Pulmonary aspiration:

Definition:
It is defined as the entry of liquid or solid material into the trachea and lungs. Anesthesia-related aspiration
occurs when patients without sufficient laryngeal protective reflexes passively or actively regurgitate gastric contents.

Symptoms:
May range from: mild symptoms such as hypoxia to complete respiratory failure and ARDS and even
cardiopulmonary collapse and death.
Pulmonary syndromes include:
1. Acid associated pneumonitis
2. Particle associated aspiration (airway obstruction)
3. Bacterial infection (esp Staph aureus, pseudomonas, enterobacter, etc.) with subsequent development of lung
abscess, exogenous lipoid pneumonia, chronic interstitial fibrosis (occur especially when the aspirate is not
sterile)
Which of these symptoms develop depend upon the composition and volume of aspirate.

Most common of these is Aspiration Pneumonitis.

It is damage to the lung parenchyma resulting from sterile, acid (or bile) gastric contents.
Severity is modified by: degree of acidity, volume of aspirate, presence or absence or particulate matter in the
aspirated fluid.

Risk factors:
1. Medications:
a. Due to effect of medications on the LES, level of consciousness and loss of protective reflexes.
b. Eg. Propofol, volatile anesthetics, beta agonists, opioids, atropine, thiopental, etc.
c. Risk is even greater when topical anesthesia to the larynx is employed, because the cough reflex is
compromised.
2. Predisposing conditions:
a. GI obstruction
b. Need for emergency surgery
c. Previous esophageal surgery
d. Lack of co-ordination of swallowing or respiration
e. Esophageal cancer
f. Hiatal hernia
g. Obesity
3. Provider expertise:
a. Improper decision
b. Lack of experience
c. Lack of knowledge in application of CP dutin RSI
d. Failure to provide anti-aspiration prophylaxis

Prevention:
1. Pre-operative risk assessment:
a. Presence of risk factors like GERD, esophageal dysmotility, difficulty swallowing, diabetes, gas
bloat, etc.
2. Preoperative fasting:
a. As per standard ASA guidelines
3. Preemptive NG placement:
a. Specially in cases with suspected ileus/obstruction but not for each and every case.
b. Sometimes, its placement itself may result into vomiting and aspiration in addition to other usual
complications with NG placement.
4. H2 blockers, PPI, and Prokinetics:
a. H2 blockers: cimetidine, famotidine, nizatidine, and ranitidine
b. PPI: Pantop, Omeprazole, etc.
c. Prokinetics: Domperidone, Metoclopramide, etc.
d. Use of non-particulate antacid
5. RSI:
6. Patient positioning during induction:
a. Head down tilt of 15-20 degree combined with Sellick position for head to neck orientation is optimal
for minimizing tracheal and bronchial aspiration.
Management in acute intraoperative aspiration:
1. Requires a high index of suspicion and immediate response.
2. Should immediately diagnose the gastric content in oropharynx or airways.
3. Additional signs include:
a. Persistent hypoxia
b. High airway pressure
c. Bronchospasm
d. Abnormal breath sounds following intubation
e. Even cardiopulmonary arrest may occur if not identified in time.
4. Maneuvers:
a. If the content is seen in oropharynx going towards airway, then immediately patient should be
positioned with head down and rotated laterally if possible.
b. Orotracheal and endotracheal suctioning is indicated
c. Airway be secured as rapidly as possible to prevent further soilage and to facilitate airway clearance
(flexible bronchoscopy can be of help in these)
d. If particulate matter is present, rigid bronchoscopy may be required.
5. Further decision to proceed with surgery varies from case to case and patients condition of oxygenation,
ventilation.
6. Antibiotics and steroid use should be individualized and not recommended for routine use.
7. If arrest occurred,
a. Immediate CPR
b. Airway clearance maneuver done
c. Early institution of ECMO if available.