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Feeding abnormalities, swallowing dysfunction, and gastrointestinal issues cause poor weight gain, oral motor dysfunction, and air swallowing in children with Rett syndrome (RTT). Pneumonia is the leading cause of death. Our study describes fiberoptic endoscopic swallowing findings in 11 female RTT children. Each patient was evaluated using the 8-point Penetration/Aspiration Scale (PAS). The average age was 7 years. All patients had tongue dyskinesis and prolonged oral stage. Eight girls exhibited liquid entering the airway without coughing, whereas 6 did well with pureed meal. Three girls had pneumonia. Age was not correlated with pneumonia episodes ( P = .18). Pureed material was related with pneumonia ( P = .006), whereas liquids were not. Pureed PAS was positively correlated with Liquid PAS ( P = .008) and age ( P = .004). All aspiration/penetration incidents occurred before the pharyngeal phase. No patient under 7 years experienced pneumonia episodes. Silent aspiration can occur early in infancy, although pneumonia episodes can occur later., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia., Methods: We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan-Meier curves, and used logistic regression to identify independent prognostic factors., Results: 803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ 2  = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death., Conclusion: The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient., (© 2024. The Author(s).)

Objective: To evaluate the combined impact of videofluoroscopic swallow study (VFSS) and therapeutic feeding and swallowing interventions on clinical outcomes in children with oropharyngeal dysphagia (OPD)., Methods: This was an uncontrolled longitudinal analytical study in which OPD patients were evaluated before and after VFSS. Children ≤ 24 months of age diagnosed with OPD in a clinical setting and undergoing VFSS for investigation and management of OPD were included in the study. The study participants received therapeutic feeding and swallowing interventions after having undergone VFSS, being followed at an outpatient clinic for pediatric dysphagia in order to monitor feeding and swallowing difficulties. Respiratory and feeding outcomes were compared before and after VFSS., Results: Penetration/aspiration events were observed in 61% of the VFSSs (n = 72), and therapeutic feeding and swallowing interventions were recommended for 97% of the study participants. After the VFSS, there was a reduction in the odds of receiving antibiotic therapy (OR = 0.007) and in the duration of antibiotic therapy (p = 0.014), as well as in the odds of being admitted to hospital (p = 0.024) and in the length of hospital stay (p = 0.025). A combination of oral and enteral feeding became more common than oral or enteral feeding alone (p = 0.002)., Conclusions: A high proportion of participants exhibited penetration/aspiration on VFSS. Therapeutic feeding and swallowing interventions following a VFSS appear to be associated with reduced respiratory morbidity in this population.

Objective: To evaluate management strategies and pulmonary outcomes for breastfed infants with oropharyngeal dysphagia., Study Design: We performed a retrospective cohort study of breastfed infants diagnosed with oropharyngeal dysphagia with documented aspiration or laryngeal penetration on videofluoroscopic swallow study (VFSS). Medical records were reviewed for VFSS results and speech-language pathologist recommendations following VFSS, results of chest x-ray, results of bronchoalveolar lavage (BAL) within 1 year of VFSS, and aspiration-related hospitalizations occurring before or within 1 year of VFSS. Subjects were categorized as cleared or not cleared to breastfeed based on the VFSS. Proportions were compared with Chi-square and Fisher's exact tests and means with Student's t-tests., Results: Seventy-six infants (4.7 ± 0.4 months old) were included; 50% (38) had aspiration and 50% (38) had laryngeal penetration. After VFSS, 70% (53) were cleared to breastfeed while 30% (23) were not cleared to breastfeed. Patients with aspiration were less likely to be cleared to breastfeed (p = .006); however, 55% (21/38) of those with aspiration were still cleared to breastfeed. Infants cleared to breastfeed had significantly more pulmonary hospitalizations (p = .04) and were also at increased risk of elevated neutrophil count (p = .02) and culture growth on BAL (p = .01). Significantly increased abnormal neutrophil count was also found in those cleared to breastfeed with laryngeal penetration (p = .01)., Conclusions: Infants with oropharyngeal dysphagia counseled to continue breastfeeding had increased risk of BAL inflammation and more pulmonary hospitalizations compared to those that were told to stop breastfeeding., (© 2023 Wiley Periodicals LLC.)

