Effectiveness of Conventional Dysphagia Therapy (CDT), Neuromuscular Electrical Stimulation (NMES), and Transcranial Direct Current Stimulation (tDCS) in Acute Post-Stroke Dysphagia: A Comparative Evaluation.

This study aims to compare the effectiveness of conventional dysphagia therapy (CDT), neuromuscular electrical stimulation (NMES), and transcranial direct current stimulation (tDCS) in the treatment of post-stroke dysphagia. A single-blind randomized controlled trial was conducted with 40 acute stroke patients - 18 females and 22 males with a mean age of 65.8 ± 11.9. The subjects were grouped into 4, with 10 individuals in each. The procedures administered to groups were as follows: the first group, sham tDCS and sham NMES; the second group, tDCS and sham NMES; the third group, NMES and sham tDCS; and the fourth group, all therapy procedures. CDT was applied to all groups either as a standalone procedure or combined with one or two of the instrumental techniques. Gugging Swallowing Screen (GUSS) and Videofluoroscopic Swallowing Study (VFSS) were employed to determine the severity of dysphagia and the effectiveness of treatment modalities. Additionally, the Penetration Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS), and Dysphagia Severity Rating Scale (DSRS) were administered to interpret VFSS data. Pre- and post-treatment comparisons of all groups have revealed a statistically significant difference for all parameters except for the PAS scores at International Dysphagia Diet Standardization Initiative (IDDSI)-Level 4 consistencies. However, the differences between pre- and post-treatment scores of the fourth group across all parameters were significant - GUSS (p = 0.005), FOIS (p = 0.004), DSRS (p = 0.005), PAS IDDSI-4 (p = 0.027), PAS IDDSI-0 (p = 0.004). Inter-group comparisons, on the other hand, pointed out that the difference between pre- and post-treatment GUSS, FOIS, DSRS, and PAS scores at IDDSI Level-0 consistencies was statistically significant for all groups - GUSS (p = 0,009), FOIS (p = 0,004), DSRS (p = 0,002), PAS IDDSI-0 (p = 0,049). Closer examination of treatment groups indicated that the tDCS + CDT group, the NMES + CDT group, and the group that underwent the combination of three modalities made better progress than the one that was treated with only CDT. Though not statistically significant, the NMES + CDT group achieved better improvement than the tDCS + CDT group. This study has yielded that the group in which NMES, tDCS, and CDT were applied in combination has achieved better results than all the other groups. All treatment modalities applied to accelerate the general recovery process in acute stroke patients with dysphagia were found to be effective for the treatment of post-stroke swallowing disorders. The use of instrumental treatments such as NMES and tDCS enhanced the effectiveness of the treatment and provided more significant progress. Furthermore, combining treatment modalities such as NMES and tDCS was more effective when compared to using only conventional therapy. As a result, the most effective treatment outcomes were obtained by the group receiving CDT, NMES, and tDCS in combination. Therefore, the use of combined approaches has been recommended in appropriate patients; yet the provisional results should be tested in randomized trials with more participants.

Analysis of Clinical Features and Related Factors of Silent Aspiration in Hospitalized COPD Patients.

