High Risk Of Aspiration Research Articles

Increased cortical-medulla functional connectivity is correlated with swallowing in dysphagia patients with subacute infratentorial stroke

Patients with infratentorial stroke (IS) exhibit more severe dysphagia and a higher risk of aspiration than patients with supratentorial stroke. Nevertheless, a large proportion of patients with IS regain swallowing function within 6 months; however, the neural mechanism for this recovery remains unclear. We aimed to investigate possible neuroplastic changes involved using functional magnetic resonance imaging (fMRI) and their relation to swallowing function. We assessed 21 patients with IS (mean age: 59.9 ± 11.1 years) exhibiting dysphagia in the subacute phase and 21 healthy controls (mean age: 57.1 ± 7.8 years). Patient evaluations were based on the functional oral intake scale (FOIS), videofluoroscopic swallow study (VFSS), and fMRI. Temporal swallowing measures and the penetration-aspiration scale (PAS) were obtained using VFSS. Whole-brain–medulla resting-state functional connectivity (rsFC) was calculated and compared between patients and healthy controls. The rsFCs were also correlated with functional measures within the patient group. In patients with IS, whole-brain–medulla rsFCs were significantly higher in the precuneus, the left and right precentral gyrus, and the right supplementary motor area compared to those in healthy controls (P < 0.001, family-wise error-corrected cluster-level P < 0.05). The rsFCs to the medulla for the left (r = −0.507, P = 0.027) and right side (r = −0.503, P = 0.028) precentral gyrus were negatively correlated with the PAS. The rsFC between the left (r = 0.470, P = 0.042) and right (r = 0.459, P = 0.048) precentral gyrus to the medulla was positively correlated with upper esophageal sphincter opening durations (UOD). In addition, PAS was also correlated with UOD (r = −0.638, P = 0.003) whereas the laryngeal closure duration was correlated with the hyoid bone movement duration (r = 0.550, P = 0.015). Patients with IS exhibited overall modulation of cortical-medulla connectivity during the subacute phase. Patients with higher connectivities showed better swallowing performance. These findings support that there is cortical involvement in swallowing regulation after IS and can aid in determining potential treatment targets for dysphagia.

흡인 위험성이 있는 뇌 병변 장애아동 어머니의 양육 경험

Purpose: The purpose of this study was to explore the parenting experiences that mothers of children with brain lesions with problems swallowing had. Methods: Data was collected through in-depth interviews with 5 mothers who have children with this disability who have a high risk of aspiration at mealtime. The key question in this study was “What is the nature of the burden that mothers of children with brain lesions who are at risk of aspiration experienced?”. The phenomenological analysis was applied. Results: Qualitative data were categorized into 18 themes, 6 theme clusters and 3 categories. These are the categories that were extracted: ‘Enduring the reality in which is difficult to accept’, ‘Whirlwind of emotions felt in the family’, ‘Wishes that cries out in the fog’. Conclusion: It is necessary to develop a support program for mothers who take care of children with disabilities. Rehabilitation nursing plans should be established so that mothers of children with disabilities who are at risk of aspiration can strengthen their energy on their own.

Esophageal achalasia detected by vomiting during induction of general anesthesia: a case report

BackgroundEsophageal achalasia is a rare disease with a high risk of aspiration during anesthesia induction. Here, we describe our experience involving a case of undiagnosed esophageal achalasia with profuse vomiting during anesthesia induction.Case presentationA 58-year-old woman was scheduled for orthopedic surgery under general anesthesia. She vomited a large amount of watery contents during anesthesia induction, and planned surgery was postponed. After recovery from anesthesia, she informed us that she usually had to drink a large amount of water to get food into her stomach and purged watery vomit every night before sleep. However, she attributed it to her constitutional problem, not to a specific disease. She was subsequently diagnosed with esophageal achalasia and underwent Heller myotomy with Dor fundoplication before her re-scheduled orthopedic surgery.ConclusionsA detailed history of dysphagia and regurgitation should be taken in preoperative examinations to prevent unexpected aspiration due to undiagnosed achalasia.

