Cardiac arrest after pulmonary aspiration in hospitalised patients: a national observational study.

OBJECTIVE: To study characteristics and outcomes among patients with in-hospital cardiac arrest (IHCA) due to pulmonary aspiration. DESIGN: A retrospective observational study based on data from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR). SETTING: The SRCR is a nationwide quality registry that covers 96% of all Swedish hospitals. Participating hospitals vary in size from secondary hospitals to university hospitals. PARTICIPANTS: The study included patients registered in the SRCR in the period 2008 to 2017. We compared patients with IHCA caused by pulmonary aspiration (n=127), to those with IHCA caused by respiratory failure of other causes (n=2197). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was 30-day survival. Secondary outcome was sustained return of spontaneous circulation (ROSC) defined as ROSC at the scene and admitted alive to the intensive care unit. RESULTS: In the aspiration group 80% of IHCA occurred on general wards, as compared with 63.6% in the respiratory failure group (p<0.001). Patients in the aspiration group were less likely to be monitored at the time of the arrest (18.5% vs 38%, p<0.001) and had a significantly lower rate of sustained ROSC (36.5% vs 51.6%, p=0.001). The unadjusted 30-day survival rate compared with the respiratory failure group was 7.9% versus 18.0%, p=0.024. In a propensity score analysis (including variables; year, age, gender, location of arrest, initial heart rhythm, ECG monitoring, witnessed collapse and a previous medical history of; cancer, myocardial infarction or heart failure) the OR for 30-day survival was 0.46 (95% CI 0.19 to 0.94). CONCLUSIONS: In-hospital cardiac arrest preceded by pulmonary aspiration occurred more often on general wards among unmonitored patients. These patients had a lower 30-day survival rate compared with IHCA caused by respiratory failure of other causes.

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.

Preventing Aspiration Complications: Implementing a Swallow Screening Tool.

AIMS: The aim of this study was to decrease the number of patients with acquired aspiration mortality. DESIGN: This was an evaluation research study. Data were collected on acutely ill hospitalized patients from January 2013 to December 2017. METHODS: In 2016, a 1100-bed Midwestern quaternary care facility found an increasing trend in mortality rates of patients with acquired aspiration from 2013 to 2015. A need for improved detection of patients at risk of aspiration was identified. A multidisciplinary team analyzed this need and developed a screening process found on the American College of Chest Physicians practice guidelines and the Massey Bedside Swallowing Screen to reduce these rates. Nurses implemented the aspiration risk screening process on all hospitalized patients. Data were collected through nursing responses and chart reviews. RESULTS: Initial implementation of the aspiration risk screening process yielded procedural concerns that were ameliorated through increased education and refinement of the screen. After refinement and reimplementation, mortality data from 2016 to 2017 revealed a decrease to zero aspiration-related events. CONCLUSION: Our findings suggest implementation of a nursing-led aspiration risk screening process with acutely ill patients is a factor in decreasing patient mortality from acquired aspiration. These clinical practice changes of identifying patients at risk of aspirating and involving dysphagia therapists prior to oral intake increase patient safety while decreasing acquired aspiration mortality. IMPACT: This study addressed upward trends in patient mortality with acquired aspiration. Mortality rates declined after implementation of the aspiration risk screening process on hospitalized patients. These findings have potential to impact healthcare personnel and all acutely ill hospitalized patients.

Vomiting and aspiration of gastric contents: a possible life-threatening combination in underwater diving.

Vomiting and aspiration of gastric contents into the airways and lungs is a common and well-known clinicopathological entity. This phenomenon might also occur in underwater diving, where it can lead to life-threatening or fatal situations. This article presents two incidents involving diving-related vomiting with associated aspiration of gastric contents. One case, a 39-year-old commercial diver using a full-face diving mask, was fatal and the other was a 33-year-old, female recreational scuba diver in whom underwater vomiting was complicated by pulmonary aspiration of a solid foreign body (a peanut) into the right lower lobe bronchus. The peanut was successfully removed and, following bronchoscopic pulmonary lavage, the patient made an uneventful recovery. The causes and consequences of nausea and vomiting within the underwater environment are discussed and possible interpretative problems are highlighted.

