Aspiration Pneumonia

Evaluation of the therapeutic effect of high-flow nasal cannula oxygen therapy on patients with aspiration pneumonia accompanied by respiratory failure in the post-stroke sequelae stage

Background

The aim of the present study was to evaluate the therapeutic effect of high-flow nasal cannula (HFNC) oxygen therapy on patients with aspiration pneumonia accompanied by respiratory failure in the post-stroke sequelae stage, with the goal of providing more effective oxygen therapy and improving patient prognosis.

Methods

Retrospective analysis was conducted on 103 elderly patients with post-stroke aspiration pneumonia and moderate respiratory failure (oxygenation index: 100–200 mmHg) that had been admitted. The patients were divided into two groups according to the mode of oxygen therapy that was used: the Venturi mask group and the HFNC treatment group. The two groups were analyzed and compared in terms of the changes in the blood gas indices measured at different points in time (4, 8, 12, 24, 48, and 72 h), the proportion of patients that required transition to invasive auxiliary ventilation, and the 28-day mortality rate.

Results

A total of 103 patients were retrospectively analyzed; 16 cases were excluded, and 87 patients were included in the final patient group (42 in the HFNC group and 45 in the Venturi group). There was a statistically significant difference in the oxygenation indices of the HFNC group and the Venturi group (F = 546.811, P < 0.05). There was a statistically significant interaction between the monitored oxygenation indices and the mode of oxygen therapy (F = 70.961, P < 0.05), and there was a statistically significant difference in the oxygenation indices for the two modes of oxygen therapy (F = 256.977, P < 0.05). HFNC therapy contributed to the improvement of the oxygenation indices at a rate of 75.1%. The Venturi and HFNC groups also differed significantly in terms of the proportion of patients that required transition to invasive auxiliary ventilation within 72 h (P < 0.05). The HFNC group’s risk for invasive ventilation was 0.406 times that of the Venturi group (P < 0.05). There was no statistical difference in the 28-day mortality rate of the two groups (P > 0.05).

Conclusion

HFNC could significantly improve the oxygenation state of patients with post-stroke aspiration pneumonia and respiratory failure, and it may reduce the incidence of invasive ventilation.

The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair

BACKGROUND

Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair.

METHODS

Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications.

RESULTS

Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small.

CONCLUSION

Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.

Clinicopathologic and radiographic features in 33 cats with aspiration and 26 cats with bronchopneumonia (2007-2017)

Background

Aspiration pneumonia (AP) and bronchopneumonia (BP) are poorly characterized diseases in cats that share clinical similarities to inflammatory airway disease (IAD).

Objectives

Describe clinicopathologic, radiographic, and microbiologic features in cats with AP and BP and compare findings to those in cats with IAD.

Animals

Thirty‐three cats with AP and 26 with BP; 44 cats with IAD.

Methods

Retrospective case‐control study. Results extracted for all cats included signalment, physical examination findings, historical details, and potential risk factors for aspiration. Diagnostic test results were summarized including CBC, bronchoalveolar (BAL) fluid analysis and microbial culture. Radiographs were reviewed in masked fashion and scored for severity. Results of BAL fluid analysis were assessed for evidence of septic inflammation.

Results

Cats with AP were less likely to be presented for evaluation of cough (P < .001) and more likely to be hypothermic (P = .01) than were cats with IAD or BP. Median duration of signs was significantly shorter in cats with AP (12 days) compared to cats with BP or IAD (270 and 180 days; P = .01). Radiographically, cats with AP were more likely to have an alveolar pattern and higher total score than were cats with BP or IAD. Mycoplasma spp. were the organisms most commonly cultured from BAL fluid in cats with BP, but were not cultured from any cats with AP.

Conclusion and Clinical Importance

Pneumonia must be distinguished from IAD in cats with cough and AP should be considered in cats with acute onset of tachypnea.

Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review

Background

It is customary to believe that a patient with a Glasgow Coma Scale (GCS) score less than or equal to 8 should be intubated to avoid aspiration. We conducted a systematic review to establish if patients with GCS ≤ 8 for trauma or non-traumatic emergencies and treated in the acute care setting (e.g., Emergency Department or Pre-hospital environment) should be intubated to avoid aspiration or aspiration pneumonia/pneumonitis, and consequently, reduce mortality.

Methods

We searched six databases, Pubmed, Embase, Scopus, SpringerLink, Cochrane Library, and Ovid Emcare, from April 15th to October 14th, 2020, for studies involving low GCS score patients of whom the risk of aspiration and related complications was assessed.

Results

Thirteen studies were included in the final analysis (7 on non-traumatic population, 4 on trauma population, 1 pediatric and 1 adult mixed case studies). For the non-traumatic cases, two prospective studies and one retrospective study found no difference in aspiration risk between intubated and non-intubated patients. Two retrospective studies reported a reduction in the risk of aspiration in the intubated patient group. For traumatic cases, the study that considered the risk of aspiration did not show any differences between the two groups. A study on adult mixed cases found no difference in the incidence of aspiration among intubated and non-intubated patients. A study on pediatric patients found increased mortality for intubated versus non-intubated non-traumatic patients with a low GCS score.

Conclusion

Whether intubation results in a reduction in the incidence of aspiration events and whether these are more frequent in patients with low GCS scores are not yet established. The paucity of evidence on this topic makes clinical trials justifiable and necessary.

Trial registration

Prospero registration number: CRD42020136987.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-020-00814-w.

Recurrent aspiration pneumonia precipitated by obstructive sleep apnea

OBJECTIVE

The clearance of the pharynx by deglutition and the respiratory phase patterns associated with deglutition are important in protecting airways and lungs against aspiration. The deglutition and respiratory phase patterns during sleep in patients (without swallowing disorders while awake) with obstructive sleep apnea (OSA) precipitating recurrent intractable aspiration pneumonia were investigated.

METHODS

After videoendoscopic and videofluorographic examinations of swallowing showed subjects had no swallowing disorders while awake, two adults with recurrent intractable aspiration pneumonia precipitated by severe OSA were examined via time-matched digital recordings of polysomnography and surface electromyography of the muscles (thyrohyoid and suprahyoid muscles) related to swallowing and compared with the same patients before and under CPAP therapy.

RESULTS

CPAP therapy cured recurrent intractable aspiration pneumonia. Swallows following and/or followed by inspiration (uncoordinated deglutition with respiration), which were frequently observed before CPAP therapy, were markedly reduced under CPAP therapy. On the other hand, swallows following and/or followed by expiration (coordinated deglutition with respiration) markedly increased under CPAP therapy. Deglutition was related to the sleep stage. The deeper the sleep stage, the lower the deglutition frequency. Before and under CPAP therapy, swallowing was infrequent and absent for long periods. However, respiratory phase patterns associated with sleep-related deglutition in patients with OSA under CPAP therapy markedly improved.

