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PubMed2006

Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects.

BACKGROUND: Women in normal labour may sometimes go on to have general anaesthesia if labour becomes abnormal, for example if a caesarean section is required. General anaesthesia carries a very small risk of regurgitation and inhalation of stomach contents into the lungs. This can cause inflammation, particularly if the fluid is acidic, and can lead to severe morbidity and very occasionally mortality. Labour hormones increase the risk of gastric aspiration or Mendelsohn's syndrome, though the exact incidence is unknown. The routine administration of acid prophylaxis drugs to all women in normal labour is commonly practiced worldwide, to reduce gastric aspiration by reducing the volume and acidity of stomach contents. OBJECTIVES: To assess the effectiveness of routine prophylaxis drugs for women in normal labour to reduce gastric aspiration and its effects. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2005), EMBASE (1974 to April 2005) and CINAHL (1982 to April 2005). SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of women in normal labour assessing the routine administration of drugs (antacids, H(2) receptor antagonists, dopamine antagonists and proton-pump inhibitors) compared with placebo/no treatment, and compared with other drugs for reducing gastric aspiration. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility, quality, extracted data and performed double-data entry. MAIN RESULTS: Three trials were included, involving 2465 women, assessing the effects of antacids, H(2) receptor antagonists and dopamine antagonists. There were no trials on proton-pump inhibitors. None of the trials were of good quality, and none assessed the incidence of gastric aspiration, Mendelsohn's syndrome or their consequences. All the studies assessed vomiting, and there was limited evidence that vomiting may be reduced by antacids (relative risk (RR) 0.46, 95% confidence interval (CI) 0.27 to 0.77, n = 578, one trial) or by dopamine antagonists given alongside pethidine (RR 0.40, 95% CI 0.23 to 0.68, n = 584, one trial). Comparisons between different drugs showed no significant differences, though the number of participants was small. There was no evidence that H(2) receptor antagonists improved outcomes compared with antacids, though only one trial addressed this issue. AUTHORS' CONCLUSIONS: There is no good evidence to support the routine administration of acid prophylaxis drugs in normal labour to prevent gastric aspiration and its consequences. Giving such drugs to women once a decision to give general anaesthesia is made, is assessed in another Cochrane review.

Antacids↗
PubMed2004

Predictive values for aspiration after endoscopic laser resections of malignant tumors of the hypopharynx and larynx.

BACKGROUND: CO2-laser surgery is a relatively new treatment for selected carcinomas of the upper aerodigestive tract. The purpose of our study was to evaluate prospectively the functional results for swallowing after CO2-laser resections. METHODS: The sample was composed of 210 consecutive patients with malignancies of the larynx and hypopharynx treated with CO2 laser between February 1998 and January 2002. Endoscopic resections included all T1 and T2 tumors and selected T3 and T4 tumors. T1 glottic tumors were not included in the analysis. We assessed the need for a feeding tube and the period the tube remained in place, aspiration pneumonia, tracheotomy secondary to aspiration, the need for a permanent or temporary gastrostomy, and total laryngectomy secondary to aspiration. RESULTS: The nasogastric feeding tube was used in 23.2% of small tumors (2.5 +/- 8.04 days) and in 63% of locally advanced tumors (13.95 +/- 22.55 days). Frequency and period of storage of the feeding tube were higher in locally advanced tumors (p=.0001). Twelve patients (5.7%) had postoperative pneumonia and 59 (28.1%) had temporary postoperative cough during oral intake. Aspiration symptoms correlated with location (p=.001) and locally advanced tumors (p=.016). Eight patients (3.8%) needed a postoperative tracheotomy for severe swallowing difficulties; six (2.9%) of them were definitive and two (0.95%) temporary. Thirteen gastrostomies (6.2%) were performed to avoid severe aspirations; five of them were definitive. The need for gastrostomy correlated significantly with location (p=.002), pT3 and pT4 tumors (p=.002), age (p=.02), and postoperative radiotherapy (p=.04). No correlation was found with the period of feeding tube (p=.38), or aspiration pneumonia (p=.24). CONCLUSIONS: Endoscopic resection of laryngeal and hypopharyngeal tumors is associated with good recovery of deglutition. Many tracheotomies are avoided, the need for a feeding tube is usually reduced, and organ preservation is often feasible even in locally advanced tumors.

