Diagnosis of gastric aspiration by fiberoptic bronchoscopy

Is There a Role for Bronchoscopy in Aspiration Pneumonia?

Aspiration represents the passage of oropharyngeal content to the lower respiratory tract. The interplay between the host and the aspirate proprieties determines the subsequent aspiration syndrome. A low pH, typical of gastric aspirate, favors chemical pneumonitis, whereas an increased bacterial inoculum causes aspiration pneumonia. About a quarter of patients with aspiration pneumonitis will develop a bacterial superinfection during the course of recovery. While antibiotic therapy is indicated for aspiration pneumonia, supportive care remains the cornerstone of treatment in aspiration pneumonitis. However, the overlapping clinical features of these syndromes lead to initiation of antimicrobial therapy in most cases of aspiration. Bronchoscopy can aid in clinical decision-making by direct airway visualization and also by providing access to a series of emerging biomarkers. Invasive microbiological studies increase diagnostic yield and enable a tailored antibiotic treatment. In conjunction with stewardship programs, invasive sampling and novel molecular diagnostics can decrease the amount of inappropriate antibiotic therapy. In the context of foreign body aspiration, bronchoscopy represents both diagnostic and treatment gold standard.

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature

BACKGROUND

Chronic cough is often associated with gastroesophageal reflux disease (GERD). The role of gastroenterologist in the management of the chronic cough is to identify and manage GERD. Ineffective esophageal motility is often associated with GERD induced cough. Chronic cough is often refractory to medical and surgical management despite adequate acid control. Unresponsiveness warrants a thorough pulmonary evaluation. The pathophysiology of refractory cough in these patients is poorly understood, and hence management is often challenging.

CASE PRESENTATION

A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough.

CONCLUSION

Frequent sips of water can be used in the management of the gastroesophageal reflux and ineffective motility induced cough. It results in increased esophageal clearance of acid, nonacid reflux, and ingested pharyngeal secretions, thus breaking the cycle of cough generated increased intra-abdominal pressure with reflux and more cough.

Flexible Fiberoptic Bronchoscopy in the Intensive Care Unit

For the past 20 years, flexible fiberoptic bronchoscopy (FOB) has been shown to be an important procedure in the diagnosis and management of patients in intensive care units (ICU). In adults, FOB is used therapeutically to remove retained secretions and to correct atelectasis not improved by conservative means. In the pediatric population, however, FOB is mainly used to diagnose tracheal disease in critically ill children. The principal risks of FOB are hypoxemia and dysrhythmias; hemor rhage and pneumothorax may occur as a result of biopsy procedures. In competent hands, these adverse compli cations of FOB are minimal. Although rigid bronchos copy remains pivotal in most pediatric bronchoscopic procedures, massive hemoptysis, foreign body removal, and laser therapy for occluding tumors of the upper airway, flexible FOB has an increasingly important role in the diagnosis and management of these disorders.

The approach to pediatric cough

OBJECTIVE

To provide an overview of pediatric cough, with specific emphasis on various causes, to aid in diagnosis and treatment.

DATA SOURCES

Relevant articles and references published between January 1, 1961, and May 1, 2009, were found through a PubMed search using the following keywords: pediatric cough and cough in children.

STUDY SELECTION

All key relevant articles and textbook sections were reviewed, and the most relevant were selected for inclusion in this review.

RESULTS

Although asthma, gastroesophageal reflux disease, and postnasal drip can be causes of cough in children, it is important to think of other potential causes, such as bronchitis, postviral cough, and foreign-body inhalation. Testing and treatment for cough will vary, depending on the presentation and diagnosis. Just as in adults, in children, the cause of cough can be multifactorial.

CONCLUSIONS

Pediatric cough is commonly encountered by primary care physicians and allergists. Physicians should be aware of the various potential causes of cough in children to properly determine the cause so that testing and treatment can proceed appropriately.

Chronic Cough Due to Gastroesophageal Reflux Disease

OBJECTIVES

To critically review and summarize the literature on cough and gastroesophageal reflux disease (GERD), and to make evidence-based recommendations regarding the diagnosis and treatment of chronic cough due to GERD.

DESIGN/METHODOLOGY

Ovid MEDLINE literature review (through March 2004) for all studies published in the English language and selected articles published in other languages such as French since 1963 using the medical subject heading terms "cough," "gastroesophageal reflux," and "gastroesophageal reflux disease."

RESULTS

GERD, singly or in combination with other conditions, is one of the most common causes of chronic cough. In patients with normal chest radiographic findings, GERD most likely causes cough by stimulation of an esophageal-bronchial reflex. When GERD causes cough, there may be no GI symptoms up to 75% of the time. While 24-h esophageal pH monitoring is the most sensitive and specific test in linking GERD and cough in a cause-effect relationship, it has its limitations. In addition, there is no general agreement on how to best interpret the test, and it cannot detect non-acid reflux events. Therefore, when patients fit the clinical profile that has a high likelihood of predicting that GERD is the cause of cough, antireflux medical therapy should be empirically instituted. While some patients improve with minimal medical therapy, others require more intensive regimens. When empiric treatment fails, it cannot be assumed that GERD has been ruled out as a cause of chronic cough. Rather, an objective investigation for GERD is then recommended because the empiric therapy may not have been intensive enough or medical therapy may have failed. Surgery may be efficacious when intensive medical therapy has failed in selected patients who have undergone an extensive objective GERD evaluation.

CONCLUSIONS

Accurately diagnosing and successfully treating chronic cough due to GERD can be a major challenge.