The mortality risk factor of community acquired pneumonia patients with chronic obstructive pulmonary disease: a retrospective cohort study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is one of the most common comorbidities in community acquired pneumonia (CAP) patients. We aimed to investigate the characteristics and mortality risk factors of COPD patients hospitalized with CAP. METHODS: A retrospective cohort study was conducted at Shanghai Pulmonary Hospital and Shanghai Dahua Hospital. Clinical and demographic data in patients diagnosed with CAP were collected between January 2015 and June 2016. Logistic regression analysis was performed to screen mortality risk factors of COPD patients hospitalized with CAP. RESULTS: Of the total 520 CAP patients, 230 (44.2%) patients had been diagnosed comorbid with COPD (COPD-CAP). CAP patients comorbid with COPD patients had higher rate of need for ICU admission (18.3% vs 13.1%) and need for NIMV (26.1% vs 1.4%) than without COPD (nCOPD-CAP). The PSI, CURB-65 and APACHE-II scores in COPD-CAP patients were higher than that in nCOPD-CAP patients (95 vs 79, P < 0.001; 1 vs 1, P < 0.001; 13 vs 8, P < 0.001, respectively). Logistic regression analysis indicated that aspiration, D-dimer > 2.0 µg/mL and CURB-65 ≥ 3 were risk factors associated with in-hospital mortality ((odd ratio) OR = 5.678, OR = 4.268, OR = 20.764, respectively) in COPD-CAP patients. The risk factors associated with 60-day mortality in COPD-CAP patients were comorbid with coronary heart disease, aspiration, need for NIMV (non-invasive mechanical ventilation) and CURB-65 ≥ 3 (OR = 5.206, OR = 7.921, OR = 3.974, OR = 18.002, respectively). CONCLUSIONS: COPD patients hospitalized with CAP had higher rate of need for NIMV, need for ICU admission and severity scores than those without COPD. Aspiration, D-dimer > 2.0 µg/mL, comorbid with coronary heart disease, need for NIMV and CURB-65 ≥ 3 were mortality risk factors in CAP patients comorbid with COPD.

Evaluation of the natural history of patients who aspirate.

OBJECTIVES/HYPOTHESIS: The natural clinical progression of aspiration to eventual pulmonary compromise is not well understood. We hypothesized that dietary modification recommendations, Penetration-Aspiration Scale (PAS) score, and dysphagia etiology would be associated with changes in time to first pulmonary event and overall survival for patients with documented aspiration on radiologic testing. This study identified a cohort of patients with detectable unsensed penetration or aspiration on videofluoroscopic swallowing study (VFSS), and followed this cohort over time for development of pulmonary events and death. We then evaluated the association of aspiration severity and dietary modification recommendations on incidence of these endpoints. STUDY DESIGN: Retrospective chart review. METHODS: A total of 2,616 VFSS exam reports were reviewed from our institution performed between January 1, 2009 and December 31, 2010. Aspiration or unsensed penetration (PAS of 5 or greater) was detected in 564 (21.5%) of these patients, who were then included in the study cohort. Medical records were reviewed retrospectively for development of pulmonary events (pneumonia, pneumonitis, or other life-threatening pulmonary illness) and all-cause mortality for up to 54 months after initial VFSS. Univariate Kaplan-Meier analysis and multivariate Cox regression were performed for time to first pulmonary event and survival predicted by recommended diet, PAS score, and dysphagia etiology. RESULTS: Dysphagia etiology was highly associated with increased development of pulmonary events for some patients, especially those with generalized nonspecific dysphagia due to deconditioning or frailty (hazard ratio [HZ] vs. stroke 2.95, 95% confidence interval [CI]: 1.53-5.69, P = .001) and esophageal dysphagia (HZ: 2.66, 95% CI: 1.17-6.02, P = .019). Dysphagia etiology was also associated with increased mortality for patients with generalized nonspecific dysphagia due to deconditioning or frailty (HZ: 3.32, 95% CI: 2.0-5.52, P < .001), postsurgical patients (HZ: 1.73, 95% CI: 1.05-2.86, P = .032), and chronic neurologic disease (HZ: 1.87, 95% CI: 1.12-3.13, P = .017). Dietary modification recommendations at the time of VFSS (prohibition of oral intake or modification of food consistency) had no significant impact on time to first pulmonary event (P = .37) or survival (P = .17), whereas PAS score was associated with decreased time to first pulmonary event on univariate but not multivariate analysis (HZ for 1-point increase: 1.6, 95% CI: 0.99-1.36, P = .067). Kaplan-Meier estimate of overall 3-year mortality for this patient cohort was 39%. CONCLUSIONS: Etiology of dysphagia is associated with a higher mortality rate and development of pulmonary events in patients with unsensed penetration or aspiration on VFSS, especially for those patients with generalized deconditioning and frailty or esophageal dysphagia. Severity of aspiration as defined by PAS was not associated with altered overall survival. Recommendations for dietary modification to a nothing by mouth status or modified food consistency had no statistically significant association with development of pulmonary events or survival in patients with detectable unsensed penetration or aspiration on VFSS compared to full-diet recommendation. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:S1-S10, 2017.

