 have since remained in medical literature.20 However, 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 uid, adjusted to a pH of 1.63 Aspiration of 0.4 0.6 ml/kg at pH 1 produced mild to moderate clinical signs and radiological changes in the rhesus monkey, but no deaths. The effects of acid aspiration have both an immediate and a delayed onset. The effects of the acid are evident within 5 seconds of contact and are noted from the trachea to the alveoli. There is loss of ciliated and non-ciliated cells within 6 hours, and regeneration is evident after 3 days and complete in 7 days.64 There is a release of pro-inammatory cytokines such as TNF-a and interleukin-8 inducing neutrophil recruitment. There is upregulation of cell adhesion molecules (including E-, L-, P-selectins, B2 integrins and ICAM-1), which cause increased thromboxane and oxygen radical release.65 The effects of osmolality and chemical composition need further evaluation. Aspiration of either fresh or salt water in near-drowning victims also produces an inammatory picture similar to acid aspiration.66 Bile aspiration with pH 7.19 produced worse physiological and histological changes than gastric acid pH 2.24 in the porcine model.22 Although rare, it is possible that aspiration of large particles from the stomach, or of an unexpected foreign body previously swallowed by the patient, could result in complete airway obstruction or obstruction of a large bronchus. Immediate airway obstruction causing asphyxia will lead to death. Aspirated particles need immediate removal with direct laryngoscopy, forceps and suction. Oxygenation and ventilation must be initiated immediately to prevent further hypoxia. Endotracheal intubation is required in an attempt to prevent further contamination. Although there are no denitive data regarding improved outcome after aspiration with long-term intubation in intensive care patients, tracheal intubation facilitates bronchoscopy and removal of particulate matter.67 Aspiration pneumonias are generally polymicrobial. Anaerobes were recovered in 62 100% of patients with aspiration pneumonia.68 Nursing home and hospitalized patients are more likely to have respiratory tract pathogens.69 Hospitalized patients are

728 C. P. H. Kalinowski and J. R. Kirsch

commonly on gastric acid suppressants and are enterally fed, which often results in colonization of the stomach by gram-negative bacteria. These patients are also more likely to have oropharyngeal colonization with Staphylococcus aureus and gram-negative enteric bacilli.68 Pseudomonas aeruginosa, Klebsiella species and Escherichia coli are the most common gram-negative bacteria and Staphylococcus aureus the predominant gram-positive organism in nosocomial aspiration pneumonia.70

INDUCTION OF ANAESTHESIA AND INTUBATION OF THE TRACHEA Several studies indicate that a signicant number of aspiration events occur during induction of anaesthesia and laryngoscopy.10 17 Placement of a cuffed endotracheal tube is currently the best method for isolating the airway from the gastrointestinal tract, but cannot serve as an absolute preventive measure. In patients at risk for pulmonary aspiration, the endotracheal tube may be placed awake or after rapid sequence induction of anaesthesia and application of cricoid pressure. Hazards of a rapid sequence induction include inadequate depth of anaesthesia and inadequate muscle relaxation during laryngoscopy, resulting in coughing, regurgitation and vomiting. 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. However, Ovassapian reviewed 129 awake oral and nasal bre-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.71 Few studies have demonstrated the optimum position of the patient to reduce aspiration risk during induction of anaesthesia or during laryngoscopy. Sellick, in describing application of cricoid pressure, 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.72 Once successful intubation of the trachea has occurred, pulmonary aspiration appears to be less frequent in patients placed in a 458 head-elevated position.73

OBESITY Obesity appears to be a contributing factor in several studies for pulmonary aspiration of gastric contents. Presumed increased intra-abdominal pressure, high residual gastric volume, low pH, delayed gastric emptying and gastro-oesophageal reux disease increases the risk of aspiration pneumonitis in the obese patient.74 Recent studies have questioned the validity of this dogma. For example, Harter et al demonstrated that high volume, low pH (HVLP) gastric contents (. 25 ml, pH , 2.5) were more frequent in thin, than in obese patients, and in premedicated as compared to non-premedicated patients.75 In addition, there was no difference between obese and normal-size patients with regard to the resistance gradient between the stomach and gastro-oesophageal junction, regardless of position.76 In patients with reux, coughing may be due to intermittent episodes of aspiration, particularly during sleep. However, coughing may also be induced via an oesophageal-tracheobronchial reex caused by distal oesophageal receptor

Prophylaxis and treatment for aspiration 729

stimulation by gastric contents.77 Regardless of the exact mechanism of reuxinduced cough, patients with this disease experience improved symptoms with antireux therapy.

