Association between pharyngeal residue and posterior oral spillage with penetration and aspiration in Stroke

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Uso da máscara laríngea descartável em adenotonsilectomias

JUSTIFICATIVA E OBJETIVOS: A intubação traqueal associada a operações das vias aéreas faz com que complicações como laringoespasmo, broncoespasmo e períodos de redução da saturação de oxigênio sejam frequentemente relatados em adenotonsilectomias, procedimento que, por sua natureza, eleva a incidência de tais complicações. O objetivo deste estudo foi analisar a ocorrência de problemas respiratórios comparando-se o uso da máscara laríngea (ML) descartável com a intubação orotraqueal em adenotonsilectomias. MÉTODOS: Foram avaliados 204 pacientes pediátricos submetidos a anestesia geral para adenotonsilectomias e alocados em dois grupos, aleatoriamente: grupo Cânula Traqueal (CT, n = 100) e grupo Máscara Laríngea (ML, n = 104). Foram observados os níveis de saturação de pulso de oxigênio (SpO2) após a indução anestésica (SpO2-1), após o estabelecimento de campo operatório (SpO2-2), ao término do procedimento cirúrgico (SpO2-3), três minutos após a retirada do dispositivo respiratório (SpO2-4) e na admissão da sala de recuperação anestésica (SpO2-5). As complicações respiratórias foram relatadas. RESULTADOS: Os valores médios e os desvios padrão de SpO2 nos grupos CT e ML foram, respectivamente: SpO2-1: 98,9 ± 1,0 e 98,7 ± 0,8 (p > 0,25); SpO2-2: 97,4 ± 1,0 e 94,9 ± 4,3 (p < 0,001); SpO2-3: 96,9 ± 1,1 e 97,2 ± 1,1 (p = 0,037); SpO2-4: 91,7 ± 9,0 e 95,2 ± 2,2 (p < 0,001); SpO2-5: 94,0 ± 2,1 e 95,8 ± 2,6 (p < 0,001). No grupo ML, em 12 pacientes, foi necessária alguma manobra para ajuste do dispositivo e correção de vazamento durante o ato operatório. A ML foi substituída pela CT em quatro pacientes. As complicações respiratórias foram similares entre os grupos. CONCLUSÕES: Adenotonsilectomias em pacientes pediátricos com o emprego da ML, em comparação com a CT, resulta em menores valores de SpO2 intraoperatórios e, eventualmente, necessidade de substituição da ML pela CT. Apesar de a ML viabilizar a cirurgia, pela segurança, o uso da CT é preferível.

Intubação traqueal e o paciente com o estômago cheio

A aspiração pulmonar do conteúdo gástrico, apesar de pouco frequente, exige cuidados especiais para sua prevenção. A depressão da consciência durante a anestesia predispõe os pacientes a esta grave complicação pela diminuição na função do esfíncter esofágico e dos reflexos protetores das vias aéreas. Guias de jejum pré-operatório elaborados recentemente sugerem períodos menores de jejum, principalmente para líquidos, permitindo mais conforto aos pacientes e menor risco de hipoglicemia e desidratação, sem aumentar a incidência de aspiração pulmonar perioperatória. O uso rotineiro de agentes que diminuem a acidez e volume gástrico parece estar indicado apenas para pacientes de risco. A intubação traqueal após indução anestésica por meio da técnica de sequência rápida está indicada naqueles pacientes, com risco de aspiração gástrica, em que não há suspeita de intubação traqueal difícil. A indicação correta da técnica, sua aplicação criteriosa e a utilização racional das drogas disponíveis podem promover condições excelentes de intubação, com curto período de latência, rápido retorno da consciência e da respiração espontânea, caso haja falha na intubação traqueal.O presente artigo tem como objetivo discutir os métodos atualmente utilizados para controlar o volume e o pH do conteúdo gástrico, proteger as vias aéreas durante as manobras de intubação e reduzir o refluxo gastroesofágico.

National training course, emergency medical technician - paramedic. Instructor's lesson plans. Module III: shock and fluid therapy.

