Aspiration

Question 1

Question 1:
What is aspiration, and when does it occur?

Answer 1

Answer 1:

• Aspiration occurs when something is breathed into the airways instead of being swallowed.
• It can happen when substances like GI contents, oropharyngeal secretions, or foreign bodies enter the airway.

Question 2

Question 2:
What are the three kinds of substances that can be aspirated?

Answer 2

Answer 2:
The three kinds of substances that can be aspirated are:

(i) GI Contents: Contents from the esophagus or stomach, including vomit or regurgitated materials that enter the airway.

(ii) Oropharyngeal Secretions: Secretions from the oral cavity and pharyngeal area directed toward the trachea instead of the esophagus.

(iii) Foreign Body: Any foreign object that enters the airway.

Question 3

Question 3:
What are the components involved in the gag/cough reflex?

Answer 3

Answer 3:
The gag/cough reflex is mediated by the CNS and involves the following nerves:

Glossopharyngeal nerves
Vagus nerve
Accessory nerves

Question 4

Question 4:
What happens if the gag/cough reflex is impaired?

Answer 4

Answer 4:
If the gag/cough reflex is impaired, it will not prevent substances like GI contents, oropharyngeal secretions, or foreign bodies from entering the airway.

Question 5

Question 5:
Name three disease processes that can cause a decreased gag/cough reflex.

Answer 5

Answer 5:
Three disease processes that can cause a decreased gag/cough reflex are:
(i) Stroke
(ii) Tumor
(iii) Trauma

Question 6

Question 6:
What is GERD, and how does it relate to aspiration?

Answer 6

Answer 6:

• GERD stands for Gastroesophageal Reflux Disease.
• It occurs when gastric acid repeatedly flows back into the distal esophagus.
• GERD can increase the risk of aspiration if the acidic contents reach the airway.

Question 7

Question 7:
Which gastrointestinal motility disorder can contribute to aspiration risk, and what is its main characteristic?

Answer 7

Answer 7:

• Achalasia
• Its main characteristic is decreased motility of the esophagus.

Question 8

Question 8:
What is a Tracheoesophageal Fistula, and is it usually a congenital or acquired condition?

Answer 8

Answer 8:
* an opening in the connection between the trachea and the esophagus.

• It is usually a congenital problem.

Question 9

Question 9:
What is Meconium Aspiration, and which group of neonates is at an increased risk for it?

Answer 9

Answer 9:
Meconium Aspiration occurs when neonates (those who are over 42 weeks) have an increased risk of aspirating meconium (stool) , which contains amniotic fluid and feces.

This condition is associated with Meconium-stained amniotic fluid (MASF).

Question 10

Question 10:
What are the two neuromuscular junction (NMJ) disorders mentioned in the notes that can lead to impaired gag reflex?

Answer 10

Answer 10:

(i) Guillain-Barre Syndrome, an acute inflammatory demyelinating polyneuropathy.

(ii) Myasthenia Gravis, the most common NMJ disorder where autoantibodies attack the postsynaptic Ach receptors, leading to fatigable muscle weakness.

Question 11

Question 1:
What are the general clinical features of aspiration?

Answer 11

Answer 1:

1. Coughing - Due to inflammation and irritation of the mucosa.
2. Stridor - A loud sound heard during inspiration due to blockage of the upper airway.
3. Wheezing - Sound heard during expiration due to blockage of the lower airway.
4. Decreased breath sounds - Little air getting in and out due to partial obstruction, which can lead to hyper-expansion of the lungs or atelectasis.
5. Mediastinal and tracheal shift - Ipsilateral shift, especially in full obstruction, due to the need for more air in the collapsed lung.
6. Cyanosis - Bluish discoloration of the digits and mucous membranes.

Question 12

Question 2:
Which bronchus is more commonly affected during aspiration, and why?

Answer 12

Answer 2:

The right bronchus is more commonly affected than the left bronchus during aspiration.
This is because the right bronchus is wider and more vertical than the left bronchus, making it more susceptible to blockage by aspirated substances.

Question 13

Question 3:
What are the complications of aspiration?

Answer 13

Answer 3:
The complications of aspiration include:

1. Pneumonitis and Pneumonia - Caused by the harsh nature of gastric contents with low pH and bacterial contents.
2. Cough with sputum - More suggestive of pneumonia than pneumonitis.
   Wheezing - Due to bronchospasm.
3. Fever - More suggestive of pneumonia than pneumonitis, especially if high-grade, caused by an increase in cytokines leading to an increase in temperature.
4. Hypoxemia - Due to decreased ventilation of alveoli, and monitoring if it worsens and does not respond to oxygen.

Question 14

Question 4:
What is the difference between pneumonitis and pneumonia in terms of clinical presentation?

Answer 14

Answer 4:

• Pneumonitis is characterized by cough without significant sputum production.
• Pneumonia is characterized by cough with significant sputum production.

