An uncommon etiological factor for aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with cerebrospinal fluid rhinorrhea: a case report.

BACKGROUND: Aspiration pneumonitis is an inflammatory disease of the lungs which is difficult to diagnose accurately. Large-volume aspiration of oropharyngeal or gastric contents is essential for the development of aspiration pneumonitis. The role of cerebrospinal fluid (CSF) rhinorrhea is often underestimated as a rare etiological factor for aspiration in the diagnosis process of aspiration pneumonitis. CASE PRESENTATION: We present a case of a patient with 4 weeks of right-sided watery rhinorrhea accompanied by intermittent postnasal drip and dry cough as the main symptoms. Combined with clinical symptoms, imaging examination of the sinuses, and laboratory examination of nasal secretions, she was initially diagnosed as spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, and intraoperative endoscopic findings and postoperative pathology also confirmed this diagnosis. Her chest computed tomography showed multiple flocculent ground glass density shadows in both lungs on admission. The patient underwent endoscopic resection of meningoencephalocele and repair of skull base defect after she was ruled out of viral pneumonitis. Symptoms of rhinorrhea and dry cough disappeared, and pneumonitis was improved 1 week after surgery and cured 2 months after surgery. Persistent CSF rhinorrhea caused by spontaneous sphenoid sinus meningoencephalocele was eventually found to be a major etiology for aspiration pneumonitis although the absence of typical symptoms and well-defined risk factors for aspiration, such as dysphagia, impaired cough reflex and reflux diseases. CONCLUSIONS: We report a rare case of aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, which can bring more attention and understanding to the uncommon etiology for aspiration, so as to make more accurate diagnosis of the disease and early surgical treatment.

Glyphosate poisoning - a case report.

Glyphosate is the most commonly used broad-spectrum, non-selective herbicide in the world. The toxicity is supposed to be due to uncoupling of oxidative phosphorylation and the surfactant polyoxyethylene amine (POEA)- mediated cardiotoxicity. Clinical features of this herbicide poisoning are varied, ranging from asymptomatic to even death. There is no antidote and aggressive supportive therapy is the mainstay of treatment for glyphosate poisoning. We present a 69-year-old female patient with suicidal consumption of around 500 ml of Glycel®. Initially, gastric lavage was done and intravenous fluids were given. Within two hours of presentation, the patient developed respiratory distress needing intubation, hypotension needing vasopressor support, and severe lactic acidosis. She also developed acute respiratory distress syndrome, hypokalemia, hypernatremia, and aspiration pneumonia. Our patient was critically ill with multiple poor prognostic factors, but with timely aggressive supportive management, the patient gradually recovered.

Anesthesia for peroral endoscopic myotomy in Japan.

PURPOSE OF REVIEW: Peroral endoscopic myotomy (POEM) was developed in Japan as a less invasive treatment for esophageal achalasia requiring general anesthesia under positive pressure ventilation. In 2018, the Japan Gastroenterological Endoscopy Society published the first guidelines describing the standard care for POEM. Based on these guidelines, we discuss the typical approach to anesthesia during POEM for the management of esophageal achalasia in Japan. RECENT FINDINGS: Prior cleansing of the esophagus is essential to prevent both aspiration during induction of anesthesia and contamination of the mediastinum and thoracic/abdominal cavity by esophageal remnants after endoscopic resection of the esophageal mucosa. Although rare, adverse events related to intraoperative carbon dioxide insufflation occur. These are treated through percutaneous needle decompression and insertion of a chest drainage tube for pneumoperitoneum and pneumothorax, respectively. Caution should be exercised regarding the development of subcutaneous emphysema and its involvement in airway obstruction. SUMMARY: Prevention of aspiration pneumonia and adverse events related to the insufflation of carbon dioxide is essential in the management of esophageal achalasia through POEM. Close cooperation between gastrointestinal endoscopic surgeons and anesthesiologists is indispensable in POEM.

Safe Use of Contrast Media: What the Radiologist Needs to Know.

Iodinated and gadolinium-based contrast media are used on a daily basis in most radiology practices. These agents often are essential to providing accurate diagnoses, and are nearly always safe and effective when administered correctly. However, reactions to contrast media do occur and can be life threatening. Therefore, it is critical for faculty and staff to know how reactions to contrast agents manifest and how to treat them promptly. The decline in renal function seen occasionally after intravenous administration of iodinated contrast agents is poorly understood and likely multifactorial, and its association with the contrast medium may be overemphasized. However, it is important that radiologists be aware of current understanding and strategies to decrease the incidence of renal dysfunction. Nephrogenic systemic fibrosis, a skin disease, is an adverse reaction related to use of some gadolinium-based contrast agents in patients with chronic renal failure. The types of gadolinium most often associated with this condition and the indications for withholding gadolinium are important and are discussed in this article. The use of enteric contrast agents and contrast agents during pregnancy and nursing are reviewed briefly. Current knowledge for safe use of contrast media and key concepts that all radiologists should know are summarized in this review.

