Fiberoptic Endoscopic Evaluation of Swallowing Findings in Children With Rett Syndrome

Feeding abnormalities, swallowing dysfunction, and gastrointestinal issues cause poor weight gain, oral motor dysfunction, and air swallowing in children with Rett syndrome (RTT). Pneumonia is the leading cause of death. Our study describes fiberoptic endoscopic swallowing findings in 11 female RTT children. Each patient was evaluated using the 8-point Penetration/Aspiration Scale (PAS). The average age was 7 years. All patients had tongue dyskinesis and prolonged oral stage. Eight girls exhibited liquid entering the airway without coughing, whereas 6 did well with pureed meal. Three girls had pneumonia. Age was not correlated with pneumonia episodes (P = .18). Pureed material was related with pneumonia (P = .006), whereas liquids were not. Pureed PAS was positively correlated with Liquid PAS (P = .008) and age (P = .004). All aspiration/penetration incidents occurred before the pharyngeal phase. No patient under 7 years experienced pneumonia episodes. Silent aspiration can occur early in infancy, although pneumonia episodes can occur later.

Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty?

PURPOSE

Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia.

METHODS

We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan-Meier curves, and used logistic regression to identify independent prognostic factors.

RESULTS

803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ2 = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death.

CONCLUSION

The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient.

Cough Correlates of Functional Swallow Outcomes in Atypical Parkinsonism

BACKGROUND

Swallow and cough impairments lead to aspiration and reduced clearance of aspirate material. Both behaviors are impaired in Parkinson's disease, but it is unknown whether a similar relationship of dysfunction exists in forms of atypical Parkinsonism (APD). Elucidating this association in APD may lead to early, comprehensive airway protection treatment.

OBJECTIVES

We tested the hypotheses that swallow deficits in APD are associated with impaired cough and that airway protective dysfunction is associated with longer disease duration.

METHODS

Swallowing difficulty was described by 11 participants with APD. Penetration-Aspiration Scale (PAS) and DIGEST scores for thin liquid trials were extracted from medical records of videofluoroscopic swallow study reports. Voluntary and capsaicin induced-reflex cough measures of flow, volume, and timing were analyzed.

RESULTS

While most participants did not have post-swallow residue, ~80% received abnormal PAS scores and reported swallowing difficulty. Those with abnormal PAS scores had lower voluntary cough expired volume (P = 0.037; mean rank difference = 5.0); lower reflex inspiratory flow rate (P = 0.034; mean rank difference = 5.5); and longer reflex expiratory flow rise time (P = 0.034; mean rank difference = 5.5). Higher PAS scores and reduced reflex cough volume acceleration were significantly correlated (r = -0.63; P = 0.04) and longer disease duration predicted larger voluntary cough expired volume (R2  = 0.72) and longer flow rise times (R2  = 0.47).

CONCLUSIONS

As swallow safety worsens, so might the ability to clear the airways with effective cough in in APD; particularly with longer disease duration. Assessing cough in conjunction with swallowing is important for informing airway protection treatment plans in APD.

Breastfeeding in infants who aspirate may increase risk of pulmonary inflammation

OBJECTIVE

To evaluate management strategies and pulmonary outcomes for breastfed infants with oropharyngeal dysphagia.

STUDY DESIGN

We performed a retrospective cohort study of breastfed infants diagnosed with oropharyngeal dysphagia with documented aspiration or laryngeal penetration on videofluoroscopic swallow study (VFSS). Medical records were reviewed for VFSS results and speech-language pathologist recommendations following VFSS, results of chest x-ray, results of bronchoalveolar lavage (BAL) within 1 year of VFSS, and aspiration-related hospitalizations occurring before or within 1 year of VFSS. Subjects were categorized as cleared or not cleared to breastfeed based on the VFSS. Proportions were compared with Chi-square and Fisher's exact tests and means with Student's t-tests.

RESULTS

Seventy-six infants (4.7 ± 0.4 months old) were included; 50% (38) had aspiration and 50% (38) had laryngeal penetration. After VFSS, 70% (53) were cleared to breastfeed while 30% (23) were not cleared to breastfeed. Patients with aspiration were less likely to be cleared to breastfeed (p = .006); however, 55% (21/38) of those with aspiration were still cleared to breastfeed. Infants cleared to breastfeed had significantly more pulmonary hospitalizations (p = .04) and were also at increased risk of elevated neutrophil count (p = .02) and culture growth on BAL (p = .01). Significantly increased abnormal neutrophil count was also found in those cleared to breastfeed with laryngeal penetration (p = .01).

CONCLUSIONS

Infants with oropharyngeal dysphagia counseled to continue breastfeeding had increased risk of BAL inflammation and more pulmonary hospitalizations compared to those that were told to stop breastfeeding.

Sensitivity and specificity of the EAT-10 and SDQ-DP in identifying the risk of dysphagia in Parkinson's disease

BACKGROUND

 The early identification of risk for dysphagia in patients with Parkinson's disease (PD) is essential for the prevention of nutritional and pulmonary complications.

OBJECTIVE

 To analyze the sensitivity and specificity of the Swallowing Disturbance Questionnaire (SDQ-PD) and the Eating Assessment Tool (EAT-10) in identifying dysphagia risk in patients with early and intermediate stages of PD.

