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PubMed1992

Meconium aspiration syndrome: reflections on a murky subject.

Meconium-stained amniotic fluid occurs in approximately 12% of live births. In approximately one third of these infants meconium is present below the vocal cords. However, meconium aspiration syndrome develops in only 2 of every 1000 live-born infants. Ninety-five percent of infants with inhaled meconium clear the lungs spontaneously. Recent investigations have suggested that a reexamination of our assumptions about the etiology of meconium aspiration syndrome is in order. Several authors have provided evidence that support the hypothesis that it is not the inhaled meconium which produces the primary pathologic condition of meconium aspiration syndrome but rather it is fetal asphyxia that is the etiologic agent. Asphyxia in utero produces pulmonary vasospasm and hyperreactivity of the pulmonary vessels. With severe asphyxia the fetal lungs undergo pulmonary vascular damage with pulmonary hypertension. The damaged lungs are then unable to clear the meconium. In the most severe cases there is right-to-left shunting and persistent fetal circulation with subsequent fetal death. The incidence of meconium aspiration may thus be essentially unaffected by current obstetric and pediatric interventions at birth. For the asphyxiated or distressed infant we recommend suctioning at birth and tracheal intubation. In the healthy fetus observation may be sufficient.

Asphyxia Neonatorum↗

PubMed1983

Three methods for gradual cervical dilatation prior to vacuum aspiration in late first trimester pregnancy.

Sixty healthy women at 8 to 12 weeks of gestation were divided into three groups of 20 women each to evaluate three methods for gradual cervical dilatation prior to vacuum aspiration - Group I: Laminaria tent: Group II: Isaptent, and Group III: 250 ug 15-methyl-PGF2 alpha intramuscular injection. The three methods showed comparable cervical dilatation (10.46 mm) over a mean period of 3 hours 40 minutes. Administration of 15-methyl-PGF2 alpha, though relatively simple, had significant gastrointestinal side effects and bleeding per vaginum (P less than 0.001) prior to vacuum aspiration and greater blood loss (P less than 0.01) during vacuum aspiration as compared with the other two groups. No sequelae, immediate or delayed, were encountered. Isaptent indigenously made and relatively inexpensive is a reliable, safe and effective method for gradual dilatation of cervix for 8 to 12 weeks of gestation prior to vacuum aspiration and is the cervical dilator of choice.

Abortion, Induced↗

PubMed1991

Mifepristone or vacuum aspiration in termination of early pregnancy.

This trial compared the termination of early pregnancy (amenorrhoea less than 43 days) by 600 mg orally of the antiprogesteron Mifepristone to the traditional method of vacuum aspiration. Fifty women were randomly assigned to either of the treatments. All the patients treated with vacuum aspiration had a complete abortion. Three of these patients developed pelvic inflammatory diseasae (PID) after the aspiration. Another patient had the uterus perforated during the procedure, and an emergency laparotomy had to be performed. The patients in the evacuation group spent more days in bed and needed longer sick leave after the treatment than the patients in the Mifepristone group. In the Mifepristone group, six patients had incomplete abortions and all were treated by evacuation. Three of the patients developed PID after the evacuation. A decrease of 40% or more in beta hCG from the initial value to the value 1 week later were invariably associated with complete abortion. In both groups the changes in hemoglobin were insignificant and no patients needed blood transfusion or emergency evacuation. The Mifepristone treatment is a simple and safe alternative to vacuum aspiration for termination of early pregnancies.

Abortion, Incomplete↗

PubMed2005

Aspiration of gastric contents: association with prehospital intubation.

We prospectively compared the incidence of pulmonary aspiration of gastric contents between patients endotracheally intubated in the prehospital (PH) setting and those intubated in the emergency department (ED). Tracheal aspirates were collected using a standard Leukens trap from all patients as soon as possible after endotracheal intubation. Tracheal aspirates were then tested for the presence of pepsin, a sensitive and specific marker of gastric contents, using a fibrinogen digestion technique. Over 8 months, 168 patients were enrolled. The pepsin assay was positive in 10 of 20 (50%) patients intubated in the PH group, as opposed to 33 of 148 (22%) of those intubated in the ED (chi2 P=.008; odds ratio, 3.5; 95% CI, 1.34-9.08). Patients endotracheally intubated in the PH setting are more likely to have aspirated gastric contents than those intubated in the ED.

