Fiberoptic Endoscopy Evaluation of Swallowing (FEES) Findings Associated with High Pneumonia Risk in a Cohort of Patients at Risk of Dysphagia.

Aspiration detected in the fiberoptic endoscopy evaluation of swallowing (FEES) has been inconsistently associated with pneumonia, with no evidence of the risk of pneumonia from other alterations in swallowing safety detected in FEES. We conducted a dynamic, ambidirectional cohort study involving 148 subjects at risk of dysphagia in a tertiary university hospital. Our aim was to determine the risk of pneumonia attributed to alterations in swallowing safety detected during FEES. We used multivariate negative binomial regression models to adjust for potential confounders. The incidence density rate (IR) of pneumonia in patients with tracheal aspiration of any consistency was 26.6/100 people-years (RR 7.25; 95% CI: 3.50-14.98; P < 0.001). The IR was 19.7/100 people-years (RR 7.85; 95% CI: 3.34-18.47; P < 0.001) in those with laryngeal penetration of any consistency and 18.1/100 people-years (RR 6.24; 95% CI: 2.58-15.09; P < 0.001) in those with pharyngeal residue of any consistency. When adjusted for aspiration, the association of residue and penetration with pneumonia disappeared, suggesting that their risk of pneumonia is dependent on the presence of aspiration and that only aspiration is independently associated with pneumonia. This increased risk of pneumonia was significant in uni- and multivariate negative binomial regression models. We found an independently increased risk of pneumonia among patients with dysphagia and aspiration detected during FEES. Alterations in the oral and pharyngeal phases of swallowing, without aspiration, did not increase the risk of pneumonia.

Sensitivity and specificity of the EAT-10 and SDQ-DP in identifying the risk of dysphagia in Parkinson's disease / Sensibilidade e especificidade do EAT-10 e SDQ-DP na identificação do risco de disfagia na doença de Parkinson

Abstract Background The early identification of risk for dysphagia in patients with Parkinson's disease (PD) is essential for the prevention of nutritional and pulmonary complications. Objective To analyze the sensitivity and specificity of the Swallowing Disturbance Questionnaire (SDQ-PD) and the Eating Assessment Tool (EAT-10) in identifying dysphagia risk in patients with early and intermediate stages of PD. Methods Twenty-nine patients with PD participated in the study. EAT-10 and SDQ-PD questionnaires were applied, and a videofluoroscopic swallowing study. Dysphagia Outcome and Severity Scale (DOSS) was used to classify the presence and severity of dysphagia, and the Penetration-Aspiration Scale (PAS) was used to identify the presence of penetration/aspiration. In the statistical analysis, the sensitivity and specificity of the risk questionnaires were calculated, as well as positive predictive value, negative predictive value, and accuracy. Results EAT-10 to identify the risk of penetration/aspiration revealed a sensitivity of 71.42% and specificity of 45.45%; in the identification of the presence of dysphagia, the sensitivity was 47.61%, and the specificity was 12.5%. The SDQ-PD questionnaire for risk of penetration/aspiration demonstrated a sensitivity of 28.57%, and a specificity of 68.18%. In terms of identifying the presence of dysphagia, the sensitivity was 20%, while the specificity was 44.44%. Conclusion The SDQ-PD revealed low sensitivity and low specificity to identify the presence of dysphagia and/or penetration/aspiration in patients with early and intermediate stages of PD in this sample. Despite its low specificity, the EAT-10 exhibited good sensitivity in indicating the risk of penetration/aspiration.

Resumo Antecedentes A identificação precoce de risco para disfagia nos pacientes com doença de Parkinson (DP) é fundamental para a prevenção de complicações nutricionais e pulmonares. Objetivo Analisar a sensibilidade e especificidade dos questionários Swallowing Disturbance Questionnaire (SDQ-PD) e Eating Assessment Tool (EAT-10) para a identificação do risco de disfagia em pacientes com DP nos estágios iniciais e intermediários da doença. Métodos Participaram 29 pacientes com DP. Foi realizado a aplicação dos questionários EAT-10 e SDQ-PD e o exame de videofluoroscopia da deglutição. Para a classificação da presença e gravidade da disfagia foi utilizada a escala Dysphagia Outcome and Severity Scale e, para identificação da presença de penetração/aspiração, a escala Penetration-Aspiration Scale (PAS). Na análise estatística, calcularam-se a sensibilidade e a especificidade dos questionários de risco EAT-10 e SDQ-DP e o valor preditivo positivo, o valor preditivo negativo e a acurácia. Resultados A análise do EAT-10 para identificar o risco de penetração/aspiração revelou sensibilidade de 71.42% e especificidade de 45.45%; para identificar a presença de disfagia, a sensibilidade foi de 47,61% e a especificidade de 12.5%. Em relação ao questionário SDQ-PD, para identificar risco de penetração/aspiração, a sensibilidade foi de 28.57% e a especificidade de 68.18% e, para identificar a presença de disfagia, a sensibilidade foi de 20% e a especificidade de 44.44%. Conclusão O questionário SDQ-PD revelou baixa sensibilidade e baixa especificidade para identificar presença de disfagia e/ou penetração/aspiração em pacientes com DP em estágios iniciais e intermediários para essa amostra. O EAT-10 revelou boa sensibilidade na indicação de risco de penetração/aspiração, apesar de baixa especificidade.