METHODS

 Twenty-nine patients with PD participated in the study. EAT-10 and SDQ-PD questionnaires were applied, and a videofluoroscopic swallowing study. Dysphagia Outcome and Severity Scale (DOSS) was used to classify the presence and severity of dysphagia, and the Penetration-Aspiration Scale (PAS) was used to identify the presence of penetration/aspiration. In the statistical analysis, the sensitivity and specificity of the risk questionnaires were calculated, as well as positive predictive value, negative predictive value, and accuracy.

RESULTS

 EAT-10 to identify the risk of penetration/aspiration revealed a sensitivity of 71.42% and specificity of 45.45%; in the identification of the presence of dysphagia, the sensitivity was 47.61%, and the specificity was 12.5%. The SDQ-PD questionnaire for risk of penetration/aspiration demonstrated a sensitivity of 28.57%, and a specificity of 68.18%. In terms of identifying the presence of dysphagia, the sensitivity was 20%, while the specificity was 44.44%.

CONCLUSION

 The SDQ-PD revealed low sensitivity and low specificity to identify the presence of dysphagia and/or penetration/aspiration in patients with early and intermediate stages of PD in this sample. Despite its low specificity, the EAT-10 exhibited good sensitivity in indicating the risk of penetration/aspiration.

Validity and reliability of the Group for Learning Useful and Performant Swallowing (GLUPS) tool

INTRODUCTION

To validate the Group for Learning Useful and Performant Swallowing (GLUPS), a clinical tool dedicated to videofluoroscopy swallowing study (VFSS).

METHODS

Forty-five individuals were recruited from January 2022 to March 2023 from the Department of Otolaryngology Head and Neck Surgery of University Hospital Saint-Pierre (Brussels, Belgium). Subjects underwent VFSS, which was rated with GLUPS tool by two blinded otolaryngologists and one speech-therapist. VFSS were rated twice with GLUPS within a 7-day period to assess test-retest reliability.

RESULTS

Twenty-four patients and twenty-one controls completed the evaluations. The internal consistency (α = 0.745) and the test-retest reliability (rs = 0.941; p = 0.001) were adequate. GLUPS reported a high external validity regarding the significant correlation with the Penetration-Aspiration Scale (rs = 0.551; p = 0.001). Internal validity was adequate, because GLUPS score was significant higher in patients compared to controls (6.21 ± 4.42 versus 2.09 ± 2.00; p = 0.001). Interrater reliability did not report significant differences in the GLUPS sub- and total score among the independent judges. The mean GLUPS score of individuals without any evidence of VFSS abnormalities was 2.09/23 (95% CI  1.23-2.95), which supported that a GLUPS score ≥ 3.0 is suggestive of pathological VFSS.

CONCLUSIONS

GLUPS is a clinical instrument documenting the abnormal findings of oral and pharyngeal phases at the VFSS. GLUPS demonstrated high reliability and excellent criterion-based validity. GLUPS may be used in clinical practice for the swallowing evaluation at the VFSS.

Type 3 Laryngeal Clefts Presenting with Upper Airway Obstruction without Aspiration

Traditionally, otolaryngologists are taught that the defining clinical feature of a laryngeal cleft is aspiration. However, in a small subset of patients-even those with extensive clefts-the sole presenting feature may be airway obstruction. Here, we report two cases of type III laryngeal clefts that presented with upper airway obstruction without aspiration. The first patient was a 6-month-old male with history of tracheoesophageal fistula (TEF) who presented with noisy breathing, initially thought to be related to tracheomalacia. Polysomnogram (PSG) demonstrated moderate OSA and modified barium swallow (MBS) was negative for aspiration. In-office laryngoscopy was notable for a mismatch of tissue in the interarytenoid region. A type III laryngeal cleft was identified on bronchoscopy, and airway symptoms resolved after endoscopic repair. The second patient was a 4-year-old male with a diagnosis of asthma who presented with progressive exercise-induced stridor and airway obstruction. In-office flexible laryngoscopy revealed redundant tissue in the posterior glottis and MBS was negative for aspiration. He was found to have a type III laryngeal cleft on bronchoscopy and his stridor and upper airway obstruction resolved after endoscopic repair. While aspiration is the most common presenting symptom of a laryngeal cleft, it is important to consider that patients can have a cleft in the absence of dysphagia. Laryngeal cleft should be included in the differential diagnosis for patients with obstructive symptoms not explained by other etiologies and in those with suspicious features on flexible laryngoscopy. Laryngeal cleft repair is recommended to restore normal anatomy and relieve obstructive symptoms. Laryngoscope, 134:977-980, 2024.

Endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis using radiofrequency versus coblation

PURPOSE

To assess the outcomes of endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis (BAVFP) using radiofrequency versus coblation.

METHODS

This was a randomized prospective cohort study that carried out on 40 patients with BAVFP who were subjected to endoscopic/assisted microscopic posterior cordotomy. The patients were randomly allocated into two groups: group (A) patients were operated with radiofrequency, and group (B) patients were operated with coblation. Glottic chink, grade of dyspnea, voice handicap index 10 (VHI10), and aspiration were evaluated pre-operatively and 2 weeks and 3 months post-operatively.

RESULTS

There was a significant improvement in the glottic chink and VHI10 scores postoperatively with a non-significant difference between both groups regarding the degree of improvement. In addition, there was a significant improvement of the grade of dyspnea with a non-significant impact on the degree of aspiration in both groups post operatively. There was a lower incidence of oedema and granulation formation in the coblation group but without a statistical significance.

CONCLUSION

Both techniques are effective alternatives for performing posterior transverse cordotomy in cases of BAVFP.