Emergency Medical Services↗

PubMed2005

Meconium aspiration induces oxidative injury in the hippocampus of newborn piglets.

BACKGROUND: Meconium aspiration-induced hypertensive lung injury has been associated with neuronal damage in the newborn, but the mechanisms of the injury are poorly known. AIMS: The aim of the study was to determine the contribution of oxidative stress to the brain damage after pulmonary meconium contamination. STUDY DESIGN: Sixteen anesthetized and ventilated newborn piglets were studied for 6 h. Eight piglets were instilled with a bolus of human meconium intratracheally and eight piglets with saline instillation served as controls. Brain tissue lipid peroxidation products (TBARS), reduced glutathione (GSH), myeloperoxidase activity and oxidized DNA were analyzed as indicators of oxidative stress. RESULTS: Meconium aspiration did not change the systemic or carotid hemodynamics, but caused a well-established pulmonary hypertensive response. Sustained increase in additional oxygen demand was also observed after meconium insult, but no actual hypoxemia or hypercarbia was evident during the whole study period. Myeloperoxidase activity was elevated in the cerebellum after pulmonary meconium instillation, whereas concentrations of peroxidation products and glutathione were similar in the cortical, cerebellar and hippocampal regions of the two groups. Still, the amount of oxidized DNA was increased in the hippocampus of the meconium-aspirated piglets when compared to controls. CONCLUSIONS: Our data thus suggest that oxidative injury associated with pulmonary, but not systemic, hemodynamic disturbances may contribute to hippocampal damage after meconium aspiration in newborns.

Analysis of Variance↗

PubMed2006

Inhaled nitric oxide treatment inhibits neuronal injury after meconium aspiration in piglets.

BACKGROUND: Meconium aspiration-induced hypertensive lung injury is frequently associated with neuronal damage. Inhaled nitric oxide (iNO) is widely used in the treatment of pulmonary hypertension, but its effects on the brain are poorly known. AIMS: The aim of this study was to determine the effects of iNO treatment on the neuronal tissue after meconium aspiration. STUDY DESIGN: 71 anesthetized, catheterized and ventilated newborn piglets were studied for 6 h. Thirty-five piglets were instilled with a bolus of human meconium intratracheally and 36 piglets with saline instillation served as controls. Nineteen meconium piglets and 17 control piglets were continuously treated with 20 ppm of iNO, started at 30 min after the insult. The extent of neuronal injury was analysed histologically, and the levels of brain tissue lipid peroxidation products, reduced glutathione (GSH), myeloperoxidase activity and oxidized DNA were analysed as indicators of oxidative stress. RESULTS: iNO treatment diminished the pulmonary hypertensive response caused by meconium aspiration, but did not change systemic or carotid hemodynamics. NO administration was associated with reduced neuronal injury and diminished amount of oxidized DNA in the hippocampus of the meconium piglets. Further, iNO treatment was associated with decreased level of GSH in the cortex, but no change in lipid peroxidation production or myeloperoxidase activity was detected in any of the studied brain areas. CONCLUSIONS: Our results suggest that iNO treatment may inhibit DNA oxidation and neuronal injury in the hippocampus, associated with newborn meconium aspiration.

8-Hydroxy-2'-Deoxyguanosine↗

PubMedDate not supplied

Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review.

OBJECTIVE: The purpose of this literature review is to examine the effect of the interaction between gastrointestinal motility and feeding site on the aspiration risk in critically ill, tube-fed patients. METHODS AND RESULTS: A single answer to the question of the preferred feeding site is not likely to be found because the degree of aspiration risk varies significantly according to individual variations in gastrointestinal motility and multiple pre-existing and treatment-related risk factors. However, regardless of the feeding site, it is ultimately regurgitated gastric contents that are aspirated into the lungs. For this reason, the clinical assessment of greatest interest is the evaluation of gastric emptying, usually monitored clinically by measuring gastric residual volumes. CONCLUSION: Current recommendations for monitoring residual volumes and preventing aspiration are provided.

Critical Care↗

PubMed2006

Salivary gland surgery for chronic pulmonary aspiration in children.