LARYNGOSCOPY Suboptimal conditions at laryngoscopy appear to contribute signicantly to the risks of pulmonary aspiration of gastric contents.12 14,17,18 Inadequate depth of anaesthesia at laryngoscopy may manifest as coughing, bucking, laryngospasm and vomiting. These events clearly contribute to difculty with laryngoscopy and may precipitate regurgitation and pulmonary aspiration of gastric contents. Historically, cricoid pressure was suggested as a means of preventing gastric distension during ventilation of the lungs.78 Sellick suggested that it is lightly applied just prior to injection of the induction agent, and then rmly applied when consciousness is lost.79 Cricoid pressure of 44 N applied to the awake individual has been associated with laryngeal discomfort and retching.80 The use of cricoid pressure during anaesthetic induction is routine practice in patients considered at risk of aspiration of gastric contents.81 There are several studies supporting the use of cricoid pressure in preventing gastric insufation and reducing reux in children and adults.81,82 Other reports have suggested that cricoid pressure is ineffective and possibly hazardous in impeding airway patency and intubation.81,82 There are two radiological studies demonstrating that the oesophagus lies lateral to the cricoid cartilage in 49 52% of children and adults.83,84 Cricoid pressure should be sufcient to occlude the oesophagus and prevent aspiration without causing discomfort and occluding the airway. Induction of anaesthesia causes a reduction in lower oesophageal sphincter pressure to 7 14 mmHg.85 Paradoxically, application of cricoid pressure may also cause relaxation of the lower oesophageal sphincter, but does not seem to promote reux in awake healthy individuals.85 Intragastric pressure can reach 35 mmHg with gastric distension and succinylcholine. Vomiting can elevate intragastic pressure by 40 and 45 mmHg, respectively.81 Upper oesophageal pressure . 25 mmHg prevents spontaneous regurgitation in conscious supine patients.86 However, studies in cadavers suggest that rm cricoid pressure is required to prevent regurgitation (oesophageal pressures of 75 mmHg, and 30 N force).87 Maintenance of cricoid pressure during active vomiting may result in severe complications related to rupture of the oesophagus. In addition, 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. Failed intubation after a rapid sequence induction requires ventilation of the lungs with cricoid pressure in situ. Facemask or laryngeal-mask-airway (LMA) ventilation may be difcult with cricoid pressure in situ, and it should be gradually relaxed and removed if ventilation fails.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

730 C. P. H. Kalinowski and J. R. Kirsch

and tracheostomy tubes. For example, high-volume low-pressure cuffs may have longitudinal folds that allow methylene blue to leak beyond the seal of the cuff.88 Continuous subglottic aspiration of secretions has been demonstrated to delay and prevent onset of ventilator-associated pneumonia.89 In addition, there is some evidence that applying gel lubrication to tracheal tubes results in delayed aspiration,90 though use of gel may be associated with an increased risk for post-extubation pharyngitis. More recently an endotracheal tube that uses gills as a barrier, rather than an inatable cuff, has been demonstrated to have excellent efcacy in preventing aspiration. In comparison to cuffed endotracheal tubes, endotracheal tubes with gills may also cause less direct injury to the trachea.91

THE LMA Although the LMA and other supraglottic devices do not isolate the larynx from the gastrointestinal tract, their use does not appear to increase the frequency of vomiting or pulmonary aspiration. For example, a survey of 11 910 patients (no obstetric service) anaesthetized using an LMA for a variety of laparoscopic and intra-abdominal cases,92 demonstrated that regurgitation occurred in four patients, vomiting in two patients and there was one patient who experienced aspiration of gastric contents. In a meta-analysis, incidence of aspiration with use of the LMA was two of 10 000 patients.93 Likewise, Verghes prospectively audited 2359 patients undergoing anaesthesia with use of the LMA,94 and found that of the 41% patients of who underwent positive pressure ventilation, there were only ve cases of regurgitation, three of which occurred in the recovery room after LMA removal. Only one patient regurgitated during surgery, and there were no long-term sequelae. Intensity of gastric distention was compared in 209 patients (37 obese) undergoing laparoscopic gynaecological surgery under general anaesthesia, as a function of whether the patient was ventilated via an endotracheal tube airway, classic LMA or ProSeal LMA.95 Surgeons, blinded to treatment groups, were unable to discern differences in gastric distension. There was only one episode of regurgitation of gastric uid, which was observed in the drain tube of the ProSeal LMA group immediately before deation of the pneumoperitoneum.

