Diagnosis of orotracheal aspiration using radionuclide salivagram

Clinico-radiologic Features of Lung Disease Associated With Aspiration Identified on Lung Biopsy

BACKGROUND

Aspiration-related lung diseases are commonly diagnosed presumptively based on the clinical context and radiologic findings. Limited data exist on the spectrum of clinico-radiologic presentations associated with aspiration.

METHODS

This study reviewed all cases of aspiration identified on lung biopsy encountered at the Mayo Clinic between 2003 and 2017. Demographic and clinical features, including risk factors for aspiration, diagnoses suspected prior to biopsy, imaging findings, and microbiologic data, were analyzed.

RESULTS

A total of 52 consecutive adult cases of aspiration identified on lung biopsy (histologic presence of food or other particulate matter) were included; patients' median age was 59 years (range, 22 to 79 years), 38% were women, and there were five lung transplant recipients. Of these, 63% were diagnosed according to results of surgical biopsy (including four cases of lobectomy) and 37% according to results of transbronchial biopsy. Aspiration was clinically suspected prior to biopsy in 35% of the subjects. Ninety percent of subjects had at least one identifiable risk factor for aspiration; gastroesophageal reflux disease was the most common (62%), followed by a structurally abnormal esophagogastric tract and the use of consciousness-impairing medications. Only 27% of patients reported dysphagia or choking. Chest CT imaging revealed a variety of parenchymal patterns, including bronchiolitis (42%), patchy consolidation (19%), and mass (15%). Of 25 patients undergoing a video-swallow evaluation, 14 (56%) had abnormal results with laryngeal penetration with or without aspiration. Microbial cultures obtained in 21 lung biopsy specimens yielded no pathogens.

CONCLUSIONS

Aspiration can occur in the absence of subjective or demonstrable swallowing difficulties and manifest a broad spectrum of clinico-radiologic presentations.

The Effect of Nebulized Glycopyrrolate on Posterior Drooling in Patients with Brain Injury: Two Cases of Different Brain Lesions

Posterior drooling, which can lead to substantial respiratory morbidity, including unexplained lung diseases and recurrent pneumonia, is an important issue in the rehabilitation unit. There are various treatment options for posterior drooling, including pharmacologic therapy, oral motor or behavioral therapy, biofeedback, local glandular injection of botulinum toxin, irradiation, and surgery. Among them, nebulized glycopyrrolate has the following advantages: It is noninvasive and is relatively free of central adverse effects because it does not cross the blood-brain barrier unlike other anticholinergics. Although there has been one case report regarding the effectiveness of nebulized glycopyrrolate for drooling in a motor neuron patient, there have not been any reports on its effectiveness for posterior drooling. Herein, we report two cases (an 82-year-old male bilateral hemiplegic stroke patient and a 1-year-old female cerebral palsy infant with bilaterally spastic hemiplegia of posterior drooling treated with nebulized glycopyrrolate) and identify salivary aspiration and the effect of nebulized glycopyrrolate using radionuclide salivagram. Considering its advantages and effectiveness, nebulized glycopyrrolate should be considered as one of the reliable methods to manage posterior drooling in patients with impaired cognition or swallowing difficulties, such as severe brain injury.

Radionuclide Salivagram and Gastroesophageal Reflux Scintigraphy in Pediatric Patients: Targeting Different Types of Pulmonary Aspiration

OBJECTIVE

Both gastroesophageal reflux (GER) scintigraphy and radionuclide salivagram are commonly used in the detection of pulmonary aspiration in pediatric patients. This investigation is to compare the diagnostic value of these 2 imaging methods.

METHODS

This retrospective study included 4186 pediatric patients (aged 1 week to 16 years; mean age, 28 months) who underwent a GER scintigraphy and/or radionuclide salivagram. Detection rate of pulmonary aspiration by the 2 imaging techniques was compared.