Mode of access: Internet.

Designing for Safety : Implications of a Fifteen Year Review of Swallowed and Aspirated Dentures

Peer reviewed

Cervical auscultation in the diagnosis of oropharyngeal aspiration in children : a study protocol for a randomised controlled trial

Background Oropharyngeal aspiration (OPA) can lead to recurrent respiratory illnesses and chronic lung disease in children. Current clinical feeding evaluations performed by speech pathologists have poor reliability in detecting OPA when compared to radiological procedures such as the modified barium swallow (MBS). Improved ability to diagnose OPA accurately via clinical evaluation potentially reduces reliance on expensive, less readily available radiological procedures. Our study investigates the utility of adding cervical auscultation (CA), a technique of listening to swallowing sounds, in improving the diagnostic accuracy of a clinical evaluation for the detection of OPA. Methods We plan an open, unblinded, randomised controlled trial at a paediatric tertiary teaching hospital. Two hundred and sixteen children fulfilling the inclusion criteria will be randomised to one of the two clinical assessment techniques for the clinical detection of OPA: (1) clinical feeding evaluation only (CFE) group or (2) clinical feeding evaluation with cervical auscultation (CFE + CA) group. All children will then undergo an MBS to determine radiologically assessed OPA. The primary outcome is the presence or absence of OPA, as determined on MBS using the Penetration-Aspiration Scale. Our main objective is to determine the sensitivity, specificity, negative and positive predictive values of ‘CFE + CA’ versus ‘CFE’ only compared to MBS-identified OPA. Discussion Early detection and appropriate management of OPA is important to prevent chronic pulmonary disease and poor growth in children. As the reliability of CFE to detect OPA is low, a technique that can improve the diagnostic accuracy of the CFE will help minimise consequences to the paediatric respiratory system. Cervical auscultation is a technique that has previously been documented as a clinical adjunct to the CFE; however, no published RCTs addressing the reliability of this technique in children exist. Our study will be the first to establish the utility of CA in assessing and diagnosing OPA risk in young children.

Pepsin measured in induced sputum - a test for pulmonary aspiration in children?

Purpose The purpose of this study was to investigate if pepsin measured in sputum is a useful marker of pulmonary aspiration secondary to gastroesophageal reflux (GER) in children. It is possible that the induced sputum procedure could cause GER and invalidate the results. The hypothesis stated that healthy children (those without history of respiratory or gastroesophageal symptoms) would not have pepsin detected in induced sputum. Methods Children attending surgical outpatients in the Royal Belfast Hospital for Sick Children (Belfast, Northern Ireland) were recruited. After spirometry, sputum was obtained by induction with hypertonic 3% saline. Spirometry was repeated, and complications were noted. An “in-house” enzyme-linked immunosorbent assay was used to measure pepsin concentration in sputum. The lower limit of detection of pepsin was 1.19 ng/mL. Results Children (n = 21) aged 4 to 16 years were recruited. Twenty children completed the study. No adverse effects were reported. Pepsin was detected in 17 (85%) of 20 sputum samples. Conclusions The act of sputum induction appears to induce physiologic GER in a healthy childhood population. The analysis of pepsin in sputum obtained by sputum induction is therefore not useful in the investigation of reflux-related respiratory disease.

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

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.

Different doses of exogenous surfactant for treatment of meconium aspiration syndrome in newborn rabbits.

