Aspiration Pneumonitis and Aspiration Pneumonia in Neurologically Impaired Children
Aspiration Pneumonitis and Aspiration Pneumonia in Neurologically Impaired Children
Aspiration Pneumonitis and Aspiration Pneumonia in Neurologically Impaired Children
3
Journal of Paediatric Respirology and Critical Care
upper lobes and apical segments of the lower lobes are occurs in many healthy adults.5 However, the protective
commonly involved when a patient aspirate in mechanisms of forceful coughing and ciliary movement,
recumbent position while basal segments of the lower the low burden of virulent bacteria and normal immune
lobes are commonly affected if a patient aspirate in mechanisms made aspiration pneumonia infrequent in
upright position. healthy persons. Aspiration pneumonia usually refers
specifically to patients who are at increased risk for
Historically aspiration pneumonitis was described as oropharyngeal aspiration.
Mendelson’s syndrome in obstetric patients who
aspirated while receiving general anesthesia during In patients with aspiration pneumonia, the episode of
obstetrical procedures. The severity of lung injury aspiration is generally not witnessed. The diagnosis is
depends on the nature of the aspirate: high vs. low considered when a patient at high risk of aspiration
volume, acidic vs. neutral pH, particulate vs. non- developed radiographic evidence of pneumonia in a
particulate, contaminated vs. non-contaminated, and characteristic bronchopulmonary segment. Its diagnosis
virulence of the organism. Usually a pH of 2.5 or less is confirmed when a protected brush specimen/bronchial
together with volume of gastric aspirate of 0.3 ml/kg is alveolar lavage specimen yield pathogenic organism in
required for the development of aspiration pneumonitis.7 significant concentration.
However, particulate aspiration can cause severe
pulmonary damage even if pH of the aspirate is above Anaerobes are believed to be the commonest organisms
2.5. Gastric contents are sterile under normal conditions in aspiration pneumonia in adults and children.10-12 Two
because of the acidic environment which prevents recent adult studies using protected brush specimen in
bacterial growth. Colonisation of gastric contents by intensive care setting found that aerobic organisms are
pathogenic organisms may occur if the pH in the more common.13,14 However, anaerobic conditions were
stomach is increased, e.g., in patients taking antacids not preserved during transport in both studies. Also in
or proton pump inhibitors. one study14 all patients were given Penicillin G before
sampling with a protected specimen brush was
If the aspiration is witnessed, patient should be put into performed. In community-acquired aspiration
lateral position and the upper airway should be suctioned pneumonia, aerobic organisms commonly isolated
immediately. In patients who are unable to protect their include Strep pneumoniae, Staph aureus, and gram
airways, e.g., patients with impaired consciousness, negative bacilli.15 If the patient comes from institution
endotracheal intubation should be considered. Since or long stay care facility, Pseudomonas aeruginosa is
aspiration pneumonitis is the result of a non-infectious also a common organism.16 A study in children11 using
inflammatory process, most authorities agree that percutaneous transtracheal specimens found that
prophylactic antibiotics are not indicated.7,9 Overuse of multiple organisms are involved in aspiration pneumonia
antibiotics may select for more resistant organisms in with mixed aerobes and anaerobes present in 90% of
patients with uncomplicated chemical pneumonitis. tracheal aspirates. The common anaerobic organisms
Antibiotics should be considered when there is likely to involved in these children include Bacteroides
be bacterial infection, e.g., when aspiration pneumonitis melaninogenicus, Peptococcus, Peptostreptococcus,
worsens or fails to resolve within 48 hours after Fusobacterium, Bacteroides fragiliis, Veillonella, and
aspiration. Prophylactic corticosteroids were commonly Bacteroides oralis while the common aerobic bacteria
used to treat pneumonitis in the past but studies found include Alpha-hemolytic strep, Pseudomonas
that they have no significant effect on patients’ outcome aeruginosa, Strep Pneumoniae, E. coli, Klebsiella and
and complication rates and is therefore not Staph aureus.