Context: Silent aspiration is a common complication of chronic obstructive pulmonary disease (COPD). COPD's acute-exacerbation phase may be associated with silent aspiration, impacting a patient's prognosis. Silent aspiration may be more likely to occur in patients in poor basic physical condition. Objective: The study intended to explore the clinical features and other factors related to silent aspiration in patients hospitalized with COPD. Design: The research team designed a retrospective study using data from medical records of patient's hospitalized with COPD. Setting: The study took place at the Sixth Hospital of Wuhan at the Affiliated Hospital of Jianghan University in Wuhan, China. Participants: Participants were 49 patients with acutely aggravated COPD who had been hospitalized between January 2019 and December 2019 at the hospital. Intervention: Participants had all received a radionuclide salivary test at the hospital in the past for silent aspiration. Based on the test results, 15 patients were included in the positive group, and 34 patients were included in the negative group. Outcome Measures: The study compared the two groups': (1) clinical features- respiratory difficulty on the modified Medical Research Council (mMRC) scale, rate of concomitant pneumonia, number of prior admissions to the intensive care unit (ICU), number of acute exacerbations within the year preceding the study, and proportion of patients with two or more acute exacerbations within the year preceding the study; (2) lung function-forced expiratory volume (FEV1), (FEV1%pre), and FEV1/ forced vital capacity (FVC %); (3) blood gases-partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2); and (4) laboratory parameters-white blood cell (WBC) counts, C-reactive protein (CRP), procalcitonin (PCT), and percentage of neutrophils. The research team used univariate and multivariate, logistic regression analysis to identify risk factors for silent aspiration in hospitalized COPD patients. All participants were followed for a mean duration of 18.98 ± 3.09 months, with a range 12 to 24 months. Results: No patients died during the follow-up. No statistically significant differences existed between the groups in age, gender, course of illness, or other clinical variables (P > .05). The positive group had significantly lower scores on the mMRC than did the negative group. Some of the positive group's results were significantly higher than those of the negative group: (1) rate of concomitant pneumonia, (2) number of prior admissions to the ICU, (3) number of acute exacerbations within the year preceding the study, and (4) proportion of patients with two or more acute exacerbations within the year preceding the study (P < .05). No statistical differences existed between the groups in the FEV1, PaO2), PaCO2, WBCs, or percentage of neutrophils (P > .05). The FEV1%pre and FEV1/FVC%) were significantly lower and the CRP and PCT levels were significantly higher in the positive group than in the negative group (P < .05). Conclusion: The mMRC scores, concomitant pneumonia, and prior admission to the ICU were risk factors for silent aspiration in hospitalized COPD patients. Hospital staff should pay more attention to patients with those risk factors during hospitalizations.

Profiles of polypharmacy in older adults and medication associations with signs of aspiration.

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

Clinical trial readiness study of distal myopathy and dysphagia in nephropathic cystinosis.

BACKGROUND: Nephropathic cystinosis is a lysosomal storage disorder with late-onset systemic complications, such as myopathy and dysphagia. Currently employed outcome measures lack sensitivity and responsiveness for dysphagia and myopathy, a limitation to clinical trial readiness. METHODS: We evaluated 20 patients with nephropathic cystinosis in two visits over the course of a year to identify outcomes sensitive to detect changes over time. Patients also underwent an expiratory muscle strength training program to assess any effects on aspiration and dysphagia. RESULTS: There were significant differences in the Timed Up and Go Test (TUG) and Timed 25-Foot Walk (25-FW) between baseline and 1-y follow-up (P < .05). Maximum expiratory pressure (MEP) and peak cough flow (PCF) significantly improved following respiratory training (P < .05). CONCLUSIONS: Improved respiratory outcomes may enhance patients ability to expel aspirated material from the airway, stave off pulmonary sequelae associated with chronic aspiration, and yield an overall improvement in physical health and well-being.

Acute Respiratory Obstruction due to Accidental Inhalation of Perlite: A Novel Mechanism for Upper Airway Occlusion with Cast Formation.

A 56-year-old man died following a fall resulting in complete submersion into a deep pit containing insulation material, expanded perlite. The most striking finding at autopsy was of impacted, moist pale yellow perlite that extended from the epiglottis into the main bronchi resulting in complete obstruction of the larger and smaller airways with cast formation. Perlite inhalation differs from inhalation of inert materials such as sand and wheat due to its hygroscopic properties and ability to expand forming an occlusive cast. Subsequent analyses of perlite from the worksite and within the airways indicated that hydration of perlite and adsorption of organic molecules into the perlite glass flakes had formed an interlocking, three-dimensional structure that was likely responsible for triggering a coagulation-flocculation process causing strong cohesion between the aggregates of glass flakes. This unique mechanism was likely responsible for the formation of the plug of perlite that obstructed the upper airway.

Effect of abdominal massage on prevention of aspiration in intubated and enterally fed patients: A randomized controlled trial.