Background: Swallow and cough impairments lead to aspiration and reduced clearance of aspirate material. Both behaviors are impaired in Parkinson's disease, but it is unknown whether a similar relationship of dysfunction exists in forms of atypical Parkinsonism (APD). Elucidating this association in APD may lead to early, comprehensive airway protection treatment., Objectives: We tested the hypotheses that swallow deficits in APD are associated with impaired cough and that airway protective dysfunction is associated with longer disease duration., Methods: Swallowing difficulty was described by 11 participants with APD. Penetration-Aspiration Scale (PAS) and DIGEST scores for thin liquid trials were extracted from medical records of videofluoroscopic swallow study reports. Voluntary and capsaicin induced-reflex cough measures of flow, volume, and timing were analyzed., Results: While most participants did not have post-swallow residue, ~80% received abnormal PAS scores and reported swallowing difficulty. Those with abnormal PAS scores had lower voluntary cough expired volume (P = 0.037; mean rank difference = 5.0); lower reflex inspiratory flow rate (P = 0.034; mean rank difference = 5.5); and longer reflex expiratory flow rise time (P = 0.034; mean rank difference = 5.5). Higher PAS scores and reduced reflex cough volume acceleration were significantly correlated (r = -0.63; P = 0.04) and longer disease duration predicted larger voluntary cough expired volume (R 2  = 0.72) and longer flow rise times (R 2  = 0.47)., Conclusions: As swallow safety worsens, so might the ability to clear the airways with effective cough in in APD; particularly with longer disease duration. Assessing cough in conjunction with swallowing is important for informing airway protection treatment plans in APD., (© 2023 International Parkinson and Movement Disorder Society.)

Background:  The early identification of risk for dysphagia in patients with Parkinson's disease (PD) is essential for the prevention of nutritional and pulmonary complications., Objective:  To analyze the sensitivity and specificity of the Swallowing Disturbance Questionnaire (SDQ-PD) and the Eating Assessment Tool (EAT-10) in identifying dysphagia risk in patients with early and intermediate stages of PD., Methods:  Twenty-nine patients with PD participated in the study. EAT-10 and SDQ-PD questionnaires were applied, and a videofluoroscopic swallowing study. Dysphagia Outcome and Severity Scale (DOSS) was used to classify the presence and severity of dysphagia, and the Penetration-Aspiration Scale (PAS) was used to identify the presence of penetration/aspiration. In the statistical analysis, the sensitivity and specificity of the risk questionnaires were calculated, as well as positive predictive value, negative predictive value, and accuracy., Results:  EAT-10 to identify the risk of penetration/aspiration revealed a sensitivity of 71.42% and specificity of 45.45%; in the identification of the presence of dysphagia, the sensitivity was 47.61%, and the specificity was 12.5%. The SDQ-PD questionnaire for risk of penetration/aspiration demonstrated a sensitivity of 28.57%, and a specificity of 68.18%. In terms of identifying the presence of dysphagia, the sensitivity was 20%, while the specificity was 44.44%., Conclusion:  The SDQ-PD revealed low sensitivity and low specificity to identify the presence of dysphagia and/or penetration/aspiration in patients with early and intermediate stages of PD in this sample. Despite its low specificity, the EAT-10 exhibited good sensitivity in indicating the risk of penetration/aspiration., Competing Interests: There is no conflict of interest to declare., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/).)

Purpose: To assess the outcomes of endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis (BAVFP) using radiofrequency versus coblation., Methods: This was a randomized prospective cohort study that carried out on 40 patients with BAVFP who were subjected to endoscopic/assisted microscopic posterior cordotomy. The patients were randomly allocated into two groups: group (A) patients were operated with radiofrequency, and group (B) patients were operated with coblation. Glottic chink, grade of dyspnea, voice handicap index 10 (VHI10), and aspiration were evaluated pre-operatively and 2 weeks and 3 months post-operatively., Results: There was a significant improvement in the glottic chink and VHI10 scores postoperatively with a non-significant difference between both groups regarding the degree of improvement. In addition, there was a significant improvement of the grade of dyspnea with a non-significant impact on the degree of aspiration in both groups post operatively. There was a lower incidence of oedema and granulation formation in the coblation group but without a statistical significance., Conclusion: Both techniques are effective alternatives for performing posterior transverse cordotomy in cases of BAVFP., (© 2023. The Author(s).)

