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Aspiration Pneumonia in Dogs: Pathophysiology, Prevention, and Diagnosis

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Aspiration Pneumonia in Dogs: Pathophysiology, Prevention, and Diagnosis 3 CE Credits Aspiration Pneumonia in Dogs: Pathophysiology, Prevention, and Diagnosis Heidi M. Schulze, DVM, DACVECC Alta Vista Animal Hospital Ottawa, Ontario, Canada Louisa J. Rahilly, DVM, DACVECC Cape Cod Veterinary Specialists Buzzards Bay, Massachusetts Abstract: Aspiration pneumonia and aspiration pneumonitis are associated with significant morbidity in veterinary and human medicine. A variety of medical conditions and medications can predispose patients to aspiration, and every precaution should be taken to prevent aspiration from occurring. For dogs that aspirate oral or gastric contents and subsequently develop pneumonia, monitoring and supportive care are imperative. This article discusses the pathophysiology, prevention, and diagnosis of aspiration pneumonia. For more information, please see the companion article, “Aspiration result.4 The second phase of aspiration pneumonia begins 4 to 6 Pneumonia in Dogs: Treatment, Monitoring, and Prognosis.” hours after aspiration, lasts for 12 to 48 hours, and is characterized by infiltration of neutrophils into the alveoli and pulmonary intersti- ulmonary aspiration is the inhalation of fluid and/or particu- tium.1,3 This inflammatory phase is characterized by ongoing lates into the airways. In clinical medicine, aspirated material vascular leakage of proteins with continued development of high- comes from the contents of the gastric and/or oral cavities. protein pulmonary edema, neutrophil sequestration and activation, P 3,4 Aspiration pneumonitis is the result of inhalation of these contents and release of further proinflammatory cytokines. These first into the respiratory tract with subsequent inflammation of the two stages constitute aspiration pneumonitis. The third phase, airways and pulmonary parenchyma.1–3 Aspiration pneumonia is which constitutes the dif- a bacterial infection of the pulmonary parenchyma that develops ference between aspiration secondary to aspiration. It may occur simultaneously with aspiration pneumonitis and aspiration Key Points pneumonitis if the aspirated contents are contaminated with bacteria. pneumonia, involves bac- • Many conditions can predispose It may also occur when patients with aspiration pneumonitis develop terial colonization of the dogs to aspiration pneumonia. secondary bacterial colonization of the airways.1–4 airways and pulmonary parenchyma.1,4,5 • Preliminary diagnosis of aspiration Pathophysiology pneumonia is based on history, Aspiration pneumonia develops in three stages. The first stage occurs Predisposing Etiologies physical examination, and thoracic immediately after aspiration.1 During this phase, damage to the Many conditions can in- radiography. airways and pulmonary parenchyma is a direct result of the nature crease the risk of aspiration • Definitive diagnosis of aspiration of the aspirated fluid (i.e., irritant or acidic).3,5 This caustic tissue and resultant pneumonia pneumonia is based on culture of damage triggers the activation of cytokines and other inflammatory in dogs (BOX 1). Dogs that pulmonary exudate. mediators.2 The inflammation leads to necrosis of type I alveolar have recently been heavily cells, bronchiolar constriction, pulmonary hemorrhage, increased sedated or undergone gen- • Causative agents are often mucus production, increased vascular permeability resulting in eral anesthesia are at risk oropharyngeal commensal bacteria extravasation of proteins into the pulmonary parenchyma, and for aspiration.6–9 Premedi- or enteric bacteria. pulmonary edema.4,5 Ultimately, alveolar collapse and atelectasis cation with narcotics can Vetlearn.com | December 2012 | Compendium: Continuing Education for Veterinarians® E1 ©Copyright 2012 Vetstreet Inc. This document is for internal purposes only. Reprinting or posting on an external website without written permission from Vetlearn is a violation of copyright laws. Aspiration Pneumonia in Dogs: Pathophysiology, Prevention, and Diagnosis Box 1. Conditions Predisposing to Aspiration of Gastric Contents3,4 Large volumes of intragastric food/fluid Nasogastric tube placement • Delayed gastric emptying Foreign body/obstruction — Gastrointestinal motility disorders — Ileus Impairment of protective airway reflexes — Pyloric outflow obstruction • Impaired consciousness — Bowel obstruction — Sedation/general anesthesia — Pain — Head trauma — Anxiety — Seizures — Opioid administration — Encephalopathy — Pregnancy — Coma — Obesity • Impaired airway function • Recent consumption of a meal — Laryngeal or pharyngeal dysfunction or surgery • Enteral (via tube) overfeeding — Airway trauma Esophageal disorders Other • Esophageal obstruction (foreign body, persistent