Background Aspiration is a serious side effect of delayed gastric emptying and increased residual volume in intensive care patients. Aspiration can increase the risk of pneumonia and death. Currently, pharmaceutical methods are the most commonly used techniques for decreasing aspiration, but non-pharmaceutical methods may also be effective in reducing aspiration. One of these methods is an abdominal massage. The present study aimed to examine the effect of abdominal massage on aspiration incidence in intensive care patients with an endotracheal tube. Methods This study was a randomized controlled clinical trial. Seventy intensive care patients with an endotracheal tube were chosen by convenience sampling and allocated to an intervention or a control group by the minimization method. The intervention group was provided with a 15-min abdominal massage twice a day for 3 days, while the control group received only routine cares. The patients' respiratory secretion was suctioned before and after the intervention, and immediately after suctioning, the incidence of the aspiration was assessed using special strips which are sensitive to respiratory secretion pH and glucose. SPSS 18 was used to analyze data. Descriptive statistics were used. T independent, Mann-Whitney U, χ2, and Fisher exact tests were used to compare two groups. Results The incidence rates of the aspiration were 5.7% (confidence interval: 0.0-14.3%) and 20% (confidence interval: 8.6-34.3%) in the abdominal massage and the control groups, respectively. The incidence of aspiration differed between two groups, but it was not statistically significant (p=0.07). Conclusion Although the low rate of aspiration in the abdominal massage group did not differ significantly with that of the control group, it can be clinically important. It is suggested that further studies be conducted to confirm the effect of abdominal massage on the prevention of aspiration in intensive care patients with an endotracheal tube.

Aural stimulation with capsaicin prevented pneumonia in dementia patients.

OBJECTIVE: In the present study, we examined the effects of daily application of capsaicin ointment to the external auditory canal for 6 months on the development of pneumonia in elderly dementia patients at high risk of aspiration. METHODS: Twenty-nine oldest-old bedridden dementia inpatients at high risk of aspiration were enrolled in the present study. Ointment containing 0.025% capsaicin was applied to each external auditory canal with a cotton swab alternatively once a day for 6 months. RESULTS: The incidence of pneumonia during the 6 months before the intervention was 1.80±0.37 in these patients. However, this incidence significantly decreased to 0.40±0.29 (p<0.01) during the 6 months of the alternative application of capsaicin ointment to each auditory canal. No adverse effect such as otalgia was observed. CONCLUSION: These findings suggest that daily long-term aural stimulation with capsaicin ointment enhanced the cough reflex via Arnold's ear-cough reflex as a glottis protective measure, resulting in the reduction of incidence of pneumonia in elderly dementia patients at high risk of aspiration. The daily aural stimulation with capsaicin ointment may be a safe and promising intervention to prevent aspiration pneumonia in elderly people, especially those who cannot undergo swallowing exercise.

Neuromuscular electrical stimulation improves feeding and aspiration status in medically complex children undergoing feeding therapy.

OBJECTIVES: Neuromuscular electrical stimulation (NMES) therapy in the head and neck has been effectively used to rehabilitate swallowing in adult patients with acquired dysphagia. Limited data is available for the effectiveness of NMES in medically complex children with dysphagia and aspiration. This study intends to determine the efficacy of NMES as a therapeutic adjunct to improve aspiration and feeding status in medically complex children with severe dysphagia undergoing comprehensive speech and swallow therapy. STUDY DESIGN: Case series. SETTING: Tertiary children's hospital. SUBJECTS: and Methods: Medically complex children undergoing treatment for dysphagia using NMES during a three year period were included. Duration of treatment routinely ranged from 20 to 26 weeks. Demographic information, pre and post-NMES treatment aspiration status via modified barium swallow (MBS), and pre and post-NMES treatment feeding status were examined. RESULTS: 15 medically complex children underwent NMES as a component of their feeding therapy. The mean age was 2.51 ±â€¯3.20 years. Mean pre-treatment Functional Oral Intake Scale(FOIS) was 3.07 ±â€¯1.94. Following NMES, FOIS improved to 4.47 ±â€¯2.26 (p < 0.0001). Fourteen patients were evaluated with MBS prior to NMES. Pre-treatment aspiration and penetration were noted in 10 and 2 patients respectively. Two patients did not aspirate on pre-treatment MBS. Improvement was noted in 9 of 11 children with post-treatment MBS. CONCLUSION: NMES was safely completed in all children without complication. Improvement in aspiration status was seen in 83.3% of patients with pre- and post-treatment MBS. Feeding status as measured by textures was advanced in all patients with a significant improvement in FOIS. Future prospective studies are required to investigate the specific role in children with acquired and congenital dysphagia.

