Pulmonary Aspiration In Children Research Articles

Semi-quantitative assessment optimized the grading of pulmonary aspiration on salivagram in children.

Salivagram is one of the imaging modalities to detect pulmonary aspiration in children. This study aims to optimize the classification of pulmonary aspiration detected by salivagram with a semi-quantitative analytical method. This is a retrospective study involving 737 patients (471 males, 266 females; aged 1month to 8years; mean age 5.3months, median age 3.0months old) with suspected pulmonary aspiration, who had salivagram done between January 2018 and June 2019. Positive cases were divided into 10 groups (Grade 1, R2, L2, R2L2, R3, L3, R3L2, R2L3, R3L3, and 4) according to the scintigraphic findings. Aspiration index was determined as the ratio of the count in the respiratory tract to the total count in the image field of view and compared among different groups using the receiver operating characteristics (ROC) curve analysis. A total of 180 cases had positive scintigraphic findings of various grades of aspiration (24.4%, 180/737). There is a high consistency among the two independent nuclear medicine physicians involved in the study, in determining both the disease gradings (κ = 0.919;95% CI: 0.915-0.923) and aspiration index (ICC = 0.994;95% CI: 0.993-0.996). There is no significant difference (p > 0.05) in aspiration index among the gradings in "mild" group (grade 1, R2, L2, L2R2), and "moderate" group (grade R3, R3L2, R3L3). After dividing the different grades into "mild", "moderate" and "severe" groups, the aspiration index of "mild" group is 4.40 ± 2.01, that of "moderate" group is 16.43 ± 8.20, and that of "severe" group is 46.94 ± 14.81. Difference in groups was statistically significant (p < 0.0001). In ROC curve analysis, AUC of "mild" and "moderate" groups is 0.970 and that of "moderate" and "severe" groups is 0.943; the cut-off value with highest diagnostic efficiency is 6.75 between "mild" and "moderate" groups and 38.00 between "moderate" and "severe" groups. We introduced a semi-quantitative analytical method in pulmonary aspiration on salivagram, to optimize and supplement to the current classification of pulmonary aspiration.

Impact of clear fluid fasting on pulmonary aspiration in children undergoing general anesthesia: Results of the German prospective multicenter observational (NiKs) study.

A preliminary national audit of real fasting times including 3324children showed that the fasting times for clear fluids and light meals were frequently shorter than recommended in current guidelines, but the sample size was too small for subgroup analyses. Therefore, the primary aim of this extended study with more participating centers and a larger sample size was to determine whether shortened fasting times for clear fluids or light meals have an impact on the incidence of regurgitation or pulmonary aspiration during general anesthesia in children. The secondary aim was to evaluate the impact of age, emergent status, ASA classification, induction method, airway management or surgical procedure. After the Ethics Committee's approval, at least more than 10000 children in total were planned to be enrolled for this analysis. Patient demographics, real fasting times, anesthetic and surgical procedures, and occurrence of target adverse events defined as regurgitation or pulmonary aspiration were documented using a standardized case report form. At fifteen pediatric centers, 12093 children scheduled for surgery or interventional procedures were included between October 2018 and December 2019. Fasting times were shorter than recommended in current guidelines for large meals in 2.5%, for light meals in 22.4%, for formula milk in 5.3%, for breastmilk in 10.9%, and for clear fluids in 39.2%. Thirty-one cases (0.26%) of regurgitation, ten cases (0.08%) of suspected pulmonary aspiration, and four cases (0.03%) of confirmed pulmonary aspiration were reported, and all of them recovered quickly without any consequences. Fasting times for clear fluids shortened from 2hours to 1hour did not affect the incidence of adverse events (upper limit 95% CI 0.08%). The sample size of the cohort with fasting times for light meals shorter than 6hours was too small for a subgroup analysis. An age between one and 3years (odds ratio 2.7,95% CI 1.3 to 5.8%; P<.01) and emergent procedures (odds ratio 2.8,95% CI 1.4 to 5.7;P<.01) increased the incidence of adverse events, whereas ASA classification, induction method, or surgical procedure had no influence. The clear fluid fasting times were shortest under 6/4/0 as compared to 6/4/1 and 6/4/2 fasting regimens, all with an incidence of 0.3% for adverse events. This study shows that a clear fluid fasting time shortened from 2hours to 1hour does not affect the incidence of regurgitation or pulmonary aspiration, that an age between one and 3years and emergent status increase the incidence of regurgitation or pulmonary aspiration, and that pulmonary aspiration followed by postoperative respiratory distress is rare and usually shows a quick recovery.