Introduction: To validate the Group for Learning Useful and Performant Swallowing (GLUPS), a clinical tool dedicated to videofluoroscopy swallowing study (VFSS)., Methods: Forty-five individuals were recruited from January 2022 to March 2023 from the Department of Otolaryngology Head and Neck Surgery of University Hospital Saint-Pierre (Brussels, Belgium). Subjects underwent VFSS, which was rated with GLUPS tool by two blinded otolaryngologists and one speech-therapist. VFSS were rated twice with GLUPS within a 7-day period to assess test-retest reliability., Results: Twenty-four patients and twenty-one controls completed the evaluations. The internal consistency (α = 0.745) and the test-retest reliability (r s  = 0.941; p = 0.001) were adequate. GLUPS reported a high external validity regarding the significant correlation with the Penetration-Aspiration Scale (r s  = 0.551; p = 0.001). Internal validity was adequate, because GLUPS score was significant higher in patients compared to controls (6.21 ± 4.42 versus 2.09 ± 2.00; p = 0.001). Interrater reliability did not report significant differences in the GLUPS sub- and total score among the independent judges. The mean GLUPS score of individuals without any evidence of VFSS abnormalities was 2.09/23 (95% CI  1.23-2.95), which supported that a GLUPS score ≥ 3.0 is suggestive of pathological VFSS., Conclusions: GLUPS is a clinical instrument documenting the abnormal findings of oral and pharyngeal phases at the VFSS. GLUPS demonstrated high reliability and excellent criterion-based validity. GLUPS may be used in clinical practice for the swallowing evaluation at the VFSS., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Head imaging is often performed in children with persistent dysphagia with aspiration to evaluate for Chiari malformations that may be associated with dysphagia. Unfortunately, the frequency of Chiari malformations or other head imaging abnormalities in children who aspirate is unknown. The goal of this study is to determine the frequency of head imaging abnormalities in children with evidence of aspiration or penetration on video fluoroscopic swallow study (VFSS)., Setting: Tertiary Children's Hospital., Methods: We performed retrospective analysis of children with a diagnosis of aspiration evaluated at our center from January 2010 through April 2021. In this study, we included children with VFSS confirmed aspiration or penetration, brain magnetic resonance imaging (MRI) performed at our center, and without known genetic, congenital craniofacial, or neurologic abnormalities., Results: Of the 977 patients evaluated in our system during that time with a diagnosis of aspiration, 185 children met the inclusion criteria. Eight children were diagnosed with Chiari malformations (4.3%) and 94 head MRIs were abnormal (51.4%). There was no difference in VFSS findings (frequency of aspiration, penetration, penetration-aspiration score, or recommended thickness of liquid) in children with a Chiari malformation versus other abnormalities or normal brain imaging. The majority of other non-Chiari brain imaging abnormalities were nonspecific. There was no difference in VFSS findings in children with abnormal MRI findings versus normal MRI., Conclusions: Brain imaging abnormalities are common in children who aspirate. Intervenable lesions are rare. Further studies are required to determine patients that will most likely benefit from brain imaging., (© 2023 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB., (This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Accidental foreign body aspiration is not uncommon during a dental procedure and remains a real risk for many dental procedures. Although approximately 50% of patients are asymptomatic after aspiration of a foreign body, understanding the appropriate next steps in management of these patients is critical in preventing morbid and even lethal outcomes in some instances. Appropriate knowledge of identification and management of such instances is important for all practicing dentists. This article goes into the diagnosis and management of both uncomplicated foreign body ingestion and complicated foreign body aspirations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aspiration pneumonia (AP) is a sub-type of community-acquired pneumonia (CAP) still poorly recognized especially in the absence of an aspiration event. A further difficulty is the differentiation between AP and aspiration pneumonitis. From a clinical perspective, AP is becoming increasingly relevant as a potential cause of severe and life-threatening respiratory infection among frail and very old patients, particularly among those with CAP requiring inpatient care. Moreover, AP is frequently underdiagnosed and a clear-cut definition of this pathological entity is lacking. There are different factors that increase the risk for aspiration, but other common factors influencing oral colonization such as malnutrition, smoking, poor oral hygiene or dry mouth, are also important in the pathogenesis of AP and should be considered. While there is no doubt in the diagnosis of AP in cases of a recent witnessed aspiration of oropharyngeal or gastric content, we here proposed a definition of AP that also includes silent unobserved aspirations. For this reason, the presence of one or more risk factors of oropharyngeal aspiration is required together with one or more risk factors for oral bacterial colonization. This proposed definition based on expert opinion not only unifies the diagnostic criteria of AP, but also provides the possibility to devise easily applicable strategies to prevent oral colonization., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

