Brain imaging abnormalities in children with dysphagia with aspiration: A retrospective study.

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.

Validity and reliability of the Group for Learning Useful and Performant Swallowing (GLUPS) tool.

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 (rs = 0.941; p = 0.001) were adequate. GLUPS reported a high external validity regarding the significant correlation with the Penetration-Aspiration Scale (rs = 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.

Endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis using radiofrequency versus coblation.

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.

Influential factors for visit time for tracheobronchial foreign bodies in pediatrics.

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.

Utilization of endobronchial electrocautery for removal of an impacted airway foreign body.

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.

Correlation Between Pharyngeal Residue and Aspiration in Fiber-Optic Endoscopic Evaluation of Swallowing: An Observational Study.

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.

The Role of the Anesthesiologist in Preventing Severe Maternal Morbidity and Mortality.

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."

[Probabilistic algorithm for management of suspected foreign body aspiration in children]. / Protocolo probabilístico para el manejo del cuerpo extraño en la vía aérea.

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.

OBJETIVOS: Creación de un protocolo de manejo del cuerpo extraño (CE) en vía aérea (VA) basado en una escala de probabilidad. MATERIAL Y METODOS: Estudio retrospectivo observacional de pacientes con sospecha de aspiración de CE en 15 años. Los parámetros fueron valorados con un SCORE que contempla atragantamiento presenciado, estridor y sibilancias durante el atragantamiento, hipoventilación unilateral y radiografía alterada. Dicha escala los relaciona con una probabilidad de presencia de CE en VA, donde una puntuación ≤ 1 se asocia a menos de un 10% y ≥ 4 a > 50%. Según la probabilidad se plantea: observación, TAC o instrumentación de VA. A continuación se intentó optimizar en función de nuestra casuística. RESULTADOS: Se analizaron 109 pacientes (mediana 25 meses), identificándose CE en 88, principalmente frutos secos. De las variables predictoras solo fueron significativas: la hipoventilación unilateral y la radiografía alterada. En nuestra serie se observó la misma probabilidad ascendente entre la escala y la presencia de CE, excepto en la puntuación de 1 que fue del 57%, lo que atribuimos a un sesgo de información. Si el CE no era fruto seco, material inorgánico o hueso, era muy improbable su aspiración (p= 0) por lo que lo incluimos en el SCORE con un -1. CONCLUSIONES: La aplicación de la escala implicaría la realización de un 7,5% más de TAC en pacientes sin CE pero evitando un 8,5% de instrumentaciones de la VA. Nuestros resultados presentan un sesgo de información, propio de un estudio retrospectivo. Actualmente hemos iniciado la implementación prospectiva.

Oropharyngeal Dysphagia Is Strongly Correlated With Apparent Life-Threatening Events.

OBJECTIVES: The aim of the present study was to investigate the prevalence of oropharyngeal dysfunction with resultant aspiration in patients admitted after apparent life-threatening events (ALTE) and to determine whether historical characteristics could predict this oropharyngeal dysphagia and aspiration risk. METHODS: We retrospectively reviewed the records of all patients admitted to Boston Children's Hospital between 2012 and 2015 with a diagnosis of ALTE to determine the frequency of evaluation for oropharyngeal dysphagia using video fluoroscopic swallow studies (VFSS) and clinical feeding evaluations, to determine the prevalence of swallowing dysfunction in subjects admitted after ALTE and to compare presenting historical characteristics to swallow study results. RESULTS: A total of 188 children were admitted with a diagnosis of ALTE of which 29% (n = 55) had an assessment of swallowing by VFSS. Of those who had a VFSS, 73% (n = 40) had evidence of aspiration or penetration on VFSS. Of all of the diagnostic tests ordered on patients with ALTEs, the VFSS had the highest rate of abnormalities of any test ordered. None of the historical characteristics of ALTE predicted which patients were at risk for aspiration. In patients who had both clinical feeding evaluations and VFSS, observed clinical feedings incorrectly identified 26% of patients as having no oropharyngeal dysphagia when in fact aspiration was present on VFSS. CONCLUSIONS: Oropharyngeal dysphagia with aspiration is the most common diagnosis identified in infants presenting with ALTEs. The algorithm for ALTE should be revised to include an assessment of VFSS as clinical feeding evaluations are inadequate to assess for aspiration.

