aspiration pneumonia - to debz

[Guest guest]

Hi Debs,

I am not sure how to answer your questions because I am not

that familiar with the procedures that were done with you or the

modern equipment that is available to do them.

The first thing to emphasize is that the airway tube (our trachea)

and the eating or food tube (the esophagus) are two different

structures that share space in the neck but do not connect at all

except that they share an " opening " in the mouth. You have to

remember that once you get away from the mouth the food tube

goes to the stomach and the air tube goes to the lungs. That is

why you can be intubated and endoscoped at the same time

theoretically....the only limiting factor is to have the equipment

available that will not get in each other's way in the common

space - the mouth.

Basically what I can say is that the NG tube as well as the

endoscope is snaked down your esophagus into your stomach

then into the duodenum. The NG can just be advanced as far as

your stomach (to aspirate that contents) or into the duodenum to

aspirate the fluid in that location. After an ERCP or abdominal

surgery, when there is a concern that the bowels will not function

for instance, an NG tube will be placed to make sure that no

obstuction is taking place which will injure the bowel. In

addition, some endoscopists use an NG tube to aspirate fluid

after an ERCP in the hopes that it will reduce the occurence of

post-ERCP pancreaitis. I am not sure how successful this is or

how widespread its use. The endoscope that is used for the

ERCP is snaked into your tummy, through your duodenum then

into your common bile duct and pancreatic duct (to inject the dye

that is used so that the x-rays can show the ducts).

Intubation, on the other hand, is basically putting in an artificial

airway to ensure that the patients breathing tube (trachea) that

goes from mouth to lungs cannot get blocked. Most times in an

unconscious person, the tongue is the biggest culprit for

this....when you relax and especially when you are on your back,

your tongue falls " back " and blocks the airway. In addition, if

there is any trauma or swelling of the throat due to allergies for

instance it can block the airway. In OR work under GA, like

and Kaye mentioned, it is not so much that your airway

is blocked as it is that your muscles are paralyzed so you cannot

breathe normally. So the airway is established in order for the

anesthesiologist to breathe for you as well as administer the

correct medications. The question that is coming up in our

discussion is that the equipment that is used for the ERCP and

the airway may interfere with each other because they both have

to share space in the mouth where the trachea (breathing) and

esophagus (eating) have a common " opening " . The thought that

we are tossing around is " is there enough space to manipulate?

Can the endoscope be advanced through the mouth when there

is an articial airway in place " ?

In emergency care or emergency surgery it is common to use

NG tubes in conjunction with intubation. The main reasons that I

can think of off-hand (and I know that I am missing many

examples, but this is not my area of expertise by any means) is

that in emergency work, it is common that the patient has a full

stomach (think how often a person will eat) and the surgeon

needs to clear the stomach out, both for the operating field and

to ensure that the patient will not aspirate.

When a person is unconscious due to trauma or GA, there is a

chance that the valves that keep the stomach contents from

going backwards (from stomach to mouth) is relaxed so much

that it doesn't work. Then the stomach contents flow into your

mouth which can drain into your trachea and enter your lungs. If

this happens, it is a very life threatening condition because the

acidity can eat away the tissue in the lungs. There is a high

mortality rate for aspiration pneumonia. That is why you read

that unconscious people (like after drinking too much) are in

such danger of aspirating and dying from it. In addition, there is a

high chance of them choking on the fluid in the immediate

aftermath of going unconscious (which is why people try to lay

them with their heads turned to the side - laying on their tummy

or side - not back). Aspiration pneumonia may not kill you

immediately, but can quite quickly cause you to go downhill

(days to weeks I think).

What intubation does is that it ensures that air can get into the

lungs by providing a hollow tube for air to flow and it also

prevents regurgitation from getting in, too, by blocking the airway

around the tube so nothing can seep around the outside of the

tube. I think of it as a plastic straw with a clear baggy around it.

You put the straw into the throat then inflate the plastic bag to

snug up around the tube between it and the person's tissue. In

the rescue squad, we litterally blew it up like a balloon.

