Search

Foreign body aspiration (FBA) can be encountered in all age groups, especially in children under 3 years of age. In this study, we aimed to evaluate our results in children and adults who underwent rigid bronchoscopy due to a history of foreign body aspiration.In a single-center study, 822 consecutive patients with suspected foreign body aspiration and undergoing rigid bronchoscopy between January 2000 and August 2021 in our clinic were retrospectively evaluated.There were 451 (54.9%) male and 371 (45.1%) female patients. The mean age was 8.1 ± 14.0 (range 1 month-84 years). 525 (63.9%) of the cases consisted of cases under 3 years old, including 3 years old. There were 726 (88.3%) pediatric patients (≤18 years old), and 96 (11.7%) adult patients. The most important symptoms were cough in 690 (83.9%) cases and wheezing in 492 (59.9%) cases. The most frequently aspirated foreign bodies in children were sunflower seeds (14.2%, n = 71), food particles (11.4%, n = 57) and needles (52%, n = 10.4). The most frequently aspirated foreign bodies in adults were needles (39.5%, n = 28), non-needle metallic objects (21.1%, n = 15) and food particles (11.3%, n = 8). No mortality was observed in any of the patients who underwent rigid bronchoscopy.FBA is higher in children and direct radiological findings are less than in adults. Current findings show that FBAs in children are more difficult to diagnose and more dangerous clinically.

ObjectiveDysphagia is a common symptom with associated complications ranging from mild discomfort to life-threatening pulmonary compromise. Videofluoroscopic swallow is the ‘gold standard’ evaluation for oropharyngeal dysphagia, but little is known about how patients’ performance changes over time.MethodThis was a retrospective cohort study evaluating dysphagia patients’ clinical course by serial videofluoroscopic swallow study. Univariate analysis followed by multivariate analysis were used to identify correlations between pneumonia outcomes, diet allocation, aetiology and comorbidities.ResultsThis study identified 104 patients (53 per cent male) stratified into risk groups by penetration-aspiration scale scores. Mean penetration-aspiration scale worsened over time (p < 0.05), but development of pneumonia was not associated with worsened penetration-aspiration scale score over time (p = 0.57) or severity of dysphagia (p = 0.88).ConclusionOur dataset identified a large cohort of patients with oropharyngeal dysphagia and demonstrated mean penetration-aspiration scale tendency to worsen. Identifying prognostic factors associated with worsening radiological findings and applying this to patients at risk of clinical swallowing difficulty is needed.

Background Perioperative pulmonary aspiration of gastric contents has been associated with severe morbidity and death. The primary aim of this study was to identify outcomes and patient and process of care risk factors associated with gastric aspiration claims in the Anesthesia Closed Claims Project. The secondary aim was to assess these claims for appropriateness of care. The hypothesis was that these data could suggest opportunities to reduce either the risk or severity of perioperative pulmonary aspiration. Methods Inclusion criteria were anesthesia malpractice claims in the American Society of Anesthesiologists Closed Claims Project that were associated with surgical, procedural, or obstetric anesthesia care with the year of the aspiration event 2000 to 2014. Claims involving pulmonary aspiration were identified and assessed for patient and process factors that may have contributed to the aspiration event and outcome. The standard of care was assessed for each claim. Results Aspiration of gastric contents accounted for 115 of the 2,496 (5%) claims in the American Society of Anesthesiologists Closed Claims Project that met inclusion criteria. Death directly related to pulmonary aspiration occurred in 66 of the 115 (57%) aspiration claims. Another 16 of the 115 (14%) claims documented permanent severe injury. Seventy of the 115 (61%) patients who aspirated had either gastrointestinal obstruction or another acute intraabdominal process. Anesthetic management was judged to be substandard in 62 of the 115 (59%) claims. Conclusions Death and permanent severe injury were common outcomes of perioperative pulmonary aspiration of gastric contents in this series of closed anesthesia malpractice claims. The majority of the patients who aspirated had either gastrointestinal obstruction or acute intraabdominal processes. Anesthesia care was frequently judged to be substandard. These findings suggest that clinical practice modifications to preoperative assessment and anesthetic management of patients at risk for pulmonary aspiration may lead to improvement of their perioperative outcomes. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Objective: To assess the effect of Passy-Muir® Valve (PMV) tolerance on respiratory illness and respiratory related hospital admissions in tracheostomy-dependent children. Methods: Retrospective cohort study of 262 patients who underwent tracheostomy placement between 2012 and 2018 at a tertiary free-standing children’s hospital. Outcome measures studied were number of reported upper respiratory infections and respiratory related hospitalizations per year (RRH/year). Results: About 135 (51.5%) tracheostomy-dependent children underwent PMV trials, and 106 (78.5%) of these children were able to tolerate PMV for at least 1 hour daily. When comparing children who tolerated PMV versus those who did not, the latter group had significantly higher rates of subglottic stenosis but no significant differences in RRH/year or average age. In those children who tolerated PMV and achieved routine use of PMV > 1 hour/day, an average of 1.14 RRH/year occurred prior to PMV tolerance, as compared with 0.57 RRH/year after PMV tolerance ( P = .003). Multivariate analysis shows that in patients Conclusion: In tracheostomy-dependent children who tolerate PMV use routinely >1 hour/day there are decreased rates of respiratory related hospitalizations (RRH). Children

Background Patients experience endotracheal intubation in various settings with wide-ranging risks for postintubation complications such as aspiration and ventilator-associated conditions. Objectives To evaluate associations between intubation setting, presence of aspiration biomarkers, and clinical outcomes. Methods This study is a subanalysis of data from the NO-ASPIRATE single-blinded randomized clinical trial. Data were prospectively collected for 513 adult patients intubated within 24 hours of enrollment. Patients with documented aspiration events at intubation were excluded. In the NO-ASPIRATE trial, intervention patients received enhanced oropharyngeal suctioning every 4 hours and control patients received sham suctioning. Tracheal specimens for α-amylase and pepsin tests were collected upon enrollment. Primary outcomes were ventilator hours, lengths of stay, and rates of ventilator-associated conditions. Results Of the baseline tracheal specimens, 76.4% were positive for α-amylase and 33.1% were positive for pepsin. Proportions of positive tracheal α-amylase and pepsin tests did not differ significantly between intubation locations (study hospital, transfer from other hospital, or field intubation). No differences were found for ventilator hours or lengths of stay. Patients intubated at another hospital and transferred had significantly higher ventilator-associated condition rates than did those intubated at the study hospital (P = .02). Ventilator-associated condition rates did not differ significantly between patients intubated in the field and patients in other groups. Conclusions Higher ventilator-associated condition rates associated with interhospital transfer may be related to movement from bed, vehicle loading and unloading, and transport vehicle vibrations. Airway assessment and care may also be suboptimal in the transport environment.

