Validation of nasal tracheal aspiration in children with lung disease.

BACKGROUND: Nasal tracheal aspiration (NTA) is a frequently used diagnostic method to assess of infections in the lower airways. However, the validity of the method has not previously been compared to bronchoalveolar lavage (BAL) in non-intubated children with a lung disease. We hypothesised that NTA performed by health professionals using the nares vocal cord distance to be placed at the entrance of the trachea, will result in same finding of bacteria in the lower airways as the gold standard of BAL. METHODS: In a prospective study, 173 paired samples of NTA and BAL were obtained between June 2016 to August 2018. Samples were collected from all patients undergoing bronchoscopy with spontaneous breathing during general anaesthesia. This study compares the microbiological results from the cultures obtained by investigating complete concordance i.e. identical pathogenic bacteria and coherence i.e. absence or presence of pathogenic bacteria growth between NTA and BAL. RESULTS: Samples were collected in 164 patients, 158 children between 21 days and 18 years of age and six young adults still treated at the paediatric department. The overall similarity (complete agreement) was found in 49% [41-56], sensitivity was 35% [27-45], specificity was 66% [55-76], positive predictive value was 36% [27-46] and negative predictive value was 64% [54-64] concerning complete pathogenic bacteria concordance. If we only considered coherence growth of pathogenic bacteria, similarity was 71% [63-79], sensitivity was 74% [64-81], specificity was 66% [55-76], positive predictive value was 75% [65-82] and negative predictive value was 65% [54-75]. Patients with cystic fibrosis showed a similarity of 88% [73-95], a sensitivity of 92% [76-99], a specificity of 71% [36-95], a positive predictive value of 92% [76-99] and a negative predictive value of 71% [36-95] concerning coherence growth of pathogenic bacteria. CONCLUSION: The study indicates that NTA compared to BAL as the gold standard is not clinically useful to assess positive findings of specific bacteria in the lower airway tract. Statistically significantly increased sensitivity and positive predictive value were found in cystic fibrosis patients concerning coherence growth. The clinical usage of NTA remains important as negative findings are of clinical value. However, BAL continues to be preferred as a significantly superior diagnostic tool.

Nasal packing: When a routine practice becomes a life-threatening emergency.

Aspiration of unsecured nasal packs of any sort must be suspected in patients presenting with acute airway situations and a recent history of nose procedures. An immediate removal is mandatory to avoid long-term complications and even death.

Simultaneous Videofluoroscopy and Endoscopy for Dysphagia Evaluation in Preterm Infants-A Pilot Study.

Introduction: The assessment of dysphagia in preterm infants has been limited to clinical bedside evaluation followed by videofluoroscopic swallow study (VFSS) in selected patients. Recently, fiberoptic endoscopic evaluation of swallowing (FEES) is being described more in literature for preterm infants. However, it is unclear if one test has a better diagnostic utility than the other in this population. Furthermore, it is also unclear if performing FEES and VFSS simultaneously will increase the sensitivity and specificity of detecting dysphagia compared to either test performed independently. Objectives: The primary objective of this study is to evaluate the feasibility of performing VFSS and FEES simultaneously in preterm infants. Our secondary objective is to determine whether simultaneously performed VFSS-FEES improves the diagnostic ability in detecting dysphagia in preterm infants compared to either test done separately. Methods: In this pilot study, we describe the process involved in performing simultaneous VFSS-FEES in five preterm infants (postmenstrual age ≥36 weeks) with dysphagia. A total of 26 linked VFSS-FEES swallows were analyzed, where the same bolus during the same swallow was compared using simultaneous fluoroscopy and endoscopy. The sensitivity and specificity of detecting penetration and aspiration were evaluated in simultaneous VFSS-FEES compared with each test done independently. Results: Our results demonstrated that performing simultaneous VFSS-FEES is feasible in preterm infants with dysphagia. All patients tolerated the procedures well without any complications. Our pilot study in these five symptomatic preterm infants demonstrated a low incidence of aspiration but a high incidence of penetration. Simultaneous VFSS-FEES (26 linked swallows) improved the ability to detect penetration compared to each test done separately. Conclusion: To our knowledge, this study is the first to demonstrate the feasibility of performing VFSS and FEES simultaneously in symptomatic preterm infants with dysphagia resulting in potentially higher diagnostic yield than either procedure done separately.

Airway protection & patterns of dysphagia in infants with down syndrome: Videofluoroscopic swallow study findings & correlations.

