Barium Aspiration

Aspiration is the most common complication of barium swallow or follow-through investigations. It is still very rare, around 0.04%. However, most episodes of aspiration have no clinical sequaelae. (19)

The severity of barium aspiration usually depends on the volume of barium aspirated. The distribution of the barium into the lobes of the lungs is usually dependent on the position of the patient during the procedure, though it can be bilateral in large aspirations. (20–23) Barium aspiration causes respiratory problems by three main mechanisms. Firstly, the viscous barium sulphate may obstruct the airways, and the lungs can struggle to clear the liquid. Secondly, the presence in the airways interferes with gas exchange and ventilation-perfusion mismatch, and this can lead to hypoxia, pneumonia, adult respiratory distress syndrome, respiratory failure and death. Lastly, long term, the aspiration can cause pulmonary fibrosis (the barium is phagocytosed by alveolar macrophages, causing the fibrosis) and bronchial granulomas. (19,23)

Risk factors for aspiration in those born with OA/TOF

1. Barium swallow may be used to diagnose feeding issues in infancy before diagnosis is known, allowing aspiration via the unrepaired TOF. (24)
2. Infancy is also a risk factor. (21)
3. Those born with OA/TOF are much more likely to have this investigation, both as children and in adulthood, though some previous rationales for the investigation are now superseded by newer investigations, and due to concerns about lifelong radiation exposure. (19)
4. The presence of undiagnosed recurrent TOF, albeit rare, will also lead to barium aspiration, and some adults will have endured barium aspiration as infants when these investigations were carried out before the diagnosis of OA/TOF was known. (20)
5. Dysphagia is a major risk factor for barium aspiration.
6. GORD, another common OA/TOF issue, also increases the risk of aspiration. (21)

Treatment

There is no standard management protocol for management of acute aspiration of barium. Treatment of symptoms and stabilising the patient is the priority:

• Oxygen
• Antibiotics if infection is present
• Stabilise the patient
• Bronchio-alveolar lavage isn’t routinely recommended as it may disperse the barium through the lungs
• Chest physiotherapy may promote clearance of the barium (21)

Long term

Management of symptomatic pulmonary fibrosis and bronchial granuloma is beyond the scope of this booklet. However, if respiratory symptoms develop/persist after a known episode of barium aspiration, chest x-ray and CT chest can delineate the extent of the problem, and/or endoscopy for bronchial granuloma, and referral to respiratory physicians is recommended. Voloudaki et al. (2002) reported such CT changes as ‘thickened interlobular septa, subpleural lines, subpleural cysts, and centrilobular micronodules along with barium particles in a subpleural distribution’. (25)