BACKGROUND Nephropathic cystinosis is a lysosomal storage disorder with late-onset systemic complications, such as myopathy and dysphagia. Currently employed outcome measures lack sensitivity and responsiveness for dysphagia and myopathy, a limitation to clinical trial readiness. METHODS We evaluated 20 patients with nephropathic cystinosis in two visits over the course of a year to identify outcomes sensitive to detect changes over time. Patients also underwent an expiratory muscle strength training program to assess any effects on aspiration and dysphagia. RESULTS There were significant differences in the Timed Up and Go Test (TUG) and Timed 25-Foot Walk (25-FW) between baseline and 1-y follow-up (P

Objectives: To highlight the importance of recognizing the postcricoid cushion as a surgically treatable cause of newborn aspiration in select cases unresponsive to conservative measures. Methods: A retrospective review was performed on a single case of neonatal aspiration at a tertiary care pediatric hospital. Results: Resolution of aspiration was achieved in an otherwise healthy six-week old term infant following ablation of a postcricoid cushion using microlaryngeal instrumentation and coblation. Prior airway and swallowing evaluations, along with a trial of reflux therapy and pacing of feeds, preceded the surgical excision, successfully avoiding gastrostomy tube placement. Conclusions: Otolaryngology consults for neonatal dysphagia and aspiration are challenging. The postcricoid cushion is considered an anatomic variant that can engorge with crying. When large, it can prevent feeds from entering the esophagus and lead to pooling and aspiration. The postcricoid cushion is evident on flexible fiberoptic laryngoscopy, but without a vigilant eye may be easily overlooked. This single case report suggests that surgical ablation may be effective management in select cases after ruling out concomitant aerodigestive pathology and neurodevelopmental causes of aspiration and only after conservative therapy has failed. A video demonstrating the surgical ablation is included.

This study described swallowing patterns in a large head/neck cancer (HNC) cohort.In a retrospective review of data from a randomized controlled trial, we studied timing of penetration events as they related to aspiration and oral/pharyngeal residue.Retrospective review of a multicenter randomized controlled trial.In total, 168 patients who were3 months postradiation received baseline modified barium swallow evaluations. Retrospective analyses of data from these exams were studied, including Penetration-Aspiration Scale (PAS) scores and timing of these events (before, during, or after the swallow), as well as percentage of oral and pharyngeal residue.Aspiration occurred more frequentlyThe predominant pattern for this sample of postradiation patients with HNC with dysphagia was aspiration that occurred after the swallow, rather than before or during the swallow. The aspiration was directly caused by penetration events that occurred during the swallow, resulting in aspiration as the airway reopened. Patients demonstrated more pharyngeal residue than oral residue, but a weak relationship was found between residue and penetration/aspiration events. These results guide clinicians in targeting appropriate swallowing interventions.

BACKGROUND Predominance of blind feeding tube placement makes esophageal tube misplacement and aspiration risk commonplace. Accurate estimation of nose-to-stomach length could reduce this risk. Standards for estimating this length were audited against the length measured from guided tube placement. METHODS This prospective, single-center observational study used electromagnet-guided tube placement to measure the length from nose to gastric body flexure as part of routine care. This measurement was used to audit standard equations used to estimate this length from external measures: xiphisternum-ear-nose + 10 cm (XEN+10), nose-ear-xiphisternum (NEX), and Hanson_A and Hanson_B. RESULTS From April 23, 2015, to March 2, 2020, measurements were obtained from 200 primary tube placements. Median length to the gastric body flexure (61 cm) was significantly different from that to the pre-gastroesophageal junction flexure (48 cm) or lengths predicted by NEX (51 cm) or Hanson_A (50.5 cm) and Hanson_B (56.1 cm) (all P < .00001) but similar to XEN+10 (61 cm). Esophageal placement was a potential risk for all methods (NEX: 96.3%, Hanson_A: 99.5%, Hanson_B: 86.9%, XEN+10: 43.2%) and a definite risk for most (NEX and Hanson_A: 14.9%, Hanson_B: 1%, XEN+10: 0%). CONCLUSIONS NEX and Hanson methods of predicting the length from nose to gastric body flexure are too short and risk esophageal misplacement. XEN+10 reduces but does not eliminate this risk. External measurement predictions are clinically unsafe as a guide blind tube placement. Guided placement is recommended.

Background: Dysphagia is a complication following radziation therapy (RT) for head and neck cancers (HNC). Radiologic findings of posterior pharyngeal wall thickening (PPWT) after RT has not been q...

Background Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear. Methods Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX. Results Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively. Conclusion Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.

In the present study, we examined the effects of daily application of capsaicin ointment to the external auditory canal for 6 months on the development of pneumonia in elderly dementia patients at high risk of aspiration.Twenty-nine oldest-old bedridden dementia inpatients at high risk of aspiration were enrolled in the present study. Ointment containing 0.025% capsaicin was applied to each external auditory canal with a cotton swab alternatively once a day for 6 months.The incidence of pneumonia during the 6 months before the intervention was 1.80±0.37 in these patients. However, this incidence significantly decreased to 0.40±0.29 (p0.01) during the 6 months of the alternative application of capsaicin ointment to each auditory canal. No adverse effect such as otalgia was observed.These findings suggest that daily long-term aural stimulation with capsaicin ointment enhanced the cough reflex via Arnold's ear-cough reflex as a glottis protective measure, resulting in the reduction of incidence of pneumonia in elderly dementia patients at high risk of aspiration. The daily aural stimulation with capsaicin ointment may be a safe and promising intervention to prevent aspiration pneumonia in elderly people, especially those who cannot undergo swallowing exercise.

Background Pulmonary aspiration is one of the most important complications of obstetric anesthesia. Prevention of pulmonary aspiration is commonly performed by the application of different anesthetic maneuvers and administration of drugs. This study aimed to assess the non-physician anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia. Methods This survey study was conducted from October 01 to November 05, 2020, on a total of 490 anesthetic providers working in hospitals in Ethiopia. A structured checklist was used to collect data from non-physician anesthetic providers. Results Four hundred and ninety (490) anesthetic providers participated in our study. The majority of the respondents (84%) were working in the public sector. Most of the cesarean delivery was done under regional anesthesia and more than half of anesthetic providers in Ethiopia administered aspiration prophylaxis routinely. Metoclopramide was the most frequently given as a prophylaxis for pulmonary aspiration. Conclusions More than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent cesarean delivery to prevent aspiration.

Background Cases of foreign body aspiration in children may be encountered in emergency departments. A suggestive history is important in diagnosing aspirated foreign body owing to the difficulty in making a diagnosis on the basis of an abnormal physical examination or chest radiography alone. The aim of this study was to examine the sensitivity and specificity of the presenting symptoms, physical examination, and radiologic findings as predictors of foreign body aspiration in children. In addition, a feasible simple algorithm with a scoring system was generated to indicate bronchoscopic investigation. Methods In a retrospective cohort, medical records of patients aged less than 16 years with suspected foreign body aspiration who underwent flexible or rigid bronchoscopy were included. Data including age, sex, symptoms, physical examination findings, radiological features, nature and location of the foreign body, and outcome of the bronchoscopy were collected, and multivariable binary logistic regression analysis was employed for prediction of foreign body aspiration. Results A total of 203 children were included, and the model showed excellent discrimination power for positive foreign body aspiration (area under the curve = 0.911) with an accuracy, sensitivity, and specificity of 86.2, 90.6, and 76.6%, respectively. The total weighted risk score at a cut-off > 2 showed a significant good power of discrimination (area under the curve = 0.879), with a sensitivity of 79.9% and specificity of 84.4%. Accordingly, a clinical algorithm was recommended. Conclusions The proposed scoring system and clinical algorithm might help in decision making with regard to the need and type of bronchoscopy in children presenting with potential foreign body aspiration. However, further prospective multicenter studies should be conducted to validate this scoring system.