CONCLUSIONS

In patients (without swallowing disorders while awake) with OSA precipitating recurrent intractable aspiration pneumonia, the high rate of uncoordinated deglutition with respiration (swallows following and/or followed by inspiration) during sleep were markedly reduced and the rate of coordinated deglutition with respiration (swallows following and/or followed by expiration) was markedly increased under CPAP therapy. Sleep-related deglutition and respiratory phase patterns are likely to adversely influence aspiration pneumonia in patients with OSA. CPAP therapy improved not only apnea-hypopnea during sleep and sleep quality but also sleep-related deglutition, especially respiratory phase patterns associated with deglutition in patients with OSA. CPAP therapy may decrease the risk of aspiration and greatly improve aspiration-related diseases such as aspiration pneumonia.

Comparison of physical properties of voluntary coughing, huffing and swallowing in healthy subjects

Coughing, huffing and swallowing protect the airway from aspiration. This study was conducted to compare the physical properties of voluntary coughing, huffing and swallowing in healthy subjects. Ten healthy men were asked to huff, cough and swallow repeatedly. Electromyograms (EMGs) were recorded from the left side of the external oblique (EO), sternocleidomastoid, suprahyoid (SH) and thyrohyoid muscles. Airflow was recorded using a face mask with two-way non-rebreathing valves. The expiratory velocity of huffing and coughing and the SH EMG of all actions presented high intraclass correlation coefficients (> 0.8). The inspiratory and expiratory velocities did not differ significantly between coughing and huffing. The expiratory acceleration of coughing was significantly higher than that of huffing, whereas the expiratory volume of coughing was significantly smaller than that of huffing. The EO EMG of coughing and huffing were significantly larger than that of swallowing. The EO EMG activity during the expiratory phase was significantly higher than that of the other phases of both coughing and huffing. The SH EMG of coughing and huffing were significantly smaller than that of swallowing. Correlation analysis revealed that the expiratory velocity of coughing was strongly positively correlated with that of huffing. The expiratory volume of huffing was significantly positively correlated with hand grip strength. These results suggest that EO and SH muscle activities during huffing or coughing differ those during swallowing, and huffing and coughing may work similarly in expiratory function.

Review of the Chest CT Differential Diagnosis of Ground-Glass Opacities in the COVID Era

Coronavirus disease 2019 (COVID-19), a recently emerged lower respiratory tract illness, has quickly become a pandemic. The purpose of this review is to discuss and differentiate typical imaging findings of COVID-19 from those of other diseases, which can appear similar in the first instance. The typical CT findings of COVID-19 are bilateral and peripheral predominant ground-glass opacities. As per the Fleischner Society consensus statement, CT is appropriate in certain scenarios, including for patients who are at risk for and/or develop clinical worsening. The probability that CT findings represent COVID-19, however, depends largely on the pretest probability of infection, which is in turn defined by community prevalence of infection. When the community prevalence of COVID-19 is low, a large gap exists between positive predictive values of chest CT versus those of reverse transcriptase polymerase chain reaction. This implies that with use of chest CT there are a large number of false-positive results. Imaging differentiation is important for management and isolation purposes and for appropriate disposition of patients with false-positive CT findings. Herein the authors discuss differential pathology with close imaging resemblance to typical CT imaging features of COVID-19 and highlight CT features that may help differentiate COVID-19 from other conditions.

Risk factors for aspiration pneumonia in patients with dysphagia undergoing videofluoroscopic swallowing studies: A retrospective cohort study

Prediction of aspiration pneumonia development in at-risk patients is vital for implementation of appropriate interventions to reduce morbidity and mortality. Unfortunately, studies utilizing a comprehensive approach to risk assessment are still lacking. The objective of this study was to analyze the clinical features and videofluoroscopic swallowing study (VFSS) findings that predict aspiration pneumonia in patients with suspected dysphagia.Medical records of 916 patients who underwent VFSS between September 2014 and June 2018 were retrospectively analyzed. Patients were divided into either a pneumonia group or a non-pneumonia group based on diagnosis of aspiration pneumonia. Clinical information and VFSS findings were evaluated.One hundred seven patients (11.7%) were classified as having pneumonia. Multivariate analysis indicated that aspiration during the 2- cubic centimeter thick-liquid trial of VFSS (odds ratio [OR] = 3.23, 95% confidence interval [CI]: 1.93-5.41), smoking history (OR = 2.63, 95% CI: 1.53-4.53), underweight status (OR = 2.27, 95% CI: 1.31-3.94), abnormal pharyngeal delay time (OR = 1.60, 95% CI: 1.01-2.53), and a Penetration-Aspiration Scale level of 8 (OR = 3.73, 95% CI: 2.11-6.59) were significantly associated with aspiration pneumonia development. Integrated together, these factors were used to develop a predictive model for development of aspiration pneumonia (DAP), with a sensitivity of 82%, specificity of 56%, and an area under the receiver operating characteristic curve of 0.73.The best predictors for DAP included videofluoroscopic findings of aspiration during a 2-cubic centimeter thick-liquid trial, prolonged pharyngeal delay time, a Penetration-Aspiration Scale level of 8, history of smoking, and underweight status. These 5 proposed determinants and the associated DAP score are relatively simple to assess and may constitute a clinical screening tool that can readily identify and improve the management of patients at risk for aspiration pneumonia.

Oral Health, Oral Microbiota, and Incidence of Stroke-Associated Pneumonia-A Prospective Observational Study

Stroke-associated pneumonia is a major cause for poor outcomes in the post-acute phase after stroke. Several studies have suggested potential links between neglected oral health and pneumonia. Therefore, the aim of this prospective observational study was to investigate oral health and microbiota and incidence of pneumonia in patients consecutively admitted to a stroke unit with stroke-like symptoms. This study involved three investigation timepoints. The baseline investigation (within 24 h of admission) involved collection of demographic, neurological, and immunological data; dental examinations; and microbiological sampling (saliva and subgingival plaque). Further investigation timepoints at 48 or 120 h after baseline included collection of immunological data and microbiological sampling. Microbiological samples were analyzed by culture technique and by 16S rRNA amplicon sequencing. From the 99 patients included in this study, 57 were diagnosed with stroke and 42 were so-called stroke mimics. From 57 stroke patients, 8 (14%) developed pneumonia. Stroke-associated pneumonia was significantly associated with higher age, dysphagia, greater stroke severity, embolectomy, nasogastric tubes, and higher baseline C-reactive protein (CRP). There were trends toward higher incidence of pneumonia in patients with more missing teeth and worse oral hygiene. Microbiological analyses showed no relevant differences regarding microbial composition between the groups. However, there was a significant ecological shift over time in the pneumonia patients, probably due to antibiotic treatment. This prospective observational study investigating associations between neglected oral health and incidence of SAP encourages investigations in larger patient cohorts and implementation of oral hygiene programs in stroke units that may help reducing the incidence of stroke-associated pneumonia.

Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles?

Ventilator-associated pneumonia (VAP) is related with high mortality, duration of mechanical ventilation and costs. Recent studies have questioned the safety and effectiveness of oral chlorhexidine to prevent VAP. We sought to verify whether the adverse effects of this substance outweigh its benefits. We searched several databases and selected studies that investigated the use of oral chlorhexidine and its impact on mortality. No association between oral chlorhexidine and lower VAP rates was found on meta-analyses of double-blind randomized trials, however significant increase in mortality was reported. It is speculated that chlorhexidine can cause damage to several organic sectors and cytotoxicity. Although it still can be beneficial in specific settings, robust evidence to recommend its routine application for all mechanically ventilated patients is lacking; therefore, given the possibility of harm, it would be better to follow the principle of non-maleficence until more studies becomes available.

The Modified Volume-Viscosity Swallow Test as a Predictor of Aspiration Pneumonia after Acute Ischemic Stroke

OBJECTIVES

Dysphagia is common in patients with acute ischemic stroke patients (AIS) and it increases the risk of aspiration pneumonia after AIS. The volume-viscosity swallow test (V-VST) is a useful dysphagia screening tool. Therefore, we aim to explore the association between dysphagia (using the modified V-VST) and aspiration pneumonia in acute ischemic stroke patients.

PATIENTS AND METHODS

All patients with acute ischemic stroke (AIS) admitted during 1 January 2018 and 31 December 2018 were screened in this study by completing the modified V-VST within 24 hours after admission. The information of aspiration pneumonia was obtained from electronic medical system (EMS) and discharge notes.

RESULTS

Among 624 AIS patient, there were 152(24.36%) patients who suffered from aspiration pneumonia (95% CI, 20.65% - 27.35%) during hospitalization. Among all of them, patients with both impaired safety and impaired efficacy (HR, 7.53, 95%CI, 3.42-16.58, P < 0.001)) had a higher risk of aspiration pneumonia than those with only safety impaired (HR, 2.38, 95%CI, 1.40-4.04, P < 0.001) or only efficacy impaired (HR, 2.47, 95%CI, 1.33-4.57, P = 0.004). The risk of aspiration pneumonia was also associated with their completed volume at each viscosity. The patients with all impairment of three viscosities were also found to be related to the higher risk of developing aspiration pneumonia (P = 0.029).

CONCLUSIONS

The Modified V-VST is an easy-hand on, reliable screening tool for dysphagia among patients with AIS. Patient subgroup analyses based on the modified V-VST might be able to predict the risk of aspiration pneumonia during hospitalization.

COVID-19 and renin-angiotensin system inhibition: role of angiotensin converting enzyme 2 (ACE2) - Is there any scientific evidence for controversy?

Renin-angiotensin system (RAS) blockers are extensively used worldwide to treat many cardiovascular disorders, where they are effective in reducing both mortality and morbidity. These drugs are known to induce an increased expression of angiotensin-converting enzyme 2 (ACE2). ACE2 acts as receptor for the novel SARS coronavirus-2 (SARS-CoV-2) which raising the important issue of possible detrimental effects that RAS blockers could exert on the natural history and pathogenesis of the coronavirus disease-19 (COVID-19) and associated excessive inflammation, myocarditis and cardiac arrhythmias. We review the current knowledge on the interaction between SARS-CoV-2 infection and RAS blockers and suggest a scientific rationale for continuing RAS blockers therapy in patients with COVID-19 infection.

Ingredients of Jelly Products Affect Aspiration-Related Pulmonary Inflammation; in an Animal Study

Diet modification is an important intervention in the management of patients with dysphagia. Food entering the airway, same as oral bacterium, causes pulmonary inflammation; therefore, the elucidation of inflammatory responses to different foods is important. This study aimed to investigate the differences in the severity of inflammatory response induced by intratrachial injection of foods with different nutritional components. Two jelly products, the one containing only carbohydrates (KURIN jelly: Isocal Jelly KURIN^®) and the other containing carbohydrates, proteins, and lipids (HC jelly: Isocal Jelly HC^®), were prepared. These jelly products (dilution with saline, 50% volume/volume) and saline, as control, were intratracheally administered to Sprague-Dawley rats at a dose of 1 ml/kg (KURIN group (n = 15), HC group (n = 15), Saline group (n = 15)). At 1, 2 and 7 days after administration, lungs were harvested and histological analysis was performed. The severity of induced inflammation was evaluated using the Acute Lung Injury (ALI) score with hematoxylin-eosin staining, and the expression of IL-1β, IL-6 and TNF-α, markers of airway inflammation, were observed with immunostaining. The ALI score in the HC jelly group was significantly higher than the KURIN jelly group and the Saline group (P < 0.01) at 1 and 2 days after administration, while the ALI score in the KURIN jelly group was higher than Saline group only at 2 day after administration. Numerous positive cells for IL-1β, IL-6 and TNF-α were observed only in the HC jelly group at 1 and 2 days after administration. There were no significant histological differences between the three groups at 7 days after administration. Our data suggests that the severity of inflammation caused by aspiration differs depending on the ingredients of the foods, and the nutrients contained in foods might be considered in dietary management for the patients with dysphagia.

Declined Functional Status Prolonged Hospital Stay for Community-Acquired Pneumonia in Seniors

Purpose

Among senior community-acquired pneumonia (CAP) survivors, functional status after hospitalization is often decreased. This study investigated the change of functional status affecting delayed discharge.

Patients and Methods

This retrospective observational study was conducted in two medical facilities from January 2016 to December 2018. Hospitalized CAP patients >64 years old were divided into two groups: an early group discharged ≤1 week after ending antibiotic treatment and a delayed group discharged >1 week after ending antibiotic treatment. The primary outcome was decline in functional status.

Results

The early group comprised 170 patients and the delayed group comprised 155 patients (median age: 78 vs 82 years; p = 0.007). Distribution of the causative microorganisms and initial prescription of antibiotics showed no significant differences in the two groups (p=0.38; p=0.83, respectively) More patients showed decline in functional status in the delayed group than the early group (16 (9.4%) vs 49 (31.6%), p<0.001), even if rehabilitation was more frequently conducted (77 (45.3%) vs 118 (76.1%); p<0.001). Higher medical expenses were observed in the delayed group ($8631 vs $3817, respectively; p<0.001). Multivariable regression analysis of factors contributing delayed discharge revealed that decreased functional status, pneumonia severity index (PSI) categories, rehabilitation enrolled, aspiration and age were independently associated with delayed discharge (odds ratio 4.31, 95% confidence interval (CI) 2.32–7.98; 2.34, 95% CI 1.43–3.82; 15.96, 95% CI 4.56–55.82 (PSI V vs II); 2.48, 95% CI 1.11–5.98; and 1.03, 95% CI 1.01–1.06; respectively).