Overfeeding and overhydration in elderly medical patients: lessons from the Liverpool Care Pathway.

This paper describes three elderly patients who were admitted to hospital with aspiration pneumonia. They were kept nil by mouth (NBM) for a number of days, while being given intravenous hydration initially and enteral feeding subsequently. During that time they deteriorated and appeared to be dying, so the Liverpool Care Pathway (LCP) for the dying was used to support their care. Artificial nutrition and hydration were stopped. They quickly improved and the LCP was discontinued. Two of the patients deteriorated again on reintroduction of enteral feeding and/or intravenous fluids, only to improve a second time following withdrawal of feeding and fluids. Vulnerable elderly patients should not be made NBM except as a last resort. Clinicians should be alert to the possibility of refeeding syndrome and overhydration as reversible causes of clinical deterioration, particularly in frail elderly patients. Use of the LCP in these patients provided a unique opportunity to witness the positive effects of withdrawal of excessive artificial nutrition and hydration.

[Hypersalivation - inauguration of the S2k Guideline (AWMF) in short form]. / Hypersalivation - Ersterstellung der S2k-Leitlinie (AWMF) in gekürzter Darstellung.

Hypersalivation describes a relatively excessive salivary flow, which wets the patient himself and his surroundings. It may result because of insufficient oro-motor function, dysphagia, decreased central control and coordination. This reduces social interaction chances and burdens daily care. Multidisciplinary diagnostic and treatment evaluation is recommended already at early stage and focus on dysphagia, and saliva aspiration. Therefore, a multidisciplinary S2k guideline was developed. Diagnostic tools such as fiberoptic endoscopic evaluation of swallowing and videofluoroscopic swallowing studies generate important data on therapy selection and control. Especially traumatic and oncologic cases profit from swallowing therapy programmes in order to activate compensation mechanisms. In children with hypotonic oral muscles, oralstimulation plates can induce a relevant symptom release because of the improved lip closure. In acute hypersalivation, the pharmacologic treatment with glycopyrrolate and scopolamine in various applications is useful but its value in long-term usage critical. The injection of botulinum toxin into the salivary glands has shown safe and effective results with long lasting saliva reduction. Surgical treatment should be reserved for isolated cases. External radiation is judged as ultima ratio. Therapy effects and symptom severity has to be followed, especially in neurodegenerative cases. The resulting xerostomia should be critically evaluated by the responsible physician regarding oral and dental hygiene.

Saturation of Percutaneous Oxygen Decreases with Meal Consumption in Patients with Acute Pneumonia.

OBJECTIVE: This study aimed to investigate how respiratory status may be affected during meal consumption in patients with acute pneumonia, mainly aspiration pneumonia, using percutaneous oxygen saturation (SpO2) and pulse rate (PR) measurements. METHODS: We recruited 44 inpatients at the Towada City Hospital and divided them into 'pneumonia' and 'control' groups. Generalized linear mixed effects model was used for analysis. The pneumonia group comprised 22 patients (mean age 81.2 ± 7.0 years, body mass index [BMI] 21.1 ± 4.0 kg/m2) with 1-3 points A-DROP scores. The control group comprised 22 patients (mean age 80.5 ± 4.9 years, BMI 20.9 ± 2.9 kg/m2) with no obvious respiratory diseases. SpO2 and PR were measured 30 min before, during, and 30 min after meals. RESULTS: SpO2 was significantly lower during meals in the pneumonia group (-1.60%; 95% confidence interval = -2.76 to -0.44). There were no significant changes in PR during or after meals in the pneumonia group. CONCLUSIONS: This study suggests pneumonia may worsen respiratory status during meal intake. Patients with pneumonia may be unable to eat adequately due to worsened oxygenation during meals, even in the absence of aspiration. Therefore, it is important to observe whether there is a decrease in respiratory status during meals.

Dysphagia.

Dysphagia, or difficult swallowing, can result in malnutrition, dehydration, aspiration pneumonia, and airway obstruction. Some primary etiologies of dysphagia include neurological disorders, traumatic brain injury, Parkinson's disease, chronic obstructive pulmonary disease, head and neck cancer, cervical spine injury, and stroke. Home care clinicians are often the first healthcare professionals to encounter patients exhibiting signs of dysphagia and can play an important role in identifying, referring, and educating patients with dysphagia. This article will discuss the broad types of dysphagia, the signs and symptoms that suggest dysphagia, and the possible etiology and treatment.

Management of Aspiration Risk in Stroke.

