Acta Anaesthesiol Taiwan 2010;48(2):94−98

C ASE R EPORT

Unexpected Pulmonary Aspiration During

Endoscopy Under Intravenous Anesthesia
Po-Jung Lai1,2, Fa-Chang Chen1, Shung-Tai Ho1, Chen-Hwan Cherng1,
Szu-Tzu Liu2, Che-Hao Hsu1*
1
Department of Anesthesiology, Tri-service General Hospital/National Defense Medical Center,
Taipei, Taiwan, R.O.C.
2
Department of Anesthesiology, Songshan Armed Forces General Hospital, Taipei, Taiwan, R.O.C.

Received: Apr 27, 2009 Intravenous anesthesia is commonly used during endoscopy. This approach greatly
Revised: Jan 27, 2010 improves patient satisfaction with pain control. The risks of anesthesia are usually
Accepted: Feb 1, 2010 focused on the cardiopulmonary effects of anesthetics. The risk of pulmonary aspi-
ration is often overlooked, unless there are other risk factors that may increase the
KEY WORDS: incidence of pulmonary aspiration. Here, we report a patient with unexpected
anesthesia; aspiration pneumonia after gastroscopy under intravenous anesthesia. We suggest
conscious sedation; that pulmonary aspiration should be taken into consideration as a risk associated
with anesthesia for gastroscopy.
gastroscopy;
pneumonia

1. Introduction overlooked. This report describes an instance of

Endoscopy is commonly used to detect diseases of
the digestive tract. Because patients usually feel un-
comfortable during the examination, sedatives are
commonly used to reduce the painful sensations and
unpleasant experiences during these procedures.
In particular, intravenous sedation has been intro-
duced to reduce patient anxiety during endoscopy.
Although sedation improves the quality of the pro-
cedure and the patient reports better satisfaction,
there are some potential risks. In particular, the
risks of anesthesia during endoscopy include cardio-
pulmonary effects1 and possible iatrogenic injuries,
such as perforation of the alimentary canal. How-
ever, there are some complications that are often
aspiration pneumonia after gastroscopy.
2. Case Report
The patient was a 65-year-old man (height, 161 cm;
weight, 65 kg; body mass index, 25.1 kg/m2) with a
history of being a hepatitis C carrier for 20 years
and who had coronary artery disease for 1 year.
Apart from these diseases, his general condition was
fine. There were no symptoms of upper respiratory
infection before the examination. He was scheduled
to undergo a series of routine physical examina-
tions, which included gastroscopy and colorecto-
scopy; the patient had adequately fasted before the

*Corresponding author. Department of Anesthesiology, Tri-service General Hospital/National Defense Medical Center, Taipei,
Taiwan, R.O.C.
E-mail: hsuchehao@yahoo.com.tw

©2010 Taiwan Society of Anesthesiologists

Unexpected pulmonary aspiration during endoscopy 95

A B

C D

Figure 1 (A) X-ray taken in the morning 1 day before endoscopy showed a clear lung field. (B) X-ray taken the
evening after endoscopy showed diffuse infiltration over the left lung. (C) Progression of the pneumonia during hos-
pitalization. (D) Remission on the day of discharge.