Conclusion

Functional status decline was independently associated with extended hospitalization.

Normal Respiratory Flora as a Cause of Community-Acquired Pneumonia

Background

Intensive studies have failed to identify an etiologic agent in >50% cases of community-acquired pneumonia (CAP). Bacterial pneumonia follows aspiration of recognized bacterial pathogens (RBPs) such as Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus after they have colonize the nasopharynx. We hypothesized that aspiration of normal respiratory flora (NRF) might also cause CAP.

Methods

We studied 120 patients hospitalized for CAP who provided a high-quality sputum specimen at, or soon after admission, using Gram stain, quantitative sputum culture, bacterial speciation by matrix-assisted laser desorption ionization time-of-flight, and viral polymerase chain reaction. Thresholds for diagnosis of bacterial infection were ≥10⁵ colony-forming units (cfu)/mL sputum for RBPs and ≥10⁶ cfu for NRF.

Results

Recognized bacterial pathogens were found in 68 of 120 (56.7%) patients; 14 (20.1%) of these had a coinfecting respiratory virus. Normal respiratory flora were found in 31 (25.8%) patients; 10 (32.2%) had a coinfecting respiratory virus. Infection by ≥2 RBPs occurred in 10 cases and by NRF together with RBPs in 13 cases. Among NRF, organisms identified as Streptococcus mitis, which share many genetic features of S pneumoniae, predominated. A respiratory virus alone was found in 16 of 120 (13.3%) patients. Overall, an etiologic diagnosis was established in 95.8% of cases.

Conclusions

Normal respiratory flora, with or without viral coinfection, appear to have caused one quarter of cases of CAP and may have played a contributory role in an additional 10.8% of cases caused by RBPs. An etiology for CAP was identified in >95% of patients who provided a high-quality sputum at, or soon after, the time of admission.

The importance of airway and lung microbiome in the critically ill

During critical illness, there are a multitude of forces such as antibiotic use, mechanical ventilation, diet changes and inflammatory responses that could bring the microbiome out of balance. This so-called dysbiosis of the microbiome seems to be involved in immunological responses and may influence outcomes even in individuals who are not as vulnerable as a critically ill ICU population. It is therefore probable that dysbiosis of the microbiome is a consequence of critical illness and may, subsequently, shape an inadequate response to these circumstances.Bronchoscopic studies have revealed that the carina represents the densest site of bacterial DNA along healthy airways, with a tapering density with further bifurcations. This likely reflects the influence of micro-aspiration as the primary route of microbial immigration in healthy adults. Though bacterial DNA density grows extremely sparse at smaller airways, bacterial signal is still consistently detectable in bronchoalveolar lavage fluid, likely reflecting the fact that lavage via a wedged bronchoscope samples an enormous surface area of small airways and alveoli. The dogma of lung sterility also violated numerous observations that long predated culture-independent microbiology.The body's resident microbial consortia (gut and/or respiratory microbiota) affect normal host inflammatory and immune response mechanisms. Disruptions in these host-pathogen interactions have been associated with infection and altered innate immunity.In this narrative review, we will focus on the rationale and current evidence for a pathogenic role of the lung microbiome in the exacerbation of complications of critical illness, such as acute respiratory distress syndrome and ventilator-associated pneumonia.

Avoiding ventilator-associated pneumonia: Curcumin-functionalized endotracheal tube and photodynamic action

Hospital-acquired infections are a global health problem that threatens patients' treatment in intensive care units, causing thousands of deaths and a considerable increase in hospitalization costs. The endotracheal tube (ETT) is a medical device placed in the patient's trachea to assist breathing and delivering oxygen into the lungs. However, bacterial biofilms forming at the surface of the ETT and the development of multidrug-resistant bacteria are considered the primary causes of ventilator-associated pneumonia (VAP), a severe hospital-acquired infection for significant mortality. Under these circumstances, there has been a need to administrate antibiotics together. Although necessary, it has led to a rapid increase in bacterial resistance to antibiotics. Therefore, it becomes necessary to develop alternatives to prevent and combat these bacterial infections. One possibility is to turn the ETT itself into a bactericide. Some examples reported in the literature present drawbacks. To overcome those issues, we have designed a photosensitizer-containing ETT to be used in photodynamic inactivation (PDI) to avoid bacteria biofilm formation and prevent VAP occurrence during tracheal intubation. This work describes ETT's functionalization with curcumin photosensitizer, as well as its evaluation in PDI against Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli A significant photoinactivation (up to 95%) against Gram-negative and Gram-positive bacteria was observed when curcumin-functionalized endotracheal (ETT-curc) was used. These remarkable results demonstrate this strategy's potential to combat hospital-acquired infections and contribute to fighting antimicrobial resistance.

Analysis of microbial changes in the tonsillar formalin-fixed paraffin-embedded tissue of Chinese patients with IgA nephropathy

BACKGROUND

Immunoglobulin A nephropathy (IgAN) is a prevalent chronic glomerular disease contribution to end-stage renal failure (ESRD). The tonsillar microbiota is closely associated with IgAN diseases based on the mucosal immune response. However, the composition and function of in tonsillar microbiota in participant patients with IgAN remains unknown. In this study, we detected the tonsillar microbiota changes of IgAN patients in Heilongjiang province located in northeast China.

MATERIAL AND METHODS

We collected from 21 patients with IgAN and 16 patients with chronic tonsillitis (CT) who had undergone tonsillectomy previously. Histological review of all samples from formalin-fixed paraffin-embedded (FFPE) tissue were performed. Extracted DNA from FFPE tissue blocks, after that V4 regions of 16S ribosomal RNA (rRNA) sequencing and comparative analyses of tonsillar flora between two groups were performed. The statistical analysis used the SPSS version of 21.

RESULTS

Visualization of microorganisms by Gram and Warthin-Starry (WS) silver stains, preliminarily observed the morphological characteristics of microbiome in FFPE tissue cases, such as bacteria or fungi. Tonsillar FFPE samples from the IgAN patients and CT controls showed significant differences in tonsillar microbial certain compositions and functions. We found that there were eight dominant genera that can be available to distinguish IgAN patients from CT controls. Compared with CT controls, at genus level, the relative abundances of Methylocaldum and unclassified_f_Prevotellaceae were significantly higher, while the abundances of Anaerosphaera, Halomonas, Trichococcus, Peptostreptococcus, norank_f_Synergistaceae and unclassified_k_norank_d_Bacteria were significantly lower in IgAN patients. Principal co-ordinates analysis (PCOA) distinguished IgAN patients from CT controls, and receiver operating characteristic (ROC) curves analysis confirmed that the diagnosis of disease has certain diagnostic significance. In addition, Functional analysis revealed that partly Enzymes and KOs were increased in the IgAN patients.

