Aspiration pneumonitis due to Kussmaul breathing
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SILENT ASPIRATION PNEUMONITIS DUE TO KUSSMAUL BREATHING IN
DIABETIC KETOACIDOSIS
Yanai H, Yoshikawa R
1. Department of Internal Medicine, National Center for Global Health and Medicine
Kohnodai Hospital, Ichikawa, Chiba, Japan
Correspondence
Dr. Hidekatsu Yanai. Department of Internal Medicine, National Center for Global
Health and Medicine Kohnodai Hospital, Chiba 272-8516, Japan.
Email: [email protected]
Yanai H, Yoshikawa R. Silent Aspiration pneumonitis due to Kussmaul breathing in
diabetic ketoacidosis. Case Study Case Rep. 2011; 1(3): 154 - 156.
Sir,
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) are
emergencies in diabetic patients. Aspiration pneumonitis may be life-threatening
complication of DKA and HHS. Silversides JA, et al. indicated that current guidelines
fail to encourage safe management of patients with DKA and HHS at risk of aspiration1.
Gastroparesis including gastric dilatation and vomiting have been considered to make
aspiration of gastric contents in comatose diabetic patients1.
We experienced a 60-year-old male comatose DKA patient who developed silent
aspiration pneumonitis without an episode of vomiting. He was admitted in a coma with
Kussmaul breathing in the supine body position. On the next day of the admission, he
developed fever and cough, and serum C-reactive protein level increased (from 0.74 to
2.61 mg/dl) and chest X-ray revealed consolidation which was not found on the
admission (Figure 1). At this time, this patient did not eat and drink anything, and also
did not vomit. This clinical course and chest computed tomographic findings indicated
that this patient developed silent aspiration pneumonitis (Figure 2).
Why did he develop aspiration pneumonitis? This patient showed Kussmaul breathing,
which is deep rapid respiration to provide respiratory compensation for metabolic
acidosis, and he was also in the supine body position. This may induce aspiration of oral
bacteria, resulting in the onset of aspiration pneumonitis. His pneumonitis was promptly
ameliorated by the use of antibiotics. In cases of DKA, pneumonia is the most common
cause of death (8 cases among 21 dead patients) 2. Aspiration of gastric contents while the
patient was in hospital was documented as the cause of death in only one case, and
aspiration has been speculated to have occurred before admission in other patients2. It
remains unclear whether this speculation is right or not.
To our knowledge, silent aspiration pneumonitis due to Kussmaul breathing in DKA has
not been discussed anywhere, and then the same management of aspiration was
recommended for patients with DKA and HHS. When we observe the development of
fever in DKA patients showing Kussmaul breathing, we should think of aspiration
pnuemonitis, even if they do not have an episode of vomiting. Supine body position has
been suggested to increase risk for nosocomial pneumonia including aspiration
pneumonitis, and the semirecumbent body position appears to reduce risk for
nosocomical pneumonia in patients with decreased consciousness3. To prevent silent
Case Study and Case Report 2011; 1(3): 154 - 156.
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Aspiration pneumonitis due to Kussmaul breathing
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aspiration pneumonitis, comatose DKA patients should be in the semirecumbent body
position.
Figure 1. Chest X-ray.
Figure 2. Chest computed tomography.
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REFERENCES
1. Silversides JA, Farling PA. Diabetic ketoacidosis guidelines and protection from
aspiration pneumonitis. Diabet Med 2009; 26: 829.
2. Hamblin PS, Topliss DJ, Chosich N, Lording DW, Stockigt JR. Deaths associated with
diabetic ketoacidosis and hyperosmolar coma. 1973-1988. Med J Aust 1989; 151: 439444.
3. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body
position as a risk factor for nosocomial pneumonia in mechanically ventilated patients:
a randomised trial. Lancet 1999; 354: 1851-1858.
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