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 < .001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>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., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Dear Editor, Aspiration of a foreign body into the tracheobronchial tree can occur at any age, though it occurs more commonly in children. In small children, the foreign body commonly gets lodged in the central airways (trachea and mainstem bronchi); hence, the presentation is usually sudden onset of cough and dyspnea or even lifethreatening respiratory failure in an otherwise healthy child. A witnessed aspiration or a history of aspiration can usually be elicited.

Background: Gastric dilation is frequently observed in trauma patients. However, little is known about average gastric volumes comprising food, fluids and air. Although literature suggests a relevant risk of gastric insufflation when endotracheal intubation (ETI) is required in the pre-hospital setting, this assumption is still unproven., Methods: Primary whole body computed tomographic (CT) studies of 315 major trauma patients admitted to our Level 1 Trauma Centre Salzburg during a 7-year period were retrospectively assessed. Gastric volumes were calculated employing a CT volume rendering software. Patients intubated in the pre-hospital setting by emergency physicians (PHI, N = 245) were compared with spontaneously breathing patients requiring ETI immediately after arrival in the emergency room (ERI, N = 70)., Results: The median (range) total gastric content and air volume was 402 (26-2401) and 94 (0-1902) mL in PHI vs. 466 (59-1915) and 120 (1-997) mL in ERI patients (p = .59 and p = .35). PHI patients were more severely injured when compared with the ERI group (injury severity score (ISS) 33 (9-75) vs. 25 (9-75); p = .004). Mortality was higher in the PHI vs. ERI group (26.8% vs. 8.6%, p = .001). When PHI and ERI patients were matched for sex, age, body mass index and ISS (N = 50 per group), total gastric content and air volume was 496 (59-1915) and 119 (0-997) mL in the PHI vs. 429 (36-1726) and 121 (4-1191) mL in the ERI group (p = .85 and p = .98). Radiologic findings indicative for aspiration were observed in 8.1% of PHI vs. 4.3% of ERI patients (p = .31). Gastric air volume in patients who showed signs of aspiration was 194 (0-1355) mL vs. 98 (1-1902) mL in those without pulmonary CT findings (p = .08)., Conclusion: In major trauma patients, overall stomach volume deriving from food, fluids and air must be expected to be around 400-500 mL. Gastric dilation caused by air is common but not typically associated with pre-hospital airway management. The amount of air in the stomach seems to be associated with the risk of aspiration. Further studies, specifically addressing patients after difficult airway management situations are warranted.

Introduction: Foreign body (FB) aspiration is a frequent and preventable source of morbidity and mortality, especially in children under 4 years of age. Few comprehensive studies exist on presentation and outcome of apple aspirations in children., Methods: In a retrospective analysis of bronchoscopy records of a tertiary medical care center from January 2007 to August 2019, we identified pediatric cases of suspected apple aspirations., Results: A total of 11 suspected apple aspirations were identified (observation time 12.7 years, n = 5858 bronchoscopies, n = 226 interventions due to suspected FB aspirations in total). The mean age of patients was 24 months (standard error mean, 7 months; range, 8-83 months), and 6 out of 11 cases (55%) were male. Bronchoscopy confirmed apple aspiration in n = 6/11 cases (55%). In n = 2/11 cases (18%), a bite of the apple was located in the esophagus causing significant tracheal narrowing, and in n = 3/11 cases (27%), no FB was found. In all cases of airway FB identification, extraction was successful. Hypersalivation was associated with esophageal FB location, whereas persistent cough, stridor, or dyspnea were associated with airway FB location. Outcomes ranged from complete reconstitution 1 day after bronchoscopy in most cases to hypoxemia with severe brain damage in one patient., Discussion: This analysis shows that apple aspirations are not entirely uncommon in children and may lead to disastrous complications. Typical signs of airway location are persistent cough, stridor or dyspnea, whereas hypersalivation may point toward an esophageal location. In each case of suspected apple aspiration, timely bronchoscopy with possible FB extraction should be performed by an experienced team., (© 2020 Wiley Periodicals LLC.)