CONCLUSIONS

Histological screening results were very helpful for further gene sequencing, not only to supplement the observation of bacterial morphology and structure, but also to prepare for subsequent gene sequencing and bioinformatics analysis. We elucidated subtle relevance between changes in tonsillar microbiota and IgAN patients, which can be utilized to predict the incidence of IgAN disease. In addition, we predicted that some enzymes, and KOs were closely related to IgAN.

Is α-Amylase an Important Biomarker to Detect Aspiration of Oral Secretions in Ventilated Patients?

Alpha-amylase has emerged as a biomarker of interest in detecting aspiration of oral secretions. In several studies, most ventilated patients have α-amylase values detected in pulmonary secretions. Values of α-amylase are high (as expected) in oral secretions and lowest in bronchoalveolar lavage samples. Around 5-7% of oral α-amylase is detectable in tracheal secretions. Once secretions are aspirated, the duration of detection of α-amylase in pulmonary secretions is unknown. Evidence varies on the relationship between α-amylase and clinical outcomes. Although detection of α-amylase in pulmonary secretions is useful to identify that aspiration has occurred, the lack of standardized reference values, the lack of knowledge regarding duration of detection following aspiration, and mixed findings related to clinical outcomes, limit its usefulness as a measurement tool. If α-amylase is to be used in research and/or clinical practice, additional data are needed to assist in interpretation and application of findings.

Pulmonary manifestations of gastroesophageal reflux disease

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a widespread condition with a significant impact on the quality of life and healthcare resources. In addition to its gastrointestinal problems, GERD has been linked to a variety of respiratory diseases either as a direct cause, or as a risk factor to the inability to control or worsening of the disease.

AREAS COVERED

We performed a literature search in the PubMed database for articles addressing GERD and pulmonary diseases. This review will discuss several different pulmonary diseases affected by GERD ranging from upper airway including chronic cough, vocal cord dysfunction, lower airway diseases including COPD, asthma, and bronchiolitis obliterans syndrome to parenchymal diseases such as interstitial lung diseases. The review will discuss several different pulmonary manifestations of GERD and their contribution to patient mortality and morbidity. It will also review the mechanisms leading to these diseases, diagnostic workup, and the role of the available treatment options.

EXPERT OPINION

GERD is often overlooked as a cause of respiratory symptoms and illnesses. The literature is sparse on the relation between GERD and respiratory diseases such as interstitial lung diseases and bronchiolitis obliterans including its role in pathogenesis, mechanisms of lung injury, and whether treatment of GERD is effective in managing such illnesses.

Diagnosis and management of pediatric cerebrospinal fluid leakage secondary to inner ear malformations: A report of 13 cases

OBJECTIVES

Inner ear malformations (IEM) with cerebrospinal fluid (CSF) leakage in children is a rare condition, nevertheless, it may lead to meningitis. Early diagnosis and treatment are crucial. The aims of the study were to summarize the clinical characteristic of pediatric CSF leakage secondary to IEM, and to recommend transcanal endoscopic ear surgery (TEES) as an effective surgical technique for the treatment of CSF leakage with IEM in children.

METHODS

This was a retrospective study. Thirteen children and fourteen ear surgery were included. Demographics, detail history, laboratory data, Audio test, and imageological examination results were recorded. All the pediatric patients underwent TEES.

RESULTS

Most (92.31%) of the children presented with a history of rhinorrhea. 69.23% (9/13) of the children had suffered from meningitis, and the other had presented with respiratory tract infections. The follow-up duration ranged from 0.75 years to 5.29 years. Transcanal endoscopic repair of CSF leakage secondary to IEM was the first surgery with a success rate of 92.86% (13 out of 14 cases). A fistula could be found in the stapes footplate in all pediatric patients.

CONCLUSION

Even if there has been no history of meningitis, the diagnosis of CSF leakage in children suffering from unilateral rhinorrhea and recurrent respiratory tract infection is considered. Auditory brainstem response (ABR) and Temporal bone computed tomography (CT) examinations are suggested to identify IEM. The TEES procedure is recommended in our study as the first choice that repairs CSF leakage secondary to IEM.

Neurogenic pulmonary edema following acute stroke: The progress and perspective

Neurogenic pulmonary edema (NPE) following acute stroke is an acute respiratory distress syndrome (ARDS) with clinical characteristics that include acute onset, apparent pulmonary interstitial fluid infiltration and rapid resolution. The pathological process of NPE centers on sympathetic stimulation and fulminant release of catecholamines, which cause contraction of resistance vessels. Elevated systemic resistance forces fluid into pulmonary circulation, while pulmonary circulation overload induces pulmonary capillary pressure that elevates, and in turn damages the alveolar capillary barrier. Damage to the alveolar capillary barrier leads to pulmonary ventilation disorder, blood perfusion disorder and oxygenation disorder. Eventually, NPE will cause post-stroke patients' prognosis to further deteriorate. At present, we lack specific biological diagnostic indicators and a meticulously unified diagnostic criterion, and this results in a situation in which many patients are not recognized quickly and/or diagnosed accurately. There are no drugs that are effective against NPE. Therefore, understanding how to diagnose NPE early by identifying the risk factors and how to apply appropriate treatment to avoid a deteriorating prognosis are important scientific goals. We will elaborate the progress of NPE after acute stroke in terms of its pathophysiological mechanisms, etiology, epidemiology, clinical diagnosis and early prediction, comprehensive treatment strategies, and novel drug development. We also propose our own thinking and prospects regarding NPE.

Validation for using electronic health records to identify community acquired pneumonia hospitalization among people with and without HIV

Background

Cohort studies identifying the incidence, complications and co-morbidities associated with community acquired pneumonia (CAP) are largely based on administrative datasets and rely on International Classification of Diseases (ICD) codes; however, the reliability of ICD codes for hospital admissions for CAP in people with HIV (PWH) has not been systematically assessed.

Methods

We used data from the Veterans Aging Cohort Study survey sample (N = 6824; 3410 PWH and 3414 uninfected) to validate the use of electronic health records (EHR) data to identify CAP hospitalizations when compared to chart review and to compare the performance in PWH vs. uninfected patients. We used different EHR algorithms that included a broad set of CAP ICD-9 codes, a set restricted to bacterial and viral CAP codes, and algorithms that included pharmacy data and/or other ICD-9 diagnoses frequently associated with CAP. We also compared microbiologic workup and etiologic diagnosis by HIV status among those with CAP.

