A Double-Blind Randomized Controlled Trial to Determine the Preventive Effect of Hangekobokuto on Aspiration Pneumonia in Patients Undergoing Cardiovascular Surgery.

PURPOSE: This study aimed to assess whether hangekobokuto (HKT) can prevent aspiration pneumonia in patients undergoing cardiovascular surgery. METHODS: We performed a single-center, double-blinded, randomized, placebo-controlled study of HKT in patients undergoing cardiovascular surgery. JPS HKT extract granule (JPS-16) was used as HKT. The primary endpoint was defined as the prevention of postoperative aspiration pneumonia. The secondary endpoints included complete recovery from swallowing and coughing disorders. RESULTS: Between August 2014 and August 2015, a total of 34 patients were registered in this study. The rate of subjects with postoperative aspiration pneumonia was significantly lower in the HKT group than in the placebo group (p = 0.017). In high-risk patients for aspiration pneumonia, the rate was significantly lower in the HKT group than in the placebo group (p = 0.015). The rate of subjects with swallowing disorders tended to be lower in the HKT group than in the placebo group (p = 0.091), and in high-risk patients, the rate was significantly lower in the HKT group than in the placebo group (p = 0.038). CONCLUSIONS: HKT can prevent aspiration pneumonia in patients undergoing cardiovascular surgery. In high-risk patients for aspiration pneumonia, HKT can prevent aspiration pneumonia and improve swallowing disorders.

Respiratory complications following hydrocarbon aspiration in children.

Accidental hydrocarbon ingestion may lead to aspiration and chemical pneumonitis in children. In this review article, the clinical course of hydrocarbon pneumonitis, chest radiographic abnormalities, complications, and treatment interventions are summarized. Most children remain asymptomatic and without complications following ingestion of a hydrocarbon. In approximately 15% of ingestions, aspiration pneumonitis occurs and evolves over the first 6-8 hr presenting with fever, tachypnea, hypoxemia, and tachycardia. A symptom zenith is reached within 48 hr followed by progressive improvement. Up to 5% of pneumonitis cases progress rapidly to acute respiratory failure. Chest radiographic abnormalities develop by 4-8 hr after ingestion, but they are not always predictive of clinical pneumonitis. Patients with history of hydrocarbon ingestion should be monitored for 6-8 hr in the emergency department and a chest radiogram should be obtained at the end of the observation period. Spontaneous or induced emesis and gastric lavage have been related to aspiration pneumonitis. Children who are symptomatic are admitted to the hospital for cardiorespiratory status monitoring and supportive care. Approximately 90% of hospitalized patients have a benign clinical course. Increased work of breathing with or without altered sensorium and seizures are indications for admission to the intensive care unit. Hypoxemia unresponsive to supplemental oxygen and/or severe central nervous system involvement require mechanical ventilation. Corticosteroids do not seem to offer any benefit and antibiotics are administered in cases of bacterial superinfection. Pneumatoceles may become evident after the first 6-10 days of symptoms on follow-up chest radiograms and they resolve up to 6 months later. Pediatr Pulmonol. 2016;51:560-569. © 2016 Wiley Periodicals, Inc.

A pilot study of respiratory muscle training to improve cough effectiveness and reduce the incidence of pneumonia in acute stroke: study protocol for a randomized controlled trial.

BACKGROUND: After stroke, pneumonia is a relevant medical complication that can be precipitated by aspiration of saliva, liquids, or solid food. Swallowing difficulty and aspiration occur in a significant proportion of stroke survivors. Cough, an important mechanism protecting the lungs from inhaled materials, can be impaired in stroke survivors, and the likely cause for this impairment is central weakness of the respiratory musculature. Thus, respiratory muscle training in acute stroke may be useful in the recovery of respiratory muscle and cough function, and may thereby reduce the risk of pneumonia. The present study is a pilot study, aimed at investigating the validity and feasibility of this approach by exploring effect size, safety, and patient acceptability of the intervention. METHODS/DESIGN: Adults with moderate to severe stroke impairment (National Institutes of Health Stroke Scale (NIHSS) score 5 to 25 at the time of admission) are recruited within 2 weeks of stroke onset. Participants must be able to perform voluntary respiratory maneuvers. Excluded are patients with increased intracranial pressure, uncontrolled hypertension, neuromuscular conditions other than stroke, medical history of asthma or chronic obstructive pulmonary disease, and recent cardiac events. Participants are randomized to receive inspiratory, expiratory, or sham respiratory training over a 4-week period, by using commercially available threshold resistance devices. Participants and caregivers, but not study investigators, are blind to treatment allocation. All participants receive medical care and stroke rehabilitation according to the usual standard of care. The following assessments are conducted at baseline, 4 weeks, and 12 weeks: Voluntary and reflex cough flow measurements, forced spirometry, respiratory muscle strength tests, incidence of pneumonia, assessments of safety parameters, and self-reported activity of daily living. The primary outcome is peak expiratory cough flow of voluntary cough, a parameter indicating the effectiveness of cough. Secondary outcomes are incidence of pneumonia, peak expiratory cough flow of reflex cough, and maximum inspiratory and expiratory mouth pressures. DISCUSSION: Various novel pharmacologic and nonpharmacologic approaches for preventing stroke-associated pneumonia are currently being researched. This study investigates a novel strategy based on an exercise intervention for cough rehabilitation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN40298220.

