Large-volume barium aspiration
Gregory L. Hundemer, MD, Varun Kumar, and Muthiah Vaduganathan, MD, MPH
We present a case of large-volume barium aspiration in a 56-year-old
woman with stage IV tongue squamous cell carcinoma and longstanding
dysphagia. The patient rapidly developed hypoxemic respiratory failure
from the resultant chemical pneumonitis. However, her respiratory status
improved with supportive care alone in 48 hours. Barium aspiration is
rare and often produces dramatic radiographic findings, but is generally
associated with a favorable prognosis.
B
arium studies are commonly used in the interrogation
of the upper gastrointestinal tract. Although barium
sulfate is an inert material, it rarely can cause severe
complications (1), as described in this case.
CASE DESCRIPTION
A 56-year-old cachectic woman with longstanding dysphagia and multiple episodes of aspiration pneumonia presented
with orthostasis in the setting of poor oral intake, weight loss,
and progressive failure to thrive. She had stage IV tongue squamous cell carcinoma and was receiving palliative chemotherapy.
In anticipation of a gastric tube placement, barium was administered the night before the planned procedure. The following
morning, she acutely developed increased work of breathing
and profound hypoxemia.
On examination, her temperature was 100.4°F; pulse, 160
beats per minute; blood pressure, 111/55 mm Hg; respiratory
rate, 30 breaths/minute; and oxygen saturation, 70% on room air.
Her oxygen saturation improved to 95% on a 100% high-flow
set running at 15 L per minute. She coughed frequently. Her
breath sounds were course at the bilateral bases with mild accessory muscle use. Her extremities were warm and without edema.
The white blood cell count was 21.5 × 103 cells/mm3, which had
increased from 4.8 × 103 cells/mm3 the day before. Her troponin
T level was <0.01 ng/mL. A comprehensive metabolic panel was
normal. An electrocardiogram showed sinus tachycardia without
ischemic changes. A chest radiograph demonstrated aspiration
of barium, highlighting her bilateral airways and bronchial tree,
most pronounced in the lower lobes (Figure 1a).
In the medical intensive care unit, she required a 100%
nonbreather mask initially to maintain adequate oxygenation,
but otherwise appeared comfortable without overt respiratory
Proc (Bayl Univ Med Cent) 2015;28(2):183–184
distress. She was provided with supportive management including chest physiotherapy, a percussion vest, and an Acapella
device to promote cough and clearance of the barium material.
Over the following 48 hours, her respiratory status gradually
improved and she no longer required supplemental oxygen.
At discharge, her chest radiograph (Figure 1b) showed small
quantities of barium, primarily in the left lower lobe.
DISCUSSION
Barium studies are often used to evaluate disordered swallowing, despite the risk of aspiration. Aspiration of large quantities of
barium sulfate and attendant complications are rare (2). Barium
has not been shown to commonly cause chemical pneumonitis
(3). In fact, cases have been reported of incidental diagnosis of
barium aspiration on chest imaging in patients who were completely asymptomatic after the initial study (4). Before the advent
of bronchoscopy, inhalation bronchography with barium contrast
was used to identify respiratory pathology without major complications or symptoms in human and nonhuman animals (3).
Mechanical obstruction leading to alveolar dead space as
well as uncommon acute inflammatory reactions have been
reported (5–7). Cases with severe respiratory complications
appear to occur at higher frequency in patients with extensive
comorbid diseases. Dysphagia and head and neck malignancy
are common risk factors for high-volume aspiration (1, 5, 8),
and these risk factors were present in our patient.
Although data are sparse guiding the optimal management
of barium aspiration, potential treatment strategies vary based
on the quantity of barium aspirated, the patient’s comorbid
disease profile, and the presenting symptoms. Many patients
are completely asymptomatic after barium swallow, and in these
cases, no intervention is required (2). The acute immunologic
response seen in gastric content aspiration is not normally seen
with barium aspiration alone (9, 10). However, when gastric
contents are aspirated with barium and the patient develops
From the Department of Medicine, Massachusetts General Hospital, Harvard
Medical School, Boston, Massachusetts (Hundemer, Vaduganathan), and the
Department of Medicine, Baylor College of Medicine, Houston, Texas (Kumar).
