Excessive Secretions Research Articles

Short-Term Effect of Autogenic Drainage on Ventilation Inhomogeneity in Adult Subjects With Stable Non-Cystic Fibrosis Bronchiectasis.

Lung clearance index (LCI), a measure of ventilation inhomogeneity derived from a multiple-breath washout test, is a promising tool for assessing airway function in patients with non-cystic fibrosis bronchiectasis. However, it is unknown whether ventilation inhomogeneity could improve after successful elimination of excessive secretions within bronchiectasis. The objective of this work was to assess the short-term effects of lung secretion clearance using the autogenic drainage technique on standard lung function tests and LCI in subjects with non-cystic fibrosis bronchiectasis. Nitrogen-based multiple-breath washout, spirometry, and body plethysmography tests were performed 30 min before autogenic drainage in adults with stable non-cystic fibrosis bronchiectasis. The autogenic drainage session was followed by a 5-min break, after which the tests were repeated in the same order. Sputum expectorated during autogenic drainage was quantified as dry weight and correlated with change between post- and pre-measurements (Δ). Paired t test or Wilcoxon signed-rank tests were used to compare pre- and post-autogenic drainage measurement outcomes. A P value of ≤.05 was considered as statistically significant. Twenty-four subjects were studied (18 females, median age [range]: 65 [21-81] y). Mean ± SD LCI significantly improved after autogenic drainage (10.88 ± 2.62 vs 10.53 ± 2.35, P = .042). However, only 20% of subjects with mucus hyperproduction during autogenic drainage had a ΔLCI that exceeded measurement variability. The percent of predicted slow vital capacity (SVC%) also slightly improved (88.7 ± 19.3% vs 90 ± 19.1%, P = .02). ΔLCI was inversely related to dry sputum weight (r = -.48, P = .02) and ΔSVC% (r = -.64, P = .001). ΔSVC% also correlated with dry sputum weight (r = 0.46, P = .02). In adults with non-cystic fibrosis bronchiectasis and mucus hypersecretion, autogenic drainage improved ventilation inhomogeneity. LCI change may be the result of the maximum recruited lung volume and the amount of cleared mucus secretion. (ClinicalTrials.gov registration NCT02411981.).

Airway-Clearance Techniques in Children and Adolescents with Chronic Suppurative Lung Disease and Bronchiectasis.

Common symptoms of chronic suppurative lung disease or bronchiectasis in children and adolescents are chronic cough with sputum production, retention of excess secretions in dilated airways, and a history of recurrent infections. Clinical management includes the prescription of airway-clearance techniques (ACTs) to facilitate mucociliary clearance, optimize sputum expectoration, relieve symptoms, and improve well-being. A wide range of ACTs are available for selection, and these strategies may be applied in isolation or in combination. The choice of technique will depend in part on the age of the child, their clinical state, and factors which may influence treatment adherence. While the evidence base for ACTs in children and adolescent with these conditions is not robust, the current available evidence in addition to clinical expertise provides guidance for technique prescription and clinical effect. An overview of the most commonly applied ACTs, including their physiological rationale and discussion of factors influencing prescription in children and adolescents is outlined in this review.

Placement of tracheobronchial silicone Y-stents: Multicenter experience and systematic review of the literature.

Background:Airway obstruction or tracheoesophageal fistula (TEF) near the tracheal carina requires placement of Y-shaped stents. Herein, we describe our multicenter experience with the placement of Dumon silicone Y-stents. We also conduct a systematic review for studies describing the deployment of airway silicone Y-stents.Methods:This was a retrospective analysis of consecutive subjects who underwent placement of silicone Y-stents. The clinical details including the underlying diagnosis, indication for the placement of silicone Y-stents, success of stent placement, and follow-up are presented. The PubMed and EMBASE databases were also reviewed for studies describing the placement of silicone Y-stents.Results:During the study, 27 silicone Y-stents were placed. The mean (standard deviation) age of the study population (85.2% males) was 57.7 (13.5) years. The stents were placed for airway obstruction in 77.8% and TEF in 29.6% of the patients. The most common underlying disease was carcinoma of the esophagus. The degree of airway obstruction was grade 3–4 in 18 subjects, and respiratory failure was encountered in 18 subjects. The stent was deployed successfully in all the subjects. No deaths were encountered during stent placement. Most subjects had rapid relief of symptoms following the procedure. Excessive secretions and mucostasis were the most common stent-related complications followed by the development of granulation tissue. The systematic review yielded nine studies (338 subjects with airway obstruction and/or TEF). The most common indication for silicone Y-stent placement was tracheobronchial obstruction and TEF due to malignancy. Benign disorders that necessitated stent placement included postintubation tracheal stenosis, airway malacia, and others. The stent was successfully placed in 98% with only one periprocedural death. Granulation tissue formation and mucostasis were the most common stent-related complications.Conclusion:Placement of silicone Y-stent is a safe and effective procedure that provides quick relief of symptoms in subjects presenting with airway obstruction and TEF at or near the tracheal carina.

