Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942004000200014
Brazilian Journal of Anesthesiology
Review Article

Prevenção da aspiração pulmonar do conteúdo gástrico

Prevention of pulmonary gastric contents aspiration

Eduardo Toshiyuki Moro

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JUSTIFICATIVA E OBJETIVOS: Apesar da baixa incidência, a aspiração pulmonar do conteúdo gástrico pode ter conseqüências devastadoras para o indivíduo. A diminuição na função do esfíncter esofágico e dos reflexos protetores das vias aéreas causadas pela depressão da consciência, predispõe os pacientes a esta grave complicação. Neste artigo, foi realizada uma revisão dos aspectos fisiológicos associados ao refluxo gastroesofágico, bem como os métodos utilizados para preveni-lo. CONTEÚDO: São feitos comentários sobre os mecanismos envolvidos na aspiração do conteúdo gástrico, suas conseqüências e métodos de prevenção, incluindo recentes guias de jejum pré-operatório elaborados após revisão da literatura, o uso racional de drogas que atuam no pH e volume gástrico e, finalmente, o efeito de diferentes métodos de manutenção da via aérea na prevenção da aspiração pulmonar. CONCLUSÕES: A aspiração pulmonar do conteúdo gástrico, apesar de pouco freqüente, exige cuidados especiais para sua prevenção. Guias de jejum pré-operatório elaborados recentemente sugerem períodos menores de jejum, principalmente para líquidos, permitindo mais conforto aos pacientes e menor risco de hipoglicemia e desidratação, sem aumentar a incidência de aspiração pulmonar perioperatória. O uso rotineiro de drogas que diminuem a acidez e volume gástrico parece estar indicado apenas para pacientes de risco. O melhor método de proteção da via aérea contra a aspiração continua sendo a intubação traqueal. Outros métodos de manutenção da via aérea vêm sendo adotados, mas a eficácia na prevenção da aspiração ainda é inferior, embora representem importante alternativa em casos de falha de intubação traqueal.

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Abstract

BACKGROUND AND OBJECTIVES: Despite its low incidence, aspiration of pulmonary gastric contents may have devastating consequences. Esophageal sphincter function and protective airway reflexes decrease caused by conscience depression, predisposes patients to this severe complication. This article is a review of physiological aspects associated to gastroesophageal reflux, as well as of the methods to prevent it. CONTENTS: Comments are made about the mechanisms involved in gastric contents aspiration, its consequences and preventive methods, including recent preoperative fasting guidelines developed after review of the literature, the reasonable use of drugs acting on gastric pH and volume, and finally the effects of different airway control methods on pulmonary aspiration prevention. CONCLUSIONS: Aspiration of pulmonary gastric contents, despite its low frequency, demands special preventive care. Recently developed preoperative fasting guidelines suggest shorter fasting periods especially for liquids, allowing more comfort to patients and less risk of hypoglycemia and dehydration, without increasing the incidence of perioperative pulmonary aspiration. The routine use of drugs decreasing gastric acidity and volume seems to be indicated only for poor risk patients. The best method to protect airways against aspiration is still tracheal intubation. Other airway control methods have been adopted, but their efficacy in preventing aspiration is lower, although representing major alternatives in cases of intubation failure.

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References

Warner MA. Is pulmonary aspiration still an import problem in anesthesia?: Review article. Current Op Anaesthesiology. 2000;13:215-218.

Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obst Gynecol. 1946;52:191-205.

Ortenzi AV, D`Ottaviano CR. Jejum Pré-Operatório e o Paciente de Estômago Cheio. Atualização em Anestesiologia. 1996:94-106.

Olsson GL, Hallen B, Hambraeus-Jonzon K. Aspiration during anaesthesia: a computer-aided study of 185,358 anaesthetics. Acta Anaesthesiol Scand. 1986;30:84-92.

Mellin Olsen J, Fasting S, Gisvold SE. Routine preoperative gastric emptying is seldom indicated: A study of 85,594 anaesthetics with special focus on aspiration pneumonia. Acta Anaesthesiol Scand. 1996;40:1184-1188.

Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesio- logy. 1993;78:56-62.

Warner MA, Warner ME, Warner DO. Perioperative pulmonary aspiration in infants and children. Anesthesiology. 1999;90:66-71.

Borland LM, Sereika SM, Woelfel SK. Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome. J Clin Anesth. 1998;10:95-102.