Asociación entre el tiempo de enfermedad previo a broncoscopia y tiempo de alta posbroncoscopia en pacientes pediátricos con aspiración de cuerpo extraño: estudio de cohorte retrospectivo en un centro de referencia peruano, 2014-2019 / Association between pre-bronchoscopy time of illness and post-bronchoscopy discharge time in pediatric patients with foreign body aspiration: retrospective cohort study in a Peruvian referral center, 2014-2019

RESUMEN Objetivos. Determinar la asociación entre el tiempo de enfermedad previo a broncoscopia y el tiempo de alta posbroncoscopia en pacientes pediátricos con aspiración de cuerpo extraño. Materiales y métodos. Estudio de cohorte retrospectivo. El estudio y la revisión de historias clínicas se realizó en el Hospital de Emergencias Pediátricas de Lima, Perú. Se revisaron 324 historias clínicas, de las cuales, 183 historias fueron seleccionadas por contar con diagnóstico de cuerpo extraño en vías aéreas y estar adecuadamente llenadas. Para el análisis bivariado se utilizó la prueba exacta de Fisher y U de Mann Whitney, mientras que para el cálculo del riesgo relativo (RR) y su respectivo intervalo de confianza (IC) al 95% se utilizó regresión de Poisson. Resultados. Se incluyeron 183 pacientes, de los cuales, el 65,6% fueron hombres con una media de 2,4 años. La localización más frecuente fue el árbol bronquial derecho y cuerpo extraño de material orgánico. La mayoría (72,7%) de pacientes tuvieron un alta temprana antes de las 24 horas. Se encontró una asociación entre el tiempo de enfermedad previo a la broncoscopia y el tiempo alta posbroncoscopia (RR: 2,94, IC 95%: 1,72-5,01). Conclusiones. Existe una asociación estadísticamente significativa entre el tiempo de enfermedad previo a la broncoscopia y el tiempo de estancia hospitalaria posextracción del cuerpo extraño al ajustar por edad, sexo tipo de cuerpo extraño y maniobra de boca como medida de rescate. Este hallazgo es relevante debido a que pone en evidencia la importancia de una atención temprana, diagnóstico oportuno y manejo precoz en el paciente pediátrico.

ABSTRACT Objective. To determine the association between pre-bronchoscopy time of illness and post-bronchoscopy discharge time in pediatric patients with foreign body aspiration. Materials and methods. Retrospective cohort study. Medical records were studied and reviewed at the Pediatric Emergency Hospital of Lima, Peru. We reviewed 324 medical records, and selected 183 because they had the diagnosis of foreign body aspiration and complete data. Fisher's exact test and Mann Whitney U test were used for the bivariate analysis, while Poisson regression was used to calculate the Relative Risk (RR) and its 95% confidence interval (CI). Results. We included 183 patients, of whom 65.6% were men with a mean age of 2.4 years. The most frequent location of the foreign body was the right bronchial tree and most of them were made of organic material. The majority (72.7%) of patients were discharged before 24 hours. We found an association between the time of illness prior to bronchoscopy and post-bronchoscopy discharge time (RR: 2.94, 95%CI: 1.72 - 5.01). Conclusions. The time of illness prior to bronchoscopy and the length of hospital stay after removal of the foreign body were significantly associated when adjusted for age, sex, type of foreign body and mouth sweep maneuver as a rescue measure. Our findings are relevant because they highlight the importance of early care, timely diagnosis and early management of pediatric patients.

A way forward in pulmonary aspiration incidence reduction: ultrasound, mathematics, and worldwide data collection

Abstract Aspiration of gastric contents during induction of general anesthesia remains a significant cause of mortality and morbidity in anesthesia. Recent data show that pulmonary aspiration still accounts for many cases with implications on mortality despite technical and technological evolution. Practical, ethical, and methodological issues prevent high-quality research in the setting of aspiration and rapid sequence induction/intubation, and significant controversy is ongoing. Patients' position, drugs choice, dosing and timing, use of cricoid force, and a reliable risk assessment are widely debated with significant questions still unanswered. We focus our discussion on three approaches to promote a better understanding of rapid sequence induction/intubation and airway management decision-making. Firstly, we review how we can use qualitative and quantitative assessment of fasting status and gastric content with the point-of-care ultrasound as an integral part of preoperative evaluation and planning. Secondly, we propose using imaging-based mathematical models to study different patient positions and aspiration mechanisms, including identifying aspiration triggers. Thirdly, we promote the development of a global data collection system aiming to obtain precise epidemiological data. Therefore, we fill the gap between evidence-based medicine and experts' opinion through easily accessible and diffused computer-based databases. A better understanding of aspiration epidemiology obtained through focused global data gathering systems, the widespread use of ultrasound-based prandial status evaluation, and development of advanced mathematical models might potentially guide safer airway management decision making in the 21st century.

PEEP-ZEEP Compared with Bag Squeezing and Chest Compression in Mechanically Ventilated Cardiac Patients: Randomized Crossover Clinical Trial.

Background and Objectives: Perform the bag squeezing and PEEP-ZEEP techniques associated with manual chest compression in mechanically ventilated cardiac patients in order to observe their effectiveness in the removal of pulmonary secretions and safety from a hemodynamic and ventilatory point of view. Methods: This is a randomized crossover clinical trial developed in a hospital in southern Brazil. We included hemodynamically stable male and female patients aged over 18 years who used invasive mechanical ventilation for at least 48 h. The control group was established for the bag-squeezing technique and the intervention group for the PEEP-ZEEP maneuver, both associated with manual chest compression. Tracheal aspiration was performed 2 h before in order to match the groups in relation to the volume of secretion, and also immediately at the end of the techniques in order to measure the amount of secretion collected. Results: The sample had 36 individuals with a mean age of 70.3 years, 21% of the patients were male, and the majority (10.4%) were hospitalized for ischemic heart disease. DBP (p = 0.024), MAP (p = 0.004) and RR (p = 0.041) showed a significant difference in the post-moment in both groups. There was a significant difference in the reduction of peak pressure values (p = 0.011), in the moment after performing the techniques, and also in the Cdyn (p = 0.004) in the control group versus moment. Conclusions: Both maneuvers are safe in terms of hemodynamics and ventilatory mechanics, in addition to being capable of favoring airway clearance through secretion removal, and they can be used in routine physiotherapeutic care.