Adult↗
PubMed1996

Hypertonic saline treatment of acid aspiration-induced lung injury.

Airway acid aspiration leads to severe microvascular lung injury and pulmonary edema. Recent studies have demonstrated that other conditions associated with microvascular injury such as sepsis and burns can be effectively treated with low-volume hypertonic saline (HTS). Thus, the present study aimed to test whether HTS attenuates aspiration-induced lung injury in the rat. Intratracheal administration of 0.2 ml of 0.1 N HCl (n = 7) induced pulmonary leukosequestration [myeloperoxidase (MPO) activity +446 +/- 34%, P < 0.05; bronchoalveolar lavage (BAL) fluid neutrophil count + 178 +/- 23%, P < 0.05], edema (division 43 +/- 6%, P < 0.01), and microvascular permeability defect (BAL protein concentration +675 +/- 34%, P < 0.01). These changes were associated with tissue hypoxia (skeletal muscle PO2, 49 +/- 8 mm Hg, P < 0.05) and elevated serum TNF alpha (750 +/- 38 pg/ml, P < 0.01). HTS (2400 mosmole/liter) at 5 ml/kg, administered 20 min after aspiration (n = 7), reduced lung pulmonary edema by 58 +/- 7% (P < 0.05) and improved tissue oxygen tension (PO2, 85 +/- 7 mm Hg, P < 0.05) but failed to alter lung MPO and BAL fluid protein and leukocyte count response. Also, HTS did not reduce TNF alpha response to aspiration. These data point to a potential therapeutic role for low-volume HTS in treating aspiration-induced lung injury. In addition, our data suggest that HTS is acting by rapidly shifting fluid from the pulmonary interstitium to the intravascular compartment because it did not inhibit the inflammatory response to aspiration.

Animals↗
PubMed1996

Prandial aspiration and pneumonia in an elderly population followed over 3 years.

The purpose of our study was to prospectively determine pneumonia frequency and correlate it with prandial liquid aspiration and feeding status in frail elderly nursing home residents. Initially, 152 patients had video swallowing examinations (81 oropharyngeal dysphagia, 19 thoracic dysphagia, 52 without dysphagia). Those diagnosed with oropharyngeal impairment were subsequently managed with swallowing therapy or artificial feeding modalities. Patients were followed for 3 years (unless they expired earlier) and clinical courses were categorized according to the degree of prandial aspiration and feeding (PAF) status. Subjects with new lung infiltrates persisting for at least 5 days with appropriate clinical findings were diagnosed as having pneumonia and were classified according to the PAF status months in which these findings occurred. Fifty-six pneumonias were diagnosed during 4,280 months with the following frequencies: no aspiration months 0.6%; minor aspiration months 0.9%; major aspiration/oral feeding months 1.3%; major aspiration/artificial feeding months 4.4%, p < 0.001. Our results indicate that there is not a simple and obvious relation between prandial liquid aspiration and pneumonia. Artificial feeding does not seem to be a satisfactory solution for preventing pneumonia in elderly prandial aspirators.

Aged↗
PubMed1990

Approaches to the patient with aspiration and swallowing disabilities.

Aspiration, or soiling of the tracheobronchial tree, can produce life-threatening pulmonary disease. Intermittent or persistent aspiration may cause symptoms including cough, intermittent fever, recurrent tracheobronchitis, atelectasis, pneumonia, and/or empyema. The pulmonary disease may be associated with weight loss, cachexia, and dehydration. In many cases the aspiration is caused by laryngeal dysfunction, allowing pulmonary contamination by swallowed material. In other cases the aspiration is caused by a dysfunction of the oral, pharyngeal, or esophageal phases of swallowing. In some cases the aspiration is caused by a combination of laryngeal and swallowing dysfunction. Geriatric patients are more likely to experience aspiration, since muscle weakness causing mechanical disability and neurologic impairment are more common in this age group. Therefore, with the ever-increasing aging of our population, these disabilities will be on the rise, with an associated increase in pulmonary disease and death. The approach to evaluation and management of these disorders must be based on an understanding of the underlying functional impairment.