Dysphagia and Chronic Pulmonary Aspiration in Children

1. James D. Tutor, MD* 1. *Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center, LeBonheur Children’s Hospital, and St. Jude Children’s Research Hospital, Memphis, TN * Abbreviations: FEES: : fiberoptic endoscopic evaluation of swallowing FEESST: : fiberoptic endoscopic evaluation of swallowing with sensory testing GER: : gastroesophageal reflux VFSS: : videofluoroscopic swallow study Dysphagia and the accompanying pulmonary aspiration are frequently unrecognized by pediatricians and caregivers as a cause of chronic respiratory symptoms such as recurrent wheezing, recurrent pneumonias, chronic cough, stridor, and brief resolved unexplained events (formerly known as acute life-threatening events). In addition, clinicians may be unfamiliar with the proper evaluation or treatment of patients with dysphagia and chronic aspiration. After completing this article, readers should be able to: 1. Recognize the signs and symptoms associated with dysphagia and chronic pulmonary aspiration. 2. Know the conditions predisposing to dysphagia and aspiration in children. 3. Understand the tests that should be used to diagnose dysphagia and chronic pulmonary aspiration. 4. Know when and to what subspecialist(s) to refer the patient who has dysphagia and chronic aspiration. 5. Know the methods available to treat dysphagia and chronic aspiration. 6. Know how to recognize and treat aspiration pneumonia in infants and children. “Dysphagia, defined as difficult or improper swallowing of oral solids, liquids, or both, can lead to aspiration, the inhalation of foreign material into the lower airway. This can produce significant respiratory morbidity and mortality in children.” (1) Dysphagia is described as being oropharyngeal when transfer of the food bolus from the mouth to the esophagus is impaired. The striated muscles of the mouth, pharynx, and upper esophageal sphincter are affected in oropharyngeal dysphagia. Esophageal dysphagia occurs if there is difficulty transporting the food bolus down the esophagus to the stomach. (2) Aspiration may occur in children who have problems with dysphagia. Aspiration can be either acute or chronic and recurrent. Aspiration can lead to pulmonary problems such as recurrent wheezing, recurrent pneumonias, and the development of severe impairment of …

Real fasting times and incidence of pulmonary aspiration in children: Results of a German prospective multicenter observational study.

Prolonged fasting before anesthesia is still common in children. Shortened fasting times may improve the metabolic and hemodynamic condition during induction of anesthesia and the perioperative experience for parents and children and simplify perioperative management. As a consequence, some centers in Germany have reduced fasting requirements, but the national guidelines are still unchanged. This prospective multicenter observational study was initiated by the Scientific Working Group for Pediatric Anesthesia of the German Society of Anesthesiology and Intensive Care Medicine to evaluate real fasting times and the incidence of pulmonary aspiration before a possible revision of national fasting guidelines. After the Ethics Committee's approval, at least 3000children were planned to be enrolled for this analysis. Patient demographics, real fasting times, anesthetic and surgical procedures and occurrence of regurgitation or pulmonary aspiration were documented using a standardized case report form. Results were presented as median [interquartile range] (range) or incidence (percentage). At ten pediatric centers, 3324 children were included between October 2018 and May 2019. The real fasting times for large meals were 14 [12.2-15.6] (0.5-24)hours, for light meals 9 [5.6-13.3] (0.25-28.3)hours, for formula milk 5.8 [4.5-7.4] (0.9-24)hours, for breast milk 4.8 [4.2-6.3] (1.3-25.3)hours and for clear fluids 2.7 [1.5-6] (0.03-22.8)hours. Prolonged fasting (deviation from guideline >2hours) was reported for large meals in 88.3%, for light meals in 54.7%, for formula milk in 44.4%, for breast milk in 25.8% and for clear fluids in 34.2%. Eleven cases (0.33%) of regurgitation, four cases (0.12%) of suspected pulmonary aspiration and two cases (0.06%) of confirmed pulmonary aspiration were reported; all of them could be extubated after the end of the procedure and recovered without any incidents. This study shows that prolonged fasting is still common in pediatric anesthesia in Germany that pulmonary aspiration with postoperative respiratory distress is rare and that improvements to current local fasting regimens and national fasting guidelines are urgently needed.