Introduction: Children with Down syndrome (DS) often present with chronic respiratory symptoms. Congenital airway anomalies have been described but data about prevalence is scarce and a comparison to controls is lacking. We aim to compare the endoscopic and clinical data of children with DS to controls without significant medical history., Methods: All endoscopic procedures under general anesthesia (broncho- and/or direct laryngoscopy) in patients with DS were reviewed. We compared clinical and endoscopic data to a cohort of children with respiratory symptoms but without any other relevant medical history., Results: Endoscopic data were available for 65 patients with DS. The median age was 2.9 years (range: 0.2-17), 63% were boys. The most common clinical presentation was recurrent respiratory infections (37%). Other major symptoms were chronic cough and/or noisy breathing (23%) and stridor (20%). Endoscopy was normal in 29% of patients. The largest group of patients (44%) had some form of airway malacia. Tracheal bronchus and subglottic stenosis were each isolated findings in 3.1% of patients. Twenty percent presented with combined airway anomalies. The control group consisted of 150 children (matched for age and sex) without significant underlying disease. The most common presentations were chronic cough and/or noisy breathing (29%), persistent radiographic abnormalities (20%), and suspicion of aspiration of a foreign body (15%). In the majority of controls (68%), no airway anomaly was found. Other findings were malacia (22%), tracheal bronchus (1%), and subglottic stenosis (1%). A combined anomaly was found in 5%., Conclusion: Congenital airway anomalies were seen in 71% of patients with DS, compared with 32% of controls. Combined anomalies are more frequent in DS. Complete lower airway endoscopy is recommended in patients with DS as it may influence therapeutic decision-making., (© 2020 Wiley Periodicals, Inc.)

Objective: To study characteristics and outcomes among patients with in-hospital cardiac arrest (IHCA) due to pulmonary aspiration., Design: A retrospective observational study based on data from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR)., Setting: The SRCR is a nationwide quality registry that covers 96% of all Swedish hospitals. Participating hospitals vary in size from secondary hospitals to university hospitals., Participants: The study included patients registered in the SRCR in the period 2008 to 2017. We compared patients with IHCA caused by pulmonary aspiration (n=127), to those with IHCA caused by respiratory failure of other causes (n=2197)., Primary and Secondary Outcome Measures: Primary outcome was 30-day survival. Secondary outcome was sustained return of spontaneous circulation (ROSC) defined as ROSC at the scene and admitted alive to the intensive care unit., Results: In the aspiration group 80% of IHCA occurred on general wards, as compared with 63.6% in the respiratory failure group (p<0.001). Patients in the aspiration group were less likely to be monitored at the time of the arrest (18.5% vs 38%, p<0.001) and had a significantly lower rate of sustained ROSC (36.5% vs 51.6%, p=0.001). The unadjusted 30-day survival rate compared with the respiratory failure group was 7.9% versus 18.0%, p=0.024. In a propensity score analysis (including variables; year, age, gender, location of arrest, initial heart rhythm, ECG monitoring, witnessed collapse and a previous medical history of; cancer, myocardial infarction or heart failure) the OR for 30-day survival was 0.46 (95% CI 0.19 to 0.94)., Conclusions: In-hospital cardiac arrest preceded by pulmonary aspiration occurred more often on general wards among unmonitored patients. These patients had a lower 30-day survival rate compared with IHCA caused by respiratory failure of other causes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This study aims to investigate the inflential factors for visit time for tracheobronchial foreign bodies in pediatrics, and to shorten the time of diagnosis and reduce complications., Methods: A questionnaire survey was designed and conducted among the caretakers of children with tracheobronchial foreign bodies, and the related inflential factors for visit time were analyzed., Results: The visit time for tracheobronchial foreign body was correlated with the age of the child, the type of foreign body, the educational level of the caretaker, a history of foreign body aspiration were provided, an examination was performed during the visit, the anti-inflammatory and anti-allergic treatment, and transfer to a higher level hospital. Age, history of foreign body aspiration were provided, and anti-inflammatory and anti-allergic treatment were the independent inflential factors for the time of diagnosis (P < 0.05)., Conclusion: The visit time for tracheobronchial foreign bodies was affected by many factors. It is necessary to strengthen the publicity scope and intensity on health education for tracheobronchial foreign bodies in community doctors and parents, to shorten the time of diagnosis and reduce complications.