Mitragynine concentrations in two fatalities.

Two cases of fatalities are reported of which the recreational use of Mitragyna speciosa ("kratom") could be confirmed. One of these cases presents with one of the highest postmortem mitragynine concentrations published to date. Our results show that even extremely high mitragynine blood concentrations following the consumption of kratom do not necessarily have to be the direct cause of death in such fatalities as a result of an acute overdose. The two cases are compared with regard to the differences in mitragynine concentrations detected and the role of mitragynine in the death of the subjects. Irrespective of the big differences in mitragynine concentrations in the postmortem blood samples, mitragynine was not the primary cause of death in either of the two cases reported here. Additionally, by rough estimation, a significant difference in ratio of mitragynine to its diastereomers in the blood and urine samples between the two cases could be seen.

Infant Videofluoroscopic Swallow Study Testing, Swallowing Interventions, and Future Acute Respiratory Illness.

OBJECTIVES: Tube feedings are commonly prescribed to infants with swallowing abnormalities detected by videofluoroscopic swallow study (VFSS), but there are no studies demonstrating efficacy of these interventions to reduce risk of acute respiratory illness (ARI). We sought to measure the association between swallowing interventions and future ARI, among VFSS-tested infants. METHODS: Retrospective cohort of all infants (<12 months) tested with VFSS at a children's hospital between January 1, 2010, and January 1, 2012. Hospital ARI encounters (emergency, observation, or inpatient status) in a 22-hospital integrated health care delivery system, between the first VFSS and age 3 years, were measured. VFSS results were grouped by normal, intermediate, and oropharyngeal aspiration (OPA), with OPA further subdivided by silent versus cough and thin versus thick liquid OPA. Cox regression modeled the association between swallowing interventions (thickened or nasal tube feedings) and ARI, accounting for changes in swallowing and interventions over time. RESULTS: 576 infants were tested with a VFSS in their first year of life, receiving a total of 1051 VFSSs in their first 3 years of life. More than 60% of infants received a measured feeding intervention. With the exception of infants with silent OPA who received thickened feedings, neither thickening nor nasal tube feedings, compared with no intervention, were associated with a decreased risk of subsequent ARI. CONCLUSIONS: Swallowing interventions and repeated testing are common among VFSS-tested infants. However, the importance of diagnosing and intervening on VFSS-detected swallowing abnormalities for the majority of tested infants remains unclear.

Providing Oral Nutrition to Women in Labor: American College of Nurse-Midwives.

Historically, oral intake for women during labor has been limited to nothing by mouth or clear liquids only. These restrictions are based on the risk of aspiration during or after the administration of general anesthesia. While aspiration can be life threatening, older methods of anesthesia are rarely used in current intrapartum care, and evidence is inconclusive that withholding oral nutrition reduces the risk of gastric aspiration. Additionally, withholding oral nutrition may result in the development of ketosis and may potentially contribute to a woman's stress and dissatisfaction with the birth experience. The purpose of this Clinical Bulletin is to review the evidence related to this practice and provide recommendations to promote informed, shared decision making regarding oral intake during labor with women at low risk for gastric aspiration.

