Pulmonary aspiration

Aspiration Prevention Surgery: Clinical Factors Associated With Improvements in Oral Status Intake and Suction Frequency

OBJECTIVE

In recent years, the use of aspiration prevention surgery (APS) for the treatment of severe dysphagia has been on the rise. However, relevant clinical studies have included small samples, and the frequency of, and risk factors for postoperative complications have not been clarified. We investigated the clinical features of patients undergoing APS and whether oral-intake status and suction frequency could be reduced.

STUDY DESIGN

A case series.

SETTING

Single-institution academic center.

METHODS

We retrospectively evaluated medical charts generated from 2010 to 2021. The clinical characteristics of patients undergoing APS, changes in the oral-intake status (Functional Oral Intake Scale, FOIS), suction frequency before and after surgery, risk factors for postoperative complications, and factors contributing to improvements in postoperative oral-intake status were retrieved.

RESULTS

We included the data of 100 patients (median age: 65 years, 72 men). Amyotrophic lateral sclerosis was the most common primary disease (28%), and glottis closure was the most common APS (69%). Postoperatively, 78% of patients showed improvements in the FOIS score, and suction frequency decreased in 85% of cases. Postoperative complications were observed in 10 patients (10%), wound infection in 6, and bleeding in 4; all improved. Higher preoperative FOIS scores were significantly associated with postoperative complications (p = 0.02).

CONCLUSION

APS contributed to improving the FOIS score and helped reduce the suction frequency in most cases. APS can be performed safely with proper perioperative management, even in patients with poor preoperative general conditions and nutritional status.

Ten common questions (and their answers) on medical futility

The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.

Fat laden macrophages in tracheal aspirates as a marker of reflux aspiration: a negative report

OBJECTIVES

Refluxed gastric material aspirated into the lungs is an important cause of acute and chronic pulmonary disease. Currently, the presence of fat-laden macrophages (FLM) in tracheobronchial secretions of children is a conventional marker for reflux aspiration. However, this assay is limited by its apparent lack of specificity. The aim of this study was to reevaluate the role of this assay in diagnosing reflux aspiration.

METHODS

The tracheal aspirates of sixty-four consecutive children with clinically significant gastroesophageal reflux undergoing upper gastrointestinal endoscopy under general anesthesia, and 34 other children from the routine operative schedule were evaluated. Both groups were further subdivided on the basis of presence or absence of associated respiratory symptoms. After intubation, tracheal aspirates were collected, fixed, and stained for FLM. By grading the amount of intracellular fat present, a semiquantitative lipid index was computed. Tracheal aspirates with a lipid index of 100 or greater were considered positive.

RESULTS

Twenty-four of the 64 children with reflux symptoms and 14 of 34 children without reflux symptoms were positive for FLM. Sixteen of 37 children with both gastroesophageal reflux and respiratory symptoms and 10 of 26 children negative for both tested positive for FLM. The mean lipid index of the subgroup of children with both reflux and respiratory symptoms was not significantly different from that of the subgroup that was negative for both conditions. Despite computing a semiquantitative lipid index, an index of 100 or greater only had a sensitivity of 38% and specificity of 59%.

CONCLUSION

Assay of FLM in the tracheal aspirates of children considered at risk of reflux aspiration is not a sensitive or specific as a marker for reflux aspiration.

[Acute lipoid pneumonia caused by accidental aspiration of vaseline used in nasogastric intubation]

Exogenous lipoid pneumonia is a rare disease which is often underdiagnosed. Exogenous lipoid pneumonia has traditionally been considered a chronic process secondary to continued aspiration or inhalation of fatty substances. In its acute form exogenous lipoid pneumonia sometimes coincides with accidental massive aspiration of lipidic material, as has been traditionally described for fire eaters. We review the literature and report a case of acute lipoid pneumonia secondary to accidental aspiration of vaseline used to place a nasogastric tube, which had been inserted for gastric lavage after a suicide attempt by flurazepam ingestion.

Satisfaction of patients treated surgically for intractable aspiration

STUDY OBJECTIVE

Impaired laryngeal protective function can result in intractable aspiration requiring surgical treatment. There are, however, few reports evaluating the satisfaction of patients and the efficacy of surgical therapy. The purpose of this study is to determine whether surgery for intractable aspiration is beneficial for alleviating depression and improving the mood of patients who have undergone surgical treatment and whether patients and their families are satisfied with the therapy.

