Large-volume Aspiration Research Articles

An uncommon etiological factor for aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with cerebrospinal fluid rhinorrhea: a case report

BackgroundAspiration pneumonitis is an inflammatory disease of the lungs which is difficult to diagnose accurately. Large-volume aspiration of oropharyngeal or gastric contents is essential for the development of aspiration pneumonitis. The role of cerebrospinal fluid (CSF) rhinorrhea is often underestimated as a rare etiological factor for aspiration in the diagnosis process of aspiration pneumonitis.Case presentationWe present a case of a patient with 4 weeks of right-sided watery rhinorrhea accompanied by intermittent postnasal drip and dry cough as the main symptoms. Combined with clinical symptoms, imaging examination of the sinuses, and laboratory examination of nasal secretions, she was initially diagnosed as spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, and intraoperative endoscopic findings and postoperative pathology also confirmed this diagnosis. Her chest computed tomography showed multiple flocculent ground glass density shadows in both lungs on admission. The patient underwent endoscopic resection of meningoencephalocele and repair of skull base defect after she was ruled out of viral pneumonitis. Symptoms of rhinorrhea and dry cough disappeared, and pneumonitis was improved 1 week after surgery and cured 2 months after surgery. Persistent CSF rhinorrhea caused by spontaneous sphenoid sinus meningoencephalocele was eventually found to be a major etiology for aspiration pneumonitis although the absence of typical symptoms and well-defined risk factors for aspiration, such as dysphagia, impaired cough reflex and reflux diseases.ConclusionsWe report a rare case of aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, which can bring more attention and understanding to the uncommon etiology for aspiration, so as to make more accurate diagnosis of the disease and early surgical treatment.

INCIDENCE AND PREDICTORS OF 30-DAY READMISSION IN PATIENTS HOSPITALIZED WITH ASPIRATION PNEUMONIA

SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Aspiration pneumonia is a subtype of pneumonia caused by large-volume aspiration of oropharyngeal colonization or gastric content. Our study aimed to estimate the rate, risk factors, and costs associated with 30- day readmissions after aspiration pneumonia hospitalizations in a large, nationally representative cohort. METHODS: We analyzed the 2016 and 2017 U.S. National Readmission Database (NRD) to identify adult patients admitted with a principal diagnosis of aspiration pneumonia. A readmission was defined as the first admission to any hospital for any non-trauma diagnosis within 30 days of the index admission. We examined the baseline demographics, national readmission rates, resource utilization. We used the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM) to identify the diagnosis. Multivariate logistic regression was used to identify predictors of 30- day readmission. RESULTS: A total of 252,904 patients admitted with aspiration pneumonia were identified. The mean age was 73.8. 43.7% of patients were female. 35% of patients had dysphagia, 26.9% had dementia, 17% had altered mental status, 13.3% had palliative care encounter. The all-cause 30-day readmission rate was 17%. The in-hospital and 30-day mortality rate was 7.9% and 9.2%, respectively. The in-hospital mortality rate for readmitted patients was 9.4%. The most common five reasons for all-cause readmission were aspiration pneumonia, sepsis, unspecified pneumonia, acute kidney injury, chronic obstructive pulmonary disease with (acute) exacerbation. After adjusting for multiple covariates, readmission within 30 days was independently associated with higher Charlson comorbidity score [adjusted odds ratio (aOR) 1.1, 95% confidence interval (CI) 1.10- 1.12, p<0.001], dysphagia (aOR 1.1, 95% CI 1.06- 1.14, p<0.001). Female sex (aOR 0.93, 95% CI 0.89- 0.96, p<0.001), palliative encounter (aOR 0.37, 95% CI 0.34- 0.40, p<0.001), higher income (aOR 0.92, 95% CI 0.87- 0.97, p<0.001), using private insurance (aOR 0.74, 95% CI 0.69- 0.79, p<0.001), alcohol use (aOR 0.90, 95% CI 0.83- 0.98, p=0.016), dementia (aOR 0.82, 95% CI 0.78- 0.85, p<0.001) were associated with decreased all-cause readmissions. The mean length of stay (LOS) of index admissions and readmissions was 6.62 vs 6.71 days (p=0.122), and the mean cost was $13,987 vs. $14,598 (p<0.001). CONCLUSIONS: Patients admitted for aspiration pneumonia were frequently readmitted to the hospital within 30 days after discharge. We found a significant burden of 30-day readmissions, including higher in-hospital mortality rate and resource utilization. CLINICAL IMPLICATIONS: Our findings might be used to develop strategies to reduce early readmission of aspiration pneumonia. Additional attention should be directed toward these patients in the form of careful discharge planning and a multidisciplinary approach to swallowing management. DISCLOSURES: No relevant relationships by Si Li, source=Web Response No relevant relationships by Bojana Milekic, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response No relevant relationships by Yichen Wang, source=Web Response