INTRODUCTION: Chronic aspiration in the neurologically impaired child has a considerable morbidity and occasional morbidity. Hospitalization, physician visits and health costs associated with the sequelae of aspiration are considerable. AIM: To assess the efficacy of salivary gland surgery to treat chronic aspiration in children. SETTING: Tertiary pediatric center. STUDY DESIGN: A 6 year retrospective chart review of all patients undergoing salivary gland surgery to treat chronic aspiration. OUTCOME PARAMETERS: (1) Rate of lower respiratory tract infection (LRTI); (2) baseline oxygen saturation pre- and post-surgery. RESULTS: Sixty-two patients aged 7-279 months (mean 68 months) underwent four duct ligation or bilateral submandibular gland excision with unilateral or bilateral parotid duct ligation. The mean rate was 1.2/year pre-operatively and 0.7/year post-operatively (p=0.6). There was, however, a significant improvement in the baseline post-operative oxygen saturation (mean 94.3%) when compared to the pre-operative baseline oxygen saturation (mean 92.8%, p=0.003). Analysis of the cerebral palsy subgroup was performed (n=13). In this group there was no difference between mean pre- and post-operative LRTI rate (p=0.5) nor change in baseline oxygen saturation (p=0.83). Children under 3 years of age showed a reduction in the LRTI rate (mean of 2.1 versus 0.7 episodes per year, p=0.04) and an improvement in the post-operative baseline oxygen saturation (p=0.001) following surgery. CONCLUSIONS: Unlike a previous publication from this institution, when evaluating the population sample as a whole, there was no significant improvement in the rate of LRTI following salivary gland surgery, however, there was an improvement in baseline oxygen saturation, possibly reflecting an improvement in lung function. There was an improvement in neither outcome parameter in children with cerebral palsy and improvements in both outcome measures in children under the age of 3.

Adolescent↗

PubMed2006

Nutrition, hydration, and dysphagia in long-term care: Differing opinions on the effects of aspiration.

OBJECTIVES: This study examined the management of aspiration in skilled nursing settings, by determining speech-language pathologists' and nursing staff members' agreement about aspiration, interventions, and impact on residents' nutrition and hydration status, as determined by agreement scores on a questionnaire. DESIGN: Cross sectional descriptive. SETTING: Health care; skilled nursing facility. PARTICIPANTS: Seventy-eight speech-language pathologists (SLPs) and 83 nursing caregivers. INTERVENTION: Participants completed a survey questionnaire requesting a level of agreement with statements about aspiration and interventions for aspiration. Questionnaires also included demographic questions for analysis purposes. MEASUREMENTS: Agreement scores on a modified Likert scale. RESULTS: There were no significant differences in agreement scores for SLPs by formal training or years of experience. Nurses showed differences by experience for 2 statements, and by level of certification for 3 statements. There were significant differences between responses for nurses and SLPs for 7 of the 10 items. Both groups demonstrated content knowledge that conflicts with principles documented in the medical literature. CONCLUSION: Results suggest that both SLP and nursing training programs should include more evidence from multidisciplinary sources, specifically the medical literature, to improve the knowledge base of clinicians providing care to residents with swallowing disorders.

Aged↗

PubMed2006

Pepsin in bronchoalveolar lavage fluid: a specific and sensitive method of diagnosing gastro-oesophageal reflux-related pulmonary aspiration.

OBJECTIVES: Gastro-oesophageal reflux (GOR)-related aspiration is associated with respiratory disease, but the current "gold standard" investigation, the lipid-laden macrophage index (LLMI), is flawed. A specific marker of GOR-related aspiration should originate in the stomach, but not the lung. An assay to detect gastric pepsin in the bronchoalveolar lavage (BAL) of children was developed and validated. METHODS: Gastro-oesophageal reflux was diagnosed in 33 children using intra-oesophageal pH monitoring. Thirteen asymptomatic negative controls requiring endotracheal intubation for elective surgery and 5 positive control patients with observed aspiration were recruited. All subjects received a BAL; the fluid obtained was analysed for the pepsin content and the LLMI. RESULTS: All subjects in the negative control group were negative for pepsin. The positive control group had a significantly greater median pepsin level (P < .01) compared with negative controls. Patients with proximal oesophageal GOR and chronic cough also had significantly elevated pepsin levels (P = .04). The LLMI was not significantly elevated by the presence of cough or GOR. CONCLUSIONS: This study suggests that GOR-related aspiration plays a role in chronic cough in children with known GOR. Detecting pepsin in BAL fluid may therefore become an important adjunct in patient selection for antireflux surgery.

Bronchoalveolar Lavage Fluid↗

PubMed1995

Aspiration pneumonia following surgically placed feeding tubes.

