Aspiration-Related Pulmonary Syndromes

doi:10.1378/chest.14-1049

Chest

Volume 147, Issue 3, March 2015, Pages 815-823

https://doi.org/10.1378/chest.14-1049 Get rights and content

Aspiration of foreign matter into the airways and lungs can cause a wide spectrum of pulmonary disorders with various presentations. The type of syndrome resulting from aspiration depends on the quantity and nature of the aspirated material, the chronicity, and the host responses. Aspiration is most likely to occur in subjects with a decreased level of consciousness, compromised airway defense mechanisms, dysphagia, gastroesophageal reflux, and recurrent vomiting. These aspiration-related syndromes can be categorized into airway disorders, including vocal cord dysfunction, large airway obstruction with a foreign body, bronchiectasis, bronchoconstriction, and diffuse aspiration bronchiolitis, or parenchymal disorders, including aspiration pneumonitis, aspiration pneumonia, and exogenous lipoid pneumonia. In idiopathic pulmonary fibrosis, aspiration has been implicated in disease progression and acute exacerbation. Aspiration may increase the risk of bronchiolitis obliterans syndrome in patients who have undergone a lung transplant. Accumulating evidence suggests that a causative role for aspiration is often unsuspected in patients presenting with aspiration-related pulmonary diseases; thus, many cases go undiagnosed. Herein, we discuss the broadening spectrum of these pulmonary syndromes with a focus on presenting features and diagnostic aspects.

Section snippets

Epidemiology

Aspiration-related pulmonary syndromes are encountered in subjects of any age, from infancy to the aged. However, specific pulmonary syndromes are more likely to be encountered in certain age groups or in clinical contexts in which there are risk factors for aspiration. For example, foreign body aspiration is encountered most commonly in young children and the elderly, particularly those with impaired mental status or swallowing mechanism.14, 15 Aspiration pneumonitis typically occurs in the

Risk Factors for Aspiration

Major risk factors for aspiration include depressed consciousness, compromised airway defenses, dysphagia, gastroesophageal reflux disease (GERD), and recurrent vomiting (Table 2).13, 16 States of depressed consciousness include general anesthesia, alcohol intoxication, and drug overdose. Under these conditions, swallowing mechanisms and airway defenses are impaired. Airway defenses are also impaired in subjects with vocal cord immobility, oropharyngeal deformities caused by surgery or

Pathophysiology

When aspiration occurs in healthy subjects, the amount of aspirated material is usually minimal and cleared without clinical sequelae. When aspiration results in adverse clinical consequences, the character of the evolving illness is determined by the nature and volume of the aspirated material, the chronicity, and the host responses.

In patients with GERD, laryngeal injury with mucosal damage results from direct exposure to refluxed gastroduodenal contents that include acid, pepsin, and bile

Diagnostic Evaluation

Evaluation of a patient suspected of having an aspiration-related pulmonary syndrome is tailored to the individual context and the specific syndrome (based on clinical and radiologic features) being addressed. Several modalities are available to evaluate subjects with dysphagia. Videofluoroscopic swallow study (performed by a speech therapist or radiologist) is generally considered to be the procedure of choice and should assess oral, pharyngeal, and esophageal phases.9, 12, 17 Other methods of

Vocal Cord Dysfunction

Several laryngeal manifestations have been associated with GERD; these include chronic laryngitis, laryngospasm, vocal fold granuloma, and vocal cord dysfunction.26, 27 The most relevant of these entities to pulmonologists is vocal cord dysfunction, which is commonly misdiagnosed as asthma. Vocal cord dysfunction is characterized by episodes of airflow obstruction due to true vocal cord adduction during inspiration, occasionally during expiration, or both.²⁷ Vocal cord dysfunction is thought to

Aspiration Pneumonitis

Two aspiration-related pulmonary syndromes that are most familiar to physicians are aspiration pneumonitis and aspiration pneumonia. Aspiration pneumonitis refers to acute lung injury occurring after inhaling a large volume of regurgitated gastric contents.¹⁶ This syndrome typically occurs in patients who have altered consciousness, such as that resulting from sedation, general anesthesia, drug overdose, seizure, massive stroke, or traumatic brain injury.13, 52 Although the initial lung injury

Conclusions

Aspiration can be clinically occult and elicits a broad spectrum of pulmonary syndromes. Integration of the clinical context (including risk factors for aspiration) and awareness of clinicoradiologic findings associated with these disorders will facilitate recognition of these diverse syndromes, which often go undiagnosed.

