Acute aspiration

Case history

A 62-year-old woman with systemic lupus erythematosus undergoes a head magnetic resonance imaging for acute mental status changes suggesting lupus cerebritis. The patient has been taking prednisone each day for several months. She has a diagnosis of GORD, for which she takes a proton-pump inhibitor. During the imaging study in the supine position, the patient vomits and aspirates gastric contents consisting of yellowish-greenish fluid. Severe respiratory distress and hypoxaemia develop, and she requires endotracheal intubation, mechanical ventilation, and admission to the intensive care unit. Physical examination reveals bilateral crackles and wheezes.

Other presentations

In the UK, aspiration of gastric contents is commonly seen, particularly in older patients due to associated swallowing dysfunction and comorbidities, or as a consequence of substance misuse.

Aspiration is more common in older patients who have comorbidities, particularly those that affect swallowing function such as stroke. Other presentations include scenarios where the patient has an impaired conscious level (which causes loss of airway protection mechanisms), gastrointestinal disorders, conditions that affect gastric emptying, and oesophageal abnormalities. Additionally, patients undergoing upper airway or endoscopic procedures are at risk, such as during a general anaesthetic or in the intensive care unit, or following gastrointestinal studies with barium. Limited protection is provided by a nasogastric tube, a percutaneous endoscopic gastrostomy, or an endotracheal or tracheostomy tube, and in fact they may increase the risk.[2]Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar 1;344(9):665-71. http://www.ncbi.nlm.nih.gov/pubmed/11228282?tool=bestpractice.com Patients with acute aspiration can develop aspiration pneumonitis, pneumonia, and acute respiratory distress syndrome.