Transient respiratory distress and difficulty passing a nasogastric tube in a newborn baby.

A baby was born at 30 weeks and 5 days’ gestation, by emergency caesarean section after onset of labour. It was a twin pregnancy, with an antenatal history of polyhydramnios, but no risk factors for sepsis. Polyhydramnios is excess amniotic fluid in the amniotic sac during a pregnancy. The baby was the second twin and weighed 1160 g. On delivery the baby had irregular respirations, low saturations, and excessive secretions necessitating intermittent positive pressure ventilation. Ten minutes after the delivery she was intubated and given surfactant through an endotracheal tube. Soon after, her respiratory effort improved and she was extubated and managed with short term nasal continuous positive airway pressure (CPAP) before stepping down to self ventilation within hours. On examination the baby had a left pre-auricular skin tag, but was not dysmorphic. No limb abnormalities were found. Examination of the abdomen was unremarkable except for a single umbilical artery. Perineal examination showed a urethra and vagina and no patent anus. Three attempts at passing a nasogastric tube were unsuccessful and a radiograph showed it coiling in the upper oesophagus. A Replogle tube—used to suction excess saliva from the oesophagus—was placed before the baby was transferred to a surgical unit. A radiograph of the chest and abdomen was obtained (fig 1). Fig 1 Neonatal chest and abdominal radiograph 1. Describe the findings in the radiograph. 2. Which diagnoses are evident or suspected? 3. What further investigations should be performed and why? 4. How should this baby be managed …

“What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery

“What’s the Risk?” Assessing and Mitigating Risk in Cardiothoracic Surgery

Effect of Cornet Device to Clear the Excess Trachea Bronchial Secretions in a 45 Year Old Right Middle and Lower Lobe Pneumonia Patient- A Case Report

A 45- year old woman diagnosed as right middle and lower lobe pneumonia had been referred for chest physiotherapy to evacuate secretions and to improve oxygenation. The X-ray and Computed tomography findings revealed patchy areas of collapse, consolidation and fibrotic strands in right middle and lower lobes. The physical examination findings also confirmed the signs of consolidation and collapse i.e decreased air entry on right side and presence of crepitations. Chest physiotherapy mainly aimed to clear the excess trachea bronchial secretions in pneumonia. Chest physiotherapy with the help of positive expiratory device –Cornet was given twice daily for ten days. Cornet device uses the principle of positive expiratory pressure which creates an airway oscillation inside the airways. This causes thinning down of mucus and the patient can expectorate the secretions with the help of cough or huff. The X-ray findings showed improvement in right lower lobe and there was no radiological evidence of consolidation and collapse post chest physiotherapy. The patient responded to treatment well and she was discharged successfully. It is concluded that the present case study advocates the use of Cornet device to clear the excess tracheobronchial secretions. Cornet device is easy to use without any supervision and the patient may use at home also.