A way forward in pulmonary aspiration incidence reduction: ultrasound, mathematics, and worldwide data collection.

Aspiration of gastric contents during induction of general anesthesia remains a significant cause of mortality and morbidity in anesthesia. Recent data show that pulmonary aspiration still accounts for many cases with implications on mortality despite technical and technological evolution. Practical, ethical, and methodological issues prevent high-quality research in the setting of aspiration and rapid sequence induction/intubation, and significant controversy is ongoing. Patients' position, drugs choice, dosing and timing, use of cricoid force, and a reliable risk assessment are widely debated with significant questions still unanswered. We focus our discussion on three approaches to promote a better understanding of rapid sequence induction/intubation and airway management decision-making. Firstly, we review how we can use qualitative and quantitative assessment of fasting status and gastric content with the point-of-care ultrasound as an integral part of preoperative evaluation and planning. Secondly, we propose using imaging-based mathematical models to study different patient positions and aspiration mechanisms, including identifying aspiration triggers. Thirdly, we promote the development of a global data collection system aiming to obtain precise epidemiological data. Therefore, we fill the gap between evidence-based medicine and experts' opinion through easily accessible and diffused computer-based databases. A better understanding of aspiration epidemiology obtained through focused global data gathering systems, the widespread use of ultrasound-based prandial status evaluation, and development of advanced mathematical models might potentially guide safer airway management decision making in the 21st century.

Analysis of 108 flexible bronchoscopies for the removal of foreign bodies from the airways

ABSTRACT Objective To describe the clinical, bronchoscopic, diagnostic, and therapeutic aspects between children and adults. Methods This retrospective study compared the clinical and bronchoscopic characteristics of adults and children who underwent bronchoscopy for suspected foreign body aspiration. Data on sex, outpatient or emergency origin, bronchoscopy results, characteristics of the aspirated foreign body, and complications were analyzed. Results In total, 108 patients were included in the analysis, with foreign body aspiration diagnosed in 69% of patients (30 children and 44 adults). In 91% of patients, there was a clinical history suggestive of aspiration. The mean age of the adults was 65.89 (±19.75) years, and that of the children was 2.28 (±1.78) years. Most of the children were under 3 years of age (80%), while adults were mostly 70 years of age or older (54.5%). Emergency care was more common among children than adults. The most common foreign bodies found in both age groups were organic bodies, primarily seeds. The most frequent locations of foreign bodies were the lobar bronchi in adults and the main bronchi in children. Flexible bronchoscopy is the primary method for diagnosis and treatment. Transient hypoxemia occurred particularly frequently in children (5%). Conclusion Foreign body aspiration, particularly that involving seeds, is more common in the extremes of age. A clinical history suggestive of aspiration is crucial in determining the need for bronchoscopy, which should be performed as early as possible. Flexible bronchoscopy is an effective and safe diagnostic technique.

Risk of pulmonary aspiration during semaglutide use and anesthesia in a fasting patient: a case report with tomographic evidence

ABSTRACT Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety.

Associação entre o número de deglutições, resíduo faríngeo e broncoaspiração na esclerose múltipla / Association between the number of swallowing, pharyngeal residue and bronchopulmonary aspiration in multiple sclerosis

RESUMO Objetivo verificar a associação entre o número de deglutições e presença de resíduo faríngeo e broncoaspiração em pessoas com esclerose múltipla. Métodos estudo transversal observacional de exames de videofluoroscopia de 231 deglutições de indivíduos com esclerose múltipla. Três fonoaudiólogas avaliaram as deglutições de IDDSI 1 (International Dysphagia Diet Standardisation Initiative) (5 ml e 10 ml) e IDDSI 4 (8 ml) quanto à presença de resíduo faríngeo e de penetração/aspiração. Deglutições que não apresentaram resíduo faríngeo foram classificadas como deglutições sem resíduos faríngeos (DSR) e as que apresentaram, como deglutições com resíduos faríngeos (DCR), sendo estas últimas subdivididas em resíduos faríngeos em todas as ofertas ou eventuais (DCR1 e DCR2). O número de deglutições foi analisado por um avaliador cego e comparado com os dados demográficos e clínicos. Resultados das 231 deglutições, 73 (31,6%) apresentaram resíduos faríngeos. O número médio de deglutições foi semelhante nas deglutições sem e com resíduos faríngeos em cada consistência e volume e nas variáveis idade, gênero, tipo de esclerose múltipla e incapacidade funcional. Houve associação entre a média do número de deglutições e a ausência de penetração/aspiração, quando comparada às deglutições sem e com resíduos faríngeos, nas DCR2 e em indivíduos acima de 50 anos. Ao analisar intragrupo, observou-se associação nas DCR, sendo maior na ausência de penetração/aspiração e nas DCR2. Conclusão não houve correlação entre o número de deglutições e a presença de resíduos em recessos faríngeos na esclerose múltipla. Todavia, o número de deglutições foi maior quando houve resíduo e ausência de disfagia e de penetração/aspiração, em indivíduos mais velhos.

ABSTRACT Purpose To verify the association between the number of swallows and the presence of pharyngeal residue and bronchoaspiration in people with Multiple Sclerosis. Methods An observational cross-sectional study of videofluoroscopic examinations of 231 swallows from individuals with Multiple Sclerosis. Three speech therapists evaluated IDDSI 1 (International Dysphagia Diet Standardisation Initiative) (5ml and 10ml) and IDDSI 4 (8ml) deglutitions for pharyngeal residue and penetration/ aspiration. Swallows with no pharyngeal residue were classified as swallows without pharyngeal residue (SWTR) and those with pharyngeal residue (SWR), the latter subdivided into pharyngeal residue in all or occasional offerings (SWR1 e SWR2). The number of swallows was analyzed by a blind evaluator and compared with demographic and clinical data. Results Of the 231 swallows, 73 (31.6%) showed pharyngeal residues. The mean number of swallows was similar in the deglutitions with and without pharyngeal residues in each consistency and volume and in the variables age, gender, type of Multiple Sclerosis and functional disability. There was an association between the mean number of swallows and the absence of penetration/aspiration when comparing deglutitions with and without pharyngeal residues, in SWR2 and in individuals over 50 years of age. When analyzing intragroup, an association was observed in SWR, being higher in the absence of penetration/aspiration and in SWR2. Conclusion There was no correlation between the number of swallows and the presence of residues in pharyngeal recesses in multiple sclerosis. However, the number of swallows was higher when there was residue and absence of dysphagia and penetration/aspiration, and in older individuals.

Factors associated with bronchopulmonary aspiration: a national-based study / Factores asociados con la aspiración broncopulmonar: estudio de base nacional / Fatores associados à aspiração broncopulmonar: estudo de base nacional

ABSTRACT Objectives: to determine the prevalence of bronchopulmonary aspiration in the Brazilian scenario, the factors associated with the incident and the variables associated with death. Methods: a cross-sectional and analytical study, carried out from analysis of notifications of incidents related to bronchopulmonary aspiration of the Health Surveillance Notification System, from January 2014 to December 2018. Results: of the 264,590 notifications, 553 referred to aspiration, whose prevalence rate was 0.21%. There was an association between the event and age, ethnicity, main medical diagnosis, country region, service type, health unit and consequences for patients. Furthermore, four independent predictor variables for death were found: living in the North or South regions, being elderly and receiving healthcare at night. Conclusions: the prevalence rate of bronchopulmonary aspiration was small, but with a negative impact on patients.

RESUMEN Objetivos: determinar la prevalencia de broncoaspiración en el escenario brasileño, los factores asociados al incidente y las variables asociadas a la muerte. Métodos: estudio transversal y analítico, realizado a partir del análisis de notificaciones de incidentes relacionados con la aspiración broncopulmonar del Sistema de Notificación de Vigilancia Sanitaria, de enero de 2014 a diciembre de 2018. Resultados: de las 264.590 notificaciones, 553 se refirieron a aspiración, cuya tasa de prevalencia fue del 0,21%. Hubo asociación entre el evento y la edad, etnia, diagnóstico médico principal, región del país, tipo de servicio, unidad de salud y consecuencias para el paciente. Además, se encontraron cuatro variables predictoras independientes de muerte: vivir en la región Norte o Sur, ser anciano y recibir atención médica por la noche. Conclusiones: la tasa de prevalencia de aspiración broncopulmonar fue pequeña, pero con impacto negativo en los pacientes.

RESUMO Objetivos: determinar a prevalência de aspiração broncopulmonar no cenário brasileiro, os fatores associados ao incidente e as variáveis associadas ao óbito. Métodos: estudo transversal e analítico, realizado a partir da análise das notificações de incidentes relacionados à aspiração broncopulmonar do Sistema de Notificações em Vigilância Sanitária, no período de janeiro de 2014 a dezembro de 2018. Resultados: das 264.590 notificações, 553 se referiam à aspiração, cuja taxa de prevalência foi de 0,21%. Houve associação entre o evento e idade, etnia, diagnóstico médico principal, região do país, tipo de serviço, unidade de saúde e consequência para o paciente. Ainda, verificaram-se quatro variáveis preditoras independentes para o óbito: residir na Região Norte ou Sul, ser idoso e receber atendimento à saúde no período noturno. Conclusões: a taxa de prevalência de aspiração broncopulmonar foi pequena, mas com impacto negativo para os pacientes.

Fatores predisponentes do volume residual gástrico após preparo expresso com manitol / Gastric residual volume factors after bowel preparation with mannitol express

ABSTRACT BACKGROUND: Bowel preparation with mannitol is a well-established method in Brazil. However, factors that interfere with the gastric emptying time period are yet to be known. Knowing these factors may favor the examination scheduling logistics and the individualized orientation for each patient. OBJECTIVE: Know the factors that can contribute to the gastric emptying time after intestinal preparation with express mannitol. METHODS: This is a prospective observational study to know factors that may contribute on the gastric emptying timing: predominant type of diet, comorbidities, medication usage, previous surgeries, number of evacuation per week, bearer of bowel obstipation, fecal type, diet type, number of evacuations after the home usage of bisacodyl before the ingestion of mannitol and number of evacuations after the ingestion of mannitol until reaching a proper bowel preparation. Before starting the colonoscopy exam, an upper digestive endoscopy exam was made to aspirate the gastric content. RESULTS: Sample was composed of 103 patients, 55 (53.4%) women, medium age 61 (±12.1) years, medium weight 75.3 (±14.1) kg, medium height 1.7 (±10) m and medium BMI of 26.6 (±3.9) kg/m2. Average gastric residual volume was 120.9 (0-900) mL. Gastric residual volume (GRV) below 100 mL (GRV ≤100 mL) occurred in 45 (43.6%) patients, 24 (53.3%) women, medium age of 61.0 years and medium BMI of 26.7 kg/m2. Gastric residual volume above 100 mL (GRV >100 mL) occurred on 58 (56.3%) patients, 29 (50%) women, medium age of 61.0 years and medium BMI of 26.2 kg/m2. Comparing both groups, average fasting time period after the ingestion of mannitol was significantly higher on the group with GRV ≤100 mL than group with GRV >100 mL, 123.1 (60-246) vs 95.3 (55-195) minutes, respectively. There was also statistical significance concerning the usage of ezetimibe 6 (13.7%) in the group with GRV ≤100 mL and statistical significance in the group with GRV >100 mL concerning the usage of paroxetine 3 (6.7%) and tadalafil 3 (6.7%) and surgical history of prostatectomy 3 (6.7%) and bridle withdrawal 3 (6.7%). CONCLUSION: We may conclude in this study that the usage of ezetimibe and fasting above 2 hours after the ingestion of mannitol decrease significantly the incidence of a GRV >100 mL. The usage of paroxetine, tadalafil and surgical history of prostatectomy or bridle withdrawal may contribute to increase de incidence of a GRV >100 mL.

RESUMO CONTEXTO: O preparo intestinal com manitol é um método bem estabelecido no Brasil. No entanto, os fatores que interferem no tempo de esvaziamento gástrico ainda não são conhecidos. O conhecimento desses fatores pode favorecer a logística de agendamento do exame e a orientação individualizada para cada paciente. OBJETIVO: Estudar os fatores que podem contribuir para o tempo de esvaziamento gástrico após o preparo intestinal com manitol expresso. MÉTODOS: Trata-se de um estudo observacional prospectivo com o objetivo de conhecer os seguintes fatores que podem contribuir no tempo de esvaziamento gástrico: tipo de dieta predominante, comorbidades, uso de medicamentos, cirurgias anteriores, número de evacuações por semana, portador de obstipação intestinal, tipo fecal, tipo de dieta, número de evacuações após o uso domiciliar de bisacodil antes da ingestão de manitol e número de evacuações após a ingestão de manitol até atingir o preparo intestinal adequado. Antes de iniciar o preparo intestinal, os pacientes responderam a um questionário clínico. O endoscópio foi introduzido para aspirar o conteúdo gástrico, antes de iniciar a colonoscopia. RESULTADOS: A amostra foi composta por 103 pacientes, sendo 55 mulheres, com média de idade de 61 anos, peso médio de 75,3 kg, altura média de 1,7 m e IMC médio de 26,6 kg/m2. O volume residual gástrico médio medido foi 120,9 (0-900) mL. Volume residual gástrico inferior a 100 mL (VRG ≤100 mL) foi encontrado em 45 (43,6%) pacientes, sendo 24 (53,3%) mulheres, com média de idade de 61,0 anos e IMC médio de 26,7 kg/m2. Volume residual gástrico acima de 100 mL (VRG >100 mL) ocorreu em 58 (56,3%) pacientes, sendo 29 (50%) mulheres, com idade média de 61,0 anos e IMC médio de 26,2 kg/m2. Comparando os dois grupos, notou-se que o tempo médio de jejum após a ingestão de manitol foi significativamente maior no grupo com VRG ≤100 mL do que no grupo com VRG> 100 mL, 123,1 (60-246) vs 95,3 (55-195) minutos, respectivamente. Também houve significância estatística em relação ao uso de ezetimiba 6 (13,7%), sendo maior no grupo com VRG ≤100 mL. Além disso, houve significância estatística no grupo com VRG >100 mL quanto ao uso de paroxetina 3 (6,7%) e tadalafil 3 (6,7%) e história cirúrgica de prostatectomia 3 (6,7%) e retirada de bridas 3 (6,7%). CONCLUSÃO: Podemos concluir neste estudo que o uso de ezetimiba e o jejum acima de 2 horas após a ingestão de manitol diminuem significativamente a incidência de um VRG> 100 mL. O uso de paroxetina, tadalafil e história cirúrgica de prostatectomia ou retirada de bridas podem contribuir para o aumento da incidência de um VRG >100 mL.

Aspiration in the Fiberoptic Endoscopic Evaluation of Swallowing Associated with an Increased Risk of Mortality in a Cohort of Patients Suspected of Oropharyngeal Dysphagia.

There is a general lack of published studies on the risk of mortality due to alterations in the safety of swallowing detected during the fiberoptic endoscopic evaluation of swallowing (FEES). We aimed at assessing the risk of mortality of the detection of aspiration, penetration, and pharyngeal residues by FEES. A cohort of consecutively evaluated patients suspected of experiencing oropharyngeal dysphagia undergoing FEES at a tertiary care university hospital were prospectively followed up on to assess mortality. The FEES findings, comorbidities, and potential confounders were studied as predictors of death using a Cox multivariate regression analysis. A total of 148 patients were included, 85 of whom were male (57.4%). The mean age (± standard deviation) was 52.7 years (± 22.1). The median of the follow-up time was 4.5 years. The most frequent conditions were stroke in 50 patients (33.8%), brain and spine traumas in 27 (18.2%), and neurodegenerative diseases in 19 (12.8%). Variables associated with mortality in bivariate analyses were age > 65 years (p < 0.001), pneumonia (p = 0.046), aspiration of any consistency (p < 0.001), and pharyngeal residues (p = 0.017). Variables independently associated with mortality in the Cox multivariate model were age (> 65 years) [adjusted hazard ratio (HR) 5.76; 95% CI 2.72 to 17.19; p = 0.001] and aspiration (adjusted HR: 3.96; 95% CI 1.82 to 14.64; p = 0.003). Aspiration detected by FEES and an age > 65 years are independent predictors of mortality in patients with oropharyngeal dysphagia.