BACKGROUND: The enteral route is preferred in surgical patients requiring nutritional support; however, controversy surrounds the choice of location of feeding tube placement. Although jejunostomy has been commonly accepted as superior to gastrostomy for long-term nutritional support because of an assumed lower risk of aspiration pneumonia, recent studies suggest that reevaluation of common practices of surgical tube placement is warranted. PATIENTS AND METHODS: We conducted a retrospective chart review of gastrostomy and jejunostomy procedures from 1986 to 1993. Demographic information and complications related to the procedure were reviewed. Aspiration pneumonia was defined as respiratory symptoms, leukocytosis, and infiltrate on chest radiograph. RESULTS: Sixty-nine gastrostomies and 86 jejunostomies were performed during the study period. Six patients were diagnosed with aspiration pneumonia; 2 cases of which occurred with jejunostomy and 4 cases occurred with gastrostomy (P = not significant). CONCLUSIONS: There was no difference in rates of pulmonary aspiration or other complications between gastrostomy and jejunostomy. We suggest that when a surgically placed feeding tube is required, the determination of appropriate procedure be based on clinical factors such as the technical difficulty of the operation or long-term feeding goals.

Enteral Nutrition↗

PubMed1985

Aspiration pneumonia and complications of inhalation of smoke and toxic gases.

Pulmonary aspiration of oral, esophageal, or gastric content poses a significant hazard to animals. Aspiration of acidic, alkaline, or ingesta-containing gastric contents can cause serious morbidity and mortality. Clinicians must be aware of conditions and clinical situations in which there is increased risk of aspiration. The most important aspect of the mitigation of the pneumonic complications of aspiration is prevention.

Adrenal Cortex Hormones↗

PubMed1990

Manual translaryngeal jet ventilation and the risk of aspiration in a canine model.

STUDY OBJECTIVES: Manual translaryngeal jet ventilation (TLJV) is a safe and effective method of maintaining normal ventilation in apneic subjects. Little data exist on the amount of airway protection afforded with this technique of airway management. We sought to evaluate the risk of aspiration during manual TLJV. SETTING: Data were collected in a laboratory animal model. DESIGN: A prospective, nonrandomized, controlled trial was performed. PARTICIPANTS: Seventeen adult apneic mongrel dogs were enrolled. INTERVENTIONS: Intratracheal Gastrograffin was instilled and radiographic changes assessed during ventilation using a 0 to 3 scale (none to severe). Thirty-six trials were performed, with equal numbers at both 30 degrees and 45 degrees head elevation. The three groups studied were animals without airway protection (control), animals with a cuffed endotracheal tube (tube), and animals with a percutaneous TLJV cannula and a 50-psi oxygen source ventilated at a rate of 20 breaths per minute (jet). MEASUREMENTS AND MAIN RESULTS: Significantly less radiographic evidence of aspiration was noted in the jet and tube groups at 30 degrees and 45 degrees compared with control animals (P = .002 each). At 45 degrees head elevation a trend toward increased aspiration scores in the jet group compared with the tube group (P = .065) was observed. CONCLUSION: In our model, manual TLJV at 20 breaths per minute and an I:E ratio of 1:2 provided protection from aspiration comparable to that observed with a cuffed endotracheal tube at 30 degrees head elevation. At 45 degrees elevation, this protection was diminished.

Animals↗

PubMedDate not supplied

Laryngeal framework surgery for the management of aspiration in high vagal lesions.

PURPOSE: The purpose of this study is to ascertain the effectiveness of laryngeal framework surgery, including medialization thyroplasty (MT), with or without arytenoid adduction (AA), on preventing aspiration, improving diet, and aiding in the subsequent decannulation of individuals with high vagal lesions. PATIENTS AND METHODS: A retrospective chart review was performed on each patient presenting with a high vagal lesion who was treated with laryngeal framework surgery from June 1992 to April 1996 at a university medical center. Thirty-five patients were identified; there were 20 women and 15 men, with a median age of 51. Information regarding etiology of the lesion, characteristics of the vocal cord deficits, degree of aspiration, the presence of other neurologic deficits and concurrent pulmonary disease, treatment, and outcome was obtained. The final outcome regarding voice, the presence and degree of aspiration, diet, and decannulation following MT, with or without AA, was assessed to determine the effectiveness of these procedures. RESULTS: Thirty-five patients underwent 40 MTs and 19 AAs. Ninety-four percent of patients who experienced aspiration improved, and 79% who had required tracheotomy were decannulated. Ninety percent of patients were noted to have subjective improvement in voice postoperatively. CONCLUSION: Laryngeal framework surgery improves airway, deglutition, and voice in individuals suffering from high vagal lesions, and facilitates the rehabilitation of these patients.