The danger of course, is that you need to ensure that the

intubation tube is going into the lungs and the NG tube is going

into the stomach. You do not want to be suctioning the lungs with

the NG tube nor do you want to be putting air into the stomach

thinking you are breathing for the person (you can burst the

stomach for one thing and you are cutting off the air supply for

another thing). So it is a technique that while simple, is very

critical to do right!

So in your case, the gagging could have been that you were not

" under " as deeply as you should have been. The gag reflex is

one of the strongest ones that we have and it can indicate the

level of unconsciousness of the patient (I believe that this is

so...remember that it has been along time since I have done ER

work). So your gagging may have been that you were brought out

too quickly or that you were not anesthesized to the right degree.

This could have been the anesthesiologists oversight or

because the two doctors were not communicating about the

procedure, or it could have been for another reason

altogether......

The fact that you did aspirate into your lungs under general may

indicate that either the intubation wasn't snuggly done and it

allowed fluid to " seep " around it, or you were not intubated at all

(that MAC that was mentioned) or that the NG tube was

somehow mis-handled (and I hesitate to say that because it

implies a mistake and that may not be so). I cannot even

speculate on your exact situation but I do know that aspiration is

considered a very dangerous situation and one that is to be

avoided at all costs. I do not think it is caused by the tubes going

the wrong way per se or from having 2 going down at all. There

is a chance that if an NG tube was mis-placed into the lungs and

it was being used to lavage the stomach (let's say they were

trying to wash out some stomach contents so they were using

the NG tube to put fluid into the stomach) then they may end up

putting fluid into the lungs instead....which is a bad, bad

thing.....although maybe not as bad as aspirating stomach

contents (depending on volume for example).

This is the best I can do with my limited knowledge of OR

techniques and airway / NG placement. I am just throwing out

my thought processes and I could be really off the mark so take

what I am writing as at best, a starting place. I hesitated to even

try but I thought that this may at least give you a general idea.

Laurie

[Guest guest]

Hi Debs,

The only thing that I can think of as a possibility and again, these

are wild guesses and I may not even be in the right universe, let

alone the right ballpark...but maybe the GI guy tried to advance

the NG tube into the trachea and when he tested by using saline

or something he ended up putting it into the lungs...... Basically a

mis-placement issue, that could only have happened if you were

not intubated, for example.

Otherwise, the only other thing maybe is that as he was

advancing the tube he was too aggressive and he displaced

some of the stomach contents. But again, if you were intubated,

it shouldn't have gotten into your lungs.

The other thing is maybe the GI doc told the anesthesiologist

that he was done, to extubate you and then he (the GI doc) did

some last minute adjustment or something without warning the

anesth and so it caused fluid to go into your lungs because the

airway tube was already removed.

There really is not any way to know exactly what happened....obth

because I am very ignorant of OR procedures and equipment

and protocol and because so many things could have

contributed to the incident.

The reason why it is considered bad is that stomach contents

are highly erosive (the enzymes and stuff) and if this gets into

your lungs it will eat away lung tissue. In the same way that

pancreatic enzymes can eat away pancreas tissues if they are

not flowing correctly. In addition, stomach contents contain a

high degree of bacteria that in the GI tract will not cause harm but

in the lung can cause infection - especially when the tissue has

been harmed by the digestion from the stomach enzymes. The

other danger is just the fluid itself.....putting fluid into the lungs

prevents O2 - C02 exchange and if there is enough interference

the person can suffocate. The reason why this is so much more

dangerous than a " normal " pneumonia is because life support,

using antibiotics, etc is not as effected. It can be a catastrophic

infection that the body, no matter how strong it was before this

happened, cannot fight it. There may be more factors involved

but off hand this is what I can remember.

I am feeling really sick today and I am planning on getting out of

here real soon to go home and go to bed. I think I am getting the

flu or something so I am not going to be around too much for a

while I think. We finally got rain last night - not alot (just short of

an inch) but it may give us a short reprieve.

Laurie

aka: rockbuster