Results

Five hundred forty-nine patients were identified as having an ICD-9 code compatible with a CAP diagnosis (13% of PWH and 4% of the uninfected, p < 0.01). The EHR algorithm with the best overall positive predictive value (82%) was obtained by using the restricted set of ICD-9 codes (480-487) in primary position or secondary only to selected codes as primary (HIV disease, respiratory failure, sepsis or bacteremia) with the addition of EHR pharmacy data; this algorithm yielded PPVs of 83% in PWH and 73% in uninfected (P = 0.1) groups. Adding aspiration pneumonia (ICD-9 code 507) to any of the ICD-9 code/pharmacy combinations increased the number of cases but decreased the overall PPV. Allowing COPD exacerbation in the primary position improved the PPV among the uninfected group only (to 76%). More PWH than uninfected patients underwent microbiologic evaluation or had respiratory samples submitted.

Conclusions

ICD-9 code-based algorithms perform similarly to identify CAP in PLWH and uninfected individuals. Adding antimicrobial use data and allowing as primary diagnoses ICD-9 codes frequently used in patients with CAP improved the performance of the algorithms in both groups of patients. The algorithms consistently performed better among PWH.

Prognosis of pathogen-proven acute respiratory distress syndrome diagnosed from a protocol that includes bronchoalveolar lavage: a retrospective observational study

Background

To treat patients with acute respiratory distress syndrome (ARDS), it is important to diagnose specific lung diseases and identify common risk factors. Our facility focuses on using bronchoalveolar lavage (BAL) to identify precise risk factors and determine the causative pathogen of ARDS within 24 h of intensive care unit (ICU) admission. This study evaluated the prognoses of pathogen-proven ARDS patients who were diagnosed or identified with risk factors using a diagnostic protocol, which included BAL, compared with the prognoses of pathogen-unproven ARDS patients.

Methods

This retrospective observational study was conducted in the ICU at a tertiary hospital from October 2015 to January 2019. We enrolled patients with respiratory distress who were on mechanical ventilation for more than 24 h in the ICU and who were subjected to our diagnostic protocol. We compared the disease characteristics and mortality rates between pathogen-proven and pathogen-unproven ARDS patients.

Results

Seventy ARDS patients were included, of whom, 50 (71%) had pathogen-proven ARDS as per our protocol. Mortality rates in both the ICU and the hospital were significantly lower among pathogen-proven ARDS patients than among pathogen-unproven ARDS patients (10% vs. 50%, p = 0.0006; 18% vs. 55%, p = 0.0038, respectively). Pathogen-proven ARDS patients were independently associated with hospital survival (adjusted hazard ratio, 0.238; 95% confidence interval, 0.096–0.587; p = 0.0021).

Conclusions

Our diagnostic protocol, which included early initiation of BAL, enabled diagnosing pathogen-proven ARDS in 71% of ARDS patients. These patients were significantly associated with higher hospital survival rates. The diagnostic accuracy of our diagnostic protocol, which includes BAL, remains unclear.

Aspiration Risk Factors, Microbiology, and Empiric Antibiotics for Patients Hospitalized With Community-Acquired Pneumonia

BACKGROUND

Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role.

RESEARCH QUESTION

What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP?

STUDY DESIGN AND METHODS

This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups.

RESULTS

We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P = .021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P < .001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics.

INTERPRETATION

Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.

Early-onset pneumonia following bag-mask ventilation versus endotracheal intubation during cardiopulmonary resuscitation: A substudy of the CAAM trial

AIM

Early-onset pneumonia (EOP) is a common in-hospital complication in survivors of out-of-hospital cardiac arrest. In this substudy of the CAAM trial, we aimed to compare whether bag mask ventilation (BMV) compared to endotracheal intubation (ETI) performed during cardiopulmonary resuscitation increases the risk of developing EOP.

METHODS

Adult patients from the CAAM trial that survived beyond 12 h of hospitalization were included. Information about in-hospital management and outcome of study subjects was systematically collected. Our primary aim was to compare the incidence of EOP in the BMV and ETI group using a series of bivariate analysis adjusting for one variable at a time and a logistic regression controlled for survival beyond 96 h, age, gender, catecholamine administration, no flow time, and initial shockable rhythm.

RESULTS

Of 627 patients from the CAAM trial that survived to hospital admission, 409 patients were hospitalized beyond 12 h and thus included (202 randomized to BMV and 20 7 randomized to ETI). Patients in the BMV group had a significantly longer period of unsecured airway during prehospital cardiopulmonary resuscitation (BMV (median): 33 min; ETI (median): 17 min, p < 0.0001). No significant difference in the development of EOP according to airway management was identified on univariate analysis (BMV: 53%, ETI: 53%, Odds Ratio 1.0 [0.7-1.5], p = 1.0). We found no difference in the development of EOP according to airway management in the series of bivariate analyses or in the multivariable regression analysis either.

CONCLUSION

In this substudy of the CAAM trial, development of early-onset pneumonia in out-of-hospital cardiac arrest survivors did not depend on airway management technique during CPR.

A 95-year-old patient with unexpected coronavirus disease 2019 masked by aspiration pneumonia: a case report

Background

Severe acute respiratory syndrome coronavirus-2 infection has become a pandemic disease (coronavirus disease 2019). The infection has moved from China to the rest of the world and Italy represents one of the most affected countries. Older adults are more susceptible to develop complications with the consequent highest mortality rates.

Case presentation

We report a case of a 95-year-old Caucasian woman affected by pneumonia, initially defined as common aspiration pneumonia in a bedridden patient with vascular dementia, which later turned out to be coronavirus disease 2019 pneumonia during the initial spread of severe acute respiratory syndrome coronavirus-2 in our district. Some features of a computed tomography scan of her chest and her clinical history with known dysphagia had led at first to a different diagnosis with a consequent exposure of health professionals to infectious risk in two distinct hospitals. In this case report, we describe the clinical/imaging features of coronavirus disease 2019 pneumonia and the diagnostic process that led to a correct diagnosis in a nonagenarian with multiple comorbidities.

Conclusions

This case report highlights both the possible pitfalls in diagnosing coronavirus disease 2019 pneumonia in very old patients with comorbidities and the greater than expected spread of the infection, even in individuals with reduced interpersonal contacts and no defined epidemiological link.

Cardiothoracic Patients with Unilateral Vocal Fold Paralysis: Pneumonia Rates Following Injection Laryngoplasty

Objective:

Recurrent laryngeal nerve injury is a potential complication of cardiothoracic surgery and cause of unilateral vocal fold paralysis (UVFP). Injection laryngoplasty (IL) is an intervention offered to patients with UVFP to alleviate symptoms including dysphagia, dysphonia and weak cough. There is no definitive evidence that IL prevents pneumonia. In this study, we compare rates of pneumonia in patients with UVFP secondary to cardiothoracic surgery who did or did not undergo IL.