The Ethics of Feeding the Aspirating Child in an Age of Increasing Patient Complexity.

The Ethics of Feeding the Aspirating Child in an Age of Increasing Patient Complexity.

Exercise for Better ALS Management?

Exercise for Better ALS Management?

Improving the safety of thoracentesis

Thoracentesis is a common bedside procedure associated with iatrogenic complications including pneumothorax. Experienced clinicians using optimal procedural techniques within a supportive system can achieve improvements in safety. However, clinicians have been relatively slow to adopt these changes. This review examines the available literature regarding procedural safety of thoracentesis with emphasis on best practice models to reduce iatrogenic complications. Recent studies have identified procedure-specific variables that are independently associated with iatrogenic pneumothorax including inexperienced operators, lack of ultrasound imaging, and large-volume aspiration of fluid. Development of a best practice model including procedural training within a focused procedural group that utilizes ultrasound imaging further improves thoracentesis procedural safety. Several procedural modifications have led to improvements in thoracentesis procedural safety in reducing iatrogenic complications. Herein, we review the known risks associated with thoracentesis and identify the modifiable and nonmodifiable risk factors. On the basis of recent studies, we make recommendations and encourage incorporation of 'best practice' techniques for thoracentesis procedures.

Giant abdominal tumor of the ovary

A giant abdominal tumor can exert a mass effect on surrounding structures. We report here a 34-year-old single female who presented with an increased abdominal girth and was subsequently found to have a giant abdominal mass. Large volume aspiration (85 L) at a slow rate (1 L/min) was initially performed before surgical resection to prevent the development of severe clinical hypotension after large volume aspiration. The patient underwent left salpingo-oophorectomy. Histology revealed a serous cystadenoma of the ovary. Systemic hemodynamics were sequentially measured during the perioperative period. The patient is now well.

Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival.

Pneumonia is a major cause of morbidity and mortality in long-term care facilities. Prior studies of pneumonia have failed to identify risk factors potentially amenable to intervention. Our objectives were to (1) identify modifiable risk factors for the occurrence of pneumonia and (2) determine the long-term impact of pneumonia on survival. We performed a case-control study among residents of a Veterans Affairs long-term care facility. Case patients included all patients developing pneumonia from 2 days to 1 year after admission. Control subjects were matched for admission date, level of nursing care, and dependence in activities of daily living. Patients were followed up for 2 years or until death or discharge from the facility. We identified 104 case-control pairs. Risk factors significantly associated with pneumonia included witnessed aspiration (odds ratio, 13.9; 95% confidence interval, 1.7-111.0; P =.01), sedative medication (odds ratio, 2.6; 95% confidence interval, 1.2-5.4; P =.01), and comorbidity score (odds ratio, 1.2; 95% confidence interval, 1.0-1.4; P =.05). Mortality due to pneumonia was 23% at 14 days. Patients with pneumonia had a significantly higher mortality than did controls at 1 year (75% vs 40%; P<.001); survival curves converged at 2 years. In a Cox proportional hazards regression model, an episode of pneumonia was independently associated with mortality during follow-up (odds ratio, 2.6; 95% confidence interval, 1.7-3.9; P<.001). Among long-term care patients closely matched for age, level of dependency, and duration of institutionalization, an episode of pneumonia is associated with significant excess mortality that persists for up to 2 years. Two identified risk factors, large-volume aspiration and receipt of sedating medication, are potentially amenable to intervention.

