Modified Reflux Scintigraphy Detects Pulmonary Microaspiration in Severe Gastro-Esophageal and Laryngopharyngeal Reflux Disease.

INTRODUCTION: Previously described methodologies for detecting laryngopharyngeal reflux (LPR) have limitations. Symptoms alone are non-diagnostic, and pH-impedance studies have poor sensitivity. Pulmonary micro-aspiration is under-recognised in LPR and gastro-esophageal reflux disease (GERD). The present study aimed to describe the results of a modified technique for scintigraphic reflux studies in two groups with severe reflux: those with typical reflux symptoms and those with laryngopharyngeal manifestations of reflux. METHODS: A prospective database of severely symptomatic, treatment-resistant reflux patients was grouped based upon predominant symptom profile of typical GERD or LPR. All patients underwent reflux scintigraphy. Results were obtained for early scintigraphic reflux contamination of the pharynx and proximal esophagus, and delayed contamination of the pharynx and lungs after 2 h. RESULTS: 187 patients were studied (82 GERD, 105 LPR). The LPR patients were predominantly female (70.5% vs. 56.1%; p = 0.042) and older than the GERD group (median age 60 years vs. 55.5 years; p = 0.002). Early scintigraphic reflux was seen at the pharynx in 89.2% (GERD 87.7%, LPR 90.4%; p = 0.133), and at the proximal esophagus in 89.7% (GERD 88.9%, LPR 90.4%; p = 0.147). Delayed contamination of the pharynx was seen in 95.2% (GERD 93.9%, LPR 96.2%; p = 0.468). Delayed pulmonary aspiration was seen in 46% (GERD 36.6%, LPR 53.3%; p = 0.023). CONCLUSION: Reflux scintigraphy demonstrated a high rate of reflux-related pulmonary aspiration. Contamination of the proximal esophagus and pharynx was observed frequently in both groups of severe disease. The likelihood of pulmonary aspiration and potential pulmonary disease needs to be entertained in severe GERD and LPR.

Long-Term Radiologic Evaluation of Microaspirations among Patients after Esophagectomy.

OBJECTIVES: Aspirations are common after esophagectomy. Data are lacking regarding its long-term radiological manifestations. The purpose of this study is to determine the incidence and radiological patterns of aspirations among long-term survivors and evaluate their clinical significance. METHODS: The records of all patients who underwent esophagectomy between October 2003 and December 2011 and survived more than 3 years were reviewed. Preoperative, first routine postoperative, and latest chest computed tomography (CT)scans were reviewed. Imaging studies were reviewed for radiological signs suspicious of aspirations, conduit location, anastomotic site, and maximal intrathoracic diameter. Data regarding patients' complaints during clinic visits were also collected. RESULTS: A total of 578 patients underwent esophagectomy during the study period. One-hundred twenty patients met the inclusion criteria. Median follow-up was 83.5 months. Cervical and intrathoracic anastomoses were performed in 103 and 17 patients, respectively. A higher rate of CT findings was found in postoperative imaging (n = 51 [42.5%] vs. n = 13 [10.8%] respectively, p < 0.05). Most of these were found in the lower lobes (61%). A higher rate of lesions was found among patients in whom the conduit was bulging to the right hemithorax compared with totally mediastinal or completely in the right hemithorax (54.5 vs. 35.2% and 34.6%, respectively, p < 0.05). No correlation was found with conduit diameter or anastomotic site. These lesions were more prevalent among patients who complained of reflux or cough during meals (NS). CONCLUSIONS: A significantly higher rate of new CT findings was found in postoperative imaging of this post-esophagectomy cohort, suggesting a high incidence of aspirations. The locations of the conduit, rather than anastomosis site, seem to play a role in the development of these findings. Further research is needed to evaluate the clinical significance of these findings.

A Quality Improvement Initiative to Reduce Gastrostomy Tube Placement in Aspirating Patients.

