Characteristics and outcomes of patients hospitalized following pulmonary aspiration

Prevalence, predictors, and outcomes of acute respiratory distress syndrome in severe stroke

OBJECTIVES

Patients with severe stroke are at high risk of developing acute respiratory distress syndrome (ARDS), but this severe complication was often under-diagnosed and rarely explored in stroke patients. We aimed to investigate the prevalence, early predictors, and outcomes of ARDS in severe stroke.

METHODS

This prospective study included consecutive patients admitted to neurological intensive care unit (neuro-ICU) with severe stroke, including acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The incidence of ARDS was examined, and baseline characteristics and severity scores on admission were investigated as potential early predictors for ARDS. The in-hospital mortality, length of neuro-ICU stay, the total cost in neuro-ICU, and neurological functions at 90 days were explored.

RESULTS

Of 140 patients included, 35 (25.0%) developed ARDS. Over 90% of ARDS cases occurred within 1 week of admission. Procalcitonin (OR 1.310 95% CI 1.005-1.707, P = 0.046) and PaO2/FiO2 on admission (OR 0.986, 95% CI 0.979-0.993, P < 0.001) were independently associated with ARDS, and high brain natriuretic peptide (OR 0.994, 95% CI 0.989-0.998, P = 0.003) was a red flag biomarker warning that the respiratory symptoms may be caused by cardiac failure rather than ARDS. ARDS patients had longer stays and higher expenses in neuro-ICU. Among patients with ARDS, 25 (62.5%) were moderate or severe ARDS. All the patients with moderate to severe ARDS had an unfavorable outcome at 90 days.

CONCLUSIONS

ARDS is common in patients with severe stroke, with most cases occurring in the first week of admission. Procalcitonin and PaO2/FiO2 on admission are early predictors of ARDS. ARDS worsens both short-term and long-term outcomes. The conflict in respiratory support strategies between ARDS and severe stroke needs to be further studied.

The safety of preoperative carbohydrate drinks in extremely elderly patients assessed by gastric ultrasonography: a randomized controlled trial

BACKGROUND

Modern perioperative guidelines encourage drinking oral carbohydrates 2 h before management. Nevertheless, research on the safety of preoperative carbohydrate drinks, particularly in extremely elderly patients is lacking. We aimed to evaluate the safety of carbohydrate drinks 2 h before surgery in extremely elderly patients (≥ 80 years) using gastric ultrasonography.

METHODS

We conducted a randomized prospective comparative study of 70 patients aged over 80 years who were scheduled for total knee arthroplasty, hip fracture or humerus fracture surgery. These patients were randomly assigned to the carbohydrate group (n = 35), which fasted from midnight, except for drinking 355 mL of a carbohydrate-containing fluid 2 h before surgery, or the fasting group (n = 35), which fasted from midnight and drank no fluid before surgery. The primary outcome of the study was the cross-sectional area (CSA) of the gastric antrum in the right lateral decubitus position (RLDP) before surgery. The secondary outcomes included CSA in the supine position, intraoperative blood glucose levels and their variability coefficients, Perlas grade, and the visual analog scale of subjective feelings.

RESULTS

The CSA in the RLDP and supine positions revealed no differences between the carbohydrate and fasting groups at 0 h preoperatively (P > 0.05). In the qualitative assessment, preoperative 0-h Perlas grading did not differ significantly between the groups (P > 0.05). From 2 h before surgery to transfer out of the post-anesthesia care unit, the average blood glucose level of patients in the carbohydrate group was significantly higher than that in the fasting group (P < 0.001) but remained within the normal range. Moreover, the blood glucose variability coefficient was significantly lower in the carbohydrate group than in the fasting group (P = 0.009). Oral intake of 355 mL carbohydrates before surgery significantly relieved patients' feelings (P < 0.001).

CONCLUSION

Preoperative consumption of carbohydrate drinks 2 h before surgery is safe in "healthy" extremely elderly patients. In addition, preoperative drinking has potential value in maintaining ideal blood glucose levels and stable blood glucose fluctuations perioperatively and improving subjective perceptions of preoperative preparation. This finding warrants further investigation in clinical practice.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Registration Number ChiCTR1900024812), first registered on 29/07/2019.