Injury patterns and features of cycling fatalities in South Australia.

There has been an increase in cycling in Australia. This means that more cyclists are at risk of injuries, which account for a proportion of transport-related fatalities. In this study, all cyclist fatalities from 2002 to 2013 in South Australia where post-mortem examinations were performed were investigated. There were 42 deaths representing 3% of the total road fatalities over the same time. Of this total number of cases, 13 deaths (31%) involved collapse (mostly natural causes from an underlying medical condition) and 29 (69%) resulted from trauma. There were no cases of hyperthermia. Of the decedents 95% were male, and the mean age at death was 47 years. Fatal incidents were more likely to occur during April and November, and on a Monday. However, statistical analysis was not possible due to the small number of cases. Fatalities (traumatic and collapse) predominantly occurred whilst the cyclist was riding (86%). The majority of riding fatalities were as a result of collision with vehicles (81%). Drugs (including alcohol) were detected in two (15%) of the 13 cases of the collapses, and in seven (26%) of the 27 trauma cases tested. In trauma cases, death was most often due to multiple injuries. The most frequent area for injury was the head (found in 90% of traumatic deaths). Despite the increasing numbers of cyclists on South Australian roads over the last decade, death rates have trended downwards suggesting that road safety campaigns and the provision of more dedicated bicycle lanes have had a positive outcome.

[Aspiration in a specialised weaning unit--an underestimated problem]. / Aspiration auf der Weaningstation--ein unterschätztes Problem.

This retrospective case series shows that 45 % of patients aspirated straight after removal of the tracheal cannula. The present case series includes 82 patients with long-term mechanical ventilation (LTMV) admitted to a specialised weaning unit. Aspiration was proven after patients sipped water coloured with patent blue V. Colour was detected with a bronchoscope after passing through the tracheostoma and directed toward the VC. The aspiration rate in this study is in good agreement with other reports in the literature.We could find no significant statistical differences concerning age (p = 0.97), gender (47 % vs. 49), number of bronchoscopies (p = 0.91) and comorbidities (p = 0.326) between patients with and without aspiration. The duration of the stay at the ward and the duration of ventilation as well as the parameter Hb at the time of admission (p = 0.566), CO2(p = 0.288/p = 0.716), HCO3 (p = 0.915/p = 0.612) and CRP (p = 0.402/p = 0.523) at the time of admission and discharge also showed no significant differences.The Kaplan Meier curves show a considerable divergence between patients with and without aspiration. However, the Log Rank Test (p = 0.348) and the univariate Cox Regression (HR 1.4, 95 % CI 0.689 - 2.849) were not significant. We believe that this can be attributed to the event rate, which was too low in our collective. This trend to a higher mortality of patients with aspiration might be due to weakness of the respiratory muscles when there is reduced coughing. Proof of aspiration in these patients is only one aspect of a multidimensional problem. Larger, prospective cohort studies are needed to show whether aspiration can serve as a prognostic marker.

Aspiration-related deaths in 57 consecutive patients: autopsy study.

BACKGROUND: Aspiration can cause a diverse spectrum of pulmonary disorders some of which can lead to death but can be difficult to diagnose. PATIENTS AND METHODS: The medical records and autopsy findings of 57 consecutive patients in whom aspiration was the immediate cause of death at Mayo Clinic (Rochester, MN, USA) over a 9-yr period, from January 1 2004 to December 31 2012 were analyzed. RESULTS: The median age at death was 72 years (range, 13-95 years) and included 39 (68%) males. The most common symptom before death was dyspnea (63%) and chest radiography revealed bilateral infiltrates in the majority (81%). Most common precipitating factors for aspiration were depressed consciousness (46%) and dysphagia (44%). Aspiration-related syndromes leading to death were aspiration pneumonia in 26 (46%), aspiration pneumonitis in 25 (44%), and large airway obstruction in 6 patients (11%). Aspiration was clinically unsuspected in 19 (33%) patients. Antimicrobial therapy had been empirically administered to most patients (90%) with aspiration pneumonia and aspiration pneumonitis. CONCLUSION: We conclude aspiration-related deaths occur most commonly in the elderly with identifiable risks and presenting bilateral pulmonary infiltrates. One-third of these aspiration-related pulmonary syndromes were clinically unsuspected at the time of death.