Alexander NG, Graham S. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg. 2001;93:494-513.

Flick RP, Schears GJ, Warner MA. Aspiration in pediatric anesthesia: is there a higher incidence compared with adults?. Current Op Anesth. 2002;15:323-327.

Deaths due to complications of anaesthesia. Report on confidential enquirer into maternal deaths in England and Wales. :1957-1998.

Roberts RB, Shirley MA. Reducing the risk of acid aspiration during cesarean section. Anesth Analg. 1974;53:859-868.

Plourde G, Hardy JF. Aspiration pneumonia: assessing the risk of regurgitation in the cat. Can Anesth Soc J. 1986;33:345-348.

Raidoo DM, Rocke DA, Brock-Utne JG. Critical volume for pulmonary acid aspiration: reappraisal in a primate model. Br J Anaesth. 1990;65:248-250.

Splinter WM, Schaefer JD. Unlimited clear fluid ingestion two hours before surgery in children does not affect volume or pH of stomach contents. Anaesth Intensive Care. 1990;18:522-526.

Soreide E, Holst-Larsen H, Veel T. The effects of chewing gum on gastric contents prior to induction of general anesthesia. Anesth Analg. 1995;80:985-989.

Macuco MV. Jejum pré-operatório: validade de critérios. Rev Bras Anestesiol. 1998;48:295-308.

Kallar SK, Everett LL. Potential risks and preventive measures for pulmonary aspiration: new concepts in preoperative fasting guidelines. Anesth Analg. 1993;77:171-182.

Hutchinson A, Maltby JR, Reid CR. Gastric fluid volume and pH in elective inpatients. Part I: coffee or orange juice versus overnight fast. Can J Anaesth. 1988;35:12-15.

Maltby JR, Reid CR, Hutchinson A. Gastric fluid volume and pH in elective inpatients. Part II: coffee or orange juice with ranitidine. Can J Anaesth. 1988;35:16-19.

Schreiner MS, Triebwasser A, Keon TP. Ingestion of liquids compared with preoperative fasting in pediatric outpatients. Anesthesiology. 1990;72:593-597.

Schreiner MS. Gastric fluid volume: is it really a risk factor for pulmonary aspiration?. Anesth Analg. 1998;87:754-756.

Splinter WM, Schreiner MS. Preoperative fasting in children. Anesth Analg. 1999;89:80-89.

Andres JM, Mathias JR, Clench MH. Gastric emptying in infants with gastroesophageal reflux. Measurement with a technetium-99m-labeled semisolid meal. Dig Dis Sci. 1988;33:393-399.

Côté CJ. Changing concepts in preoperative medication and NPO status of pediatric patient. ASA Refresher Courses in Anesthesiology. 1995;22:101-116.

Minami H, McCallum RW. The physiology and pathophysiology of gastric emptying in humans. Gastroenterology. 1984;86:1592-1610.

Agarwal A, Chari P, Singh H. Fluid deprivation before operation. The effect of a small drink. Anaesthesia. 1989;44:632-634.

Moore JG, Christian PE, Coleman RE. Gastric emptying of varying meal weight and composition in man. Evaluation by dual liquid and solid-phase isotopic method. Dig Dis Sci. 1981;26:16-22.

Warde D. Fasting children for anaesthesia and surgery. Ir Med J. 1991;84:4-5.

Phillips S, Daborn AK, Hatch DJ. Preoperative fasting for paediatric anaesthesia. Br J Anaesth. 1994;73:529-536.

Moukarzel AA, Sabri MT. Gastric physiology and function: effects of fruit juices. J Am Coll Nutr. 1996;15(^s5):18S-25S.

Bailey CR. Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Survey Anesth. 2002;46:137-138.

Kahrilas PJ, Dodds WJ, Dent J. Effects of sleep, spontaneous gastroesophageal reflux and a meal on upper esophageal sphincter pressure in normal human volunteers. Gastroenterology. 1987;92:466-471.

Eriksson LI, Sundman E, Olsson R. Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology. 1997;87:1035-1043.

Sundman E, Witt H, Olsson R. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium,. Anesthesiology. 2000;92:977-984.

Berg H. Is residual neuromuscular block following pancuronium a risk factor for postoperative pulmonary complications?. Acta Anaesthesiol Scand. 1997;110:156-158.

Coranza R, Nandwani N, Tring JP. Upper airway reflex sensitivity following general anaesthesia for day-case surgery. Anaesthesia. 2000;55:367-370.