Identification of genetic profile and biomarkers involved in acute respiratory distress syndrome

PURPOSE

The purpose of this study was to profile genetic causal factors of acute respiratory distress syndrome (ARDS) and early predict patients at high ARDS risk.

METHODS

We performed a phenome-wide Mendelian Randomization analysis through summary statistics of an ARDS genome-wide association study (1250 cases and 1583 controls of European ancestry) and 33,150 traits. Transcriptomic data from human blood and lung tissues of a preclinical mouse model were used to validate biomarkers, which were further used to construct a prediction model and nomogram.

RESULTS

A total of 1736 traits, including 1223 blood RNA, 159 plasma proteins, and 354 non-gene phenotypes (classified by Biochemistry, Anthropometry, Disease, Nutrition and Habit, Immunology, and Treatment), exhibited a potentially causal relationship with ARDS development, which were accessible through a user-friendly interface platform called CARDS (Causal traits for Acute Respiratory Distress Syndrome). Regarding candidate blood RNA, four genes were validated, namely TMEM176B, SLC2A5, CDC45, and VSIG8, showing differential expression in blood of ARDS patients compared to controls, as well as dynamic expression in mouse lung tissues. Importantly, the addition of four blood genes and five immune cell proportions significantly improved the prediction performance of ARDS development, with 0.791 of the area under the curve from receiver-operator characteristic, compared to 0.725 for the basic model consisting of Acute Physiology and Chronic Health Evaluation (APACHE) III Score, sex, body mass index, bacteremia, and sepsis. A model-based nomogram was also developed for the clinical practice.

CONCLUSION

This study identifies a wide range of ARDS relevant factors and develops a promising prediction model, enhancing early clinical management and intervention for ARDS development.

Pneumonia-associated Emergency Transfers, Functional Decline, and Mortality in Nursing Home Residents

OBJECTIVE

To describe nursing home residents (NHRs) transferred to the emergency department (ED) with pneumonia, and investigate the association of pneumonia with functional ability and mortality.

DESIGN

Case-control observational multicenter study.

SETTING AND PARTICIPANTS

Participants of the FINE study, including 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks (1 per season) in 2016, mean age 87.2 years ± 7.1, 68.4% women.

METHODS

Activities of daily living (ADL) performance evolution between (1) 15 days before transfer and (2) within 7 days after discharge back to the nursing home was compared in NHRs with or without pneumonia. The association of pneumonia with functional evolution was investigated by a mixed-effect linear regression of ADL and mortality was compared by a χ² test.

RESULTS

NHRs with pneumonia (n = 232; 22.4%) were more likely to have a lower ADL performance than NHRs without pneumonia (n = 805, 77.6%). They presented with a more severe clinical condition, were more likely to be hospitalized after ED and to stay longer in ED and in hospital. They showed a 0.5 decline in median ADL performance after transfer and a significantly higher mortality than NHRs without pneumonia (24.1% and 8.7%, respectively). Post-ED functional evolution did not differ significantly between NHRs with or without pneumonia.

CONCLUSIONS AND IMPLICATIONS

Pneumonia-associated ED transfers resulted in longer care pathways and higher mortality, but no significant difference in functional decline. This study identified a suggestive course of symptoms that could facilitate early identification of NHRs developing pneumonia and early management to prevent ED transfer.

Aspiration Risk Factors in Hospitalized Patients Following Trauma

Introduction

Risk factors for aspiration are not well characterized in the trauma patient population. Improved understanding is important due to features of this patient population that place them at high risk for morbidity and mortality with aspiration.

Methods

In a retrospective analysis of patients who suffered a traumatic injury from 2016 to 2018, potential risk factors were recorded and analyzed with logistic regression to evaluate the trauma patient at risk for aspiration.

Results

Of the 146 patient charts analyzed, 56 (38%) had at least one documented aspiration event, while 90 (62%) patients had none. Multivariate logistic regression found a significant association between impaired consciousness and aspiration events (p = 0.012).

Conclusions

This study was a novel characterization of trauma patients likely to have experienced an aspiration event while hospitalized. The results suggested candidate risk factors for aspiration exist in a trauma-specific population. Impaired consciousness is likely to show a significant association with aspiration in trauma patients in future studies.