Methods:

A retrospective chart review identified patients diagnosed with UVFP by an otolaryngologist using flexible laryngoscopy following cardiothoracic surgery from January 1, 2008 to December 31, 2017. Each subject was grouped by IL status and assessed for subsequent pneumonia within 6 months of their diagnosis of UVFP. The association of IL with pneumonia was evaluated using Cox proportional hazards regression.

Results:

Of 92 patients who met inclusion criteria, 35 (38%) underwent IL and 57 (62%) did not. Twenty patients developed pneumonia, four who had undergone IL and 16 who had not; 12 patients developed aspiration pneumonia including two having undergone IL and 10 who had not. Those who had IL were less likely to develop total pneumonia compared to those who had not (HR = 0.33, P = .045). The protective effect of IL was not as clearly sustained when measuring for aspiration pneumonia, specifically (HR = 0.34; P = .10).

Discussion:

Injection laryngoplasty may reduce the risk of pneumonia in patients with UVFP secondary to cardiothoracic surgery; however, further research is needed to quantify the potential protective nature of IL in this patient population.

Level of evidence:

3 (A retrospective cohort study).

Non-ventilator health care-associated pneumonia (NV-HAP): Pathogenesis and microbiology of NV-HAP

Studies demonstrate that those at risk for developing nonventilator associated pneumonia (NV-HAP) include the very young and the very old, as well as persons with compromised immune systems cardiovascular and/or pulmonary disease. This section includes a review of the pathogenesis and microbiology of NV-HAP, including bacterial as well as viral and fungal pathogens. Etiology, modes of transmission, and specific prevention strategies associated with various causative microorganisms are highlighted.

Pneumonia prevention effects of perioperative oral management in approximately 25,000 patients following cancer surgery

AIM

We conducted a multicenter study to explore the risk factors of developing pneumonia and the effectiveness of perioperative oral management (POM) for the prevention of pneumonia in postsurgical patients.

METHODS AND RESULTS

A survey covering eight regional hospitals was conducted over 4 years, from April 2010 to March 2014. Using the Diagnosis Procedure Combination database, a target group of 25,554 patients with cancer who underwent surgery was selected and assessed from a population of 346,563 patients without pneumonia on admission (sample population). The study compared the incidence of pneumonia and attempted to identify the significant predictive factors for its occurrence in these patients using multiple logistic regression analysis. Comparative assessment for the occurrence of pneumonia before and after POM implementation showed a significant incidence decrease after POM introduction in the target group, with no such change observed in the sample population. Multiple logistic regression analysis showed that the odds ratio for pneumonia occurrence after POM introduction was 0.44, indicating a reduced risk of pneumonia.

CONCLUSION

POM in cancer patients was indeed effective in reducing the incidence of pneumonia in hospitals and thereby helped in preventing pneumonia during hospitalization.

Pneumonia in Parkinson's disease: barium aspiration in videofluoroscopic swallowing study

Barium aspiration into the tracheobronchial tree is a remarkable warning sign of dysphagia-related aspiration pneumonia. Clinical swallowing assessment is warranted for patients with aspiration pneumonia and videofluoroscopic swallowing study is a good add-on tool for dysphagia treatment plan. In patients with Parkinson's disease, dysphagia is often overlooked due to atypical presentations.

Diagnosis of EVALI: General Approach and the Role of Bronchoscopy

A 23-year-old man arrives at the ED with a 3-week history of dyspnea, dry cough, fevers, and night sweats. Two weeks previously, he was evaluated in an outpatient clinic and given a course of azithromycin for presumed infectious pneumonia. His symptoms did not improve, and he was seen 1 week later in an urgent care center and given a prescription for doxycycline, which he has been taking without improvement. He states that he feels miserable, has severe nausea and vomiting, and has not eaten in several days. His only medical history is childhood asthma. He reports no surgeries and takes no medications. He has no risk factors for HIV, does not smoke combustible cigarettes or use IV drugs, and has not recently traveled. Examination shows a room air saturation of 89%, a temperature of 38.3°C, and a respiratory rate of 22 breaths/min. Results of his examination are normal, and there are no rales or wheezing heard in the lungs. Chest radiograph shows bilateral, consolidative opacities. WBC count is 14,000, with left shift. Results of biochemistries are normal. Erythrocyte sedimentation rate is 104, and procalcitonin is 0.08. Urine toxicology screen is positive for tetrahydrocannabinol (THC). Asked specifically about vaping and e-cigarette use, he reports that he recently began using THC "carts" that his friend gets from an unknown supplier. What is the diagnosis and what additional steps are necessary to confirm it? Is bronchoscopy indicated?

Effects of Expiratory Muscle Strength Training on Videofluoroscopic Measures of Swallowing: A Systematic Review

Purpose Expiratory muscle strength training (EMST) is increasingly utilized in dysphagia rehabilitation; however, little is known about the effects of this approach on swallowing function or physiology. We conducted a systematic review to appraise and synthesize evidence regarding the effects of EMST on videofluoroscopic measures of swallowing in individuals with medical diagnoses, in which dysphagia is a concern. Method A literature search was conducted according to Cochrane guidelines. Of 292 nonduplicate articles, 11 were judged to be relevant for review. These underwent detailed review for study quality, risk of bias evaluation, and synthesis of swallowing outcomes. Results The selected articles described EMST in a variety of patient populations using either the EMST150 or the Phillips Threshold positive expiratory pressure device. The typical protocol involved five sets of five breaths through the device (25 breaths/day), 5 days per week for 4 weeks. Exercise loads were set between 50% and 75% depending on the population, and treatment was typically supervised by a clinician weekly. The Penetration-Aspiration Scale was the most commonly reported videofluoroscopic outcome measure. Conclusions differed as to whether or not swallowing improved following a course of EMST. Differences in videofluoroscopy protocols, methods of summarizing participant performance, and statistical approaches across studies meant that meta-analysis of swallowing outcomes could not be completed. Conclusion This review failed to find clear evidence regarding the effects of EMST on videofluoroscopic measures of swallowing. Heterogeneity in the etiologies and baseline severity of dysphagia across studies and in the methods used to measure swallowing outcomes was a particular barrier to data synthesis.

Risk factors for the development of aspiration pneumonia in elderly patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort

Aspiration pneumonia (AP) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of AP in elderly patients with femoral neck fractures.We recruited 426 patients (age 84.9 ± 7.4 years) with a history of hip surgery carried out at Toyama Municipal Hospital. AP occurred in 18 out of 426 cases (4.23%). Statistical test has found significant differences in age, gender, serum albumin level, and cognitive impairment, between AP and non-AP groups. Subsequently multiple logistic regression analysis was conducted to investigate the risk factors for AP, including age, gender, serum albumin, cognitive impairment, and activities of daily living (ADL). Adjusted odds ratio showed significant differences in age, gender, and serum albumin, whereas no significant differences were found in cognitive impairment and ADL.This study suggested that serum albumin seemed to be a risk factor for AP but were necessary to assess under adjustment of confounding factors, including age and gender. Monitoring serum albumin level seemed to be important for the postoperative management of AP, especially in elderly patients receiving surgery of femoral neck and trochanteric fractures.

