Airway Pepsin Levels in Otherwise Healthy Surgical Patients Receiving General Anesthesia with Endotracheal Intubation

Overview

Journal Chest

Publisher Elsevier

Specialty Pulmonary Medicine

Date 2012 Nov 3

PMID 23117366

Citations 6

Authors

J Kyle Bohman

Daryl J Kor

Rahul Kashyap

Ognjen Gajic

Emir Festic

Zhaoping He

Augustine S Lee

Affiliations

Soon will be listed here.

Abstract

Background: Airway pepsin has been increasingly used as a potentially sensitive and quantifiable biomarker for gastric-to-pulmonary aspiration, despite lack of validation in normal control subjects. This study attempts to define normal levels of airway pepsin in adults and distinguish between pepsin A (exclusive to stomach) and pepsin C (which can be expressed by pneumocytes).

Methods: We performed a prospective study of 51 otherwise healthy adult patients undergoing elective extremity orthopedic surgery at a single tertiary-care academic medical center. Lower airway samples were obtained immediately following endotracheal intubation and just prior to extubation. Total pepsin and pepsin A concentrations were directly measured by an enzymatic activity assay, and pepsin C was subsequently derived. Pepsinogen/pepsin C was confirmed by Western blot analyses. Baseline characteristics were secondarily compared.

Results: In all, 11 (22%; 95% CI = 9.9%-33%) had detectable airway pepsin concentrations. All 11 positive specimens had pepsin C, without any detectable pepsin A. Pepsinogen/pepsin C was confirmed by Western blot analyses. In a multivariate logistic regression, men were more likely to have airway pepsin (OR, 12.71, P = .029).

Conclusions: Enzymatically active pepsin C, but not the gastric-specific pepsin A, is frequently detected in the lower airways of patients who otherwise have no risk for aspiration. This suggests that nonspecific pepsin assays should be used and interpreted with caution as a biomarker of gastropulmonary aspiration, as pepsinogen C potentially expressed from pneumocytes may be detected in airway samples.

Citing Articles

Oral Care Associated With Less Microaspiration in Ventilated Cardiac Patients.

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PMID: 37181916 PMC: 10174743. DOI: 10.1097/PG9.0000000000000290.

Pepsin A in Tracheal Secretions From Patients Receiving Mechanical Ventilation.

Talbert S, Bourgault A, Rathbun K, Abomoelak B, Deb C, Mehta D Am J Crit Care. 2021; 30(6):443-450.

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Intubation Setting, Aspiration, and Ventilator-Associated Conditions.

Talbert S, Detrick C, Emery K, Middleton A, Abomoelak B, Deb C Am J Crit Care. 2020; 29(5):371-378.

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Characteristics and outcomes of patients hospitalized following pulmonary aspiration.

Lee A, Festic E, Park P, Raghavendran K, Dabbagh O, Adesanya A Chest. 2014; 146(4):899-907.

PMID: 24811480 PMC: 4188146. DOI: 10.1378/chest.13-3028.

Accuracy of alpha amylase in diagnosing microaspiration in intubated critically-ill patients.

Dewavrin F, Zerimech F, Boyer A, Maboudou P, Balduyck M, Duhamel A PLoS One. 2014; 9(6):e90851.

PMID: 24603906 PMC: 3946401. DOI: 10.1371/journal.pone.0090851.

References

Kageyama T, Takahashi K . Pepsinogen C and pepsin C from gastric mucosa of Japanese monkey. Purification and characterization. J Biochem. 1976; 80(5):983-92. DOI: 10.1093/oxfordjournals.jbchem.a131386. View

Warner M, Warner M, Weber J . Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology. 1993; 78(1):56-62. DOI: 10.1097/00000542-199301000-00010. View

Metheny N, Chang Y, Ye J, Edwards S, Defer J, Dahms T . Pepsin as a marker for pulmonary aspiration. Am J Crit Care. 2002; 11(2):150-4. PMC: 2408999. View

Wang L, Liu X, Liu Y, Zeng F, Wu T, Yang C . Correlation of pepsin-measured laryngopharyngeal reflux disease with symptoms and signs. Otolaryngol Head Neck Surg. 2010; 143(6):765-71. DOI: 10.1016/j.otohns.2010.08.018. View