Bronchial Aspiration of Capsule Endoscope.

Capsule endoscope aspiration is an increasingly reported complication, potentially responsible for respiratory distress and asphyxia. This adverse event is primarily managed by rigid bronchoscopy when spontaneous expulsion does not occur. This complication is all the more detrimental to patients as it can delay or jeopardize further digestive exploration. We report direct repositioning of the capsule in the stomach at the same time as bronchoscopy, thus making second-line gastrointestinal endoscopy needless.

The role of soluble and insoluble gastric fluid components in the pathogenesis of obliterative bronchiolitis in rat lung allografts.

Repetitive gastric fluid aspirations have been shown to lead to obliterans bronchiolitis (OB), but the component or components of gastric fluid that are responsible are unknown. This study investigates the role of particulates and, separately, soluble material in gastric fluid during the development of OB. Whole gastric fluid (WGF) was collected from male Fischer 344 (F344) rats and separated by centrifugation into particle reduced gastric fluid (PRGF) and particulate components resuspended in normal saline (PNS). Orthotopic left lung transplants from male Wistar-Kyoto rats into F344 rats were performed using a modification of the nonsuture external cuff technique with prolonged cold ischemia. Rats were subjected to weekly aspiration of 0.5 ml/kg of WGF (n = 9), PRGF (n = 10), PNS (n = 9), or normal saline (control, NS; n = 9) for 8 weeks following transplantation. Lung allografts treated with WGF, PRGF, or PNS developed a significantly greater percentage of OB-like lesions compared with the control. No statistical difference was observed when comparing the fibrosis grades or the percentage of OB lesions of WGF, PRGF, and PNS groups, suggesting that both soluble and insoluble components of gastric fluid can promote the development of aspiration-induced OB and fibrosis in lung allografts.

Bile acids induce activation of alveolar epithelial cells and lung fibroblasts through farnesoid X receptor-dependent and independent pathways.

BACKGROUND AND OBJECTIVE: The roles of bile acid microaspiration and bile acid-activated farnesoid X receptor (FXR) in the pathogenesis of idiopathic pulmonary fibrosis (IPF) remain unclear. We hypothesized that bile acids activate alveolar epithelial cells (AECs) and lung fibroblasts, which may be regulated by FXR activation. METHODS: Human AECs and normal or IPF-derived lung fibroblast cells were incubated with the three major bile acids: lithocholic acid (LCA), deoxycholic acid (DCA) and chenodeoxycholic acid (CDCA). The AECs injury indices, epithelial-mesenchymal transition (EMT) and lung fibroblast activation were evaluated. FXR expression in IPF lungs and the roles of FXR and FXR-independent pathways in bile acid-induced profibrotic effects were also investigated. RESULTS: LCA, DCA and CDCA reduced cell viability and increased intracellular reactive oxygen species (ROS) production in A549 cells. They all induced EMT, as shown by enhanced α-SMA and vimentin and decreased E-cadherin levels. LCA directly induced differentiation of lung fibroblasts to myofibroblasts. All three bile acids promoted cellular migration but not proliferation of lung fibroblasts. FXR expression was upregulated in IPF lungs, and inhibition of FXR restrained the bile acid-induced EMT and lung fibroblast activation. Differentiation and proliferation were enhanced in lung fibroblasts exposed to conditioned medium from bile acid-stimulated A549 cells, which contained increased levels of profibrotic factors. TGF-ß/Smad3 signaling was also involved in the bile acid-induced EMT and lung fibroblast differentiation. CONCLUSION: Bile acid microaspiration may promote the development of pulmonary fibrosis by inducing activation of AECs and lung fibroblasts via FXR-dependent and independent pathways.

Rapid Aspiration Screening for Suspected Stroke: Part 2: Initial and Sustained Nurse Accuracy and Reliability.

