Aspiration Pneumonia

K-B

Dr. Abdul Rohman, SpP

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 Mendelsons syndrome: the chemical injury of the lungs secondary to aspiration of gastric contents.
KEY POINTS: ASPIRATION SYNDROMES
1. 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 material 1. Type
a.Fluids : - toxic (bile, acid, HC)

- Inert (mucous , water)

b.Solids : - tiny

-large balus of food

2. Volume
-

Small
1 segment damage

large
localized

3. Distribution

All segment ARDS

< 2,5 ( asam ) severe lung injury Neutral or non acidic minimal damage

4. pH

I N F L A M M A T I O N

Pathophysiology of Aspiration
B. Associated pathogens
1. Predominant : Oropharyngeal flora 1 : 10

(10 million aerobes :

100 million anaerobes) 2. Distal airway & lung

parenchyma : sterile

I N F E C T I O N

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 hemorrhage Labor and delivery Trauma

7. Iatrogenic factors

( > 60% )

General anesthesia Cardiopulmonary resuscitation Attempting emergency intubation Tracheostomy Nasogastric feeding tamponade Esophageal ballon tamponade Recent 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 mel Staphylococ Peptostreptococ Fusobacterium nucleatum 2. PAN (Pneumon Aspirasi Nosokomial Kolonisasi 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 insidious Pdu 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 meningkat Sputum (Gram): banyak lekosit & kuman campuran X-ray : infiltrat segmen paru dependent disertai kavitas & efusi pleura Lokasi tersering lobus kanan tengah dan atau lobus atas Lain-2 : elektrolit, BUN, kreatinin, AGD & kultur darah

DIAGNOSIS
A. CLINICAL PRESENTATION
determined by the nature and the quality of the aspirate 1. Massive aspiration (trauma victims seizure disorders) : - Acute respir failure - Hypotension - Deep cyanosis - Decreased cardiac output - Marked stridor - Tachypnea - Pulmonary edema - Dyspnea 2. Small volume After 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

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 clindamisin Lama Terapi : 2 mi R 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

MANAGEMENT
Protecting 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 EVALUATION
Be 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/tanpa disertai 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