Adult↗

PubMed2001

Variables associated with meconium aspiration syndrome in labors with thick meconium.

OBJECTIVE: To examine the possible maternal and fetal variables associated with meconium aspiration syndrome in labors with thick meconium. STUDY DESIGN: The fetal heart rate tracings, cord pH, Apgar scores and maternal risk factors were evaluated in singleton pregnancies with vertex presentation and thick meconium in labor. The study included 33 consecutive fetuses which developed a moderate or severe meconium aspiration syndrome and 104 consecutive fetuses which had a favorable outcome. RESULTS: Significant differences between fetuses with meconium aspiration syndrome and healthy fetuses were found in the following parameters: baseline FHR (154+/-17 vs. 136+/-10, P<0.0001), small accelerations/30 min (1.47+/-1.52 vs. 3.04+/-1.2, P<0.0001), large accelerations/30 min (1.46+/-1.96 vs. 3.5+/-2.31, P<0.0003), decelerations/30 min (4.9+/-3.9 vs. 2.4+/-2.1, P<0.0034), number of fetuses with reduced beat-to-beat variability (9/33 vs. 0/104, P<0.0001), cord pH (7.21+/-0.09 vs. 7.33+/-0.08, P<0.0013) and Apgar scores at 1 min (5+/-2 vs. 8+/-1, P<0.0001) and Apgar scores at 5 min (8+/-2 vs. 9.7+/-0.6, P<0.0001). Maternal risk factors were found in two of 33 sick infants and in 13 of 104 healthy infants. CONCLUSION: Thick meconium by itself is not associated with adverse fetal outcome. However, the incidence of meconium aspiration syndrome increases in cases of a non-reassuring FHR.

Apgar Score↗

PubMed1997

Immunohistochemical detection of human milk components aspirated in lungs of an infant.

We examined an autopsy case of an infant whose cause of death was suspected to be asphyxia due to human breast milk aspiration. In order to demonstrate aspirated milk in the lungs, we conducted immunohistochemical staining using eight antibodies against the components of human milk. Seven of the eight antibodies reacted positively with the substances suspected to be aspirated milk. We concluded that immunohistochemical staining with these antibodies is useful to demonstrate human milk aspiration and provide some keys for detecting the causes of unexpected infant deaths.

Autopsy↗

PubMed1997

Incidence of aspiration after urgent intubation.

This study sought to determine the incidence of aspiration after urgent endotracheal intubation (ET) performed in the emergency department (ED), and to offer a descriptive evaluation of these intubations. In a retrospective review of 133 charts, 87 patients met inclusion criteria. Aspiration occurred in 3 (3.5%) patients (95% confidence interval, 0%, 7.4%). One had witnessed aspiration, and 2 had positive sputum cultures. None of the 87 patients had a positive chest radiograph or unexplained hypoxemia up to 48 hours after ET. Rapid-sequence induction and oral ET was performed in 79 (91%) patients, whereas 4 spontaneously breathing patients were nasally intubated. Seventy percent of patients underwent ET by PGY I or II residents, 29% by PGY III or IV residents, and 1% by ED attending physicians. Seventy-seven patients were intubated on the first attempt, and airway blood or vomitus during ET was noted in 11 patients. This study offers significant descriptive information regarding urgent ET performed in the ED, and shows that aspiration after urgent ET occurs infrequently in ED patients.

Adult↗

PubMed1999

Effects of qing fei tang (TJ-90) on aspiration pneumonia in mice.

The effects of Qing Fei Tang (Sei-hai To in Japanese), a Chinese traditional medical mixture, on aspiration pneumonia were studied using mice inoculated with both Streptococcus pneumoniae and gastric juice as aspiration pneumoniae models. Daily (4 weeks) oral usage of Qing Fei Tang before inoculation reduced remarkably the mortality rate of mice. In this aspiration pneumonia model, xanthine oxidase (XO) activity in the lung tissues was elevated, but this elevation was remarkably decreased by use of Qing Fei Tang. These results suggest that Qing Fei Tang pretreatment can reduce oxygen radical production in inflammed lungs and may reduce the mortality for aspiration pneumonia.

Animals↗