Brain imaging abnormalities in children with dysphagia with aspiration: A retrospective study

OBJECTIVE

Head imaging is often performed in children with persistent dysphagia with aspiration to evaluate for Chiari malformations that may be associated with dysphagia. Unfortunately, the frequency of Chiari malformations or other head imaging abnormalities in children who aspirate is unknown. The goal of this study is to determine the frequency of head imaging abnormalities in children with evidence of aspiration or penetration on video fluoroscopic swallow study (VFSS).

SETTING

Tertiary Children's Hospital.

METHODS

We performed retrospective analysis of children with a diagnosis of aspiration evaluated at our center from January 2010 through April 2021. In this study, we included children with VFSS confirmed aspiration or penetration, brain magnetic resonance imaging (MRI) performed at our center, and without known genetic, congenital craniofacial, or neurologic abnormalities.

RESULTS

Of the 977 patients evaluated in our system during that time with a diagnosis of aspiration, 185 children met the inclusion criteria. Eight children were diagnosed with Chiari malformations (4.3%) and 94 head MRIs were abnormal (51.4%). There was no difference in VFSS findings (frequency of aspiration, penetration, penetration-aspiration score, or recommended thickness of liquid) in children with a Chiari malformation versus other abnormalities or normal brain imaging. The majority of other non-Chiari brain imaging abnormalities were nonspecific. There was no difference in VFSS findings in children with abnormal MRI findings versus normal MRI.

CONCLUSIONS

Brain imaging abnormalities are common in children who aspirate. Intervenable lesions are rare. Further studies are required to determine patients that will most likely benefit from brain imaging.

Development of organized pleural empyema as a result of occult foreign body aspiration

Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB.

Cardiac arrest after pulmonary aspiration in hospitalised patients: a national observational study

OBJECTIVE

To study characteristics and outcomes among patients with in-hospital cardiac arrest (IHCA) due to pulmonary aspiration.

DESIGN

A retrospective observational study based on data from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR).

SETTING

The SRCR is a nationwide quality registry that covers 96% of all Swedish hospitals. Participating hospitals vary in size from secondary hospitals to university hospitals.

PARTICIPANTS

The study included patients registered in the SRCR in the period 2008 to 2017. We compared patients with IHCA caused by pulmonary aspiration (n=127), to those with IHCA caused by respiratory failure of other causes (n=2197).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was 30-day survival. Secondary outcome was sustained return of spontaneous circulation (ROSC) defined as ROSC at the scene and admitted alive to the intensive care unit.

RESULTS

In the aspiration group 80% of IHCA occurred on general wards, as compared with 63.6% in the respiratory failure group (p<0.001). Patients in the aspiration group were less likely to be monitored at the time of the arrest (18.5% vs 38%, p<0.001) and had a significantly lower rate of sustained ROSC (36.5% vs 51.6%, p=0.001). The unadjusted 30-day survival rate compared with the respiratory failure group was 7.9% versus 18.0%, p=0.024. In a propensity score analysis (including variables; year, age, gender, location of arrest, initial heart rhythm, ECG monitoring, witnessed collapse and a previous medical history of; cancer, myocardial infarction or heart failure) the OR for 30-day survival was 0.46 (95% CI 0.19 to 0.94).

CONCLUSIONS

In-hospital cardiac arrest preceded by pulmonary aspiration occurred more often on general wards among unmonitored patients. These patients had a lower 30-day survival rate compared with IHCA caused by respiratory failure of other causes.

Successful management of severe acute respiratory distress syndrome caused by sodium polystyrene sulfonate aspiration: A case report

RATIONALE

Sodium polystyrene sulfonate is commonly administered to treat hyperkalemia. Severe pneumonia due to aspiration of this drug is rare and no survival case has thus far been reported.

PATIENT CONCERNS

A 45-year-old man was hospitalized for acute decompensated heart failure and acute kidney injury with hyperkalemia. He aspirated sodium polystyrene sulfonate while consuming the drug. Severe acute respiratory distress syndrome (ARDS) developed rapidly, and he was transferred to the intensive care unit (ICU).

DIAGNOSES

Chest radiography results after aspiration showed new consolidation in the left upper lung. He underwent emergency bronchoscopy, which revealed a considerable amount of yellow mud-like material in the trachea and bronchi. Chest radiography results after the bronchoscopic removal of the foreign material revealed rapid resolution of the left upper lung consolidation.

INTERVENTIONS

In the ICU, mechanical ventilation with low tidal volume and high positive end-expiratory pressure was administered and extracorporeal membrane oxygenation (ECMO) was set up for treating severe ARDS. We arranged an emergency bronchoscopy for diagnosis and removal of polystyrene sulfonate.

OUTCOMES

ECMO was discontinued after 10 days and the patient was discharged after approximately 2 weeks.

LESSONS

Aspiration of sodium polystyrene sulfonate is not common but can be lethal. Clinicians should be cautious and appropriately inform patients of the aspiration risk while administering this drug. Mechanical ventilation and bronchoscopy were effective treatments for severe ARDS caused by aspiration of this drug.

