Gut: first published as 10.1136/gut.30.2.233 on 1 February 1989. Downloaded from Gut, 1989, 30, 233-238 Case report Laryngospasm and reflex central apnoea caused by aspiration of refluxed gastric content in adults M BORTOLOTTI From the Ist Medical Clinic, University ofBologna, Italy SUMMARY Two patients with attacks of choking caused by aspiration of gastric contents in the laryngotracheal tube are presented. One had such severe attacks of respiratory arrest, that tracheostomy was done. The common symptoms of gastro-oesophageal reflux such as pirosis, acid regurgitation, or retrosternal burning were absent in both patients and upper gut radiological and endoscopic examinations were negative. Histology ofthe oesophageal mucosa showed a deep chronic oesophagitis, and the 24-hour pH-monitoring of the upper oesophagus showed frequent gastro- oesophageal refluxes. Manometry showed hypotonic lower oesophageal sphincter with marked alterations ofperistalsis. In the patient with tracheostomy a 24 pH monitoring of the hypolaryngeal zone showed decreased pH at the time ofchoking attacks. In the other patient further investigations showed that amyotrophic lateral sclerosis was the cause of the oesophageal motility disorder. An intense antireflux treatment abolished the respiratory attacks in both patients. http://gut.bmj.com/ Aspiration of gastric contents in the respiratory tree episodes of reflex central apnoea. In one of the is not rare in patients with gastro-oesophageal reflux. patients the attacks were so severe that tracheostomy Henderson' reported a frequency of27-9% in a group was necessary. Subsequent examinations revealed of 1000 consecutive patients with gastro-oesophageal that the 'trigger factor' was a gastro-oesophageal on October 1, 2021 by guest. Protected copyright. reflux. In adults the frequent consequence of gastric reflux with aspiration of the gastric contents in the contents aspiration is represented by broncopul- larynx. monary manifestations, as bronchial asthma, recurrent respiratory infections, and chronic Case histories bronchitis.'-5 Respiratory arrest caused by aspiration is observed almost exclusively in infants less than one PATIENT 1 year old, in whom it is believed to be the main cause A 57 year old man was admitted to the Emergency of 'cot deaths'.'9 This happens even in absence of Department of the University Hospital for an gross aspiration, being the result of laryngospasm of episode of choking that lasted two to three minutes reflex central apnoea. Respiratory arrest caused by and relieved spontaneously. The patient was sent to gastro-oesophageal reflux is quite exceptional in the ORL Department for a full investigation. He had adults and may present some diagnostic difficulties. a 15 day history of nocturnal crisis of choking that In this paper we describe two patients admitted woke him up suddenly with a sense of 'blocked to the Emergency Department of the University breathing' lasting a few seconds, followed by non- Hospital for choking attacks caused by functional productive cough rapidly relieved by sitting up. obstruction of airways at the level of the larynx with During the day the respiratory crisis with cough and gasp was induced by physical effort, especially lifting Address for correspondence: Dr Mauro Bortolotti, Via Massarenti 48, 40138 weights, trunk flexions, and by the supine position Bologna, Italy. while working. Indirect laryngoscopy revealed a Accepted for publication 21 July 1988. normal larynx except for a mild erithema of the true 233 Gut: first published as 10.1136/gut.30.2.233 on 1 February 1989. Downloaded from 234 Bortolotti vocal cords which showed normal motility at deep Ex-flow (1/s) inspiration. Tomography of the larynx showed no 14r morphological alterations of the glottic or hypo- 12 glottic regions. Electrocardiography and chest x-ray 10 examination were negative with no signs of pul- monary emboli. Routine examinations were normal, 8 6 as well as serum calcium and magnesium, and renal .I. function. Endocrinological and neurological exami- 4 nations did not reveal any alterations and so EEG 2 and TC of the head. Despite the steroid and anti- -A I.n« . j-v~u biotic treatment immediately undertaken the attacks 1 2 3 4 Z 6 7 8 of choking continued to appear mainly at night and 2 v(1) compelled the patient to remain awake overnight and 4 sit upright, as the supine position triggered the crisis. On the third day of his admission, during a very 6 severe attack of choking, the ORL specialist carried 8 out a tracheostomy. Direct laryngoscopy confirmed 101 the alterations previously observed during the 121 indirect one. After tracheostomy the nocturnal 14L respiratory attacks decreased in frequency and In-flow (1/s) intensity but did not disappear and the patient continued to complain of 'arrest of breathing' and Fig. 2 Measurement oftheforced expiratory volume (ex- non-productive cough. As the upper x-ray showed flow, tracing above the ordinate) andforced inspiratory some gastro-oesophageal refluxes, the patient was volume (in-flow, tracing