Question 15

Question 5:
What is the reason behind wheezing in aspiration?

Answer 15

Answer 5:

• Wheezing in aspiration is caused by bronchospasm, resulting from the irritation and inflammation of the airways due to the aspirated substances.

Question 16

Question 6:
Why do lungs hyper-expand in cases of partial obstruction during aspiration? What are the findings

Answer 16

Answer 6:
because only a limited amount of air can get in and out of the airways, leading to air trapping and hyper-expansion of the lung tissue.

• This appear as Hyper-Resonance to percussion

Question 17

Question 7:
What is the clinical significance of mediastinal and tracheal shift in cases of aspiration?

Answer 17

Answer 7:
Mediastinal and tracheal shift, especially in cases of full obstruction during aspiration, is clinically significant because it indicates that more air is needed in the collapsed lung.

• To summarize, mediastinal and tracheal shift in cases of aspiration are significant because they indicate potential airway obstruction and can lead to conditions like atelectasis.

Question 18

Question 1:
What is ARDS, and what are its main features?

Answer 18

Answer 1:

• ARDS stands for Acute Respiratory Distress Syndrome.
• Its main features include diffused alveolar damage leading to severe hypoxemia that is poorly responsive to oxygen.
• It is characterized by bilateral infiltrates and consolidations within less than one week of the aspiration event, and the hypoxemia is not due to heart failure.

Question 19

Question 2:
What is the clinical presentation of lung abscess?

Answer 19

Answer 2:
Cough with foul-smelling sputum.
Fever.

Question 20

Question 3:
Which type of microorganisms are commonly associated with lung abscess?

Answer 20

Answer 3:
Lung abscess is commonly associated with ANAEROBES, which are microorganisms that thrive in environments with low oxygen levels.

Question 21

Question 4:
How does meconium aspiration affect the airways and the lungs?

Answer 21

Answer 4:

• Meconium aspiration in post-term neonates can cause clogging of the airways, leading to hyperinflation of the lungs.

Question 22

Question 5:
What are the potential complications of meconium aspiration?

Answer 22

Answer 5:
Leaking into the pleural cavity and mediastinum, leading to pneumothorax and pneumomediastinum.

Question 23

Question 1:
What is the first important step in diagnosing aspiration in a patient with an obstruction?

Answer 23

Answer 1:

• to get a bronchoscopy immediately.
• This procedure allows visualization of the foreign body and can also be used to remove the foreign body or mucus.

Question 24

Question 2:
Why is the right lung more likely to be affected by aspiration than the left lung?

Answer 24

Answer 2:

the right bronchus is wider and more vertical, making it easier for a foreign body to enter.

Question 25

Question 3:
What areas of the lung are more likely to be affected depending on the patient’s position during aspiration?

Answer 25

Answer 3:

• Lying supine: More likely to affect the upper segments of the right lower lobe.
• Sitting/standing: Gravity pulls the foreign body down the lower lobes, affecting the basal and posterior segments of the right lower lobe.
• Lying on the right side: The foreign body can flow into the right upper lobe, particularly the posterior segments or right middle lobe.

Question 26

Question 4:
How can a chest X-ray (CXR) help in diagnosing aspiration?

Answer 26

Answer 4:
by looking for the foreign body or its effects:

• If the foreign body is visible, it can be identified on the CXR.
• In cases of complete bronchus obstruction, the affected lung will not fill with air, leading to lung collapse and atelectasis, and a shift in the mediastinum to the affected side.
• In cases of partial bronchus obstruction, the lung distal to the obstruction will be hyper-expanded/hyper-inflated.

Question 27

Question 5:
What are the signs on a CXR that indicate a high risk of pneumonia or pneumonitis after aspiration of GI/oropharyngeal secretions?

Answer 27

Answer 5:

• Infiltration or consolidation.
• Increased fever due to an increase in cytokines that raises temperature.
• Increased sputum production.
• Elevated white blood cell count (leukocytosis).

Question 28

Question 6:
How can a sputum culture be helpful in diagnosing pneumonia after aspiration?

Answer 28

Answer 6:

A sputum culture can help confirm the presence of pneumonia after aspiration by identifying the type of pathogen causing the infection.

Question 29

Question 5:
How can you differentiate between pneumonitis and pneumonia based on the CXR?

Answer 29

Answer 5:
It can be challenging to differentiate between pneumonitis and pneumonia based solely on a single CXR.
To differentiate between the two, it’s essential to look at the patient’s physical exam:

Check for fever, white blood cell count, and sputum production.

• Observe if the opacity is staying consistent on the CXR.
• If there are signs of infection with fever, leukocytosis, and sputum production, it is more likely to be pneumonia.
• Serial imaging may be needed to make a definitive diagnosis.

Question 30

Question 1:
What is the first-line treatment for a patient showing signs of upper airway obstruction due to a foreign body?