69-Year Old Man With Dysphagia and Nasal Regurgitation

69-Year Old Man With Dysphagia and Nasal Regurgitation

IRON PILL ASPIRATION MIMICKING ASTHMA

TOPIC: Lung Pathology TYPE: Medical Student/Resident Case Reports INTRODUCTION: Foreign body aspiration can be a life-threatening event. Aspiration of iron pill can cause significant bronchial destruction via necrosis. Iron pill quickly disintegrates in the airway, inducing deep mucosal necrosis responsible for severe complications if not diagnosed promptly. We report a case of iron pill aspiration with asthma like presentation leading to severe bronchial stenosis. CASE PRESENTATION: A 50-year-old nonsmoking female, with past medical history of hypertension and arthropathy was referred to pulmonology for wheezing and shortness of breath that started after she had accidentally aspirated an iron pill. Examination was significant for expiratory wheezing. X-ray of the chest was normal. Bronchoscopy performed for the removal of the iron pill revealed complete obstruction of the right lower lobe (RLL) bronchus with thick mucoid secretions coated in iron and granulation tissue. Follow up bronchoscopy showed similar findings which included severe persistent airway inflammation. Cultures obtained grew cryptococcus neoformans. For which patient was she was treated with oral Diflucan for 1 year. Pulmonary function test showed no evidence of restriction or obstruction Once the infection was fully treated patient underwent endobronchial ultrasound (EBUS) which was performed as a therapeutic intervention for the RLL lesion as patient still had persistent symptoms of wheezing. EBUS showed severe stenosis of the RLL which was relieved following CRE balloon-tipped catheter insertion into the stenotic segment of the lower trachea followed by local intralesional steroid injection. On follow up three months later patient reported significant improvement in her symptoms. DISCUSSION: Iron pill aspiration syndrome is a relatively rare cause of severe bronchial inflammation leading to endobronchial stenosis [1,2]. The diagnosis is made by the presence of history of aspiration, airway inflammation and iron deposition as noted on histopathology. Oxidation of iron pill can cause bronchial mucosal inflammation, ulceration and necrosis which progresses to bronchial narrowing and possibly irreversible stenosis [3]. Early diagnosis with bronchoscopy and treatment plays a crucial role in overall prognosis. Our case represents a remarkable recovery with balloon dilation and intralesional steroid injection resulting in relief of stenosis. CONCLUSIONS: •Physicians should be very prudent with prescribing iron pills in individuals who are at high risk of aspiration in order to avoid serious bronchial complications. •Prompt bronchoscopic intervention and management is required to prevent progression to serious complications. •Physicians should consider balloon dilation with intralesional steroid injection for patients with refractory symptoms after removal of the foreign object. REFERENCE #1: Caterino U., Battistoni P., Batzella S., Iacono R. Dello, Lucantoni G., Galluccio G. Syndrome of iron pill inhalation in four patients with accidental tablet aspiration: severe airway complications are described. Respir. Med. Case Rep. 2015, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501451/ REFERENCE #2: Management of Iron Pill Aspiration Syndrome: Advanced Bronchoscopic InterventionMonali Patil MD* Arjun Mohan MD; and Kassem Harris MD University at Buffalo, Buffalo, NY, https://journal.chestnet.org/article/S0012-3692(16)57346-2/pdf REFERENCE #3: The Iron Lung: When Iron Pill Aspiration Results in an Immediate Bronchoscopy. A Successful Medical Therapy to a Serious ConditionSarah Abuseif, Mohamed Elsawaf, Gustavo De La Luz, https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A5565 DISCLOSURES: No relevant relationships by Camelia Chirculescu, source=Web Response No relevant relationships by Adel El Abbassi, source=Web Response No relevant relationships by Saman Saeed, source=Web Response No relevant relationships by Haniya Saeed, source=Web Response No relevant relationships by Dima Youssef, source=Web Response

