Amyotrophic Lateral Sclerosis survival analysis: Swallowing and non-oral feeding.

BACKGROUND: Dysphagia-related complications, such as aspiration pneumonia and malnutrition, are major causes of death among patients with Amyotrophic Lateral Sclerosis (ALS). OBJECTIVE: To analyze clinical features associated with worsened swallowing and non-oral feeding in ALS. METHODS: This is a long-term study of 33 ALS patients, who were observed between 2006 and 2011 in three month intervals. These subjects underwent Fiberoptic Endoscopic Evaluation of Swallowing and Functional Oral Intake Scale classification. Survival analysis was performed using Cox Regression. RESULTS: The worsening of swallowing functionality was more rapid in late-onset ALS patients (risk of 4% per year) and individuals with bulbar onset ALS (risk of 188% per year). Non-oral feeding was associated with both the later onset of ALS symptoms (risk of 7.5% per year) and shorter disease duration (risk of 13% per year). CONCLUSION: Worsened swallowing was more rapid in individuals who were older at symptoms onset and who had bulbar onset ALS. Non-oral feeding was associated with both age at symptoms onset and shorter disease duration.

Neumonía aspirativa en pacientes adultos mayores / Aspiration pneumonia in the elderly patients

En la neumonía aspirativa hay evidencia radiológica de infiltrado parenquimal pulmonar en diferentes segmentos, como consecuencia del paso de secreciones contaminadas por agentes patógenos que proceden de la región orofaríngea o gastroesofágica hacia el árbol traqueobronquial. Se presenta principalmente en adultos mayores y en pacientes con alteraciones neurodegenerativas. Los mecanismos implicados en la aspiración son: la disfagia orofaríngea funcional y las alteraciones gastroesofágicas. Los gérmenes implicados son Streptococcus pneumoniae, Haemophilus influenza y S. aureus cuando la neumonía aspirativa ocurre en la comunidad y bacilos gramnegativos si es de ocurrencia intrahospitalaria. Los anaerobios pocas veces son agentes responsables. La historia clínica, radiografía pulmonar y otros procedimientos como la videofluroscopia orofaríngea, resultan útiles para el diagnóstico. El tratamiento está basado en el uso de antibióticos principalmente contra gérmenes aeróbicos grampositivos y gramnegativos y, excepcionalmente, contra anaerobios en situaciones especiales; y, medidas para disminuir las condiciones que favorecen la broncoaspiración.

In aspiration pneumonia there is radiological evidence of an infiltrate in the pulmonary parenchyma, in different segments, as a result of the passage of secretions contaminated by pathogens that come from the region of oropharyngeal or gastroesophageal tube to the tracheobronchial tree. It occurs mainly in the elderly and in patients with neurodegenerative disorders. The involved mechanisms in the aspiration are: functional oropharyngeal dysphagia and gastroesophageal alterations. The involved germs are Streptococcus pneumoniae, Haemophilus influenza and Staphylococcus aureus when the aspiration pneumonia occurs in the community and gram-negative bacilli in hospital occurrence. Anaerobic bacteria are rarely responsible agents. The clinical history, pulmonary x-ray and other procedures such as oropharyngeal videofluoroscopy are useful for diagnosis. Treatment is mainly based on the use of antibiotics against gram-positive and gram-negative aerobic germs and, exceptionally, against anaerobes in special situations; and, measures to reduce the conditions that favor the aspiration into lungs.

Laryngeal lesion in leprosy and the risk of aspiration.

Leprosy affects the larynx, damaging its mucosa and sensory nerves and loss of sensation may result in aspiration of food and secretions. The laryngeal lesion may be insidious. Post-mortem studies showed bronchopneumonia that could have originated from aspiration. In patients with laryngeal symptoms, dysphagia or aspiration pneumonia loss of laryngeal sensation should be looked for.