Some previously reported cases of brain evisceration in catastrophic craniocerebral injuries showed the presence of brain swelling. The aim of this study was to observe the occurrence of focal or diffuse brain swelling in such cases in order to explain the underlying mechanism. An observational autopsy study included 23 adults, 18 males and 5 females, whose average age was 48 ± 22 years (range: 19-89 years) and who died as the result of catastrophic craniocerebral injury with brain evisceration. In all the examined cases, either focal (12 cases) or diffuse (11 cases) brain swelling was present. Grossly visible brain contusions (either cortical or deep) were rarely present - only in 6 out of 23 cases, while microscopic brain contusions were observed in 22 out of 23 cases, with 1 remaining case of microscopic subarachnoid bleeding. Blood aspiration in the lungs, as a vital reaction, was noted in 20 out of 23 cases. Microscopic examination showed absence of edema in 20 cases and mild edema in only 3 cases, while microscopic signs of moderate or severe edema were absent. Brain swelling in cases of brain evisceration likely represents a biomechanical reaction (i.e. decompression) due to a sudden decrease in intracranial pressure. The rapidity of death, together with marked absence of microscopic signs of edema, suggests that this is not a form of biological response to injury, but rather a pure physical phenomenon, strictly in a living person. In such cases, the occurrence of brain swelling and parenchymal microbleeding should be considered vital reactions.

Contains fulltext : 229043.pdf (Publisher’s version ) (Closed access) PURPOSE OF REVIEW: This review focuses on the use of point-of-care ultrasound (PoCUS) in the obstetric context for airway management and assessment of aspiration risk, the placement of neuraxial blocks and the diagnosis and follow-up of cardiorespiratory dysfunction. RECENT FINDINGS: Gastric ultrasound is a useful aspiration risk assessment tool in pregnant patients. Total gastric fluid assessment models and specific cut-offs between high-risk and low-risk stomachs are presented. Airway assessment is useful to detect specific changes in pregnancy and to guide airway management. Handheld ultrasound devices with automated neuraxial landmark detection capabilities could facilitate needle placement in the future. Lung and cardiac ultrasonography is useful in the management of preeclampsia, pulmonary arterial hypertension and peripartum cardiomyopathy. SUMMARY: Owing to its noninvasiveness, ease of accessibility and lack of exposure to radiation, PoCUS plays an increasing and essential role in aspiration risk assessment, airway management, neuraxial anaesthesia and cardiorespiratory diagnosis and decision-making during pregnancy.

Vocal fold movement impairment may significantly compromise postoperative recovery and quality of life of patients following thoracic or cardiothoracic surgery or prolonged intubation. The literature is limited and there is no standard screening protocol for the optimal postoperative swallowing and aspiration evaluations. We performed retrospective review of adult patients undergoing early vocal fold (VF) injection laryngoplasty for acute postoperative Vocal fold movement impairment (

A 3,040-g appropriate-for–gestational age girl is delivered vaginally at 38 weeks by an 18-year-old primigravida following induction of labor for preeclampsia. Pregnancy complications included obesity and elevated maternal serum α-fetoprotein without open neural tube defect on ultrasonography. The mother had received 2 g/hour of magnesium sulfate during labor. The infant’s Apgar scores are 8 and 9 at 1 and 5 minutes, respectively, and she requires routine postdelivery care. The resuscitation team notes normal physical examination findings, including appropriate tone and intact spine, and the infant remains with her mother. At 90 minutes after birth, she is lying skin to skin on her mother’s chest after attempting breastfeeding and is found by her nurse to be pale, limp, and apneic. She is placed on a radiant warmer, positive pressure ventilation is initiated, and the NICU team is called. On arrival, the NICU team finds the neonate to have cyanosis, hypotonia, and apnea. Her heart rate is 60 beats/min. Despite improvement with positive pressure ventilation, the infant requires intubation for persistent apnea. On physical examination, she is stuporous with no spontaneous activity, and has absent primitive reflexes, flaccid tone, and sluggish pupils. She is admitted to the NICU for management of respiratory failure and neonatal encephalopathy. Her initial arterial blood gas demonstrates severe metabolic acidosis (pH 7.00/pCO2 35/pO2 124/HCO3 9/base deficit -23, lactate 14.9 mg/dL [1.7 mmol/L]). Comprehensive metabolic panel is normal except for low serum carbon dioxide (14 mEq/L [14 mmol/L]) and elevated magnesium (4.7 mg/dL [2.35 mmol/L]). She receives mechanical ventilation and whole-body therapeutic hypothermia is initiated. Umbilical lines are placed. She …

The contribution of hyoid and laryngeal movement deficits to penetration or aspiration in dysphagia is unclear, partly due to large variations in normal hyolaryngeal kinematics for swallowing. In healthy volunteers, laryngeal and hyoid kinematics relate to the requirements for laryngeal vestibule closure suggesting a central schematic control of movement magnitude and patterning for airway protection. Our first aim was to determine if patients with severe dysphagia showed evidence of an impaired swallowing schema, by examining if their kinematic measures were related to their hyolaryngeal space before swallow onset, and if hyolaryngeal movement synchrony for vestibule closure was disrupted. Our second aim was to determine the kinematic measures that predicted bolus penetration and aspiration in dysphagia. The methods included two-dimensional measures of the hyoid and laryngeal anterior and superior displacement and velocity, and the change in laryngeal vestibule area made from videofluoroscopic swallow recordings of 21 healthy volunteers and 21 patients with dysphagia on tube feeding secondary to the stroke or head and neck cancer. The results demonstrated that the patients did not adapt their hyolaryngeal movements during swallowing to their initial hyolaryngeal space. Further, none of the patients' measures of hyoid or laryngeal peak velocity timing were synchronized with vestibule closure, demonstrating a disorganized movement patterning. Laryngeal elevation peak velocity independently predicted penetration and aspiration. In conclusion, the central schema for swallowing patterning was disturbed, impairing the integration of kinematic actions for airway protection in severe dysphagia, while laryngeal peak elevation velocity predicted penetration and aspiration on patient swallows.

The purpose of this study was to conduct a quantitative analysis of the temporal and sequential events of the pharyngeal phase of swallowing in 45 poststroke patients who presented or did not present with supraglottic penetration and/or laryngotracheal aspiration and to compare the groups with each other and to a group of 46 patients with normal swallowing. All individuals were assessed by videofluoroscopy and the temporal and sequential measures for the swallowing of 3 mL and 5 mL of thickened liquid, 3 mL of liquid, and 3 mL and 5 mL of pasty were obtained by analyzing the recorded exams on Virtual Dub software. The following events were measured: time of maximal displacement and sustaining of the hyoid and larynx, duration of velopharyngeal sphincter (VS) and supraglottic closure, total inversion time of the epiglottis, duration of pharyngeal constriction, and duration of upper esophageal sphincter (UES) opening. For the analysis of the temporal sequence, the initial time of larynx and hyoid elevation, VS closure, epiglottic inversion, supraglottic closure, pharyngeal constriction, and opening of the UES were obtained. For 5 mL of thickened liquid, the maximum hyoid elevation time was greater for patients with normal swallowing and the time the supraglottis remained closed was higher in the aspirators group. The time of pharyngeal constriction during swallowing of 3 mL of thickened liquid was lower in the aspirators group. During the swallowing of 3 mL of thin liquid, it was observed that in the aspirators group, the larynx took longer to reach its maximum elevation and the epiglottis took longer to complete its total inversion. The analysis of the temporal sequence showed that patients in the aspirators group presented greater disorganization with significant alteration of the time interval between the events.

