Otterbein University Digital Commons @ Otterbein

Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work

7-2018

Aspiration Pneumonitis

Meghan Little Otterbein University, [email protected]

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Part of the Nursing Commons

Recommended Citation Little, Meghan, "Aspiration Pneumonitis" (2018). Nursing Student Class Projects (Formerly MSN). 311. https://digitalcommons.otterbein.edu/stu_msn/311

This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact [email protected]. Aspiration Pneumonitis Meghan Little BSN, RN, CCRN Otterbein University, Westerville, Ohio

Introduction Presentation of Process Underlying Pathophysiology Implications for Nursing Care References As Bartlett (2018) explains, there are many extensive experimental animal studies on the • The certified registered nurse anesthetist (CRNA) plays a large role in • Bartlett, J. G. (2018, May 18). Aspiration • Anesthesia is an essential Signs and Symptoms Additional medications routinely used pathophysiology of aspiration pneumonitis. In these test animals, the inoculum used must have preventing anesthesia-related aspiration pneumonitis. during anesthesia that are known to pneumonia in adults. Retrieved from element of healthcare today, • The primary sign of intraoperative a pH of ≤2.5, and a large amount must be used – approximately 1-4ml/kg. This converts to an decrease lower esophageal sphincter • https://www.uptodate.com/contents/aspiratio however, it is not without its aspiration is visualization of gastric amount 25 mL of gastric acid in human adults. Bartlett (2018) states that it is likely that when The CRNA should always conduct a preoperative risk assessment so that tone include: propofol, β-agonists, n-pneumonia-in-adults complications. One major contents in the oropharynx or passing lesser amounts of gastric acid are aspirated in humans, the process of pneumonitis is more they are aware of any conditions that the patient has that may increase opiods, atropine, thiopental, tricyclics, Deguchi, S., Komasawa, N., Ueno, T., Omori, M., & complication of anesthesia is into the airway during intubation subtle to where is escapes clinical detection or causes a less severe form. This concept supports their risk of aspirating, such as GERD, esophageal dysmotility, difficult glycopyrrolate (Nason, 2015). Minami, T. (2016). Evaluation of pH on aspiration pneumonitis. (Nason, 2015). the notion that patients with GERD may suffer from bouts of recurrent pneumonitis more swallowing, diabetes, delayed gastric emptying, obstructing cancer (Nason, frequently than those who do not have GERD (Bartlett, 2018). 2015). removed tracheal tubes after general • Predisposing conditions: anesthesia: A prospective observational study. • Inflammation of the lung tissue • Other signs of intraoperative According to Bartlett (2018), in the above-mentioned test animals, the pathophysiologic gastroesophageal reflux disease (GERD), • Journal of Clinical Anesthesia, 35, 346-349. caused by aspiration of a foreign aspiration include persistent hypoxia, changes that occur in aspiration pneumonitis occur rapidly. In as little as three minutes of The CRNA must educate their patients on the importance of fasting esophageal dysmotility, difficulty doi:10.1016/j.jclinane.2016.08.016 substance, such as, food, high airway pressures, bronchospasm, aspirating, pathologic processes such as atelectasis, peribronchial hemorrhage, pulmonary before surgery to reduce their risk of aspirating. According to Nason swallowing, diabetes, delayed gastric Dibardino, D. M., & Wunderink, R. G. (2015). meconium, or secretions, can be and abnormal breath sounds (Nason, edema, and degeneration of bronchial epithelial cells begin to take place. The alveolar sacs (2015), the American Society of Anesthesiologists Committee on Standards emptying, gastrointestinal obstruction, Aspiration pneumonia: A review of modern referred to as aspiration 2015). become filled with polymorphonuclear leukocytes and fibrin by hour four. At this point, alveolar and Practice Parameters currently allow: need for emergent surgery, previous trends. Journal of Critical Care, 30(1), 40-48. pneumonitis (McCance, Huether, consolidation occurs due to the lung’s gross edema and hemorrhage. Causing further injury to • Consumption of a light meal up to 6 hours prior to surgery esophageal surgery, lack of coordination doi:10.1016/j.jcrc.2014.07.011\ Brashers, & Rote, 2014). • According to DiBardino& Wunderlink lung tissue, proinflammatory cytokines, including tumor necrosis factor (TNF)-alpha and • Clear liquids up to 2 hours prior to surgery of swallowing, esophageal cancer, hiatal interleukin (IL)-8 are released. These findings have also been found on autopsy of patients have McCance, K. L., Huether, S. E., Brashers, V. L., & (2015), additional clinical features that Rote, N. S. (eds.). (2014). Pathophysiology: The • Anesthetic agents can cause hernia, obesity (Nason, 2015) died from aspiration pneumonia. (Bartlett, 2018). can be seen with aspiration • The CRNA should utilize current preoperative medication Biologic Basis for Disease in Adults and reduced cough and gag reflexes, recommendations such as the use of H2 blockers, proton pump inhibitors pneumonitis: • Children (7th ed.). St. Louis, MO: which in turn interferes with an Lack of provider experience and • Fever and prokinetics, which are effective in increasing the pH and reducing the Elsevier/Mosby. individual’s ability to handle expertise (Nason, 2015): • Tachycardia volume of gastric contents, as well as promoting gastric emptying (Nason, Metheny, N. A. (2016). Prevention of Aspiration in oropharyngeal secretions and 2015). • Abnormal chest radiograph • Adults. Critical Care Nurse, 36(1), E20-E24. refluxed gastric contents “In the retrospective review of anesthesia-related aspirations by doi:10.4037/ccn2016831 (Metheny, 2016). • The CRNA may utilize the rapid sequence induction technique on Sakai and colleagues, 10 of the 14 Morehead, R. S. (2009, December 01). Gastro- Risk Factors patients who are considered high-risk cases to minimize the risk of cases were attributed to improper oesophageal reflux disease and non-asthma • “Anesthesia-related aspiration aspirating during intubation (Nason, 2015). This technique includes: • “Causes of aspiration pneumonia lung disease. Retrieved from occurs when patients without anesthesia technique “ (Nason, during the perioperative period can be • Preoxygenation, rapid administration of induction and paralytic http://err.ersjournals.com/content/18/114/23 sufficient laryngeal protective 2015). divided into anesthesia-, surgery-, and agents, cricoid pressure, avoidance of bag and mask ventilation, and 3 reflexes passively or actively device- related factors. The most transoral insertion of an endotracheal tube using direct or video Nason, K. S. (2015). Acute Intraoperative regurgitate gastric contents” consistent risk factors related to Diagnosis laryngoscopy (Nason 2015). Pulmonary Aspiration. Thoracic Surgery Clinics, (Nason, 2015). anesthesia are light anesthesia, 25(3), 301-307. • Is typically presumptive based on the residual neuromuscular blockade after • In cases where cricoid pressure during intubation is contraindicated, doi:10.1016/j.thorsurg.2015.04.011 • Anesthesia-related aspiration clinical feature noted above (Bartlett, anesthesia, and prolonged other options to reduce the risk of aspiration during intubation include Salem, M. R., Khorasani, A., Zeidan, A., & Crystal, occurs in as many as 1 in every 2- 2018) Figure 2. CT scan from an individual with aspiration revealing nodular airspace anesthesia.” (Deguchi, Komasawa, awake intubation and the use of 40° head-up positioning during induction G. J. (2017). Cricoid Pressure Controversies. 3,000 surgical procedures requiring infiltration (#), focal ground-glass opacification (arrow) and centrilobular Ueno, Omori & Minami, 2016). (Salem, Khorasani, Zeidan & Crystal, 2017) Anesthesiology, 126(4), 738-752. anesthesia, and consequently, • Chest radiography abnormalities may nodules with tree-in-bud changes (arrowheads) (Morehead, 2009). doi:10.1097/aln.0000000000001489 approximately half of those appear within two hours after • Medications: Sethi, S. (2017, March). Aspiration Pneumonia and patients who aspirate during their suspected aspiration (Bartlett, 2018). Conclusions • Anesthesia itself puts patients Chemical Pneumonitis - Lung and Airway operation develop a lung-related Significance of Pathophysiology at risk for aspiration by reducing Anesthesia-related aspiration pneumonitis is a potentially fatal Disorders - Merck Manuals Consumer Version. injury such as aspiration • If a bronchoscopy is obtained, it may level of consciousness and by • Understanding the pathophysiology behind anesthesia-related aspiration will aid in the perioperative complication that is preventable in many cases. Understanding Retrieved from pneumonitis or pneumonia (Nason, show erythema of the bronchi, causing loss of protective prevention of its occurrence and minimization of its harmful effects. the pathophysiologic process of aspiration pneumonitis is essential in https://www.merckmanuals.com/home/lung- 2015). indicating acid injury (Bartlett, 2018). reflexes (Nason, 2015). preventing and treating its occurrence. In order to reduce its associated and-airway-disorders/pneumonia/aspiration- • If a patient has aspirated during surgery, the anesthesia provider will rely on his or her morbidity and mortality, anesthesia providers must be aware of the risk factors pneumonia-and-chemical-pneumonitis • Complications stemming from knowledge of pathophysiologic processes to decide whether or not to proceed with the case and utilize the most current prevention and treatment strategies. Son, Y. G., Shin, J., & Ryu, H. G. (2017). Pneumonitis aspiration pneumonitis can range (Nason, 2015). and pneumonia after aspiration. Journal of in severity based on the content, Dental Anesthesia and Pain Medicine, 17(1), 1. quantity, and acidity of the • One major element that will influence this decision is the severity of pathophysiologic doi:10.17245/jdapm.2017.17.1.1 aspirate, in addition to certain processes that may have occurred such as atelectasis, peribronchial hemorrhage and Types of Anesthesia. (n.d.). Retrieved from characteristics of the patient, such pulmonary edema (Bartlett, 2018). https://www.uclahealth.org/anes/types-of- as host defense mechanisms. anesthesia Severity can range from mild and • Additional factors that will influence the provider’s decision include: the necessity of the subclinical pneumonitis to surgery, the patient’s oxygen saturation and lung compliance, and how well the patient progressive respiratory failure and responds to interventions such and bronchodilators and positive end-expiratory pressure death (Son, Shin, & Ryu, 2017). (Nason, 2015).

• In order to reduce the • Antibiotics are not typically recommended as they are not usually effective for aspiration occurrence of anesthesia-related pneumonitis, however, they are often given because it is hard to distinguish chemical aspiration pneumonitis, education pneumonitis from bacterial aspiration pneumonia (Sethi, 2017). on prevention and treatment is essential. • Depending on the volume of aspirated contents, mechanical ventilation should be considered Figure 1. A patient undergoing anesthesia (“Types of Anesthesia,” n.d.) when there is concern for the development of acute respiratory distress syndrome (ARDS) Figure 3. Cricoid pressure application (Salem, et al., 2016). (Nason, 2015).