RESULTS

The detection rate for pulmonary aspiration in patients undergoing both procedures was 1.9% (5 of 266) for GER scintigraphy and 22.2% (59 of 266) for radionuclide salivagram. Fifty-six of 59 patients with proven aspiration on radionuclide salivagram demonstrated no such findings on GER scintigraphy, whereas 2 of 5 patients with proven aspiration on GER scintigraphy demonstrated no such findings on radionuclide salivagram. In patients who underwent only 1 procedure (either GER scintigraphy or salivagram), the detection rate for pulmonary aspiration was 0.4% (15 of 3551) for GER scintigraphy and 20.3% (75 of 369) for radionuclide salivagram.

CONCLUSIONS

Radionuclide salivagram showed a much higher detection rate for pulmonary aspiration compared with GER scintigraphy. However, this may be related to a significantly higher prevalence of antegrade versus retrograde aspiration in our study population. Our results also suggest that not all episodes of retrograde aspiration can be detected by a radionuclide salivagram, and the requested scan should be tailored to the type of suspected aspiration.

Comparison between the radionuclide salivagram and videofluoroscopic swallowing study methods for evaluating patients with aspiration pneumonia

OBJECTIVE

A videofluoroscopic swallowing study (VFSS) is generally used to assess dysphagia and aspiration, although false-negative results may be obtained. Saliva aspiration may cause false-negative VFSS findings in elderly people. A radionuclide salivagram can be useful in detecting saliva aspiration. We therefore compared these two methods for the evaluation of patients with aspiration pneumonia.

METHODS

We prospectively enrolled 50 patients with aspiration pneumonia into this study. All patients underwent VFSS, and were evaluated on the Penetration-Aspiration Scale. A salivagram was performed on the day after VFSS and each patient received 1 mL Tc-99 m DTPA sublingually. Both dynamic and delayed images were obtained.

RESULTS

Aspiration was observed in 34% of patients by salivagram and in 42% by VFSS. The frequency of tests that were positive for aspiration pneumonia using a combination of the two methods was 52%. Five patients with positive aspiration findings on salivagram were negative on VFSS. The association between VFSS and salivagram findings was significant but the total agreement was 72%. The frequency of aspiration pneumonia was significantly associated with an abnormal salivagram finding.

CONCLUSIONS

A salivagram may be a useful method for the evaluation of aspiration in elderly people, and a combination of the VFSS and salivagram methods could enable a more effective investigation of aspiration pneumonia.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities

OBJECTIVE

This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Pediatric Gastrointestinal Nuclear Medicine

General localization of gastrointestinal bleeding through the use of labeled red blood cells may be performed in children, or (99m)Tc-pertechnetate may be used if a Meckel's diverticulum is suspected. As in adults, cholecystitis and biliary leak may be assessed in children via (99m)Tc-IDA derivatives. Gastroesophageal reflux can be evaluated by oral consumption of the child's usual diet labeled with (99m)Tc sulfur colloid. For the scintigraphic determination of pulmonary aspiration, a relatively high concentration of tracer within a drop of liquid is placed beneath the child's tongue followed by dynamic imaging of the respiratory tract. Colonic transit scintigraphy can aid in the identification and therapeutic decision-making in patients with functional fecal retention, the most common cause of chronic constipation in children. (18)F-DOPA positron emission tomography is useful for classifying pancreatic involvement in infantile hyperinsulinism as focal or diffuse, thereby differentiating between patients who should receive curative focal pancreatic resection versus those who should receive medical management. Assessment of protein-losing enteropathy can be conducted scintigraphically and, compared with fecal alpha-1 antitrypsin collection, the scintigraphic method can detect esophageal and gastric protein loss. Also, scintigraphic quantification of protein loss can be performed without the requirement for fecal collection. Intestinal inflammation in children with inflammatory bowel disease can be evaluated using (99m)Tc white blood cells. The scintigraphic method is safe, accurate, well-tolerated by children and complementary to endoscopy in most patients.