OBJECTIVE To determine the frequency of reflux and aspiration in children subjected to reinforced laryngeal mask during laparoscopic surgery in the Trendelenburg position, and evaluate its feasibility. STUDY DESIGN A descriptive study. PLACE AND DURATION OF STUDY Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, from January 2017 to May 2018. METHODOLOGY A total of 300 children, who underwent laparoscopic high ligation of the hernial sac in the Trendelenburg position under general anesthesia, were enrolled into the present study. Reflux and aspiration were assessed by precise saliva pH to determine the pH value at laryngeal mask airway, and at sites on laryngeal mask corresponding to the larynx, face and peripheral area. Then, the presence of food residue was observed at various sites to determine whether there was reflux or aspiration during the operation. RESULTS Suspected reflux (9.67%) was observed in 29 children and suspected aspiration was observed in nine children (3%). There was no definite reflux or aspiration observed in any of the children. Furthermore, the prevalence of suspected reflux was higher in children who were >3 years and overweight, compared to children with a normal body mass index and an age of

To investigate the natural history of silent aspiration in the pediatric population.Retrospective chart review of patients (age3 years) who underwent modified barium swallow studies (MBSS), between January 1, 2007, to December 31, 2017, were studied to compare comorbidities and determine course of resolution in those with silent aspiration.A total of 148 charts were reviewed. Patients that underwent surgical intervention for laryngeal anomalies causing silent aspiration and those with overt aspiration or oral aversion were excluded. Of the 56 patients in the study, 25 had silent aspiration and 31 demonstrated no silent aspiration on MBSS. There was a higher rate of overall comorbidities amongst silent aspirators (96.0% vs. 48.4%, p=0.003) in comparison to patients with no silent aspiration on MBSS. Silent aspirators had higher rates of cerebral palsy (16.0% vs. 0%, p=0.034), and seizures (36.0% vs. 3.2%, p=0.003). Of the 20 patients with silent aspiration with an MBSS completed beyond the initial one, 13 (65.0%) experienced resolution, 5 (20.0%) did not experience resolution by age 5, and 2 (10.0%) had unknown resolution due to being lost to follow up or not yet reaching age 5. No statistically significant associations were found between comorbidities, gender, presence of a gastrostomy tube and resolution.Silent aspiration in children is associated with neurological comorbidities, particularly cerebral palsy and seizures. More than half of the patients with silent aspiration spontaneously resolve over time. Expectant management, close surveillance, and clinical assessments can be considered in these patients on an individual basis.

1. Jane Soung, MD* 2. Sriram Ramgopal, MD* 3. Brett McAninch, MD* 1. *Division of Pediatric Emergency Medicine, Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, PA An 8-month-old previously healthy girl presents to the emergency department with concerns of “not breathing right.” Just before arrival she awoke from her nap screaming. She appeared grey and was breathing rapidly. Her babysitter called 911, and she was brought to the emergency department for further care. The patient had an isolated tactile temperature 4 days before arrival and has been having nasal congestion for approximately 1 week. There are no sick contacts in the household, and the child attends an in-home child care. Her medical history includes term vaginal delivery, up-to-date immunizations, and a maternal uncle with cystic fibrosis. In the emergency department the child is cyanotic and is crying vigorously. Her pulse oximetry is 66% on room air, although there is difficulty getting a proper reading on the pulse oximeter. She is afebrile, her heart rate is 186 beats/min, blood pressure is 112/66 mm Hg, and respiratory rate is 58 breaths/min. There is bilateral air entry on the respiratory examination without audible wheeze or crackles. Cardiac examination is significant for tachycardia but with regular rhythm and without gallop or appreciable murmur. The remainder of the child’s examination findings are normal. She is placed on a nonrebreather mask, her color improves, and pulse oximetry increases to the 80s. A venous blood gas shows pH 7.23, Pco2 of 51 mm Hg, and a bicarbonate level of 21 mEq/L (21 mmol/L). Given this child’s respiratory distress and decreased oxygen saturation, a portable anteroposterior chest radiograph is obtained (Fig 1). Figure 1. Initial anteroposterior radiograph showing almost complete opacification of the right hemithorax (arrow). Note no mediastinal shift and normal …

The penetration-aspiration scale (PAS) is an 8-point scale used to characterize the depth and response to airway invasion during videofluoroscopy. Though widely used in the field of deglutition, there is a lack of consensus regarding the statistical properties of the scale. In order to better understand the state of the literature and the statistical use of the PAS, a systematic review was undertaken to descriptively examine trends in statistical and reporting practices of the PAS since its inception. Online databases were searched for studies citing the original PAS article, which yielded 754 unique articles. Of these, 183 studies were included in the review. Results showed inconsistencies in the statistical use of the scale; 79 studies treated the PAS as ordinal, 71 as categorical, and 49 as interval. Ten types of categorizations were identified. Reporting of power analyses (9%), as well as inter- (26%) and intra-rater (17%) reliability, was uncommon. Among studies that administered multiple bolus volumes or consistencies, 55% reported PAS analyses at the participant/group level only. This review confirms the existence of discrepancies in the statistical treatment of the PAS. A lack of consensus among researchers limits comparisons between studies. The approach to handling this scale dictates the statistical tests used, potentially affecting results and interpretations. Consistent application of statistically sound approaches to PAS analyses is vital for the future of deglutition research.

Little is known about esophageal transit times (ETT) in relation to underlying comorbid disease or aspiration risk. Our study evaluated liquid ETT in patients relative to underlying comorbid disease and compared this with ETT in healthy adults. We examined whether prolonged ETT was associated with swallow risk.Prospective observational study.Radiology department.Patients included those referred to speech pathology for a videofluoroscopic study of swallowing (VFSS) within a tertiary hospital.A total of 617 patients (49% female; mean ± SD age, 77 ± 15 years) and 139 healthy adults (56% female; age, 59 ± 22 years) were included. All patients underwent a standardized VFSS with esophageal screening. Patients were categorized by chief underlying disorder: previous stroke (n = 207), other neurologic condition (n = 188), respiratory conditions (n = 91), or gastroenterology conditions (n = 131). All VFSSs were analyzed with objective measures. ETT and penetration-aspiration scores were compared between groups.Advancing age was significantly associated with increased ETT (Liquid ETTs differ among patients with different underlying primary diagnoses. Patients following stroke show significantly prolonged ETT and increased risk of aspiration. Prolonged ETT may influence symptom complaint and warrants consideration.

Objective This study sought to summarize the clinical characteristics of foreign body aspiration(FBA) in children with negative multi-detector Computed Tomography(MDCT) results and to explore the essential points which determined the patients to undergo bronchoscopy. Methods The medical records of 48 pediatric patients admitted to the department of respiratory medicine in our hospital from January 2011 to October 2018 and diagnosed with foreign body aspiration and negative chest MDCT results were retrospectively analyzed. They were compared with the patients of FBA whose MDCT findings suggested indirect signs, such as atelectasis or emphysema. Results Of the 48 patients, 33 were boys (68.8%) and 15 girls (31.2%), with a mean age of 35.3 months(range, 7–156 months). Cough (47 cases, 97.9%), fever (25 cases, 52.1%) and wheezing (23 cases,47.9%)were the main symptoms.39 patients (81.3%) had abnormal physical signs. None of the MDCT or three dimension(3D) images based on MDCT revealed foreign bodies in these children, while the results were: signs of lung infection without atelectasis or emphysema 52.1%(25 cases), increase of lung markings16.7%(8 cases),bronchiectasis 6.3%(3 cases), or normal 27.1%(13 cases). 41 Patients were successfully removed their foreign bodies(A further 5 had the FB removed from the tracheobronchial tree but it was then swallowed before retrieval. The remaining 2 cases had to be referred to another hospital for further management), most of which were organic. The shapes of foreign bodies were small granular (23 cases, 56.1%), sheet or powder (18 cases, 43.9%). The control group was 13 patients of FBA whose MDCT findings suggested indirect signs of atelectasis or emphysema during the same time. The result of comparison showed the clear history of FBA was statistically different between the two groups. Conclusions Foreign body aspiration could not be ruled out with negative MDCT in patients clinically suspected. Typical foreign body aspiration history and ineffective conservative treatment could provide important basis of performing bronchoscopy. Complicated with lung infection and the shape of foreign bodies may affect the false negative results of MDCT.