Algoritmo para el manejo de la aspiración pulmonar crónica en pediatría / Algorithm for the management of chronic pulmonary aspiration in pediatrics

La aspiración pulmonar es el pasaje de alimentos, reflujo gastroesofágico y/o saliva a la vía aérea de manera suficiente que ocasione síntomas respiratorios crónicos o recurrentes. Es una ausa importante de neumonía recurrente, enfermedad pulmonar progresiva, bronquiectasias e, incluso, muerte. La aspiración es intermitente y, con frecuencia, ocurre en niños con anomalías médicas subyacentes o síndromes que ocasionan síntomas respiratorios similares a la aspiración pulmonar crónica, por lo que, muchas veces, el diagnóstico de aspiración se demora hasta que haya una lesión pulmonar significativa. Se describen los métodos diagnósticos disponibles y sus limitaciones, y las opciones de tratamiento de la aspiración pulmonar crónica en la población pediátrica.

Pulmonary aspiration is the passage of food, gastroesophageal reflux and/or saliva to the airway in a manner sufficient to cause chronic or recurrent respiratory symptoms. It is an important cause of recurrent pneumonia, progressive lung disease, bronchiectasis and even death.Aspiration is intermittent and often occurs in children with underlying medical conditions or syndromes that cause respiratory symptoms similar to chronic pulmonary aspiration, so diagnosis of aspiration is often delayed until there is a significant lung injury. The available diagnostic methods and their limitations, and treatment options of chronic pulmonary aspiration in the pediatric population are described.

[Algorithm for the management of chronic pulmonary aspiration in pediatrics]. / Algoritmo para el manejo de la aspiración pulmonar crónica en pediatría.

Pulmonary aspiration is the passage of food, gastroesophageal reflux and/or saliva to the airway in a manner sufficient to cause chronic or recurrent respiratory symptoms. It is an important cause of recurrent pneumonia, progressive lung disease, bronchiectasis and even death. Aspiration is intermittent and often occurs in children with underlying medical conditions or syndromes that cause respiratory symptoms similar to chronic pulmonary aspiration, so diagnosis of aspiration is often delayed until there is a significant lung injury. The available diagnostic methods and their limitations, and treatment options of chronic pulmonary aspiration in the pediatric population are described.

La aspiración pulmonar es el pasaje de alimentos, reflujo gastroesofágico y/o saliva a la vía aérea de manera suficiente que ocasione síntomas respiratorios crónicos o recurrentes. Es una causa importante de neumonía recurrente, enfermedad pulmonar progresiva, bronquiectasias e, incluso, muerte. La aspiración es intermitente y, con frecuencia, ocurre en niños con anomalías médicas subyacentes o síndromes que ocasionan síntomas respiratorios similares a la aspiración pulmonar crónica, por lo que, muchas veces, el diagnóstico de aspiración se demora hasta que haya una lesión pulmonar significativa. Se describen los métodos diagnósticos disponibles y sus limitaciones, y las opciones de tratamiento de la aspiración pulmonar crónica en la población pediátrica.

Comparação entre técnicas de higiene brônquica em pacientes mecanicamente ventilados: ensaio clínico randomizado / Comparison of bronchial hygiene techniques in mechanically ventilated patients: a randomized clinical trial

RESUMO Objetivo: Comparar a eficiência das técnicas de vibrocompressão e hiperinsuflação com ventilador mecânico de forma isolada e a associação das duas técnicas (hiperinsuflação com ventilador mecânico + vibrocompressão), na quantidade de secreção aspirada e na alteração de parâmetros hemodinâmicos e pulmonares. Métodos: Ensaio clínico randomizado com pacientes críticos em ventilação mecânica, realizado na unidade de terapia intensiva de um hospital universitário. Os pacientes foram randomizados para receber uma das técnicas de higiene brônquica por 10 minutos (vibrocompressão, ou hiperinsuflação com ventilador mecânico, ou hiperinsuflação com ventilador mecânico + vibrocompressão). Após, foram novamente randomizados para receber inicialmente a técnica (previamente randomizada) ou apenas a aspiração isolada. Foram analisados o peso de secreção aspirada (em gramas), dados de mecânica ventilatória e cardiopulmonares, antes e após a aplicação das técnicas. A frequência de reintubação traqueal, o tempo de ventilação mecânica e a mortalidade, também foram avaliados. Resultados: Foram incluídos 93 pacientes (29 vibrocompressão, 32 hiperinsuflação com ventilador mecânico e 32 hiperinsuflação com ventilador mecânico + vibrocompressão) em ventilação mecânica por mais de 24 horas. O grupo hiperinsuflação com ventilador mecânico + vibrocompressão foi o único que apresentou aumento significativo da secreção aspirada, quando comparado a aspiração isolada 0,7g (0,1 - 2,5g) versus 0,2g (0,0 - 0,6g), com valor de p = 0,006. Conclusão: Quando comparada à aspiração isolada, a associação das técnicas hiperinsuflação com ventilador mecânico + vibrocompressão foi mais eficiente na quantidade de secreção aspirada.