Case Presentation: A 65-year-old man was referred for evaluation of several years of chest congestion and cough productive of yellow sputum as well as recently noted abnormalities on chest imaging. He denied dyspnea, weight loss, fevers, chills, or hemoptysis. He had no history of systemic illness, pneumonia, other respiratory illness, gastroesophageal reflux, or sinusitis. He had a remote smoking history. He worked as a railroad conductor and had occupational exposure to asbestos, as well as to other uncharacterized dusts and fumes. The patient spent most of his life in Washington and California and regularly traveled through the California Central Valley. Other travel history included trips to Southeast Asia, Iceland, and Europe in the remote past. The patient had one dog but no exposure to other animals. His only medication was loratadine, taken daily for allergic rhinitis. He applied petroleum jelly to his nares nightly to moisturize his nasal passages., (Copyright © 2019. Published by Elsevier Inc.)

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, <2-11.4 mgA/L)., Conclusions: Lentil aspiration is an important cause of HP in infants of weaning age with force-feeding practices. Further studies are needed to identify aspirated antigens which cause HP in aspiration prone children., (© 2019 Wiley Periodicals, Inc.)

We report a case of a 7-year-old boy with clinical and radiographic evidence of foreign body (FB) aspiration with a 2-week delay in diagnosis. The retrieval of the pushpin with traditional bronchoscopic instrumentation was made difficult by granulation tissue formation. A cryoprobe through a flexible bronchoscope was used to successfully remove the FB. To our knowledge, this is the first report of interventional bronchoscopy with a cryoprobe to remove a pushpin in a child under suspension laryngoscopy and spontaneous ventilation. A high index of suspicion is crucial for identifying FBs early and minimizing granulation tissue development which complicates FB removal., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To investigate the natural history of silent aspiration in the pediatric population., Methods: Retrospective chart review of patients (age < 3 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., Results: 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., Conclusions: 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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

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., (Copyright © 2019. Published by Elsevier B.V.)

Rationale: Sodium polystyrene sulfonate is commonly administered to treat hyperkalemia. Severe pneumonia due to aspiration of this drug is rare and no survival case has thus far been reported., Patient Concerns: A 45-year-old man was hospitalized for acute decompensated heart failure and acute kidney injury with hyperkalemia. He aspirated sodium polystyrene sulfonate while consuming the drug. Severe acute respiratory distress syndrome (ARDS) developed rapidly, and he was transferred to the intensive care unit (ICU)., Diagnoses: Chest radiography results after aspiration showed new consolidation in the left upper lung. He underwent emergency bronchoscopy, which revealed a considerable amount of yellow mud-like material in the trachea and bronchi. Chest radiography results after the bronchoscopic removal of the foreign material revealed rapid resolution of the left upper lung consolidation., Interventions: In the ICU, mechanical ventilation with low tidal volume and high positive end-expiratory pressure was administered and extracorporeal membrane oxygenation (ECMO) was set up for treating severe ARDS. We arranged an emergency bronchoscopy for diagnosis and removal of polystyrene sulfonate., Outcomes: ECMO was discontinued after 10 days and the patient was discharged after approximately 2 weeks., Lessons: Aspiration of sodium polystyrene sulfonate is not common but can be lethal. Clinicians should be cautious and appropriately inform patients of the aspiration risk while administering this drug. Mechanical ventilation and bronchoscopy were effective treatments for severe ARDS caused by aspiration of this drug.