To assess the reliability and construct validity of the Penetration-Aspiration Scale in children.This was a retrospective cohort study of pre- and postoperative video modified barium swallow studies from children who underwent interarytenoid injection augmentation for unexplained persistent pharyngeal dysphagia. Two pediatric speech and language pathologists reviewed each study twice in a blinded and randomized fashion.Tertiary academic pediatric hospital.Thirty children were identified with adequate pre- and postoperative modified barium swallow studies within 4 weeks of intervention. Children were separated into clinical outcome groups based on ability to advance to thinner diet consistencies postoperatively. Construct validity was assessed with a mixed linear model to test the hypothesis that only the clinically improved group would receive better Penetration-Aspiration Scale scores after surgery. Reliability was assessed by calculating chance-corrected agreement between raters (interrater) and raters' repeat evaluations (intrarater).Inter- and intrarater reliabilities (Cohen's κ) were both excellent. Results of the mixed model revealed a significant interaction between outcome group and pre- and postoperative time interval. As hypothesized, this involved a significant improvement in Penetration-Aspiration Scale score only in the improved group.These findings suggest that the Penetration-Aspiration Scale is a reliable and valid measure of clinical response to interarytenoid injection augmentation in children.

RATIONALE A variety of inhaled antigens have been implicated to cause hypersensitivity pneumonitis (HP). We observed that children force-fed with lentil-based weaning food had persistent respiratory symptoms and radiology similar to HP. OBJECTIVES To describe the clinical features of lentil HP. METHODS We conducted a retrospective review of records of children with lentil HP attending Pediatric Chest Clinic at a tertiary care hospital in North India from 2008-2018. We included case records with elevated immunoglobulin G (IgG) specific for lentil antigen. MEASUREMENTS AND MAIN RESULTS Nine children (seven boys) were identified with median (IQR) age of onset of symptoms and diagnosis at 9 (6, 12) and 11 (10, 16) months, respectively. Chronic cough (100%), shortness of breath (89%), fever (78%), vomiting (56%), and wheezing (33%) were common symptoms. Fine crackles were heard in 33% of children, none had clubbing. CT scans showed nodular opacities and consolidation in 78% and 67% children, respectively. Bronchoalveolar lavage showed increased neutrophils and lymphocytes (67% and 33%, respectively). All children showed rapid remission with systemic steroids (prednisolone), starting at a median dose of 1 (1, 1.1) mg kg-1 day-1 . One child had a clinical relapse which was treated with oral steroids again. IgG specific to lentil antigens was elevated in children with lentil HP (21->200 mgA/L) compared with children with other chronic respiratory illnesses (n = 7

Dysphagia and vocal cord dysfunction are frequent complications after congenital heart surgery. Both are risk factors for aspiration, which can lead to pneumonia, progressive lung disease, and respiratory arrest. A protocol was implemented to promote early detection of aspiration in a high-risk cohort of patients. Retrospective data were collected on all patients under 120 days old who underwent the Norwood procedure, aortic arch repair, Blalock-Taussig shunt placement, or cervical cannulation for extracorporeal membrane oxygenation from 10/2012 to 05/2016 at a single institution. Patients underwent an assessment of symptoms, fiberoptic endoscopic evaluation of swallowing (FEES), and modified barium swallow (MBS) study in the postoperative period prior to initiating oral feeds. Patients with and without aspiration were compared. Of the 96 patients included in the study, one-third (33%) of patients had evidence of vocal cord dysfunction by FEES and just over half (51%) had evidence of aspiration by FEES or MBS. Most (73%) of the patients with aspiration were asymptomatic and a majority (53%) of patients with aspiration had normal vocal cord function. Aspiration is common after congenital heart surgery, and an assessment of vocal cord or swallow function in isolation may lead to underdiagnosis. A comprehensive protocol including MBS and FEES is necessary for the early detection of vocal cord dysfunction and aspiration and may prevent adverse outcomes in high-risk postoperative patients.

Ryuji Hori1,2, Rika Ishida,1 Masaaki Isaka,3 Takahito Nakamura,4 Yoshitaka Oku51Department of Physical Therapy, Morinomiya University of Medical Science, Suminoe-ku, Osaka 559-8611, Japan; 2Department of Rehabilitation, Hoshigaoka Medical Center, Hirakata, Osaka 573-8511, Japan; 3Department of Physical Therapy, Osaka Yukioka College of Health Science, Ibaraki, Osaka 567-0801, Japan; 4Center of Respiratory Disease, Hoshigaoka Medical Center, Hirakata, Osaka 573-8511, Japan; 5Department of Physiology, Hyogo College of Medicine, Nishinomiya, Hyogo 663-8501, JapanPurpose: As shown in our previous study, inspiration after swallowing (SW-I) increases during the bi-level positive airway pressure ventilation (BiPAP) in healthy subjects because swallowing-associated non-inspiratory flow (SNIF) triggers inspiratory support, while SW-I during continuous positive pressure ventilation (CPAP) is rare. In the present study, we evaluated the coordination between breathing and swallowing during spontaneous breathing, BiPAP, and CPAP in patients with chronic obstructive pulmonary disease (COPD).Patients and methods: This study is a prospective intervention study at the Hoshigaoka Medical Center (November 01, 2015–April 30, 2018). We simultaneously recorded the respiratory flow, laryngeal motion, and swallowing sounds during saliva swallowing in patients with COPD. We estimated the respiratory phase after swallowing, frequency of SNIF, the duration of the respiratory pause during swallowing, and timing of swallowing in the respiratory cycle and compared these parameters among control, CPAP, and BiPAP conditions.Results: The expiration after swallowing (SW-E) frequency was associated with the occurrence of SNIF (p

To clarify the reliability of fiberoptic endoscopic evaluation of swallowing (FEES) compared to videofluoroscopic swallowing studies (VFSSs). Second, we explored the effect of the chin-down maneuver in the presence or absence of vocal fold paralysis (VFP) using FEES in patients with 3-field lymphadenectomy (3FL) postesophagectomy.Retrospective data collection from FEES and VFSS.Dysphagic clinics in the ear, nose, and throat department.Patients (N=15) underwent esophagectomy with 3FL at the Department of Gastroenterologic Surgery, during a period of 12 months.The patients underwent FEES and VFSS with neutral and chin-down maneuvers 2 weeks postoperatively. Two raters of speech pathology blindly scored aspiration, penetration, delayed initiation, and pharyngeal clearance in the pyriform sinus and vallecula, respectively, from recorded movie clips of both examinations, using the penetration aspiration scale (PAS) and modified Hyodo FEES rating scale.The intrarater and interrater correlation coefficients of each parameter examined with FEES. Statistical comparison of each parameter between FEES and VFSS and of each parameter evaluated using FEES between 2 maneuvers with or without VFP.The intrarater and interrater correlation coefficients of the PAS and pyriform sinus examined with FEES were both statistically consistent between the 2 raters. The PAS and pyriform sinus evaluated using FEES were significantly correlated with those evaluated in a VFSS (P.05). The 2 parameters evaluated using FEES were significantly (P.05) improved with the chin-down maneuver compared to the neutral maneuver, especially in VFP patients.FEES performed postesophagectomy with 3FL for evaluation of aspiration is as reliable statistically as VFSSs. The chin-down maneuver is especially useful for reducing the PAS score and pyriform sinus in VFP patients.