Predicción clínica de aspiración en pacientes con patología neurológica aguda / Clinical prediction of aspiration in acute neurological patients

Glottic dysfunction is a frequent condition in patients with acute neurological diseases: the incidence in stroke patients is between 45 - 51 percent increasing mortality three times. The principal complication is aspiration, which demands the involvement of pulmonary physicians and neurologists. The purpose of this study is to evaluate wet voice, water swallow test and cervical auscultation as clinical predictors of aspiration using endoscopical observation as a gold standard. During a period of one year we have prospectively evaluated these tests in acute neurological patients hospitalized in an intensive care unit. Wet voice, 3 oz water swallow test and cervical auscultation demonstrated sensibilities of 66.7, 88.9 and 77.8 percent, with a respective specificity of 85.2, 59.3 and 77.8 percent. Positive predictive values were 60, 42.1 and 53.8 percent, with negative predictive values of 88.5, 94.1 and 91.3 percent respectively. These results support the utility of clinical aspiration screening as a simple and valuable technique that can be done at the bedside.

La disfunción glótica es una entidad prevalente en enfermos con patología neurológica aguda: compromete aproximadamente entre el 45 al 51 por ciento de los pacientes que padecen un ataque cerebrovascular, incrementando su mortalidad en una relación de 3/1. Su complicación principal es el síndrome aspirativo, que involucra diversas especialidades, entre ellas enfermedades respiratorias y neurología. El propósito de este estudio ha sido evaluar la fonación húmeda, el test del vaso de agua y la auscultación cervical como indicadores clínicos de aspiración frente a la certificación nasolaringoscópica, considerada patrón estándar de evaluación al lado de la cama del enfermo. Evaluamos prospectivamente durante un año a pacientes neurológicos agudos hospitalizados en una unidad de tratamiento intensivo. La fonación húmeda, el test del vaso de agua y la auscultación cervical demostraron sensibilidades de 66,7, 88,9 y 77,8 por ciento, con una especificidad respectiva de 85,2, 59,3 y 77,8 por ciento. Los valores predictivos positivo fueron de 60, 42,1 y 53,8 por ciento, con valores predictivos negativo de 88,5, 94,1 y 91,3 por ciento respectivamente. Nuestros resultados permiten afirmar que el monitoreo clínico de aspiración es un instrumento sencillo y valioso, que puede ser realizado al lado de la cama del enfermo.

Cricopharyngeal dysfunction in a patient with achalasia.

A 64-year-old man had intense dysphagia and aspiration of 1 month's duration. The patient had lower esophageal sphincter (LES) achalasia and cricopharyngeal dysfunction, with generalized muscle weakness discovered by neurologic examination. Endoscopy showed no lesions of the mouth, pharynx, larynx, or esophagus. The diagnosis of achalasia was made by manometry. The LES did not relax with deglutition; the contractions in the esophageal body were nonperistaltic and of low amplitude; and the upper esophageal sphincter pressure did not decrease after deglutition. A scintigraphic study of the oral and pharyngeal phases of swallowing showed a mouth and pharyngeal retention of 90% of the volume swallowed.

Diagnóstico de las enfermedades del tórax / Diagnosis of diseses of the chest

Enfermedades embólicas y trombóticas de los pulmones. Hipertensión y edema de pulmón. Enfermedades de las vías áereas. Enfermedades pleuropulmonares causadas por la inhalación de polvo inorgánico. Enfermedades pulmonares causadas por aspiración de cuerpos extraños

Diagnóstico de las enfermedades del tórax / Diagnosis of diseses of the chest

Enfermedades embólicas y trombóticas de los pulmones. Hipertensión y edema de pulmón. Enfermedades de las vías áereas. Enfermedades pleuropulmonares causadas por la inhalación de polvo inorgánico. Enfermedades pulmonares causadas por aspiración de cuerpos extraños

Síndrome de aspiraçäo de mecônio / Meconium aspiration syndrome

Analisamos cinqüenta e dois casos de síndrome de aspiraçäo de mecônio (SAM) hospitalizados na Unidade de Neomatologia do Hospital de Clínicas de Porto Alegre no período de 1§ de junho de 1982 a 30 de junho de 1985. Neste período, a SAM foi responsável por 3,5% das internaçöes, 41 RN (Grupo I) evoluíram favoravelmente e 11 RN (Grupo 2) foram a óbito, 79% versus 21%. As características clínicas predominantes foram: peso ao nascer maior que 2.500g (85%), peso adequado para a idade, AIG, (65%), idade gestacional acima de 37 semanas (86%) RX característico de pneumonia de aspiraçäo (92%) e mecônio na traquéia (85%). A distribuiçäo por sexo foi igual. Estes fatores assim como a gravidez de alto risco, parto por via cesariana, Apgar no 1§ minuto menor que 3, intubaçäo traqueal e nascimentos fora ou dentro do HCPA näo influíram de modo significativo na evoluçäo da doença, p < 0,05. No entanto, os RN do Grupo 2, óbitos, tiveram estatisticamente significativa maior freqüência de Apgar do 5§ minuto menor que 5(64% versus 18%), concentraçöes de oxigênio maior que 40% (100% versus 51%) p < 0,01, ventilaçäo mecânica IMV (82% versus 5%), pneumotórax hipertensivo (45% versus 0%) e persistência da circulaçäo fetal (54%) versus 0%) p < 0,001 do que os RN do Grupo I (vivos). A presença de septicemia (45% versus 24%) näo interferiu na evoluçäo da doença, p > 0,05

