Aspiration of nasal secretions into the lungs in patients with acute sinonasal infections

Pulmonary aspiration of sinus secretions in patients with cystic fibrosis

BACKGROUND

Indirect evidence suggests that sinonasal secretions are aspirated into the lungs of patients with cystic fibrosis (CF), contributing to infection, subsequent tissue damage, and decreased lung function. Our objective is to determine whether sinonasal secretions are transferred to the lungs in patients with CF-related sinus disease and healthy subjects, particularly in the recumbent position and during sleep.

METHODS

We performed a prospective, controlled trial to detect pulmonary aspiration of radiolabeled albumin applied to the nasal mucosa of study subjects with chronic sinusitis related to CF and control subjects without sinus disease. Radioactive counts were measured in the lungs and compared to background counts in both groups after 8 hours of rest/sleep.

RESULTS

Complete data was collected on 12 CF patients and 6 controls. Eleven patients with CF demonstrated higher lung counts than background counts. The average counts of radiolabeled albumin in the lungs of CF patients were significantly greater than background counts (p = 0.03). Controls did not demonstrate this finding (p > 0.90), with only one-half demonstrating lung counts greater than background counts.

CONCLUSION

This study provides direct evidence of aspiration of sinonasal secretions into the lungs of patients with CF and healthy adults in the recumbent position. The fact that both patients and controls aspirated secretions suggests that aspiration alone does not account for the pathogenesis of lung disease in CF patients.

Allergic rhinitis and chronic rhinosinusitis: their impact on lower airways

Anatomy, pathophysiology, epidemiology, and disease characteristics link the upper and lower airways. Nonspecific symptoms such as cough, congestion, shortness of breath, and recurrent infection may be related to the upper airway, lower airway, or both. Patients with the most severe disease often exhibit symptoms and findings of inflammation at both sites. Recent literature suggests that medical treatment and, when appropriate, surgical therapy directed at the upper airway can yield improvements in the lower airway. An understanding of the diagnosis and management of diseases at both sites will afford patients the best possible outcomes.

Oral Symptoms Predict Mortality: a Prospective Study in Japan

Several studies have reported positive associations between oral infections and systemic diseases. The purpose of the present study was to evaluate the effects of oral symptoms on mortality from cardiovascular disease (CVD) and pneumonia. Using data from a cohort study in Japan, we analyzed 4,139 individuals aged 40–79 years. The baseline questionnaire included the following items related to oral symptoms: ‘sensitive teeth’, ‘difficulty in chewing tough food substances’, ‘bleeding gums’, and ‘mouth feels sticky’. We used the Cox proportional hazard model to estimate hazard ratios (HRs) and 95% confidence intervals (95%CIs) for mortality, after adjustments for lifestyle, socio-economic factors, and history of diseases. Persons complaining that their ‘mouth feels sticky’ had a two-fold higher risk of pneumonia (HR = 2.1; 95%CI, 1.2–3.6), while those complaining of ‘sensitive teeth’ had a lower risk of CVD (HR = 0.4; 95%CI, 0.2–0.9). Some oral symptoms may be predictors of mortality from pneumonia and CVD.

Non-allergic rhinitis: diagnosis and management

Patients in the rhinitis clinic with negative skin prick tests present a challenge. Non-allergic rhinitis consists of a variety of conditions including infection, hormonal changes, drugs and autonomic dysfunction. There is also a range of systemic disorders to be considered. The pathogeneses of many of these are less well understood than that of allergic rhinitis, diagnosis and treatment pathways are also more complex. A detailed accurate history needs to be taken followed by relevant investigations which may include allergen challenge, because skin prick and RAST-negative allergic rhinitis is now recognised. Nitric oxide levels may prove helpful: elevated levels suggest inflammation, very low levels indicate the possibility of primary ciliary dyskinesia or cystic fibrosis. Treatment is of the underlying cause when found: for those without obvious pathology a trial of combined therapy with topical corticosteroids plus antihistamine or plus anti-cholinergic may be worth while. A complex inter-relationship between allergic and infectious rhinitis is becoming apparent.

Pulmonary aspiration risk during emergency department procedural sedation--an examination of the role of fasting and sedation depth

The assessment of pre-procedure fasting and control of sedation depth are prominent elements of widely disseminated procedural sedation guidelines and of the Joint Commission on Accreditation of Healthcare Organizations' standards. Both exist primarily to minimize the risk of pulmonary aspiration of gastric contents. This paper critically examines the literature on pre-procedure fasting and controlling sedation depth in association with pulmonary aspiration, and interprets this evidence in the context of modern emergency medicine practice. The article reviews the pathophysiology of aspiration and changing concepts regarding aspiration risk over the last decade. After reviewing studies on aspiration risk during general anesthesia, the paper reviews the risk of aspiration during labor and delivery as a more appropriate comparison group for aspiration risk during emergency department procedural sedation and analgesia (ED PSA). It is noted that aspiration during ED PSA has not been reported in the medical literature and that aspiration during general anesthesia and labor and delivery is uncommon. The literature provides no compelling evidence to support specific fasting periods for either liquids or solids prior to PSA, and existing guidelines for elective patients are of necessity arbitrary and based upon consensus opinion. The article discusses the implications in the areas of training and preparedness, monitoring, and research for the emergency physician practicing PSA.

Difficult-to-manage asthma. How to pinpoint the exacerbating factors

In difficult-to-manage asthma, effective control depends on identification and alleviation of exacerbating factors, such as ongoing allergen exposure, chronic sinusitis, GERD, and emotional stress. Level of compliance with the prescribed medication regimen should be evaluated in all patients. Hormonal factors (i.e., menses, use of exogenous hormones by female patients, and hyperthyroidism) also can exacerbate asthma. When aggressive management fails, the possibility of a misdiagnosis should be considered. Other conditions that can mimic asthma include COPD, congestive heart failure, airway obstruction due to various causes, vocal cord dysfunction, and esophageal spasm. Referral to an asthma specialist is advised in severe or resistant cases.