Detection of pepsin in tracheal secretions after forced small‐volume aspirations of gastric juice

Metheny, Norma A.; Dahms, Thomas E.; Chang, Yie‐Hwa; Stewart, Barbara J.; Frank, P; Clouse, Ray E.

doi:10.1177/014860710402800279

Cited by 33 publications

(22 citation statements)

References 13 publications

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“…Additional modifications of our laboratory procedures to detect lower levels of amylase are warranted; however, the values we obtained were similar to those reported for patients receiving mechanical ventilation who had risk factors for aspiration and infections. 5,7,8 Our findings are consistent with those of other reports 5,6,[8][9][10][11][12]14,[26][27][28][29][30][31][32][33][34][35][36] of pepsin and amylase as biomarkers of microaspiration. Dewavrin and colleagues 36 argue that the use of amylase is only moderately accurate in diagnosing microaspiration.…”

Section: Discussionsupporting

confidence: 92%

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Sole¹,

Conrad²,

Bennett³

et al. 2014

American Journal of Critical Care

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worth, RN, MSN, CCRN, CCNS, and Devendra Indulal Mehta, MBBS, MSc(dist), MRCP Background Endotracheal intubation increases the risk for microaspiration of secretions around the tube cuff. Pepsin has been used as a biomarker for gastric aspiration. Amylase is a newer proposed biomarker for aspiration of oral contents. Objective To assess the presence of pepsin and amylase in paired oral-tracheal secretions of adult patients treated with mechanical ventilation. Methods In this descriptive study, paired samples of oral and tracheal secretions were obtained from adult patients at baseline and again within 4 hours when a need for endotracheal suctioning was assessed. Assays of pepsin and amylase were processed in a specialty diagnostic laboratory. Results The sample consisted of 10 men and 3 women with a median age of 56 years. The majority were intubated with a subglottic suction endotracheal tube (9 patients, 69%), receiving synchronized intermittent mandatory ventilation (10 patients; 77%), and receiving enteral feedings (11 patients; 85%) through a tube distally placed in the stomach (8 patients; 67%). Pepsin was present in oral secretions of 9 patients (69%), and in tracheal specimens of 7 patients (54%) at one or both sampling times. Amylase was detected in all patients' oral secretions and in tracheal secretions of 5 patients (38%) at one or both sampling times. Conclusions Many patients had pepsin, amylase, or both in tracheal aspirates. Pepsin was more commonly detected than was amylase. Although the relationship of this finding to longterm outcomes was not assessed, findings indicate that microaspiration of oral and gastric secretions occurs frequently.

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Section: Discussionsupporting

confidence: 92%

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Sole¹,

Conrad²,

Bennett³

et al. 2014

American Journal of Critical Care

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“…In an animal study 36 with forced aspiration, pepsin was detected for up to 6 hours at decreasing levels. Researchers in future studies should measure the concentration of pepsin in micrograms, not merely the presence of pepsin in order to describe new reflux and aspiration events.…”

Section: Implications For Practicementioning

confidence: 97%

Head-of-Bed Elevation and Early Outcomes of Gastric Reflux, Aspiration and Pressure Ulcers: A Feasibility Study

Schallom¹,

Dykeman²,

Metheny³

et al. 2014

American Journal of Critical Care

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A closed-book, multiple-choice examination following this article tests your under standing of the following objectives:1. Describe the risks and benefits of head-of-bed elevation. 2. Identify the findings at 30° and 45° head-ofbed elevation. 3. Discuss the early outcomes regarding head-ofbed elevation. Background Guidelines recommending head of bed (HOB) elevation greater than 30º to prevent ventilator-associated pneumonia conflict with guidelines to prevent pressure ulcers, which recommend HOB elevation less than 30º. Objectives To examine the feasibility of 45º HOB elevation and describe and compare the occurrence of reflux, aspiration, and pressure ulcer development at 30º and 45º HOB elevation. Methods A randomized 2-day crossover trial was conducted. HOB angle was measured every 30 seconds. Oral and tracheal secretions were analyzed for pepsin presence. Skin was assessed for pressure ulcers. Wilcoxon signed rank tests and

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“…The procedure for the assay has been described previously; in an animal model, the assay was found to have a sensitivity of 93% and a specificity of 100% (13). Within 1 hr after collection, each secretion was prepared in a research laboratory for later analysis.…”

Section: Pepsin Immunoassaymentioning

confidence: 99%

Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: Frequency, outcomes, and risk factors

Metheny

Clouse

Chang

et al. 2006

Critical Care Medicine

332

240

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Objectives-To describe the frequency of pepsin-positive tracheal secretions (a proxy for the aspiration of gastric contents), outcomes associated with aspiration (including a positive Clinical Pulmonary Infection Score [a proxy for pneumonia] and use of hospital resources), and risk factors associated with aspiration and pneumonia in a population of critically ill tube-fed patients.Design-Prospective descriptive study conducted over a 2-yr period. Setting-Five intensive care units in a university-affiliated medical center with level I trauma status.Patients-Each of the 360 adult patients participated for 4 days. Among the inclusion criteria were mechanical ventilation and tube feedings. An exclusion criterion was physician-diagnosed pneumonia at the time of enrollment. Intervention-None.Measurements and Major Results-Almost 6,000 tracheal secretions collected during routine suctioning were assayed for pepsin; of these, 31.3% were positive. At least one aspiration event was identified in 88.9% (n = 320) of the participants. The incidence of pneumonia (as determined by the Clinical Pulmonary Infection Score) increased from 24% on day 1 to 48% on day 4. Patients with pneumonia on day 4 had a significantly higher percentage of pepsin-positive tracheal secretions than did those without pneumonia (42.2% vs. 21.1%, respectively; p < .001). Length of stay in the intensive care unit and need for ventilator support were significantly greater for patients with pneumonia (p < .01). A low backrest elevation was a risk factor for aspiration (p = .024) and pneumonia (p = .018). Other risk factors for aspiration included vomiting (p = .007), gastric feedings (p = .009), a Glasgow Coma Scale score <9 (p = .021), and gastroesophageal reflux disease (p = .033). The most significant independent risk factors for pneumonia were aspiration (p < .001), use of paralytic agents (p = .002), and a high sedation level (p = .039).Conclusions-Aspiration of gastric contents is common in critically ill tube-fed patients and is a major risk factor for pneumonia. Furthermore, it leads to greater use of hospital resources. Modifiable risk factors for aspiration need to be addressed. Keywords critical illness; enteral nutrition; aspiration pneumonia; risk factors; gastroesophageal reflux; gastric emptyingThe authors have no financial interests to disclose.The study was performed at Saint Louis University Hospital, in St. Louis, MO. NIH Public Access Author ManuscriptCrit Care Med. Author manuscript; available in PMC 2008 May 23. Published in final edited form as:Crit Care Med. 2006 April ; 34(4): 1007-1015. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptTracheobronchial aspiration can be defined as the inhalation of oropharyngeal or gastric contents into the respiratory tract (1). Although aspiration from either source is important, the type of greatest concern in critically ill tube-fed patients is tracheobronchial aspiration of gastric contents. The extent to which aspiration of gastric contents occurs is difficu...

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Detection of pepsin in tracheal secretions after forced small‐volume aspirations of gastric juice

Cited by 33 publications

References 13 publications

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Pepsin and Amylase in Oral and Tracheal Secretions: A Pilot Study

Head-of-Bed Elevation and Early Outcomes of Gastric Reflux, Aspiration and Pressure Ulcers: A Feasibility Study

Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: Frequency, outcomes, and risk factors

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