Langton JA, Murphy PJ, Barker P. Measurement of the sensitivity of the upper airway reflexes. Br J Anaesth. 1993;70:126-130.

Murphy PJ, Langton JA, Barker P. Effect of oral diazepam on the sensitivity of the upper airway reflexes. Br J Anaesth. 1993;70:131-134.

Erskine RJ, Murphy PJ, Langton JA et al. Effect of age on the sensitivity of upper airway reflexes. Br J Anaesth. 1993;70:574-575.

Mc Intyre JWR. Evolution of 20th century attitudes to prophylaxis of pulmonary aspiration during anaesthesia. Can J Anaesth. 1998;45:1024-1030.

Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia. Lancet. 1961;19:404-406.

Gallimore SC, Hoite RW. . .

Singh O. Effect of preoperative fasting in children and adults. Midle East J Anesthesiol. 1985;8:235-239.

Bush GH, Steward DJ. Severe hypoglycemia associated with preoperative fasting and intraoperative propranolol: A case report and discussion. Paediatr Anaesth. 1996;6:415-417.

Maekawa N, Mikawa K, Yaku H. Effects of 2, 4 and 12 hours fasting intervals on preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis in children. Acta Anaesthesiol Scand. 1993;37:783-787.

Shirley DJ, Mathieu A, Gunter J. Effects of fasting interval on risk factors for pulmonary aspiration in pediatric patients: a meta-analysis. Anesth Analg. 1995;80:S440.

Guyton AC, Hall JE. Tratado de Fisiologia Médica. 2002;64:686-701.

Manchikanti L, Colliver JA, Marrero TC et al. Assessment of age-related acid aspiration risk factors in pediatric, adult, and geriatric patients. Anesth Analg. 1985;64:11-17.

Ong BY, Palahniuk RJ, Cumming M. Gastric volume and pH in out-patients. Can Anaesth Soc J. 1978;25:36-39.

Cote CJ, Goudsouzian NG, Liu LM et al. Assessment of risk factors related to the acid aspiration syndrome in pediatric patients-gastric pH and residual volume. Anesthesiology. 1982;56:70-72.

Sutherland AD, Maltby JR, Sale JO et al. The effect of preoperative oral fluid and ranitidine on gastric fluid volume and pH. Can J Anaesth. 1987;34:117-121.

Splinter WM, Stewart JA, Muir JG. The effect of preoperative apple juice on gastric contents, thirst and hunger in children. Can J Anaesth. 1989;36:55-58.

Goresky GV, Maltby JR. Fasting guidelines for elective surgical patients. Can J Anaesth. 1990;37:493-495.

Litman RS, Wu CL, Quinlivan JK. Gastric volume and pH in infants fed clear liquids and breast milk prior to surgery. Anesth Analg. 1994;79:482-485.

Read MS, Vaughan RS. Allowing preoperative patients to drink: effects on patients` safety and comfort of unlimited oral water until 2 hours before anesthesia. Acta Anaesthesiol Scand. 1991;35:591-595.

Practice guideline for preoperative fasting. and use of pharmacology agents to reduce the risk of pulmonary aspiration: application to health patients undergoing elective procedures. Anesthesiology. 1999;90:896-905.

Ferrari LR, Rooney FM, Rockoff MA. Preoperative fasting practices in pediatrics. Anesthesiology. 1999;90:978-980.

Fasting S, Soreide S, Raeder JC. Changing preoperative fasting policies. Impact of a national consensus. Acta Anaesthesiol Scand. 1998;42:1188-1191.

Emerson BM, Wrigley SR, Newton M. Preoperative fasting for paediatric anaesthesia: A survey of current practice. Anaesthesia. 1998;53:326-330.

Green CR, Pandit SK, Schork MA. Preoperative fasting time: is the traditional policy changing? Results of a national survey. Anesth Analg. 1996;83:123-128.

Haas U, Motsch J, Schreckenberger R. Pramedication and preoperative fasting in pediatric anesthesia. Results e survey. Anaesthetist. 1998;47:838-843.

Dubin AS, Jense HG, Mc Crane JM. Sugarless gum chewing before surgery does not increase gastric volume or acidity. Can J Anaesth. 1994;41:603-606.

Wong CA, Loffredi M, Ganchiff J. Gastric emptying of water in term pregnancy. Anesthesiology. 2002;96:1395-1400.