カプサイシン軟膏による外耳道刺激は高齢認知症患者の肺炎を予防する

Abstract Objective In the present study, we examined the effects of daily application of capsaicin ointment to the external auditory canal for 6 months on the development of pneumonia in elderly dementia patients at high risk of aspiration. Methods Twenty-nine oldest-old bedridden dementia inpatients at high risk of aspiration were enrolled in the present study. Ointment containing 0.025% capsaicin was applied to each external auditory canal with a cotton swab alternatively once a day for 6 months. Results The incidence of pneumonia during the 6 months before the intervention was 1.80 ± 0.37 in these patients. However, this incidence significantly decreased to 0.40 ± 0.29 (p Conclusion These findings suggest that daily long-term aural stimulation with capsaicin ointment enhanced the cough reflex via Arnold’s ear-cough reflex as a glottis protective measure, resulting in the reduction of incidence of pneumonia in elderly dementia patients at high risk of aspiration. The daily aural stimulation with capsaicin ointment may be a safe and promising intervention to prevent aspiration pneumonia in elderly people, especially those who cannot undergo swallowing exercise.

MAO-B İnhibitörü Kullanan Progresif Supranükleer Palsi’li Hastada Spinal Anestezi Deneyimi

Progressive supranuclear palsy (PSP) is a rare clinical syndrome characterized by postural instability and mild dementia. The classical clinical picture of PSP includes severe gait and balance disorder, general bradykinesia, frontal dementia, visual disorders, dysarthria and dysphagia. Aspiration pneumonia is the leading cause of death in advanced PSP. We aimed to present our experiences in a 72-year-old patient with PSP using MAO-B inhibitor as an update for anaesthesiologists. We recommend that it should be taken into consideration that patients with PSP have a high risk of aspiration due to dysphagia and use of various medical treatments with high drug interaction and regional anaesthesia should be preferred. At the same time, we recommend the careful use of opioids during general or regional anaesthesia if the drug cannot be discontinued in patients using MAO-B inhibitor.

Olfactory Stimulation Successfully Improves Swallowing Function of Aged Rats Through Activating Central Neuronal Networks and Downstream DHPR-RyR-mediated Neuromuscular Activities.

Presbyphagia is age-related changes in swallowing function, which imposes a high risk of aspiration in older adults. Considering olfactory stimulation (OS) can influence behavioral activities by modulating neuronal excitability, the present study aims to determine whether OS could improve the swallowing function of aged rats through activating the central neuronal networks and downstream muscular activities participated in the control of swallowing. Aged male Wistar rats received OS by inhaling a mixture of plant-based volatile molecules twice a day for 12 days were subjected to functional magnetic resonance imaging (fMRI) and c-fos, choline acetyltransferase (ChAT) immunostaining to detect the neuronal activities of the orbitofrontal cortex (OFC) and medullary nuclei engaged in swallowing control, respectively. The functional effects of OS on downstream pharyngeal muscle activity were examined by evaluating the dihydropyridine receptor-ryanodine receptor (DHPR-RyR)-mediated intramuscular Ca2+ expression, and analyzing the amplitude/frequency of muscle contraction, respectively. In untreated rats, only moderate signal of fMRI and mild c-fos/ChAT expression was detected in the OFC and medullary nuclei, respectively. However, following OS, intense signals of fMRI and immunostaining were clearly expressed in the orbitofronto-medullary networks. Functional data corresponded well with above findings in which OS significantly enhanced DHPR-RyR-mediated intramuscular Ca2+ expression, effectively facilitated a larger amplitude of pharyngeal muscle contraction, and exhibited better performance in consuming larger amounts of daily dietary. As OS successfully activates the neuromuscular activities participated in the control of swallowing, applying OS may serve as an effective, easy, and safe strategy to greatly improve the swallow function of aging populations.

ASPECTS OF INVASIVE MECHANICAL VENTILATION IN PATIENTS WITH ARDS CAUSED BY COVID-19

Mortality among patients with severe pneumonia and / or acute respiratory distress syndrome (ARDS) due to COVID-19 infection, who underwent mechanical ventilation (MV), is characterized by a fairly high frequency. However, despite the large number of patients receiving appropriate treatment, the question of choosing the optimal ventilation parameters remains poorly understood. In our article, we reviewed the available literature data on the indications for mechanical ventilation, parameters of MV, the need for prone-positioning of patients with ARDS caused by COVID-19 infection in intensive care units to identify unresolved issues.Despite the large number of publications about respiratory support in patients with severe coronavirus infection, there are only general principles regarding the indications for switching to invasive ventilation. Most authors identified the following clinical situations: progression of hypoxemia and / or respiratory failure but with constant oxygen support with increasing percentage of oxygen in the respiratory mixture, use of high-flow cannula or non-invasive ventilation for 1 hour without improvement; persistent hypercapnia, multiorgan failure, coma, high risk of aspiration, hemodynamic instability.According to most of the studies analyzed, the main components of the ventilation strategy should be based on the principles of pulmonary protective ventilation and include the use of low tidal volumes (Vt = 4-8 ml / kg of ideal body weight) and ventilation with plateau pressure Pplat &lt;30 cm H2O (plateau pressure - air pressure measured after an inspiratory pause of 0.5 s). At the same time, many authors recommend using prone position and high levels of positive end-expiratory pressure (PEEP) compared to low levels in patients with ARDS on the background of COVID-19.The approach to invasive mechanical ventilation in ARDS caused by SARS-CoV-2 still requires further research and answers to a number of questions.

Characteristics, Management, and Clinical Outcomes of Patients with Hospital-Acquired and Ventilator-Associated Pneumonia: A Multicenter Cohort Study in Korea.

BackgroundHospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant public health issues in the world, but the epidemiological data pertaining to HAP/VAP is limited in Korea. The objective of this study was to investigate the characteristics, management, and clinical outcomes of HAP/VAP in Korea.MethodsThis study is a multicenter retrospective cohort study. In total, 206,372 adult patients, who were hospitalized at one of the 13 participating tertiary hospitals in Korea, were screened for eligibility during the six-month study period. Among them, we included patients who were diagnosed with HAP/VAP based on the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) definition for HAP/VAP.ResultsUsing the IDSA/ATS diagnostic criteria, 526 patients were identified as HAP/VAP patients. Among them, 27.9% were diagnosed at the intensive care unit (ICU). The cohort of patients had a median age of 71.0 (range from 62.0 to 79.0) years. Most of the patients had a high risk of aspiration (63.3%). The pathogen involved was identified in 211 patients (40.1%). Furthermore, multidrug resistant (MDR) pathogens were isolated in 138 patients; the most common MDR pathogen was Acinetobacter baumannii. During hospitalization, 107 patients with HAP (28.2%) had to be admitted to the ICU for additional care. The hospital mortality rate was 28.1% in the cohort of this study. Among the 378 patients who survived, 54.2% were discharged and sent back home, while 45.8% were transferred to other hospitals or facilities.ConclusionThis study found that the prevalence of HAP/VAP in adult hospitalized patients in Korea was 2.54/1,000 patients. In tertiary hospitals in Korea, patients with HAP/VAP were elderly and had a risk of aspiration, so they were often referred to step-down centers.

Comparison of LMA® Gastro™ airway and gastrolaryngeal tube in endoscopic retrograde cholangiopancreatography: a prospective randomized observational trial.

New generation airway devices with different designs have been developed as an alternative to endotracheal intubation in order to avoid adverse events associated with sedation in endoscopic procedures and to provide patent airway. We aimed to compare two supraglottic airway devices (SGADs), the LMA® Gastro™ airway and gastrolaryngeal tube (GLT), in terms of airway efficiency, performance during procedure and adverse events in endoscopic retrograde cholangiopancreatography (ERCP). A hundred-three ERCP patients without high risk of aspiration were included. Patients were randomly allocated to the LMA Gastro and GLT groups. The primary study outcomes were the comparison of the two SGADs in terms of oropharyngeal leak pressure (OLP). Secondary study outcome was SGADs-related adverse events. Procedures were completed with SGADs in fifty patients in each group. The rate of successful insertion at first attempt was 72% in GLT and 96% in LMA Gastro (P=0.004). The mean OLP of LMA Gastro Group (31.8 cmH<inf>2</inf>O) was significantly higher than that of the GLT Group (26.5 cmH<inf>2</inf>O), (P=0.0001). However, endoscopists' satisfaction was higher in GLT (P=0.0001). Mucosal damage and sore throat were lower in LMA Gastro Group. LMA® Gastro™ had a higher OLP than GLT. However, GLT was better for endoscopist satisfaction, as it provides more satisfying maneuverability. As to secondary outcome advers events were lower in LMA® Gastro™. The lower complication rates associated with the device and providing a more patent airway also highlighted the apparent clinical efficacy of LMA® Gastro™ than GLT, in ERCP.

