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Impact of swallowing therapy on aspiration rate following treatment for locally advanced head and neck cancer.

This study examines the efficacy of swallowing therapy in cancer-free patients who developed aspiration following treatment for locally advanced head and neck cancer. The records of 41 patients who underwent swallowing therapy for aspiration were reviewed. All patients were cancer free at a median follow-up of 25 months (6-150 months). Their treatment were respectively chemoradiation (24), and postoperative radiation (17). All patients had two or more modified barium swallow (MBS). Dysphagia severity was graded from 1 to 7. Dysphagia grade was compared before and following swallowing therapy. Before swallowing therapy, there were 16 grade 5 (trace aspiration), and 25 grade 6-7 (severe aspiration). In the chemoradiation group, there were nine grade 5, five grade 6, and 10 grade 7. Corresponding numbers for the postoperative group were: seven grade 5, seven grade 6, and three grade 7. Following swallowing therapy, there were six grade 3, seven grade 4, 10 grade 5, six grade 6, and 12 grade 7. In the chemoradiation group, there were four grade 3, three grade 4, four grade 5, five grade 6, and eight grade 7. In the postoperative group, there were two grade 3, four grade 4, six grade 5, one grade 6, and four grade 7. Overall, 13 patients (32%) had improvement of their dysphagia severity. Seven of them were in the chemoradiation group (29%), and six (35%) were in the postoperative group. Among 25 patients who presented with grade 6-7 aspiration, only nine (36%) improved to grade 5 or less. Four of them (27%) were in the chemoradiation group, and five (29%) were in the postoperative group. Swallowing therapy is effective to improve dysphagia severity and reduce the need for tube feedings. However, a significant number of patients still suffered from chronic severe aspiration. New strategies must be devised to improve their outcome.

Adult↗

Using a monitored test to assess risk of aspiration in postoperative patients.

Pulmonary aspiration is associated with high morbidity and mortality rates. Older adult patients have been shown to be particularly at risk for aspiration. A randomized controlled trial was conducted to investigate the efficacy of a simple, noninvasive screening test-the monitored sip test-in identifying patients at risk for aspiration, including "silent aspirators." Based on clinical judgment using the study's outcome measures, incidence of aspiration-related lung injury was high (ie, 37.5%); however, no identification of patients at risk for aspiration occurred after either the use of the monitored sip test or routine cautious introduction of fluids during the data collection phase of the study.

Aged↗

Failure of acute perinatal asphyxia or meconium aspiration to produce persistent pulmonary hypertension in a neonatal baboon model.

OBJECTIVE: Our purpose was to determine whether perinatal asphyxia or meconium aspiration, or both, can produce the physiologic and histologic pulmonary vascular changes associated with the meconium aspiration syndrome. STUDY DESIGN: Twenty neonatal baboons were studied in four groups: 1, control; 2, meconium aspiration; 3, asphyxia (intermittent cord compression); and 4, asphyxia with meconium aspiration. Animals were ventilated for 24 hours under ketamine, diazepam, and pancuronium. Data were analyzed by means of mixed model analysis of measures. RESULTS: Meconium significantly impaired oxygenation (p < 0.001), whereas concurrent asphyxia moderated this effect (p < 0.034). Meconium also increased the need for ventilatory support (p < 0.002). No animal had persistent pulmonary hypertension; neither systemic nor pulmonary systolic pressures differed statistically between the groups. No animal showed evidence of abnormal pulmonary arteriolar muscularization. CONCLUSION: Sublethal perinatal asphyxia or meconium aspiration were insufficient to produce either the physiologic or histologic changes of severe meconium aspiration syndrome. It is unlikely that intrapartum fetal distress alone can produce this syndrome in human neonates.

Acute Disease↗

Silent aspiration after coronary artery bypass grafting.