recommended.7,9
In one retrospective study17 on antimicrobials treatment
of aspiration or tracheotomy-associated pneumonia in
Aspiration pneumonia neurologically impaired children, three groups of
antibiotics were used, namely: iv ticarcillin-clavulanate
Aspiration pneumonia is an infectious process that followed by oral amoxicillin-clavulanate, iv followed by
develops after aspirating colonised oropharyngeal or oral clindamycin, and iv ceftriaxone followed by oral
gastric material. As we have seen, aspiration of small cefixime. Ceftazidime was added if previous tracheal
amounts of oropharyngeal secretions during sleep aspirate culture reviewed Pseudomonas. A satisfactory
4
Volume 4 No. 3, September 2008 Review Ar ticle
clinical and microbiological response was observed in not recognised. In a study on videofluoroscopic
89% and 91% in the first two groups respectively assessment of dysphagia in children with severe spastic
compared with in only 50% in the third group. It was cerebral palsy, Mirrett et al 4 found that the overall
concluded that ticarcillin-clavulanate and clindamycin incidence of aspiration was 77% while incidence of silent
treated groups had significantly better outcome than the aspiration only is 68%.
ceftriaxone treated group in these neurologically
impaired children. The improved efficacy of clindamycin Assessment of the cough and gag reflexes is unreliable
as well as ticarcillin-clavulanic acid, as compared to in identifying patients at risk of aspiration. The clinically
ceftriaxone, may be due to their excellent antibacterial observable oral phase of swallowing also does not
activity against penicillin-resistant anaerobic bacteria as provide reliable clues as to whether or not the patient is
over 40% of the common pigmented Prevotella sp and swallowing safely.4 A videofluoroscopic swallowing study
Fusobacterium can resist beta-lactam antibiotics by performed by a speech therapist can provide a clear
producing beta-lactamase. 17,18 Common antibiotics picture of the entire swallowing process and its safety.
effective against beta-lactamase producing anaerobes During the study patient is given liquid or solid in different
include clindamycin, metronidazole, chloramphenicol, texture in different position. Videofluoroscopic images
combination of penicillin and a beta-lactamase inhibitor, are taken and analysed to assess the various stages of
and imipenem while antibiotics generally not effective swallowing, including oral preparation, pharyngeal
against beta-lactamase-producing anaerobes include triggering, and pharyngeal clearing/peristalsis. Presence
beta-lactam resistant penicillins, and second and third of aspiration and gastro-esophageal reflux can be seen
generation cephalosporins.17 from the images. If a patient is found to have swallowing
dysfunction, individualised early intervention can be
Antimicrobial therapy is directed at the major pathogens introduced with the help from the speech therapist. This
encountered in different patient groups. In community- could be choosing the appropriate texture of food for
acquired pneumonia, the usual oropharyngeal flora is the patient, reducing the bite size, positioning like
most likely involved and treatment with penicillin with or keeping the chin tucked and the head turned while
without beta-lactamase inhibitor is a good choice.18,19 If feeding etc. Alternative form of feeding like gastrostomy
aspiration pneumonia occurs in hospitalised or feeding is required in patients who continue to aspirate
institutionised children with neurological impairment or despite training and using of specific feeding strategies.
tracheotomy, a different spectrum of organisms will be
involved because of the modified oral flora and
prevalence of gram-negative rods in hospital patients. Gastrostomy feeding and aspiration
We should take into account of previous culture results
which may reveal colonisation by pathogens like Gastrostomy is frequently done for patients with oral-
Pseudomonas and Klebsiella. Because multiple motor dysfunction and poor oral intake with resultant
organisms may be involved in these groups of under-nutrition. Studies have demonstrated that
hospitalised patients, final antibiotic choice needs to rely gastrostomy tube feeding has resulted in increased
on culture results. Pending culture results, a penicillin weight gain and subcutaneous fat deposition, reduction
with beta-lactamase inhibitor plus coverage for gram in time spent feeding and improved quality of life for
negative organisms or Pseudomonas in previously carers and is superior to nasogastric tube feeding in
colonised patient is probably appropriate.18,19 delivering nutrition.20,21
5
Journal of Paediatric Respirology and Critical Care
morbidity following insertion of gastrostomy tube in morbidity and mortality in neurologically impaired
children with cerebral palsy and there was a reduction children. Early assessment for risk of aspiration, including
in chest infections in those who had a proven unsafe the use of videofluoroscopic swallow study, is useful in
swallow. A systemic review21 on gastrostomy feeding setting specific treatment goals for each patient.
