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“Dirty drowning” related lung injury in a paediatric intensive care unit

Accidental drowning represents a leading cause of paediatric injury worldwide. Dirty water and sand/mud aspiration during submersion is quite rare though possibly lifethreatening, due to the complex mechanism of asphyxia. Aspiration of particulate matter should be considered in all dirty water drowning, and early bronchoscopy, and/ or airway lavage, should be undertaken when diagnosis is uncertain. Even if the early mechanical consequences of large quantity of contaminated water are overcome1, sand, mud, and a variety of microbes entering into their lower airways pose a significant infectious risk for both pulmonary and extrapulmonary complications.2– 4 Although relatively uncommon, sand and particulate aspiration in the neardrowning child should be excluded because of the associated spectrum of injuries. Acute respiratory failure secondary to inadequate ventilation may develop if the oropharynx and upper airway are partially occluded by sand. Damage to the bronchioles and alveoli can result in significant airway inflammation and acute lung injury requiring prolonged mechanical ventilatory support. Initial Chest XRay is often nonspecific, and sometimes only diffuse atelectatic or an alveolar patchy picture can be seen [Figure 1]. According to some authors, a role for early airway clearance has been suggested,1 possibly preventing further airway damage and barotrauma; moreover, submersion in dirty water makes it necessary for an early bronchoalveolar lavage to remove particulate and, possibly, to reduce the bacterial and fungal load.1,2 Undiagnosed foreign body in the bronchial tree may result in serious longterm sequelae such as recurrent pneumonia, atelectasis, or bronchiectasis.5 Traditionally, clinical outcome in children after neardrowning has been associated with cardiac arrest, a submersion time of >15 min, with no bystander CPR, an extended resuscitation time with the use of epinephrine/profound metabolic acidosis, and deep hypothermia.3 For patients experiencing dirty drowning, the early development of pneumonia is likely if the aspiration into the airway is accompanied by a large inoculum of infectious agents. Therefore, beyond early airway injury and cerebral hypoxia, infectious complications can have a profound influence on the clinical outcome. Late deaths from fungal Central Nervous System (CNS) complications have also been described, underlining the need for early fungal investigations and treatment2,6 A recent review paper regarding neardrowning intensive care7 could not demonstrate a significant advantage when using prophylactic antibiotics in neardrowning patients and highly contaminated submersion water. However, for dirtydrowned children, both antibiotic and antimycotic prophylaxis appear mandatory. We report the ICU management of five children (four male and one female), aged 2– 15 years (median age nine years), who were retrieved by heliambulance after being submersed in dirty water, suffering from asphyxia and aspiration of water contaminated by sand and/or mud. All the patients presented with a severe hypoxemic Acute Respiratory Failure (ARF). Three of them received an emergency intubation on site, while two were intubated at PICU admission. Four of them underwent early airway clearance, that in wo cases was guided by fibrobronchoscopy. The admission blood gas analysis showed in all cases a picture of respiratory acidosis with a reduced P/F. The only patient with further pulmonary complications (bilateral barotrauma, early severe pneumonia, refractory hypoxaemia) did not undergo early intubation and bronchoalveolar lavage. He required invasive ventilation for 26 days, while median invasive mechanical ventilation duration in all patients was five days, and reached a maximum Oxygenation Index (OI) of 35 (median of maximum OI in all patients: 15), also requiring iNO and eventually ExtraCorporeal Membrane Oxygenation. He was also the only patient with late complications (seizures with MRI finding of CNS bleeding) and remained in PICU for 87 days (median PICU stay of all dirty drowning patients was eight days). Main clinical and laboratory findings are illustrated in supporting information Table S1, and admission chest radiograms in Figure 1. This clinical series consists of five chidren admitted to the PICU after being retrieved from neardrowning in “dirty” and possibly contaminated fresh water: available literature mostly depicts isolated case reports or mixed series.6 Drowning in dirty water remains a relatively uncommon occurrence in paediatrics, while it can lead to respiratory failure secondary to inadequate ventilation for occlusive phenomena at onset (mud, sand)1; however, airway inflammation and acute lung injury can develop in the following hours requiring even prolonged mechanical ventilatory support. Inhomogeneous lung damage may facilitate air leaks whenever airway pressure is required to achieve gas exchange. Sequential lung washing followed by exogenous surfactant administration has also been described,1 and it seems reasonable because high amounts of lavage fluids can dilute and remove natural surfactant, possibly increasing the risk of lung atelectasis.