Chronic Pulmonary Aspiration in Children: Diagnosis and Management

Chronic pulmonary aspiration (CPA) is a common cause of morbidity in children with complex aerodigestive disorders. CPA can be caused by swallowing dysfunction, anatomic, or dynamic abnormalities of the airways, and/or other circumstances that overcome the child's natural capacity to protect the airway. Diagnostic evaluation for suspected aspiration aims to characterize the swallowing function, identify the etiology of aspiration, including anatomic and/or dynamic abnormalities causing aspiration, and evaluate for the development of aspiration sequelae (e.g., bronchiectasis). CPA management approach should be guided by the recognized risk factors and co-morbidities, and directed to decrease the events of aspiration, improve clearance of aspirated material, and limit the development of aspiration sequelae (e.g., chronic inflammation and recurrent infections). This article presents a practical approach for the diagnosis and management of chronic pulmonary aspiration (CPA) in children.

Identification of perioperative pulmonary aspiration in children using quality assurance and hospital administrative billing data.

Perioperative aspiration is a rare but potentially devastating complication, occurring in 1-10 per 10000 anesthetics based on studies of quality assurance databases. Quality assurance reporting is known to underestimate the incidence of adverse outcomes, but few large studies use supplementary data sources. This study aims to identify the incidence of and risk factors for perioperative aspiration in children using quality assurance data supplemented by administrative billing records, and to examine the utility of billing data as a supplementary data source. Aspiration events for children receiving anesthesia at a tertiary care pediatric hospital between 2008 and 2014 were identified using (i) a perioperative quality assurance database and (ii) hospital administrative billing records with International Classification of Diseases, Ninth Revision Clinical Modification coded diagnoses of aspiration. Records were subject to review by pediatric anesthesiologists. Following identification of all aspiration events, the incidence of perioperative aspiration was calculated and risk factors were assessed. 47272 anesthetic cases were evaluated over 7years. The quality assurance database identified 20 cases of perioperative aspiration occurring in surgical inpatients, same-day admissions, and outpatients. Using hospital administrative data (which excludes outpatients with shorter than a 24-hour stay), 9 cases of perioperative aspiration were identified of which 6 had not been found through quality assurance data. Overall, International Classification of Diseases, Ninth Revision coding demonstrated a positive predictive value of 94.5% for any aspiration event; however, positive predictive value was <4% for perioperative aspiration. A total incidence of 5.5 perioperative aspirations per 10000 (95% CI: 3.7-8.0 per 10000) anesthetics was found. Quality assurance data offer an efficient way to measure the incidence of rare events, but may underestimate perioperative complications. International Classification of Diseases, Ninth Revision codes for aspiration used as a secondary data source were nonspecific for perioperative aspiration, but when combined with record review yielded a 30% increase in identified cases of aspiration over quality assurance data alone. The use of administrative data therefore holds potential for supplementing quality assurance studies of rare complications.

Image characteristics and classification of salivagram in the diagnosis of pulmonary aspiration in children.