BACKGROUND: "Silent" aspiration was recognized to be a more frequent complication at this hospital in patients who have had coronary artery bypass grafting than in the general surgical population. METHODS: A case-control retrospective study covering a 4.5-year period was conducted to determine risk factors for pharyngeal dysfunction resulting in silent aspiration. RESULTS: Significant predictors of silent aspiration were age, history of cerebral vascular disease, insulin-dependent diabetes mellitus, myocardial infarction, and chronic obstructive pulmonary disease. Intraaortic balloon pump and number of units of fresh-frozen plasma were the only independent intraoperative factors associated with silent aspiration in a model using continuous variables directly. Cold fibrillation was used in 7 of 53 study cases but no control patients, so it could not be modeled. Postoperative complications occurring with greater frequency included neurologic complications, adverse pulmonary outcomes, repeat surgical interventions, infection, and death. Using an Aspiration Risk Profile developed from the retrospective study, in a detailed prospective study of 10 patients, 3 of 4 patients with postoperative dysphagia had objective evidence of stroke. CONCLUSIONS: These findings suggest that postoperative coronary artery bypass graft dysphagia may be the result of intraoperative cerebral injury, and that careful postoperative clinical evaluation of coronary artery bypass graft patients with risk factors may result in early diagnosis of pharyngeal dysfunction with the goals of preventing silent aspiration and reducing morbidity, mortality, and hospital cost.

Age Factors↗

Pneumonia associated with aspiration following stroke.

OBJECTIVE: To determine the association between demonstrated aspiration and pneumonia in stroke patients. METHODS: Chart review of 441 consecutive stroke patients admitted to a stroke rehabilitation unit within 4 months of their stroke over an 8-year period. Videofluoroscopic modified barium swallow (VMBS) was performed on all patients suspected of aspirating. In all patients, the presence or absence of pneumonia was noted. RESULTS: Eighty-four of the 441 (19.0%) stroke patients transferred for rehabilitation demonstrated aspiration of thin liquids on VMBS. Twelve of the 441 (2.7%) developed pneumonia while in hospital, either in the acute or rehabilitation phases. The incidence of pneumonia among proven aspirators on VMBS was 10 of 84 (11.9%) patients. Two of the 357 (0.6%) patients who were presumed nonaspirators developed pneumonia. Brain stem and right hemispheric stroke patients had a higher incidence of pneumonia. CONCLUSIONS: Pneumonia is an uncommon complication of stroke. However, approximately 12% of stroke rehabilitation patients diagnosed as aspirators on VMBS developed pneumonia, a 20-fold increase over presumed nonaspirators. VMBS is a potentially valuable tool in determining those patients at risk of aspiration pneumonia.

Acute Disease↗

Aspiration in unilateral recurrent laryngeal nerve paralysis after surgery.

PURPOSE: Dysphonia with hoarseness and breathiness are the key symptoms of unilateral recurrent laryngeal nerve (RLN) paralysis, whereas aspiration is not usually described. The aim of this prospective study was to assess the incidence of aspiration in patients with unilateral recurrent laryngeal nerve paralysis after head and neck or thoracic surgery. PATIENTS AND METHODS: Five patients were included and evaluated within the first week and again 2 months postoperatively. Position, tone, and tension of the true vocal cord as well as assessment of the glottic axis, arytenoid position, laryngeal sensation, status of the pyriform sinus, and salivary stasis were studied. Swallowing evaluation was performed using flexible fiberoptic laryngoscopy during dry swallowing, thick cream, methylene blue liquid as well as with swallowing videofluoroscopy. RESULTS: Three patients had no aspiration, one patient had silent aspiration, and one had symptomatic aspiration. CONCLUSION: We conclude that aspiration may occur in unilateral recurrent laryngeal nerve paralysis and have to be systematically evaluated after pneumonectomy.

Adult↗

Histopathologic effects of lipid content of enteral solutions after pulmonary aspiration in rats.