Deglutition Disorders↗
PubMed2003

Prone ventilation following witnessed pulmonary aspiration: the effect on oxygenation.

OBJECTIVE: Pulmonary aspiration is a significant cause of admission to the ITU and is associated with significant morbidity and mortality. Aspiration in the supine position produces posterior collapse/consolidation, similar to that seen in ALI/ARDS patients. Prone positioning has been shown to improve oxygenation in ALI/ARDS, but no studies have been performed on pulmonary aspiration. DESIGN: A prospective crossover study. SETTING: Twelve-bed ITU. PATIENTS AND PARTICIPANTS: Eleven patients admitted to ITU with respiratory failure secondary to witnessed pulmonary aspiration requiring ventilation and an FIO(2) >0.50 after 12 h. INTERVENTIONS: Patients were placed in a prone position for 8 h and then turned supine for 8 h. Prone positioning was repeated if the FIO(2) remained >0.50. Ventilator settings were not altered in the study period. MEASUREMENTS AND RESULTS: Arterial blood gas analysis was performed every 2 h. The PaO(2)/FIO(2) gradient was calculated. Oxygenation improved on turning prone, with a significant increase in the PaO(2)/FIO(2) ratio ( P<0.01). There was a fall in this gradient on return to the supine position. There was a significant improvement in oxygenation on turning prone for the second period ( P<0.01). Overall, there was a significant improvement in the PaO(2)/FIO(2) ratio in the final supine position when compared to the first ( P<0.05). CONCLUSION: This study demonstrates a significant improvement in oxygenation in the prone position in pulmonary aspiration. Early prone positioning in patients with pulmonary aspiration requiring ventilation may improve oxygenation by altering V/Q relationships similarly to ARDS, but also may aid drainage of secretions, opening up alveoli and preventing progression to established pneumonitis.

Adult↗
PubMed2006

Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients.

OBJECTIVE: To assess the incidence and outcome of clinically significant aspiration pneumonitis in intensive care unit (ICU) overdose patients and to identify its predisposing factors. DESIGN: Retrospective cohort study. SETTING: Medical ICU of an academic tertiary care hospital. PATIENTS: A total of 273 consecutive overdose admissions. MEASUREMENTS AND RESULTS: Clinically significant aspiration pneumonitis was defined as the occurrence of respiratory dysfunction in a patient with a localised infiltrate on chest X-ray within 72 h of admission. In our cohort we identified 47 patients (17%) with aspiration pneumonitis. Importantly, aspiration pneumonitis was associated with a higher incidence of cardiac arrest (6.4 vs 0.9%; p = 0.037) and an increased duration of both ICU stay and overall hospital stay [respectively: median 1 (interquartile range 1-3) vs 1 (1-2), p = 0.025; and median 2 (1-7) vs 1 (1-3), p < 0.001]. In multivariate logistic regression analysis, Glasgow Coma Scale (GCS) score [odds ratio (OR) for each point of GCS 0.8; 95% confidence interval (CI) 0.7-0.9; p = 0.001], ingestion of opiates (OR 4.5; 95% CI 1.7-11.6; p = 0.002), and white blood cell count (WBC) (OR for each increase in WBC of 10(9)/l 1.05; 95% CI 1.0-1.19; p = 0.049) were identified as independent risk factors. CONCLUSIONS: Clinically relevant aspiration pneumonitis is a frequent complication in overdose patients admitted to the ICU. Moreover, aspiration pneumonitis is associated with a higher incidence of cardiac arrest and increased ICU and total in-hospital stay.

Adult↗
PubMed2006

Modified endoscopic swallowing test for improved diagnosis and prevention of aspiration.