Background: The number of contrast media-related procedures is ever increasing due to the widespread availability of theoretically safe, low osmolar iodinated contrast material. Although intravenously administered contrast is known to precipitate myasthenic crisis, oral contrast aspiration as a causative factor is not yet documented as such. A 48-year-old Sinhalese man diagnosed as having myasthenia gravis, was evaluated for progressive dysphagia with an upper gastrointestinal contrast study. Iodinated contrast material (iohexol) was used as the contrast medium and there was direct evidence of contrast aspiration during the study. Several minutes after the procedure, severe respiratory distress with evidence of myasthenic crisis requiring intubation and intensive care admission was noted. Treatment with intravenous immunoglobulin, high-dose steroids, and broad-spectrum intravenously administered antibiotics led to an uneventful recovery, although the latter part of the clinical course was complicated with total left lung collapse. Myasthenic crisis can be precipitated by various factors and a successful recovery requires mechanical respiratory support with immunomodulatory and steroid therapy. This is the first reported case that describes the development of myasthenic crisis following iohexol-associated aspiration pneumonitis.

Objectives: To examine the correlation between pharyngeal residue severity and clearance to penetration/aspiration on fiber-optic endoscopic examination of swallowing (FEES)., Design: Retrospective cohort., Setting: Kaplan Medical Center dysphagia clinic., Participants: Patients (N=110) visiting a dysphagia clinic between 2014 and 2016 undergoing FEES., Interventions: 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., Main Outcome Measures: YPR-SRS and number of clearing swallows were correlated with the PAS of the same bolus challenge., Results: 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., Conclusions: 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., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Foreign body aspiration is a life-threatening medical condition that requires prompt action. Delayed diagnosis is associated with long-term serious complication often leading to death. In adults, it can remain undetected for a long period of time. The patient gives a long history of a cough, which clinicians often ignore. A chest radiograph is unreliable to exclude the disease as it may not show radiolucent objects. Diagnostic bronchoscopy is necessary to exclude the disease. We report a case of 70-year-old woman who had a 1-month history of a cough and was admitted for shortness of breath, and on further evaluation, we incidentally detected calcium tablets in her bronchus. The present case demonstrates the need for early bronchoscopy especially when the cause of a chronic cough is not known.

The aim of this study was to identify which characteristics, collected by bedside swallowing evaluation (BSE) and fiberoptic endoscopic evaluation of swallowing (FEES), are a risk or a protective factor for aspiration. This retrospective study included data on 1577 consecutive patients, collected by BSE and FEES. Bivariate analysis was performed to verify the association of each variable with aspiration (Chi-Square test). The variables associated with aspiration were entered into a multivariate logistic model to quantify this association. Several variables were significantly associated (p < 0.05) with aspiration; cooperation, sensation, laryngeal elevation and direct therapy were found to be protective factors against aspiration. The regression model identified the most variables related with aspiration, among which tracheotomy, material pooling and spillage. Patients able to perform dry swallows were 77% less likely to aspirate (protective factor). Several variables are involved in protection of airways during swallowing. Their interaction, in patients with swallowing disorders, offers the clinician the best means of interpreting BSE and FEES., (Copyright © 2018 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Introduction: The aim is to create a protocol for the managing of foreign body aspiration in children based on a probability scale., Material and Methods: Retrospective observational study, including patients admitted with suspected foreign body aspiration (FBA) in the last 15 years. The parameters were assessed with a SCORE that included witnessed choking, stridor and wheezing during choking, unilateral reduced air entry and abnormal X-Ray. This scale relates them to a probability of FBA, where a score ≤ 1 is associated with less than 10% and ≥ 4 with more than 50% of FBA. According to the probability, we propose: observation, chest Computed Tomography (CT) or bronchoscopy. Then, we tried to adapt it to our casuistry., Results: A total of 109 children admitted between 2002-2017 were included. The median age was 25 months, a foreign body was found in 88 patients, the most frequent being organic (seeds and nuts). Significant predictors of FBA were unilateral reduced air entry and abnormal X-Ray. In our study, we found the same ascending probability between the scale and the presence of foreign body, except for SCORE 1, which was 57% what we attribute to an information bias. If the foreign body were not nuts, inorganic or bone, its aspiration was very unlikely, that is why we included it in the SCORE with -1., Conclusion: The use of the algorithm would imply the performance of 7% more of CT in patients without a FBA, but avoiding an 8.5% of bronchoscopy. Our results present an information bias, characteristic of a retrospective study.