PATIENTS AND STUDY DESIGN

Seven patients with recurrent aspiration pneumonia that could not be controlled by appropriate medical therapies participated in the study. These patients had no hope of recovering laryngeal function. Six underwent laryngectomy and one underwent laryngotracheal separation. After surgery, we evaluated the efficacy of the therapy and the patients' satisfaction with the therapy.

METHODS

The following clinical variables concerning surgical procedure were examined: operation time, time until oral intake, videofluorographic study, and surgical complications. The treatment methods including feeding status were also examined before and after surgery. In addition, the following markers were examined to evaluate the efficacy of the surgery: score of aspiration pneumonia, body mass index, total protein, albumin, hematocrit, WBC count, C-reactive protein, erythrocyte sedimentation rate, and the Barthel Index, an indicator of daily activity. Furthermore, the grade of depression and mood, and satisfaction of patients and their caretakers among family members were scored by the Zung self-rating depression scale, a 20-picture face scale, and the visual analog scale.

RESULTS

After surgical therapy, we confirmed by videofluorography that aspiration was completely prevented. No surgical complications occurred. By 18 +/- 6 days, all seven patients were able to ingest a meal orally. The need for extensive medical care and repeated hospitalizations became unnecessary after surgery. The control of pneumonia and albumin improved significantly. The grade of depression and mood of patients and their families also improved significantly. Satisfaction scores of patients receiving therapy were very high.

CONCLUSIONS

Our study shows that surgical therapy to prevent aspiration improves the depression and mood of patients and their families as well as feeding status and clinical outlook. Surgical therapy for patients with intractable aspiration is effective and beneficial.

Role of CD11b in focal acid-induced pneumonia and contralateral lung injury in rats

Neutrophil emigration in response to acid aspiration does not require the adhesion complex, CD11/ CD18. This study examined the role of CD11b/CD18 using the anti-CD11b F(ab')2, 1B6, in focal HCI-induced intracapillary neutrophil sequestration and edema formation within rat lungs, as well as the effect of pretreatment with endotoxin on this injury. The results show that at the site of aspiration pneumonia, anti-CD11b F(ab')2 did not inhibit neutrophil sequestration or edema formation, either with or without endotoxin pretreatment. In the contralateral lung, focal HCI aspiration induced neutrophil sequestration that was inhibited by the anti-CD11b F(ab')2, but no edema formation. The combined effect of endotoxin pretreatment and HCI aspiration induced CD11b/CD18-independent edema formation in the contralateral lung. These data indicate that CD11b/CD18-independent pathways mediate neutrophil sequestration and edema formation at that pneumonic site with or without pretreatment with endotoxin. CD11b/CD18 mediates neutrophil sequestration at distant sites when no endotoxin is present, although this CD11b/CD18-dependent sequestration is not association with edema formation. The combined effects of endotoxin and HCI aspiration induce edema formation at distant sites that could not be prevented by inhibiting the function of the CD11b/CD18 prior to aspiration.

Aspiration and acute lung injury

Aspiration is a common clinical entity whose consequences range from the relatively benign to fulminant acute respiratory failure and death. Clinical situations in which airway protection is lost or compromised predispose patients to aspiration. Treatment of aspiration, while generally supportive, depends in part upon the material aspirated and the resulting clinical syndrome. When mechanical ventilatory support is required, the avoidance of iatrogenic complications, including worsening lung injury, becomes especially important. Preventative measures, either to minimize the chances of aspiration, or to reduce the potential for injury consequent to aspiration may be highly effective in reducing the incidence of aspiration syndromes.

Aspiration pneumonia. A threat when deglutition is compromised

Aspiration results from abnormal structure or from dysfunction during the oral, pharyngeal, or esophageal stage of deglutition. Chemically induced inflammation of the lungs and obstruction of the airways may ensue. Feeding and swallowing problems may occur at any age, but they are particularly prevalent in the elderly, and the morbidity and mortality that result from impaired oral intake are now recognized as a major geriatric problem. Aspiration pneumonitis and/or pneumonia has a high morbidity and mortality rate. Medical management is mainly aimed at supportive care with the hope of resolution over time. Complications demand aggressive measures. Prevention of aspiration is apt to be more rewarding than treatment of consequences. All predisposing factors should be carefully assessed by the physician and modified whenever possible.