Laryngopharyngeal sensation is important in the normal process of swallowing, it is often impaired after neurological events and it has been common practice in such an occurrence to order non-oral tube feeding to prevent aspiration. This study assesses a novel approach to the evaluation of the laryngopharyngeal sensation that allows for improved triage of aspiration risk and more lenience towards oral feeding. This is a case series with follow-up period ranging from 6 to 24 months. Forty patients with neurological deficiencies were tested by a modified laryngopharyngeal sensation study that included evaluation of both supra and infra-glottis. All patients had impaired supra glottic sensation but had good infra glottic sensation that enabled cough protection. All had received oral feeding. Main outcome measure is incident aspiration pneumonia. Twenty-two patients maintained oral feeding without any evidence of aspiration. Eighteen patients had some aspirations associated with cough, and were maintained on modified oral feeding. Out of these 18 patients, four patients (10% of the entire group) developed aspiration pneumonia. The presented procedure identified patients with impaired supraglottic sensation but preserved good infra glottic sensation. This observation enables safe oral feeding in most patients and therefore offers a better quality of life for these individuals.

Adult↗
PubMed1985

Fatal meconium aspiration syndrome occurring despite airway management considered appropriate.

A combined obstetric-pediatric approach to tracheal toilet is said to prevent serious cases of the potentially fatal meconium aspiration syndrome. After delivery of the head a DeLee trap is used to suction the oropharynx and nasopharynx. Immediately following delivery, endotracheal suction is performed in an effort to remove any remaining meconium-stained amniotic fluid. Although routinely using this approach, we continue to have occasional cases of fatal meconium aspiration syndrome. Therefore, we reviewed the outcome of infants born through meconium-stained fluid. During a 5-year period, 1420 (15%) of 9299 live-born infants had meconium-stained fluid. Thirty (2.1%) of these 1420 developed meconium aspiration syndrome and 12 (40%) died; eight received a postmortem examination. Four had unequivocal evidence of meconium aspiration, two had large numbers of intra-alveolar squamous cells, and two had no evidence of aspiration. We conclude that aggressive airway management during and immediately after delivery does not always prevent fatal meconium aspiration syndrome.

Amniotic Fluid↗
PubMed1989

Meconium aspiration syndrome: intrapartum and neonatal attributes.

To identify the fetus and newborn at risk for meconium aspiration syndrome the perinatal characteristics of 238 infants delivered through meconium-stained amniotic fluid were prospectively examined. All infants with meconium-stained amniotic fluid were routinely suctioned with a DeLee apparatus before tracheal intubation and suctioning. The type and presence of meconium in the trachea, neonatal breathing before intubation, and Apgar scores were recorded in the delivery room. Intrapartum fetal monitoring data were collected for 80% (190/238) of the mothers and umbilical artery pH for 74% (177/238) of the newborns. Despite suctioning with a DeLee apparatus and endotracheal suctioning, meconium was present in the trachea in 87/238 (37%) and meconium aspiration syndrome developed in 22 (9.2%). A total of 73% of newborns who had meconium aspiration syndrome were delivered through thick meconium. Thick meconium, the presence of fetal tachycardia, and absence of intrapartum fetal cardiac accelerations identified the fetus at high risk for meconium aspiration syndrome. The presence of these monitoring findings and thick meconium should alert obstetricians to the possibility of a fetus that requires intervention. Low umbilical artery pH, Apgar scores less than 5, and meconium in the trachea further characterized the newborn at high risk for meconium aspiration syndrome. The combination of these findings may best identify the infant delivered through meconium-stained amniotic fluid who requires close observation for meconium aspiration syndrome.

Amniotic Fluid↗
PubMed1992

Esophageal manometry and 24-hour pH monitoring in the diagnosis of pulmonary aspiration secondary to gastroesophageal reflux.