A Patient With a Chronic Cough: An Unexpected Case of Calcium Pill Aspiration

Foreign body aspiration is a life-threatening medical condition that requires prompt action. Delayed diagnosis is associated with long-term serious complication often leading to death. In adults, it can remain undetected for a long period of time. The patient gives a long history of a cough, which clinicians often ignore. A chest radiograph is unreliable to exclude the disease as it may not show radiolucent objects. Diagnostic bronchoscopy is necessary to exclude the disease. We report a case of 70-year-old woman who had a 1-month history of a cough and was admitted for shortness of breath, and on further evaluation, we incidentally detected calcium tablets in her bronchus. The present case demonstrates the need for early bronchoscopy especially when the cause of a chronic cough is not known.

[Probabilistic algorithm for management of suspected foreign body aspiration in children]

INTRODUCTION

The aim is to create a protocol for the managing of foreign body aspiration in children based on a probability scale.

MATERIAL AND METHODS

Retrospective observational study, including patients admitted with suspected foreign body aspiration (FBA) in the last 15 years. The parameters were assessed with a SCORE that included witnessed choking, stridor and wheezing during choking, unilateral reduced air entry and abnormal X-Ray. This scale relates them to a probability of FBA, where a score ≤ 1 is associated with less than 10% and ≥ 4 with more than 50% of FBA. According to the probability, we propose: observation, chest Computed Tomography (CT) or bronchoscopy. Then, we tried to adapt it to our casuistry.

RESULTS

A total of 109 children admitted between 2002-2017 were included. The median age was 25 months, a foreign body was found in 88 patients, the most frequent being organic (seeds and nuts). Significant predictors of FBA were unilateral reduced air entry and abnormal X-Ray. In our study, we found the same ascending probability between the scale and the presence of foreign body, except for SCORE 1, which was 57% what we attribute to an information bias. If the foreign body were not nuts, inorganic or bone, its aspiration was very unlikely, that is why we included it in the SCORE with -1.

CONCLUSION

The use of the algorithm would imply the performance of 7% more of CT in patients without a FBA, but avoiding an 8.5% of bronchoscopy. Our results present an information bias, characteristic of a retrospective study.

Video-fluoroscopic swallowing study scale for predicting aspiration pneumonia in Parkinson's disease

Introduction

A number of video-fluoroscopic swallowing study (VFSS) abnormalities have been reported in patients with Parkinson’s disease (PD). However, the most crucial finding of subsequent aspiration pneumonia has not been validated fully. We conducted a retrospective and case-control study to determine the clinically significant VFSS findings in this population, and to propose a practical scale for predicting aspiration pneumonia in patients with PD.

Methods

We enrolled 184 PD patients who underwent VFSS because of suspected dysphagia. The patients who developed aspiration pneumonia within six months of the VFSS were assigned as cases and the patients without aspiration pneumonia at six months were designated as controls. Logistic regression analysis was performed to determine the prognostic VFSS features based on the data of swallowing 3 mL of jelly, which were used to make a PD VFSS scale (PDVFS). The validity of the new PDVFS was evaluated by ROC analysis. Additionally, we used the survival time analysis to compare time to death between groups, stratified by the PDVFS score.

Results

Twenty-five patients developed aspiration pneumonia. Among the previously-proposed VFSS features, mastication, lingual motility prior to transfer, aspiration, and total swallow time were identified as significant prognostic factors. We combined these factors to form the PDVFS. The PDVFS score ranges from 0 to 12, with 12 being the worst. ROC analysis revealed 92% sensitivity and 82% specificity at a cutoff point of 3. The higher PDVFS group showed shorter time-to-death than the lower PDVFS group (log rank P = 0.001).

Conclusion

Our newly developed VFSS severity scale (based on jelly swallowing) for patients with PD was easy to rate and could predict subsequent aspiration pneumonia and poor prognosis in patients with PD.

The bacterial species associated with aspirated foreign bodies in children

OBJECTIVE

Inhaled foreign bodies in children are common and may be complicated by secondary airway tract infection. The inhaled foreign body may act as carrier of infectious material and the aim of this study was to explore the bacterial species associated with aspirated foreign bodies in a cohort of children.

METHODS

Retrospective case series of 34 patients who underwent rigid laryngobronchoscopy because of foreign body aspiration. Each patient had a sample taken from tracheobronchial secretions during the procedure.

RESULTS

The average patient age was 31.2 months and the average hospital stay was 2.5 days. Of the foreign bodies 24 (71%) were organic in nature and 10 (29%) were non-organic. Twenty eight (82.3%) patients had mixed oropharyngeal flora organisms growth. Fifteen (44%) samples were positive for organisms other than oropharyngeal flora with the most common cultured organisms being: Streptococcus pneumonia (4/12%), Haemophilus influenza (4/12%), Moraxella catarrhalis (4/12%). Four samples (12%) grew a fungus; Candida albicans was cultured in 3 patients and Aspergillus glaucus was identified in one sample. Of the non-oropharyngeal organisms 7(47%) demonstrated antibiotic resistance with four having resistance to amoxycillin, two resistant to penicillin and one resistant to cotrimoxazole.

CONCLUSION

Some children who present with aspirated foreign body may be complicated with secondary airway infection. Antibacterial treatment might be considered in some of these cases. The regimen of antibiotics should aim to cover oropharyngeal flora, S. pneumonia, H. influenza and Moraxella catarrhalis.

[Incidence, pathomorphism and outcomes of the bronchopulmonary dysplasia associated with microaspiration of gastric contents]

Today the influence of the digestive tract functional violations followed by microaspiration of gastric contents (MAGC) on the incidence, features and outcomes of bronchopulmonary dysplasia BPD) remains little studied. Focusing on this aspect makes the research actual.

