Death due to Pulmonary Aspiration arising from Breast Feeding

Need for Autopsy in every death –

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Death due to Pulmonary Aspiration arising from Breast Feeding

When solid, liquid, or gastric contents are accidentally aspired into the respiratory passages is a medical emergency, both amongst the children, and the adults. If the same is not medically intervened then, the fatality can cause death due to asphyxia.

When pharyngeal secretions, food or drink, or stomach contents enters into the larynx also known as the voice box from the oropharynx or gastrointestinal tract and lower respiratory tract, the condition is stated to be Pulmonary aspiration. Such a state of traumatic inhalation can be a direct one, or it may be mistakenly delivered into the tracheo-bronchial tree during positive pressure ventilation. When pulmonary aspiration occurs during eating and drinking, the aspirated material is often termed as “going down the wrong pipe”. The consequences of pulmonary aspiration may have no fatal injury; or can cause chemical pneumonitis or pneumonia; or, death within minutes in the weirdest case.  

Death due to asphyxiation arising out of aspiration may be referred to as ‘choking’.

Death from choking causes due to, ‘pure hypoxia from occlusion of the airway’, where in all the attendant signs of congestion, cyanosis and perhaps petechiae may be present, when the victim struggles to breathe for a considerable period of time. However, as observed that higher proportion of deaths occurring before any possible hypoxic manifestations usually gets time to take effect; these fatalities are caused by neurogenic cardiac arrest, either purely neurogenic or accelerated by excess catecholamine release from the adrenaline response.

Choking is exclusively accidental in nature. Homicidal choking is argumentatively possible in infant victims. In the case of a psychiatric person suicidal choking is evitable. Different causes of death in choking are asphyxia, laryngeal spasm, vagal inhibition and reflex neurogenic cardiovascular failure.

It is not necessary that every time a large foreign body, capable of blocking the air passages can cause asphyxia completely. Even a small object blocking the lumen partially may cause death by laryngeal spasm. In adults, choking always doesn’t involves food, but can be commonly associated with acute alcoholic intoxication, bad fitting dentures, neurological injury or senility. Complications usually develop after a latent interval, if the person survives. A survey has demonstrated that about 25 lakh people have succumbed to the ‘pulmonary aspiration or foreign body in the airways’ in 2023.

Similarly, aspiration can cause signs and symptoms in a baby such as:

• Weak sucking,

• Choking or coughing while feeding,

• Other signs of feeding trouble, like a red face, watery eyes, or facial grimaces,

• Stopping breathing while feeding,

• Faster breathing while feeding,

• Voice or breathing that sounds wet after feeding,

• Slight fever after feedings,

• Wheesing and other breathing problems,

• Repeated lung or airway infections,

Usually, any foreign object present in the air passages can excite violent coughing out, but if this is not successful in expelling the object out, choking results. The universal sign for choking is “hands clutched to the throat”, but if the victim is unable to exhibit the signal, then the following indications should be looked for:

• Inability to talk,

• Difficulty breathing or noisy breathing,

• Inability to cough forcefully,

• Skin, lips and nails turning blue or dusky,

• Loss of consciousness,

When choking is encountered, then the “five-and-five” approach recommended by the Red Cross Society should be adhered to. They are:

•  5 back blows to be given between the person’s shoulder blades with the heel of the hand.

•  5 abdominal thrusts to be given (Heimlich Manoeuvre).

•  5 back blows and 5 abdominal thrusts to be given alternately until the blockage is dislodged.

To clear the airway of an unconscious person:

• the person should be lowered on his or her back onto the floor.

• the airway is to be cleared. If a blockage is visible at the back of the throat or high in the throat, a finger should be inserted into the mouth and the cause of the blockage needs to be swept out. But caution should be taken in not pushing the food or object deeper into the airway, which can happen easily in young children.

• Cardiopulmonary Resuscitation (CPR) should be initiated, if the object remains lodged and the person doesn’t respond even after taking the above measures. The chest compressions used in CPR may dislodge the object. The mouth needs to be rechecked periodically.

To clear the airway of a choking neo-natal:

• Assuming in a seated position and holding the infant face down on the therapist’s forearm, which is resting on the thigh.

     •   The infant should be thumped gently but firmly five times on the middle of the back using the heel of the hand. The combination of gravity and the back blows should release the blocking object.

     •    The infant should be held face up on the forearm with the head lower than the trunk if the above doesn’t work. Using two fingers placed at the centre of the infant’s breastbone, five quick chest compressions must be given.

     • The back blows and chest thrusts should be repeated if breathing doesn’t resume. Emergency medical help should be called for.

• Infant CPR should be initiated right away if one of these techniques manages to open the airway but the infant doesn’t resume breathing.

• If the child is older than 1 year, only abdominal thrusts should be given.

Choking of the respiratory passages from aspiration requires medical intervention at the earliest. Apart from medical professionals dealing with such cases, it is equally important for the general public to know how to tackle the situation by emergency first aid and all must have such first aid training to save valuable human life.

In a weirdest case: A female baby, aged one year, was admitted to a Government Medical College & Hospital, on a summer morning, in a gasping state and upon reaching the emergency ward of paediatrics ward of the hospital, the baby was pronounced dead immediately thereafter. As per the attending doctor, the child was suffering from asthmatic bronchitis, and the probable cause of death was aspiration of milk, as the mother was continuously feeding the child. The mother was thoroughly diagnosed, and was found to be getting treatment from the psychiatric department of the same hospital, and was on Qutan 50 Tablet. The baby was sent for Post Mortem analysis.

Post Mortem Examination: – Rigor Mortis was not fully developed; bluish discoloration was present on lips, nails and ear lobule; frothy secretions were present in the nostrils.

Internal examination revealed that, organs were with generalised congestion, milky white frothy secretions were present in the mouth, pharynx & oesophagus, larynx and trachea were full of milky white fluid and frothy secretions, stomach was full of milky white and greenish coloured liquid and semi digested food material. Viscera were preserved for chemical and histopathological examination.

The provisional cause of death was given as “Death due to asphyxia resulting from choking from aspiration of gastric contents into the respiratory passage. However, final opinion will be given on receiving the reports of chemical and histopathological examination of viscera”.

On receiving the reports of chemical and histopathological examination of viscera, the final opinion on cause of death was given as “From post-mortem findings & the reports of Chemical and Histopathological examination of viscera, the cause of death in this case is asphyxia resulting from choking from aspiration of gastric contents into the respiratory passage, sufficient to cause death in the ordinary course of nature.

This case had demonstrated the omnipotent importance of Post Mortem; had it not been done; it would have been cited to be a natural death caused “due to cardio-respiratory failure”.

Writer Suvro Sanyal

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