Twenty-three consecutive patients who had persistent respiratory symptoms of unexplained etiology were evaluated to determine the presence of gastroesophageal reflux (GER) and its relationship to their respiratory complaints. Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) pressures and the characteristics of the peristaltic waves in the proximal and distal esophagus were determined. Esophageal acid exposure 5 cm and 20 cm above the LES was measured using a pH probe with two antimony sensors. Aspiration was diagnosed when respiratory symptoms occurred during or within 3 minutes after a reflux episode, recorded at both levels of the esophagus. Based on these criteria, 12 patients were considered nonaspirators (group A), and 11 were categorized as aspirators (group B). Aspirators had: (1) lower LES pressure (6.1 +/- 3.1 versus 12 +/- 4.8 mm Hg, p less than 0.01); (2) decreased amplitude of peristalsis in the proximal esophagus (34 +/- 16 versus 59 +/- 21 mm Hg, p less than 0.01) and distal esophagus (46 +/- 25 versus 91 +/- 28 mm Hg, p less than 0.01), and higher incidence of simultaneous, nonperistaltic waves (30% versus 4%); and (3) lower UES pressure (44 +/- 23 versus 74 +/- 38 mm Hg). Impaired peristalsis in aspirators caused a higher acid exposure (11.4% +/- 8.0% versus 1.0% +/- 0.7% of time pH less than 4, p less than 0.01) and delayed clearance (5.5 +/- 6.5 versus 0.7 +/- 0.4 min) in the proximal esophagus. Our study shows that, in patients with respiratory symptoms of unexplained etiology, esophageal manometry and 24-hour pH monitoring will identify a subgroup of true aspirators. These patients suffer from a panesophageal motor dysfunction that affects all three barriers to aspiration: the LES, the esophageal "pump mechanism," and the UES.

Adult↗
PubMed1993

Chin-down posture effect on aspiration in dysphagic patients.

Use of the chin-down posture during swallowing has been reported to reduce the occurrence of aspiration in some dysphagic patients. This study measured four pharyngeal dimensions in 30 neurologically impaired patients who aspirated before the swallow because of a delay in triggering the pharyngeal swallow, 15 for whom the posture eliminated aspiration and 15 who aspirated despite the chin-down position. Patients who did not benefit from the posture were significantly younger and aspirated material from the pyriform sinus rather than the valleculae when the pharyngeal swallow was triggered. Changes in pharyngeal dimensions with the chin down were not significantly different for both patient groups, except for epiglottic angle, which increased significantly more in the group who continued to aspirate. Changes in pharyngeal dimensions with chin-neutral versus chin-down differed somewhat from those reported in a previous publication. Possible reasons for these differences are discussed.

Adult↗
PubMed1989

Laryngeal diversion in the treatment of chronic aspiration in children.

Chronic aspiration in children can be life-threatening, especially in patients with underlying pulmonary disorders. Numerous surgical procedures have been described to treat chronic aspiration. In patients with severe chronic aspiration, laryngeal diversion is the most effective procedure for reducing soilage of the pulmonary tract. Over a 10-year period at the Children's Hospital of Philadelphia, 14 patients with life-threatening aspiration were managed with a laryngeal diversion. Surgical correction of aspiration resulted in stabilization or improvement of pulmonary function in these patients. The surgical management of chronic aspiration in the pediatric patient is discussed.

Adolescent↗
PubMed2004

A new pepsin assay to detect pulmonary aspiration of gastric contents among newly intubated patients.

Aspiration of gastric contents by endotracheally intubated patients is associated with significant morbidity and mortality. Previous studies suggest that pepsin in tracheal aspirates may be a valuable marker of occult aspiration. We sought to show the sensitivity and specificity of a new, pepsin-specific assay in humans. A prospective, case-controlled study was conducted with subjects serving as their own controls. After planned endotracheal and nasogastric intubation for elective surgery, 20 participants had tracheal and gastric aspirates withdrawn. A blinded investigator tested samples for the presence of pepsin using the assay. Positive samples were then tested with pepstatin, a specific pepsin inhibitor, to ensure that positive results were due to pepsin. All tracheal aspirates tested negative and all gastric aspirates tested positive for pepsin. Pepstatin halted pepsin activity in all positive samples, ensuring that positive results were due to pepsin. A pepsin-specific assay is extremely reliable for detecting gastric contents in humans.

Adult↗
PubMed2004

Strategies for prophylaxis and treatment for aspiration.