right aortic arch, stricture) • Tracheostomy • Esophageal dysmotility • Gastric intubation — Megaesophagus • Cleft palate — Myasthenia gravis or other peripheral neuropathy — Reflux esophagitis • Weakness, paresis, or paralysis — Achalasia • Metabolic derangements (severe hypokalemia, hypomagnesemia) • Gastroesophageal sphincter incompetence predispose patients to gastric reflux, regurgitation, and possible with water up to 2 hours before anesthesia, is sufficient to minimize aspiration.10 Neurologic conditions that affect esophageal or laryn- reflux during general anesthesia. Another study18 found that fasting geal function, as well as head trauma and seizures, also predispose for longer periods of time increased the acidity of the gastric envi- patients to aspiration.3,11–14 In a 2009 study of dogs undergoing ronment, which would result in more severe pulmonary damage general anesthesia for diagnosis and/or treatment of intervertebral from reflux and aspiration. Patients at risk for aspiration should have disk disease, patients that vomited or regurgitated after anesthesia, their esophagus and stomach suctioned before extubation. Ensuring were tetraparetic, had cervical lesions, or underwent longer anes- intact gag and swallow reflexes before extubation in patients under- thetic procedures (4.5 h compared with just under 4 h, on average) going anesthesia, especially those at risk for reflux or regurgitation, or more than one anesthetic procedure were more likely to develop is imperative. If an episode of regurgitation or reflux is witnessed, pneumonia.15 In addition, patients with feeding tubes may be at the oropharyngeal cavity should be suctioned. increased risk of aspiration due to gastric distention and atony At-risk patients may benefit from prophylactic therapy to reduce after feeding.1 Other conditions such as vomiting or regurgitation the incidence of gastric reflux; however, reviews of this practice in (for any reason), oropharyngeal or esophageal obstructive lesions, both the human and veterinary literature are mixed. Metoclopramide anxiety, and pain may predispose patients to aspiration. Long-term at high doses was shown to significantly decrease the incidence of treatment with histamine type 2 (H2) blockers or proton pump gastric reflux in canine patients premedicated with morphine that inhibitors (PPIs) can lead to alkalinization of the gastric lumen and underwent general anesthesia.19 However, a more recent report20 secondary colonization of the gastric lumen with enteric bacteria.16 found that neither ranitidine nor high-dose metoclopramide Therefore, a greater potential for bacterial aspiration pneumonia reduced the incidence of reflux in anesthetized dogs. Patients in may be present in patients receiving these medications.16 the latter study were not premedicated with opioids; thus, the effectiveness of ranitidine and high-dose metoclopramide at Preventive Measures minimizing the reflux caused by opioids was not evaluated in this Numerous measures can be taken to prevent aspiration pneumonia study. The use of omeprazole, a potent PPI, has also been evaluated in patients with a known risk factor. Preoperative fasting of patients, and shown to reduce gastroesophageal reflux in dogs undergoing when possible, is recommended. However, the ideal length of the fast anesthetic procedures when administered preoperatively.21 How- is debatable. Recent studies report that the historical 12- to 18-hour ever, another study22 showed that esomeprazole, the S-isomer of preanesthetic fast is not only unnecessary but also potentially omeprazole, failed to reduce the incidence of gastric reflux in harmful to patients.17,18 Shiun et al17 demonstrated that an 8-hour fast, dogs premedicated with hydromorphone and maintained with Vetlearn.com | December 2012 | Compendium: Continuing Education for Veterinarians® E2 Aspiration Pneumonia in Dogs: Pathophysiology, Prevention, and Diagnosis with aspiration pneumonia had a normal rectal temperature, 58% had a normal respiratory rate, and 28% to 31% had normal lung sounds at the time of diagnosis.25,26 Thoracic radiography is the gold standard for preliminary di- agnosis of aspiration pneumonia (FIGURE 1A and FIGURE 1B). Three- view radiographs are advised be- cause multiple lung lobes may be involved.25,26 Interstitial, alveolar, A and mixed pulmonary patterns 25,26 Figure 1. (A) Right lateral thoracic radiograph. Note the prominent may be evident. Diagnostic dif- lobar sign (white arrow), lung consolidation, and air bronchograms ferentials for radiographic lung (yellow arrow). Multiple lung lobes appear to be involved.(B) lobe consolidation are listed in Ventrodorsal thoracic radiograph of patient in 1A. Note the significant BOX 2. The lung lobe(s) involved involvement of the left cranial lung lobe ( ) and, to a white arrow depend on the position of the lesser extent,
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