Objective To determine differences between continuous videofluoroscopic swallow studies (VFSS) with a pulse rate and frame rate of 30 and the same swallows reduced to 15 frames per second (fps) on measures of swallowing function in patients after acute ischemic stroke. Design Blinded comparison. Setting Acute hospital. Participants Patients after ischemic stroke (N=20). Interventions Not applicable. Main Outcome Measures Single and sequential sips of thin liquids, single sips of nectar liquids, pudding, and cookie boluses were rated on measures of timing of swallowing events, Modified Barium Swallowing Impairment Profile component scores, and Penetration-Aspiration Scale scores. The ratings for videos at 15 fps and 30 fps were compared by Wilcoxon signed rank tests. Results Pharyngeal transit time was longer and bolus entry into the hypopharynx was later for 30 fps than for 15 fps. Components of Oral Residue and Pharyngoesophageal Segment Opening ratings were more severe for 15 fps than 30 fps, whereas Bolus Transport and Initiation of Pharyngeal Swallow were rated as more severe for 30 fps than for 15 fps. There was no difference between 30 fps and 15 fps on the remaining measures, including Penetration-Aspiration Scale scores. Conclusion Continuous VFSS recorded at 30 fps and their down-sampled 15 fps duplicates yielded contrasting results on certain durational and functional measures of swallowing, though not on others. VFSS should be administered continuously or at 30 pulses per second for valid assessment of swallowing while using other methods to reduce radiation exposure.

Background and objectives: Pregnant women are considered patients at risk for pulmonary aspiration of gastric contents. The study aim was to evaluate the gastric antral cross-sectional area using ultrasound. Method: In this prospective study, 85 scheduled term pregnant women underwent gastric ultrasound. The outcomes were the measurement of the gastric antral cross-sectional area (main outcome), the estimated gastric volume, the incidence of pregnant women at risk for pulmonary aspiration, and the association between gastric antral cross-sectional area and clinical-demographic characteristics. Gastric antral cross-sectional area and gastric volume were compared according to body mass index

INTRODUCTION: Dysphagia is a highly prevalent disorder in Parkinson’s Disease (PD) characterized by changes in swallowing kinematics, residue, and airway invasion. These changes can lead to serious medical morbidities including malnutrition, aspiration pneumonia, and death. However, little is known about the most predictive causes of residue and airway invasion in this patient population. Therefore, the aims of this study were to: 1) assess how disease severity affects residue, airway invasion, and swallowing kinematics in PD; and 2) determine which swallowing kinematic variables were most predictive of residue and airway invasion. METHODS: A secondary analysis of forty videofluoroscopic swallow studies (VFSS) from individuals with early through mid-stage PD was performed. Airway invasion (Penetration-Aspiration Scale ‘PAS’), residue (Bolus Clearance Ratio ‘BCR’), and ten spatiotemporal swallowing kinematic variables were analyzed. Statistical analyses were used to determine if disease severity predicted residue, depth of airway invasion, and swallowing kinematics, and to examine which swallowing kinematic variables were most predictive of residue and the presence of airway invasion. RESULTS: Results revealed that residue and the presence airway invasion were significantly predicted by swallowing kinematics. Specifically, airway invasion was primarily influenced by the extent and timing of airway closure, while residue was primarily influenced by pharyngeal constriction. However, disease severity did not significantly predict changes to swallowing kinematics, extent of residue, or depth of airway invasion during VFSS assessment. DISCUSSION: This study comprehensively examined the pathophysiology underlying dysphagia in people with early to mid-stage PD. The results of the present study indicate that disease severity alone does not predict swallowing changes in PD, and therefore may not be the best factor to identify risk for dysphagia in PD. However, the swallowing kinematics most predictive of residue and the presence of airway invasion were identified. These findings may help to guide the selection of more effective therapy approaches for improving swallowing safety and efficiency in people with early to mid-stage PD.

Postswallow pharyngeal pooling may be a risk factor for tracheal aspiration. However, limited literature shows the potential association between pharyngeal pooling and aspiration in head and neck cancer (HNC) patients. This study investigates the relationship between postswallow pharyngeal pooling and aspiration in HNC patients with oropharyngeal dysphagia. Furthermore, the effects of tumor stage, tumor location, and cancer treatment on aspiration were examined. Ninety dysphagic HNC patients underwent a standardized fiberoptic endoscopic evaluation of swallowing (FEES) using thin and thick liquid boluses. For each swallow, three visuoperceptual ordinal variables were scored: postswallow vallecular pooling, postswallow pyriform sinus pooling, and aspiration. Logistic regression analyses with correction for the location of pooling, tumor stage, tumor location, and cancer treatment were performed to explore the association between pooling and aspiration. No significant association was found between postswallow vallecular pooling and aspiration for thin liquid. However, severe versus mild-to-moderate postswallow vallecular pooling of thick liquid was significantly associated to aspiration. Similar results were seen after correction for the presence of pyriform sinus pooling, tumor stage, tumor location, or type of cancer treatment. This study showed a significant association between severe postswallow pyriform sinus pooling of thick liquid and aspiration, independent of the presence of vallecular pooling, tumor stage, tumor location, or cancer treatment. Concluding, location (valleculae versus pyriform sinuses), liquid bolus consistency (thin versus thick liquid), and amount of postswallow pharyngeal pooling (no pooling, mild/moderate pooling, severe pooling) have an influence on the probability of aspiration in dysphagic HNC patients, and they should be carefully considered during FEES, even in the absence of aspiration during the examination. Electronic supplementary material The online version of this article (10.1007/s00455-019-09992-x) contains supplementary material, which is available to authorized users.

OBJECTIVES/HYPOTHESIS Timing and indication for surgical intervention is a major challenge in managing pediatric oropharyngeal dysphagia. No study has evaluated a natural course of swallowing dysfunction in otherwise healthy infants. Our objective was to review the outcomes and time to resolution of abnormal swallow in infants with aspiration. STUDY DESIGN Retrospective case series at a tertiary children's hospital. METHODS Fifty patients under 1 year old with aspiration on a modified barium swallow study were included. Patients born

To examine the correlation between pharyngeal residue severity and clearance to penetration/aspiration on fiber-optic endoscopic examination of swallowing (FEES).Retrospective cohort.Kaplan Medical Center dysphagia clinic.Patients (N=110) visiting a dysphagia clinic between 2014 and 2016 undergoing FEES.FEES were scored for penetration/aspiration with the Penetration Aspiration Scale (PAS), for residue severity using the Yale Pharyngeal Residue Severity Rating Scale (YPR-SRS). The numbers of swallows required to clear the pharynx were recorded. The first and the worst bolus challenges for each consistency (liquid, purée, solid) were analyzed.YPR-SRS and number of clearing swallows were correlated with the PAS of the same bolus challenge.The study population's mean age was 67±13.4 years; 54% were men (n=58). A significant correlation was found between the YPR-SRS and the PAS for all consistencies tested, in each anatomical site (vallecula or pyriform sinus) and for both the first and worst bolus challenges (P.001 for all). The correlation of residue with aspiration was stronger when vallecula and pyriform sinuses scores were summated (Pearson product-moment correlation coefficient=0.573/0.631/0.446 for liquid/purée/solid for worst bolus challenge). Incorporating the number of clearing swallows to the YPR-SRS strengthened the correlation with PAS.Residue severity and clearance correlate with penetration/aspiration on FEES. The YPR-SRS can be applied to standardize description of residue in FEES and to aid in dysphagia evaluation.