Ophthalmic atropine for sublingual use: A novel treatment for excessive respiratory secretions

We describe a novel case of utilizing ophthalmic atropine suspension via sublingual route to control excessive secretions in a critically ill patient. In addition, a medication event related to a labeling and administration event is described where the patient received the drug via ophthalmic route. A 32-year-old Hispanic female presenting with NMDA-receptor antibody mediated encephalitis experienced a prolonged intensive care unit (ICU) stay secondary to hypercarbic respiratory failure complicated by excessive respiratory secretions. After one week on mechanical ventilation, the patient was set to undergo a percutaneous endoscopic gastrostomy (PEG) tube placement and tracheotomy. The patient’s respiratory status was compromised by copious secretion production, preventing the patient from being transitioned to the general care floor. For secretion control, pharmacological interventions such as scopolamine transdermal patches and glycopyrrolate oral tablets were trialed, however systemic exposure to these agents resulted in urinary retention requiring catherization with a mild and persistent tachycardia. Ophthalmic atropine was administered sublingually at a dose of 1 mg every six hours to provide local relief of the patient's secretion production. Secretion production improved within 72 hours and the patient’s urinary retention resolved at the time of scopolamine and glycopyrrolate discontinuation. Previously in the literature the use of sublingual atropine was only described for secretion control in patients receiving end of life care, drug induced sialorrhea and neuro-developmental disorders. As observed in this case report, sublingual atropine may be an effective treatment to control respiratory secretions in critically ill patients who are unable to tolerate other therapies.

Adrenal Cortical Tumor with Rare Presentation of Psychosis

Adrenal cortical tumors are rare tumors and the common presenting symptoms are related with excessive glucocorticoids secretions leading to cushinoid features and systemic manifestations of the excess steroids hormonal secretions We are presenting a case of Adrenal cortical tumor presenting as primarily psychosis nbsp hence Adrenal cortical tumor should always be considered in the differential diagnosis of evaluation of psychosis

Flexible Bronchoscopy Is Safe and Effective in Adult Subjects Supported With Extracorporeal Membrane Oxygenation.

Previous studies have demonstrated the safety of flexible bronchoscopy (FB) in mechanically ventilated subjects. However, the safety of FB in adult subjects receiving extracorporeal membrane oxygenation (ECMO) has not been described previously. A retrospective review was conducted of all adult subjects who underwent FB while receiving ECMO support at the University of Alabama at Birmingham Hospital from January 1, 2013, to December 31, 2014. Physiologic variables, pre- and post-FB ECMO, and ventilator settings were recorded. 79 adult subjects underwent FB receiving ECMO with a total of 223 bronchoscopies. The most common indications for bronchoscopy included diagnostic evaluation of infection in subjects with pneumonia (29%) and clearance of excessive secretions (22%). In 70% of subjects, moderate or greater amounts of secretions were noted. FB yielded positive culture data in 37 subjects (47%), which resulted in a change to the antibiotic regimen in 14 subjects (38%) with positive culture data. No significant differences in mean PaO2 /FIO2 , mean ECMO flow, mean sweep gas, ventilator settings, or hemodynamic parameters (heart rate, oxygen saturation, and mean blood pressure) were noted before and after FB. Complications were mild and transient: blood-tinged secretions after FB in 21% cases, which resolved spontaneously, intraprocedural hypoxemia in 2.2% of cases, and dysrhythmia in <1% of cases. There were no episodes of ECMO cannula dislodgement or inadvertent extubation. FB can be used safely in adult subjects supported with ECMO and is not associated with significant hemodynamics changes, bleeding, or mechanical complications during ECMO support.

Increased expression of immune modulator proteins and decreased expression of apolipoprotein A-1 and haptoglobin in blood plasma of sarin exposed rats

Sarin is a highly toxic organophosphonate and neural enzyme acetylcholinesterase (AChE) inhibitor. Inhibition of AChE causes large accumulation of acetylcholine at synaptic cleft leading to hyper activation of nicotinic and muscarinic acetylcholine receptors, causing excessive secretions, muscle fasciculation, nausea, vomiting, respiratory distress and neurological effects. There are cases in which long term psychomotor function deficiency, reduced learning and memory functions have been observed several years after exposure of sarin among survivors. This phenomenon is called Organophosphorus ester Induced Chronic Neurotoxicity (OPICN) and cannot be explained by AChE inhibition alone. Plasma proteomics at earlier stages was carried out to study changes reflected at blood level that can help predict possible neurological insults at an early time point to take proper therapeutic interventions against OPICN.In the present study, a 0.5 LD50 dose of sarin was administered to Wistar rats and possible changes in blood plasma proteomic profile were investigated after one and seven days of sarin exposure. Proteins were separated on 2-dimensional gel electrophoresis and identified by MALDI-TOF/MS. Expression profile of major proteins was validated by Western blot. Result showed that after exposure of sarin inhibition of AChE persisted after one week of exposure. There were 14 plasma proteins that showed significant changes in expression (>1.5-fold). It included proteins related to immune function, neurodegenerative condition and chaperone function. Interestingly sarin exposure caused decreased expression of plasma Apolipoprotein A-1 and Haptoglobin on day seven, which are the putative early molecular markers for cognitive impairment and neurodegenerative changes.

