Case Study
The bedside nurse initiated a rapid response event after the patient had an aspiration event where he had desaturated to the 70 s. Upon prompt arrival of the rapid response team, the patient was found to be a 77-year-old male with a known history of chronic obstructive pulmonary disease, coronary artery disease, type 2 diabetes mellitus, hypertension, and poor oral dentition. He was admitted a few hours earlier for right-sided weakness in the upper and lower extremities with a left-sided facial droop and was being evaluated for a stroke. The patient was still to be seen by speech therapy. His daughter had brought in some chicken noodle soup which he was eating, and started choking on it.
Vital Signs
Temperature: 98.2 °F, axillary
Blood Pressure: 155/97 mmHg
Pulse: 110 beats per min (bpm) – regular rhythm.
Respiratory Rate: 28 breaths per min
Pulse Oximetry: 72% on room air, improved to 85% when placed on a 15 L/min (LPM) non-rebreather (NRB)
Focused Physical Examination
A quick exam showed an elderly male sitting up in bed in significant respiratory distress. He was alert and oriented and followed all commands appropriately. A pulmonary exam showed tachypnea with coarse breath sounds in the right lung. Diffuse wheezing was also present in all lung fields. His cardiac exam was significant for tachycardia with normal heart sounds, no murmur. The patient had weakness of the right upper and right lower extremity, with a left-sided facial droop which was similar to prior documentation. A detailed neurological exam was not done given tenuous respiratory status.
Interventions
A cardiac monitor and pads were attached immediately. Emergent endotracheal intubation was done at the bedside to secure the airway. Arterial blood gas was obtained, which later showed a pH of 7.19, pCO2 of 118, pO2 of 50, oxygen saturation of 85% on 15 LPM NRB. Stat chest X-ray (CXR) was obtained, which showed an endotracheal tube in the correct place. It also showed diffuse bilateral opacities/consolidation, most prominent in the left mid and lower lung zones, consistent with aspiration pattern ( Fig. 22.1 ). Stat dose of ampicillin-sulbactam was ordered, and the patient was immediately transferred to the intensive care unit for therapeutic bronchoscopy and pulmonary toilet.
Final Diagnosis
Hypoxic respiratory failure secondary to aspiration of food contents.
Aspiration Pneumonia
Aspiration pneumonia is the inflammation and infection of the pulmonary parenchyma caused by the penetration of the respiratory tract by oropharyngeal or gastric secretions. In contrast, aspiration pneumonitis is the inflammation of lung parenchyma from sterile oro-gastric contents, especially gastric acid ( Table 22.1 ). Risk factors associated with aspiration pneumonia include pathologies that lead to an inability to clear oral secretions. It can present in a variety of manners depending on different inoculums ( Table 22.2 ).
| Features | Aspiration pneumonia | Aspiration pneumonitis |
|---|---|---|
| Inoculum | Oropharyngeal material colonized with flora | Sterile gastric contents |
| Mechanism of injury | Infection and inflammation of pulmonary parenchyma from bacteria | Inflammation of pulmonary parenchyma from gastric acid |
| Microbiological profile | Mixed gram-positive and gram-negative organisms, particularly anaerobes | Sterile initially, however, can develop superinfection later on |
| Pre-disposing factors | Dysphagia | Altered mental status, peri-procedural |
| Clinical features |
|
|
| Treatment | Broad-spectrum antibiotics that cover anaerobes, e.g., ampicillin-sulbactam in stable patients, carbapenems in sick patients |
|
| Clinical course | Cure rate 76%-88% with broad-spectrum antibiotics |
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