Current Status of Suction Lipectomy in Canada: A Cross-Sectional Survey of Plastic Surgeons

Background Suction lipectomy is the most common aesthetic surgery performed in North America. The safety of the procedure has recently been questioned, particularly with respect to large volume aspiration. Objective To delineate Canadian liposuction practice patterns and perceived complication rates. Subjects and Methods A survey was mailed to all plastic surgeons registered with the Canadian Society of Plastic Surgeons. The survey assessed surgeon demographics, hospital admission rates following liposuction, techniques used, wetting solutions, aspirate volumes and complications. Results A total of 322 surveys were mailed. The response rate was 44%. Of the 142 surgeons who responded, 119 regularly performed suction lipectomy. They reported that 70% of patients had suction lipectomy performed on an outpatient basis. Forty per cent of procedures were performed in private clinics. On average, surgeons performed 40 liposuctions/year without ancillary procedures and 27 liposuctions/year with ancillary procedures. Fifteen per cent of surgeons used ultrasound-assisted liposuction as an adjunct to traditional liposuction, although less than 1% used it exclusively. The ratio of aspirate to infiltrate was 0.25 to one in 45% of cases, 0.5 to one in 37%, one to one in 17% and one to one in fewer than 1%. In 69% of patients, 1 to 2 L was aspirated, while in fewer than 5% of patients, more than 3.5 L was aspirated. Early complication rates were as follows: hematoma and seroma 2.6%, infection 1.3% and skin loss 0.01%. Contour irregularity was the main late complication, occurring in 12% of patients. No cases of venous thrombosis, or pulmonary or fat emboli were reported. No deaths were reported. Conclusions Suction lipectomy is performed commonly by Canadian plastic surgeons, with the majority using a wet or superwet technique. In the vast majority of patients, fewer than 3500 cm3 are aspirated. The complication rate is perceived to be low.

Risk factors for developing pneumonia within 48 hours of intubation.

Two hundred fifty intubated patients were followed during the first 48 h after intubation in order to identify potential risk factors for developing pneumonia within this period. Thirty-two developed pneumonia during this time. Univariate analysis established that large volume aspiration, presence of sedation, intubation caused by respiratory/cardiac arrest or decrease in the level of consciousness, emergency procedure, cardiopulmonary resuscitation (CPR), and Glasgow coma score < 9 were significantly associated with pneumonia. In contrast, prior infection and prior antimicrobial use were associated with a protective effect. Presence of subglottic secretion drainage and 15 other variables had no significant effect. Multivariate analysis selected CPR (odds ratio [OR] = 5.13, 95% confidence intervals [CI] = 2.14, 12.26) and continuous sedation (OR = 4.40, 95% CI = 1.83, 10.59) as significant risk factors for pneumonia, while antibiotic use (OR = 0.29, 95% CI = 0.12, 0.69) showed a protective effect. Our findings emphasize that risk factors for pneumonia change during the intubation period, and preventing pneumonia requires a combined approach.

Massive liposuction in the moderately obese patients: A preliminary study

The purpose of this study was to evaluate the efficacy and safety of large-volume liposuction on moderately obese women (>125% of ideal body weight) after diet and exercise routines had been established. Twelve consecutive women with an average ideal body weight greater than 130.6% underwent liposuction after demonstrating certain lifestyle changes. An average aspirate of 5393 ml (range, 2250 to 9390 ml) was removed with a combination of superficial syringe liposculpture and deep machine vacuum. Ancillary procedures were performed on five patients. none of the patients had transfusions. The patients returned to work in 10 days (range, 3 to 16 days) and felt "normal" in 19 days. Three months after surgery, the average weight loss was 6.8 kg. Six months after surgery, the average weight loss was 5.6 kg. Under certain circumstances, large volume aspiration liposuction appears to be a safe and effective weight reduction technique.