Objectives Deep interarytenoid notch (DIN) is a congenital variation of the larynx often associated with dysphagia and aspiration (DA) in young children. Feeding therapy with thickeners and surgical management with injection larygoplasty (IL) are used with various efficacies. Thickeners address the functional domain and IL addresses the anatomical domain of treatment. Our objective was to evaluate DIN patients managed with both interventions. Methods We conducted a retrospective pilot descriptive study of DIN patients with DA aged 1–3 years receiving thickeners and IL. Patients received a systematic weekly reduction of thickeners, referred to as the Thickener Weaning Protocol (TWP), based on clinical signs and symptoms of DA. The outcomes were assessed by the rate of thickener level reduction and DA-related sign/symptom frequency achieved at 6 months post-treatment. Results Thirteen patients with DIN associated DA were analyzed. The TWP was initiated within 2 months in 77% of patients, and within 4 months in 100% of patients. Thickener scores improved from an average of 5.76 (3/4 honey) to 2.15 (thin) (p = 0.001). DA-related signs/symptoms frequency improved from an average of 3.3 to 0.84 (p = 0.05). Conclusions These findings suggest that treatment of DIN associated DA with a combination of thickeners and IL results in significant clinical improvements in young children.

To compare the results of a simultaneously performed videofluoroscopic swallowing study and fiberendoscopic evaluation of swallowing in patients with dysphagia after surgery and radiotherapy for oropharyngeal or laryngeal cancer. This prospective study included 31 patients who were examined simultaneously with a standardized protocol. The fiberendoscopic and videofluoroscopic swallowing loops were independently scored by two otorhinolaryngologists/phoniatricians and two radiologists. The presence of penetration/aspiration, the amount of pharyngeal residues and the position of the bolus head when triggering of pharyngeal swallow begins were evaluated. Generalized linear models were used to model the impact of rater, method, bolus and quantities as well as specified moderation effects on scorings. In addition, post hoc Wilcoxon tests were used. Rater agreement was assessed using weighted kappas and their 95% confidence intervals. A total of 202 swallow sequences in 29 patients was evaluated. Interrater agreement was substantial to excellent for both methods (weighted k = 0.979–0.613). Significant differences between both methods were found when assessing the penetration-aspiration scale (p = 0.001, tendency of higher scores by videofluoroscopic (median = 2.59) as opposed to fiberendoscopic (median = 2.14) and the residue severity scores in the valleculae (p = 0.029) and the sinus piriformes (p = 0.002) with larger residues scored by fiberendoscopic evaluation of swallowing. No significant differences were found regarding the time point of triggering (p = 0.273). Simultaneous evaluation of swallowing with FEES and VFSS showed significantly different results in symptomatic patients after tumor operation and radiotherapy. Electronic supplementary material The online version of this article (10.1007/s00455-019-09979-8) contains supplementary material, which is available to authorized users.

Introduction Although injection laryngoplasty (IL) is a well-accepted treatment strategy in older children and adults with unilateral vocal fold immobility (UVFI), its efficacy and safety have not been well studied in neonates and young children. Objectives The main objective of this study was to evaluate the clinical and radiographic effects of IL on aspiration & dysphagia in neonates and young children with UVFI. Methods This was a retrospective chart review of infants and children who underwent IL at a tertiary children's hospital. The primary endpoints were improved aspiration and avoidance of gastrostomy tube placement. Additional endpoints included adverse airway and swallowing effects of IL. Results Eight patients were included in this case series. A total of 10 injection laryngoplasties were performed. Average corrected age of patients undergoing IL was 1.22 years(range 0.5–3.6 y). Seven out of 8 patients had preoperative modified barium swallow (MBS). Five out of seven showed improvement in aspiration. Three out of six (50%) patients who did not have gastrostomy tube preoperatively, were able to avoid gastrostomy tube. No adverse effects were noted following IL. One patient with severe tracheomalacia ultimately required tracheostomy 5 months after IL. Conclusion Injection laryngoplasty appears to be a safe and effective therapeutic option in neonates and young children with unilateral vocal cord immobility and associated aspiration. It may be an effective treatment to improve aspiration and avoid gastrostomy tube placement. Further investigation is warranted. Level of evidence 4.

We assess the utility of a Centers for Disease Control and Prevention (CDC) guidelines-based coronavirus disease 2019 (COVID-19) screening checklist for postmortem severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) surveillance, detailing the relationship between the histologic findings at autopsy and attribution of death to COVID-19.SARS-CoV-2 nasopharyngeal swabs were collected at the time of autopsy in all "checklist-positive" decedents. Additional "checklist-negative" decedents were randomly tested daily. Lung slides were blindly reviewed by 3 pathologists, assessing for the presence of diffuse alveolar damage (DAD) and other findings. Sixteen decedents had positive postmortem SARS-CoV-2 nasopharyngeal swabs and underwent complete autopsies. Seven decedents had positive screening checklists. Of these, 4 had DAD and 1 had COVID-19-associated thromboembolic disease. Of the 9 decedents with negative screening checklists, 2 had DAD, but only 1 was attributed to COVID-19; the other was likely drug related. Acute bronchopneumonia was the second most common finding, and aspiration was the likely etiology in cases without concomitant DAD. COVID-19-related DAD was identified more commonly in decedents who screened positive by CDC checklist, but false-negatives did occur. Medical examiner offices should maintain a low threshold for random testing of decedents even when COVID-19 is not suspected.

Polypharmacy and specific medication classes are prevalent in older adults. Their relationships with swallowing disorders are not well explored, which would best be managed holistically, with consideration of medication profiles. This study aimed to establish profiles of polypharmacy in older adults and investigate the associations of polypharmacy and medication class with signs of aspiration during swallowing.This was a secondary retrospective analysis of data from 291 adults aged 60 years and older. Polypharmacy was profiled numerically and described. Multivariate logistic regression was used to identify associations between medication classes with signs of aspiration, while controlling for independent variables of demographics, functional status, and medical history.Three distinct profiles of polypharmacy were described. Higher numbers of medications were associated with higher age, lower functional status, nursing home residency, multimorbidity, and showing signs of aspiration. Thirty-four classes of medications were found in this study, benzodiazepines were the only class independently associated with signs of aspiration.Different profiles of polypharmacy can be observed in older adults, but none were independently associated with signs of aspiration. In addition to known demographic and functional status variables, benzodiazepine-use was found to be independently associated with signs of aspiration (p = .005, B = 7.94).