OBJECTIVE: We compared the pulmonary histopathologic effects of different enteral formulas with various lipid contents during the subacute period of aspiration in rats. METHODS: Fifty Wistar albino rats, weighing 180 to 300 g, were randomly assigned to one of five groups (n = 10). Anesthesia was induced with an intraperitoneal injection of 100 mg/kg of ketamine hydrochloride, rats were intubated endotracheally with a 16-gauge angiocatheter, and 0.9% saline (group 1, control), Impact (group 2), Jevity (group 3), Biosorb Energy Plus (group 4), or Pulmocare (group 5) with a lipid content of 0, 28, 39.3, 58, or 93.3 g/L, respectively, was injected into the lungs in a volume of 3 mL/kg. Seven days later, rats were killed, and lungs with trachea were removed en bloc for histopathologic examination. For histopathologic assessment, slides were examined for the presence of peribronchial inflammatory cell infiltration, alveolar septal infiltration, alveolar edema, alveolar exudate, alveolar histiocytes, interstitial fibrosis, granuloma, and necrosis formation. The degree of severity was assessed by using a 4-point scale. One-way analysis of variance and Student-Newman-Keuls test were used for statistical analysis. RESULTS: Peribronchial inflammatory cell infiltration was present in all groups but was significantly more severe in group 2 than in groups 1, 4, and 5 (P < 0.05). Alveolar edema was statistically higher in group 2 than in group 1 (P < 0.05). Alveolar septal infiltration was statistically higher in group 4 than in group 1. Alveolar histiocytes were statistically higher in groups 2 and 3 (P < 0.01) and groups 4 and 5 (P < 0.05) than in group 1. Alveolar exudate, interstitial fibrosis, granuloma, and necrosis formation were absent in all groups. CONCLUSION: The pulmonary histopathologic effects of aspiration of Impact were severe peribronchial inflammatory cell infiltration (greater than aspiration of Biosorb and Pulmocare), abundant alveolar histiocytes, and alveolar edema in comparison with aspiration of saline, even though Impact had the lowest lipid content of all studied formulas. We concluded that the tissue damage occurring after pulmonary aspiration of Impact is more severe than after aspiration of Pulmocare.

Animals↗

A guided approach to surgery for aspiration: two case reports.

Aspiration frequently occurs in patients with a competent glottis. Analysis using a modified barium swallow (MBS) can reveal an extraglottic mechanism of aspiration in these patients. The MBS examination guided the design of two surgical procedures in patients with severe aspiration. The surgery corrected the underlying extraglottic cause of aspiration while preserving glottic function. In one case the epiglottoplasty controlled aspiration due to spillage over the epiglottis into the airway. In the other case translaryngeal resection of the cricoid lamina combined with cricopharyngeal myotomy controlled aspiration of residue in the hypopharynx. After surgery, both patients had their gastrostomy and cuffed tracheostomy tubes removed and were discharged home on a normal oral diet. Detailed analysis of deglutition by a modified barium swallow can provide a scientific basis to guide the surgical management of patients with severe dysphagia.

Aged↗

Risk perception and acceptance--one process or two? The impact of aspirations on perceived risk and preferences.

The experiments discussed here are aimed at determining whether risk perception and risk acceptance are two distinct psychological processes. This study is motivated by the idea of a double-criterion model of choice. In particular, in line with risk-value (R-V) models, in which risk is treated as a primitive, it is tested whether risk is independent of aspirations and whether preferences depend on aspirations. In two experiments, 305 university students were presented with pairs of risky projects and were asked to compare their riskiness and select one. The aspiration level, defined as the target return on the project, was set through an explicit instruction. In Experiment 1, a within-subject designwas applied, and thus aspirations were set at two different levels. In Experiment 2, with a between-subject design, two different aspiration levels were set for each group. The results indicate that risk ordering is insensitive to changes in aspirations, but preferences are sensitive to those changes. This supports distinctness of risk perception and risk acceptance. The findings are discussed in terms of the CPT and SP/A models and the R-V approach. It appears that double-criterion models provide better and psychologically sounder predictions of subjects' preferences.

Aspirations, Psychological↗

Aspiration and regurgitation prophylaxis in paediatric anaesthesia.

BACKGROUND: Surveys of aspiration prophylaxis in paediatric anaesthesia do not exist. METHODS: A postal survey was sent out to all UK members of the Association of Paediatric Anaesthetists (APA) to assess current practice. We asked about minimum fasting times for liquids and solids/milk, their routine acid aspiration prophylaxis and perceived risk factors for emergency and elective surgery in children those less than 1 year old and those aged 1-14 years. We also asked if the APA member had more than 10 years experience in paediatric anaesthesia. RESULTS: One hundred and two (55.1%) APA members replied out of a total of 185 questionnaires sent. Eighty-eight (88/102) were considered valid. Fasting in emergencies is approximately 4 h for solids/milk and 2 h for clear liquids. Fasting for elective surgery is between 5 and 6 h for solids/milk and 2 h for clear liquids. Pharmacological methods to reduce the risk of aspiration are not used. Mechanical methods vary from 40-50% for cricoid pressure and 20-30% for nasogastric aspiration if a tube is present. The presence of a hiatus hernia is perceived by over 80% as a risk factor, previous aspiration by over 60%, difficult intubation, cerebral palsy and sepsis by 20-30%. CONCLUSION: Perceived risk factors vary with "experience": hiatus hernia, difficult intubation and cerebral palsy are less important whereas previous aspiration and renal failure appear to be more important for paediatric anaesthetists with less than 10 years in paediatric anaesthetic practice.