OBJECTIVE: To determine registered nurses' (RNs') ability to obtain and maintain accurate procedural skills and reliable interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. DESIGN: Prospective, observation study. SETTING: A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS: RNs (N=15) were recruited and trained in the administration and interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. INTERVENTIONS: RNs completed a total of 239 screenings of patients admitted with suspected stroke over a 2-year period. RNs administered the swallowing screening items and interpreted the patient's response to each item. Independent of the RN, a speech-language pathologist simultaneously interpreted the response of the participant with stroke to each swallowing screening item. MAIN OUTCOME MEASURES: Reliability of the interpretation and accuracy of the administration of the swallowing screening items. RESULTS: The average accuracy rate for the administration of the Rapid Aspiration Screening for Suspected Stroke was 98.33%, with the overall accuracy rate for each procedural task ranging from 95.42% to 100%. For the specific swallowing screening items that formed the Rapid Aspiration Screening for Suspected Stroke, dysarthria and a positive sign after water swallow, reliability was high (k=.817). The accuracy rate for the administration and reliability of the interpretation of the swallowing screening items improved as RNs gained experience, and both were maximized at 20 screening opportunities. CONCLUSIONS: RNs demonstrate both excellent accuracy of procedural administration and reliability of interpretation of the items of the Rapid Aspiration Screening for Suspected Stroke. With feedback and repeated opportunities to practice, maintenance of skills is achievable.

Rapid Aspiration Screening for Suspected Stroke: Part 1: Development and Validation.

OBJECTIVE: To develop and validate a nurse-administered screening tool to identify aspiration risk in patients with suspected stroke. DESIGN: Validity study comparing evidence-based swallowing screening items with the videofluoroscopic swallowing study (VFSS) results. SETTING: A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS: Consecutive patients (N=250) admitted with suspected stroke. INTERVENTIONS: Patients were administered evidence-based swallowing screening items by nurses. A VFSS was completed within 2 hours of swallowing screening. MAIN OUTCOME MEASURES: Validity relative to identifying VFSS-determined aspiration for each screening item and for various combinations of items. RESULTS: Aspiration was identified in 29 of 250 participants (12%). Logistic regression revealed that age (P=.012), dysarthria (P=.001), abnormal volitional cough (P=.030), and signs related to the water swallow trial (P=.021) were significantly associated with aspiration. Validity was then determined on the basis of the best combination of significant items for predicting aspiration. The results revealed that age >70 years, dysarthria, or signs related to the water swallow trial (ie, cough, throat clear, wet vocal quality, and inability to continuously drink 90mL water) yielded 93% sensitivity and 98% negative predictive value. CONCLUSIONS: The final validated tool, Rapid Aspiration Screening for Suspected Stroke, is a valid nurse-administered tool to detect risk of aspiration in patients presenting with suspected stroke.

[Incidence, pathomorphism and outcomes of the bronchopulmonary dysplasia associated with microaspiration of gastric contents].

UNLABELLED: Today the influence of the digestive tract functional violations followed by microaspiration of gastric contents (MAGC) on the incidence, features and outcomes of bronchopulmonary dysplasia BPD) remains little studied. Focusing on this aspect makes the research actual. OBJECTIVE: determination of the nature of influence of MAGC on the progress and course of BPD. METHODS: 373 newborns exposed to artificial pulmonary ventilation (APV) in the neonatal period were examined. In a tracheobronchial aspirate (TBA) the marker of MAGC-pepsin--was determined. Its activity was measured by extinction value with subsequent analysis of the incidence and nature of the course of bronchopulmonary dysplasia (BPD) in patients against MAGC and without it. During the three years follow-up period outcomes of BPD and features of combined pathology were established. RESULTS: it was revealed that in children suffered from MAGC the incidence of BPD was higher and grew in proportion to the increase of pepsin activity in TBA and the reduction of gestational age. The extinction increase in TBA values was followed by the increase in duration of APV and the subsequent oxygen therapy, and also the severity of BPD clinical course. By the end of 3 years clinical recovery was detected in 55.2% of children suffering from BPD without MAGC whereas in patients with BPD against MAGC this outcome occured only in 0.9% of cases. CONCLUSION: MAGC is clinically significant for the etiology, pathogenesis and pathomorphism of BPD. The proposed method of early detection of MAGC and algorithm of complex therapy can reduce its severity and improve the forecast accuracy of neonatal adaptation.

Ameliorative effect of Leflunomide on lung injury following an aspiration.