Preoperative Gastric Ultrasound in Surgical Patients who Undergo Rapid Sequence Induction Intubation

BackgroundThe evaluation of preoperative aspiration risk in surgical patients is mainly based on clinical judgement. The aim of this study was to estimate the proportion of surgical patients who undergo rapid sequence induction intubation that have gastric contents and volume which might give a hint that the patient could be at low or high risk of aspiration assessed by gastric ultrasound, and the feasibility of this approach in the clinical setting. MethodsIn this prospective observational study, seventy-two adult surgical patients who underwent rapid sequence induction intubation underwent gastric ultrasound before induction of anaesthesia. Based on gastric contents and volumes measured in the antrum of the stomach, the findings were categorised into low and high risk of aspiration. ResultsEvaluation of the gastric contents was possible in 63/72 patients (88% [95% CI: 80–95%]). Among these, the number of patients with indicators for low aspiration risk was 32/63 (51% [95% CI: 38–63%]). The mean examination time was 2 min 50 s (SD ±1 min 16 s [95% CI 2 min 32 s to 3 min 8 s]). ConclusionsThis small observational study provides hints that half of the patients undergoing rapid sequence induction intubation have, according to gastric ultrasound assessment, not an elevated risk of aspiration. We also showed that a transcutaneous gastric ultrasound examination is easy, fast without time delay and doable immediately before induction of anaesthesia in the operating theatre.

QP2: Challenges Treating Severe Oral Mucositis Pain in Patients at High Risk for Aspiration

Background: Mucositis is one of the most common adverse reactions encountered in patients receiving chemotherapy and radiation therapies, particularly in the head and neck region. It is associated ...

Use of a non-invasive accelerometric method for diagnosing gastroesophageal reflux in premature infants

ObjectiveTo evaluate the clinical usefulness of a non-invasive accelerometric device to diagnose GER in preterm babies.Study designAn accelerometer was taped over the sub-xiphoid process in 110 preterm (GA 29.6 ± 3.3 wk) infants (133 studies). Low frequency, sub-audible signals were captured via digital recording (sampling rate 200 Hz), then re-sampled (rate = 60 Hz) to create a spectrogram (focused range 0–30 Hz). Mean amplitude in the focused range was calculated.ResultsOf 85 studies with simultaneous pH-metry and accelerometry, 18 had concurrent positive and 23 had concurrent negative scores, 42 had negative pH scores when accelerometry was positive (≥1 µV), consistent with non-acid reflux. Eleven infants at high risk of aspiration received surgical interventions. All but 1 had negative pH scores while 10/11 had positive accelerometry.ConclusionsThe non-invasiveness of this accelerometric technique allows for GER screening and for repeated testing to assess efficacy of interventions.

Association between Esophageal Dysmotility and Long-Term Outcomes in Lung Transplant Recipients