Diagnosis and treatment of chronic cough due to gastro-esophageal reflux disease and postnasal drip syndrome

Gastro-esophageal reflux disease (GERD) and postnasal drip syndrome (PNDS) are common causes of chronic cough. In patients with normal chest radiographs, GERD most likely causes cough by an esophageal-bronchial reflex. When GERD causes cough, there may be no gastrointestinal symptoms up to 75% of the time. While 24-h esophageal pH monitoring is the most sensitive and specific test in linking GERD and cough in a cause and effect relationship, it has its limitations. There is no general agreement on how to best interpret the test and it cannot detect non-acid reflux events. While some patients improve with minimal medical therapy, others require intensive regimens. Surgery may be efficacious when intensive medical therapy has failed. Because there are no pathognomonic findings of PNDS, the diagnosis is inferential and is based upon a combination of clinical findings, the results of ancillary testing, and the response to specific therapy. Specific therapy depends upon the rhinosinus disease(s) causing the PND. A common error in managing PNDSs is to assume that all H(1)-antagonists are equally efficacious. The second-generation, relatively non-sedating H(1)-antagonists have been found to be less effective than the first-generation agents in treating cough due to non-histamine-mediated PNDSs.

Gastroesophageal reflux in the patients with asthma

Thirty one patients with asthma (mean age was 44.4 10.7; range 18-63) were investigated for gastroesophageal reflux (GER). The patients were separated into two groups according to presence of reflux and/or nocturnal symptoms. 13 patients had one of the reflux and/or nocturnal asthma symptoms (Group 1), whereas 18 patients had none of them (Group 2). To assess GER patients underwent to scintigraphy with Tc99m. GER was determined 4 of 13 patients in group 1 (30,7 %) and 1 of 18 patients in group 2 (5,5 %). There was significant difference between the group 1 and group 2 in that respect (p < 0,001). The patients with established GER (5 patients) were given Omeprazole (a proton pomp inhibitor) 40 mg daily for 4 weeks following a 2 week placebo period. The patients recorded their daily and nocturnal symptoms of asthma, additional salbutamol use, morning and evening peak expiratory flow rates (PEFR) measurements in a daily chart during placebo and omeprazole treatment without changing their antiasthma treatment. Their PEFR, FEV1 values, daily and nocturnal symptoms and additional beta agonist use did not changed after omeprazole treatment except one. But their reflux symptoms (heartburn and regurgitation) were improved. As a consequence, we suggested that asthmatics which have some complaints of reflux should be searched for GER. Not the respiratory functions but GER symptoms can be improved w

Respiratory complications of gastrointestinal diseases

Further advances in the ability to diagnose GER disease by use of ambulatory pH monitoring have unveiled a host of extraesophageal manifestations of GERD. These include pulmonary symptoms of asthma, recurrent pneumonia, cough or bronchitis, and infant apnea. Many of these symptoms may be the sole presentations of GER in these patients. It is important that the clinician is aware of these atypical presentations of GERD. The expanding use of ambulatory pH monitoring is helping to clarify the underlying pathophysiology of these disorders as well as to improve the ability to diagnose the atypical manifestations of GERD.

Value of C-reactive protein in the detection of bacterial contamination at the time of presentation in drug-induced aspiration pneumonia

STUDY OBJECTIVES

To compare the plasma concentration of C-reactive protein (CRP) with traditional markers for diagnosis of bacterial pneumonia in patients with suspected aspiration.

DESIGN

Prospective, nonrandomized, controlled study of consecutive hospital admissions.

SETTING

Toxicology ICU in a university hospital.

PATIENTS OR PARTICIPANTS

Acutely poisoned comatose patients admitted to the hospital with suspicion of aspiration pneumonia.

INTERVENTIONS

Distal protected catheter sampling per fiberoptic bronchoscopy and bacteriologic culture were employed as a standard to detect the bacterial component of suspected aspiration pneumonia. Plasma CRP concentrations, temperature, and WBC count were measured on hospital day 1.

MEASUREMENTS AND RESULTS

Sixty-six patients were evaluated. Thirty-two had bacterial contamination by positive culture (> or =10(3) cfu/mL). Multiple receiver-operating characteristic (ROC) curves were used to compare each parameter for detection of infection secondary to aspiration. The ROC curve of CRP concentrations showed that a CRP >75 mg/L is associated with bacterial contamination with a sensitivity of 87%, specificity of 76%, positive predictive value of 78%, and negative predictive value of 87%. ROC curves of temperature and WBC count demonstrated poor diagnostic value of these markers in indicating the bacterial component of suspected aspiration pneumonia.

CONCLUSIONS

Early measurement of CRP is useful for the diagnosis of aerobic bacterial content of aspiration pneumonia and perhaps in determining the need for invasive bacteriologic sampling. Temperature and WBC count are poor indicators of bacterial infection of aspiration pneumonia in poisoned patients.

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.

Diagnosis of occult meat aspiration by fiberoptic bronchoscopy

Cytologic examination of bronchial washings from a patient with a persistent localized pulmonary infiltrate revealed large numbers of striated muscle fibers. The patient died shortly after bronchoscopy, and postmortem examination provided evidence of recurrent aspiration pneumonias. Since skeletal muscle fibers are not likely to enter the tracheobronchial tree from any endogenous source, it is proposed that this unusual cytologic finding is virtually diagnostic of recent food aspiration.

The chronic bronchitis complex in children

In childhood, a clear definition, etiology, natural history, therapy, and prognosis have not been described for chronic bronchitis. In fact, its validity as a single disease entity is in question. This article offers a pragmatic approach by considering "chronic bronchitis" as a pathophysiologic description of a symptom complex that results from the interaction of both intrinsic and extrinsic factors. In this schema, the physician should rule out more specific diagnoses and prevent further airway disease by limiting exogenous causes of airway damage and treating identifiable endogenous ones.

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.