Practice Guideline for obstetrical anesthesia: a report by the American Society of Anesthesiologists Task Force on Obstetrical Anesthesia. Anesthesiology. 1999;90:600-611.

Juvin P, Fevre G, Merouche M. Gastric residue is not more copious in obese patients. Anesth Analg. 2001;93:1621-1622.

Nishina K, Mikawa K, Takao Y. A comparison of rabeprazole, lansoprazole, and ranitidine for improving preoperative gastric fluid property in adults undergoing elective surgery. Anesth Analg. 2000;90:717-721.

Nishina K, Mikawa K, Maekawa N. A comparison of lanzoprazole, omeprazole, and ranitidine for reducing preoperative gastric secretion in adult patients undergoing elective surgery. Anesth Analg. 1996;82:832-836.

Escolano F, Castano J, Lopez R. Effects of omeprazole, ranitidine, famotidine and placebo on gastric secretion in patients undergoing elective surgery. Br J Anaesth. 1992;69:404-406.

Manning B, Mc Greal G, Winter DC. Nasogastric intubation causes gastroesophageal reflux in patients undergoing elective laparotomy. Br J Surg. 2000;87:637.

Vanner RG, Pryle BJ. Regurgitation and oesophageal rupture with cricoid pressure: a cadaver study. Anaesthesia. 1992;47:732-735.

Salem MR, Joseph NJ, Heyman HJ. Cricoid compression is effective in obliterating the esophageal lumen in the presence of a nasogastric tube. Anesthesiology. 1985;63:443-446.

Ferrer M, Bauer TT, Torres A et al. Effect of nasogastric tube size on gastroesophageal reflux and microaspiration in intubated patients. Ann Intern Med. 1999;130:991-994.

Roewer N. Can pulmonary aspiration of gastric contents be prevented by balloon occlusion of the cardia? A study with a new nasogastric tube. Anesth Analg. 1995;80:378-383.

Schwarzmann GF, Wurmb T, Grein CA et al. Difficult airway management: combination of the laryngeal mask airway with a new gastric balloon tube. Anesthesiology. 1998;89:1237A.

Thwaites AJ, Rice CP, Smith I. Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia. 1999;54:376-381.

Salem MR, Wong AY, Mani M et al. Efficacy of cricoid pressure in preventing gastric inflation during bag-mask ventilation in pediatric patients. Anesthesiology. 1974;40:96-98.

Lawes EG, Campbell I, Mercer D. Inflation pressure, gastric insufflation and rapid sequence induction. Br J Anaesth. 1987;59:315-318.

Asai T, Barclay K, McBeth C. Cricoid pressure applied after placement of the laryngeal mask prevents gastric insufflation but inhibits ventilation. Br J Anaesth. 1996;76:772-776.

Vanner RG, O`Dwyer JP, Pryle BJ. Upper oesophageal sphincter pressure and the effect of cricoid pressure. Anaesthesia. 1992;47:95-100.

Toumadre JP, Chassard D, Berrada KR. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology. 1997;86:7-9.

Skinner HJ, Bedforth NM, Girling KJ et al. Effect of cricoid pressure on gastroesophageal reflux in awake subjects. Anaesthesia. 1999;54:798-808.

Palmer JH, Mac G Ball DR. The effect of cricoid pressure on the cricoid cartilage and vocal cords: an endoscopic study in anaesthetized patients. Anaesthesia. 2000;55:263-268.

Vanner RG, Clarke P, Moore WJ et al. The effect of cricoid pressure and neck support on the view at laringoscopy. Anaesthesia. 1997;52:896-900.

Asai T, Barclay K, Power I. Cricoid pressure impedsd placement of the laryngeal mask airway. Br J Anaesth. 1995;74:521-525.

Aoyama K, Takenaka I, Sata T. Cricoid pressure impedes positioning and ventilation through the laryngeal mask airway. Can J Anaesth. 1996;43:1035-1040.

Meek T, Vincent A, Duggan JE. Cricoid pressure: can protective force be sustained?. Br J Anaesth. 1998;80:672-674.

Young PJ, Basson C, Hamilton D. Prevention of tracheal aspiration using the pressure-limited tracheal tube cuff. Anaesthesia. 1999;54:559-563.

Young PJ, Ridley AS. Ventilator-associated pneumonia: Diagnosis, pathogenesis and prevention. Anaesthesia. 1999;54:1183-1197.