Pulmonary consequences of aspiration

Aspiration can lead to serious pulmonary disease and occasionally death. Substances aspirated commonly include bacteria or gastric contents or both, but may be as unusual as diesel oil or a variety of foreign bodies. Pulmonary symptoms range from a subtle cough, wheezing, or hoarseness to severe dyspnea or asphyxiation. We discuss the mechanism of pulmonary disease caused by aspiration as well as the appropriate treatment.

Association of lipid-laden alveolar macrophages and gastroesophageal reflux in children

The association of lipid-laden alveolar macrophages (LLAM) and gastroesophageal reflux (GER) was investigated prospectively in 115 patients in two groups. Group 1 included 74 children with chronic respiratory tract disorders and documented GER by prolonged esophageal pH monitoring, barium esophagram, and esophagoscopy; group 2 included 41 children with chronic respiratory tract disorders without GER. LLAM were present in 63 (85%) and eight (19%) children from groups 1 and 2, respectively (P less than 0.0001). Thus a strong association between the presence of LLAM and GER in children with chronic respiratory tract disorders was established. We suggest that LLAM from bronchial lavage may be a useful marker for tracheal aspiration in children with GER in whom chronic lung disease may subsequently develop.

Alcohol and the gastrointestinal tract

The effects of acute and chronic ethanol ingestion on esophageal motility and the potential complications of these alterations are reviewed. Injury to the gastric mucosa and the small intestine and alterations in intestinal absorption can also result from alcohol abuse.

Pulmonary aspiration presenting with generalised convulsions

Foreign body in the tracheobronchial tree is a relatively infrequent, but, potentially fatal event, requiring rapid and expert intervention. The symptoms and signs may be mistaken for asthma and pneumonia, - or, as in the case described, with grand mal epileptiform seizures. This emphasises the need to take a thorough case history, and to have a high index of suspicion in a case presenting with convulsion associated with cough, wheezing or respiratory distress.

Relationship between colloid osmotic pressure and pulmonary artery wedge pressure in patients with acute cardiorespiratory failure

Close relationships between progressive respiratory failure, roentgenographic signs of pulmonary opacification and decreases in the difference between colloid osmotic pressure of plasma and the pulmonary artery wedge pressure (colloid-hydrosatic pressure gradient) were demonstrated in 49 critically ill patients with multisystem failure, in patients in shock. The potential importance of this relationship is underscored by the observation that fatal progression of pulmonary edema was related to a critical reduction in the colloid-hydrostatic pressure gradient to levels of less than 0 mm Hg. More often, reduction in colloid osmotic pressure rather than increases in left ventricular filling pressure (pulmonary artery wedge pressure) accounted for the decline in colloid-hydrostatic pressure gradient. Routine measurement of colloid osmotic pressure, preferably in conjunction with pulmonary artery wedge pressure, is likely to improve understanding of the mechanisms of acute pulmonary edema.

Effects of corticosteroids in the treatment of patients with gastric aspiration

Forty-three of 88 patients suspected of having aspirated gastric contents met stringent criteria for the diagnosis of aspiration of gastric contents. One group of 25 patients was treated with corticosteroids and a second group of 18 patients was treated without corticosteroids. The two groups were clinically well matched according to all variables except that the patients who did not receive corticosteroids had greater hypoxemia and a higher incidence of infiltration on chest roentgenogram which would indicate that these patients had received greater pulmonary injury from aspiration of gastric contents. Thirty-two per cent of the patients who received steroids died compared to 28 per cent of those who did not receive steroids. Although the mortality rate difference was not statistically significant, the occurrence of gram-negative pneumonia five days after aspiration was more frequent in the patients treated with steroids.