Hypoxia‐inducible factor (HIF)‐1α‐induced regulation of lung injury in pulmonary aspiration is mediated through NF‐kB

Aspiration‐induced lung injury is a common grievance encountered in the intensive care unit (ICU). It is a significant risk factor for improving ventilator‐associated pneumonia (VAP) and acute respiratory distress syndrome (ARDS). Hypoxia‐inducible factor (HIF)‐1α is one of the primary transcription factors responsible for regulating the cellular response to changes in oxygen tension. Here, we sought to determine the role of HIF‐1α and specifically the role of type 2 alveolar epithelial cells in generating the acute inflammatory response following acid and particles (CASP) aspiration. Previous studies show HIF‐1 α is involved in regulating the hypoxia‐stimulated expression of MCP‐1 in mice and humans. The CASP was induced in C57BL/6, ODD‐Luc, HIF‐1α (+/+) control, and HIF‐1α conditional knockout (HIF‐1α (−/−) mice). Following an injury in ODD mice, explanted organs were subjected to IVIS imaging to measure the degree of hypoxia. HIF‐1α expression, BAL albumin, cytokines, and histology were measured following CASP. In C57BL/6 mice, the level of HIF‐1α was increased at 1 h after CASP. There were significantly increased levels of albumin and cytokines in C57BL/6 and ODD‐Luc mice lungs following CASP. HIF‐1α (+/+) mice given CASP demonstrated a synergistic increase in albumin leakage, increased pro‐inflammatory cytokines, and worse injury. MCP‐1 antibody neutralized HIF‐1α (+/+) mice showed reduced granuloma formation. The NF‐κB expression was increased substantially in the HIF‐1α (+/+) mice following CASP compared to HIF‐1α (−/−) mice. Our data collectively identify that HIF‐1α upregulation of the acute inflammatory response depends on NF‐κB following CASP.

Elevation of High-sensitive Troponin T Predicts Mortality After Open Pancreaticoduodenectomy

BACKGROUND

Open pancreaticoduodenectomy has a high complication and measurable mortality rate. Recent reports (based across multiple surgical disciplines) demonstrate that elevated postoperative high sensitivity troponin T (hsTnT) predicts adverse outcomes in non-cardiac surgery. The aim of this study was to evaluate postoperative hsTnT as a prognostic marker of mortality, major adverse cardiovascular events (MACE), post-operative non-cardiac complications and length of stay (including intensive care stay) in open pancreaticoduodenectomy.

METHODS

A retrospective review of open pancreaticoduodenectomy patients was undertaken from 01/10/2017-31/03/2019. Receiver operating characteristic (ROC) curves were calculated to identify ideal cut-off values for hsTnT. Univariate and multivariate analyses were performed to scrutinize the relationship between mean hsTnT and 30-day, 90-day mortality, MACE, post-operative non-cardiac complications and length of stay.

RESULTS

One hundred and nine patients were identified. ROC curves demonstrated a strong correlation between elevated mean hsTnT and 30-day, 90-day mortality and MACE (AUC = 0.937, AUC = 0.852, AUC = 0.779, respectively). Multivariate analysis showed mean hsTnT > 21 ng/l was significantly associated with 90-day mortality (OR 43.928, p = 0.004) and MACE (OR 8.177, p = 0.048).

CONCLUSIONS

HsTnT is predictive of mortality and MACE in the context of open pancreaticoduodenectomy. Association between hsTnT and prolonged critical care stay was less significant. Non-cardiac complications and length of stay show no significant association with hsTnT.

Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review

Background

It is customary to believe that a patient with a Glasgow Coma Scale (GCS) score less than or equal to 8 should be intubated to avoid aspiration. We conducted a systematic review to establish if patients with GCS ≤ 8 for trauma or non-traumatic emergencies and treated in the acute care setting (e.g., Emergency Department or Pre-hospital environment) should be intubated to avoid aspiration or aspiration pneumonia/pneumonitis, and consequently, reduce mortality.

Methods

We searched six databases, Pubmed, Embase, Scopus, SpringerLink, Cochrane Library, and Ovid Emcare, from April 15th to October 14th, 2020, for studies involving low GCS score patients of whom the risk of aspiration and related complications was assessed.