INTRODUCTION: Down syndrome is a genetic condition that affects 1:737 births. Along with cardiac, otolaryngologic, and developmental anomalies, infants with Down syndrome can have swallowing difficulties resulting in respiratory infections. This study aims to characterize the airway protection and dysphagia seen in infants with Down syndrome. METHODS: This is a retrospective chart review of infants with Down syndrome who underwent videofluoroscopic swallow studies (VFSS) from 2008 to 2018 at a tertiary children's hospital. Demographic data and VFSS findings were collected. RESULTS: 89.8% (114/127) of infants presented with at least one element of oral dysphagia, while 72.4% (92/127) had at least one element of pharyngeal dysphagia. Sucking skills were classified as abnormal in 63.7% of the patients and bolus formation-control was determined to be deficient (abnormal) in 62.2% of the patients. Oral residuals were present in 37.8% of the patients. With regard to pharyngeal phase, the swallow initiation was considered abnormal in 53.5% of the patients. Pharyngeal residue was present in 17.3% and pharyngo-nasal reflux was present in 27.5% of the patients. CONCLUSIONS: Swallowing assessments in infants with Down syndrome suspected of dysphagia should be considered, especially in those with any alterations in pulmonary health.

Equine airway inflammation in loose-housing management compared with pasture and conventional stabling.

Icelandic horses are often stabled in loose-housing systems, and to date this type of stabling has not been evaluated with regard to its potential impact on respiratory health. The objective was to assess if differences in management systems (eg, conventional stable, loose housing and pasture only) affect the degree of airway inflammation, evaluated by cytology of tracheal aspirate (TA) and bronchoalveolar lavage (BAL) fluid. In total, 84 Icelandic horses (aged 8.1±4.6 years) housed under three different management systems (conventional stables [n=29], loose-house systems [n=29] and pasture [n=26]) were included. Endoscopy including mucus scoring, TA and BAL was performed. TA and BAL cytologies were evaluated by performing both the total cell count (TCC) and the differential cell count (DCC). Significantly higher BAL neutrophil DCC (P=0.032, P=0.040) and TA TCC (P=0.007, P=0.028) were found for each of the two groups of horses with indoor access (conventional stable and loose housing) compared with the pasture group. Regardless of stabling environment, weak positive correlations were found between TA and BAL TCC (r=0.37, P<0.001), between TA TCC and TA neutrophil ratio (r=0.33, P=0.002), as well as between TA and BAL neutrophil ratio (r=0.39, P=<0.001). A larger proportion of horses with indoor access showed evidence of subclinical airway inflammation characterised by an increase in TA and BAL neutrophil ratios.

Análise dos critérios utilizados para aspiração traqueal em unidades de terapia intensiva de hospitais de Araxá ­ MG / Analysis of criteria used for traqueal aspiration in intensive therapy units of Araxá hospitals ­ MG

Em pacientes que se encontram internados na Unidade de Terapia Intensiva muitas vezes é necessário o uso de ventilação mecânica, para manutenção das vias aéreas superiores. Essa necessidade limita a mobilização e a expectoração das secreções brônquicas, sendo necessário fazer uso de aspiração traqueal. O Objetivo foi avaliar os critérios utilizados para aspiração traqueal em unidades de Terapia Intensiva de hospitais de Araxá-MG. Trata-se de um estudo previamente aprovado pelo CEP-Uniaraxá e pelos hospitais envolvidos na pesquisa, do tipo transversal, descritiva e quali-quantitativo. Foi aplicado um questionário composto por 9 questões discursivas entregues aos profissionais das instituições participantes. Resultados foram avaliados 15 profissionais sendo 40% Técnicos em enfermagem, 27% Enfermeiros 27% Fisioterapeutas e 6% Auxiliares de enfermagem. Quanto a importância da aspiração 41% dos participantes responderam que a desobstrução das vias aéreas pela aspiração traqueal é de extrema importância para o paciente. Concluímos que o procedimento de aspiração traz vários riscos aos pacientes. Requer atenção, cuidado e habilidade, o que nos faz concluir que é necessário um melhor aperfeiçoamento da técnica para um melhor atendimento e manutenção da saúde do paciente(AU)

In patients who are hospitalized in the Intensive Care Unit, it is often necessary to use mechanical ventilation to maintain the upper airways. This necessity limits the mobilization and the expectoration of the bronchial secretions, being necessary to make use of tracheal aspiration. The objective was to evaluate the criteria used for tracheal aspiration in Intensive Care units of hospitals in Araxá-MG. This is a study previously approved by CEP-Uniaraxá and the hospitals involved in the research, of a crosssectional, descriptive and quali-quantitative type. A questionnaire composed of 9 discursive questions was given to the professionals of the participating institutions. Results were evaluated 15 professionals being 40% Nursing technicians, 27% Nurses 27% Physiotherapists and 6% Nursing auxiliaries. Regarding the importance of aspiration, 41% of the participants answered that the airway clearance by tracheal aspiration is extremely important for the patient. We conclude that the aspiration procedure poses several risks to patients. It requires attention, care and skill, which makes us conclude that a better improvement of the technique is required for a better care and maintenance of the patient's health(AU)

Detection of the etiological agents of hospital-acquired pneumonia - validity and comparison of different types of biological sample collection: a prospective, observational study in intensive care patients.

