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

Gastroesophageal Reflux Revealed by 18 F-MFBG PET/CT

ABSTRACT

A 56-year-old woman who had a lung transplant 4 months ago presented frequent vomiting for 1 month. Barium meal and 99m Tc gastroesophageal scintigraphy showed no gastroesophageal reflux. The patient was enrolled in a clinical trial and underwent 18 F-MFBG PET/CT dynamic imaging. At the seventh minute of dynamic imaging, the images revealed reflux from the cardia into the esophagus and reached the oral cavity.

Neurological impairment and malnutrition in children: The role of home enteral nutrition in real life

Objective

Recent decades have brought an increased survival of children with Neurologic Impairment (NI) but malnutrition and digestive comorbidity remain important challenges to face. We designed the present study to assess the course of nutritional status following standardized Home Enteral Nutrition (HEN) program and to evaluate impact of changing mode of feeding, as a part of overall multidisciplinary management, on digestive co-morbidity as Gastro-Esophageal Reflux Disease (GERD), Oropharyngeal Dysphagia (OPD), constipation and airway aspiration.

Methods

We performed a retrospective analysis on NI children entered into Institutional HEN program due to NI disorders between January 2011 and 2019. Demographic, anthropometric characteristics (BMI z-score and weight for age z-score) and symptoms (GERD, OPD constipation and airway aspiration) were collected at the enrolment and during the follow up.

Results

We enrolled 402 patients (median age: 39 months); overall survival was 97%. Nutritional status was significantly improved by HEN; in particular growth profile significantly changed within the first 2 years following HEN beginning; GERD and airways aspirations decreased after HEN beginning. Constipation and OPD remained unchanged over time.

Conclusions

Malnutrition and digestive complaints are distinctive features of NI children. Nutritional status improve after 2 years from the beginning of standardized nutritional interventions. Overall multidisciplinary care, including standardized HEN protocols, seems to also impact on GERD and airway aspirations, which can decrease over time. It is possible that constipation and OPD, unchanged over time, are more dependent on underlying diseases than on overall treatments.

Oro-pharyngo-esophageal radionuclide scintigraphy predicts aspiration pneumonia risk and associated survival in post-irradiated nasopharyngeal carcinoma patients

OBJECTIVE

To demonstrate that oro-pharyngo-esophageal radionuclide scintigraphy (OPERS) not only detects tracheobronchial aspiration after swallowing, but also quantifies the amount of aspiration and subsequent clearance.

METHODS

Data collected between 2014 and 2019 were reviewed for aspiration pneumonia at 12 and 24-months after OPERS. The predictive value for aspiration pneumonia on flexible endoscopic evaluation of swallowing (FEES), videofluoroscopic swallowing study (VFSS), and OPERS, and the overall survival of patients with or without aspiration were determined.

RESULTS

Thirty-seven patients treated with radiotherapy for nasopharyngeal carcinoma (NPC) were reviewed. The incidence of aspiration detected on FEES, VFSS, and OPERS was 78.4%, 66.7%, and 44.4%, respectively. Using VFSS as a gold standard, the sensitivity and specificity of OPERS for aspiration was 73.7% and 100%. The positive and negative predictive values for aspiration were 100% and 66.7%, respectively, with an overall accuracy of 82.8%. A history of aspiration pneumonia was one factor associated with a higher chance of subsequent aspiration pneumonia within 12 months (odds ratio: 15.5, 95% CI 1.67-145.8, p < .05) and 24 months (odds ratio: 23.8, 95% CI 3.69-152.89, p < .01) of the swallowing assessment. Aspiration detected by OPERS was a significant risk factor for future aspiration pneumonia at 12 and 24 months respectively. Significantly, better survival was associated with an absence of aspiration on OPERS only, but not on FEES or VFSS.

CONCLUSION

OPERS predicts the safety of swallowing, the incidence of subsequent aspiration pneumonia, and the survival prognosis in post-irradiated NPC dysphagia patients.

LEVEL OF EVIDENCE

3.

Semi-quantitative assessment optimized the grading of pulmonary aspiration on salivagram in children

OBJECTIVE

Salivagram is one of the imaging modalities to detect pulmonary aspiration in children. This study aims to optimize the classification of pulmonary aspiration detected by salivagram with a semi-quantitative analytical method.

METHODS

This is a retrospective study involving 737 patients (471 males, 266 females; aged 1 month to 8 years; mean age 5.3 months, median age 3.0 months old) with suspected pulmonary aspiration, who had salivagram done between January 2018 and June 2019. Positive cases were divided into 10 groups (Grade 1, R2, L2, R2L2, R3, L3, R3L2, R2L3, R3L3, and 4) according to the scintigraphic findings. Aspiration index was determined as the ratio of the count in the respiratory tract to the total count in the image field of view and compared among different groups using the receiver operating characteristics (ROC) curve analysis.

