Pneumonia Aspirasi

pada Anak
Divisi Respirologi Anak
Ilmu Kesehatan Anak FK Unand-RS Dr. M.
Djamil

Sejarah

400 thn SM : Hippocrates bahaya

aspirasi
Mendelson th 1946 : aspiration lung
injury
Sampai 50 thn terakhir masih menjadi
tantangan pada anak dan dewasa

Definisi

Pneumonia aspirasi : istilah umum

untuk beberapa sindrom klinik
Gejala klinik tergantung material
yang teraspirasi
Tipikal : berisi makanan / cairan
berasal dari lambung
Bisa juga zat lain seperti minyak
tanah, benda asing
Komplikasi : infeksi

Klasifikasi

Menurut waktu kejadian :

- akut
- silent
Menurut jumlah materi :
- sedikit
- masif
Menurut jenis material :
padat
cairan

Klasifikasi
Acute,
large-volume aspiration

Recurrent, small-volume
aspiration and GER

Foreign bodies

Near drowning

Hydrocarbon (kerosene)

Conditions Predisposing to
aspiration Lung Injury
Anatomic and
mechanical

Neuromuscular

Miscellaneus
Poor or oral
hygiene

Nasogastric
tube

Laryngeal cleft

Prematurity

tracheostomy

Cleft palate

Cerebral palsy

ETT

GER

Hydrocephalus

Micrognathia
Macroglosia

Muscular
distrophy

1. Pneumonia Aspirasi akut/masiv

Tipikal : mengandung makanan

/cairan dari lambung
Mengakibatkan perubahan patologi
dan fisiologi, tgtg pH dan jumlah
material

Large/small particle
Acid/neutral liquid

Reflex airway
clossure
Airway obstruction

Severe hypoventilation

Hypoxemia

Patofisiologi

Aspiration

Pulmonary edema

Hemorrhagic pneumonitis

Destruction and
dilution of surfactant

Atelectasis

Pathologycal changes
Time (after aspiration event)

Pathologic changes

A few minutes (acid asp.)

Atelectasis local

Before 24 hours

Epithelial degeneration of bronchus,

Pulmonary edema, hemorrhagic with
necrosis type 1 alveolar cells,
infiltrations and fibrins in alveolar
spaces

Next 24-36 hours

Alveolar consolidation, mucosal

sloughing

After 48 jam

Hyaline membran may be seen

By 72 hours

Regeneration of bronchial epithelium,

proliferation of fibroblast, decrease
acut inflammation

After 2-3 weeks

Parenchymal scarring, bronchiolitis

obliterans

Clinical Manifestations

Involved witnessed inhalation of

vomit or tracheal suctioning of
gastric contents
Have several risk for aspiration
Mild or severe respiratory distress
Classic Mendelson syndrome :
asthma like reaction wheezing,
hypoxemia, hypercapnia

Clinical manifestations

Fever, coughing and wheezing

Lab. finding : leukocytosis
(infection +)
Radiological : infiltrates, esp. right
upper lobes

Management

Supportive : oxygen therapy, mechanical

ventilation with PEEP
Bronchoscopy and lavage for large particle
No value to lavage for neutralized acid
aspirated
Maintained intravascular volume
Corticosteroid : still controversial, usefull
when gived close to the time of massive
aspiration, ..?

Outcomes

Mortality : 40 80 %
Infectious complications : 50%
Antibiotic for initial therapy :
penicillin, ampicillin, clindamycin
Chest percussive therapy

Conditions Predisposing to infectious

complications of Aspiration

Gingivitis
Decayed teeth
Gastric outlet or intestinal obstruction
Enteral tube feeding
Prolonged hospitalization
Enditracheal intubation
Use of antacid/H2 blockers

2. Recurrent, small-volume
aspiration and GER

Microaspiration or silent aspiration

Small aspiration into the lung
GER : Gastro Eosophagal Reflux
There is a relationship among
recurrent aspiration, GER and
respiratory disease

Mechanisms for the association of

GER and Respiratory disease
GER, causing respiratory disease
Aspiration
Direct effect : bronchitis, tracheitis, pneumonia, atelectasis
Reflex from irritation of trachea or upper airway,
laryngospasm, bronchospasm
Indirect effect : inflammatory or another alteration
predisposising to airway hyperreactivity
Esophageal : airway reflex wiout aspiration
Respiratory disease causing GER
diaphragma flattening and changes of intraabdominal pressure
gradient
Effect of medication causing decreased lower esophageal sphincter
pressure