OBJECTIVE

determination of the nature of influence of MAGC on the progress and course of BPD.

METHODS

373 newborns exposed to artificial pulmonary ventilation (APV) in the neonatal period were examined. In a tracheobronchial aspirate (TBA) the marker of MAGC-pepsin--was determined. Its activity was measured by extinction value with subsequent analysis of the incidence and nature of the course of bronchopulmonary dysplasia (BPD) in patients against MAGC and without it. During the three years follow-up period outcomes of BPD and features of combined pathology were established.

RESULTS

it was revealed that in children suffered from MAGC the incidence of BPD was higher and grew in proportion to the increase of pepsin activity in TBA and the reduction of gestational age. The extinction increase in TBA values was followed by the increase in duration of APV and the subsequent oxygen therapy, and also the severity of BPD clinical course. By the end of 3 years clinical recovery was detected in 55.2% of children suffering from BPD without MAGC whereas in patients with BPD against MAGC this outcome occured only in 0.9% of cases.

CONCLUSION

MAGC is clinically significant for the etiology, pathogenesis and pathomorphism of BPD. The proposed method of early detection of MAGC and algorithm of complex therapy can reduce its severity and improve the forecast accuracy of neonatal adaptation.

Foreign Body Aspiration in the Elderly

Foreign body aspiration is common in children and in the elderly, who may present with subtle symptoms. Clinical suspicion is crucial and bronchoscopy is the main diagnostic and therapeutic procedure available. This is the case of a man, 78 years old, with a history of chronic obstructive pulmonary disease, who presented with respiratory distress following oral intake of tablets. History taking and physical examination raised suspicion. The diagnosis was confirmed with flexible bronchoscopy and rigid bronchoscopy was carried out for treatment. The patient's condition is stable and he is under investigations for dysphagia.

Enrichment of the lung microbiome with oral taxa is associated with lung inflammation of a Th17 phenotype

Microaspiration is a common phenomenon in healthy subjects, but its frequency is increased in chronic inflammatory airway diseases, and its role in inflammatory and immune phenotypes is unclear. We have previously demonstrated that acellular bronchoalveolar lavage samples from half of the healthy people examined are enriched with oral taxa (here called pneumotypeSPT) and this finding is associated with increased numbers of lymphocytes and neutrophils in bronchoalveolar lavage. Here, we have characterized the inflammatory phenotype using a multi-omic approach. By evaluating both upper airway and acellular bronchoalveolar lavage samples from 49 subjects from three cohorts without known pulmonary disease, we observed that pneumotypeSPT was associated with a distinct metabolic profile, enhanced expression of inflammatory cytokines, a pro-inflammatory phenotype characterized by elevated Th-17 lymphocytes and, conversely, a blunted alveolar macrophage TLR4 response. The cellular immune responses observed in the lower airways of humans with pneumotypeSPT indicate a role for the aspiration-derived microbiota in regulating the basal inflammatory status at the pulmonary mucosal surface.

Violent death in a rare peroxisomal disease--Zellweger syndrome

Peroxisomal diseases are rare (1:50,000), genetically determined disorders (autosomal recessive), systemic, multiorgan illnesses with prominent involvement of the nervous system, caused either by the failure to form or to maintain the peroxisome, or by a defect in the function of a single or multiple peroxisomal enzymes. Peroxisomes contain approximately 50 enzymes which are responsible for many metabolic reactions, and play an important role in the oxidation of saturated very-long-chain fatty acids (VLCFA). The authors present the case of a Romanian boy, who died at the age of 1.6 of one of the peroxisomal diseases-Zellweger syndrome. Newborn infants with Zellweger syndrome have a typical dysmorphic facies, neonatal seizures, profound hypotonia, and eye abnormalities. Major abnormalities are present in the liver (fibrotic), kidney (cortical cysts), and brain (lipid-laden macrophages and histiocytes in cortical and periventricular areas, demyelination, centrosylvian polymicrogyria and pachygyria)-cerebro-hepato-renal syndrome (CHRS) (Zellweger). Infants with Zellweger syndrome rarely live more than a few months, but in this case the survival was longer, and the cause of death was not directly the peroxisomal disease but a violent cause of death-mechanical asphyxia with tracheo-bronchial food aspiration. The authors present the results of investigations carried out during the child's life, but also data collected at the autopsy and hystopathological postnecroptic investigations. By presenting this case, the authors wish to bring to your attention a rare pathology in forensic practice by the paradox of finding a common violent cause of death, asphyxia with food aspiration, in a rare metabolic-genetic disease, which is usually fatal by itself.

Ameliorative effect of Leflunomide on lung injury following an aspiration

BACKGROUND

We aimed to investigate the therapeutic effectiveness of leflunomide (LEF) in lung injury after an aspiration of unknown pathophysiology.

MATERIAL AND METHODS

Forty-two healthy Sprague Dawley rats were anesthetized and allocated to six experimental groups: saline (S) aspirated, S+LEF, hydrochloric acid (HCl) aspirated, HCl+LEF, formula aspirated (FOR), and FOR+LEF. The treatment groups (S+LEF, HCl+LEF, and FOR+LEF) received 20 mg/kg/day intraperitoneal (i.p.) injection of LEF for seven days. At the end of the seven days, blood and tissue samples were taken from the rats for histopathological, biochemical, and immunohistochemical examination.