Adjunctive functional pharyngeal electrical stimulation reverses swallowing disability after brain lesions.

BACKGROUND & AIMS: Oropharyngeal dysphagia is an important disability that occurs after stroke; it contributes to aspiration pneumonia and death, and current modalities for rehabilitation of dysphagia have uncertain efficacy. We therefore examined the role of pharyngeal electrical stimulation (PES) in expediting human swallowing recovery after experimental (virtual) and actual (stroke) brain lesions. METHODS: First, healthy subjects (n = 13) were given 1-Hz repetitive transcranial magnetic stimulation to induce a unilateral virtual lesion in pharyngeal motor cortex followed by active or sham (control) PES. Motor-evoked potentials and swallow accuracy were recorded before and after the lesion to assess PES response. Thereafter, 50 acute dysphagic stroke patients underwent either a dose-response study, to determine optimal parameters for PES (n = 22), or were assigned randomly to groups given either active or sham (control) PES (n = 28). The primary end point was the reduction of airway aspiration at 2 weeks postintervention. RESULTS: In contrast to sham PES, active PES reversed the cortical suppression induced by the virtual lesion (F(7,70) = 2.7; P = .015) and was associated with improvement in swallowing behavior (F(3,42) = 5; P = .02). After stroke, 1 PES treatment each day (U = 8.0; P = .043) for 3 days (U = 10.0) produced improved airway protection compared with controls (P = .038). Active PES also reduced aspiration (U = 54.0; P = .049), improved feeding status (U = 58.0; P = .040), and resulted in a shorter time to hospital discharge (Mantel-Cox log-rank test, P = 0.038). CONCLUSIONS: This pilot study of PES confirms that it is a safe neurostimulation intervention that reverses swallowing disability after virtual lesion or stroke.

Effects of granulocyte colony-stimulating factor (G-CSF) and neutrophil elastase inhibitor (ONO-5046) on acid-induced lung injury in rats.

It has been suggested that neutrophils play an important role in acid-aspirated lung injury. We examined the effects of the high dose of granulocyte-colony stimulating factor (G-CSF), which is capable of increasing peripheral neutrophils, and a specific neutrophil elastase inhibitor (ONO-5046) on acid lung injury in rats. Animals were anesthetized and normal saline (NS, 2 mL kg(-1)) or hydrochloric acid (HCl, 0.1 N 2 mL kg(-1)) was then instilled into trachea. Thirty minutes before HCl instillation, G-CSF (150 microg kg(-1)) was injected subcutaneously or ONO-5046 (10 mg kg(-1) h(-1)) was infused continuously into the right jugular vein. Animals were ventilated during the experiments. Five hours after HCl or NS instillation, bronchoalveolar lavage fluid (BALF) and lung tissue samples were obtained. Total nuclear cell count, absorbance, albumin, tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, cytokine-induced neutrophil chemoattractant (CINC), neutrophil elastase in BALF, wet-to-dry (W/D) ratio were measured. HCl aspiration markedly increased these values in BALF and W/D ratio. Both ONO-5046 and G-CSF attenuated the parameters increased by acid-induced lung injury in rats. The data suggests that neutrophils play an important role in acid-induced lung injury. However, high-dose G-CSF does not exacerbate acid-aspirated lung injury in rats, although this agent causes an increase in peripheral neutrophils.

The traditional Chinese medicine banxia houpo tang improves swallowing reflex.

A marked depression of swallowing reflex has been found in patients with aspiration pneumonia. We have examined the effects of Banxia Houpo Tang (BHT, Hange Koboku-To in Japanese), on swallowing reflex among the elderly. Thirty-two patients, mean age 74.2 +/- 1.7 years who had at least one episode of aspiration pneumonia, were divided into two groups. Twenty patients took BHT extracts of 7.5 g per day for four weeks, and the other 12 patients took a placebo. The swallowing reflex was measured by a bolus injection of 1 ml of distilled water into the pharynx through a nasal catheter. The reflex was evaluated by the latency time of response, which was the time from the injection to the onset of swallowing. The latency of response decreased significantly from 11.6 +/- 3.0 sec to 2.6 +/- 0.4 sec in the group treated with BHT (p < 0.01), while in the other group with placebo it was from 11.0 +/- 4.0 to 10.8 +/- 3.6 (p > 0.5). Depletion of substance P in the pharynx causes impairments of the swallowing reflex. Substance P in the saliva of treated patients increased from 9.2 +/- 2.5 fmol/ml to 15.0 +/- 2.2 fmol/ml after BHT treatment (p < 0.01), while levels were 8.0 +/- 4.0 fmol/ml before and 7.1 +/- 3.1 fmol/ml after among the placebo group (no significant difference). We suggest that BHT improves the impaired swallowing reflex and may help to prevent aspiration pneumonia in the elderly.