Acute effects of sucralfate aspiration: Clinical and laboratory observations

Study Objective: To assess the complications associated with the aspiration of sucralfate. Design: Clinical (case report) and bench observations. Setting: Inpatient intensive care unit and experimental animal laboratory. Subjects: The case of a critically ill patient who aspirated sucralfate is presented. Fifteen Sprague-Dawley rats served as experimental animals to investigate the acute histologic effects of large-volume aspiration of sucralfate. Interventions: The patient underwent emergent intubation to relieve acute upper airway obstruction. All the animals were anesthetized and had tracheostomies performed. The experimental groups had acidic intratracheal injections of 2 ml/kg of a nonparticulate liquid (pH, 2.3; n = 6) or a sucralfate aspirate (1 ml/kg of a 5% sucralfate suspension of pH 3.6, followed by 1 ml/kg 0.1 of normal hydrochloric acid of pH 1.0; n = 4). Four hours after simulated aspiration, the rats were sacrificed and their lungs removed for histologic examination by light microscopy. Measurements and Main Results: Differences were noted in histopathologic injury in the experimental groups compared to the control group using a numeric scoring scale. Nonparticulate acidic liquid aspiration caused a significant increase ( p < 0.05) in inflammation. Sucralfate caused a significant increase ( p < 0.05) in lung hemorrhage. A nonsignificant trend was seen with simulated sucralfate aspiration for edema and inflammation. No long-term sequelae were attributed to the clinical aspiration episode. Conclusions: Acute complications associated with aspiration of sucralfate have been identified. In the laboratory setting, simulated aspiration of sucralfate led to acute lung injury.

Acute histologic effects of simulated large-volume aspiration of sucralfate into the lungs of rats

Sucralfate is an effective agent in reducing the incidence of upper GI tract (UGIT) stress bleeding and nosocomial pneumonia in critically ill patients. Many of these patients are not intubated and are at increased risk for aspiration of large volumes of UGIT contents containing sucralfate. The effects of aspirated sucralfate are unknown. To investigate this, large-volume aspiration (2 ml/kg) was simulated in freshly tracheostomized rats (n = 6, all experimental groups) using normal saline, particulate antacid, and sucralfate adjusted to pH 3.6 and 5.0. Four hours after aspiration, the rats were killed and their lungs were formalin-fixed. Significant increases in lung inflammation were seen by light microscopy in all experimental groups at pH 3.6. Antacid aspirated at pH 5.0 induced significant increases in airway as well as parenchymal inflammation. At pH 3.6, the antacid aspiration led to significant increases in lung edema and hemorrhage. Sucralfate aspiration produced significant increases in pulmonary hemorrhage at pH 5.0. Our microscopic findings are consistent with the acute pulmonary histopathologic changes known to occur after large-volume aspiration of particulate materials, including antacids. Additionally, we show that large-volume aspiration of sucralfate produced significant acute pneumonitis, including pulmonary hemorrhage. In view of the proven usefulness of sucralfate, further investigations are indicated to evaluate these experimental findings before extrapolating to critically ill patients.

Nosocomial Pneumonia: A Multivariate Analysis of Risk and Prognosis

One hundred and twenty consecutive episodes of nosocomial pneumonia (NP) in 118 nonneutropenic adults admitted to a 1,000-bed teaching hospital were studied in order to investigate the prognosis and risk factors. The overall fatality rate was 36.6 percent. The identification of a "high-risk" microorganism (Pseudomonas aeruginosa, Enterobacteriaceae, and other Gram-negative bacilli, Streptococcus faecalis, Staphylococcus aureus, Candida sp, Aspergillus sp, and episodes of polymicrobial pneumonia), bilateral involvement on chest x-ray examination, the presence of respiratory failure, inappropriate antibiotic therapy, and age older than 60 years or an underlying condition ultimately or rapidly fatal were those factors selected by a stepforward logistic regression analysis as independently worsening the prognosis. A series of variables frequently quoted as predisposing to NP was determined to be either present or absent in the same 120 cases of NP and in an equal number of randomly selected control subjects. After adjusting for confounding, factors significantly predisposing to NP were tracheal intubation, depressed level of consciousness, underlying chronic lung disease, thoracic or upper abdominal surgery, prior episode of a large volume aspiration, and age older than 70 years. Since some of the factors influencing the risk or the prognosis of NP are amenable to medical intervention, a percentage of NP might be prevented and its prognosis can be improved.