RESULTS

There was a significant increase in serum levels of YKL-40, a chitinase-like protein, in the HCl group after the aspiration (p<0.01). The increase in serum YKL-40 levels decreased significantly with LEF treatment (p<0.01). There was no significant difference in serum YKL-40 levels in the FOR group compared to the control group at pretreatment and in the FOR+LEF group at post-treatment. There was a significant increase in serum thiobarbituric acid-reactive species (TBARS) values in the HCl and FOR groups compared to the control group (p=0.001 and p<0.01, respectively). In both treatment groups, the serum TBARS values significantly decreased after treatment with LEF (p=0.001 and p<0.05, respectively). There was a significant improvement in the histopathological scores, which deteriorated after the aspiration, and in the number of inducible nitric oxide synthase (iNOS)-positive cells after treatment with LEF.

Flexible bronchoscopy with multiple modalities for foreign body removal in adults

OBJECTIVES

Aspiration of the lower airways due to foreign body is rare in adults. This study aimed to determine the outcome of patients who received flexible bronchoscopy with different modalities for foreign body removal in the lower airways.

PATIENTS AND METHODS

Between January 2003 and January 2014, 94 patients diagnosed with foreign body in the lower airways underwent flexible bronchoscopy with different modalities, which included forceps, loop, basket, knife, electromagnet, and cryotherapy. The clinical presentation, foreign body location and characteristics, and applications of flexible bronchoscopy were analyzed.

RESULTS

Forty (43%) patients had acute aspiration, which developed within one week of foreign body entry and 54 (57%) had chronic aspiration. The most common foreign bodies were teeth or bone. More patients with chronic aspiration than those with acute aspiration were referred from the out-patient clinic (48% vs. 28%), but more patients with acute aspiration were referred from the emergency room (35% vs. 6%) and intensive care unit (18% vs. 2%). Flexible bronchoscopy with different modalities was used to remove the foreign bodies (85/94, 90%). Electromagnet or cryotherapy was used in nine patients to eliminate the surrounding granulation tissue before foreign body removal. In the nine patients with failed flexible bronchoscopy, eight underwent rigid bronchoscopy instead and one had right lower lung lobectomy for lung abscess.

CONCLUSIONS

Flexible bronchoscopy with multiple modalities is effective for diagnosing and removing foreign bodies in the lower respiratory airways in adults, with a high success rate (90%) and no difference between acute and chronic aspirations.

Tablet in the bronchus--an unusual cause for persistent cough in a 64 year old gentleman

Foreign body aspiration in adults without any background risk factors is uncommon. We report a 64 year gentleman evaluated for persistent cough incidentally detected to have a foreign body (FB) in the left main bronchus (LMB), which after removal by rigid bronchoscopy turned out to be a tablet. This demonstrates the possible risk of silent aspiration of solid foreign bodies and in our case presenting as a persistent cough after months of aspiration. Bronchoscopic evaluation should be carried out in the differential diagnosis of persistent or recurrent pulmonary symptoms.

[Specificities of pneumonia in geriatrics]

Pneumonia is a major cause of morbidity and mortality leading to a high rate of hospitalization especially in theelderly. It is often a sign of frailty and is associated with a poor prognosis. However, taking into account the geriatric specificities (risk factors, atypical clinical presentations with "geriatric syndromes", ethical debate) using an interdisciplinary and a comprehensive geriatric approach remains an important responsibility of the general practitionner. This article summarizes these specificities and offers interventions targeted on the characteristics of elderly patients.

The effect of the training given to the child development students about foreign body aspiration upon their knowledge levels

OBJECTIVE

This study was semi-experimentally conducted in order to determine knowledge levels of child development students about foreign body aspiration and to explore the effect of the training given to these students about foreign body aspiration upon their knowledge levels.

METHODS

The research was conducted with a total of 231 students who studied at the department of child development of two high schools and one vocational higher school in Erzincan Province located in the east of Turkiye between May 2011 and February 2012. The data were gathered using a questionnaire form of 38 questions. The training on foreign body aspiration (Power point presentation, video presentation and practice on a dummy) was provided in three phases. For the data evaluation; percentages, chi-square test and Mc Nemar test were used.

RESULTS

It was found out in the study that 91.8% of the students did not take any training/course about foreign body aspiration and 55% confronted situations of foreign body aspirations (ear, nose, airway). After the training about foreign body aspiration; it was noted that the number of the students who knew risky behaviors for foreign body aspiration increased and the increase in the number of the students was at the highest level among high schools (p<0.05). It was seen that the training was most effective among the university students in terms of knowing first-aid intervention in case a foreign body would obstruct airway among the children aged<1 year (p<0.05).

CONCLUSION

It was noted that the training which was applied on the dummy by using visual aids about foreign body aspiration increased the knowledge level of the students. Based on this finding, it may be recommended that nurses should perform their counseling and educator roles more actively for the families and those who are responsible for the baby care about foreign body aspiration by playing a more active role in the health care team.

[Foreign body aspiration in Kigali University Teaching Hospital, Rwanda]

We present the case of a 12-year-old girl referred to Kigali University Teaching Hospital (KUTH) for persistent cough, fever and haemoptysis. Respiratory symptoms started acutely with a stridor at age 4. Thereafter she developed a chronic cough with intermittent fever. She was treated ambulatory in the health care centre with oral antibiotics and finally referred to the district hospital at age 7. The chest X-ray then suggested tuberculosis for which a 6 month treatment was given with no improvement. The cough persisted and haemoptysis appeared so the patient was referred to the reference hospital (KUTH). Chest X-ray showed diffuse lesions of the left lung with bronchiectasis. Bronchoscopy revealed the presence of a foreign body in the left intermediary bronchus and a piece of plastic was extracted. Symptoms rapidly disappeared with antibiotic treatment. This case illustrates how important it is to include foreign body inhalation in the differential diagnosis of respiratory disease in children. Bronchoscopy plays a key role in diagnosis and treatment. The authors point out the advantages of the joint efforts of the Belgian Development Aid Agency (BTC) and the Université libre de Bruxelles (ULB) in the development of this activity in the Rwandese context.