A salivagram is a common method capable of detecting pulmonary aspiration. This investigation focused on describing the characteristics of salivagram and classifying the image to increase the clinical value of this imaging method. A retrospective analysis was carried out of 428 patients (aged 1-36 months, mean age 4.5 months) diagnosed with respiratory tract infection and suspect pulmonary aspiration subjected to a salivagram, and the resulting images were classified on the basis of their features. The positive rate of aspiration was 24.5% (105 of 428); 53.3% (56 of the 105) of the aspiration patients showed unilateral aspiration and 46.7% (49 of the 105) of the aspiration patients showed bilateral aspiration. In the initial images (appearing within the first 10 min) from the 105 patients showing aspiration, 59% (62 of 105) were from the airway and 82.9% (87 of 105) were from the stomach. The images were classified by grade (0-4) according to the degree of the aspiration, where a higher grade of aspiration is related to a longer course of disease (P=0.041; R=0.919). A deeper understanding of the image characteristics is helpful for those seeking to further utilize salivagram. The creation of an image classification system allows for image information to be more accurately expressed and can guide clinical diagnosis and treatment.

Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite.

International guidelines recommend 2 h of clear fluid fasting prior to general anesthesia. The pediatric anesthesia unit of Uppsala University Hospital has been implementing a more liberal fasting regime for more than a decade; thus, children scheduled for elective procedures are allowed to drink clear fluids until called to the operating suite. To determine the incidence of perioperative pulmonary aspiration in pediatric patients allowed unlimited intake of clear fluids prior to general anesthesia. Elective pediatric procedures between January 2008 and December 2013 were examined retrospectively by reviewing anesthesia charts and discharge notes in the electronic medical record system. All notes from the care event and available chest x-rays were examined for cases showing vomiting, regurgitation, and/or aspiration. Pulmonary aspiration was defined as radiological findings consistent with aspiration and/or postoperative symptoms of respiratory distress after vomiting during anesthesia. Of the 10,015 pediatric anesthetics included, aspiration occurred in three (0.03% or 3 in 10,000) cases. No case required cancellation of the surgical procedure, intensive care or ventilation support, and no deaths attributable to aspiration were found. Pulmonary aspiration was suspected, but not confirmed by radiology or continuing symptoms, in an additional 14 cases. Shortened fasting times may improve the perioperative experience for parents and children with a low risk of aspiration.

Salivary Amylase Level in Bronchoalveolar Fluid as a Marker of Chronic Pulmonary Aspiration in Children.

Background: Chronic pulmonary aspiration is a common cause of chronic respiratory symptoms in children. However, there is no gold standard diagnostic test for aspiration. In this study, we explore the diagnostic value of measuring salivary amylase in bronchoalveolar lavage (BAL) fluid as a marker of chronic aspiration in children with different chronic respiratory illnesses. Methods: Measurements of salivary amylase in BAL fluid were routinely done in patients undergoing flexible bronchoscopy. Patients' demographic and clinical data were extracted from records and reviewed by one of the investigators. Patients were classified into three different groups based on the reviewer's assessment of risk for aspiration. BAL amylase measurements were masked from the reviewer. Multiple regression analysis was used to determine the effect of the patients' clinical variables on BAL amylase. Results: Sixty-four patients (median age 2 years; range 0-14 years) were included. Indications for bronchoscopy included chronic cough (n=20), chronic wheezing (n=27), Cystic Fibrosis (n=6), recurrent pneumonia (n=5), and lung infiltrate in immunocompromised patients (n=6). Young age, history of excessive drooling, and wet cough were predictive of high BAL amylase. Thirteen patients were considered at no risk of aspiration, 41 patients were at low risk, and 10 patients were at high risk based on clinical symptoms and other diagnostic tests. No significant differences in BAL amylase levels were found between the three groups. However, when high and low risk groups were combined and compared to the no risk group, there was a significantly higher BAL amylase level in the combined at risk groups (1,722 vs. 307 U/L; p=0.03). Receiver operator curve analysis demonstrated that amylase cutoff value of 250 U/L differentiates between the two risk groups with sensitivity of 66.7% and specificity of 69.2%. Conclusion: Salivary amylase level in BAL can help identify children at risk for chronic pulmonary aspiration.