ABSTRACT Objective: To compare the effects of vibrocompression and hyperinflation with mechanical ventilator techniques alone and in combination (hyperinflation with mechanical ventilator + vibrocompression) on the amount of aspirated secretion and the change in hemodynamic and pulmonary parameters. Methods: A randomized clinical trial with critically ill patients on mechanical ventilation conducted in the intensive care unit of a university hospital. The patients were randomly allocated to receive one of the bronchial hygiene techniques for 10 minutes (vibrocompression or hyperinflation with mechanical ventilator or hyperinflation with mechanical ventilator + vibrocompression). Afterwards, the patients were again randomly allocated to receive either the previous randomly allocated technique or only tracheal aspiration. The weight of aspirated secretions (in grams), ventilatory mechanics and cardiopulmonary data before and after the application of the techniques were analyzed. The tracheal reintubation frequency and time and mortality on mechanical ventilation were also evaluated. Results: A total of 93 patients (29 vibrocompression, 32 hyperinflation with mechanical ventilator and 32 hyperinflation with mechanical ventilator + vibrocompression) on mechanical ventilation for more than 24 hours were included. The hyperinflation with mechanical ventilator + vibrocompression group was the only one that presented a significant increase in aspirated secretions compared to tracheal aspiration alone [0.7g (0.1 - 2.5g) versus 0.2g (0.0 - 0.6g), p value = 0.006]. Conclusion: Compared to tracheal aspiration alone, the combination of hyperinflation with mechanical ventilator + vibrocompression techniques was most efficient for increasing the amount of aspirated secretions.

Caracterização dos casos de óbito acidental de crianças por aspiração de corpos estranhos em Minas Gerais / Characterization of children accidental death cases by aspiration of foreign bodies in Minas Gerais / Caracterización de los casos de muerte accidental infantil por aspiración de cuerpos extraños en Minas Gerais

OBJETIVO: caracterizar os casos de óbitos decorrentes de asfixia acidental por sufocação em crianças. MÉTODO: estudo descritivo e retrospectivo de dados secundários no qual procedeu-se à análise dos dados dos óbitos de crianças menores de um ano e de um a quatro anos ocorridos no estado de Minas Gerais e notificados no banco de dados do Sistema Único de Saúde, no período de 2005 a 2015. Foram identificados 233 casos de óbitos por asfixia. Entre as vítimas prevaleceram o sexo masculino (131, 56,2%), a raça/cor branca (118, 50,6%), sendo em maior proporção nas crianças menores de um ano (175, 75,1%). Os diagnósticos mais frequentes foram inalação e ingestão de alimentos, causando obstrução do trato respiratório (155, 66,5%), em menores de um ano e de um a quatro anos. RESULTADOS: foram notificados, em média, 14,6 casos por ano com grande oscilação no período estudado, sendo que no ano de 2002 houve maior número de óbitos (21, 9,0%) e em 2006 apresentou-se o menor número de casos (7, 3%). CONCLUSÃO: destaca-se a importância da implementação de medidas preventivas e educativas, com vistas a reduzir o evento, as lesões e as sequelas decorrentes.(AU)

Objective: to characterize the cases of deaths due to accidental asphyxia by suffocation in children. Method: a descriptive and retrospective study of secondary data of death certificates of children, from 2005 to 2015, including those under one year old and those from one to four years old, in the state of Minas Gerais, that were reported in the Unified Health System database. The study identified 233 cases of death from asphyxia. Among the victims, the male sex (131, 56.2%), white race/skin color (118, 50.6%), and children under one year (175, 75.1%) were the most common. The most frequent diagnoses were inhalation and food intake, causing respiratory obstruction (155, 66.5%) in children under one year and from one to four years old. Results: an average of 14.6 cases per year were reported, with great variation, during the study period. The year 2002 had the highest number of deaths (21, 9.0%) and 2006, the lowest (7, 3%). Conclusion: the importance of the implementation of preventive and educational measures to reduce this occurrences, its injuries and sequelae, is highlighted. (AU)

Objetivo: caracterizar los casos de muerte por asfixia accidental en niños. Método: estudio descriptivo y retrospectivo de datos secundarios en el que se analizaron datos de la muerte de niños menores de un año y de uno a cuatro años en el estado de Minas Gerais informados en la base de datos del Sistema Únicode Salud de 2005 a 2015. Se identificaron 233 casos de muerte por asfixia. Entre las víctimas había más varones (131; 56,2%), de tez blanca (118; 50,6%), y en una proporción mayor entre los niños menores de un año (175; 75,1%). Los diagnósticos más frecuentes fueron inhalación e ingesta de alimentos, causando obstrucción del tracto respiratorio (155; 66.5%) en niños menores de un año y de uno a cuatro años. Resultados: en promedio, se informaron 14,6 casos por año con gran oscilación durante el período de estudio; en 2002 hubo más cantidad de muertes (21; 9,0%) y en 2006 menos muertes (7; 3%). Conclusión: se realza la importancia de la implementación de medidas preventivas y educativas para reducir los eventos, lesiones y secuelas. (AU)

¿El reflujo gastroesofágico y la aspiración de contenido gástrico están implicados en la etiopatogenia y la progresión de la fibrosis pulmonar idiopática? / Does gastroesophageal reflux and gastric content aspiration have some role in the pathogenesis and progression of Idiopathic Pulmonary Fibrosis?

Resumen El reflujo gastroesofágico (RGE) y la aspiración oculta de contenido digestivo están probablemente implicados en la etiopatogenia y progresión de la fibrosis pulmonar idiopática (FPI). Los mecanismos patogénicos involucrados son la disminución de la distensibilidad pulmonar y el consiguiente aumento de la presión negativa intratorácica durante la inspiración, así como la disminución de los mecanismos de control de la motilidad esofágica o del tono del esfínter esofágico inferior. La prevalencia de RGE y anomalías de la motilidad esofágica están aumentadas en los pacientes con FPI comparado con la población general. Entre los pacientes con FPI, el 67-76% demostraron exposición anormal al contenido ácido en el esófago. Sin embargo, no hubo relación entre la gravedad del RGE y la gravedad de la FPI. Los estudios que han examinado el tratamiento antirreflujo en esta población han sido escasos. Incluso, algunos datos sugieren que el tratamiento antiácido puede ser perjudicial en algunos pacientes con esta condición. Después de analizar toda la evidencia relevante encontrada hasta la fecha, concluimos que no se puede establecer una relación causal entre el RGE, la aspiración del contenido gástrico y la patogénesis de la FPI. Además, existe escasa evidencia clínica que haya examinado el tratamiento antirreflujo en pacientes con fibrosis pulmonar idiopática.