Results

Thirteen studies were included in the final analysis (7 on non-traumatic population, 4 on trauma population, 1 pediatric and 1 adult mixed case studies). For the non-traumatic cases, two prospective studies and one retrospective study found no difference in aspiration risk between intubated and non-intubated patients. Two retrospective studies reported a reduction in the risk of aspiration in the intubated patient group. For traumatic cases, the study that considered the risk of aspiration did not show any differences between the two groups. A study on adult mixed cases found no difference in the incidence of aspiration among intubated and non-intubated patients. A study on pediatric patients found increased mortality for intubated versus non-intubated non-traumatic patients with a low GCS score.

Conclusion

Whether intubation results in a reduction in the incidence of aspiration events and whether these are more frequent in patients with low GCS scores are not yet established. The paucity of evidence on this topic makes clinical trials justifiable and necessary.

Trial registration

Prospero registration number: CRD42020136987.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-020-00814-w.

Factors Influencing the Development of Pneumonia in Patients With Head and Neck Cancer: A Meta-analysis

Objective

The aim of this study was to identify factors that are associated with the occurrence of pneumonia in patients with head and neck cancer (HNC) after treatment.

Data Sources

PubMed, Scopus, OVID, and Cochrane Library from inception to November 26, 2019.

Review Methods

A systematic review in accordance with the PRISMA guidelines and an assessment of bias were performed. Included studies reported on the risk factors of pneumonia development after HNC treatment via odds ratios and subdistribution hazard ratios from regression analysis.

Results

Fifteen studies were included, comprising 30,962 patients with a mean age of 70 years (range, 19-95 years). Of these, 71.6% are male. The results of our study indicate that the following were independent risk factors contributing to the development of pneumonia: male sex, habitual alcohol consumption, poor oral hygiene before treatment, pretreatment dysphagia, hypopharynx and nasopharynx tumor sites, use of radiotherapy with or without chemotherapy versus surgery alone, addition of chemotherapy to radiotherapy, reirradiation, neck dissection, increased duration of tracheotomy, and use of sedatives for sleeping.

Conclusion

Multiple patient-, tumor-, and treatment-specific risk factors were identified in predicting pneumonia. Recognition of these risk factors early on may help prevent or at least detect pneumonia in this vulnerable group of patients.

Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardiopulmonary resuscitation: A substudy of the CAAM trial

AIM

Early-onset pneumonia (EOP) is a common in-hospital complication in survivors of out-of-hospital cardiac arrest. In this substudy of the CAAM trial, we aimed to compare whether bag mask ventilation (BMV) compared to endotracheal intubation (ETI) performed during cardiopulmonary resuscitation increases the risk of developing EOP.

METHODS

Adult patients from the CAAM trial that survived beyond 12 h of hospitalization were included. Information about in-hospital management and outcome of study subjects was systematically collected. Our primary aim was to compare the incidence of EOP in the BMV and ETI group using a series of bivariate analysis adjusting for one variable at a time and a logistic regression controlled for survival beyond 96 h, age, gender, catecholamine administration, no flow time, and initial shockable rhythm.

RESULTS

Of 627 patients from the CAAM trial that survived to hospital admission, 409 patients were hospitalized beyond 12 h and thus included (202 randomized to BMV and 20 7 randomized to ETI). Patients in the BMV group had a significantly longer period of unsecured airway during prehospital cardiopulmonary resuscitation (BMV (median): 33 min; ETI (median): 17 min, p < 0.0001). No significant difference in the development of EOP according to airway management was identified on univariate analysis (BMV: 53%, ETI: 53%, Odds Ratio 1.0 [0.7-1.5], p = 1.0). We found no difference in the development of EOP according to airway management in the series of bivariate analyses or in the multivariable regression analysis either.

CONCLUSION

In this substudy of the CAAM trial, development of early-onset pneumonia in out-of-hospital cardiac arrest survivors did not depend on airway management technique during CPR.