Recurrent atelectasis in a preterm neonate

Excessive or thick pulmonary secretions obstructing the small airways are a common problem in neonatal population. Pulmonary collapse may occur secondary to mucus plug. Recombinant - DNase is thought to improve atelectasis by decreasing viscosity and assisting mucociliary clearance in cases of pulmonary collapse. Inhaled hypertonic saline is tried as an alternative. Here we report a case of respiratory distress syndrome with collapse of entire left lower lobe which is very rare and it responded significantly to hypertonic saline nebulisation along with chest physiotherapy and regular suctioning. Atelectasis is common in post extubated neonates but in our case it developed in pre intubation period. Here we highlight the fact that nebulized hypertonic saline can be an effective alternative to recombinant DNase in resource limited settings like in India.

Effect of Manual Hyperinflation on Arterial Oxygenation in Paediatric Patients with Upper Lobe Collapse after Cardiac Surgery

Lung hyperinflation is a technique used by physiotherapists to mobilize and remove excess bronchial secretions, reinflate areas of pulmonary collapse and improve oxygenation. To assess the efficacy of manual hyperinflation in improving arterial oxygenation (PaO2) of paediatric patients with upper lobe lung collapse after cardiac surgery. 18 paediatric patients who had undergone heart surgery and having upper lobe collapse in the post-op ventilation period underwent Manual Hyperinflation (MH). Parameters in cluded arterial oxygen tension (PaO2) value in ABG analysis, clinical findings such as collapsed upper lung lobe in chest radiograph and air entry in auscultation were collected before and 30 min post MH session and documented. The patients were treated with manual hyperinflation delivered using a pediatric AMBU bag with pressure of about 40 cm H 2O. Four sets of eight bag compressions with inflation rate of 10 breaths per minute were delivered during each manual hyperinflation. The result showed that there was a significant improvement in arterial oxygenation (PaO 2) by administering manual hyperinflation therapy for the upper lobe col lapse in post-op ventilated paediatric patients. In this study, it is evident that manual hyperinflation is an effective technique in management of Lung collapse (upper lobe) in post-op pediatric patients. This clearly demonstrates that further research in this area is warranted.

Incidence of Postoperative Vomiting and Laryngospasm in Pediatric Anesthesia Using Two Methods: Controlled Ventilation and Spontaneous Respiration

Background: Laryngospasm and postoperative vomiting are serious complications after surgery involving pediatric anesthesia, and these complications may cause morbidity. Objectives: The objective of this study was to compare the incidences of laryngospasm and vomiting between two groups of children treated with anesthesia. The patients were managed by either controlled ventilation or spontaneous respiration. Patients and Methods: This prospective clinical study was conducted with 200 children who had underwent elective infraumbilical surgery. The patients were divided to two groups of one-hundred cases, including the control ventilation (CV) and spontaneous respiration (SR) groups. Anesthesia induction and maintenance were the same in all patients. However, in the CV group, atracurium was used as a muscle relaxant to facilitate intubation and surgery. Results: The incidences of postoperative vomiting, laryngospasm, and excessive secretions were significantly higher in the CV group than the SR group (P = 0.001, 0.02 and 0.001, respectively). Conclusions: This study demonstrated that the incidences of postoperative vomiting and laryngospasm are significantly higher in patients receiving anesthesia with muscle relaxants and controlled ventilation.