OBJECTIVE: To evaluate the effects of 2 different doses of exogenous surfactant on pulmonary mechanics and on the regularity of pulmonary parenchyma inflation in newborn rabbits. METHOD: Newborn rabbits were submitted to tracheostomy and randomized into 4 study groups: the Control group did not receive any material inside the trachea; the MEC group was instilled with meconium, without surfactant treatment; the S100 and S200 groups were instilled with meconium and were treated with 100 and 200 mg/kg of exogenous surfactant (produced by Instituto Butantan) respectively. Animals from the 4 groups were mechanically ventilated during a 25-minute period. Dynamic compliance, ventilatory pressure, tidal volume, and maximum lung volume (P-V curve) were evaluated. Histological analysis was conducted using the mean linear intercept (Lm), and the lung tissue distortion index (SDI) was derived from the standard deviation of the means of the Lm. One-way analysis of variance was used with a = 0.05. RESULTS: After 25 minutes of ventilation, dynamic compliance (mL/cm H2O.kg) was 0.87 +/- 0.07 (Control); 0.49 +/- 0.04 (MEC*); 0.67 +/- 0.06 (S100); and 0.67 +/- 0.08 (S200), and ventilatory pressure (cm H2O) was 9.0 +/- 0.9 (Control); 16.5 +/- 1.7 (MEC*); 12.4 +/- 1.1 (S100); and 12.1 +/- 1.5 (S200). Both treated groups had lower Lm values and more homogeneity in the lung parenchyma compared to the MEC group: SDI = 7.5 +/- 1.9 (Control); 11.3 +/- 2.5 (MEC*), 5.8 +/- 1.9 (S100); and 6.7 +/- 1.7 (S200) (*P < 0.05 versus all the other groups). CONCLUSIONS: Animals treated with surfactant showed significant improvement in pulmonary mechanics and more regularity of the lung parenchyma in comparison to untreated animals. There was no difference in results after treatment with either of the doses used.

Mammary benign neoplasm diagnosed by fine needle aspiration biopsy in a guinea pig (Cavia porcellus)

Cytology is a well established research technique in human and veterinary medicine, but it is rarely used in small rodents. Spontaneous tumors are relatively uncommon in guinea pigs and those described in literature include a variety of organs like skin and subcutis, respiratory and reproductive tract, endocrine and hematopoietic system, and mammary gland. The objective of this article was to describe the use of the fine needle aspiration biopsy technique (FNAB) on evaluation of a mammary neoplasm in a guinea pig and describe the main cytological findings for the first time in literature.

Effects of Positive End-expiratory Pressure Titration and Recruitment Maneuver on Lung Inflammation and Hyperinflation in Experimental Acid Aspiration-induced Lung Injury

Background: In acute lung injury positive end-expiratory pressure (PEEP) and recruitment maneuver are proposed to optimize arterial oxygenation. The aim of the study was to evaluate the impact of such a strategy on lung histological inflammation and hyperinflation in pigs with acid aspiration-induced lung injury. Methods: Forty-seven pigs were randomly allocated in seven groups: (1) controls spontaneously breathing; (2) without lung injury, PEEP 5 cm H2O; (3) without lung injury, PEEP titration; (4) without lung injury, PEEP titration + recruitment maneuver; (5) with lung injury, PEEP 5 cm H2O; (6) with lung injury, PEEP titration; and (7) with lung injury, PEEP titration + recruitment maneuver. Acute lung injury was induced by intratracheal instillation of hydrochloric acid. PEEP titration was performed by incremental and decremental PEEP from 5 to 20 cm H2O for optimizing arterial oxygenation. Three recruitment maneuvers (pressure of 40 cm H2O maintained for 20 s) were applied to the assigned groups at each PEEP level. Proportion of lung inflammation, hemorrhage, edema, and alveolar wall disruption were recorded on each histological field. Mean alveolar area was measured in the aerated lung regions. Results: Acid aspiration increased mean alveolar area and produced alveolar wall disruption, lung edema, alveolar hemorrhage, and lung inflammation. PEEP titration significantly improved arterial oxygenation but simultaneously increased lung inflammation in juxta-diaphragmatic lung regions. Recruitment maneuver during PEEP titration did not induce additional increase in lung inflammation and alveolar hyperinflation. Conclusion: In a porcine model of acid aspiration-induced lung injury, PEEP titration aimed at optimizing arterial oxygenation, substantially increased lung inflammation. Recruitment maneuvers further improved arterial oxygenation without additional effects on inflammation and hyperinflation.