Hypoxia-Inducible Factor (HIF)-1α Promotes Inflammation and Injury Following Aspiration-Induced Lung Injury in Mice

Acid aspiration-induced lung injury is a common disease in the intensive care unit (ICU) and acute respiratory distress syndrome (ARDS). Hypoxia-inducible factor (HIF)-1α is a major transcription factor responsible for regulating the cellular response to changes in oxygen tension. A clear understanding of the function of HIF-1α in lung inflammatory response is currently lacking. Here, we sought to determine the role of HIF-1α in type 2 alveolar epithelial cells (AEC) in the generation of the acute inflammatory response following gastric aspiration (GA). GA led to profound hypoxia at very early time points following GA. This correlated to a robust increase in HIF-1α, tissue albumin and pro-inflammatory mediators following GA in AECs. The extent of lung injury and the release of pro/anti-inflammatory cytokines were significantly reduced in HIF-1α (-/-) mice. Finally, we report that HIF-1α upregulation of the acute inflammatory response is dependent on NF-κB following GA.

Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors

RATIONALE AIMS AND OBJECTIVES

Pulmonary aspiration is a feared complication of anaesthesia that is associated with significant morbidity and mortality. Within the small existing body of literature on medical malpractice claims related to periprocedural aspiration, very little information is available regarding the case-specific factors that were alleged to contribute to each aspiration event.

METHODS

This study searched an extensive nationwide database of medical malpractice claims and identified 43 relating to periprocedural pulmonary aspiration.

RESULTS

The most common mechanism of causation cited in these claims (37%) was the failure to secure the airway with an endotracheal tube (ETT) when an elevated aspiration risk existed, most commonly because endotracheal intubation was not originally selected as part of the anaesthetic plan. The second most common alleged category of causation (33%) was the failure to perform a proper rapid-sequence induction and/or place a nasogastric tube (NGT) for decompression prior to induction. An equal amount of cases resulted in defendant versus plaintiff verdicts (44.2% each), while a settlement was reached in the remaining 11.6% of cases.

CONCLUSION

These findings are generalizable to clinical practice improvement on a broader scale. They demonstrate the need to develop reliable, high-sensitivity tests for detecting elevated risk before clinicians can be expected to take special steps to protect susceptible patients, and they also show that medical malpractice can be alleged because of failure to uphold currently accepted standards of care even when the published evidence for those standards is weak. This study demonstrates that careful review of medical malpractice litigation can elucidate common contributory factors and facilitate improvements in clinical practice and decision-making.

Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management

The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.

Association Between Alcohol Use Disorders and Outcomes of Patients Hospitalized With Community-Acquired Pneumonia

IMPORTANCE

Patients with alcohol use disorder (AUD) are at elevated risk of developing pneumonia, but few studies have assessed the outcomes of pneumonia in patients with AUD.

OBJECTIVES

To compare the causes, treatment, and outcomes of pneumonia in patients with and without AUD and to understand the associations of comorbid illnesses, alcohol withdrawal, and any residual effects due to alcohol itself with patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted of 137 496 patients 18 years or older with pneumonia who were admitted to 177 US hospitals participating in the Premier Healthcare Database from July 1, 2010, to June 30, 2015. Statistical analysis was conducted from October 27, 2017, to August 20, 2018.

EXPOSURE

Alcohol use disorders identified from International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

Pneumonia cause, antibiotic treatment, inpatient mortality, clinical deterioration, length of stay, and cost. Associations of AUD with these variables were studied using generalized linear mixed models.

RESULTS

Of 137 496 patients with community-acquired pneumonia (70 358 women and 67 138 men; mean [SD] age, 69.5 [16.2] years), 3.5% had an AUD. Patients with an AUD were younger than those without an AUD (median age, 58.0 vs 73.0 years; P < .001), more often male (77.3% vs 47.8%; P < .001), and more often had principal diagnoses of aspiration pneumonia (10.9% vs 9.8%; P < .001), sepsis (38.6% vs 30.7%; P < .001), or respiratory failure (9.3% vs 5.5%; P < .001). Their cultures more often grew Streptococcus pneumoniae (43.7% vs 25.5%; P < .001) and less frequently grew organisms resistant to guideline-recommended antibiotics (25.0% vs 43.7%; P < .001). Patients with an AUD were treated more often with piperacillin-tazobactam (26.2% vs 22.5%; P < .001) but equally as often with anti-methicillin-resistant Staphylococcus aureus agents (32.9% vs 31.8%; P = .11) compared with patients without AUDs. When adjusted for demographic characteristics and insurance, AUD was associated with higher mortality (odds ratio, 1.40; 95% CI, 1.25-1.56), length of stay (risk-adjusted geometric mean ratio, 1.24; 95% CI, 1.20-1.27), and costs (risk-adjusted geometric mean ratio, 1.33; 95% CI, 1.28-1.38). After additional adjustment for differences in comorbidities and risk factors for resistant organisms, AUD was no longer associated with mortality but remained associated with late mechanical ventilation (odds ratio, 1.28; 95% CI, 1.12-1.46), length of stay (risk-adjusted geometric mean ratio, 1.04; 95% CI, 1.01-1.06), and costs (risk-adjusted geometric mean ratio, 1.06; 95% CI, 1.03-1.09). Models segregating patients undergoing alcohol withdrawal showed that poorer outcomes among patients with AUD were confined to the subgroup undergoing alcohol withdrawal.

CONCLUSIONS AND RELEVANCE

This study suggests that, compared with hospitalized patients with community-acquired pneumonia but without AUD, those with AUD less often harbor resistant organisms. The higher age-adjusted risk of death among patients with AUD appears to be largely attributable to differences in comorbidities, whereas greater use of health care resources may be attributable to alcohol withdrawal.

Aspiration Pneumonia and Related Syndromes

Aspiration is a syndrome with variable respiratory manifestations that span acute, life-threatening illnesses, such as acute respiratory distress syndrome, to chronic, sometimes insidious, respiratory disorders such as aspiration bronchiolitis. Diagnostic testing is limited by the insensitivity of histologic testing, and although gastric biomarkers for aspiration are increasingly available, none have been clinically validated. The leading mechanism for microaspiration is thought to be gastroesophageal reflux disease, largely driven by the increased prevalence of gastroesophageal reflux across a variety of respiratory disorders, including chronic obstructive pulmonary disease, asthma, idiopathic pulmonary fibrosis, and chronic cough. Failure of therapies targeting gastric acidity in clinical trials, in addition to increasing concerns about both the overuse of and adverse events associated with proton pump inhibitors, raise questions about the precise mechanism and causal link between gastroesophageal reflux and respiratory disease. Our review summarizes key aspiration syndromes with a focus on reflux-mediated aspiration and highlights the need for additional mechanistic studies to find more effective therapies for aspiration syndromes.

Fifty Years of Research in ARDS. Is Acute Respiratory Distress Syndrome a Preventable Disease?

Despite significant advances in our understanding and management of patients with acute respiratory distress syndrome (ARDS), the morbidity and mortality from ARDS remains high. Given the limited number of effective treatments for established ARDS, the strategic focus of ARDS research has shifted toward identifying patients with or at high risk of ARDS early in the course of the underlying illness, when strategies to reduce the development and progression of ARDS and associated organ failures can be systematically evaluated. In this review, we summarize the rationale, current evidence, and future directions in ARDS prevention.

Risk factors for aspiration pneumonia after definitive chemoradiotherapy or bio-radiotherapy for locally advanced head and neck cancer: a monocentric case control study

Background

Chemoradiotherapy (CRT) and bio-radiotherapy (BRT) are recognized as standard therapies for head and neck cancer (HNC). Aspiration pneumonia after CRT or BRT is a common late adverse event. Our aim in this study was to evaluate the cause-specific incidence of aspiration pneumonia after CRT or BRT and to identify its clinical risk factors.

Methods

We performed a retrospective analysis of 305 patients with locally advanced HNC treated by CRT or BRT between August 2006 and April 2015.

Results

Of these 305 patients, 65 (21.3%) developed aspiration pneumonia after treatment. The median onset was 161 days after treatment. The two-year cause-specific cumulative incidence by CRT or BRT was 21.0%. Multivariate analysis revealed five independent risk factors for aspiration pneumonia, namely, habitual alcoholic consumption, use of sleeping pills at the end of treatment, poor oral hygiene, hypoalbuminemia before treatment, and the coexistence of other malignancies. A predictive model using these risk factors and treatment efficacy was constructed, dividing patients into low- (0–2 predictive factors), moderate- (3–4 factors), and high-risk groups (5–6 factors), the two-year cumulative incidences of aspiration pneumonia of which were 3.0, 41.6, and 77.3%, respectively. Aspiration pneumonia tended to be associated with increased risk of death, although this was not statistically significant (multivariate-adjusted hazard ratio 1.39, P = 0.18).