Disorders associated with GER

Asthma
Chronic cough or
wheezing
Atelectases

Bronchiolitis
obliterans
Apnea, bradycardia

Bronchiectasis

Acute life threating

events
Stridor

Pulmonary fibrosis

Hoarsness

Pneumonia,
bronchitis

Laryngomalacia

3. Foreign body aspiration

Organic or anorganic material

Initially placing objects in the mouth
There is three distinct clinical phase
- period immediately after the aspiration:
coughing, gagging, chokin, stridor, wheezing,
cyanotic
- minutes to month : asymtomatic phase
- renewed symtomatic period : ough, sputum
production, fever, wheezing, hemoptysis

Supporting Management

Ro chest AP and Lateral

May be radioluscent
Ro expiration and inspirations
Bronchoscopy , Bronchography
Acute aspiration : Heimlich
maneuver
Blind finger sweeping is
contraindicated in infant

Complications after airway foreign

bady removal
Acute airway
obstruction
Pneumomediastinum

Laringeal laceration

Pneumothorax

Tracheoseophageal
fistula
Distal bronchiectasis

Massive hempotysis
Laringeal edema

Bronchial stenosis

4. Near drowning

Most likely in children under 5 years

Lung injury induced hypoxia to the lung
parenchyma as well as aspiration of water,
debris, gastric contents, or bacteria
In fresh water aspiration : pulmonary
surfactant is washed out and diluted
atelectasis
In saltwater aspiration : osmotic shift of
protein-rich fluid from the capillary into
the alveoli pulmonary edema

5. Hydrocarbon aspiration

Risk factor : preschool age, mental retardation,

etc
Kerosene : most commonly
Sign and symptom : choking, coughing, gagging
Fever, cyanosis, severe respiratory distress
Ro changes : appear after 30 minutes after ingest
hydrocarbon, most commonly in 12 hours
Decontamination like : induction of vomiting,
nasogastric lavage, are contraindicated

OSAS:

(Obstructive sleep
apnea syndrome)

a
consequence
of childhood
obesity

Introduction

Obstructive sleep apnea syndrome

(OSAS)
is a disorder of breathing during sleep
that disrupts normal ventilation as well
as sleep pattern and associated with
symptoms including habitual snoring,
sleep difficulties, and/or daytime
neurobehavioral problems
Pediatrics 2002;102:1-20

Introduction

Prevalence of OSAS in US: 1-10%

The most common symptom of OSAS
in children is snoring
Risk factors:
adenotonsillar hypertrophy
obesity
craniofacial anomalies
neuromuscular disorder
Am Fam Physician 2004;69:1147-54
Pediatrics 2002;109:704-12

Introduction

Tonsilloadenoidectomy (TA) is the

first line therapy
Clinical squealae:
neurobehavioral problems
cardiovascular problems
failure to thrive
mortality
Sleep Medicine Review 2003;7:61-80
Am Fam Physician 2004;69:1147-54

Definition

OSAS is during 8 hours of nocturnal sleep,

at least 30 apneic episodes
Apnea was defined as cessation of
respiratory flow for at least 10 seconds.
AHI: the ratio of the total number of
apneas and hypopneas observed to the
total sleep time in hour.
Pediatrics 1976; 58:23-31.

Definition

Disorder of breathing during sleep

Prolonged partial upper airway

obstruction &/ intermittent complete
obstruction

Disrupt normal ventilation during sleep

& normal sleep pattern

Symptoms: snoring, sleep difficulties, &/

daytime neurobehavioral problems
Pediatrics 2002;102:1-20

Risk factors

Enlarge tonsils and or adenoids

Craniofacial abnormalities
Age
Sex: Adult Male>>>
Obesity
(ERS Monograph 1998:63-74)

Clinical manifestation

Snoring
Sleep disorder breathing
Apnea episodes
Mouth breathing
Frequent awakening
Diaphoresis
Excessive daytime somnolent
Enuresis
Textbook of pediatrics. 17th edision. 2004:1397-86
Am Fam Phisician 2204;69:1147-54

Clinical manifestation

During wakefulness are often normal

Adenotonsillar hypertrophy: mouth

breathing, nasal obstruction during
wakefulness, adenoidal facies & hyponasal
speech

Complications: systemic hypertension,

pulmonary hypertension & poor growth
Pediatrics 2002;109:704-12
Am Fam Phisician 2204;69:1147-54