Answer 30

Answer 1:

• Chest/Abdominal Thrusting.
• This procedure is performed to dislodge the foreign body and alleviate the obstruction.

Question 31

Question 2:
When should a bronchoscopy be performed in a patient after aspiration of a foreign body?

Answer 31

Answer 2:

A bronchoscopy should be performed if the patient is not in an acute state after aspiration of a foreign body.

The type of bronchoscopy (flexible or rigid) depends on the patient’s stability.

• If the patient is stable, a flexible bronchoscopy is used.
• If the patient is unstable, a rigid bronchoscopy is preferred.

Question 32

Question 3:
What is the primary approach to treating pneumonitis, and what factors should be considered in treatment?

Answer 32

Answer 3:

The primary approach to treating pneumonitis is to address the underlying cause.

Factors that should be considered in treatment include determining the cause of the aspiration, such as decreased cough-gag reflex, stroke, seizure, CNS depression, GERD, NG tube, or fistula.

Supportive care is usually sufficient in many cases.

Question 33

Question 4:
What is the recommended treatment for pneumonia, and how are antibiotics chosen for outpatient and hospitalized patients?

Answer 33

Answer 4:

• The recommended treatment for pneumonia is antibiotics, targeting anaerobic bacteria.
• For outpatient treatment, antibiotics like Clindamycin or Amoxicillin-Clavulanate are used.
• In hospitalized patients, a sputum culture is taken to accurately identify the pathogen, and while waiting for the results, Vancomycin and Piperacillin/Tazobactam can be used as empirical therapy.

Question 34

Which of the following is a cause of aspiration?
a) Decreased gag/cough reflux
b) Tracheoesophageal fistula
c) GERD
d) All of the choices are correct.

Answer 34

Answer: d) All of the choices are correct.

Question 35

hich of the following describes pneumonitis and pneumonia?
a) Non-productive cough
b) Low-grade fever
c) Wheezing is rare.
d) Hypoxemia

Answer 35

Answer: d) Hypoxemia

Question 36

Which of the following statements about ARDS is INCORRECT?
a) It may be due to cardiovascular causes.
b) Severe hypoxemia poorly responsive to oxygen
c) Bilateral infiltrates and consolidations within less than one week of the aspiration event
d) Diffused alveolar damage

Answer 36

Answer: a) It may be due to cardiovascular causes.

Question 37

Which is the most significant risk factor for Meconium Aspiration?
a) Preterm
b) Post-term (>42 weeks)
c) Congenital fistula
d) Gestational diabetes of the mother

Answer 37

Answer: b) Post-term (>42 weeks)

Question 38

All are signs & symptoms of aspiration, EXCEPT:
a) Cyanosis
b) Stridor
c) Wheezing
d) Increased breath sounds

Answer 38

Answer: d) Increased breath sounds

Question 39

What is the first important step in evaluating a patient suspected of aspiration in terms of diagnostic procedures?
a) Obtaining a chest X-ray or CT scan promptly to assess the affected areas based on the patient’s position during aspiration.
b) Initiating immediate medical treatment without the need for further diagnostic procedures.
c) Administer antibiotics empirically to prevent potential infection.
d) Immediate bronchoscopy to visualize and potentially remove the foreign body or mucus obstruction.
e) Performing a physical examination to assess respiratory symptoms and signs.

Answer 39

Answer: d) Immediate bronchoscopy to visualize and potentially remove the foreign body or mucus obstruction.

Question 40

Which position is more likely to result in the foreign body affecting the basal and posterior segments of the right lower lobe?
a) Laying supine
b) Sitting/standing
c) Laying on their right side
d) Laying on their left side
e) It does not depend on the position

Answer 40

Answer: b) Sitting/standing

Question 41

Which of the following statements describes the most likely location of a foreign body aspiration based on the patient’s position?
a) If the patient is lying supine when aspirating: More likely to affect the upper segments of the right lower lobe.
b) If the patient is sitting/standing: Gravity would pull the foreign body further down the lower lobes. Posterior segments of the right middle lobe are more affected.
c) If the patient is lying on their right side: The foreign body can flow into the right upper lobe, particularly the posterior segments or right middle lobe.
d) The location of the foreign body aspiration is not influenced by the patient’s position.
e) It is impossible to determine the location based on the patient’s position.

Answer 41

Answer: b) If the patient is sitting/standing: Gravity would pull the foreign body further down the lower lobes. Posterior segments of the right middle lobe are more affected.

Question 42

When assessing a chest X-ray (CXR) for possible fluid aspiration, pneumonia, or pneumonitis, which of the following findings would not suggest the presence of pneumonia?
a) Infiltration or consolidation observed on the CXR.
b) Increased oxygen requirement due to consolidated areas causing hypoxemia.
c) Elevated body temperature due to increased cytokines.
d) Increased sputum production.
e) Mediastinal shift to the ipsilateral side.

Answer 42

Answer: e) Mediastinal shift to the ipsilateral side.