and cerebral palsy found that there is little evidence to Aspiration should be suspected in a patient with
conclude whether gastro-oesophageal reflux was dysphagia and an infiltration in a dependent
increased or decreased with gastrostomy feeding. bronchopulmonary segment. Although there is some
overlap between aspiration pneumonitis and aspiration
pneumonia, they are two different clinical entities
Surgical manag ement for intractable requiring different treatment. Aspiration pneumonitis is
pulmonary aspiration a noninfectious inflammatory process and does not need
antibiotic treatment. On the other hand, aspiration
Intractable or chronic pulmonary aspiration is a life- pneumonia should be treated with antibiotics covering
threatening problem. Initial management for recurrent common aerobic and anaerobic organisms according to
aspiration includes swallowing training, positioning, food the prevalence of pathogens in different patient groups.
texture changes, alternative feeding route like
gastrostomy feeding and medications such as anti-
emetics, anti-reflux drugs and antibiotics. If all the initial References
management fails, surgical procedures can be done to
tackle the problem.25 1. Seddon PC, Khan Y. Respiratory problems in children with
neurological impairment. Arch Dis Child 2003;88:75-8.
2. Plioplys AV. Survival rates of children with severe neurologic
Tracheotomy is useful in improving pulmonary toilet in
disabilities: a review. Semin Pediatr Neurol 2003;10:120-9.
patients with sputum retention. However, it is not 3. Plioplys AV, Kasnicka I, Lewis S, Moller D. Survival rates
satisfactory for prevention of aspiration. The presence among children with severe neurologic disabilities. South Med
of the tube in the trachea may in itself compromise J 1998;91:161-72.
laryngeal elevation during swallowing. For more severe 4. Mirrett PL, Riski JE, Glascott J, Johnson V. Videofluoroscopic
assessment of dysphagia in children with severe spastic
aspiration, more definitive and aggressive surgical
cerebral palsy. Dysphagia 1994;9:174-9.
intervention, including glottic closure, laryngeal closure, 5. Rebuck JA, Rasmussen JR, Olsen KM. Clinical aspiration-
total laryngectomy and laryngo-tracheal separation had related practice patterns in the intensive care unit: a physician
been tried with some success. survey. Crit Care Med 2001;29:2239-44.
6. Gleeson K, Eggli DF, Maxwell SL. Quantitative aspiration
Takamizawa et al 26 reported their experience of during sleep in normal subjects. Chest 1997;111:1266-72.
7. Marik PE. Aspiration pneumonitis and aspiration pneumonia.
laryngotracheal separation for intractable aspiration N Eng J Med 2001;344:665-71.
pneumonia in 11 neurologically impaired children. The 8. Gomes GF, Pisani JC, Macedo ED, Campos AC. The
procedure of laryngotracheal separation involved nasogastric feeding tube as a risk factor for aspiration and
dividing the trachea obliquely. The distal end of the aspiration pneumonia. Curr Opin Cin Nutr Metab Care 2003;
trachea was sutured to the skin creating a wide 6:327-33.
9. Moore FA. Treatment of aspiration in intensive care unit
tracheotomy while the proximal trachea was
patients. JPEN J Parenter Enteral Nutr 2002;26:S69-74.
anastomosed to the esophagus or closed. In their study 10. Cesar L, Gonzalez C, Calia FM. Bacteriologic flora of
laryngo-tracheal separation decreased the frequency aspiration-induced pulmonary infections. Arch Int Med 1975;
of pneumonia and the frequency of suctioning required 135:711-4.
and all parents rated the operation as excellent or good 11. Brook I. Percutaneous transtracheal aspiration in the diagnosis
and treatment of aspiration pneumonia in children. J Ped 1980;
in terms of its improvement of quality of life. The authors
96:1000-4.
concluded that laryngotracheal separation can be 12. Brook I, Finegold SM. Bacteriology of aspiration pneumonia
recommended for neurologically impaired children with in children. Pediatrics 1980;65:1115-20.
intractable aspiration as a primary surgical intervention. 13. Marik PE, Careau P. The role of anaerobes in patients with
ventilator-associated pneumonia and aspiration pneumonia.
Chest 1999;115:178-83.
Conclusions
14. Mier L, Dreyfuss D, Darchy B, Lanore JJ, Djedaïni K, Weber
P, et al. Is penicillin G an adequate initial treatment for
aspiration pneumonia? A prospective evaluation using a
Aspiration and its complications cause significant protected specimen brush and quantitative cultures. Intensive
6
Volume 4 No. 3, September 2008 Review Ar ticle