examinations (nil per os since 22:00 hours on the
previous night). Fleet enema was performed twice
the day before the examination at 13:00 and 21:00
hours, and comprised 45 mL of Fleet mixed with
360 mL of a residual-free drink.
The endoscopy started at 11:10 hours and fin-
ished at 11:30 hours. The patient was placed in the
left-lateral decubitus position during the procedure.
Oxygen was supplied via a face mask and assisted
ventilation was not necessary. Before the gastros-
copy, 5 mL of simethicone was given to eliminate
excessive gastric gas bubbles and facilitate the in-
sertion of the gastroscope. No other medications or
local anesthetic were used. The patient received
75 μg fentanyl, 2 mg midazolam and 50 mg propofol
before the gastroscopy. Ten minutes later, the gas-
troscopy was completed, and 20 mg propofol was
given before starting the colorectoscopy. The pa-
tient was completely unconscious and immobile
during the procedure, and no lavage was used.
On completion of the gastroscopy, gastric juice was
removed by suction. The entire procedure was done
smoothly and lasted for about 20 minutes. There
was no agitation, choking, coughing or vomiting.
After the procedure, he was placed in a recov-
ery room for 1 hour. However, the patient felt mild
dyspnea and chilliness, and fever set in a few hours
later. Therefore, he was sent to our emergency de-
partment for further examination. A chest X-ray
showed diffuse infiltration over the upper and lower
lobes of the left lung. He was admitted for further
treatment under the impression of acute pneumonia
of unknown cause. During hospitalization, the pa-
tient received antibiotic treatment with fluoroquin-
olone. A computed tomography scan of the chest
was performed the next day and showed ground-
glass opacity and consolidation in the left upper and
lower lung. Based on these imaging findings, aspi-
ration pneumonia was highly suspected. A series of
X-ray findings are shown in Figure 1. The pneumonia
96
was under control and the fever subsided gradually.
Echocardiography was also performed to rule out
congestive heart failure with cardiogenic pulmonary
edema. Blood and sputum cultures revealed nega-
tive findings. After 10 days of medical treatment,
the pneumonia subsided and he was discharged in
a stable condition.
In terms of the possible causes of the pneumo-
nia, there was no solid evidence for a specific patho-
genesis, although aspiration was considered the most
likely cause, based on the rapid onset, the absence
of previous upper respiratory infection, and X-ray
findings.
3. Discussion
Applying intravenous anesthesia for endoscopy is
usually considered safe and is a service done for
the patient’s satisfaction. Most patients are willing
to undergo endoscopy under sedation.2 Adequate
sedation may also help the examination to progress
more smoothly. Thus, sedation is now widely used
in endoscopy. Although it is considered safe under
appropriate monitoring, it still carries some risks.
The risks mostly involve cardiopulmonary compli-
cations such as hypoxia and changes in electrocar-
diography or blood pressure. The risks of pulmonary
aspiration are usually overlooked, unless the pa-
tient has a history of gastrointestinal diseases such
as gastroesophageal reflux disease,3 upper gastroin-
testinal bleeding,4 intestinal obstruction, and inad-
equate fasting time.5 Indeed, aspiration pneumonia
is seldom observed in healthy patients undergoing
regular endoscopy. In our case, there were no un-
derlying factors that would have increased the risks
of pulmonary aspiration. The precise time at which
the aspiration occurred is unknown and it may have
occurred either during or after the procedure.
Nevertheless, we believe that the pulmonary aspi-
ration occurred during the procedure because the
patient only showed left-sided pneumonia and he
was placed in the left-lateral decubitus position
during gastroscopy. In contrast, common aspiration
pneumonia is usually found in the right lung. To our
surprise, the procedure was performed smoothly
and coughing, choking and vomiting were not noted
during or after the procedure. However, it is pos-
sible that the protective reflexes were impaired by
the sedation, meaning that these symptoms were
not observed.6
Conscious sedation is usually recommended in
endoscopy.7 However, the choice and doses of an-
algesic agents vary greatly among anesthesiolo-
gists, usually depending on the patient’s response.
Lower doses of anesthetics may preserve more ac-
tive protective reflexes and have less effect on
P.J. Lai et al
cardiopulmonary function, but the patient may not
be placid and agitation may interrupt the proce-
dure. A deeper sedation level is usually considered
safe, unless the patient has underlying diseases that
may increase the risk of aspiration. However, aspi-
ration pneumonia still occurred in our patient.
Overall, the anesthesiologist should consider that
the volume of air and water injected into the stom-
ach during gastroscopy may be large, and suction
through the endoscope may not be adequate to
prevent aspiration. The experience of the examiner
may also influence the risks of aspiration. The lower
and upper esophageal sphincters prevent passive
regurgitation from the stomach to the esophagus