Background Despite well-defined recommendations, prolonged fasting times for clear fluids and solids are still common before elective surgery in adults. Extended fasting times may lead to discomfort, thirst, hunger and physiological dysfunctions. Previous studies have shown that prolonged fasting times are frequently caused by patients being misinformed as well as inadequate implementation of the current guidelines by medical staff. This study aimed to explore how long elective surgery patients fast in a German secondary care hospital before and after the introduction of an educational note for patients and re-training for the medical staff. Methods A total of 1002 patients were enrolled in this prospective, non-randomised interventional study. According to the power calculation, in the first part of the study actual fasting times for clear fluids and solids were documented in 502 consecutive patients, verbally instructed as usual regarding the recommended fasting times for clear fluids (2 h) and solids (6 h). Subsequently, we implemented additionally to the verbal instruction a written educational note for the patients, including the recommended fasting times. Furthermore, the medical staff was re-trained regarding the fasting times using emails, newsletters and employee meetings. Thereafter, another 500 patients were included in the study. We hypothesised, that after these quality improvement procedures, actual fasting times for clear fluids and solids would be more accurate on time. Results Actual fasting times for clear fluids were in the median 11.3 (interquartile range 6.8–14.3; range 1.5–25.5) h pre-intervention, and were significantly reduced to 5.0 (3.0–7.2; 1.5–19.8) h after the intervention (median difference (95%CI) − 5.5 (− 6.0 to − 5.0) h). The actual fasting times for solids also decreased significantly, but only from 14.5 (12.1–17.2; 5.4–48.0) h to 14.0 (12.0–16.3; 5.4–32.0) h after the interventions (median difference (95%CI) − 0.52 (− 1.0 to − 0.07) h). Conclusions The study showed considerably extended actual fasting times in elective adult surgical patients, which were significantly reduced by simple educational/training interventions. However, the actual fasting times still remained considerably longer than defined in recommended guidelines, meaning further process optimisations like obligatory fluid intake in the early morning are necessary to improve patient comfort and safety in future. Trial registration German registry of clinical studies (DRKS-ID: DRKS 00020530, retrospectively registered).

NPC is the most widely found malignant tumor in the head and neck region in Indonesia. Chemoradiation therapy for NPC can induce swallowing disorders (dysphagia) that adversely affects a patients quality of life. This study aimed to assess the swallowing process by flexible endoscopic evaluation of swallowing in patients with nasopharyngeal carcinoma after chemoradiation. Thirty-nine patients with NPC who had chemoradiation therapy more than one month previously underwent flexible endoscopic evaluation of swallowing and were assessed for oral transport time, sensation, standing-secretion, pre-swallowing leakage, residue, penetration, aspiration, and silent aspiration. The most common structural abnormalities were an upright and swollen epiglottis (89.4%), poor oral hygiene, and velopharyngeal closure defects (56.4%). This examination also revealed a mild degree of standing secretion (38.5%) and aspiration (10.3%). No penetration was observed in 64.1% of the patients, and no silent aspiration was observed in any of the patients. A severe degree of residue (45.7%) was observed when administering oatmeal, while the residue was mild to moderate when administering gastric rice, crackers, and milk. The residue changed to a mild degree (32.3%–51.4%) in all food administrations after the watering maneuver. The highest penetration was noted after oatmeal administration (42.8%), and the highest aspiration was found after milk administration (8.6%). Standing secretion in almost all patients was caused by hyposensitivity of the hypopharynx. Persistent residue and hyposensitivity of the hypopharynx led to aspiration. The low percentage of aspiration and silent aspiration might have been caused by the upright and swollen epiglottis that prevented aspiration. Poor oral hygiene and a dry mouth led to prolonged oral transport. Therefore, most patients had hypopharyngeal abnormalities in the form of a swollen and upright epiglottis. Secretion and food residue were also detected. Drinking helps to expedite the swallowing process by facilitating oral phase transport and reducing residues.

Background: Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. Research Question: What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? Study Design and Methods: This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. Results: We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P =.021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P 50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. Interpretation: Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.

Background The purpose of our study was to assess the frequency of occult foreign body aspiration (FBA) and to evaluate the diagnostic difficulties and therapeutic methods for these patients. Methods Between May 2000 and May 2020, 3557 patients with the diagnosis of FBA were treated in our department. Thirty-five patients with occult FBA were included in this study. A retrospective analysis of medical records was performed. Results Twenty-three male patients (65.7%) and 12 female patients (34.3%) were hospitalized due to occult FBA. The average age was 3.60 years (range 9 months-12 years). Most of the patients were younger than 3 years old (n = 25, 71.4%). Coughing (n = 35, 100%) and wheezing (n = 18, 51.4%) were the main symptoms and signs. All the patients were found to have a FBA under the fiberoptic bronchoscope. The most common organic foreign bodies were peanuts (n = 10) and the most common inorganic foreign bodies were pen caps (n = 5). The extraction of foreign bodies under rigid bronchoscopy was applied successfully in 34 patients. Only one patient needed a surgical intervention. Conclusions Occult FBA should always be considered in the differential diagnosis of chronic or recurrent respiratory diseases that are poorly explained, even in the absence of a previous history of aspiration.

BackgroundMicroaspiration of gastric and oropharyngeal secretions is the main causative mechanism of ventilator-associated pneumonia (VAP). Transesophageal echocardiography (TEE) is a routine investigation tool in intensive care unit and could enhance microaspiration. This study aimed at evaluating the impact of TEE on microaspiration and VAP in intubated critically ill adult patients.MethodsIt is a four-center prospective observational study. Microaspiration biomarkers (pepsin and salivary amylase) concentrations were quantitatively measured on tracheal aspirates drawn before and after TEE. The primary endpoint was the percentage of patients with TEE-associated microaspiration, defined as: (1) ≥ 50% increase in biomarker concentration between pre-TEE and post-TEE samples, and (2) a significant post-TEE biomarker concentration (> 200 μg/L for pepsin and/or > 1685 IU/L for salivary amylase). Secondary endpoints included the development of VAP within three days after TEE and the evolution of tracheal cuff pressure throughout TEE.ResultsWe enrolled 100 patients (35 females), with a median age of 64 (53–72) years. Of the 74 patients analyzed for biomarkers, 17 (23%) got TEE-associated microaspiration. However, overall, pepsin and salivary amylase levels were not significantly different between before and after TEE, with wide interindividual variability. VAP occurred in 19 patients (19%) within 3 days following TEE. VAP patients had a larger tracheal tube size and endured more attempts of TEE probe introduction than their counterparts but showed similar aspiration biomarker concentrations. TEE induced an increase in tracheal cuff pressure, especially during insertion and removal of the probe.ConclusionsWe could not find any association between TEE-associated microaspiration and the development of VAP during the three days following TEE in intubated critically ill patients. However, our study cannot formally rule out a role for TEE because of the high rate of VAP observed after TEE and the limitations of our methods.

BACKGROUND Simple water-swallowing screening tools are not predictive of aspiration and dysphagia in patients with Parkinson's Disease (PD). We investigated the diagnostic accuracy of a multi-texture screening tool, the Gugging Swallowing Screen (GUSS) to identify aspiration and dysphagia/penetration in PD patients compared to flexible endoscopic evaluation of swallowing (FEES). METHODS Swallowing function was evaluated in 51 PD participants in clinical 'on-medication' state with the GUSS and a FEES examination according to standardized protocols. Inter-rater reliability and convergent validity were determined and GUSS- and FEES-based diet recommendations were compared. KEY RESULTS Inter-rater reliability of GUSS ratings was high (rs = 0.8; p