OSAS
Adult

Children

Snoring
Gender
Enlarged T-A
Obesity

With pauses
M:F=8-10:1
Uncommon
Major

Continuous
M:F=1:1
Most common
Minor

Complications
Surgical

cardiopulmona Growth,
ry
behavior,
developmental
minority
Most cases

CPAP

Most common

Selected
cases

Pathophysiology

Increased fat deposition in the

pharyngeal walls
External compression by superficially
located fat masses
Increased neck circumference

Deegan PC et al. ERS Monograph 1998: 28-62

Diagnosis

Gold standard: polysomnography (PSG)

Pediatrics 2003;112:870-7

Table 1. Classification of OSAS

Severity
RDI

SaO2

Mild

5-20

>85

21-40

65-84

>40

<65

Moderate
Severe

Head and neck surgery-otolaryngology; 1998. h. 707-29

Screening test

Clinical score

Pulse oxymetry

Videotaping

Clinical score

Three questions
How often would you say your child has
difficulty breathing when he or she is
sleeping?
(0=never, 1=occasionaly, 2=frequently, 3=constantly)

Does your child stop breathing when he

or she is asleep?
(0=no, 1=yes)

How often would you say your child

snores? (0=never, 1=occasinaly,2=frequently,
3=constantly)

Clinical score

OSAS score=
1,42(a) + 1,41(b) + 0,71(c) - 3,73

Brouillette classification:
<-1= OSAS (-)
-1 3,5= doubtfull
>3,5= OSAS (+)

Management

Surgical:
Tonsilloadenoidectomy
Uvulopalatoplasty
Craniofacial correction
Tracheostomy
Am Fam Phisician 2004;69:1147-54
Sleep Medicine Review 2003;7:61-80Peditrics 2002;109:704-12

Management

Non surgical
Reducing body weight
Continuous positive airway
pressure (CPAP)
Canule oxygen
Corticosteroid
Am Fam Phisician 2004;69:1147-54
Sleep Medicine Review 2003;7:61-80
Peditrics 2002;109:704-12

Other tests

Polysomnography (PSG): severe OSAS

Obese - OSAS

Obese children with breathing

difficulties: 37 59% OSAS
Obese children with asymptomatic:
17,8% OSAS
Obese IBW > 180% OSAS more
prevalence

Obesity

The prevalence of obesity: increase

(Am J Clin Nutr 2003;77:29-36)

Underdiagnose (Clinical diagnosis Vs

BMI)
Physician: 46%
Nurse: 33%
Resident: 17 %

(J Am Board Fam Pract 2003;16:14-21)

Management

Repair craniofacial abnormalities

Tonsiloadenoidectomy
CPAP
Topical steroid
Diet

Repair craniofacial

In young children
Depend on anatomical abnormalities
Nasal surgery
Retrolingual operations
Maxillofacial surgery

Levy P et al. ERS Monograph 1998;205-26

Tonsiloadenoidectomy

Effectivity : 75-100%

(Schechter MS. Pediatrics

2002; 109:1-20)

Associated with: increased gain in

height, weight, BMI (Arch Pediatr Adolesc Med
1999;153:33-7)

Improve after tonsiloadenoidectomy,

but severe RDI often had many
respiratory problems (Arch Otolaryngol Head Neck
Surg 1995; 121:525-30)

CPAP

Indication: excessive daytime sleepiness

Improvement in

Sleepiness
Cognitive function score
Blood pressure
Quality of life
Engleman HM. Am J respir Crit Care Med 2002;65:743-4

Topical steroid

Beclomethasone (4 weeks) can

reduce adenoid hypertrophy and
nasal airway obstruction
Controversial

Demain JG et al.Pediatrics 1995:95:355-64

Weight loss

Behaviour modification
Analysis of eating
Food related behaviour

Diet therapy

Education
Poor adherence

Exercise

Regularly

Gastric surgery

Gastric volume limited

Montserrat JM et al. ERS Monograph1998:144-78..

Complications

Neurobehavioral changes
Failure to thrive
Enuresis
Respiratory tract diseases
Poor Academic performances

Mathematics (OR 3.6; 1.3-10.1), science (OR 4.3; 1.314.6), spelling (OR 3.5; 1.3-10.3)

Cardiovasculer abnormalities: corpulmonale

Urschitz MS et al. Am J Respir Crit Care Med 2003;168:464-8

Conclusions

OSAS: disease on 21st century

Obese is a risk factors of OSAS
Weight reduction is key management
of OSAS with obese childhood
beside tonsiloadenoidectomy