OBJECTIVES: Oropharyngeal dysphagia and aspiration may occur in infants and children. Currently, there is wide practice variation regarding when to feed children orally or place more permanent gastrostomy tube placement. Through implementation of an evidence-based guideline (EBG), we aimed to standardize the approach to these patients and reduce the rates of gastrostomy tube placement. METHODS: Between January 2014 and December 2018, we designed and implemented a quality improvement intervention creating an EBG to be used by gastroenterologists evaluating patients ≤2 years of age with respiratory symptoms who were found to aspirate on videofluoroscopic swallow study (VFSS). Our primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within 1 year of EBG initiation; balancing measures included total hospital readmissions or emergency department (ED) visits within 6 months of the abnormal VFSS. RESULTS: A total of 1668 patients (27.2%) were found to have aspiration or penetration noted on an initial VFSS during our initiative. Mean gastrostomy tube placement in these patients was 10.9% at the start of our EBG implementation and fell to 5.2% approximately 1 year after EBG initiation; this improvement was sustained throughout the next 3 years. Our balancing measures of ED visits and hospital readmissions also did not change during this time period. CONCLUSIONS: Through implementation of this EBG, we reduced gastrostomy tube placement by 50% in patients presenting with oropharyngeal dysphagia and aspiration, without increasing subsequent hospital admissions or ED visits.

Reliability of gastric suctioning compared with ultrasound assessment of residual gastric volume: a prospective multicentre cohort study.

We aimed to compare the reliability of aspiration via a nasogastric tube with ultrasound for assessment of residual gastric volume. Sixty-one adult patients who were mechanically ventilated and received continuous enteral feeding through a nasogastric tube for > 48 h were included. A first qualitative and quantitative ultrasound examination of the gastric antrum was followed by gastric suctioning, performed by an operator blinded to the result of the ultrasound examination. A second ultrasound examination was performed thereafter, followed by re-injection of the aspirated gastric contents (≤ 250 ml) into the stomach. A third ultrasound assessment was then immediately performed. If the suctioned volume was ≥ 250 ml, 250 mg erythromycin was infused over 30 min. A fourth ultrasound was performed 90 min after the third. Sixty (98%) patients had a qualitatively assessed full stomach at first ultrasound examination vs. 52 (85%) after gastric suctioning (p = 0.016). The calculated gastric volume significantly decreased after gastric suctioning, without a significant decrease in the number of patients with volume ≥ 250 ml. Four of the nine patients with calculated gastric volume ≥ 250 ml had vomiting within the last 24 h (p = 0.013). The antral cross-sectional area significantly decreased between the third and the fourth ultrasound examination (p = 0.015). Erythromycin infusion did not make a significant difference to gastric volume (n = 10). Our results demonstrate that gastric suctioning is not a reliable tool for monitoring residual gastric volume. Gastric ultrasound is a feasible and promising tool for gastric volume monitoring in clinical practice.

Quantification of the source, amount and duration of aspiration in the lungs of infants using gamma scintigraphy.

BACKGROUND: Aspiration can cause acute symptoms and chronic lung disease in the developing lung. However, the source of aspiration in infants is often unclear, making the choice of intervention difficult. OBJECTIVE: To quantify the source, amount and duration of lung aspiration in infants using gamma scintigraphy. METHODS: Two infants with clinical evidence of gastroesophageal reflux and oropharyngeal dysphagia swallowed formula radiolabeled with 99mtechnetium on Visit 1. Radiolabeled-formula was instilled by nasogastric tube on Visit 2. Lung aspiration was quantified over four hours and expressed as percent of total radioactivity administered. RESULTS: Aspiration was greatest with swallowing, compared to instillation, peaking between 2.0% and 2.4% within 30 min and between 0.40% and 0.65% within 20 min, respectively. Radioactivity remained above zero four hours after either administration. CONCLUSIONS: Quantification of the source, amount and duration of lung aspiration in infants is feasible using gamma scintigraphy. The impact of aspiration accrual on clinical care deserves further investigation.

Use of Static Imaging as a Substitute for Conventional Dynamic Imaging for Salivagrams in Children.