Adolescent↗

Turban pin aspiration: non-asphyxiating tracheobronchial foreign body in young islamic women.

BACKGROUND: Foreign body aspiration is rare in adults. However, in recent years, the aspiration of pins which are used for securing turbans (headscarves) is seen frequently in young women. The aim of this article was to review 105 patients who were admitted to our hospital for turban pin aspiration. METHODS: Chest X-rays were used for diagnosis. Various methods of treatment were performed: laryngoscopy in 6 patients, flexible fiberoptic bronchoscopy in 16, rigid bronchoscopy in 93, and thoracotomy in one patient, while in the other patient the turban pin was spontaneously expectorated. RESULTS: Localization of the pin in the right bronchial system was common (52%). In 6 patients, turban pins located in the larynx were extracted successfully by direct laryngoscopy. Turban pins were successfully removed with a flexible fiberoptic bronchoscope in 4 patients of the 16 (25%) and by rigid bronchoscope in 93 patients of 94 (99%). The average time until discharge was 18 hours and there was no mortality. CONCLUSIONS: Turban pin aspiration is common in Islamic populations and treatment usually requires bronchoscopic procedures. In order to minimize turban pin aspiration frequency, we recommend that turbans should be secured by traditional fastening methods or with an apparatus which cannot be aspirated.

Adolescent↗

Meconium aspiration syndrome in term neonates with normal acid-base status at delivery: is it different?

OBJECTIVE: Our aim was to compare the clinical characteristics of meconium aspiration syndrome in cases with pH > or =7.20 and in those with pH <7.20. STUDY DESIGN: Medical records of diagnostic codes from the International Classification of Diseases, Ninth Revision, were used to identify neonates with severe meconium aspiration syndrome who had been delivered at our institution from 1994 through 1998. Severe meconium aspiration syndrome was defined as a mechanical ventilator requirement of >48 hours. Clinical data including neonatal outcomes of cases of meconium aspiration syndrome associated with umbilical pH > or =7.20 at delivery were compared with data on outcomes of cases with pH <7.20. RESULTS: During this 4-year study period, 4985 singleton term neonates were delivered through meconium-stained amniotic fluid. Forty-eight cases met all study criteria, and pH values at delivery were as follows: pH > or =7.20, n = 29, and pH <7.20, n = 19. There were no differences between groups in the incidence of clinical chorioamnionitis, in the presence of meconium below the vocal cords, or in birth weight. Neonates with meconium aspiration syndrome and umbilical pH > or =7.20 at delivery developed seizures as often as those with pH <7.20 (20.1% vs 21.1%; P = 1.0). CONCLUSION: Normal acid-base status at delivery is present in many cases of severe meconium aspiration syndrome, which suggests that either a preexisting injury or a nonhypoxic mechanism is often involved.

Acid-Base Equilibrium↗

Can bedside assessment reliably exclude aspiration following acute stroke?

OBJECTIVE: To investigate the ability of a bedside swallowing assessment to reliably exclude aspiration following acute stroke. SUBJECTS: Consecutive patients admitted within 24 h of stroke onset to two hospitals. METHODS: A prospective study. Where possible, all patients had their ability to swallow assessed on the day of admission by both a doctor and a speech and language therapist using a standardized proforma. A videofluoroscopy examination was conducted within 3 days of admission. RESULTS: 94 patients underwent videofluoroscopy; 20 (21%) were seen to be aspirating, although this was not detected at the bedside in 10. In 18 (22%) of the patients the speech and language therapist considered the swallow to be unsafe. In the medical assessment, 39 patients (41%) had an unsafe swallow. Bedside assessment by a speech and language therapist gave a sensitivity of 47%, a specificity of 86%, positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 85% for the presence of aspiration. Multiple logistic regression was used to identify the optimum elements of the bedside assessments for predicting the presence of aspiration. A weak voluntary cough and any alteration in conscious level gave a sensitivity of 75%, specificity of 72%, PPV of 41% and NPV of 91% for aspiration. CONCLUSION: Bedside assessment of swallowing lacks the necessary sensitivity to be used as a screening instrument in acute stroke, but there are concerns about the use of videofluoroscopy as a gold standard. The relative importance of aspiration and bedside assessment in predicting complications and outcome needs to be studied.