Severe Endobronchial Inflammation Induced by Aspiration of a Ferrous Sulfate Tablet / 결핵및호흡기질환

Iron supplements such as ferrous sulfate tablets are usually used to treat iron-deficiency anemia in some elderly patients with primary neurologic disorders or decreased gag reflexes due to stroke, senile dementia, or parkinsonism. While the aspiration of ferrous sulfate is rarely reported, it is a potentially life-threatening condition that can lead to airway necrosis and bronchial stenosis. A detailed history and high suspicion of aspiration are required to avoid delays in diagnosis and treatment. The diagnosis can be confirmed by bronchoscopic examination and a tissue biopsy. Early removal of the aspirated tablet prevents acute complications, such as bronchial necrosis, hemoptysis, and lobar consolidation. Tablet removal is also necessary to prevent late bronchial stenosis. We presented the first case in Korea of a ferrous sulfate tablet aspiration that induced severe endobronchial inflammation.

Metal rich particulate matter impairs acetylcholine-mediated vasorelaxation of microvessels in mice.

BACKGROUND: Exposure to PM2.5 (particulate matter<2.5 µm) has been associated with changes in endothelial function. PM2.5 was collected from two Chinese cities, Jinchang (JC) and Zhangye (ZH), both with similar PM2.5 concentrations. However, JC had levels of nickel (Ni), selenium (Se), copper (Cu), and arsenic (As) that were 76, 25, 17, and 7 fold higher than that measured in ZH, respectively. We used this unique PM sample to delineate the chemical components that drive pulmonary and systemic effects and explore the mechanism(s) by which vascular dysfunction is caused. METHODS: Male FVB/N mice received oropharyngeal aspiration of water or PM2.5 from JC, ZH or ZH spiked with one of the following elements at the same concentrations found in the JC PM (Ni=4.76; As=2.36; Se=0.24; Cu=2.43 µg/mg) followed by evaluation of markers of pulmonary and systemic inflammation. Mesenteric arteries were isolated for gene expression or functional response to various agonists (Phenylephrine, Acetylcholine, and Sodium Nitroprusside) and inhibitors (L-NAME, Apocynin, and VAS2870) ex vivo. RESULTS: Protein and total cell counts from lung lavage revealed significant pulmonary inflammation from ZH (p<0.01) and JC and ZH+NiSO4 (p<0.001) as compared to control and a significant decrease in mesenteric artery relaxation (p<0.001) and this decrease is blunted in the presence of NADPH oxidase inhibitors. Significant increases in gene expression (TNF-α, IL-6, Nos3; p<0.01; NOX4; p<0.05) were observed in JC and ZH+NiSO4, as well as significantly higher concentrations of VEGF and IL-10 (p<0.01, p<0.001; respectively). CONCLUSIONS: Our results indicate that the specific toxicity observed in PM from JC is likely due to the nickel component in the PM. Further, since VAS2870 was the most successful inhibitor to return vessels to baseline relaxation values, NADPH Oxidase is implicated as the primary source of PM-induced O2•-.

Barium sulfate aspiration: Severe chemical pneumonia induced by a massive reflux of contrast medium during small bowel barium enema.

Barium contrast radiography is a conventional procedure aimed at revealing lesions of the alimentary tract using barium sulfate on X-ray irradiation. Although it is widely used in clinics, adverse effects and complications are observed, such as anaphylaxis, granuloma, fecalithes, abdomen-leaking, embolism, bacterial contamination, and aspiration. We report a case of death due to a massive barium sulfate aspiration resulted from an air-barium double contrast enema radiography. A 25-year-old female patient was hospitalized with symptoms of abdominal distention, nausea, vomiting and diarrhea for three days. A progressive respiratory distress presented only 1h after a small bowel air-barium double contrast enema. The patient died 11h later. The result of autopsy revealed the cause of death to be severe chemical pneumonitis induced by gastric fluid which was aspirated into her lungs. Barium sulfate is generally recognized to be chemically inert for the respiratory system, but a mixture of barium sulfate with gastric contents is fatal. Here we intend to suggest that, when determining the potential cause of death, medical examiners should consider a patient's status quo as well as the possible adverse effects and complications caused by the barium sulfate preparation during gastrointestinal radiography.