Conclusion

The cause-specific incidence and clinical risk factors for aspiration pneumonia after definitive CRT or BRT were investigated in patients with locally advanced HNC. Our predictive model may be useful for identifying patients at high risk for aspiration pneumonia.

Respiratory disease and the oesophagus: reflux, reflexes and microaspiration

Gastro-oesophageal reflux is associated with a wide range of respiratory disorders, including asthma, isolated chronic cough, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease and cystic fibrosis. Reflux can be substantial and reach the proximal margins of the oesophagus in some individuals with specific pulmonary diseases, suggesting that this association is more than a coincidence. Proximal oesophageal reflux in particular has led to concern that microaspiration might have an important, possibly even causal, role in respiratory disease. Interestingly, reflux is not always accompanied by typical reflux symptoms, such as heartburn and/or regurgitation, leading many clinicians to empirically treat for possible gastro-oesophageal reflux. Indeed, costs associated with use of acid suppressants in pulmonary disease far outweigh those in typical GERD, despite little evidence of therapeutic benefit in clinical trials. This Review comprehensively examines the possible mechanisms that might link pulmonary disease and oesophageal reflux, highlighting the gaps in current knowledge and limitations of previous research, and helping to shed light on the frequent failure of antireflux treatments in pulmonary disease.

Gastroesophageal Reflux Burden, Even in Children That Aspirate, Does Not Increase Pediatric Hospitalization

OBJECTIVES

Gastroesophageal reflux is common but remains a controversial disease to diagnose and treat and little is known about the role of reflux testing in predicting clinical outcomes, particularly in children at risk for extraesophageal reflux complications. The aim of this study was to determine if rates of hospitalization were affected by reflux burden even after adjusting for aspiration risk.

METHODS

We prospectively recruited, between 2009 and 2014, a cohort of pediatric patients with suspected extraesophageal reflux disease who were referred for reflux testing and underwent both multichannel intraluminal impedance with pH (pH-MII) and modified barium swallow studies. A subset of patients also underwent bronchoalveolar lavage with pepsin analysis. We determined their rates of hospitalization for a minimum of 1 year following pH-MII testing.

RESULTS

We prospectively enrolled 116 pediatric patients who presented for care at Boston Children's Hospital and underwent both pH-MII and modified barium swallow studies. There was no statistically significant relationship between reflux burden measured by pH-MII or bronchoalveolar pepsin and total number of admissions or number of admission nights even after adjusting for aspiration status (P > 0.2). There were no statistically significant relationships between reflux burden by any method and the number or nights of urgent pulmonary admissions before or after adjusting for aspiration risk (P > 0.08).

CONCLUSIONS

Even in aspirating children, reflux burden did not increase the risk of hospitalization. Based on these results, routine reflux testing cannot be recommended even in aspirating children, because the results do not impact clinically significant outcomes.

Defining characteristics and risk indicators for diagnosing nursing home-acquired pneumonia and aspiration pneumonia in nursing home residents, using the electronically-modified Delphi Method

BACKGROUND

In nursing home residents, it is not possible to distinguish pneumonia and aspiration pneumonia clinically. International literature reveals no consensus on which and how many characteristics and risk indicators must be present to diagnose (nursing home-acquired) pneumonia and aspiration pneumonia. The aim of this survey was to reach consensus among a panel of clinical medical experts in geriatrics and pulmonology about the characteristics required for diagnosing pneumonia, and about the risk indicators needed to consider the diagnosis aspiration pneumonia in nursing home residents with pneumonia.

METHODS

Literature review and three expert-rating iterations using the electronically-modified Delphi Method were carried out. After each expert rating iteration, data analysis was performed. Qualitative responses and additional (nursing home-acquired) pneumonia characteristics which were mentioned in reply to structured open-ended questions were summarised, whilst similar responses were combined and these combinations were ordered by frequency in order to use them in the next iteration. Characteristics which failed to reach consensus were considered as inconclusive and eliminated. Consensus was reached when at least 70 % of the participants agreed.