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

Prophylaxis and treatment for aspiration 731

Research agenda optimum patient position for a rapid sequence induction evaluate the efcacy of cricoid pressure in a rapid sequence induction in preventing regurgitation comparison of a rapid sequence induction and awake bre-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, pH, particulate nature, sterility, virulence of organisms and host response. Chemical pneumonitis has two phases. Aspiration often initially presents with bronchospasm, cyanosis and tachycardia. Within minutes of pulmonary aspiration there is exudation of uid that neutralizes the aspirate. The second phase involves development of acute lung injury (ALI) which may lead to frank respiratory distress syndrome. There are four clinical phases, initially characterized by mild symptoms of respiratory distress associated with neutrophil sequestration. Hypoxaemia and uffy radiological inltrates are associated with interstitial neutrophil aggregation. The work of breathing increases and worsening hypoxaemia necessitates ventilatory support. Hypoxaemia may be relatively resistant to treatment with positive endexpiratory pressure (PEEP). Progressive broproliferation with increased interstitial collagenase activity results in deposition of inelastic Type I/III collagen, indicating repair of pulmonary endothelial and epithelial cells.68 There is no evidence to suggest that any particular order of events is superior in managing the consequences of aspiration. Suggested initial management of aspiration during anaesthesia involves positioning the patient head-down, maintenance of cricoid pressure if feasible, clearing the airway of debris with suctioning and Magill forceps, and securing the airway with an endotracheal tube (Table 3). Once the endotracheal tube is

Table 3. 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, intermittent positive pressure ventilation; CPAP, continuous positive airway pressure.

732 C. P. H. Kalinowski and J. R. Kirsch

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

Prophylaxis and treatment for aspiration 733

pneumonia. A single low-risk pathogen may require treatment for 7 10 days. In the presence of antibiotic-resistant organisms, multilobar involvement, necrotizing pneumonitis, cavitation and malnutrition, treatment for 14 days or more is often required to be effective. Treatment failure is usually due to incorrect empirical therapy, persistent lung abscess or empyema. Antibiotic resistance generally results in rapid deterioration of the patient.98

Practice points head-down position to limit amount of pulmonary contamination clear airway of particles and uid with forceps and suction oxygenate, 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, continuous positive airway pressure (CPAP), biphasic positive airway pressure (BIPAP), intermittent positive pressure ventilation (IPPV), 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, abdominal surgery, the obese and consciousness-impaired. Fasting times are 2 hours for clear uids, 4 hours for breast milk, 6 hours for a light meal and up to 9 hours for larger meals. The preoperative intake of a carbohydrate-enriched drink has been shown to have potential benets in reducing postoperative insulin resistance and the catabolic response to surgery. Antacids and prokinetic drugs have not been shown to improve outcome after aspiration, and should be limited to those patients at increased risk for aspiration. Gastric contents contain bile which damages the lungs more than acid. 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,

734 C. P. H. Kalinowski and J. R. Kirsch

morbidly obese patients and reduces aspiration in ventilated patients in the ICU. Rapid sequence induction is the standard of care for non-fasted emergency cases, although well-controlled trials to support this technique are lacking. Although cricoid pressure decreases aspiration of passively regurgitated stomach contents, it may also impair laryngoscopy and ventilation. Aspiration is most likely to occur on induction of general anaesthesia and in the presence of inadequate anaesthesia during laryngoscopy. Awake bre-optic intubation should be considered in those individuals who are at risk of difcult laryngoscopy and aspiration. Long-term surveillance of patients who have aspirated is suggested to exclude underlying respiratory diathesis.

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