History of Pneumonia Presents Major Risk Factor for Aspiration or Pneumonia Following Routine Ambulatory Endoscopy

As the number of ambulatory endoscopies increases, it is imperative to identify and work to prevent complications. Respiratory complications are considered the most common associated with such procedures (including coughing, fever and shortness of breath) and are documented for an estimated 5.3 percent of patients following an ambulatory endoscopy where propofol was administered.1 Abraham Mathew, M.D., and Lisa Yoo, D.O., Gastroenterology and Hepatology, found that 1.1 percent of adults who underwent a routine ambulatory endoscopy experienced pneumonia or aspiration within 30 days after the procedure. The vast majority of cases involved pneumonia, while cases of aspiration were very low (0.07 percent).

Clinical Characteristics Chart

Dr. Yoo notes, “The strongest predictors of such complications include a patient history of pneumonia, congestive heart failure, dysphagia and stroke. To a lesser degree, use of anesthesia was also predictive.” The findings report, based on retrospective analysis of approximately 5 million routine ambulatory endoscopies performed in adults (2009-2010) in a private U.S. claims database (MarketScan), is one of the largest such analyses performed to date. In October 2015, the findings were presented at the American College of Gastroenterology (ACG) annual meeting in Honolulu, Hawaii, where it was awarded the ACG’s President’s Award.

A history of pneumonia in the past year was associated with a 19-fold increased risk of post-endoscopy aspiration or pneumonia, followed by congestive heart failure (adjusted OR 2.8, 95 percent CI 2.52-3.07), dysphagia (adjusted OR 2.3, 95 percent CI 2.11-2.41), prior stroke (adjusted OR 2.0, 95 percent CI 1.81-2.12), and use of anesthesiologists (adjusted OR 1.1, 95 percent CI 1.024- 1.113). “This was entirely counter to our predictions that use of anesthesia and patient body mass index would strongly predict pneumonia,” said Dr. Mathew.

The findings may have an impact on how routine ambulatory endoscopy is performed and how patients are instructed to prepare for the procedure. For patients with a history of pneumonia, confirming that they have fully recovered prior to the procedure might help to reduce risk. Dr. Mathew says, “It is interesting to think about other strategies to reduce respiratory risks, such as inclining the upper body and head at a slight angle, another might be to extend fasting time.” Dr. Mathew believes that current evidence is still insufficient to warrant prophylactic antibiotic treatment for selected patients since it is not known how many of the pneumonia events were related to bacterial infection. It is possible that many cases were secondary to aspiration during endoscopy.

Dr. Yoo notes, “Because we were using a claims database, we don’t know whether diagnosis was confirmed using X-ray, or presumed based on clinical signs. We also cannot know which cases were bacterial in nature or related to other factors like aspiration during endoscopy, or comorbidities.” Approximately 6 percent of the patients who experienced this complication had pneumonia within the past year. Drs. Yoo and Mathew plan to conduct future investigations that describe this patient subgroup in more detail.

Abraham Mathew, M.D.

Abraham Mathew, M.D.
Professor of Medicine
PHONE: 717-531-6261
E-MAIL: amathew@hmc.psu.edu
FELLOWSHIP: Gastroenterology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.
RESIDENCY: Internal medicine, Abington Memorial Hospital, Abington, Pa.
MEDICAL SCHOOL: Mahathma Gandhi University, Kerala, India

Connect with Abraham Mathew, M.D. on Doximity

Lisa Yoo, D.O.

Lisa Yoo, D.O.
Gastroenterology Fellow
PHONE: 717-531-6261
E-MAIL: lyoo@hmc.psu.edu
FELLOWSHIP: Gastroenterology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.
RESIDENCY: Internal medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pa.
MEDICAL SCHOOL: Lake Erie College of Osteopathic Medicine, Erie, Pa.

Connect with Lisa Yoo, D.O. on Doximity



1. Friedrich K, Scholl SG, Beck S, et al. 2014. Respiratory complications in outpatient endoscopy with endoscopist-directed sedation. J Gastrointestin Liver Dis. 23(3):255-9.

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