Artificial reflex arc: a potential solution for chronic aspiration. III: Stimulation of implanted cervical skin as a functional graft triggering glottic closure in the canine.

Stroke often impairs the ability of the vocal cords to close during deglutition, resulting in aspiration. The current study is a further advance on the application of the concept of an artificial reflex arc during swallowing. The second and third cervical branches were bilaterally isolated in four dogs and baseline sensory nerve traffic was detected via tripolar perineural electrodes. Cervical skin pressure-induced suprathreshold signals were used to trigger vocal cord contraction via bipolar electrodes passed around the recurrent laryngeal nerves. Skin subtended by the cervical nerves was implanted over the lateral aspect of the pyriform sinuses for 1 week. After reexploration, glottic closure was verified on videotape as surges in sensory nerve traffic were induced by mechanical stimulation of the pharynx. The possibility of artifactual stimulation was ruled out by lack of electrode motion during pharyngeal stimulation, spontaneous firing in the sensory nerve during light anesthesia, and sensory frequency differing from ambient 60-Hz noise. This article introduces the concept of autogenous functional graft as a basis for afferent information in electronic systems for dynamic rehabilitation of swallowing disorders.

Sucralfate does not reduce the risk of acid aspiration pneumonitis.

OBJECTIVE: To study the pulmonary effects of aspirating a mixture of sucralfate in water and sucralfate in hydrochloric acid in an animal model of aspiration pneumonia. DESIGN: Prospective, randomized, controlled study with repeated measures. SETTING: University research laboratory. SUBJECTS: Thirty-two in situ, isolated, blood perfused porcine lung preparations. INTERVENTIONS: Five control preparations received no aspiration. Twenty-seven preparations received a standard aspiration of 1.5 mL/kg body of a) distilled water (n = 5), b) sucralfate in distilled water (n = 8), c) 1/10 normal hydrochloric acid (n = 6), and d) mixture of sucralfate in distilled water and hydrochloric acid (n = 8). MEASUREMENTS: The pH measurements were made of all aspirates. Lung weight, airway pressures, and pulmonary artery pressures were continuously monitored before and for 4 hrs after aspiration. Lung wet/dry weight ratio was measured at the completion of the study. RESULTS: The pH of sucralfate mixed with distilled water was 4.9, pH of 1/10 normal hydrochloric acid was 1.0, and pH of equal volumes of a sucralfate-water suspension mixed with hydrochloric acid was 1.5. Airway pressures and pulmonary arterial pressures increased in all aspirate groups over time compared with those values of control lungs. Control lungs gained 18 +/- 3 (SEM) g over 4 hrs and the wet/dry ratio was 4.951 +/- 0.310. Lungs aspirating distilled water gained 147 +/- 49 g and the wet/dry ratio was 5.198 +/- 0.120. Lungs aspirating sucralfate and distilled water increased their weight by 109 +/- 30 g and the wet/dry ratio was 5.380 +/- 0.076. Lungs aspirating a suspension of sucralfate and water and hydrochloric acid were similar to lungs aspirating hydrochloric acid alone with weight increases of 265 +/- 30 g and 346 +/- 81 g, and the wet/dry ratio of 7.011 +/- 0.273 and 7.230 +/- 0.390, respectively. CONCLUSIONS: Sucralfate has minimal acid buffering effect. Aspiration of sucralfate mixed with distilled water causes lung edema similar to aspiration of water alone. Aspiration of a sucralfate-water suspension mixed with hydrochloric acid causes severe lung edema. These results suggest that patients given sucralfate prophylaxis for stress ulceration are at risk for acid aspiration.

A volume and pH determination of tracheal residue postaspiration.

An endotracheal tube containing pH sensors for rapid detection of episodic acid aspiration was combined with a design that provides a means of suctioning tracheal residue resulting from gastric regurgitation and aspiration. The efficacy of the tube operation was demonstrated in two patients who aspirated gastric contents.

Fire-eater's lung.

Acute pneumonitis following aspiration of petroleum products is usually related to accidental poisonings in children. We describe here two cases of hydrocarbon pneumonitis in fire-eaters, caused by accidental aspiration of petroleum during the performance of fire-eating. Both patients had cough, dyspnoea, chest pain and fever. Chest X-rays showed basal lung infiltrates and, 2 weeks later, pneumatocele formations. Reversible bronchial hyperresponsiveness and restrictive ventilatory limitation were demonstrated in one of the patients. The bronchoalveolar lavage specimen showed cytoplasmic vacuolation of the macrophages and neutrophilia. After treatment with antibiotics and corticosteroids the symptoms disappeared and the lung function values returned to normal within 2-3 weeks. Radiological resolution of the pneumatoceles occurred within 2-12 months.