Neumonitis por aspiracion / Aspiration pneumonitis

Se revisan los aspectos basicos de la profilaxis y el tratamiento de la neumonitis por aspiracion que se presenta durante el acto quirurgico. Inicialmente la fisiopatologia y la clinica de la entidad y tambien las medidas profilacticas tanto farmacologicas como de tecnicas anestesicas. Se presentan tambien los aspectos basicos de la induccion rapida y del tratamiento de la neumonitis por aspiracion cuando esta se presenta pese a las medidas preventivas. Se destaca la importancia de establecer cuales pacientes estan en riesgo de broncoaspiracion para establecer un manejo adecuado

Cytologic study of food microaspiration in recurrent obstructive bronchopathy.

Sixty-four cases of infants ranging from 4 to 24 months of age (fed on milk) who suffered from Recurrent Obstructive Bronchopathy and a group of 10 healthy children were studied during 6 months (from May to October, 1984) in order to evaluate the incidence of the microaspiration phenomenon. This was done by means of a quick, easy and very cheap cytological method which etiologically diagnoses the microaspiration through fat elements phagocitized by the alveolar macrophages. They were evident in two different ways: 1) a new method of stained cellulae of a better morphological fidelity. 2) a larger quantity of exploratory smears from each patient which allowed an easier elimination of positive falses and a better individuation of negative falses. The data obtained by the technic were statistically processed using the significance of Chi or Khy square test, so as to make an exploratory-descriptive study of the method through the comparison of the averages obtained from the samples, smears and macrophages.

Surfactant displacement by meconium free fatty acids: an alternative explanation for atelectasis in meconium aspiration syndrome.

Meconium, an ether extract of meconium, and the major free fatty acids of meconium (palmitic, stearic, and oleic acids) were all found to increase the surface tension minimum of dog lung extract in a Wilhelmy balance. Each of these fractions was instilled into the lungs of dogs (15 experimental, eight saline solution controls), and cardiac output, venous and arterial blood gases, pulmonary, atrial, and systemic pressures, airway pressure, and static lung compliance were serially monitored for 2 hours. Mean airway pressure increased and static lung compliance decreased significantly in all of the experimental groups. Although arterial pH and PaCO2 and the various hemodynamic measurements did not change during the experiment, PaO2 decreased significantly and did not return to baseline in all experimental groups. Extracts from atelectatic portions of experimental dog lung had a surface tension minimum of greater than 20 dynes/cm, whereas airway foam had a surface tension minimum of less than 10 dynes/cm, suggesting that the free fatty acids of meconium are able to strip surfactant from the alveoli.

Comparison of high-frequency jet ventilation and conventional mechanical ventilation in a meconium aspiration model.

Ten adult cats received alternately high-frequency jet ventilation and conventional mechanical ventilation after aspirating 2 ml/kg 25% human meconium in saline. Equivalent mean airway pressures were maintained during the hourly ventilator changes. Aortic pressures, pulmonary artery pressures, and central venous pressures were continuously monitored. Cardiac outputs were measured, and pulmonary and systemic vascular resistances, intrapulmonary shunts, and alveolar arterial oxygen gradients were determined at regular intervals. During the first hour after aspiration, AaDO2 and Qs/Qt were lower during HFJV (P less than 0.05); PVR and Pa were always higher during HFJV (P less than 0.05). Overall, PVR, Pa, AaDO2, and Qs/Qt rose during HFJV; these changes occurred at equivalent Paw within 15 minutes of each ventilator change (P less than 0.05). In this meconium aspiration model, conventional mechanical ventilation was the superior form of ventilatory therapy.