Salivagram revisited: justifying its routine use for the evaluation of persistent/recurrent lower respiratory tract infections in developmentally normal children

To assess and establish the utility of radionuclide salivagram in the routine evaluation of developmentally normal children with persistent/recurrent lower respiratory tract infection. 113 neurodevelopmentally normal children diagnosed with persistent/recurrent lower respiratory tract infection underwent a salivagram and a milk scan on two consecutive days. Frequency of detection of pulmonary aspiration by either procedure individually and increment in detection rates on combining the two were assessed. The agreement between the tests was also studied. Antegrade pulmonary aspiration was demonstrated using the salivagram in 39.2 % of infants and 16.1 % of children between the ages of 1 and 2 years. No antegrade aspiration was seen in children above the age of 2 years. 44 % of all antegrade aspirations identified were bilateral, while remaining 66 % were into the right lung. Milk scan revealed gastroesophageal reflux in 38 % of children and most commonly in those above the age of 2 years. Diagnosis of pulmonary aspiration as an underlying cause of the lung pathology increased from 38 % with the use of milk scan alone to 53.9 % on combining the procedures. There was a poor agreement between the two procedures (kappa -0.103). Antegrade pulmonary aspiration can be demonstrated as an underlying cause for persistent/recurrent lower respiratory tract infection in developmentally normal children, with age being an important clinical predictor. Combined use of salivagram and milk scan is warranted to objectively evaluate pulmonary aspiration in children.

The lipid laden macrophage index as a marker of aspiration in patients with type I and II laryngeal clefts

Objectives Laryngeal clefts are uncommon congenital anomalies that may cause pulmonary aspiration, leading to considerable morbidity including recurrent pneumonias. The lipid laden macrophage index (LLMI) is a potential marker of pulmonary aspiration. The objective of this study was to assess the utility of the lipid laden macrophage index as a marker of severity of pulmonary aspiration in children with laryngeal clefts and its role in the management of these patients. Methods An institutional review board approved retrospective review of all patients with laryngeal cleft who had also underwent direct laryngoscopy with rigid bronchoscopy and flexible bronchoscopy with bronchoalveolar lavage. The LLMI was measured from the lavage and compared to clinical and radiological data. Results Forty-four patients with laryngeal clefts (31 type I clefts and 13 type II clefts) underwent assessment with flexible bronchoscopy and bronchoalveolar lavage. The median age at first outpatient visit in our Center for Aero-digestive Disorder was 0.92 years in patients with type I clefts and 1.66 years in patients with type 2 clefts. All patients in this study had at least one modified barium swallow (MBS) performed to assess for aspiration. The mean LLMI was significantly higher in patients with type II (mean ± SEM) 81.8 ± 11.9 clefts compared to type I clefts 44.9 ± 5.6. Conclusions We recommend obtaining LLMI in patients with laryngeal cleft. The lipid laden macrophage index is increased in patients with more severe laryngeal clefts, thus potentially predicting those patients whom would most benefit from early surgical intervention.

Pepsin measured in induced sputum—a test for pulmonary aspiration in children?

Purpose The purpose of this study was to investigate if pepsin measured in sputum is a useful marker of pulmonary aspiration secondary to gastroesophageal reflux (GER) in children. It is possible that the induced sputum procedure could cause GER and invalidate the results. The hypothesis stated that healthy children (those without history of respiratory or gastroesophageal symptoms) would not have pepsin detected in induced sputum. Methods Children attending surgical outpatients in the Royal Belfast Hospital for Sick Children (Belfast, Northern Ireland) were recruited. After spirometry, sputum was obtained by induction with hypertonic 3% saline. Spirometry was repeated, and complications were noted. An “in-house” enzyme-linked immunosorbent assay was used to measure pepsin concentration in sputum. The lower limit of detection of pepsin was 1.19 ng/mL. Results Children (n = 21) aged 4 to 16 years were recruited. Twenty children completed the study. No adverse effects were reported. Pepsin was detected in 17 (85%) of 20 sputum samples. Conclusions The act of sputum induction appears to induce physiologic GER in a healthy childhood population. The analysis of pepsin in sputum obtained by sputum induction is therefore not useful in the investigation of reflux-related respiratory disease.