BACKGROUND: There is still a lack of evidence as to which method of biological sample collection is optimal for identifying bacterial pathogens causing hospital-acquired pneumonia (HAP). Much effort has been made to find an easy and valid approach to be used in clinical practice. METHODS: The primary endpoint of this prospective, observational study was to determine the predictive value of oropharyngeal swab (OS) and gastric aspiration (GA) as simple and non-invasive methods for diagnosing HAP. Their efficacy was compared to endotracheal aspiration (ETA) and protected specimen brushing (PSB), the standard methods approved for HAP diagnosis. RESULTS: Initially, 56 patients were enrolled. Significant amounts of bacterial pathogens were detected in 48 patients (79 isolates) in Round A and in 39 patients (45 isolates) in Round B (after 72 hours). The sensitivity rates were: ETA 98%, PSB 31%, OS 64% and GA 67% in Round A and ETA 87%, PSB 32%, OS 74% and GA 42% in Round B. Strains of 12 bacterial species were identified in the samples. The three most common etiological agents (both rounds together) were Klebsiella pneumoniae (23.7%), Burkholderia multivorans (21.1%) and Pseudomonas aeruginosa (15.8%). CONCLUSIONS: Blind ETA is an optimum method for obtaining biological samples for identification of etiological agents causing HAP in intubated patients. Microbial etiological agents were more frequently detected in ETA samples than in those collected by PSB. If ETA/PSB results are negative, samples may be collected by OS and/or GA as these techniques followed ETA in terms of the frequency of pathogen detection.

[Evaluation of pain during mobilization and endotracheal aspiration in critical patients]. / Evaluación del dolor durante la movilización y la aspiración endotraqueal en pacientes críticos.

OBJECTIVES: 1) To assess the prevalence of pain during nursing care procedures, and 2) to evaluate the usefulness of certain vital signs and the bispectral index (BIS) in detecting pain. METHODS: A prospective, observational analytical study was made of procedures (endotracheal aspiration and mobilization with turning) in critically ill sedated patients on mechanical ventilation. The Behavioral Pain Scale was used to assess pain, with scores of ≥3 indicating pain. Various physiological signs and BIS values were recorded, with changes of >10% being considered clinically relevant. RESULTS: A total of 146 procedures in 70 patients were analyzed. Pain prevalence during the procedures was 94%. Vital signs and BIS values increased significantly during the procedures compared to resting conditions, but only the changes in BIS were considered clinically relevant. In the subgroup of patients receiving preemptive analgesia prior to the procedure, pain decreased significantly compared to the group of patients who received no such analgesia (-2 [IQR: {-5}-0] vs. 3 [IQR: 1-4]; P<.001, respectively). CONCLUSIONS: The procedures evaluated in this study are painful. Changes in vital signs are not good indicators of pain. Changes in BIS may provide useful information about pain, but more research is needed. The administration of preemptive analgesia decreases pain during the procedures.

Comparative study of etiological diagnosis of nosocomial pneumonia

Nosocomial pneumonia is a common complication in patients on mechanical ventilation and results in significant mortality. Diagnosis of pneumonia in patients who are intubated and under mechanical ventilation is difficult, even with the aid of clinical, laboratorial, and endoscopic tests. The objective of this study was to compare three methods of tracheal sputum collection in patients with a clinical and radiological diagnosis of pneumonia. Twenty-two patients with a clinical diagnosis of liver disease were enrolled, 18 years of age or older, 13 males and nine females, who had been mechanically ventilated over an intubation period of 5.86 ± 4.62 days. These patients were being treated in intensive care unit (ICU) of the Liver Transplantdepartment. Secretion collection was carried out according to a protocol with three distinct methods: endotracheal aspiration with a closed aspiration system, Bal cath and bronchoalveolar lavage. Of the 22 patients analyzed, 21 (95.4 percent) showed one or more infectious agent when the closed aspiration system was used. With the Bal cathâ collection, 19 patients (86.3 percent) had one or more infectious agents; in the collection by bronchoalveolar lavage, 10 patients (45.4 percent) presented one or more infectious agent. According to the laboratorial analysis, 14 different microorganisms were isolated, the most frequent of which were Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. We concluded that aspiration with the closed system produced the most effective results in comparison with those of bronchoalveolar lavage and the Bal cathâ, and may be an acceptable method for diagnosing hospital-acquired pneumonia when no fiberoptic technique is available.