OBJECTIVE: Salivagrams are commonly used for detecting pulmonary aspiration. However, conventional dynamic imaging is relatively time-consuming and could be difficult to perform in children with poor compliance. We analyzed the characteristics of conventional dynamic imaging to obtain a simple protocol suitable for use in children. METHODS: We conducted a retrospective analysis of salivagram data from 1163 patients (783 males, 380 females; age, 1 month to 9.0 years; mean age, 5.7 months) obtained in the past 4.5 years (January 2014 to June 2018). The various timepoint images were used for diagnosis. The positivity rate, missed diagnosis rate, and sensitivity were calculated and compared. RESULTS: Dynamic imaging revealed 353 cases of pulmonary aspiration (248 males, 105 females; age, 1 month to 4.5 years; mean age, 6.2 months). The positivity rate was 30.4% (353/1163), and 95.8% (338/353) of patients presented with continuous positive images after pulmonary aspiration. Only 4.2% (15/353) of positive cases showed clearance of pulmonary aspiration. The positivity rates were 11.8%, 18.2%, 21.9%, 25.0%, 27.0%, and 29.2% at 5, 10, 15, 20, 25, and 30 minutes, respectively. About 4.2% (15/353) of positive cases on earlier images showed clearance of pulmonary aspiration on later images, which indicate both early 15-minute and later 30-minute images were necessary. CONCLUSIONS: Two static images acquired at 15 and 30 minutes might be an effective alternative to conventional salivagram, which mandates dynamic imaging.

Regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) with a laryngeal tube: A pilot crossover human cadaver study.

BACKGROUND: High-quality chest compressions are imperative for Cardio-Pulmonary-Resuscitation (CPR). International CPR guidelines advocate, that chest compressions should not be interrupted for ventilation once a patient's trachea is intubated or a supraglottic-airway-device positioned. Supraglottic-airway-devices offer limited protection against pulmonary aspiration. Simultaneous chest compressions and positive pressure ventilation both increase intrathoracic pressure and potentially enhances the risk of pulmonary aspiration. The hypothesis was, that regurgitation and pulmonary aspiration is more common during continuous versus interrupted chest compressions in human cadavers ventilated with a laryngeal tube airway. METHODS: Twenty suitable cadavers were included, and were positioned supine, the stomach was emptied, 500 ml of methylene-blue-solution instilled and laryngeal tube inserted. Cadavers were randomly assigned to: 1) continuous chest compressions; or, 2) interrupted chest compressions for ventilation breaths. After 14 minutes of the initial designated CPR strategy, pulmonary aspiration was assessed with a flexible bronchoscope. The methylene-blue-solution was replaced by 500 ml barium-sulfate radiopaque suspension. 14 minutes of CPR with the second designated ventilation strategy was performed. Pulmonary aspiration was then assessed with a conventional chest X-ray. RESULTS: Two cadavers were excluded for technical reasons, leaving 18 cadavers for statistical analysis. Pulmonary aspiration was observed in 9 (50%) cadavers with continuous chest compressions, and 7 (39%) with interrupted chest compressions (P = 0.75). CONCLUSION: Our pilot study indicate, that incidence of pulmonary aspiration is generally high in patients undergoing CPR when a laryngeal tube is used for ventilation. Our study was not powered to identify potentially important differences in regurgitation or aspiration between ongoing vs. interrupted chest compression. Our results nonetheless suggest that interrupted chest compressions might better protect against pulmonary aspiration when a laryngeal tube is used for ventilation.

Gastro-Oesophageal Reflux and Aspiration: Does Laparoscopic Fundoplication Significantly Decrease Pulmonary Aspiration?

PURPOSE: Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested. The aim of this project is to assess effectiveness of anti-reflux surgery on preventing pulmonary aspiration of gastric refluxate. METHODS: Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data were analysed. RESULTS: Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post-operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (p = 0.002) and pharynx supine and upright (p = 0.027) was confirmed on scintigraphy post-operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459-95.194; p = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 89.77, SD 20.5), modest improvements at 6 months (mean 98.4, SD 21.97) and deterioration at 12 months (mean 88.41, SD 28.07) were not significant (p = 0.07). CONCLUSION: Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow-up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery.

Ultrasonographic gastric volume before unplanned surgery.