Neurological and phychometric studies in children surviving freshwater immersion accidents

A study of the neurological and intellectual sequelae of childhood near-drowning is reported. Results are from a total population study, without selection, of all freshwater immersion accidents in which consciousness was lost in the water. Such accidents affected 56 children in the city of Brisbane and environs over the period 1971-75. 54 of these children have been re-examined medically and psychometrically. Over 95 per cent of children who survived such accidents were neurologically normal. The median i.q. of survivors was 110 (range 90-137), which is higher than that of the general population. There is a suggestion that visualmotor (performance)) skills are particularly vulnerable to freshwater immersion hypoxia. In 20 per cent of survivors subscale disparities between verbal and performance skills exceeded 15 i.q. points. No correlation between the post-immersion I.Q. and either estimated immersion-time or water temperature was demonstrated in this study. No long-term emotional or personality disorders were encountered. Uncommon gross clinical sequelae of prolonged immersion in fresh water included spastic quadriplegia and gross mental retardation. All children in this study were apparently dead at the moment of rescue; despite this, the prognosis of near-drowning in childhood is excellent

Hydrocortisone therapy in meconium aspiration syndrome: a controlled study

To evaluate the efficacy of glucocorticoids in the treatment of infants with meconium aspiration syndrome, a double-blind study using hydrocortisone or a lactose placebo was undertaken. Thirty-five infants were included in the study. No significant differences in arterial Po2, Pco2, pH, A-aDo2 gradients, in requirement for assisted ventilation, or in survival were domonstrated between the groups. In control infants, a significant decrease (p less than 0.01) in respiratory distress score was found at 48 to 72 hours of age; in treated infants, it was seen only after 72 hours. The infants in the treated group took a significantly longer (p less than 0.01) period of time to wean to room air than those in the control group (68.9 +/- 9.6 hours vs 36.6 +/- 6.9 hours). On the basis of these observations, hydrocortisone is not recommended for treatment of MAS.

Diagnosis of gastric aspiration by fiberoptic bronchoscopy

At the time of bronchoscopic observation, 28 of 31 patients proved to have aspirated gastric contents by the presence of gastric contents in the trachea or by direct observation of gastric aspiration followed by respiratory distress and erythema of subsegmental bronchi. Since gastric aspiration is a difficult diagnosis to make and few objective data are available to make the diagnosis, the present study would indicate that early fiberoptic bronchoscopic observation of the tracheobronchial tree is a useful procedure to establish a definitive diagnosis and to allow proper planning for clinical management.

Radiology in Mendelson's syndrome

Four cases of Mendelson's syndrome (acid pulmonary aspiration) are presented. They all demonstrate an acute diffuse alveolar filling pattern. This appearance is by no means specific. However, in the absence of other causes for this pattern and of evidence of left ventricular failure the radiologist may alert the clinician to the correct diagnosis. Early recognition of this syndrome will result in prompt treatment which differs significantly from that of other causes of this radiographic appearance. The differential diagnosis is discussed.

Severe drug overdose: results of treatment

The incidence and management of severe drug overdose patients over a five-year period is presented, together with results and complications. Emphasis is placed on the importance of conservative measures with minimal need for more aggressive methods of treatment.

Severe slowly resolving heroin-induced pulmonary edema

Severe heroin-induced pulmonary edema occurred in three previously healthy young men. Adequate arterial PO2 could only be achieved with the use of positive endexpiratory pressure (PEEP). Recovery was characterized by the gradual clearing of the pulmonary infiltrates and a gradual lessening of the severe restrictive ventilatory defects over many weeks. Concomitant aspiration of gastric acid was thought to be the explanation for the severity of these cases. In cases such as these, initial vigorous therapy, including PEEP for hypoxia, corticosteroids for possible aspiration and volume replacement for hypotension, is recommended.

Epidemiology of acute drug intoxications: patient characteristics, drugs, and medical complications

Of 415 adult patients treated for acute drug intoxications in a university hospital emergency room, 64 (15.4%) required admission to the medical service for intensive care. A significantly larger proportion of patients over 40 years of age required hospitalization. Forty-eight of the episodes requiring hospitalization were identified as intentional drug intoxication. Women were admitted in 41 (64.0%) instances while men were admitted on 23 (36.0%) occasions. Non-barbiturate depressants, barbiturates, tranquilizers, and antidepressants were the drug classes most commonly incriminated. Almost one-half of all patients, however, had taken multiple drugs. Medical complications in these 64 patients included coma in 43 (67.2%), acute hypertension or hypotension in 21 (32.8%), and pneumonia in 16 (25%). Complications occurring less frequently were cardiac arrest in three (4.7%), anemia in two (3.2%), neuropathies, soft tissue necrosis, quadraplegia, renal failure, bullous dermatitis, and fetal death in one patient each. Two (3.2%) patients died as a result of drug ingestions. Forty per cent of patients had experienced previous episodes of acute drug intoxication.