Comportamento da mecânica pulmonar após a aplicação de protocolo de fisioterapia respiratória e aspiração traqueal em pacientes com ventilação mecânica invasiva / Behavior of the lung mechanics after the application of protocol of chest physiotherapy and aspiration tracheal in patients with invasive mechanical ventilation

JUSTIFICATIVA E OBJETIVOS: A fisioterapia respiratória (FR) em pacientes submetidos a suporte ventilatório invasivo, atua diretamente no sistema ventilatório podendo alterar a mecânica pulmonar através da complacência pulmonar dinâmica (Cdyn) e da resistência do sistema respiratório (Rsr). Porém, as alterações descritas após a realização de FR permanecem controversas. O objetivo deste estudo foi avaliar as alterações da mecânica pulmonar em pacientes em ventilação mecânica invasiva (VMI). MÉTODO: Foi realizado estudo prospectivo e aleatório, controlado do tipo cruzado, incluindo pacientes com mais de 48 horas em VMI. Os protocolos de fisioterapia respiratória (PF) e de aspiração traqueal isolada (PA) foram aleatorizados para a ordem de aplicação, com intervalo de 24 horas entre eles. Dados da mecânica pulmonar e das variáveis cardiorrespiratórias foram coletados antes da aplicação do protocolo, imediatamente após; 30 minutos e 120 minutos após a aplicação dos protocolos. RESULTADOS: Doze pacientes completaram o estudo. A pneumonia foi a causa mais comum de insuficiência respiratória (IRpA). Não houve diferença estatisticamente significativa entre os grupos em relação à Cdyn, volume de ar corrente (VAC) e volume-minuto (VM). A Rsr diminuiu de forma significativa imediatamente após (de 10,4 ± 3 cmH2O/L/seg para 8,9 ± 2 cmH2O/L/seg; p < 0,02), 30 minutos após (de 10,4 ± 3 cmH2O/L/seg para 9 ± 2 cmH2O/L/seg; p < 0,01) e 120 min após (de 10,4 ± 3 cmH2O/L/seg para 9 ± 2 cmH2O/L/seg; p < 0,03) a aplicação do protocolo de fisioterapia respiratória. Quando comparado com o protocolo de aspiração traqueal isolada foi significativamente menor nos momentos 30 (9 ± 2 cmH2O/L/seg versus 10,2 ± 2 cmH2O/L/seg; p < 0,04) e 120 minutos (9 ± 2 cmH2O/L/segundo versus 10,4 ± 3 cmH2O/L/seg; p < 0,04). CONCLUSÕES: O protocolo de fisioterapia respiratória foi eficaz na diminuição da Rsr quando comparado com o protocolo de aspiração. Essa diminuição manteve-se...

BACKGROUND AND OBJECTIVES: The chest physiotherapy (CP) in patients submitted to invasive support ventilation acts directly in the breathing system, and it could alter the lung mechanics through the dynamic lung compliance (DynC) and resistance of the breathing system (Rbs). However the alterations after the accomplishment of CP are still controversy. The objective of this study was to evaluate the alterations of the lung mechanics in patients in invasive mechanical ventilation (IMV). METHODS: It was a prospective, randomized, and controlled and crossover study, with patient with more than 48 hours in IMV. The protocol of chest physiotherapy and isolated tracheal aspiration they were randomized for the application order with a window of 24 hours among them. Data of lung mechanics and its varied cardiorespiratory were collected moments before the protocol, immediately after the application of the protocol, 30 minutes and 120 minutes after the application of the protocols. RESULTS: Twelve patients completed the study. Pneumonia was the mean cause respiratory failure (RF). There was not statistical difference among the groups in relation to Cdyn, volume tidal (Vt) and volume minute (Ve). Rbs decreased in a significant way immediately after (of 10.4 ± 3 cmH2O/L/seg for 8.9 ± 2 cmH2O/L/seg; p < 0.02), 30 minutes after (of 10.4 ± 3 cmH2O/L/seg for 9 ± 2 cmH2O/L/seg; p < 0.01) and 120 minutes after (of 10.4 ± 3 cmH2O/L/seg for 9 ± 2 cmH2O/L/seg; p < 0.03) application the protocol of chest physiotherapy. When compared with the protocol of isolated tracheal aspiration it was significantly smaller in the 30 (9 ± 2 cmH2O/L/seg versus10.2 ± 2 cmH2O/L/seg; p < 0.04) and 120 minutes (9 ± 2 cmH2O/L/seg versus 10.4 ± 3 cmH2O/L/seg; p < 0.04). CONCLUSIONS: The protocol of chest physiotherapy was effective in the decrease of Rsr when compared with the aspiration protocol. That decrease was maintained for two hours after its application, what did not happen...