Introduction: Foreign bodies aspiration can lead to significant morbidity, few have examined in detail the deaths resulting from foreign bodies aspiration., Methods: We conducted a review of children who presented to the pediatric intensive care unit of a university hospital due to fatal foreign bodies aspiration during the period of 2010-2017., Result: Of the 28 patients, 17 (61%) patients were male and 11 (39%) were female. The range of age was 1-63 months, with mean of 15.2 months. The common foreign bodies included milk, nuts and fruits. Majority of them had round shapes. All the patients died due to asphyxia or serious complications after foreign bodies aspiration., Conclusions: Prevention and early recognition remains a critical factor to reduce the mortality of foreign bodies aspiration., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: A number of video-fluoroscopic swallowing study (VFSS) abnormalities have been reported in patients with Parkinson's disease (PD). However, the most crucial finding of subsequent aspiration pneumonia has not been validated fully. We conducted a retrospective and case-control study to determine the clinically significant VFSS findings in this population, and to propose a practical scale for predicting aspiration pneumonia in patients with PD., Methods: We enrolled 184 PD patients who underwent VFSS because of suspected dysphagia. The patients who developed aspiration pneumonia within six months of the VFSS were assigned as cases and the patients without aspiration pneumonia at six months were designated as controls. Logistic regression analysis was performed to determine the prognostic VFSS features based on the data of swallowing 3 mL of jelly, which were used to make a PD VFSS scale (PDVFS). The validity of the new PDVFS was evaluated by ROC analysis. Additionally, we used the survival time analysis to compare time to death between groups, stratified by the PDVFS score., Results: Twenty-five patients developed aspiration pneumonia. Among the previously-proposed VFSS features, mastication, lingual motility prior to transfer, aspiration, and total swallow time were identified as significant prognostic factors. We combined these factors to form the PDVFS. The PDVFS score ranges from 0 to 12, with 12 being the worst. ROC analysis revealed 92% sensitivity and 82% specificity at a cutoff point of 3. The higher PDVFS group showed shorter time-to-death than the lower PDVFS group (log rank P = 0.001)., Conclusion: Our newly developed VFSS severity scale (based on jelly swallowing) for patients with PD was easy to rate and could predict subsequent aspiration pneumonia and poor prognosis in patients with PD., Competing Interests: The authors have declared that no competing interests exist.

Anesthesiologists are responsible for the safe and effective provision of analgesia for labor and anesthesia for cesarean delivery and other obstetric procedures. In addition, obstetric anesthesiologists often have a unique role as the intensivists of the obstetric suite. The anesthesiologist is frequently the clinician with the greatest experience in the acute bedside management of a hemodynamically unstable patient and expertise in life-saving interventions. This review will discuss (1) risks associated with neuraxial and general anesthesia for labor and delivery, and (2) clinical scenarios in which the obstetric anesthesiologist is commonly called upon to function as a "peridelivery intensivist."

Objective: Inhaled foreign bodies in children are common and may be complicated by secondary airway tract infection. The inhaled foreign body may act as carrier of infectious material and the aim of this study was to explore the bacterial species associated with aspirated foreign bodies in a cohort of children., Methods: Retrospective case series of 34 patients who underwent rigid laryngobronchoscopy because of foreign body aspiration. Each patient had a sample taken from tracheobronchial secretions during the procedure., Results: The average patient age was 31.2 months and the average hospital stay was 2.5 days. Of the foreign bodies 24 (71%) were organic in nature and 10 (29%) were non-organic. Twenty eight (82.3%) patients had mixed oropharyngeal flora organisms growth. Fifteen (44%) samples were positive for organisms other than oropharyngeal flora with the most common cultured organisms being: Streptococcus pneumonia (4/12%), Haemophilus influenza (4/12%), Moraxella catarrhalis (4/12%). Four samples (12%) grew a fungus; Candida albicans was cultured in 3 patients and Aspergillus glaucus was identified in one sample. Of the non-oropharyngeal organisms 7(47%) demonstrated antibiotic resistance with four having resistance to amoxycillin, two resistant to penicillin and one resistant to cotrimoxazole., Conclusion: Some children who present with aspirated foreign body may be complicated with secondary airway infection. Antibacterial treatment might be considered in some of these cases. The regimen of antibiotics should aim to cover oropharyngeal flora, S. pneumonia, H. influenza and Moraxella catarrhalis., (Copyright © 2017 Elsevier B.V. All rights reserved.)