Salivary gland surgery for control of chronic pulmonary aspiration in children with cerebral palsy

To evaluate the outcome of surgical saliva reduction to decrease pulmonary aspiration in children with cerebral palsy and its repercussions in respiratory infection control. Twenty-nine children with neurological impairment and diagnosis of chronic pulmonary aspiration were submitted to bilateral submandibular gland excision and bilateral parotid duct ligation at the Association for the Welfare of Physically Handicapped Children, from December 2001 to December 2004. Postoperative frequency of lower respiratory tract infection, hospitalization rate due to pulmonary infection and airway secretion level after the surgery were compared to preoperative period. Twenty-nine children with cerebral palsy aged 18 months to 9 years were submitted to submandibular glands excision and parotid ducts ligation. All children had gastrostomy and no oral intake. There were no major complications; two children had reopening of one parotid duct. Frequency of lower respiratory tract infections, rate of hospitalization for treatment of pulmonary infections and level of airway secretion were statistically reduced. Preoperative mean rate of lower respiratory tract infection was 6.9/year; in postoperative period, rate was 2.4/year (p<0.001). Pneumonia hospitalization mean rate was 63.4 days/year preoperatively and 17.5 days/year postoperatively (p<0.001). There was also a significant improvement in the need for suctioning of upper airway secretion (mean 11 times/day in preoperative period and 3.1 times/day in the postoperative period; p<0.001). In children with cerebral palsy, surgical saliva reduction by submandibular glands excision and parotid ducts ligation is an effective and safe technique for frequency reduction of lower respiratory tract infection and level of airway secretion.

EDITORIAL

I am pleased to announce that Dr Jeremy Brown has recently joined our team of Associate Editors. Dr Brown is Senior Lecturer at the Centre for Respiratory Research at the University College London and his main area of research is the molecular pathogenesis of infections due to Streptococcus pneumoniae and the mechanisms of lung innate immunity. His main clinical interests are infectious diseases affecting the lung, including pneumonia, bronchiectasis, tuberculosis and infections in the immuno-compromised host. We are looking forward to his contribution to the Journal. The Editorial Office team needs to expand due to the significant growth in the Journal and employing some extra staff is long overdue. We are pleased to welcome Dr Christel Norman back from maternity leave. She will be working part-time in the Editorial Office, providing valuable assistance in managing the Journal. We are equally delighted to welcome Ms Joyanne Kelly to the Editorial Office team. Joyanne has just submitted her PhD at The University of Western Australia in the field of applied cancer research. She will take over the Administrative Editor role from Dr Neil Misso, who has relinquished this part of his Editorial Office duties. Neil's assistance over the past year has been invaluable and we are pleased that he will continue to contribute his expertise to the Journal through editing accepted papers. The first highlight in this issue is the paper ‘Evaluation of the anti-inflammatory effect of infliximab in a mouse model of acute asthma’ by Dr Deveci and colleagues, showing that the anti-tumour necrosis factor (TNF)-α mAb (infliximab) has a considerable anti-inflammatory effect on allergen-induced lung inflammation. This study emphasizes the potential for inhibition of TNF-α with infliximab as a therapeutic strategy. The second highlight in this issue, ‘Common functional polymorphisms in the cathepsin S promoter in Japanese subjects: Possible contribution to pulmonary emphysema’ by Dr Minematsu and colleagues, identifies novel functional polymorphisms in the cathepsin S gene, which has a possible association with pulmonary emphysema in the Japanese population. In ‘Procalcitonin is a valuable prognostic marker in ARDS caused by community-acquired pneumonia’, Dr Tseng and colleagues evaluate the role of procalcitonin in predicting the outcome of patients with ARDS caused by severe community-acquired pneumonia and confirmed it is a valuable biomarker for predicting mortality. The following two highlights in this issue present the results of literature meta-analyses. The meta-analysis performed by Dr Shi and colleagues in ‘Diagnostic value of carcinoembryonic antigen in malignant pleural effusion: A meta-analysis’ shows that carcinoembryonic antigen measurement is a useful tool in the diagnosis of malignant pleural effusions, and can assist in differentiating between malignant pleural mesothelioma and metastatic lung cancer. The second meta-analysis ‘Observational studies on the effect of dietary antioxidants on asthma: A meta-analysis’, undertaken by Professor Gao and colleagues, examines the association between dietary intake of the antioxidants vitamins C and E and β carotene, and the risk of asthma. The paper by Dr Hallani and colleagues ‘Enforced mouth breathing decreases lung function in mild asthmatics’ explores the impact of mouth versus nose breathing in a group of mild asthmatic subjects at rest. This study demonstrates that enforced oral breathing causes a decrease in lung function in these asthmatics, with some subjects initiating asthma symptoms. In ‘Arterial blood lactate is a useful guide to when rehabilitation should be instigated in COPD’, Dr Tanaka and colleagues evaluated the increase in lactate concentration during the early phase of exercise as an index for determining when to start pulmonary rehabilitation in COPD patients, as well as for determining muscle fatigue in the lower extremities of those patients undergoing rehabilitation. In the Short Communication ‘Neutrophil elastase activity in acute lung injury and respiratory distress syndrome’, Dr Hashimoto and colleagues investigate the role of neutrophil elastase in acute lung injury and acute respiratory distress syndrome, by treating patients with the selective neutrophil inhibitor sivelestat. Finally, the technical report by Dr Pinto and colleagues ‘Diagnosis of pulmonary aspiration—a mouse model using a starch granule test in bronchoalveolar lavage’ shows that the detection of starch granules in bronchoalveolar lavage may be a more specific way of diagnosing pulmonary aspiration in children than the less specific lipid-laden macrophages method, which is currently used in clinical practice. I hope you will enjoy this issue of Respirology.