ABSTRACT Gastroesophageal reflux (GERD) and hidden aspiration of gastric contents are probably involved in the pathogenesis and progression of idiopathic pulmonary fibrosis (IPF). The pathological mechanisms involved are decreased pulmonary distensibility and consequent increase of intrathoracic negative pressure during inspiration, as well as decreased control mechanisms of esophageal motility or lower esophageal sphincter. The prevalence of GERD and oesophageal dysmotility was higher in patients with IPF as compared with general population. Among patients with IPF, 67-76% demonstrated abnormal oesophageal acid exposure. However, no relationship was demonstrated between severity of GERD and severity of IPF. Data are scant on outcomes of antireflux treatment in patients with IPF. Actually, some data suggests that antacid treatment may be deleterious in some IPF patients. After analyzing all the relevant evidence found to date, a causal relationship between GERD, gastric content aspiration and IPF pathogenesis cannot be established. There is scant evidence examining antireflux treatment in idiopathic pulmonary fibrosis patients.

Rare chronic stridor: Case report and literature review / Estridor de extraña duración: reporte de caso y revisión

Abstract This paper reports the case of a toddler with chronic stridor of four months of evolution, treated several times by micro-nebulization (MNB) with beta 2, adrenergics, O2 and corticosteroids with partial improvement. The patient did not have complementary studies nor a clear history of foreign body aspiration (FB). During the last visit to the ER, a neck X-ray revealed a stippling sign in the upper airway. A bronchoscopy was performed, and a sharp foreign body (fishbone) was found in the upper airway, which was subsequently removed. This case is reported due to the unusual evolution of the foreign body in the upper airway, which manifested as a chronic stridor that resolved without further complications.

Resumen Se presenta el caso de una paciente prescolar con estridor crónico de 4 meses de evolución, tratada varias veces mediante micronebulizaciones (MNB) con beta 2, adrenérgicos, O2 y corticoides con mejoría parcial, sin estudios complementarios ni antecedentes claros de atoramiento con cuerpo extraño (CE). Además, se realizó una radiografía de cuello (Rx) que reveló la presencia de imagen en punta de lápiz traqueal y una broncoscopia que comprobó la existencia de un cuerpo extraño puntiagudo (espina de pescado) en la vía aérea superior. Este caso se reportó por su inusual presentación, pues es un CE en la vía aérea superior que se manifestó con estridor crónico, sin mayores complicaciones.

Chest CT findings in patients with dysphagia and aspiration: a systematic review / Achados de TC de tórax em pacientes com disfagia e aspiração pulmonar: uma revisão sistemática

ABSTRACT The objective of this systematic review was to characterize chest CT findings in patients with dysphagia and pulmonary aspiration, identifying the characteristics and the methods used. The studies were selected from among those indexed in the Brazilian Virtual Library of Health, LILACS, Indice Bibliográfico Español de Ciencias de la Salud, Medline, Cochrane Library, SciELO, and PubMed databases. The search was carried out between June and July of 2016. Five articles were included and reviewed, all of them carried out in the last five years, published in English, and coming from different countries. The sample size in the selected studies ranged from 43 to 56 patients, with a predominance of adult and elderly subjects. The tomographic findings in patients with dysphagia-related aspiration were varied, including bronchiectasis, bronchial wall thickening, pulmonary nodules, consolidations, pleural effusion, ground-glass attenuation, atelectasis, septal thickening, fibrosis, and air trapping. Evidence suggests that chest CT findings in patients with aspiration are diverse. In this review, it was not possible to establish a consensus that could characterize a pattern of pulmonary aspiration in patients with dysphagia, further studies of the topic being needed.

RESUMO O objetivo deste estudo foi realizar uma revisão sistemática dos achados de TC de tórax que caracterizem aspiração pulmonar em pacientes com disfagia, identificando as características e os métodos utilizados. Para a seleção dos estudos, foram utilizadas as bases de dados da Biblioteca Virtual em Saúde, LILACS, Indice Bibliográfico Español de Ciencias de la Salud, Medline, Biblioteca Cochrane, SciELO e PubMed. A busca foi realizada no período entre junho e julho de 2016. Foram incluídos e revisados cinco artigos, todos realizados nos últimos cinco anos, publicados em língua inglesa e oriundos de diferentes países. O tamanho da amostra nos estudos selecionados variou de 43 a 56 pacientes, com predominância de sujeitos adultos e idosos. Os achados tomográficos em pacientes com aspiração relacionada à disfagia foram variados, abrangendo bronquiectasias, espessamento da parede brônquica, nódulos pulmonares, consolidações, derrame pleural, atenuação em vidro fosco, atelectasias, espessamento septal, fibrose, aprisionamento aéreo, entre outros. As evidências sugerem que os achados de TC de tórax em pacientes que apresentam aspiração são diversificados. Nesta revisão, não foi possível estabelecer um consenso que pudesse caracterizar um padrão de aspiração pulmonar nos pacientes com disfagia, sendo importantes investigações futuras sobre o assunto.