Effect of Chronic Obstructive Pulmonary Disease on Swallowing Function in Stroke Patients

OBJECTIVE: To investigate the prevalence of chronic obstructive pulmonary disease (COPD) in stroke patients, and to assess the difference in swallowing function between stroke patients with COPD (COPD group) and stroke patients without COPD (control group). METHODS: The subjects included 103 stroke patients. They underwent the pulmonary function test and were assigned to either the COPD group or the control group. Their penetration-aspiration scale (PAS) scores and functional dysphagia scale scores were compared by performing a videofluoroscopic swallowing study. The intergroup differences in lip closure, bolus formation, mastication, and the oral transit time, laryngeal elevation, cricopharyngeal dysfunction, oronasal regurgitation, residue in pyriform sinus and vallecula, pharyngeal transit time, aspiration, and esophageal relaxation were also compared. RESULTS: Thirty patients were diagnosed with COPD. The COPD group showed statistically higher PAS scores (4.67+/-2.15) compared to the control group (2.89+/-1.71). Moreover, aspiration occurred more frequently in the COPD group with statistical significance (p<0.05). The COPD group also showed higher occurrence of cricopharyngeal dysfunction, albeit without statistical significance. CONCLUSION: This study shows that a considerable number of stroke patients had COPD, and stroke patients with COPD had higher risk of aspiration than stroke patients without COPD.

Glottal insufficiency with aspiration risk in dysphagia.

Glottal closure is an important part of the mechanism that protects the airway during the normal swallow. Glottal insufficiency disrupts glottal closure and therefore puts patients at risk of aspiration. Treatment of glottal insufficiency can be classified as surgical or nonsurgical. The objective of treating glottal insufficiency is to avoid aspiration or penetration of secretions or food into the airway. Nonsurgical treatment consists of swallowing maneuvers and other measures. Surgical treatment of glottal insufficiency includes injection laryngoplasty, medialization thyroplasty with or without arytenoid adduction or with arytenopexy and cricothyroid subluxation, hypopharyngoplasty, cricopharynx muscle dilation, and cricopharynx myotomy.

Characterizing risk factors for pediatric lamp oil product exposures.

UNLABELLED: Poisonings from lamp oil ingestion continue to occur worldwide among the pediatric population despite preventive measures such as restricted sale of colored and scented lamp oils. This suggests that optimal prevention practices for unintentional pediatric exposures to lamp oil have yet to be identified and/or properly implemented. OBJECTIVE: To characterize demographic, health data, and potential risk factors associated with reported exposures to lamp oil by callers to poison centers (PCs) in the US and discuss their public health implications. STUDY DESIGN: This was a two part study in which the first part included characterizing all exposures to a lamp oil product reported to the National Poison Data System (NPDS) with regard to demographics, exposure, health, and outcome data from 1/1/2000 to 12/31/2010. Regional penetrance was calculated using NPDS data by grouping states into four regions and dividing the number of exposure calls by pediatric population per region (from the 2000 US census). Temporal analyses were performed on NPDS data by comparing number of exposures by season and around the July 4th holiday. Poisson regression was used to model the count of exposures for these analyses. In the second part of this project, in order to identify risk factors we conducted a telephone-based survey to the parents of children from five PCs in five different states. The 10 most recent lamp oil product exposure calls for each poison center were systematically selected for inclusion. Calls in which a parent or guardian witnessed a pediatric lamp oil product ingestion were eligible for inclusion. Data on demographics, exposure information, behavioral traits, and health were collected. A descriptive analysis was performed and Fisher's exact test was used to evaluate associations between variables. All analyses were conducted using SAS v9.3. RESULTS: Among NPDS data, 2 years was the most common patient age reported and states in the Midwestern region had the highest numbers of exposure calls compared to other regions. Exposure calls differed by season (p < 0.0001) and were higher around the July 4th holiday compared to the rest of the days in July (2.09 vs. 1.89 calls/day, p < 0.002). Most exposures occurred inside a house, were managed on-site and also had a "no effect" medical outcome. Of the 50 PC-administered surveys to parents or guardians, 39 (78%) met inclusion criteria for analysis. The majority of ingestions occurred in children that were 2 years of age, that were not alone, involved tiki torch fuel products located on a table or shelf, and occurred inside the home. The amount of lamp oil ingested did not appear to be associated with either the smell (p = 0.19) or the color of the oil (p = 1.00) in this small sample. Approximately half were asymptomatic (n = 18; 46%), and of those that reported symptoms, cough was the most common (n = 20, 95%) complaint. CONCLUSIONS: Lamp oil product exposures are most common among young children (around 2 years of age) while at home, not alone and likely as a result of the product being in a child-accessible location. Increasing parental awareness about potential health risks to children from these products and teaching safe storage and handling practices may help prevent both exposures and associated illness. These activities may be of greater benefit in Midwestern states and during summer months (including the period around the July 4th holiday).

Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial.

OBJECTIVES: To determine the effect of the enhanced protein-energy provision via the enteral route feeding protocol, combined with a nursing educational intervention on nutritional intake, compared to usual care. DESIGN: Prospective, cluster randomized trial. SETTING: Eighteen ICUs from United States and Canada with low baseline nutritional adequacy. PATIENTS: One thousand fifty-nine mechanically ventilated, critically ill patients. INTERVENTIONS: A novel feeding protocol combined with a nursing educational intervention. MEASUREMENTS AND MAIN RESULTS: The two primary efficacy outcomes were the proportion of the protein and energy prescriptions received by study patients via the enteral route over the first 12 days in the ICU. Safety outcomes were the prevalence of vomiting, witnessed aspiration, and ICU-acquired pneumonia. The proportion of prescribed protein and energy delivered by enteral nutrition was greater in the intervention sites compared to the control sites. Adjusted absolute mean difference between groups in the protein and energy increases were 14% (95% CI, 5-23%; p = 0.005) and 12% (95% CI, 5-20%; p = 0.004), respectively. The intervention sites had a similar improvement in protein and calories when appropriate parenteral nutrition was added to enteral sources. Use of the enhanced protein-energy provision via the enteral route feeding protocol was associated with a decrease in the average time from ICU admission to start of enteral nutrition compared to the control group (40.7-29.7 hr vs 33.6-35.2 hr, p = 0.10). Complication rates were no different between the two groups. CONCLUSIONS: In ICUs with low baseline nutritional adequacy, use of the enhanced protein-energy provision via the enteral route feeding protocol is safe and results in modest but statistically significant increases in protein and calorie intake.

An alternative method of management of pediatric airway foreign bodies in the absence of rigid bronchoscopy.

OBJECTIVE: Pediatric airway foreign body aspiration is a life-threatening clinical entity. The standard of care for managing this situation is endoscopic retrieval using rigid bronchoscopy. However in resource-limited settings rigid bronchoscopy may not be available. This retrospective case series describes the successful application of one treatment modality for pediatric airway foreign body. METHODS: A retrospective review was performed for seven pediatric patients who were treated at Soddo Christian Hospital with a diagnosis of airway foreign body aspiration. All patients were treated in the operating room using general anesthesia, a combination of inhaled halothane and intravenous ketamine. Paralytics were not used in any patient and spontaneous breathing was maintained. Flexible fiberoptic bronchoscopy was initially performed on each patient to confirm the presence of a foreign body and identify the anatomic position with the airway. Using a standard technique, a tracheotomy was performed. If the foreign body was still noted to be distal to the tracheotomy, postural percussion was performed to dislodge the foreign body into the trachea. Once the foreign body was identified at the tracheotomy, it was removed. RESULTS: All seven patients presented in respiratory distress and were emergently managed in the operating room. The average age was 2.8 years (6 months-8 years of age). The foreign bodies were successfully removed in all patients. There were no mortalities and all patients were successfully discharged from the hospital. CONCLUSIONS: Pediatric airway foreign body aspiration is a life-threatening clinical entity in any setting, but it presents unique challenges in resource-limited settings where rigid bronchoscopy is not available. This report presents one such treatment modality and utilizes a combination of flexible fiberoptic bronchoscopy and tracheotomy to treat such patients.