Salivary gland surgery for chronic pulmonary aspiration in children

Chronic aspiration in the neurologically impaired child has a considerable morbidity and occasional morbidity. Hospitalization, physician visits and health costs associated with the sequelae of aspiration are considerable. To assess the efficacy of salivary gland surgery to treat chronic aspiration in children. Tertiary pediatric center. A 6 year retrospective chart review of all patients undergoing salivary gland surgery to treat chronic aspiration. (1) Rate of lower respiratory tract infection (LRTI); (2) baseline oxygen saturation pre- and post-surgery. Sixty-two patients aged 7-279 months (mean 68 months) underwent four duct ligation or bilateral submandibular gland excision with unilateral or bilateral parotid duct ligation. The mean rate was 1.2/year pre-operatively and 0.7/year post-operatively (p=0.6). There was, however, a significant improvement in the baseline post-operative oxygen saturation (mean 94.3%) when compared to the pre-operative baseline oxygen saturation (mean 92.8%, p=0.003). Analysis of the cerebral palsy subgroup was performed (n=13). In this group there was no difference between mean pre- and post-operative LRTI rate (p=0.5) nor change in baseline oxygen saturation (p=0.83). Children under 3 years of age showed a reduction in the LRTI rate (mean of 2.1 versus 0.7 episodes per year, p=0.04) and an improvement in the post-operative baseline oxygen saturation (p=0.001) following surgery. Unlike a previous publication from this institution, when evaluating the population sample as a whole, there was no significant improvement in the rate of LRTI following salivary gland surgery, however, there was an improvement in baseline oxygen saturation, possibly reflecting an improvement in lung function. There was an improvement in neither outcome parameter in children with cerebral palsy and improvements in both outcome measures in children under the age of 3.