and from the esophagus to the pharynx, respec-
tively, when they are working optimally. However,
their tone is reduced as consciousness is depressed.
Furthermore, the tone of the esophageal sphincter
may be influenced by the drugs administered by
the anesthesiologist.8,9 These factors may account
for the pulmonary aspiration in this patient.
Pulmonary aspiration can be classified into two
distinct clinical entities, aspiration pneumonitis and
aspiration pneumonia.10 The former is a chemical
injury caused by the inhalation of sterile gastric
contents. It usually occurs in patients with severely
impaired consciousness resulting from drug over-
dose, seizures, massive cerebrovascular accident, or
anesthesia. Meanwhile, aspiration pneumonia is an
infectious process that develops after the inhalation
of oropharyngeal material colonized by pathogenic
bacteria. The clinical presentation and symptoms
also vary. The differences between aspiration pneu-
monitis and aspiration pneumonia are summarized
in Table 1. In this case, because of the suppressed
consciousness, the symptoms developed rapidly,
within a few hours, with negative culture findings.
Thus, aspiration pneumonitis seems more likely in
this patient.
Since unexpected aspiration may occur in pa-
tients without obvious risk factors for pulmonary
aspiration, we should endeavor to prevent it from
occurring and minimize the damage it causes should
it occur. The patient described here was placed in
the left-lateral decubitus position. Some authors
have reported that some body positions, including
sitting and the semi-recumbent position, could re-
duce the incidence of aspiration.11−14 Placing pa-
tients in the head-up position is also simple. Thus,
we suggest that tilting the head up should be rou-
tinely considered during gastroscopy. Meanwhile,
reducing gastric acidity may help avoid severe in-
jury resulting from massive aspiration15 and can be
achieved by administering proton pump inhibitors
(PPI) or histamine receptor-2 (H2) antagonists be-
fore the procedure. These medications can effec-
tively increase the gastric pH and decrease the
Unexpected pulmonary aspiration during endoscopy
Table 1 Comparison of features of aspiration pneumonitis and aspiration pneumonia
Aspiration pneumonitis
Mechanism Aspiration of sterile gastric contents
Pathophysiologic Acute lung injury arising from acidic
process and particulate gastric material
Bacteriologic Initially sterile, with subsequent
findings bacterial infection possible
Main predisposing Markedly depressed level of
factors consciousness
Age group affected All age groups, but usually young persons
Aspiration event May be witnessed
Typical presentation Patient with a history of a depressed
level of consciousness in whom a
pulmonary infiltrate and
respiratory symptoms develop
Clinical features No symptoms or symptoms ranging
from a nonproductive cough to tachypnea,
bronchospasm, bloody or frothy sputum,
and respiratory distress
2−5 hours after aspiration
*Adapted with permission from Reference 10.
volume of gastric juice if administered sufficiently
early before endoscopy.16−19 As found in previous
studies, extremely low acidity and large amount of
gastric aspirates are associated with higher mor-
bidity and mortality rates.20,21 It is generally con-
sidered that a pH of less than 2.5 and a volume of
gastric aspirates greater than 0.3 mL/kg body weight
(20−25 mL in adults) may lead to aspiration pneu-
monitis.20,22−24 Prescription of either H2 antagonists
or PPIs can prevent severe morbidity or mortality
if aspiration does occur. Although routine prescrip-
tion of these drugs is not currently recommended
in the American Society of Anesthesiologists guide-
lines, and the incidence of pulmonary aspiration is
very low, it can be lethal in some patients. A single
dose of these drugs is relatively inexpensive and may
avoid medical malpractice lawsuits in the event of
severe aspiration pneumonia. We suggest that, in
the future, the prescription of H2 antagonists or PPIs
be considered as preventive therapy before endo-
scopy, particularly if the procedure is performed
under sedation.
In conclusion, this case reminds us that, even in
a healthy patient, endoscopy under sedation car-
ries the risk of pulmonary aspiration. Therefore,
we should be aware of unexpected aspiration pneu-
monia and should be particularly cautious when
performing endoscopy in combination with anes-
thetic agents. Tilting the head upwards and the
prescription of PPIs or H2 antagonists may prevent
severe aspiration. The risk of aspiration should be
97
Aspiration pneumonia
Aspiration of colonized oropharyngeal material
Acute pulmonary inflammatory response to
bacteria and bacterial products
Gram-positive cocci, Gram-negative rods,
and (rarely) anaerobic bacteria
Dysphagia and gastric dysmotility
Usually elderly persons
Usually not witnessed
Institutionalized patient with dysphagia
in whom clinical features of pneumonia and an
infiltrate in a dependent bronchopulmonary
segment develop
Tachypnea, cough, and signs of pneumonia
included in the preoperative evaluation and should
be explained to the patient as a possible risk of
the procedure.
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