Roberts N . Review article: human pepsins - their multiplicity, function and role in reflux disease. Aliment Pharmacol Ther. 2006; 24 Suppl 2:2-9. DOI: 10.1111/j.1365-2036.2006.03038.x. View

Hirschowitz B . Apparent and intrinsic sensitivity to pentagastrin of acid and pepsin secretion in peptic ulcer. Gastroenterology. 1984; 86(5 Pt 1):843-51. View

Gali B, Whalen F, Schroeder D, Gay P, Plevak D . Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnea screening tool and postanesthesia care assessment. Anesthesiology. 2009; 110(4):869-77. DOI: 10.1097/ALN.0b013e31819b5d70. View

Adeniyi K . Gastric acid secretion and parietal cell mass: effect of sex hormones. Gastroenterology. 1991; 101(1):66-9. DOI: 10.1016/0016-5085(91)90460-3. View

Kor D, Warner D, Alsara A, Fernandez-Perez E, Malinchoc M, Kashyap R . Derivation and diagnostic accuracy of the surgical lung injury prediction model. Anesthesiology. 2011; 115(1):117-28. PMC: 3986041. DOI: 10.1097/ALN.0b013e31821b5839. View

10.

Ng A, Smith G . Gastroesophageal reflux and aspiration of gastric contents in anesthetic practice. Anesth Analg. 2001; 93(2):494-513. DOI: 10.1097/00000539-200108000-00050. View

11.

Meert K, Daphtary K, Metheny N . Detection of pepsin and glucose in tracheal secretions as indicators of aspiration in mechanically ventilated children. Pediatr Crit Care Med. 2003; 3(1):19-22. DOI: 10.1097/00130478-200201000-00005. View

12.

Ward C, Forrest I, Brownlee I, Johnson G, Murphy D, Pearson J . Pepsin like activity in bronchoalveolar lavage fluid is suggestive of gastric aspiration in lung allografts. Thorax. 2005; 60(10):872-4. PMC: 1747219. DOI: 10.1136/thx.2004.036426. View

13.

Tsai M, Lin H, Lin C, Lin H, Chen Y, Pfeiffer S . Increased risk of concurrent asthma among patients with gastroesophageal reflux disease: a nationwide population-based study. Eur J Gastroenterol Hepatol. 2010; 22(10):1169-73. DOI: 10.1097/MEG.0b013e32833fb68c. View

14.

Lee J, Ryu J, Elicker B, Lydell C, Jones K, Wolters P . Gastroesophageal reflux therapy is associated with longer survival in patients with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med. 2011; 184(12):1390-4. PMC: 3262030. DOI: 10.1164/rccm.201101-0138OC. View

15.

Krishnan U, Mitchell J, Messina I, Day A, Bohane T . Assay of tracheal pepsin as a marker of reflux aspiration. J Pediatr Gastroenterol Nutr. 2002; 35(3):303-8. DOI: 10.1097/00005176-200209000-00012. View

16.

Moriyama A, Kageyama T, Takahashi K . Identification of monkey lung procathepsin D-II as a pepsinogen-C-like acid protease zymogen. Eur J Biochem. 1983; 132(3):687-92. DOI: 10.1111/j.1432-1033.1983.tb07420.x. View

17.

Smith J, Decalmer S, Kelsall A, McGuinness K, Jones H, Galloway S . Acoustic cough-reflux associations in chronic cough: potential triggers and mechanisms. Gastroenterology. 2010; 139(3):754-62. DOI: 10.1053/j.gastro.2010.06.050. View

18.

He Z, OReilly R, Bolling L, Soundar S, Shah M, Cook S . Detection of gastric pepsin in middle ear fluid of children with otitis media. Otolaryngol Head Neck Surg. 2007; 137(1):59-64. DOI: 10.1016/j.otohns.2007.02.002. View

19.

Elabiad M, Zhang J . Detection of pepsinogen in the neonatal lung and stomach by immunohistochemistry. J Pediatr Gastroenterol Nutr. 2011; 53(4):401-3. DOI: 10.1097/MPG.0b013e31821a4b78. View

20.

Farrell S, McMaster C, Gibson D, Shields M, McCallion W . Pepsin in bronchoalveolar lavage fluid: a specific and sensitive method of diagnosing gastro-oesophageal reflux-related pulmonary aspiration. J Pediatr Surg. 2006; 41(2):289-93. DOI: 10.1016/j.jpedsurg.2005.11.002. View