We aimed to measure gastric antral cross-sectional area with ultrasound and estimate the gastric volume of 300 patients before unplanned surgery, fasted for at least six hours. Measurements were successfully recorded in 263 semi-recumbent patients. The median (IQR [range]) area was 333 (241-472 [28-1803]) mm2 and the mean (SD) estimated volume was 45.8 (34.0) ml. The area exceeded 410 mm2 in 92/263 (35%) measurements. Body mass index and morphine administration were associated with larger gastric areas on multivariable linear regression analysis, with beta coefficient (95%CI) 0.02 (0.01-0.04), p = 0.01, 0.23 (0.01-0.46), p = 0.04, respectively. Fasting time was not associated with gastric area and therefore could not substitute for ultrasound measurements in this cohort.

Scintigraphy in laryngopharyngeal and gastroesophageal reflux disease: a definitive diagnostic test?

AIM: To investigate the utility of scintigraphic studies in predicting response to laparoscopic fundoplication (LF) for chronic laryngopharyngeal reflux symptoms. METHODS: Patients with upper aero-digestive symptoms that remained undiagnosed after a period of 2 mo were studied with conventional pH and manometric studies. Patients mainly complained of cough, sore throat, dysphonia and globus. These patients were imaged after ingestion of 99m-technetium diethylene triamine pentaacetic acid. Studies were quantified with time activity curves over the pharynx, upper and lower oesophagus and background. Late studies of the lungs were obtained for aspiration. Patients underwent LF with post-operative review at 3 mo after surgery. RESULTS: Thirty four patients (20 F, 14 M) with an average age of 57 years and average duration of symptoms of 4.8 years were studied. Twenty four hour pH and manometry studies were abnormal in all patients. On scintigraphy, 27/34 patients demonstrated pharyngeal contamination and a rising or flat pharyngeal curve. Lung aspiration was evident in 50% of patients. There was evidence of pulmonary aspiration in 17 of 34 patients in the delayed study (50%). Pharyngeal contamination was found in 27 patients. All patients with aspiration showed pharyngeal contamination. In the 17 patients with aspiration, graphical time activity curve showed rising activity in the pharynx in 9 patients and a flat curve in 8 patients. In those 17 patients without pulmonary aspiration, 29% (5 patients) had either a rising or flat pharyngeal graph. A rising or flat curve predicted aspiration with a positive predictive value of 77% and a negative predictive value of 100%. Over 90% of patients reported a satisfactory symptomatic response to LF with an acceptable side-effect profile. CONCLUSION: Scintigraphic reflux studies offer a good screening tool for pharyngeal contamination and aspiration in patients with gastroesophageal reflux disease.

Computed tomography pulmonary findings in healthy older adult aspirators versus nonaspirators.

OBJECTIVES/HYPOTHESIS: In previous studies, we consistently found that approximately 30% of asymptomatic healthy older adults silently aspirated liquids during a flexible endoscopic evaluation of swallowing (FEES) and that their aspiration status was stable for the following year. However, no studies have systematically evaluated effects of silent aspiration on lung parenchyma and airways. We used computed tomography (CT) to compare lungs of healthy older adult aspirators versus nonaspirators. We hypothesized that CT images would show pulmonary differences in healthy older adult aspirators versus nonaspirators. STUDY DESIGN: Prospective study. METHODS: Fifty healthy older adults (25 aspirators and 25 nonaspirators) who participated in a previous FEES were randomly selected. CT scans were performed; on inspiration, lung views were taken at 1.25 mm and 2.5 mm windows, and on expiration, lung views were taken at 2.5 mm. CT scans were reviewed by radiologists blinded to group assignment. Outcomes included bronchiectasis, bronchiolectasis, bronchial wall thickening, parenchymal band, fibrosis, air trapping, intraluminal airway debris, and tree-in-bud pattern. RESULTS: χ(2) analyses between aspirators and nonaspirators found no statistically significant differences between aspirators and nonaspirators for any outcomes (P > .05). Logistic regression analyses adjusted for smoking did not change the results. CONCLUSIONS: There were no differences in pulmonary CT findings between healthy older adult aspirators and nonaspirators. This study adds to the evidence that some aspiration may be within the range of normal for older adults, or at least does not contribute to a change in pulmonary appearance on CT images. LEVEL OF EVIDENCE: 3b.