[Symptomless aspiration of a dental bur in the lower respiratory tract--a case report]

In this study, the authors review a case of a man who asymptomatically aspired a dental bur in the lower respiratory tract during dental treatment. Lack of any symptoms of foreign body aspiration erroneously suggested swallowing of the object and its passage to the stomach. This suggestion was not excluded by a control chest radiograph. Further specialist imaging examinations allowed for establishing the definite diagnosis and the patient underwent successful retrieval of the bur using left-sided thoracotomy.

The pulmonary tissue damage associated with the aspiration of gelatinizers in rats

Various gelatinizers, which facilitate oral ingestion, are employed in patients with dysphagia. The purpose of this study was to histologically clarify the influence of various gelatinizers on the lung, using rats. We administered 0.2 ml/kg of 0.1% xanthangam, a 0.25% commercially available xanthangam gelatinizer, 0.35% ι-carrageenan, 0.5% κ-carrageenan, 1% gelatin, 0.15% agar, physiological saline, tap water, and isopropanolpurified 0.1% xanthangam/0.35% ι-carrageenan into the trachea of 8- to 9-week-old male SD rats. The lungs were extirpated after 24 and 72 hours. Neutrophil infiltration in the alveolar space was expressed as the mean number of neutrophils in 30 randomly selected high-power fields. In the xanthangam (451.0 ± 204.0 cells) -, and the ι -carrageenan (424.4 ± 257.2) treated groups, the neutrophil counts after 24 hours was significantly greater than in the physiological saline (33.0 ± 22.6) - treated group (p < 0.05). In the available xanthangam gelatinizer (290.0 ± 86.8) -treated group was no significant difference in the physiological saline-treated group. In the isopropanol-purified xanthangam (90.2 ± 42.3)-treated group, the neutrophil counts after 24 hours were significantly smaller than in the nonpurified xanthangam -treated group.These results suggest that lung tissue inflammatory response-inducing features depend on the type of gelatinizer. On the other hand, purification reduces the lung-damaging features of xanthangam.

Neonatal aspiration: not just meconium

Aspiration of uncontaminated amniotic fluid as a cause of neonatal respiratory distress is scarcely documented. A term neonate who presented with early onset respiratory distress with a radiographic appearance of an aspiration syndrome is therefore reported. Differential diagnosis and implication of this diagnosis in the management of neonatal respiratory distress are discussed. This case highlights amniotic fluid aspiration as a possible cause of severe respiratory distress even in the absence of meconium stained fluid.

PCR improves diagnostic yield from lung aspiration in Malawian children with radiologically confirmed pneumonia

Background

Accurate data on childhood pneumonia aetiology are essential especially from regions where mortality is high, in order to inform case-management guidelines and the potential of prevention strategies such as bacterial conjugate vaccines. Yield from blood culture is low, but lung aspirate culture provides a higher diagnostic yield. We aimed to determine if diagnostic yield could be increased further by polymerase chain reaction (PCR) detection of bacteria (Streptococcus pneumoniae and Haemophilus influenzae b) and viruses in lung aspirate fluid.

Methods

A total of 95 children with radiological focal, lobar or segmental consolidation had lung aspirate performed and sent for bacterial culture and for PCR for detection of bacteria, viruses and Pneumocystis jirovecii. In children with a pneumococcal aetiology, pneumococcal bacterial loads were calculated in blood and lung aspirate fluid.

Results

Blood culture identified a bacterial pathogen in only 8 patients (8%). With the addition of PCR on lung aspirate samples, causative pathogens (bacterial, viral, pneumocystis) were identified singly or as co-infections in 59 children (62%). The commonest bacterial organism was S.pneumoniae (41%), followed by H. influenzae b (6%), and the commonest virus identified was adenovirus (16%), followed by human bocavirus (HBoV) (4%), either as single or co-infection.

Conclusions

In a select group of African children, lung aspirate PCR significantly improves diagnostic yield. Our study confirms a major role of S.pneumoniae and viruses in the aetiology of childhood pneumonia in Africa.

Relevance of GERD in lung transplant patients

Lung transplantation has become a valuable treatment for end-stage pulmonary disorders in an attempt to improve quality of life and extend survival. Development of chronic rejection, also known as bronchiolitis obliterans syndrome (BOS), is responsible for the vast majority of deaths after lung transplantation. Up to 50% of lung transplant patients develop BOS within the first 5 years after transplantation. A high prevalence of gastroesophageal reflux and aspiration of gastric components has been described after lung transplantation. Reflux and aspiration have been implicated in the development of BOS and antireflux surgery has been proposed; however, the causal relationship with BOS and the impact of reflux in lung transplantation survival needs to be further elucidated.

Emergency use of extracorporeal membrane oxygenation for a foreign body obstructing the airway

We report on the successful emergency use of extracorporeal membrane oxygenation to provide oxygenation and ventilation to a patient with lifethreatening airway obstruction, and then facilitating the removal of a tracheal food bolus by rigid bronchoscopy.