Severe lower respiratory tract infection in infants and toddlers from a non-affluent population: viral etiology and co-detection as risk factors

Abstract Background Lower respiratory tract infection (LRTI) is a major cause of pediatric morbidity and mortality, especially among non-affluent communities. In this study we determine the impact of respiratory viruses and how viral co-detections/infections can affect clinical LRTI severity in children in a hospital setting. Methods Patients younger than 3 years of age admitted to a tertiary hospital in Brazil during the months of high prevalence of respiratory viruses had samples collected from nasopharyngeal aspiration. These samples were tested for 13 different respiratory viruses through real-time PCR (rt-PCR). Patients were followed during hospitalization, and clinical data and population characteristics were collected during that period and at discharge to evaluate severity markers, especially length of hospital stay and oxygen use. Univariate regression analyses identified potential risk factors and multivariate logistic regressions were used to determine the impact of specific viral detections as well as viral co-detections in relation to clinical outcomes. Results We analyzed 260 episodes of LRTI with a viral detection rate of 85% (n = 222). Co-detection was observed in 65% of all virus-positive episodes. The most prevalent virus was Respiratory Syncytial Virus (RSV) (54%), followed by Human Metapneumovirus (hMPV) (32%) and Human Rhinovirus (HRV) (21%). In the multivariate models, infants with co-detection of HRV + RSV stayed 4.5 extra days (p = 0.004), when compared to infants without the co-detection. The same trends were observed for the outcome of days of supplemental oxygen use. Conclusions Although RSV remains as the main cause of LRTI in infants our study indicates an increase in the length of hospital stay and oxygen use in infants with HRV detected by RT-PCR compared to those without HRV. Moreover, one can speculate that when HRV is detected simultaneously with RSV there is an additive effect that may be reflected in more severe clinical outcome. Also, our study identified a significant number of children infected by recently identified viruses, such as hMPV and Human Bocavirus (HBov), and this is a novel finding for poor communities from developing countries.

ERS statement on the multidisciplinary respiratory management of ataxia telangiectasia.

Ataxia telangiectasia (A-T) is a rare, progressive, multisystem disease that has a large number of complex and diverse manifestations which vary with age. Patients with A-T die prematurely with the leading causes of death being respiratory diseases and cancer. Respiratory manifestations include immune dysfunction leading to recurrent upper and lower respiratory infections; aspiration resulting from dysfunctional swallowing due to neurodegenerative deficits; inefficient cough; and interstitial lung disease/pulmonary fibrosis. Malnutrition is a significant comorbidity. The increased radiosensitivity and increased risk of cancer should be borne in mind when requesting radiological investigations. Aggressive proactive monitoring and treatment of these various aspects of lung disease under multidisciplinary expertise in the experience of national multidisciplinary clinics internationally forms the basis of this statement on the management of lung disease in A-T. Neurological management is outwith the scope of this document.

Flexible bronchoscopy contribution in the approach of diagnosis and treatment of children’s respiratory diseases: the experience of a unique pediatric unit in Tunisia.

Objective: Our study aimed at assessing the role of flexible bronchoscopy (FB) in improving diagnosis and management of children’s respiratory conditions in the pediatric unit of FB, newly created and unique in Tunisia. Methods: Retrospective study including all the FB achieved in our pediatric unit from 2009 to 2014. Results: We performed 365 FB in 333 patients aged 46 months on average (1 month - 15 years), often under conscious anesthesia (81.6%). FB was performed for diagnostic purposes in 341 cases and for therapeutic purposes in 24 cases. Eight anatomical abnormalities were revealed in 22 patients. An intraluminal bronchial obstruction was found in 71 FB, mainly due to a foreign body (n=36). A vascular anomaly was responsible for nine cases out of 17 extraluminal obstructions. Airways malacia was observed in 60 FB. Bronchoalveolar lavage was performed in 196 cases. It was determinant in 43.9% of the cases. FB was of great diagnostic value in 74.8% of the cases. It influenced the management of the patients in 58% of the cases. The FB for therapeutic purposes was beneficial in all cases. Few complications occurred (5.5%). Conclusion: FB is a safe tool providing precious diagnostic and/or therapeutic help for the clinician. Keywords: