Increased intramuscular adipose tissue of the quadriceps at admission is more strongly related to activities of daily living recovery at discharge compared to muscle mass loss in older patients with aspiration pneumonia.

BACKGROUND: Recent studies reported that an increase in intramuscular adipose tissue of the quadriceps in older patients negatively affects the recovery of activities of daily living (ADL) more than the loss of muscle mass. However, whether intramuscular adipose tissue of the quadriceps in older patients with aspiration pneumonia is related to ADL recovery remains unclear. This study aimed to determine the relationship between intramuscular adipose tissue of the quadriceps and ADL recovery in older patients with aspiration pneumonia. METHODS: Thirty-nine older inpatients who were diagnosed with aspiration pneumonia participated in this prospective study. The main outcome of this study was ADL at discharge. ADL were assessed using the Barthel Index (BI). The intramuscular adipose tissue and muscle mass of the quadriceps were evaluated at admission using echo intensity and muscle thickness observed on ultrasound images. A multiple linear regression analysis was performed to confirm whether the quadriceps echo intensity was related to the BI score at discharge, even after adjusting for confounding factors. RESULTS: The medians [interquartile range] of the BI score at admission and discharge were 15.0 [0.0-35.0] and 20.0 [5.0-55.0], respectively. The BI score at discharge was significantly higher than that at admission (p = 0.002). The quadriceps echo intensity (ß = - 0.374; p = 0.036) and BI score at admission (ß = 0.601; p < 0.001) were independently and significantly related to the BI score at discharge (R2 = 0.718; f2 = 2.546; statistical power = 1.000). In contrast, the quadriceps thickness (ß = - 0.216; p = 0.318) was not independently and significantly related to the BI score at discharge. CONCLUSIONS: Increased intramuscular adipose tissue of the quadriceps at admission is more strongly and negatively related to ADL recovery at discharge than the loss of muscle mass among older patients with aspiration pneumonia. Interventions targeting the intramuscular adipose tissue of the quadriceps may improve ADL among these patients.

Clinical Features and Voxel-Based-Symptom-Lesion Mapping of Silent Aspiration in Acute Infratentorial Stroke.

Post-stroke dysphagia (PSD) is a severe and common complication after ischemic stroke. The role of silent aspiration as an important contributing factor in the development of a dysphagia-associated complications, in particular aspiration-associated pneumonia has been insufficiently understood. The aim of this study was to investigate the characteristics and risk factors of silent aspiration in patients with acute infratentorial stroke by FEES and to identify culprit lesions in stroke patient with a high risk of silent aspiration via voxel-based-symptom-lesion mapping (VBS/ML). This study is a retrospective observational study based on a prospectively collected FEES and stroke database. Consecutive patient cases with acute ischemic infratentorial stroke and FEES examination between 2017 and 2022 were identified. Group allocation was performed based on PAS scores. Imaging analysis was performed by manual assignment and by VBS/ML. Group comparisons were performed to assess silent aspiration characteristics. Binary logistic regression analysis was performed to determine if baseline clinical, demographic, and imaging parameters were helpful in predicting silent aspiration in patients. In this study 84 patient cases with acute infratentorial stroke who underwent FEES examination were included. Patients were moderately affected at admission (mean NIH-SS score at admission 5.7 SD ± 4.7). Most lesions were found pontine. Overall 40.5% of patients suffered from silent aspiration, most frequently in case of bilateral lesions. Patients with silent aspiration had higher NIH-SS scores at admission (p < 0.05), had a more severe swallowing disorder (p < 0.05) and were 4.7 times more likely to develop post-stroke pneumonia. Patients who underwent FEES examination later than 72 h after symptom onset were significantly more likely to suffer from silent aspiration and to develop pneumonia compared to patients who underwent FEES examination within the first 72 h (p < 0.05). A binary logistic regression model identified NIH-SS at admission as a weak predictor of silent aspiration. Neither in manual assignment of the lesions to brain regions nor in voxel-wise statistic regression any specific region was useful in prediction of silent aspiration. Silent aspiration is common in patients with infratentorial stroke and contributes to the risk for pneumonia. Patients with silent aspiration are more severely affected by stroke, but cannot reliably be identified by NIH-SS at admission or lesion location. Patients suffering from acute infratentorial stroke should been screened and examined for PSD and silent aspiration.

Treating ARDS-associated air embolism: a question of priorities.

Gas embolism is a potential and often life-threatening complication of central venous catheters. We report a case of air embolism after tearing of the central catheter associated with severe acute respiratory distress syndrome. The severity of the clinical situation meant choices had to be made regarding the order of treatments. This clinical case provided useful eye-openers for patient management regarding the prioritization of treatments as well as the possibilities offered by hyperbaric oxygen therapy.

Long-term pharyngeal dysphagia after esophagectomy for esophageal cancer-an investigation using videofluoroscopic swallow studies.

Dysphagia is a common symptom of esophageal cancer (EC). Esophagectomy should relieve the presenting dysphagia as the mechanical obstruction caused by the tumor is removed. However, the new onset oropharyngeal dysphagia develops after esophagectomy and the deficit may persist increasing the risk of aspiration pneumonia and mortality as well as adversely affecting quality of life (QOL). This study investigates the persistent swallowing deficits in long-term postesophagectomy patients and explores the factors associated with dysphagia severity, penetration, and aspiration. A better understanding of the swallowing function can aid future management of the condition. A total of 29 patients who were more than six months postesophagectomy for EC, had no history of disease that would likely affect swallowing function or vocal cord palsy underwent detailed videofluoroscopic swallow studies and completed the European Organisation for Research and Treatment of Cancer QLQ-C30 and OES18 QOL questionnaires. Swallowing deficits were analyzed and rated using the videofluoroscopic dysphagia scale (VDS) and the penetration-aspiration scale (PAS). These variables were correlated with the clinical and QOL parameters to determine which factors would affect swallowing function. Our cohort consisted of 27 males and 2 females. The mean duration after esophagectomy when the swallowing study was performed was 3.2 years (range: 0.5-18.4 years). Swallowing deficits were mainly found in the pharyngeal phase of swallowing. The mean total VDS score was 36.1 (SD = 15.2, range: 11.0-69.5) out of a possible 100. The mean PAS score was 4.1 (SD = 2.5, range: 1-8) and 1.5 (SD = 0.9, range: 1-4) for thin and semisolids, respectively. Dysphagia was significantly more severe in males, those of more advanced age at esophagectomy and at swallowing assessment. Increasing pathological N stage significantly correlated with worse PAS score for thin fluid. Self-reports of more pain and less troubles with coughing were also associated with less penetration and aspiration. This study demonstrated that a mild to moderate pharyngeal dysphagia is present late after esophagectomy even in patients without VC palsy or anastomotic stricture. The long-term aspiration rate is comparable to the figures in the literature for those early after esophagectomy. It is suggested that damage to the intercostal nerves and the pulmonary vagus may affect oropharyngeal swallowing function in this population.

Pneumonia in a Teenager Hiding a Fire-Eating Stunt.

Pneumonia in children due to hydrocarbon aspiration is usually the result of an uncommon accidental event. However, an acute and severe type of pneumonia induced by hydrocarbon aspiration is occasionally experienced by entertainers known as fire-eaters. Different approaches to treat fire-eater's pneumonia appear in the literature. Although there is no consensus regarding the management of this condition, the use of antibiotic therapy is well recognized and recommended by some, whereas others recommend only supportive treatment. Steroids are indicated in severe cases.Here, we report the case of a boy who developed severe pneumonia after inhaling hydrocarbons during an attempt to mimic a fire-eater show. Slow resolution was achieved after broad-spectrum antibiotic therapy in addition to systemic and inhaled steroids and physiotherapy.

Columnar metaplasia in the remnant esophagus is a long-term indicator for pneumonia after radical esophagectomy.

BACKGROUND: This study investigated the long-term risk factors for pneumonia after esophageal reconstruction using a gastric tube via the posterior mediastinal route following esophagectomy for esophageal cancer. The influence of columnar metaplasia in the remnant esophagus was specifically assessed. METHODS: Among 225 patients who underwent esophagectomy between January 2004 and December 2010, the subjects were 54 patients who could be followed up for more than 5 years. Routine oncologic follow-up consisted of CT scanning of the abdomen and chest every 4-6 months and annual endoscopy. Data on the occurrence of pneumonia were collected by retrospective review of chest CT scans. Risk factors for pneumonia investigated by univariate and multivariate analyses included the age, gender, diameter of the stapler, length of the intrathoracic remnant esophagus, anastomotic stricture, and presence of columnar metaplasia in the remnant esophagus. RESULTS: The median age was 62.4 years (interquartile range: 55.8-68.0 years). Forty-three patients were men. Pneumonia was detected in 39 patients (72.2%). The incidence of columnar metaplasia in the remnant esophagus increases with time. Anastomotic stricture was significantly related to the absence of columnar metaplasia on endoscopy in the first year after esophagectomy (p = 0.013). Univariate analysis showed that the frequency of pneumonia was significantly related to the intrathoracic remnant esophagus length ≥4.4 cm (p = 0.014), age over 65 years (p = 0.014), and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy (p = 0.005). Among them, age over 65 years and the presence of columnar metaplasia in the remnant esophagus in the fifth year after esophagectomy were found to be independent indicators of the postoperative pneumonia by multivariate analysis. CONCLUSION: Pneumonia occurred in 72.2% (39/54) of patients after esophagectomy for esophageal cancer. The presence of columnar metaplasia after esophagectomy is an indicator for pneumonia over the long term.

Association between CT-Diagnosed Pneumonia and Endoscopic Submucosal Dissection of Gastric Neoplasms.

BACKGROUND/AIMS: This prospective cohort study aimed to elucidate the incidence and characteristics of pneumonia associated with endoscopic submucosal dissection (ESD) of gastric neoplasms using CT. METHODS: We included consecutive 188 patients with gastric neoplasms treated with ESD. All patients underwent CT before ESD and the day after ESD. Pneumonia associated with ESD was defined as lung ground glass opacity or consolidation by CT the day after ESD. RESULTS: In 188 patients, 28 patients had diabetes mellitus. Pneumonia was observed by CT in 21 patients (11.2%) after ESD. Of those, 7 patients had diabetes mellitus. By univariate analysis, compared with patients with non-pneumonia complications, risk factors for pneumonia were significantly increased in patients with diabetes mellitus (p = 0.01) and in those who underwent a long procedure time (p = 0.02). By multivariate analysis, pneumonia was significantly increased in patients with diabetes mellitus (OR 4.06, 95% CI 1.35-12.19) and in those who underwent a long procedure time (OR 1.01, 95% CI 1.00-1.02). CONCLUSIONS: The incidence of CT-diagnosed pneumonia associated with ESD was relatively high. Furthermore, it was revealed that diabetes mellitus and a long procedure time were risk factors of CT-diagnosed pneumonia.

Corticosteroids in treatment of aspiration-related acute respiratory distress syndrome: results of a retrospective cohort study.

BACKGROUND: Acute stroke patients suffering from aspiration may present with acute respiratory distress syndrome (ARDS). There is still a lack of convincing data about the efficacy of corticosteroids in the treatment of aspiration-related ARDS. Therefore, we evaluated the clinical impact of corticosteroids on aspiration-related ARDS. METHODS: Between 2012 and 2014, we conducted a retrospective study among acute stroke patients diagnosed with aspiration-related ARDS. The data analyzed included demographic characteristics, clinical manifestations, laboratory examinations, chest imaging, and hospital discharge status. RESULTS: Seventy-three acute stroke patients were diagnosed with aspiration-related ARDS. The hospital mortality rate was 39.7%. Corticosteroids were administered in 47 patients (64.4%). The mean dosage was 1.14 (standard deviation [SD] 0.47) mg/kg daily of methylprednisolone (or an equivalent) by intravenous infusion for a period of 7.3 (SD 3.8) days. Ground glass opacities in chest computed tomography images were resolved when corticosteroids were administered. The admission National Institute of Health Stroke Scale score (odds ratio [OR] 5.17, 95% confidence interval [CI] 1.27-10.64) and Acute Physiology and Chronic Health Evaluation II score (OR 2.00, 95% CI 1.12-3.56) were associated with an increased risk of hospital mortality, while albumin (OR 0.81, 95% CI 0.64-0.92) and corticosteroids therapy (OR 0.50, 95% CI 0.35-0.70) were associated with a decreased risk. CONCLUSIONS: Low-dose and short-term corticosteroid therapy may have an impact on survival in aspiration-related ARDS. The presence of ground glass opacities on the chest computed tomography, performed to rule out aspiration-related ARDS, could be translated into an increased possibility of positive response to corticosteroid therapy.

Pattern of Pulmonary Involvement and Outcome of Aspiration Pneumonia in Patients with Altered Consciousness Admitted in Dhaka Medical College Hospital.

Aspiration is well recognized as a cause of pulmonary disease and is not uncommon in patients with altered consciousness.The mortality rate of aspiration pneumonia is approximately 1% in outpatient setting and upto 25% in those requiring hospitalization. This study was done to see the pattern of pulmonary involvement and outcome of aspiration pneumonia in patients with altered consciousness admitted in medicine department of a tertiary care hospital in our country. This was a prospective observational study conducted among the 52 adult patients of aspiration pneumonia with altered consciousness admitted in the medicine department of Dhaka Medical College Hospital (DMCH), during June 2010 to December 2010. Aspiration pneumonia was confirmed by clinical examination and laboratory investigations. Hematologic measurements (TC of WBC, Hb%, ESR, platelet count), chest X-ray, blood gas analysis, blood urea, creatinine and random blood sugar, sputum for Gram staining, sputum for culture sensitivity and blood culture were done in all patients.Assessment of altered conscious patient was done by application of the Glasgow Coma Scale. Case record forms with appropriate questionnaire were filled for all patients. The mean±SD age was 57.42±13.63 years with ranged from 25 to 90 years. Out of 52 patients, 37(71.15%) patients were male and 15(28.85%) patients were female. Following aspiration 76.92% patients developed pneumonitis, 13.46% patients developed lung abscess and only 9.62% patients developed ARDS. Most (33) of the patients had opacity in right lower zone and 13 patients had opacity in the left lower zone, 6 patients had opacity in right mid zone. Only 10 patients had opacity in both lower zones. In this study overall mortality rate was 23%. If only one lobe was involved radiologically, mortality was 8.33%. If two or more lobes on one or both sides were involved, mortality was in the range of 25-91%.

The "Tree-in-Bud" Pattern on Chest CT: Radiologic and Microbiologic Correlation.

BACKGROUND: Tree-in-bud (TIB) is a radiologic pattern seen on high-resolution chest CT reflecting bronchiolar mucoid impaction occasionally with additional involvement of adjacent alveoli. Its microbiologic significance has not been systematically evaluated. OBJECTIVES: We aimed to establish the incidence of the TIB pattern as a proportion of all patients undergoing chest CT and to identify its etiology wherever possible. METHODS: We included all patients with TIB pattern detected on chest CT in our institution from January 2007 to June 2012 and correlated this radiologic finding to the microbiologic etiology, which were available, for each patient. RESULTS: During the study period, TIB pattern was described in 326 patients, which is 1.8% of all chest CTs. Of these, 220 (67.5%) patients had an infectious etiology and 34 (10.4%) had aspiration pneumonia. Other presumptive etiologies were in 13 (4%) lung malignancy, 31 (9.5%) other malignancies, 20 cases (6%) inconclusive etiology or incidental findings, and 8 (2.5%) had other inflammatory disorders. The relative incidence of the various organisms isolated reflected the overall incidence of these bacteria in community- or hospital-acquired populations independent of the TIB pattern. No correlation was found between distribution of TIB, the immune status, and the organism isolated. CONCLUSIONS: TIB pattern reflects endobronchiolar inflammation due mainly but not exclusively to an infectious cause. The microbiologic etiology in patients with this finding is similar to that of the general population (community acquired versus hospital acquired).

Aspiration induced by remifentanil: a double-blind, randomized, crossover study in healthy volunteers.

BACKGROUND: Remifentanil is widely used for monitored anesthesia care in spontaneously breathing patients. However, the authors' previous studies have shown that remifentanil induces subjective swallowing difficulties, which may increase the risk of aspiration. METHODS: Twenty-five healthy volunteers participated in a double-blind, randomized, crossover trial at the University Hospital in Örebro, Örebro, Sweden. The volunteers were studied on two different occasions during which they received either remifentanil with an effect-site target concentration of 3 ng/ml or saline over 1 h. A radionuclide tracer was infused simultaneously into the nasopharynx at a rate of 0.1 ml/min. Aspiration was determined by lung scans, and subjective swallowing difficulties and grip strength were evaluated. The primary outcome was the difference in occurrence of aspiration between remifentanil and placebo treatments. The secondary outcomes were differences in swallowing difficulty and grip strength and the association between aspiration and swallowing difficulty. RESULTS: During remifentanil and placebo infusion, 48 and 12% of the volunteers aspirated, respectively, difference: 36% (95% CI, 10 to 62%). A similar significant difference was found for swallowing difficulties but not for the association between aspiration and swallowing. No difference was found in grip strength between the two treatments. CONCLUSIONS: Remifentanil infusion at concentrations used in monitored anesthesia care increases the incidence of aspiration. However, the subjective swallowing difficulty induced by remifentanil is not indicative of the aspiration risk.

Early diagnosis of aspiration pneumonia by gastrointestinal ultrasound combined with lung ultrasound.

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Impact of the quantity and quality of erector spinae muscles on the short-term prognosis of elderly patients with aspiration pneumonia in Japan.

BACKGROUND: Whether muscle mass and muscle quality affect the prognosis of elderly patients with aspiration pneumonia is unclear. This study aimed to evaluate the relationship between erector spinae muscle mass and muscle quality on the 30-day prognosis of elderly patients with aspiration pneumonia. METHODS: Two hundred fifty-eight patients who were diagnosed with aspiration pneumonia and admitted to Sanuki Municipal Hospital for pulmonary rehabilitation intervention were included. The cross-sectional area (ESMCSA/BSA) and CT values (ESMCT) of the erector spinae muscles at the 12th thoracic vertebra were measured on chest CT images to represent muscle mass and quality, respectively. The primary outcome was defined as 30-day survival. RESULTS: Twenty-six patients died within 30 days after hospitalization. The ESMCSA/BSA ratio was significantly greater in the survival group than in the nonsurvival group (p = 0.001). The cutoff values for 30-day survival were calculated as follows: the ESMCSA/BSA was 11.046 cm2/m2 in male patients and 9.600 cm2/m2 in female patients; the ESMCT was 26.85 HU in male patients and 8.00 HU in female patients. A higher ESMCSA/BSA significantly improved 30-day survival, while ESMCT did not show a significant difference. Cox proportional hazards regression analysis revealed that the ESMCSA/BSA was independently associated with 30-day short-term prognosis (hazard ratio 0.34, p = 0.034). CONCLUSION: The short-term prognosis of elderly patients with aspiration pneumonia may be more strongly influenced by muscle mass than by the muscle quality of the erector spinae muscles.

Utility of salivagram in pulmonary aspiration in pediatric patients: comparison of salivagram and chest radiography.

OBJECTIVE: The purpose of our study was to correlate the results of the radionuclide salivagram with the corresponding chest radiography findings on patients being evaluated for salivary aspiration to determine the utility of the salivagram. MATERIALS AND METHODS: We identified 222 patients younger than 21 years who underwent salivagram and chest radiography within 3 months of each other. Salivagrams were blindly interpreted by two readers and chest radiographs were blindly interpreted by two other readers. The kappa coefficient with 95% CI was used to measure the level of interobserver agreement. Multivariate logistic regression was applied to determine whether age, sex, and neurologic diagnosis were predictors of a positive salivagram, with the odds ratio used to estimate association. RESULTS: Interobserver agreement on salivagram interpretation was excellent (κ = 0.988; p < 0.0001; 95% CI, 0.968-1.000). Interobserver agreement on chest radiography interpretation was excellent (κ = 0.905; p < 0.0001; 95% CI, 0.845-0.965). The salivagram was positive for aspiration in 55 patients (25%). Chest radiography was positive in 54 patients (24%). When the interpretations of the salivagram (normal or abnormal) were compared with interpretations of the chest radiograph (normal or abnormal), there were 213 agreements and nine disagreements (intermethod agreement κ = 0.891; p < 0.0001; 95% CI, 0.831-0.952). Independent of age (p = 0.80) and sex (p = 0.31), patients with a neurologic diagnosis had odds of a positive salivagram 5.6 times higher than other diagnoses (odds ratio = 5.6; 95% CI, 2.5-13.1; p < 0.0001). CONCLUSION: Infants with abnormal findings on salivagrams also had a high rate of abnormal findings on chest radiographs, which may indicate that some of the lung disease may be due to aspirated saliva. Salivagrams may be useful in children at risk of aspiration to identify those in whom intervention may help minimize the consequences of aspiration.

Risk factors and prognosis of pulmonary complications after endoscopic submucosal dissection for gastric neoplasia.

BACKGROUND: Hospital-acquired pneumonia after an endoscopic submucosal dissection (ESD) can prolong the patient's stay in the hospital, leading to greater healthcare costs. However, little is known of the characteristics and risk factors associated with this complication. AIMS: To analyze the clinical features of pneumonia after ESD and to suggest a treatment plan. METHODS: This was a retrospective study in which the cases of 1,661 consecutive patients who underwent ESD for 1,725 lesions between January 2008 and June 2011 were reviewed. RESULTS: Of the 1,661 patients who underwent ESD during the study period, 38 were subsequently diagnosed with pneumonia, and an additional 18 patients exhibited lung consolidation, based on chest radiography, without respiratory signs or symptoms. The remaining 1,605 patients showed neither lung consolidation on chest radiography nor respiratory signs/symptoms. Continuous propofol infusion with intermittent or continuous administration of an opioid [odds ratio (OR) 4.498, 95 % confidence interval (CI) 2.267-8.923], a procedure time of >2 h (OR 2.900, 95 % CI 1.307-6.439), male gender (OR 2.835, 95 % CI 1.164-6.909), and age >75 years (OR 2.765, 95 % CI 1.224-6.249) were independent risk factors for pneumonia after ESD. In patients with only lung consolidation (without respiratory signs and symptoms), the length of hospital stay and prognosis were not affected by antibiotics use. CONCLUSIONS: Deep sedation under continuous propofol infusion with opioid injection during ESD may be a risk factor for pneumonia.