CF combination therapy offers new hope

Cystic fibrosis (CF) is one of the most common life-limiting, autosomal-recessive genetic diseases, resulting in deficient or dysfunctionalcystic fibrosis transmembrane conductance regulator (CFTR)protein. Dysfunctions of the CFTR protein result in excess secretions inthe lungs, which lead to chronic airway infections, loss of lung function,and eventually respiratory failure. The F508del is the most commonCFTR mutation, with approximately 45%–50% of patients with CFbeing homozygous for this allele. The median survival among patientswho are homozygous for the F508del CFTR mutation is only 37 years.

Octreotide for Malignant Bowel Obstruction: Commentary on Currow et al

In the study of patients with malignant bowel obstruction (MBO) by Currow et al. in this issue, octreotide failed to significantly reduce vomiting during 72 hours of treatment, in comparison with placebo, although a multivariate analysis did find significantly reduced episodes of vomiting in the octreotide group. This study was rigorously designed and adequately powered, and suggests both the need for more research and for increased recognition of other interventions that may be useful in this condition, such as ranitidine. The results should not be taken to negate 20 years of generally positive experience, however. This experience suggests that octreotide can reduce excessive secretions and vomiting, and when combined with a corticosteroid, sometimes resolves the MBO. Additional wellcontrolled studies are needed, and the methodology used should be informed by the results of the present study and both pathophysiologic and clinical perspectives. For example, an immediate effect of octreotide on gastrointestinal secretions, and vomiting as a result

Ablation of tumor necrosis factor is associated with decreased inflammation and alterations of the microbiota in a mouse model of inflammatory bowel disease.

Inflammatory bowel disease (IBD) is associated with prolonged, excess secretions of Tumor Necrosis Factor (TNF). Many patients with IBD have successful management of IBD symptoms by blocking TNF secretion or signaling. However, some patients are non-responsive to this therapy, eventually become refractory to therapy, or Alterations in the microbiota that are associated with the lack of TNF could be a contributing cause of this therapeutic insufficiency seen in some patients. Here we use wildtype (WT) and mice lacking Tnf (Tnf -/-) in an acute TNBS colitis model to investigate the role of TNF in colitis and how its presence or absence affects the colonic microbiota. As expected, Tnf -/- had less severe inflammation than WT mice. Microbiome analysis revealed significant Tnf dependent-differences in alpha and beta diversity. There were also notable differences in many species that were also primarily Tnf dependent. Taken together, our data indicates that TNF contributes significantly to the inflammation and microbiotal alterations in that occur in IBD.

Exploring carer perceptions of training in out-of-hospital use of buccal midazolam for emergency management of seizures (2008-2012).

This study aims to explore carer perceptions of training in out-of-hospital use of buccal midazolam for emergency management of seizures. A random sample of 100 families (from n = 198) who underwent training at the Sydney Children's Hospitals Network, Randwick campus (2008-2012) were invited to participate in a telephone questionnaire. Sixty-three carers participated. Thirty-three children were female, median age at training was 4 years and seizure onset 2.75 years. Seizures were generalised in 26 children and focal in 37. Common reasons for prescription included history of prolonged seizures (38%), recent diagnosis of epilepsy (33%) and overseas travel (11%). Ninety-eight per cent of carers reported that training instructions were clear, and 94% reported the risks of using benzodiazepines were satisfactorily explained. Ninety per cent felt confident to administer the drug following training and 62% completed first aid training as recommended. Suggestions for improvement included follow-up/review and additional demonstration/practice. Twenty-one carers (33%) reported giving buccal midazolam a median five times, 67% reported it was effective in terminating the seizure and 71% called an ambulance as instructed. Problems reported in administration included excessive secretions and difficulties drawing up the solution. One child experienced breathing difficulties requiring oxygen by the paramedics. Four children were admitted to children's intensive care unit with status epilepticus requiring intubation. Training for out-of-hospital use of buccal midazolam was considered valuable by carers. Only a third of the sample subsequently used midazolam. Half of these carers reported problems in administration and one reported respiratory difficulty. These results highlight the importance of drug safety and efficacious training programmes.

Thoracic sympathectomy for peripheral vascular disease can lead to severe bronchospasm and excessive bronchial secretions.