Bronchoalveolar lavage pepsin in acute exacerbation of idiopathic pulmonary fibrosis.

Some patients with idiopathic pulmonary fibrosis experience acute exacerbations in their respiratory status leading to substantial morbidity and mortality. Occult aspiration of gastric contents has been proposed as one possible mechanism leading to these acute exacerbations. We sought to determine whether pepsin, a marker of gastric aspiration, is elevated in bronchoalveolar lavage fluid obtained from patients during acute exacerbation of idiopathic pulmonary fibrosis, compared with that obtained in stable disease. Lavage samples were obtained in a case-control study of well-characterised patients. Acute exacerbation was defined using standard criteria. Levels of lavage pepsin were compared in cases and controls, and were correlated with clinical features and disease course. 24 cases with acute exacerbations and 30 stable controls were identified. There were no significant differences in baseline demographics between the two groups. Pepsin level was an indicator of acute exacerbation status (p=0.04). On average, pepsin appeared higher in patients with acute exacerbations compared with stable controls. This difference was driven by a subgroup of eight patients (33%) with pepsin levels ≥70 ng·mL(-1). Pepsin level was not an independent predictor of survival time. These results suggest occult aspiration may play a role in some cases of acute exacerbation of idiopathic pulmonary fibrosis.

[Fatal aspiration following polydipsia in schizophrenia]. / Polydipsie bei paranoider schizophrenie mit tödlichem ausgang.

OBJECTIVE AND METHODS: Polydipsia with hyponatraemia commonly occurs with chronic psychosis and is associated with a reduced life expectancy for individuals diagnosed with schizophrenia. We describe a 51 years old man who presented with polydipsia during a relapse of paranoid schizophrenia. While treated with Clozapine, and despite regular observation and daily control of creatinine and electrolytes, the man suddenly collapsed and died after drinking huge amounts of water. No sedation from psychotropic medication or drugs and alcohol was present in this case. Sodium levels on the day of death and the day before were within normal range. A post-mortem revealed aspiration of water and gastric content as the cause of asphyxiation and death. A literature search in Medline and Embase did not yield a description of a similar case. RESULTS AND CONCLUSIONS: This case highlights the risk of aspiration associated with polydipsia in chronic schizophrenia. Daily control of electrolytes to identify hyponatremia and regular observation are recommended but may not be sufficient to prevent sudden death from drinking huge amounts of water.

Mortality related to anaesthesia in France: analysis of deaths related to airway complications.

Death certificates from the French national mortality database for the calendar year 1999 were reviewed to analyse cases in which airway complications had contributed to peri-operative death. Respiratory deaths (and comas) found in a previous national 1978-82 French survey (1:7960; 95% CI 1:12,700 to 1:5400) were compared with the death rate found in the present one: 1:48,200 (95% CI 1:140,000 to 1:27,500). In 1999, deaths associated with failure of the breathing circuit and equipment were no longer encountered and no death was found to be related to undetected hypoxia in the recovery unit. Deaths related to difficult intubation also occurred at a lower rate than in the previous report (1:46,000; 95% CI 1:386,000 to 1:13,000) in 1978-82 vs 1:176,000 (95% CI 1:714,000 to 1:46,000) in 1999, a fourfold reduction. In most cases, there were both inadequate practice and systems failure (inappropriate communication between staff, inadequate supervision, poor organisation). This large French survey shows that deaths associated with respiratory complications during anaesthesia have been strikingly reduced during this 15-year period.

[Survey of anaesthesia-related mortality in France: the role of aspiration of gastric contents]. / Enquête mortalité Sfar-Inserm: analyse secondaire des décès par inhalation de liquide gastrique.

Aspiration of gastric contents is a major complication in relation with the practice of anaesthesia. The present article is aimed at describing detailed data related to aspiration which were obtained during the French national survey on anaesthesia-related mortality conducted by both Sfar and CépiDC-Inserm. Information regarding methods of the survey and the main results has been previously published. In brief, the first part of the survey described the number and characteristics of anaesthetic procedures performed in 1996 (denominator). The second survey analysed deaths related to anaesthesia which were identified from death certificates of the calendar year 1999. Because of the numerical importance of aspiration among the causes of deaths, a secondary analysis was undertaken to assess into details factors leading to the occurrence of this complication. Eighty-three cases of death were found related to aspiration, i.e. one-fifth of deaths related completely or partially to anaesthesia, implying a death rate of one for 221,368 general anaesthetic procedures or 4.5 x 10(-6) (95% IC: 0.8 x 10(-6)-14 x 10(-6)). Patients involved were all in a severe clinical condition (ASA> or =3: 92%), very old and often scheduled for urgent abdominal surgery. Two cases of death occurred during colonoscopy but none in obstetric patients. Aspiration almost always occurred during induction of anaesthesia. Analysis of practice patterns disclosed significant deviations from recommendations. French anaesthetists should voluntarily move through a personal and active process toward an improvement of their practice to reduce the incidence of aspiration.

Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting.

BACKGROUND: Cricoid pressure is a routine part of rapid-sequence induction of general anaesthesia in obstetrics, but its efficacy in saving life is difficult to ascertain. METHODS: As part of a prospective observational study of caesarean sections performed between January 1998 and June 2000 in 27 hospitals in Malawi, the anaesthetist recorded whether cricoid pressure was applied, the method of anaesthesia, the use of endotracheal intubation, the occurrence and timing of regurgitation and any other pre- or intra-operative complications. Logistic regression was used to assess the effect of cricoid pressure, type of anaesthetic and pre-operative complications on vomiting/regurgitation and death. RESULTS: Data were collected for 4891 general anaesthetics that involved intubation. Cricoid pressure was applied in 61%; 139 women vomited or regurgitated, but only 30 on induction of anaesthesia, in 24 of whom cricoid pressure was applied. There were 77 deaths, 11 of which were associated with regurgitation, in 10 of which regurgitation contributed to the death. Nine of the 11 mothers had cricoid pressure applied. Only one died on the table, the rest postoperatively. All those who died had preoperative complications. CONCLUSION: This study does not provide any evidence for a protective effect of cricoid pressure as used in this context, in preventing regurgitation or death. Preoperative gastric emptying may be a more effective measure to prevent aspiration of gastric contents.

Lethal outcome of post-tonsillectomy hemorrhage.

Despite the large number of tonsillectomies performed little knowledge exists about post-tonsillectomy hemorrhage (PTH) with lethal outcome. This study was performed to evaluate clinical features in a larger patient population with emphasis on the onset of this complication. A nationwide collection of cases was performed based on personal communication, expert reports to lawsuits and professional boards, and case reports received after a plea published in a professional national journal. Clinical data of 29 patients were collected of whom the 18 were children (64%). With one exception all patients experienced secondary PTH (>24 h) occurring 1-28 days after tonsillectomy. Aspiration contributed to lethal outcome in 13 cases. Fatalities were unavoidable although 21 patients were in the hospital. Massive vomiting of blood was observed in 11 patients. There were 11 patients without (group A) and 18 with (group B) episodes of repeated bleeding. This study suggests that particularly children are endangered by lethal PTH. Inpatient treatment was unable to prevent lethal outcome in this selected patient population. However, it appears wise to re-admit patients with delayed PTH, since excessive PTH may occur. These unexpected and unpredictable situations require an immediate and adequate medical treatment by a skilled staff. The paucity of data currently does not allow calculation of a cut-off point at which the risk of life-threatening PTH significantly decreases. Secondary PTH remains a substantial complication.

Pediatric coin ingestion and aspiration.

OBJECTIVE: To determine the relationship between physical characteristics of the coin (size), age of the victim, the amount of coins in circulation, and the frequency and outcome of pediatric coin ingestion and aspiration injuries. METHODS: Records of coin related ingestion and aspiration injuries occurring to children 14 years of age or younger were acquired from the US Consumer Product Safety Commission (CPSC). Logistic regression was conducted to control for mutual confounding among variables. RESULTS: From 1994 to 2003, an estimated 252,338 children were treated in hospital emergency departments for non-fatal coin-related ingestion or aspiration, and additional 20 fatalities were reported during the same time span. Children 4 years of age or younger were at the highest risk. It is also observed that younger children are the most vulnerable victims of ingestion and/or aspiration of small coins (e.g., pennies), while older children are more likely to be treated due to ingestion and/or aspiration of larger coins (e.g., quarters). Pennies were involved in more incidents than all other coins combined. The hospitalization rate exhibited a negative correlation with the measure of the diameter and the weight of the coins. The overwhelming majority (94%) of the incidents were ingestion, whereas aspiration victims were more likely to encounter hospitalization. CONCLUSIONS: We hope that this study will raise public and health practitioners' awareness of the risk, and increase supervision, particular of the most vulnerable young children.