Advances in the diagnosis and management of chronic pulmonary aspiration in children

Chronic pulmonary aspiration (CPA) in children is an important cause of recurrent pneumonia, progressive lung injury, respiratory disability and death. It is sporadic, intermittent and variable, and often occurs in children with complicated underlying medical conditions and syndromes that produce symptoms indistinguishable from CPA. For most types of aspiration there is no gold-standard diagnostic test. The diagnosis of CPA is currently made clinically with some supporting diagnostic evaluations, but often not until significant lung injury has been sustained. Despite multiple diagnostic techniques, the diagnosis or exclusion of CPA in children is challenging. This is of particular concern given the outcome of unrecognised progressive lung injury and the invasiveness of definitive therapies. Although new techniques have been introduced since the 1990s and significant advances in the understanding of dysphagia and gastro-oesophageal reflux have been made, characterisation of the aspirating child remains elusive.

R156: Chronic Pulmonary Aspiration in Children with Tracheotomy

R156: Chronic Pulmonary Aspiration in Children with Tracheotomy

Intractable pulmonary aspiration in children: Which operation?

Intractable aspiration is a life-threatening medical problem. There are many surgical procedures for the treatment of intractable aspiration. Our experience with three children was reported here. After failing initial conservative measures, the first two patients had supraglottic laryngeal closure performed through an endoscopic approach with a small hole left superiorly for phonation. However, both of them developed dehiscence of the closure postoperatively, necessitating a more definitive procedure to stop the aspiration. Their symptoms of aspiration were only relieved after they underwent laryngotracheal separation. In the third child, laryngotracheal separation was performed as the initial procedure and the symptoms of recurrent aspiration were relieved. In conclusion, the treatment of intractable aspiration requires a definitive procedure from the outset and we would suggest, based on literature review and on our experience, that laryngotracheal separation is the most effective and reliable option, albeit lack of phonation is inevitable. A comprehensive review of all procedures used for treatment of this condition was also undertaken.

Perioperative pulmonary aspiration in infants and children.

Pulmonary aspiration of gastric contents during the perioperative period in infants and children may be associated with postoperative mortality or pulmonary morbidity. There has not been a recent determination of the frequency of this event and its outcomes in infants and children. The authors prospectively identified all cases of pulmonary aspiration of gastric contents during the perioperative courses of 56,138 consecutive patients younger than 18 yr of age who underwent 63,180 general anesthetics for procedures performed in all surgical specialties from July 1985 through June 1997 at the Mayo Clinic. Pulmonary aspiration occurred in 24 patients (1: 2,632 anesthetics; 0.04%). Children undergoing emergency procedures had a greater frequency of pulmonary aspiration compared to those undergoing elective procedures (1:373 vs. 1:4,544, P < 0.001). Fifteen of the 24 children who aspirated gastric contents did not develop respiratory symptoms within 2 h of aspiration, and none of these 15 developed pulmonary sequelae. Five of these nine children who aspirated and in whom respiratory symptoms developed within 2 h subsequently had pulmonary complications treated with respiratory support (P < 0.003). Three children were treated with mechanical ventilation for more than 48 h, but no child died of sequelae of pulmonary aspiration. In this study population, the frequency of perioperative pulmonary aspiration in children was quite low. Serious respiratory morbidity was rare, and there were no associated deaths. Infants and children with clinically apparent pulmonary aspiration in whom symptoms did not develop within 2 h did not have respiratory sequelae.

Perioperative pulmonary aspiration in children: a review

SummaryThe incidence of significant pulmonary aspiration in children is very low. Factors determining risk include the anaesthetist's experience, the child's ASA status, gastro‐oesophageal disease, obesity, intra‐abdominal obstruction, emergencies, trauma and the occurrence of laryngospasm. The diagnosis of pulmonary aspiration may be confused with post‐obstructive pulmonary oedema. Several approaches to risk reduction can be used and include appropriate pre‐operative fasting, acid aspiration prophylaxis and anaesthetic management. The widespread use of acid aspiration prophylaxis cannot be justified. Less emphasis should be placed on the ‘cut‐off’ values for gastric fluid contents of pH 2.5 and volume 0.4 ml·kg−1 in defining aspiration risk. Clear fluid fasts beyond 2–3 h do not result in reduced gastric fluid volume and if prolonged can be potentially harmful. It seems appropriate to use this interval in fasting guidelines for clear fluids. Recommended guidelines for solids vary from 4 h to no solids on the day of surgery.