<h3>Purpose</h3> Esophageal dysmotility is very common in patients with end-stage lung disease and post lung transplant and is thought to predispose to allograft injury through higher risk of aspiration. We routinely test lung transplant recipients for esophageal dysmotility with High Resolution Manometry (HRM) at 3 months post-transplant. We hypothesize that lung transplant recipients (LTRs) with significant esophageal dysmotility are more likely to develop lung injury leading to CLAD and death. <h3>Methods</h3> Among 1753 LTRs transplanted at our center between July 2000 and June 2018, we retrospectively analyzed 426 patients who had HRM with a 24 hour-pH impedance study available post-transplantation. Esophageal hypomotility was defined as >= 30% of failed and/or simultaneous esophageal contractions, while esophageal hypermotility was defined as evidence of higher amplitude on HRM. Cox proportional hazards models adjusted for age, sex, native lung disease, CMV matching, and transplant type (single vs double) were used to determine the association between esophageal dysmotility and death/retransplant or CLAD. <h3>Results</h3> Esophageal hypomotility and hypermotility was found in 120 (28%) and 22 (5%) patients, respectively. Mild, moderate, and severe hypomotility was found in 58 (48%), 14 (12%), and 48 (40%) patients, respectively. In multivariate analyses, esophageal hypermotility or hypomotility was not associated with CLAD (HR 0.59 [95% CI 0.21-1.60]; HR 0.79 [95% CI 0.52-1.19]). or death (HR 0.53 [95% CI 0.16-1.68]; HR 0.62 [95% CI 0.37-1.03]). The risk of CLAD or death did not vary by severity of hypomotility. <h3>Conclusion</h3> In a large single-center lung transplant cohort study, we have determined that esophageal dysmotility is not associated with CLAD or death. Concurrent GI co-morbidities, such as reflux and gastroparesis, may play a role in modifying this risk. Additionally, center-specific approaches to patient selection and/or treatment may be related to outcomes and will be further assessed in future studies.

A comparison of gastric gas volumes measured by computed tomography after high‐flow nasal oxygen therapy or conventional facemask ventilation*

High-flow nasal oxygen therapy is increasingly used to improve peri-intubation oxygenation. However, it is unknown whether it may cause or exacerbate insufflation of gas into the stomach. High-flow nasal oxygen therapy is now standard practice in our hospital for adult patients undergoing percutaneous thermal ablation of liver cancer under general anaesthesia with tracheal intubation. We compared gastric gas volumes measured from computed tomography images that had been acquired immediately after intubation in two series of patients: 50 received peri-intubation high-flow nasal oxygen therapy and another 50 received conventional facemask pre-oxygenation and ventilation before intubation and before high-flow nasal oxygen therapy became standard practice in our unit. Median (IQR [range]) gastric gas volume was 24.0 (14.2-59.9 [3-167]) cm3 in the high-flow nasal oxygen therapy group and 23.8 (12.6-38.8 [0-185]) cm3 in the facemask group. There was no difference between the two groups in the volume of gastric gas measured by computed tomography imaging (Mann-Whitney U-test, U=1136, p=0.432, n1 =n2 =50). Our results demonstrate that a small volume of gastric gas is commonly present after induction of anaesthesia, but that the use of peri-intubation high-flow nasal oxygen therapy for pre-oxygenation and during apnoea does not increase this volume compared with conventional facemask pre-oxygenation and ventilation. This is clinically relevant, as high-flow nasal oxygen therapy is increasingly being used in a peri-intubation context and in patients at higher risk of aspiration.

Dysphagia after Stroke: An Unmet Antibiotic Stewardship Opportunity.

The goal of antibiotic stewardship is to improve antibiotic use, often by reducing unnecessary treatment. Bedside dysphagia screening tools help identify patients at high risk of aspiration following stroke. Presence of dysphagia does not indicate a need for antibiotic treatment. Therefore, this retrospective, cohort study was developed to evaluate the association of dysphagia and antibiotic prescribing following stroke. There were 117 patients included. Patients were placed into 2 cohorts based on the results of the dysphagia screening, with 55 patients positive for dysphagia and 62 patients negative for dysphagia. Patients with dysphagia tended to be older, had higher National Institutes of Health stroke scores, and lower renal function. Patients with dysphagia were prescribed more empiric antibiotics than those without dysphagia (18.2% vs. 3.2%, p = 0.01). This resulted in 53 antibiotic days of therapy in the dysphagia cohort compared to 19 antibiotic days of therapy in the no dysphagia cohort (p = 0.1). No patients later developed pneumonia and only one patient was started antibiotics after 48h. Two cases of Clostridioides difficile were reported. Both patients were in the dysphagia cohort and received antibiotics. Multivariable logistic regression demonstrated that positive chest x-ray findings and failed dysphagia screen were independent conditions associated with initiating antibiotics. These findings indicate that antibiotic use was higher in patients following stroke with a positive dysphagia screen. Close monitoring of stroke patients, particularly when positive for dysphagia, might be an under-recognized antibiotic stewardship opportunity.