BACKGROUND: We aimed to investigate the therapeutic effectiveness of leflunomide (LEF) in lung injury after an aspiration of unknown pathophysiology. MATERIAL AND METHODS: Forty-two healthy Sprague Dawley rats were anesthetized and allocated to six experimental groups: saline (S) aspirated, S+LEF, hydrochloric acid (HCl) aspirated, HCl+LEF, formula aspirated (FOR), and FOR+LEF. The treatment groups (S+LEF, HCl+LEF, and FOR+LEF) received 20 mg/kg/day intraperitoneal (i.p.) injection of LEF for seven days. At the end of the seven days, blood and tissue samples were taken from the rats for histopathological, biochemical, and immunohistochemical examination. RESULTS: There was a significant increase in serum levels of YKL-40, a chitinase-like protein, in the HCl group after the aspiration (p<0.01). The increase in serum YKL-40 levels decreased significantly with LEF treatment (p<0.01). There was no significant difference in serum YKL-40 levels in the FOR group compared to the control group at pretreatment and in the FOR+LEF group at post-treatment. There was a significant increase in serum thiobarbituric acid-reactive species (TBARS) values in the HCl and FOR groups compared to the control group (p=0.001 and p<0.01, respectively). In both treatment groups, the serum TBARS values significantly decreased after treatment with LEF (p=0.001 and p<0.05, respectively). There was a significant improvement in the histopathological scores, which deteriorated after the aspiration, and in the number of inducible nitric oxide synthase (iNOS)-positive cells after treatment with LEF.

Bile acid aspiration associated with lung chemical profile linked to other biomarkers of injury after lung transplantation.

Aspiration of gastrointestinal contents has been linked to worse outcomes following lung transplantation but uncertainty exists about underlying mechanisms. We applied high-resolution metabolomics of bronchoalveolar lavage fluid (BALF) in patients with episodic aspiration (defined by bile acids in the BALF) to identify potential metabolic changes associated with aspiration. Paired samples, one with bile acids and another without, from 29 stable lung transplant patients were studied. Liquid chromatography coupled to high-resolution mass spectroscopy was used to interrogate metabolomic contents of these samples. Data were obtained for 7068 ions representing intermediary metabolites, environmental agents and chemicals associated with microbial colonization. A substantial number (2302) differed between bile acid positive and negative samples when analyzed by false discovery rate at q = 0.01. These included pathways associated with microbial metabolism. Hierarchical cluster analysis defined clusters of chemicals associated with bile acid aspiration that were correlated to previously reported biomarkers of lung injury including T cell granzyme B level and the chemoattractants CXCL9 and CXCL10. These data specifically link bile acids presence in lung allografts to inflammatory pathways known to segregate with worsening allograft outcome, and provide additional mechanistic insight into the association between reflux and lung allograft injury.

Aspirated bile: a major host trigger modulating respiratory pathogen colonisation in cystic fibrosis patients.

Chronic respiratory infections are a leading global cause of morbidity and mortality. However, the molecular triggers that cause respiratory pathogens to adopt persistent and often untreatable lifestyles during infection remain largely uncharacterised. Recently, bile aspiration caused by gastro-oesophageal reflux (GOR) has emerged as a significant complication associated with respiratory disease, and cystic fibrosis (CF) in particular. Based on our previous finding that the physiological concentrations of bile influence respiratory pathogens towards a chronic lifestyle in vitro, we investigated the impact of bile aspiration on the lung microbiome of respiratory patients. Sputum samples (n = 25) obtained from a cohort of paediatric CF patients were profiled for the presence of bile acids using high-resolution liquid chromatography-mass spectrometry (LC-MS). Pyrosequencing was performed on a set of ten DNA samples that were isolated from bile aspirating (n = 5) and non-bile aspirating (n = 5) patients. Both denaturing gradient gel electrophoresis (DGGE) and pyrosequencing revealed significantly reduced biodiversity and richness in the sputum samples from bile aspirating patients when compared with non-aspirating patients. Families and genera associated with the pervasive CF microbiome dominated aspirating patients, while bacteria associated with the healthy lung were most abundant in non-aspirating patients. Bile aspiration linked to GOR is emerging as a major host trigger of chronic bacterial infections. The markedly reduced biodiversity and increased colonisation by dominant proteobacterial CF-associated pathogens observed in the sputum of bile aspirating patients suggest that bile may play a major role in disease progression in CF and other respiratory diseases.