[An interesting journey of a grass inflorescence from broncho to dorsum: case report]

A 15-years-old male was presented with hyperemic and painful right flank mass. His medical history was consisted of a treatment for pneumonia and hemoptysis in the other hospital five months ago. Diagnostic X-rays was showed consolidation in the posterobasal segment of right pulmonary lobe and abscess in the paravertebral muscle extending from L4-5 level. The patient was discharged after antibiotic treatment. At the second hospitalization, a grass inflorescence was discharged from the fistula. When the patient was reevaluated his history was consisted of the aspiration of a grass inflorescence eight months ago. To our knowledge, this patient represents the first case of penetration by a grass inflorescence migrated out of the lumbar region.

A case of ciprofloxacin tablet aspiration

Foreign body aspirations occur among children more than adults and can cause life threatening complications. Acute respiratory failure due to foreign body aspiration in adults is a rare condition. We reported a 76-years-old woman who admitted to the emergency room with respiratory failure. The chest X-ray showed total collapse of the left lung. A ciprofloxacin tablet was observed and extracted during the bronchoscopy. To the best of our knowledge this is the first report of a ciprofloxacin tablet aspiration.

Vomitus as a cause of fatal diving accident of a commercial diver

The forensic expertise of the victim of fatal diving accident (commercial diver), who died in depth of 41 mts due of unknown reasons, had been realised by the authors. One of the authors of the paper was present on site of the diving accident as a diving medicine specialist. The autopsy revealed, that the cause of death of the diver was suffocation due to vomitus and massive aspiration of gastric content to the airways. The commercial diving technology (full-face diving mask with oro-nasal inner mask) was used. The authors point out some peculiarities in interpretation of such a fatal diving accident.

Surfactant therapy in acute respiratory distress syndrome due to hydrocarbon aspiration

Hydrocarbon aspiration causes acute lung injury, which may lead to acute respiratory distress syndrome. Surfactant has been shown to be beneficial in experimentally-induced hydrocarbon-associated acute respiratory distress syndrome. However, there has not been a clinical study evaluating the effect of surfactant application on hydrocarbon aspiration in humans. We report a 17-month-old boy with acute respiratory distress syndrome due to hydrocarbon aspiration and was successfully treated with surfactant application.

An association of gastroschisis and fatal respiratory distress: does prenatal bile aspiration cause early-onset respiratory failure in neonates?

We present a neonate with gastroschisis and evidence of bile aspiration in utero, who developed severe respiratory distress that did not respond to postnatal intensive respiratory care. Although rare, a newborn with gastroschisis may develop severe respiratory distress due to bile aspiration in utero. Given the poor outcome in this case, we suggest a possible role for prenatal diagnosis and therapy.

A case of accidental aspiration of a dental cutter into the bronchopulmonary tree: clinical implications and legal considerations

Though rare, aspiration of foreign bodies into the lower airway during dental procedures may have sequelae that endanger the patient's health. This article discusses the risks associated with routine dental procedures, patient safety precautions during endodontal therapy, and the medicolegal aspects of professional liability in dentistry. The case concerns a 31-year-old man who inhaled a dental cutter which impacted in the left posterior basal lobe. Bronchoscopy failed to retrieve the object; a magnetic resonance imaging study was performed and the object was removed by video-assisted thoracic surgery. Procedure-related criticalities, precautionary measures for patient safety, and medicolegal implications of professional negligence were identified from dentistry protocols and a review of the literature. Professional liability hinges on scrupulous exercise of care and adoption of safety precautions even in routine ''low risk'' dental procedures.

Pulmonary histopathology in an experimental model of chronic aspiration is independent of acidity

Gastroesophageal reflux has become a major health concern in industrialized countries, with drugs aimed at blocking acid production being more frequently prescribed than any other drug. Damage to lung tissue as a result of chronic aspiration of gastric fluid is a primary health risk associated with gastro-esophageal reflux, with such aspiration being suspected in the induction or exacerbation of asthma and other lung diseases. In this study, a rodent model of chronic aspiration was used to characterize the pulmonary histopathology produced by repetitive aspiration events and to investigate the pathologic roles of individual gastric fluid components such as acid and particulate food matter. Rats exposed to chronic aspiration of whole gastric fluid developed a pathology distinct from that of acute lung injury, characterized by granulomatous interstitial pneumonitis with prominent formation of multinucleated giant cells. This pattern of injury could be reproduced with chronic aspiration of particulate food matter and with chronic aspiration of pH-neutralized gastric fluid, but not with chronic aspiration of hydrochloric acid. Thus, since acid-neutralizing therapy is currently the mainstay of treatment for patients with reflux-associated respiratory symptoms, these results strongly suggest that alternative therapeutic approaches aimed at preventing chronic-aspiration induced lung injury may be warranted.

[Early fibrobronchoscopy and the microbial flora composition of bronchoalveolar lavage fluid in patients with concomitant injury during treatment in intensive care units]

Resuscitative bronchofibroscopy in victims with severe injury and aspiration has been shown to be both a method for diagnosing damages to the bronchus and lung and that for recovering airway patency in them. The most common involvement (47% of cases) in chest injury has been noted to be the lower lung with the development of pyoinflammatory processes caused by etiologically significant microorganisms, such as Staphylococcus aureus and types of Enterobacteriacea, in most cases (more than 50%).