Managing risk for aspiration in the stroke patient will assist to decrease one of the major complications that these patients experience, which is poststroke pneumonia. Using an evidenced-based dysphagia protocol is shown to reduce mortality, morbidity, and length of stay caused by poststroke pneumonia. Physicians, nurses, speech pathologists, and dieticians will be instrumental in performing ongoing assessments and aspiration-prevention strategies to improve stroke patient outcome and reduce complications. Education, and measurement of comprehension, of the care team, patient, and family concerning dysphagia management and prevention of aspiration pneumonia will assist in achieving the aforementioned goals.

[Aspiration pneumonia after spinal cord injury. Placement of PEG tubes as effective prevention]. / Aspirationspneumonie nach HWS-Verletzung. Präventiver Effekt von PEG-Sonden.

BACKGROUND: Pulmonary infections are dreaded complications in acute spinal cord injuries. The prevention of pneumonia is essential for reducing mortality and the period of hospitalization. Swallowing disorders occur frequently in patients with cervical cord injuries and are accompanied by aspiration with a high risk of pneumonia. PATIENTS AND METHODS: In this study the identification and analysis of patients with newly acquired cervical cord injuries were carried out with respect to respiratory complications, treatment and prevention. RESULTS: A total of 27 patients with a cervical cord injury (tetraplegia) were identified. Of these 20 patients (74%) were identified with a swallowing disorder and a high risk of aspiration. Of these patients 11 (PEG group) received a percutaneous feeding tube (PEG tube), 9 patients (non-PEG group) with diagnosed dysphagia were treated without PEG tube. A total of 6 patients in the non-PEG group (67%) acquired pneumonia compared to 3 patients (27%) in the PEG group. CONCLUSION: A swallowing disorder is a major risk factor for a pulmonary infection after a cervical cord injury. An early placement of a PEG tube has a preventive effect with respect to aspiration pneumonia in patients with dysphagia.

Complete Lateral Positioning Enabled Feeding in a Patient with Aspiration Pneumonia.

The complete lateral position can be used to widen the lateral pharynx in a direction that facilitates swallowing and reduces the risk of aspiration, even if the patient is unable to eat in the sitting position. Here, we report a case of aspiration pneumonia in a patient who was unable to eat in the sitting position after swallowing endoscopy, but was able to eat in the complete lateral position. By employing complete lateral positioning, more patients may be able to continue oral intake.

Early oral intake and early removal of nasogastric tube post-esophagectomy: A systematic review and meta-analysis.

BACKGROUND: Early oral intake (EOI: initiated within 1 day) and early nasogastric tube removal (ENR: removed ≤2 days) post-esophagectomy is controversial and subject to significant variation. AIM: Our aim is to provide the most up-to-date evidence from published randomized controlled trials (RCTs) addressing both topics. METHODS: We searched MEDLINE and Embase (1946-06/2019) for RCTs that investigated the effect of EOI and/or ENR post-esophagectomy with gastric conduit for reconstruction. Our main outcomes of interest were anastomotic leak, aspiration pneumonia, mortality, and length of hospital stay (LOS). Pooled mean differences (MD) and risk ratios (RR) estimates were obtained using a DerSimonian random effects model. RESULTS: Two reviewers screened 613 abstracts and identified 6 RCTs eligible for inclusion; 2 regarding EOI and 4 for ENR. For EOI (2 studies, n = 389), was not associated with differences in risk of: anastomotic leak (RR: 1.01; 95% CI: 0.407, 2.500; I2 : 0%), aspiration pneumonia (RR: 1.018; 95% CI: 0.407, 2.500), mortality (RR: 1.00; 95% CI: 0.020, 50.0). The LOS was significantly shorter in the EOI group: LOS (MD: -2.509; 95% CI: -3.489, -1.529; I2 : 90.44%). For ENR (4 studies, n = 295), ENR (removed at POD0-2 vs. 5-8 days) was not associated with differences in risk of: anastomotic leak (RR: 1.11; 95% CI 0.336, 3.697; I2 : 25.75%) and pneumonia group (RR: 1.11; 95% CI: 0.336, 3.697; I2 : 25.75%), mortality (RR: 0.87; 95% CI: 0.328, 2.308; I2 : 0%)or LOS (MD: 1.618; 95% CI: -1.447, 4.683; I2 : 73.03%). CONCLUSIONS: Our analysis showed that EOI as well as ENR post-esophagectomy do not significantly increase the risk of anastomotic leak, pneumonia, and mortality. The LOS was significantly shorter in the EOI group, and there was no significant difference in the ENR group. A paucity of RCTs has evaluated this question, highlighting the need for further high-quality evidence to address these vital aspects to post-esophagectomy care. SYSTEMATIC REVIEW REGISTRATION: CRD42019138600.

