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CAUSE:
Clinical entities
Pathophysiology
Assessment and Diagnosis
Treatment
Nursing care
Nursing Diagnosis and
Management
Impaired consciousness
Compromised glottal closure
Compromised cough reflex
Ileus or gastric dilation
Nasogastric feeding tubes (large or small bore)
Artificial airways
Disorders affecting pharyngeal and / or esophageal motility
Tracheoesophageal fistulas
General anesthesia
Cardiopulmonary resuscitation
Improper patient positioning during tube feeding
Esophageal strictures
CAUSE:
The presence of abnormal substances in the airways and alveoli as a result of aspiration is
misleadingly called aspiration pneumonia .The title is misleadingly because the aspiration of
toxic substances into the lung may or may not involve bacterial infection. Aspiration lung
disorder would be a more meaningful title, because injury to the lung can result from chemical,
mechanical, and/ or bacterial characteristics of the aspirate. Each gives rise to a specific clinical
entity (see table 1).
Table 1 Clinical entities associated with aspiration lung disorder
Inoculums
Pulmonary
sequelae
Acid
Chemical
pneumonitis,late
bacterial infection
possible
Clinical features
Therapy
Correct
hypoxia,
intravenouse
fluids, monitor
blood gas,
antibiotics for
associated
bacterial
infections
Pathophysiology
Characteristics of the aspirated material are crucial to the ultimate effects on lung tissue.
Generally, an aspirate with a low Ph spreading throughout the lung fields may quickly result in
adult respiratory distress syndrome. As seen in animal studies, the "critical pH" of less than 2.5
is thought to cause severe chemical lung injury. The coupling of a low pH and virulent
pathogens may quickly overwhelm normal defenses of the lung. Aspiration of material from the
oropharynx carries resident flora to the sterile lower respiratory tract. Elderly and hospitalized
patients show a prevalence of gram-negative bacteria in the oropharynx, which increases the
likelihood of gram-negative pneumonias associated with aspiration.
The outcome of an aspiration event depends on the amount and type of aspirate, the
distribution of aspirate in the lungs, and the patient's overall condition and defense
mechanisms. Aspiration of significant amounts can be readily noticed with respiratory distress,
dyspnea, wheezing, and coughing. However, aspiration of smaller amounts (silent aspiration)
can occur without recognition, especially in patients with altered level of consciousness.
Aspiration of gastric juices that have a pH of less than 2.5 results in a chemical burn to the
lung. If significant of acid are aspirated, extensive atelectasis can occur. Bronchospasm occurs
later and is followed by epithelial injury and disruption of the alveolar membrane. Changes in
the alveolar membrane result in fluids and cellular elements leaking into the interstitial space
and to the alveoli. The fluid decreases surfactant production, which results in atelectasis.
Aspiration of particular matter may have an immediate life-threatening result if large particles
mechanically block the major airways.
When aspiration of a significant volume or repeated aspiration of smaller volumes occurs, the
patient will develop increasing dyspnea, fever, tachypnea, and cyanosis.
If the cough reflex is intact, increased coughing occurs. Intubated patients may require more
frequent suctioning, and aspirated material may be present in secretions. Auscultation of the
lung fields demonstrates breath sounds in the affected area with associated wheezes.
Arterial blood gases reflect hypoxemia and a widened Aa Do2, while an increased FIO2 is
needed to maintain satisfactory oxygenation. Intubations followed by mechanical ventilation
may be required. If bacterial infection becomes established, the white blood cell count may
become elevated. A normal or decreased white blood cell count in the setting of infection
suggests overwhelming host invasion and a poor prognosis.
Chest x-ray changes appear 12 to 24 hours after the initial aspiration. The validity of the chest
x-ray in diagnosing aspiration lung disorder is related to the prior status of the patient. Patients
with underlying lung involvement, as commonly seen in critical care units, may already have
significant pulmonary infiltrates present on chest x-ray evaluation, clouding the interpretation.
In massive aspiration, diffuse bacterial infiltrates suggest pulmonary edema is present, whereas
lesser aspirations show atelectasis in early period. Later chest films show large, fluffy
infiltrates.
Since most aspiration events are unwitnessed, a high degree of suspicion coupled with an
ability to recognize the at-risk patient is paramount to diagnosing aspiration lung disorder.
Purposeful data collection is followed to delineate the presence or absence of aspiration lung
disorder. Radiographic and bacteriological studies should be undertaken. Recognizing
aspiration lung disorder requires understanding of the clinical spectrum of events, recognition
of the factors that predispose to aspiration, chest x- ray and laboratory data, and the
identification of pathogens from the aspirated material or uncontaminated sputum specimens.
Treatment
Nursing care
During the course of caring for the critically ill patient, the nurse must implement measures
for preventing aspiration lung disorder. If the aspiration event occurred before the patient
admission to the critical care unit, the nurse must direct interventions toward (1) maintaining
the airway and supporting respiratory function, (2) early recognition and treatment of
complications of aspiration of lung disorder, and (3) preventing further aspiration events.
Unless contraindicated, the unconscious patient should be placed on the side in a slight
Trendelburg's position to promote drainage and discourage aspiration. Placement of
nasogastric tubes(NG) for gastric decompression requires careful consideration, as NG tubes
paradoxically increase the risk of aspiration and have been frequently shown to empty the
stomach incompletely. Patients receiving continuous or intermittent tube feeding should be
maintained in at least a 30-degree head elevation. If a recumbent or head down position is
necessary, feeding should be interrupted every 30 minutes to 1 hour before assuming a flat
position is preferred, because it aids passage of gastric contents through the pylorus. Also, in
this situation the choice of the type of feeding tubes takes on added importance. Most sources
recommended intestinal feedings via a small-bore weighted tube to reduce the risk of
aspiration. Frequent checking of tube location, as well as checking for gastrin retention of the
feeding, is necessary to prevent aspiration. The standard technique used to check retention may
be difficult in small-bore, pliable catheters, because drawing back can collapse the lumen.
Therefore abdominal girths should be monitored on a serial basis. An increase in abdominal
measurements of 8 to 10 cm above the baseline should be interpreted as a significant sign of
gastric retention, and feedings should temporarily be postponed. When the residual can be
checked by aspiration, amounts greater than 150 ml of a bolus feeding or greater than 10% to
20% of the hourly flow rate in continuous feeding indicates that feeding should be withheld
until emptying occurs.
Gastrointestinal motility should be assessed regularly by auscultation of bowel sounds.
Absence of bowel sounds (5 minutes without sounds), presence of persistent distention, or
nausea and vomiting indicates that feeding should be discontinued.
Monitoring nasogastric tube placement regularly is a necessary nursing task. Placement of any
tube should be initially verified by x-ray examination or whenever the possibility of
dislodgment is suspected. There have been several reports about small-bore tubes being
inadvertently placed or dislodged into the respiratory tract.
Frequent suctioning of the oropharynx should be performed in patients with artificial airways.
This prevents pooling of secretions on the cuff and subsequent aspiration to the lower
respiratory tract. Aspiration past a properly inflated, functioning cuffed tube has been seen in
58% to 87% of patients.
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