Acute Disease↗

A novel model of aspiration in young and old guinea-pigs using LacZ gene transduction of adenovirus vector.

The effects of anaesthesia on upper airway reflexes in older animals have not been elucidated fully. We studied young (4-month-old) and old (28-month-old) guinea-pigs to examine the relationship between aspiration and altered upper airway reflexes during anaesthesia. We administered an adenovirus vector carrying Escherichia coli LacZ gene (Ad vector) intranasally to guinea-pigs with or without anaesthesia. LacZ gene expression was investigated in the nostrils and lungs of each animal under anaesthesia. No LacZ gene expression was found in the lungs of unanaesthetized animals given Ad vector. Thus intranasal administration of Ad vector was aspirated into the lower airways under anaesthesia. Next we examined the effect of age on anaesthesia-induced aspiration. At a lower concentration of halothane in 100% oxygen, greater LacZ gene expression in the lungs was measured in older than in younger animals, suggesting that older animals are liable to aspirate oropharyngeal contents into the lower airways during light anaesthesia. This novel animal model of aspiration using Ad vector may be useful to explore the mechanism of aspiration during and after anaesthesia in young and old animals.

Age Factors↗

Microbiological and clinical aspects of aspiration pneumonia.

Aspiration pneumonia is characterized by a pneumonitis in a dependent segment of the lung with typical necrosis or abscess-formation in the parenchyma. Observed aspiration or predisposition to aspiration, cavitation or abscess formation, with or without empyema fluid and isolation of distinctive micro-organisms are important clues to the diagnosis. Diagnostic procedures to collect anaerobic uncontaminated secretions are transtracheal aspiration, blood cultures, pleural fluid aspiration, fibreoptic bronchoscopic protected investigations and percutaneous transthoracic aspiration. Leading pathogens in more than 90% are anaerobic bacteria, mostly species of Bacteroides, Fusobacterium, Peptococcus and Peptostreptococcus; aerobic bacteria include Staphylococcus aureus and Gram-negative bacilli, mainly Klebsiella spp. and Pseudomonas aeruginosa. Treatment depends on bacteriological results; penicillin G and clindamycin are the most useful antibiotics against anaerobes and should be administered over a long period of time (4-12 weeks), adjusted to the clinical course of the individual patient.

Humans↗

Statistical prediction of the type of gastric aspiration lung injury based on early cytokine/chemokine profiles.

BACKGROUND: Unwitnessed gastric aspiration can be a diagnostic dilemma, and early discrimination of different forms may help to identify individuals with increased risk of development of severe clinical acute lung injury or acute respiratory distress syndrome. The authors hypothesized that inflammatory mediator profiles could be used to help diagnose different types of gastric aspiration. METHODS: Diagnostic modeling using a newly modified receiver operator characteristic approach was applied to recently published data from our laboratory on lavaged inflammatory mediators from rodents given intratracheal normal saline, hydrochloric acid, small nonacidified gastric particles, or a combination of acid and small gastric particles. Multiple animal groups and postaspiration times of injury were analyzed to gauge the applicability of the predictive approach: rats (6 and 24 h), C57/BL6 wild-type mice (5 and 24 h), and transgenic mice on the same background deficient in the gene for monocyte chemoattractant protein 1 (MCP-1 [-/-] mice; 5 and 24 h). RESULTS: Overall, the four types of aspiration were correctly discriminated in 85 of 96 rats (89%), 72 of 78 wild-type mice (92%), and 59 of 73 MCP-1 (-/-) mice (81%) by models that used a maximum of only two mediators. The severe "two-hit" aspirate of the combination of acid and small gastric particles was correctly predicted in 21 of 24 rats, 23 of 23 wild-type mice, and 21 of 21 MCP-1 (-/-) mice. Specific best-fit mediators or mediator pairs varied with aspirate type, animal type, and time of injury. Cytokines and chemokines that best predicted the combination of acid and small gastric particles were cytokine-induced neutrophil chemoattractant 1 (6 h) and MCP-1 (24 h) in rats, tumor necrosis factor alpha/macrophage inflammatory protein 2 (5 h) and tumor necrosis factor alpha/MCP-1 (24 h) in wild-type mice, and tumor necrosis factor alpha/macrophage inflammatory protein 2 (5 h) and tumor necrosis factor alpha/keratinocyte-derived cytokine (24 h) in MCP-1 (-/-) mice. CONCLUSIONS: These results support the potential feasibility of developing predictive models that use focused measurements of inflammatory mediators to help diagnose severe clinical forms of unwitnessed gastric aspiration, such as the combination of acid and small gastric particles, that may have a high risk of progression to acute lung injury/acute respiratory distress syndrome.