RESULTS

Literature review revealed 16 currently used common characteristics for diagnosing (nursing home-acquired) pneumonia. No consensus was reached about characteristics and the number of characteristics required for diagnosing (nursing home-acquired) pneumonia. However, 57 % agreed that dyspnea, fever, deterioration of general functioning, tachypnea and crepitation with auscultation are the most important characteristics and the responses by the participants suggested that two or three characteristics should be present. Subsequently, 80 % of the participants agreed on the risk indicators dysphagia, choking incident, (history of) tube feeding, neurological disease and cognitive impairment for considering the diagnosis aspiration pneumonia in nursing home residents with pneumonia.

CONCLUSIONS

No final consensus could be reached about which and how many characteristics are required for diagnosing pneumonia in nursing home residents. However, the results indicated that dyspnea, fever, deterioration of general functioning, tachypnea and crepitation with auscultation are characteristics of some importance and that at least two or three characteristics should be present. With regard to considering aspiration pneumonia in nursing home residents with pneumonia, final consensus was reached about the risk indicators dysphagia, choking incident, (history of) tube feeding, neurological disease and cognitive impairment.

Prevention of acute respiratory distress syndrome

PURPOSE OF REVIEW

The paucity of effective therapeutic interventions in patients with the acute respiratory distress syndrome (ARDS) combined with overwhelming evidence on the importance of timely implementation of effective therapies to critically ill patients has resulted in a recent shift in ARDS research. Increasingly, efforts are being directed toward early identification of patients at risk with a goal of prevention and early treatment, prior to development of the fully established syndrome. The focus of the present review is on the prevention of ARDS in patients without this condition at the time of their healthcare encounter.

RECENT FINDINGS

The primary thematic categories presented in the present review article include early identification of patients at risk of developing ARDS, optimization of care delivery and its impact on the incidence of ARDS, pharmacological prevention of ARDS, prevention of postoperative ARDS, and challenges and opportunities with ARDS prevention studies.

SUMMARY

Recent improvements in clinical care delivery have been associated with a decrease in the incidence of hospital-acquired ARDS. Despite the initial challenges, research in ARDS prevention has become increasingly feasible with several randomized controlled trials on ARDS prevention completed or on the way.

Aspiration-related acute respiratory distress syndrome in acute stroke patient

Background

Aspiration of oral or gastric contents into the larynx and lower respiratory tract is a common problem in acute stroke patients, which significantly increases the incidence of acute respiratory distress syndrome (ARDS). However, little is known about the clinical characteristics of aspiration-related ARDS in acute stroke patients.

Methods

Over 17-month period a retrospective cohort study was done on 1495 consecutive patients with acute stroke. The data including demographic characteristics, clinical manifestations, laboratory examinations, chest imaging, and hospital discharge status were collected to analysis.

Results

Aspiration-related ARDS was diagnosed in 54 patients (3.6%). The most common presenting symptom was tachypnea (respiratory rate ≥25 breaths/min) in 50 cases. Computed tomography (CT) images usually demonstrated diffuse ground-glass opacities (GGOs) and inhomogeneous patchy consolidations involving the low lobes. Age, NIHSS score, GCS score, dysphagia, dysarthria, hemoglobin concentration, serum aspertate aminotransferase (AST), serum albumin, serum sodium, and admission glucose level were independently associated with aspiration-related ARDS (odds ratio (OR) 1.05, 95% confidence interval (CI) (1.04–1.07); OR 2.87, (2.68–3.63); OR 4.21, (3.57–5.09); OR 2.18, (1.23–3.86); OR 1.67, (1.31–2.14); OR 2.31, (1.11–4.84); OR 1.68, (1.01–2.80); OR 2.15, (1.19–3.90); OR 1.92, (1.10–3.36) and OR 1.14, (1.06–1.21) respectively).

Conclusions

Aspiration-related ARDS frequently occurs in acute stroke patient with impairment consciousness. It is advisable that performing chest CT timely may identify disease early and prompt treatment to rescue patients.