Young PJ, Rollinson M, Downward G. Leakage of fluid past the tracheal tube cuff in a benchtop model. Br J Anaesth. 1997;78:557-562.

Blunt MC, Young PJ, Patil A. Gel lubrification of the tracheal tube cuff reduces pulmonary aspiration. Anesthesiology. 2001;95:377-381.

Rabey PG, Murphy PJ, Langton JA et al. Effect of the laryngeal mask airway on lower oesophageal sphincter pressure in patients during general anaesthesia. Br J Anaesth. 1992;69:346-348.

Valentine J, Stakes AF, Bellamy MC. Reflux during positive pressure ventilation through the laryngeal mask. Br J Anaesth. 1994;73:543-544.

Owens TM, Robertson P, Twomey C et al. The incidence of gastroesophageal reflux with the laryngeal mask: a comparison with the face mask using esophageal lumen pH electrodes. Anesth Analg. 1995;80:980-984.

Skinner HJ, Ho BY, Mahajan RP. Gastro-oesophageal reflux with the laryngeal mask during day-case gynaecological laparoscopy. Br J Anaesth. 1998;80:675-676.

Akhtar TM, Street MK. Risk of aspiration with the laryngeal mask. Br J Anaesth. 1994;72:447-450.

Cheong YP, Park SK, Son Y et al. Comparison of incidence of gastroesophageal reflux and regurgitation associated with timing of removal of the laryngeal mask airway: on appearance of signs of rejection versus after recovery consciousness. J Clin Anesth. 1999;11:657-662.

Brain AI, Verghese C, Strube PJ. The LMA 'ProSeal' - a laryngeal mask with an oesophageal vent. Br J Anaesth. 2000;84:650-654.

Keller C, Brimacombe J. Mucosal pressure and oropharyngeal leak pressure with the ProSeal versus the laryngeal mask airway in anaesthetized paralyzed patients. Br J Anaesth. 2000;85:262-266.

Brimacombe J, Keller C. The cuffed oropharyngeal airway vs the laryngeal mask airway: a randomized cross-over study of oropharyngeal leak pressure and fibreoptic view in paralyzed patients. Anaesthesia. 1999;54:683-685.

Lutke C. Abordagem à Via Aérea Difícil. Atualização em Anestesiologia. 2000:126-139.

Mallampati SR, Gatt SP, Gugino LD. A clinical signal to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985;32:429-434.

Benumof JL. The ASA Dificult Airway Algorithm: new thoughts/considerations. Annual Refresher Course Lectures. 1999;134:1-7.

Van Maren GA. Emergency Anaesthesia in Unprepared Patient. International Practice of Anesthesia. 1996:1291-1297.

Almeida MCS. Succinilcolina 50 anos de soberania. Rev Bras de Anestesiol. 2002;52:513-516.

Kirkegaard-Nielsen H, Caldwell JE, Berry PD. Rapid tracheal intubation with rocuronium: a probability approach to determining dose. Anesthesiology. 1999;91:131-136.

Sparr HJ, Mitterschiffthaier G. Are only large doses of rocuronium an alternative to succinylcholine for rapid-sequence induction?. Anesthesiology. 1994;80:1411-1412.

Heier T, Caldwell JE. Rapid tracheal intubation with large-dose rocuronium: a probability-based approach. Anesth Analg. 2000;90:175-179.

Engbaek J. Succinylcholine or rocuronium for rapid sequence induction. Acta Anaesthesiol Scand. 2000;44:494-495.

Irwin RS. Aspiration. Irwin and Rippe`s Intensive Care Medicine. 1999:685-692.

Caseira HA, Niederman MS. Aspiration Pneumonia, Lipoid Pneumonia and Lung Abscess. Textbook of Pulmonary Diseases. 1998:645-655.

Gibbs CP, Modell JH. Pulmonary Aspiration of Gastric Contents: Pathophysiology, Prevention and Management. Anesthesia. 1994:1437-1464.

Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344:665-671.

Bernard GR, Luce JM, Sprung CL. High-doses corticosteroids in patients with tie adult respiratory distress syndrome. N Engl J Med. 1987;317:1565-1570.

Bone RC, Fisher Jr CJ, Clemmer TP. Early methylprednisolone treatment for septic syndrome and the adult respiratory distress syndrome. Chest. 1987;92:1032-1036.

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