Animals↗

Incidence of aspiration in endotracheally intubated infants and children.

A prospective study is reported to examine the incidence of aspiration in 50 infants and children intubated with a noncuffed endotracheal tube in a multidisciplinary PICU. Aspiration was assessed by applying Evans blue dye on the tongue and searching for the dye during suctioning, in the endotracheal aspirate. Twenty-nine (58%) were medical patients and 21 (42%) surgical; ages ranged between 25 h and 4 yr (mean 18.5 months). Respiratory failure was the major indication for endotracheal intubation and mechanical ventilation in 26 (52%) of the patients, hyperventilation for increased intracranial pressure in 12 (24%), congestive heart failure in 8 (16%), and protection of airway in deeply comatose patients in 4 (8%). The patients remained intubated from 18 h to 12 days (mean 70.4 h). Evidence of aspiration was found in 8 (16%) of the patients, accompanied by changes in chest x-ray in 5 (63%) patients and a significant fall in PO2 in 3 (37%). Aspiration was not significantly affected by the presence of a nasogastric tube, level of consciousness or ventilator setting. We conclude that noncuffed endotracheal tubes of proper size that adequately seal the trachea and effectively prevent clinically significant aspiration in endotracheally intubated infants and children.

Animals↗

Aspiration-induced lung injury: role of complement.

OBJECTIVES: To examine the role of complement in the development of acid aspiration-induced lung injury in the rat. It was postulated that inhibition or depletion of complement attenuates aspiration-induced lung injury. DESIGN: Controlled animal trial. SETTING: Animal Laboratory, Jefferson Medical College, Philadelphia, PA. SUBJECTS: Anesthetized rats. INTERVENTIONS: Aspiration was induced by the intratracheal administration of 0.2 mL of 0.1 N hydrochloric acid (n = 7) and lung injury was evaluated by determining water content, myeloperoxidase activity, protein concentration, and leukocyte count in bronchoalveolar lavage fluid. Muscle PO2 was directly measured using a thin-film chamber oxygen sensor and serum tumor necrosis factor-alpha was assayed by enzyme-linked immunosorbent assay. The effect of complement inhibition by recombinant human soluble complement receptor type 1 (n = 8) or complement depletion by cobra venom factor (n = 7) on lung injury was evaluated. MEASUREMENTS AND MAIN RESULTS: Acid aspiration induced pulmonary leukosequestration, edema, and a microvascular permeability defect, along with tissue hypoxia. Pretreatment with soluble complement receptor type 1 (complement inhibition) or cobra venom factor (complement depletion) significantly reduced lung edema (-61 +/- 7%; p < .05), eliminated protein accumulation in bronchoalveolar lavage fluid (p < .01), and improved (p < .05) tissue oxygenation. In contrast, there was no effect of soluble complement receptor type 1 or of cobra venom factor on leukosequestration. CONCLUSIONS: Acid aspiration induces lung injury through a complement-dependent mechanism that leads to microvascular permeability defects. Therefore, the possibility that complement inhibitors may have a salutary effect in humans with aspiration-induced lung injury should be investigated.

Animals↗