Clinical Outcomes of Early Vancomycin Administration before Identification of Methicillin-resistant Staphylococcus aureus in Patients with Nosocomial Pneumonia / 대한구급학회지

BACKGROUND: The aim of this study is to determine the clinical outcomes of early vancomycin administration before identification of methicillin-resistant Staphylococcus aureus (MRSA) in patients with nosocomial pneumonia on a ventilator. METHODS: We retrospectively reviewed patients with nosocomial pneumonia in a 20-bed medical ICU during a period of 2 years and 2 months. This study included 52 inpatients, who were admitted for more than 72 hr and had a new or progressive lung infiltrate plus at least two of the following three criteria for pneumonia: abnormal body temperature (>38oC or 10,000/mm3 or <3,000/mm3), and purulent bronchial secretions. All of the MRSA were identified in tracheal aspirates during mechanical ventilation. RESULTS: A total of 23 patients who received vancomycin prior to identification of MRSA exhibited a 28-day mortality rate of 60%, while 29 patients who received vancomycin after identification of MRSA showed a 28-day mortality rate of 40% (p=0.17). There was no statistically significant difference in severity index and routine laboratory findings between the two groups. CONCLUSIONS: Early vancomycin administration before identification of MRSA does not appear to affect the mortality rate for patients with nosocomial pneumonia.

The Usefulness of Supine Position on Swallowing of Liquid Diet in Neurogenic Dysphagia: Comparison with Sitting Position

OBJECTIVE: The purpose of this study is to find the proper feeding posture for the safe liquid meal in the patients with neurogenic dysphagia. METHOD: Fifty patients of neurogenic dysphagia with tracheal aspiration diagnosed with the videofluoroscopic swallowing test (VFST) were evaluated. VFST using 5 cc of barium solution was done for each patient in the sitting and supine position. The results of VFST of supine position were analyzed and compared with those of sitting position for the tracheal aspiration, laryngeal penetration, premature leakage, and laryngeal spillage. RESULTS: The incidence of premature leakage, tracheal aspiration, and laryngeal penetration is significantly decreased in the supine position (56%, 14% and 46%) compared to the sitting position (96%, 100% and 100%) (p<0.001). The incidence of laryngeal penetration referable to the swallowing reflex is significantly decreased in the supine position (0%, 46%, 0%) compared to the sitting position (14%, 96%, 44%) (p<0.001). The incidence of nasal regurgitation is 2% in the sitting position and 30% in the supine position. CONCLUSION: The incidence of tracheal aspiration of liquid diet is significantly decreased in the supine position compared to the sitting position. The supine position would be safer than the sitting position in the feeding of liquid diet.

Relationship between the Type of Laryngeal Penetration and Severity of Tracheal Aspiration in the Brain Injured

OBJECTIVE: To assess the incidence of tracheal aspiration in the brain injury patients with laryngeal penetration, and to investigate the relationship between the type of laryngeal penetration and the severity of tracheal aspiration. METHOD: One hundred videofluoroscopic swallowing tests in brain injury patients who showed laryngeal penetration were analyzed retrospectively. Laryngeal penetrations were classified into three groups: anterior, posterior and both. The incidence of the tracheal aspiration among the laryngeal penetration was evaluated. The severity of the tracheal aspiration was analyzed into the three groups: mild, moderate and severe. Each type of the laryngeal penetration were compared with the severity of the tracheal aspiration. RESULTS: Seventy-one patients showed the tracheal aspiration among the 100 patients with laryngeal penetration. The incidence of tracheal aspiration according to the type of the laryngeal penetration was 100% in both, 86.8% in posterior, and 50.9% in anterior type. The more severe tracheal aspiration was associated with the higher proportion of the posterior and both types. CONCLUSION: The incidence of tracheal aspiration in laryngeal penetration was 71%. More severe tracheal aspiration occurred with both & posterior laryngeal penetration than anterior type.