Evaluation of domperidone efficacy to prevent aspiration pneumonia in patients with acute ischemic stroke: a randomized clinical trial.

BACKGROUND AND AIM: Aspiration pneumonia is an essential complication of acute ischemic stroke (AIS), which is responsible for increased three-fold mortality within a month. There is an interest towards the effect of prokinetics on prevention of stroke-associated pneumonia. The present study aimed to investigate the effect of domperidone to prevent pneumonia in patients with AIS. METHODS: In this randomized clinical trial, 150 patients with AIS were assigned to receive either domperidone 10 mg daily or placebo during hospitalization. The clinical outcomes including of aspiration pneumonia occurrence, gastrointestinal discomfort, the need for intensive care unit admission, the length of hospitalization, final mRs, and mortality were then evaluated in both groups. RESULTS: 150 [Mean age 67.5 ± 13.5 years, 90 men and 60 women] were randomized in a 1:1 ratio. Both groups were similar in terms of baseline characteristics. The domperidone group experienced significantly less dysphagia, nausea and vomiting, and aspiration pneumonia (P < 0.005). Although domperidone did not considerably reduce the mortality (P = 0.978), it resulted in lower mean mRS and shorter length of hospitalization (P < 0.001). CONCLUSION: Domperidone is an effective and well tolerated agent which could be considered as a promising agent to prevent stroke-associated pneumonia leading to a better clinical recovery.

Cough in the elderly: a novel strategy for preventing aspiration pneumonia.

Management of cough in the elderly with a deteriorated physical and mental status has received little focus. Since an aged population is rapidly increasing in developed countries, the research in this population are warranted. Cough reflex sensitivity in the elderly was shown to be hypersensitive, normosensitive and hyposensitive. The hypersensitive cough reflex is mostly due to gastro-esophageal reflux in nursing home patients. Impaired cough reflex sensitivity is assumed to play a crucial role in the development of pneumonia in the elderly. A marked depression of cough reflex sensitivity is reported in elderly patients with aspiration pneumonia. The impairment of the cough reflex in patients with aspiration pneumonia can involve both cortical facilitatory pathways for cough and medullary reflex pathways. We found the urge-to-cough in patients with aspiration pneumonia was also down-regulated, suggesting the involvement of supramedullary dysfunction in the etiology of aspiration pneumonia in the elderly. In order to prevent aspiration pneumonia in the elderly, restoration of cough reflex sensitivity is essential. We found several methods to restore cough reflex sensitivity in the elderly. They also improved the swallowing reflex, another important airway protective reflex, in the elderly. In the treatment of aspiration pneumonia, one of the most challenging steps is the start of eating for patients who usually fast at the time of hospitalization. By combining the methods to restore the cough reflex sensitivity and swallowing reflex, we developed a protocol to start eating in the elderly patients with aspiration pneumonia. Using the protocol, we reduced the incidence of re-aspiration due to start of eating in patients with aspiration pneumonia to one third of the patients without the protocol.

Voluntary and reflex cough and the expiration reflex; implications for aspiration after stroke.

Aspiration is a common result of stroke, and may lead to lung infections and pneumonia. Cough may prevent this aspiration and thus prevent the pneumonia. We review the four types of cough usually used to assess aspiration risk: voluntary cough (VC), reflex cough (RC), the laryngeal expiration reflex (LER), and cough on swallow (CoS). VC is easy to test but starts with an inspiration that may cause aspiration, and is controlled by cortico-brainstem pathways that may not be involved in influencing aspiration. RC also starts with an inspiration, and requires instrumental intervention, but is more relevant to protecting the lungs. The LER starts with an expiration, so is 'anti-aspiration', and is easy to test, but its neural mechanisms have not been fully analysed. CoS can be tested at the same time as direct observations of aspiration, but little is known about its neural mechanisms. Each method has its advocates, and the purpose of the review is to discuss how each may be applied and how the information from each may be assessed and valued.

Closure of the larynx for intractable aspiration in neurologically impaired patients.

We present three patients with intractable aspiration pneumonia in the setting of permanent neurologic impairment, who had received a tracheostomy and showed a juxtaposition of the innominate artery against the trachea. Neurologically impaired patients often show a juxtaposition or compression of the innominate artery against the trachea by chest deformity in the setting of severe scoliosis, which could result in a trachea-innominate artery fistula. For intractable aspiration, laryngotracheal separation is safely performed and effective in controlling aspiration, but is occasionally complicated by trachea-innominate artery fistula. As an alternative procedure, we performed a closure of the larynx in these three cases, using double flaps of the vocal folds and false vocal folds, as a treatment for intractable aspiration. After operation, the patients did well without complication or clinical evidence of recurrent aspiration.