RESULTS

A total of 180 cases had positive scintigraphic findings of various grades of aspiration (24.4%, 180/737). There is a high consistency among the two independent nuclear medicine physicians involved in the study, in determining both the disease gradings (κ = 0.919;95% CI: 0.915-0.923) and aspiration index (ICC = 0.994;95% CI: 0.993-0.996). There is no significant difference (p > 0.05) in aspiration index among the gradings in "mild" group (grade 1, R2, L2, L2R2), and "moderate" group (grade R3, R3L2, R3L3). After dividing the different grades into "mild", "moderate" and "severe" groups, the aspiration index of "mild" group is 4.40 ± 2.01, that of "moderate" group is 16.43 ± 8.20, and that of "severe" group is 46.94 ± 14.81. Difference in groups was statistically significant (p < 0.0001). In ROC curve analysis, AUC of "mild" and "moderate" groups is 0.970 and that of "moderate" and "severe" groups is 0.943; the cut-off value with highest diagnostic efficiency is 6.75 between "mild" and "moderate" groups and 38.00 between "moderate" and "severe" groups.

CONCLUSIONS

We introduced a semi-quantitative analytical method in pulmonary aspiration on salivagram, to optimize and supplement to the current classification of pulmonary aspiration.

Effect of nasogastric tube on salivagram result in paediatric patients

OBJECTIVE

The aim of this study was to analyse the potential effect of indwelling nasogastric tubes (NGTs) on the positive rate of pulmonary aspiration in the salivagram of paediatric patients.

METHODS

This retrospective study evaluated 290 children suffering from respiratory tract infection with clinical suspicion of pulmonary aspiration (104 cases with NGT and 186 cases without NGT). Among them, 216 had good past health, while 74 had history of oropharyngeal diseases or brain injuries. Tc-DTPA salivagrams were performed to determine whether the risk of pulmonary aspiration was different between patients with and without NGT.

RESULTS

The positive rates of aspiration in salivagram were 32.3% (60/186) and 29.8% (31/104) in the patients without and with NGT, respectively. The positive rates of the two groups had not statistically significant difference [risk ratio (RR) = 0.924; 95% confidence interval (CI): 0.644-1.326; P = 0.666]. Subgroup analyses showed that the patients with good past health had the positive rates of 24.4% (19/78) with NGT and 25.4 % (35/138) without NGT. The two groups had no statistically significant difference (RR = 0.960; 95% CI: 0.592-1.559; P = 0.870). For the patients with underlying diseases, the positive rates were 46.2% (12/26) with NGT and 52.1% (25/48) without NGT. These two groups also demonstrated no statistically significant difference (RR = 0.886; 95% CI: 0.540-1.455; P = 0.626).

CONCLUSION

The positive rate of pulmonary aspiration was relatively high in patients with respiratory tract infection who have underlying diseases but NGT feeding did not affect salivagram accuracy.

The effect of radionuclide solution volume on the detection rate of salivary aspiration in the radionuclide salivagram: A STROBE-compliant retrospective study

Despite the possibility that the methodological difference of this salivagram may influence the results for detection rate, there has been no study on the effect of the solution volume on detection rate. Moreover, to date, since the introduction of the nucleotide salivagram, there has been a tendency that a constant solution volume and nucleotide dose is not used in studies. Therefore, the aim of this study is to investigate the effect of solution volume on the detection rate of a salivagram in patients with brain lesion, and to determine the optimal solution volume of salivagram. We retrospectively reviewed clinical data and solution volume of radionuclide used in the salivagram of 77 patients with dysphagia, and the patients were divided into 2 groups according to the solution volume of the radionuclide (Group A-0.1 mL vs Group B-0.5 mL). Although, there was no significant difference between 2 groups in clinical data, there was a statistically significant difference in the detection rate of salivary aspiration between the 2 groups (3.3% vs 19.1%). Even a small difference of the solution volume of radionuclide in salivagram can affect the detection rate of salivary aspiration in patients with brain lesion. Further study with various solution volumes of radionuclide is warranted to determine the optimal solution volume of the radionuclide salivagram.

Comparison of Videofluoroscopic Swallowing Study and Radionuclide Salivagram for Aspiration Pneumonia in Children With Swallowing Difficulty

Objective

To determine whether the use of both videofluoroscopic swallowing study (VFSS) and radionuclide salivagram was beneficial for detecting aspiration-induced pneumonia in children with swallowing difficulty.