A 57-year-old male patient suffering from Buerger's disease presented with pre-gangrenous changes in right foot and ischemic symptoms in right hand. Computed tomographic angiography revealed diffuse distal disease not suitable for vascular bypass and angioplasty. Right lumbar sympathectomy was done using a retroperitoneal approach followed 1 year later by right thoracic sympathectomy using a transaxillary approach. Postoperatively, the patient had severe bronchospasm and excessive secretions in the respiratory tract resistant to theophylline and sympathomimetic group of drugs and without any clinical, laboratory and radiological evidence of infection. The patient was started on anticholinergics in anticipation that sympathectomy might have lead to unopposed cholinergic activity and the symptoms improved rapidly. The patient recovered well and was discharged on 10th post-operative day.

The cannabinoid receptor antagonist AM251 increases paraoxon and chlorpyrifos oxon toxicity in rats

Organophosphorus anticholinesterases (OPs) elicit acute toxicity by inhibiting acetylcholinesterase (AChE), leading to acetylcholine accumulation and overstimulation of cholinergic receptors. Endocannabinoids (eCBs, e.g., arachidonoyl ethanolamide [AEA] and 2-arachidonoyl glycerol [2-AG]) are neuromodulators that regulate neurotransmission by reducing neurotransmitter release. The eCBs are degraded by the enzymes fatty acid amide hydrolase (FAAH, primarily involved in hydrolysis of AEA) and monoacylglycerol lipase (MAGL, primarily responsible for metabolism of 2-AG). We previously reported that the cannabinoid receptor agonist WIN 55,212-2 reduced cholinergic toxicity after paraoxon exposure. This study compared the effects of the cannabinoid receptor antagonist AM251 on acute toxicity following either paraoxon (PO) or chlorpyrifos oxon (CPO). CPO was more potent in vitro than PO at inhibiting AChE (≈2 fold), FAAH (≈8 fold), and MAGL (≈19 fold). Rats were treated with vehicle, PO (0.3 and 0.6mg/kg, sc) or CPO (6 and 12mg/kg, sc) and subsets treated with AM251 (3mg/kg, ip; 30min after OP). Signs of toxicity were recorded for 4h and rats were then sacrificed. OP-treated rats showed dose-related involuntary movements, with AM251 increasing signs of toxicity with the lower dosages. PO and CPO elicited excessive secretions, but AM251 had no apparent effect with either OP. Lethality was increased by AM251 with the higher dosage of PO, but no lethality was noted with either dosage of CPO, with or without AM251. Both OPs caused extensive inhibition of hippocampal AChE and FAAH (>80–90%), but only CPO inhibited MAGL (37–50%). These results provide further evidence that eCB signaling can influence acute OP toxicity. The selective in vivo inhibition of MAGL by CPO may be important in the differential lethality noted between PO and CPO with AM251 co-administration.

Factors affecting postoperative respiratory tract function in type-C esophageal atresia. Thoracoscopic versus open repair.

We assessed the outcome of 72 cases of type-C esophageal atresia (EAc) treated by open (OR) or thoracoscopic (TR) repair from 2000 to 2013. During OR, direct lung retraction (DLR) is required but during TR, CO2 insufflation causes lung collapse so DLR is unnecessary. Patient demographics, operative time, respiratory tract impact (RTI: incidence of atelectasis, timing of extubation, need for reintubation, and duration of chest tube insertion), narcotic usage, commencement of oral feeding, and length of hospitalization (LOH) were compared. Seven long-gap cases were excluded, leaving 65 EAc subjects (TR = 25, OR = 40). Patient demographics, operative time, and duration of chest tube insertion were similar. No TR case required DLR. Significant differences were found in TR for narcotic usage (1.6 vs. 3.1 days), commencement of feeding (7.8 vs. 10.5 days), incidence of atelectasis (8 vs. 30 %), initial extubation (2.8 vs. 5.6 days), and LOH (33 vs. 46 days), (all p < 0.05, respectively). Postoperative tracheal tube blockage caused by excessive secretions (4 vs. 10 %) and reintubation (4 vs. 17.5 %) were less in TR but not significant. There were three anastomotic leakages in TR, one in OR. TR is less traumatic than OR because DLR is unnecessary, resulting in lower RTI and smooth recovery.