The absolute incidence of aspiration is difficult to define because of its relatively low occurrence and difficulty in diagnosis. The gastric volume predisposing to aspiration is larger than 30 ml. Fasting times for fluids have reduced; however, a large meal may require 9 hours of preoperative fasting. Preoperative carbohydrate-enriched beverages may attenuate postoperative catabolism. Aspiration occurs most frequently during induction and laryngoscopy. Awake fibre-optic intubation may be a suitable alternative in high-risk cases for aspiration. The role of cricoid pressure in anaesthesia needs re-evaluation as radiological and clinical evidence suggest that it may be ineffective and may impede intubation and ventilation. Chemoprophylaxis does not reduce the severity of aspiration pneumonitis as gastric bile is unaffected by these agents and induces a worse pneumonitis than gastric acid. Patients may be discharged home 2 hours after aspirating provided they are clinically unaffected and have postoperative surveillance.

Adult↗
PubMed2005

Aspiration in children with CHARGE syndrome.

UNLABELLED: Patients with Coloboma, Heart defect, choanal Atresia, Retarded development, Genitorenal and Ear abnormalities (CHARGE) syndrome have been reported to be at high risk for aspiration and swallowing difficulties. Aspiration has been implicated as the most common cause of mortality in these patients. To date, however, aspiration and swallowing disorders in CHARGE patients have not been independently studied. OBJECTIVE: To determine the prevalence of aspiration and swallowing dysfunction in children with CHARGE syndrome. METHODS: A retrospective chart review of 30 children with CHARGE syndrome was performed. RESULTS: Eighteen (60%) children had aspiration observed on video swallow study (VSS), flexible endoscopic evaluation of swallowing (FEES), and/or had otherwise unexplained bronchiectasis noted on CT scan of the chest. Twenty-four children (80%) had evidence of abnormal swallowing such as laryngeal penetration, dyscoordination, poor bolus mobility, or pooling of secretions. CONCLUSION: Aspiration and swallowing dysfunction are common in children with CHARGE syndrome. Formal evaluation of swallowing function should be part of the standard otolaryngologic examination for these patients.

Abnormalities, Multiple↗
PubMed2005

Intractable pulmonary aspiration in children: which operation?

Intractable aspiration is a life-threatening medical problem. There are many surgical procedures for the treatment of intractable aspiration. Our experience with three children was reported here. After failing initial conservative measures, the first two patients had supraglottic laryngeal closure performed through an endoscopic approach with a small hole left superiorly for phonation. However, both of them developed dehiscence of the closure postoperatively, necessitating a more definitive procedure to stop the aspiration. Their symptoms of aspiration were only relieved after they underwent laryngotracheal separation. In the third child, laryngotracheal separation was performed as the initial procedure and the symptoms of recurrent aspiration were relieved. In conclusion, the treatment of intractable aspiration requires a definitive procedure from the outset and we would suggest, based on literature review and on our experience, that laryngotracheal separation is the most effective and reliable option, albeit lack of phonation is inevitable. A comprehensive review of all procedures used for treatment of this condition was also undertaken.

Adolescent↗
PubMed2005

Pediatric coin ingestion and aspiration.

OBJECTIVE: To determine the relationship between physical characteristics of the coin (size), age of the victim, the amount of coins in circulation, and the frequency and outcome of pediatric coin ingestion and aspiration injuries. METHODS: Records of coin related ingestion and aspiration injuries occurring to children 14 years of age or younger were acquired from the US Consumer Product Safety Commission (CPSC). Logistic regression was conducted to control for mutual confounding among variables. RESULTS: From 1994 to 2003, an estimated 252,338 children were treated in hospital emergency departments for non-fatal coin-related ingestion or aspiration, and additional 20 fatalities were reported during the same time span. Children 4 years of age or younger were at the highest risk. It is also observed that younger children are the most vulnerable victims of ingestion and/or aspiration of small coins (e.g., pennies), while older children are more likely to be treated due to ingestion and/or aspiration of larger coins (e.g., quarters). Pennies were involved in more incidents than all other coins combined. The hospitalization rate exhibited a negative correlation with the measure of the diameter and the weight of the coins. The overwhelming majority (94%) of the incidents were ingestion, whereas aspiration victims were more likely to encounter hospitalization. CONCLUSIONS: We hope that this study will raise public and health practitioners' awareness of the risk, and increase supervision, particular of the most vulnerable young children.

Adolescent↗