Methods

From 2001 to 2016, children who underwent both VFSS and salivagram consecutively for suspected aspiration or dysphagia were included in the study. Demographic data, findings of VFSS and salivagram, and medical records were reviewed.

Results

Aspiration pneumonia (AP) was present in 34 out of 110 children; 48 showed positive aspiration findings in VFSS and 33 showed positive aspiration findings in salivagram. Among the 62 children who were negative of aspiration in VFSS, 12 (19.4%) showed positive aspiration findings in salivagram. Four out of 12 children were diagnosed with AP. The aspiration findings in both VFSS and salivagram were significantly related to AP. However, the aspiration findings in the two tests were weakly consistent. Even if one test showed negative aspiration, it was helpful to additionally detect AP using another test, which showed positive aspiration finding. If aspiration findings were positive in only one of the two tests, the probability of AP was 38.5%, whereas if they were positive in both tests, the probability increased to 66.7%. If the aspiration findings were negative in both tests, AP did not occur with a probability of 90%.

Conclusion

Salivagram is a valuable tool for monitoring of aspiration in children with swallowing difficulties. It could be helpful in assessment of children at a high risk of AP, even if the VFSS showed negative aspiration findings. Thus, testing for AP using both VFSS and salivagram is desirable.

Aspiration Incidentally Detected by a Meckel Scintigraphy

Meckel scintigraphy with Tc-pertechnetate was performed in a 5-year-old boy to determine whether a Meckel diverticulum containing ectopic gastric mucosa caused bleeding. The images did not reveal focal activity characteristic of a Meckel diverticulum. Unexpectedly, activity in the tracheobronchial tree was visualized, consistent with aspiration of the radioactive saliva.

Increased Activity in the Lung Field on Gastroesophageal Scintigraphy Is Not Always Due to Aspiration

Elevated activity in the lung field on gastroesophageal scintigraphy (milk scan) generally indicates aspiration of the gastric content that has refluxed to the pharynx. An 18-year-old man underwent to gastroesophageal scintigraphy to assess the rate of gastric emptying. Increased activity was noted in the left lower lung field during the image acquisition. Careful analysis of the images showed that this activity was caused by hiatal herniation.

Scintigraphic Evaluation of Gastroesophageal Reflux and Pulmonary Aspiration in Children

Gastroesophageal reflux (GER) and pulmonary aspiration are encountered in children of all ages. Signs, symptoms, and complications vary from mild and transient to severe life-threatening conditions. This review will present relevant clinical information on these conditions as well as common diagnostic procedures. The role of scintigraphic techniques used in the evaluation of these conditions will be discussed in detail including protocols and performance in comparison to other diagnostic methods.

Respiratory illness in children with disability: a serious problem?

Key points

Educational aims

Children with neurocognitive impairment often present with chronic or recurrent respiratory problemshttp://ow.ly/uqiG306pE9B

Detection of salivary aspiration using radionuclide salivagram SPECT/CT in patients with COPD exacerbation: a preliminary study

BACKGROUND

The aim of this prospective study was to assess the utility of radionuclide salivagram for detecting salivary aspiration in AECOPD patients and to evaluate the adding value of SPECT/CT to planar imaging.

METHODS

52 consecutive AECOPD patients underwent radionuclide salivagram SPECT/CT and water swallow test between April 2012 and March 2014. All images were interpreted independently by two experienced nuclear medicine physicians. Final diagnosis was made by consensus of two readers. The radionuclide salivagram and water swallow test results were compared using kappa values. The relationship between radionuclide salivagram results and exacerbation frequency was evaluated with the Person χ² test.

RESULTS

Salivary aspiration was diagnosed by radionuclide salivagram in 17 of 52 patients. Aspiration into the right main bronchus and branch was seen in 8 patients, bilateral main bronchi in 6 patients, and left lung field in 3 patients. SPECT/CT provided more accurate information on the extent and location of salivary aspiration, in 11 cases, SPECT/CT demonstrated aspiration of pulmonary segment bronchus and the following areas. Moreover, SPECT/CT revealed salivary aspiration corresponding to aspiration pneumonia in 8 cases. There was general agreement between the radionuclide salivagram and water swallow test results (Kappa =0.712; 95% CI, 0.504-0.920; P<0.001). The incidence of frequent exacerbations was greater among subjects with positive salivagram than among those with negative salivagram results (RR =3.43; 95% CI, 1.90-6.19; P<0.001).

CONCLUSIONS

Radionuclide salivagram is an objective method for detecting salivary aspiration in AECOPD patients. Moreover, SPECT/CT can identify more precise location of salivary aspiration and suggest a possible role for saliva in the pathophysiology of aspiration pneumonia.