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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Complications of radiation therapy can be classified as acute toxicity i.e., radiation pneumonitis, and late toxicity i.e., pulmonary fibrosis. Pulmonary fibrosis often occurs after treatment discontinuation.120 Micro aspiration-related lung injury occurs due to gastroesophageal reflux aspiration into the airway leading to chronic lipoid pneumonia, obliterative bronchiolitis, and diffuse aspiration bronchiolitis.121
Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive lung condition marked by lung scarring that progresses over time and with usual interstitial pneumonia histology (UIP). It is linked to a worsening cough, dyspnea, and a worse quality of life. Around 3 million persons worldwide suffer from IPF, and the prevalence rises sharply with advancing age. The detection of the UIP pattern, generally using high-resolution CT; lung biopsy may be necessary in certain individuals; the diagnostic approach also includes the elimination of other interstitial lung illnesses or overlapping problems. The UIP pattern is mostly bilateral, peripheral, and basal, with clusters of subpleural cystic airspaces and reticular alterations linked to traction bronchiectasis.
Although there are still many uncertainties about how to define susceptibility, it is believed that the molecular mechanisms causing IPF reflect an abnormal reparative response to repeated alveolar epithelial damage in an aging genetically sensitive individual. With the availability of two pharmacotherapeutic drugs, pirfenidone and nintedanib, that slow physiological advancement and potentially increase progression-free survival, significant progress has been made in our knowledge of the clinical treatment of IPF. The goal of current research is to develop early biomarkers for IPF that may include circulating variables, demographic information, and imaging data.
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Pulmonary aspiration is a recognized risk for patients undergoing anesthesia and surgery and for patients with a variety of underlying medical conditions. Although aspiration can occur under a variety of circumstances, the risk is greatest when a patient loses normal airway protective reflexes, whether as a result of injury, age, or related to administration of sedatives, anesthetic agents, or muscle relaxants. Anesthesiologists should be aware of the evidence on which to assess risk for aspiration, define approaches to clinical care to minimize the likelihood of aspiration, and understand how best to manage an aspiration event should it occur. Using clinical practice guidelines specific to airway management allows for the implementation of a plan to minimize the risk for aspiration. Should a patient aspirate, management of the aspiration is primarily supportive, designed to optimize oxygenation and ventilation, maintain good bronchopulmonary hygiene, and minimize the risk for repeat aspiration events. Based on clinical findings, radiologic studies, and culture results, some patients will require treatment with antimicrobial agents. Steroids and other interventions are rarely required. The evidence-based approach to managing the patient at risk for aspiration will improve clinical care and reduce complications that impact outcomes after anesthesia and surgery.
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A 75-year-old woman who had been taking methotrexate presented to our hospital for fever and dry cough. Chest computed tomography showed ground-glass opacity in the upper lobe of the right lung and foreign bodies in the lower lobe of the right bronchus. During bronchoscopy, foreign bodies were removed from the airway. We found increased levels of lymphocytes and a high CD4/CD8 ratio in the bronchoalveolar lavage fluid. Transbronchial lung biopsy revealed lymphocytic infiltration. Methotrexate was discontinued, and the imaging findings improved. Methotrexate-induced lung injury does occur unilaterally. Foreign bodies in the airway might also trigger unilateral methotrexate-induced lung injury.
Aspiration of the dental crown in an elderly patient
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Citation Excerpt :
Patients may rapidly develop cyanosis, requiring emergency orotrachealintubation [4,13]. Diagnosis can be made based on the signs and symptoms such as coughing, choking, wheezing, acute dyspnea, and muffled respiratory sounds [14]. Radiographic examination is essential to detect the presence of airway foreign bodies and determine their location [15–19] because most aspirated dental foreign bodies are radiopaque [20].
The aspiration of objects and foreign bodies requires quick and systematic care. During emergent orotracheal intubation, accidental dental crown release can cause a threat to the patient's life. This paper aimed to report a case of foreign body (dental prosthetic crown) aspiration and its management and discuss alternative approaches. An 81-year-old male patient, who was admitted to the hospital's intensive care unit (ICU) for meningitis, presented with altered consciousness, and decreased oxygen saturation. He underwent emergent orotracheal intubation. After intubation, chest radiography was performed to check for proper orotracheal tube positioning and lung expansion. The resultant images revealed the presence of a foreign body within the right lower lobe bronchus in the shape of a dental crown. The foreign body, intubation cannula and basket clamp were successfully removed, followed by reintubation of the patient. The foreign body was a prosthetic upper premolar dental crown (24). While care should be taken to avoid complications, if a foreign body is aspirated during emergent orotracheal intubation, endoscopic removal appears safe and effective. Careful creation, placement, maintenance, and preservation of prosthetic crowns are critically important in elderly patients.
Knowledge, Attitude and Practice of the Community General Practice Teams on Dysphagia Complicated with Aspiration Pneumonia after Stroke
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Recent Advances in Chest MedicineAspiration-Related Pulmonary Syndromes

Section snippets

Epidemiology

Risk Factors for Aspiration

Pathophysiology

Diagnostic Evaluation

Vocal Cord Dysfunction

Aspiration Pneumonitis

Conclusions

Acknowledgments

Chest

Am J Med

Mayo Clin Proc

Chest

Chest

Otolaryngol Clin North Am

Gastroenterol Clin North Am

Gastroenterol Clin North Am

Lancet

Chest

Clin Chest Med

Chest

Chest

Chest

Chest

Mayo Clin Proc

Chest

Chest

Chest

Clin Chest Med

J Am Coll Surg

J Heart Lung Transplant

Respir Med

Am J Med

Chest

Lancet Respir Med

Semin Arthritis Rheum

Aspiration pneumonitis and aspiration pneumonia

N Engl J Med

Aspiration diseases: findings, pitfalls, and differential diagnosis

Radiographics

High incidence of silent aspiration in elderly patients with community-acquired pneumonia

Am J Respir Crit Care Med

Silent aspiration: what do we know?

Dysphagia

Silent aspiration: results of 2,000 video fluoroscopic evaluations

J Neurosci Nurs

Aspiration pneumonias: under-diagnosed and under-treated

Curr Opin Pulm Med

Pulmonary disease due to aspiration of food and other particulate matter: a clinicopathologic study of 59 cases diagnosed on biopsy or resection specimens

Am J Surg Pathol

Aspiration lung disease

Pediatr Clin North Am

Aspiration-induced lung injury

Crit Care Med

Recent Advances in Chest Medicine
Aspiration-Related Pulmonary Syndromes