below the ordinate) in the patient 2 sent to us for further examination. Past gastro- at the time ofa choking attack. Theflattening ofthe inspiratoryflow indicates an obstruction in the extrathoracic enterological history was negative. airways. Oesophageal manometry performed with a tech- nique previously described'0 showed a very low basal tone of the LOS (4-7 mmHg) and pressure waves with ever, the 24 hour 'hypolaryngeal' pH monitoring has http://gut.bmj.com/ a lower than normal amplitude and sometimes not been carried out to date and parameters useful synchronous. Twenty four hour oesophageal pH for establishing the entity of pH drop indicative of monitoring" with the pH electrode positioned either acidjuice aspiration are not available. Gastric empty- 5 cm above the lower oesophageal sphincter and just ing test with a scintigraphic method described else- below the upper oesophageal sphincter showed a where'2 showed a moderate delay in gastric emptying higher than normal 'total reflux time' (24-5% and and some spontaneous gastro-oesophageal refluxes. 6-8%, respectively), with frequent acid refluxes Endoscopy showed a apparently normal gullet but on October 1, 2021 by guest. Protected copyright. reaching the upper oesophagus mainly during the oesophageal biopsy from the superior third showed a night. The diary kept by the patient and the event deep chronic oesophagitis. On the basis of these marker of the pH recorder indicated that the results we conclude that the patient had episodes of nocturnal respiratory crises were preceded by aspiration of gastric contents with consequent crisis acid refluxes recorded at the level of the upper of laryngospasm and reflex central apnoea, the oesophagus. The pH electrode was also positioned in pathogenesis of which will be discussed in the the tracheostomy just below the larynx and pH 'comment' section. The patient was discharged from monitoring of the hypolaryngeal lumen was carried the hospital with tracheostomy and with a treatment out for 24 hours: a drop in pH was observed during a consisting of gastric antisecretory drugs, such as respiratory crisis (Fig. 1). To our knowledge, how- famotidine, 40 mg before going to bed, prokinetic 7E- pH 0 1 h Fig. 1 Overnight recordingfrom 10pm to 6 am ofthe intraluminal pH ofthe hypoglottic region obtained by means ofa pH electrode introduced through the tracheostomy in patient 1. Note thefall in intraluminalpH at the time ofthe appearance of choking attack (*) indicating an aspiration ofacid material refluxedfrom the stomach. Gut: first published as 10.1136/gut.30.2.233 on 1 February 1989. Downloaded from Laryngospasm and reflex central apnoea caused by aspiration ofrefluxedgastric content in adults 235 drugs, as metoclopramide 10 mg before each meal oesophagus from 24-5% to 3.1% which is within the and before sleep, and antireflux drugs, as gaviscon normal range. (alginic acid+antacid) after meals and before going to bed. Dietary advice and changes in life style were PATIENT 2 also prescribed. Clinical controls were programmed A 52 year old man presented at the Emergency every three days and when required. As the respira- Department for an acute respiratory insufficiency tory crisis did not reappear and indirect laryngo- with choking, coinage and tirage. He was transfered scopy showed a normal larynx, tracheostomy was to the Pneumology Department where respiratory closed 20 days after the discharge from the hospital. tests carried out immediately showed signs of extra- At the second and six month follow up the patient did toracic airways obstruction, probably laryngeal (Fig. not complain of any significant symptoms, and 2). The patient was then sent to the ORL Depart- indirect laryngoscopy was completely normal. The 24 ment. Indirect laryngoscopy revealed a chronic hour oesophageal pH metric monitoring carried out inflammation of the vocal cords with oedema, while after a six months treatment showed a marked the laryngeal motility was normal. In the meantime, decrease of the 'total reflux time' in the lower the crisis relieved spontaneously. This respiratory 1 , 1 Min. pn 1 20 mm Hg J~~~~~~~~~4.~~~~~~, @witjwesS i<4l*l,5sVt"^^\X; i^P>P{;\W9;IL 1 2 http://gut.bmj.com/ * on October 1, 2021 by guest. Protected copyright. I I. 1 111 1 1 1, I 1 11 1 1 1 |I1 1 I -1 , . GE11 pulhrI I uII GE pull through EP pull through Fig. 3 Gastro-oesophageal (GO) and oesophagopharyngeal (EP), manometric pull through in the patient 2 with choking attacks caused by inspiration and an early stage ofa motor neurone disease. Recordingpoints 1, 2, and 3 are 5 cm apart, whereas 4, 5, and 6 are at the same level and 5 cm apartfrom No 3. Arrows indicate swallows, and 1 cm intervals ofthe stepwise pull-through are indicated at the bottom. Note the very low pressure ofthe lower oesophageal sphincter (*) and the low and synchronous pressure waves ofthe oesophageal body. In addition, 2-3 cm below and 4-5 cm above the upper oesophageal sphincter (**) the postdeglutitive pressure waves are absent indicating loss offunction ofthe striated muscle.