Prolonged neuromuscular block after rocuronium administration in laparoscopic pyloromyotomy patients: A retrospective bayesian regression analysis.

Infants undergoing pyloromyotomy are at a high risk of aspiration, making rapid sequence induction the preferred method of induction. Since succinylcholine use in infants can be associated with complications, rocuronium is frequently substituted despite its prolonged duration of action. To examine the likelihood of non-reversibility to neostigmine at the end of surgery in laparoscopic pyloromyotomies and its correlation to both rocuronium dose and out of operating room time. Patients who underwent laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis, received rocuronium, and were reversed with neostigmine were included. Bayesian multivariable logistic regression was utilized to determine the probability of non-reversibility, and Bayesian multivariable median regression was performed to ascertain the correlation between out of operating room time and non-reversibility. 306 patients were analyzed with a median surgical duration of 19min (interquartile range 16 to 23). 74% received succinylcholine for intubation followed by rocuronium, and the remaining received rocuronium alone. The median rocuronium dose was 0.41mg/kg (interquartile range 0.27 - 0.56mg/kg). Prolonged block occurred in 68 (22.2%) patients. There was a non-trivial probability of prolonged block with low rocuronium doses, and each 0.1mg/kg increase in total rocuronium dose was associated with an odds ratio of 1.36 (95% credible interval: 1.17-1.58) of neostigmine non-reversibility at the end of surgery. Non-reversibility was correlated with a substantial increase in median out of operating room time (13.4min, 95% credible interval: 5.5-20.8min), which was compounded by high rocuronium dosing (2.2min increase per 0.1mg/kg for doses greater than 0.5mg/kg, 95% credible interval: 0.7-3.6min). Prolonged blockade can occur from rocuronium administration in infants undergoing pyloromyotomy even at low doses. Therefore, consideration of appropriate rocuronium dosing or the use of sugammadex should be considered.

Is COPD associated with increased risk for microaspiration in intubated critically ill patients?

BackgroundAlthough COPD patients are at higher risk for aspiration when breathing spontaneously, no information is available on the risk for microaspiration in invasively ventilated COPD patients. The aim of our study was to determine the relationship between COPD and abundant microaspiration in intubated critically ill patients.MethodsThis was a retrospective analysis of prospectively collected data, provided by 3 randomized controlled trials on microaspiration in critically ill patients receiving invasive mechanical ventilation for more than 48 h. Abundant microaspiration was defined as the presence of pepsin and or alpha-amylase at significant levels in tracheal aspirates. In all study patients, pepsin and alpha-amylase were quantitatively measured in all tracheal aspirates collected during a 48-h period. COPD was defined using spirometry criteria.ResultsAmong the 515 included patients, 70 (14%) had proven COPD. Pepsin and alpha-amylase were quantitatively measured in 3873 and 3764 tracheal aspirates, respectively. No significant difference was found in abundant microaspiration rate between COPD and non-COPD patients (62 of 70 patients (89%) vs 366 of 445 (82%) patients, p = 0.25). Similarly, no significant difference was found in abundant microaspiration of gastric contents (53% vs 45%, p = 0.28), oropharyngeal secretions (71% vs 71%, p = 0.99), or VAP (19% vs 22%, p = 0.65) rates between the two groups. No significant difference was found between COPD and non-COPD patients in duration of mechanical ventilation, ICU length of stay, or ICU mortality.ConclusionsOur results suggest that COPD is not associated with increased risk for abundant microaspiration in intubated critically ill patients.

Is tracheotomy necessary for transoral robotic surgery base of tongue reduction in obstructive sleep apnoea syndrome? Our experience in 20 patients.

-TORS BOT reduction is a safe surgical approach for OSAS patients with BOT collapse and failure to medical treatments. -Tracheotomy may be avoided in patients without midline glossectomy due to the low risk of postoperative major hemorrhage. -Tracheotomy is associated with a higher risk of aspiration, use of feeding tube, and lengthening of both the operative time and the hospital stay.