Corresponding author: Muthiah Vaduganathan, MD, MPH, Department of
Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit
Street, GRB 730, Boston, MA 02114 (e-mail: [email protected]).
183
a
b
Figure 1. Frontal chest radiograph (a) immediately after the barium aspiration event, showing large-volume high-density barium in the more dependent airways
in the bilateral lower lungs (arrows) and (b) 48 hours after the event with supportive care in the intensive care unit, revealing considerable interval clearing of the
aspirated contrast material.
signs of infection, antibiotics have been used (6). In patients
with more progressive clinical courses who develop severe respiratory failure requiring intubation, bronchoscopy and suctioning have been attempted (8). However, complications of
bronchoalveolar lavage include the possibility for contrast to
spread to initially unaffected areas of the lung (11).
Barium studies should be used judiciously in elderly patients with multiple comorbidities and altered head and neck
anatomy. Functional endoscopic evaluation of swallowing may
provide a safer alternative to barium studies (12). Furthermore,
recent studies have attempted use of a retroesophageal suction
catheter to eliminate aspiration in patients with profound dysphagia (13). The use of retropharyngeal suction during the study
may also be worthwhile when evaluating high-risk patients to
minimize the risk of massive barium aspiration and the ensuing
complications.
Limited data exist characterizing the long-term prognoses of patients after isolated barium aspiration events. Most
patients appear to have complete recovery given the inert nature of barium; however, high-resolution chest imaging has
detected subtle evidence of early fibrosis even 1 year after
aspiration (4).
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1.
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Varatharaj A, Roome C, Allsup S. Barium aspiration. QJM 2012;105(9):
903–904.
Fuentes Santos C, Steen B. Aspiration of barium contrast. Case Rep
Pulmonol 2014;2014:215832.
Shook CD, Felson B. Inhalation bronchography. Chest 1970;58(4):333–
337.
Voloudaki A, Ergazakis N, Gourtsoyiannis N. Late changes in barium
sulfate aspiration: HRCT features. Eur Radiol 2003;13(9):2226–2229.
Gray C, Sivaloganathan S, Simpkins KC. Aspiration of high-density
barium contrast medium causing acute pulmonary inflammation—report
of two fatal cases in elderly women with disordered swallowing. Clin Radiol
1989;40(4):397–400.
Kaira K, Takise A, Goto T, Horie T, Mori M. Barium sulphate aspiration.
Lancet 2004;364(9452):2220.
Fruchter O, Dragu R. Images in clinical medicine. A deadly examination.
N Engl J Med 2003;348(11):1016.
Albeldawi M, Makkar R. Images in clinical medicine. Barium aspiration.
N Engl J Med 2012;366(11):1038.
Reich SB. Production of pulmonary edema by aspiration of water-soluble
nonabsorbable contrast media. Radiology 1969;92(2):367–370.
Nelson SW, Christoforidis AJ, Pratt PC. Further experience with barium
sulfate as a bronchographic contrast medium. Am J Roentgenol Radium
Ther Nucl Med 1964;92:595–614.
Tamm I, Kortsik C. Severe barium sulfate aspiration into the lung: clinical
presentation, prognosis and therapy. Respiration 1999;66(1):81–84.
Brady S, Donzelli J. The modified barium swallow and the functional
endoscopic evaluation of swallowing. Otolaryngol Clin North Am
2013;46(6): 1009–1022.
Belafsky PC, Mehdizadeh OB, Ledgerwood L, Kuhn M. Evaluation of
hypopharyngeal suction to eliminate aspiration: the retro-esophageal suction
(REScue) catheter. Dysphagia 2014 Sep 27 [Epub ahead of print].
Baylor University Medical Center Proceedings
Volume 28, Number 2