Persistent Feeding and Swallowing Deficits in a Mouse Model of 22q11.2 Deletion Syndrome

Disrupted development of oropharyngeal structures as well as cranial nerve and brainstem circuits may lead to feeding and swallowing difficulties in children with 22q11. 2 deletion syndrome (22q11DS). We previously demonstrated aspiration-based dysphagia during early postnatal life in the LgDel mouse model of 22q11DS along with disrupted oropharyngeal morphogenesis and divergent differentiation and function of cranial motor and sensory nerves. We now ask whether feeding and swallowing deficits persist in adult LgDel mice using methods analogous to those used in human patients to evaluate feeding and swallowing dysfunction. Compared to wild-type mice, videofluoroscopic swallow study revealed that LgDel mice have altered feeding and swallowing behaviors, including slower lick rates, longer inter-lick intervals, and longer pharyngeal transit times with liquid consistency. Transoral endoscopic assessment identified minor structural anomalies of the palate and larynx in one-third of the LgDel mice examined. Video surveillance of feeding-related behaviors showed that LgDel mice eat and drink more frequently. Furthermore, LgDel animals engage in another oromotor behavior, grooming, more frequently, implying that divergent craniofacial and cranial nerve structure and function result in altered oromotor coordination. Finally, LgDel mice have significantly increased lung inflammation, a potential sign of aspiration-based dysphagia, consistent with results from our previous studies of early postnatal animals showing aspiration-related lung inflammation. Thus, oromotor dysfunction, feeding, and swallowing difficulties and their consequences persist in the LgDel 22q11DS mouse model. Apparently, postnatal growth and/or neural plasticity does not fully resolve deficits due to anomalous hindbrain, craniofacial, and cranial nerve development that prefigure perinatal dysphagia in 22q11DS. This new recognition of persistent challenges with feeding and swallowing may provide opportunities for improved therapeutic intervention for adolescents and adults with 22q11DS, as well as others with a history of perinatal feeding and swallowing disorders.

Systemic lupus erythematosus in a patient with multiple system atrophy: A case report

RATIONALE

Multiple system atrophy is a late-onset rare neurodegenerative movement disorder which results in debilitating disease. Fever frequently ensues in the context of infections which can be associated with significant morbidity and mortality, but among alternative diagnostic possibilities neoplasms and autoimmune disorders should be considered.

PATIENT CONCERNS

We describe a case of a prolonged febrile syndrome in a 55-year-old female patient with onset of multiple system atrophy two years before presentation. Patient history and symptoms were not contributive to guide the diagnostic work-up.

DIAGNOSIS

Initial evaluation provided no specific findings. Repeat testing of auto-antibodies revealed positive antinuclear and anti-ds DNA antibodies coupled with low complement which in conjunction with renal biopsy substantiated the diagnosis of systemic lupus erythematosus flare.

INTERVENTION

Pending the biopsy result, treatment with hydroxychloroquine and corticosteroids was initiated. Due to failure to achieve remission, azathioprine was added, but symptoms persisted. Following the diagnosis of lupus nephritis, azathioprine was discontinued and induction treatment with cyclophosphamide in accordance with the Euro-Lupus regimen was initiated and upon completion followed by maintenance therapy with mycophenolate mofetil.

OUTCOMES

The patient achieved remission after cyclophosphamide was added to treatment with corticosteroids and has not experienced new flares during the next two years. The neurological syndrome has remained stable during this period.

LESSONS

To our knowledge, we report the first case of concurrent systemic lupus erythematosus and multiple system atrophy. Prolonged fever presents unique challenges in patients with rare diseases.

Unusual trifecta of infections, aspiration, and metastatic prostatic adenocarcinoma in a bronchoalveolar lavage specimen

Bronchoalveolar lavage (BAL) is a useful procedure to evaluate lung infiltrates in order to identify infection, foreign body aspiration, and neoplasms. However, it is indeed unusual to find all three in the same sample. We report such a case in a 68-year-old male with a history of metastatic prostate adenocarcinoma and longstanding chronic obstructive pulmonary disease who presented with features of pneumonia. BAL revealed Aspergillus and parainfluenza infections, food particle aspiration pneumonia, as well as metastatic prostatic adenocarcinoma. The food particles were initially confused for yeast infection, but we finally identified them as nut products. This may be the first documented case of nut product aspiration diagnosed on BAL. The potential pitfalls that may complicate the evaluation are also discussed.

New perspectives in aspiration community acquired Pneumonia

Introduction: Aspiration pneumonia is a subclass of community-acquired pneumonia that is expected to have an increasing contribution in mortality and morbidity, particularly in the elderly population over the next coming decades. While studies have revealed significant progress in identifying risk factors for aspiration pneumonia, the clinical presentation and diagnosis remain challenging to healthcare providers. Areas covered: We conducted a broad literature review using the MeSH heading in PubMed/MEDLINE of 'aspiration pneumonia' from January 1970 to July 2019. The understanding of the microbiology of aspiration pneumonia has evolved from a possible shift in the causative organisms away from anaerobes to traditional community-acquired pneumonia organisms. The importance of this shift is not yet known, but it has questioned the pathogenic role of anaerobes, appropriate anaerobic testing and the role of these pathogens in the pulmonary microbiome in patients with pneumonia. The identification of risk factors led to strategies to prevent or minimize the risk of aspiration pneumonia with moderate success. Expert opinion: Our expert opinion is that further research is needed to determine the role of the microbiome with aspiration pneumonia and patient risk factors. There is also a great need to develop clinical tools to help providers diagnose, treat, and prevent aspiration pneumonia.

Infrequent Denture Cleaning Increased the Risk of Pneumonia among Community-dwelling Older Adults: A Population-based Cross-sectional Study

Pneumonia is a leading cause of death among older adults. The effectiveness of oral care in preventing pneumonia in nursing homes and hospitals has been reported. However, in community-dwelling older adults, the role of denture cleaning in preventing pneumonia remains unknown. We aimed to investigate the association between infrequent denture cleaning and the risk of pneumonia in community-dwelling older adults. This cross-sectional study was based on the self-reported questionnaire targeting towards community-dwelling older adults aged ≥65 years. Responses of 71,227 removable full/partial denture users were included. The incidence of pneumonia within the last one-year and the frequency of denture cleaning (daily/non-daily) were treated as dependent and independent variables, respectively. The odds ratio (OR) and 95% confidence interval (CI) were calculated by the inverse probability weighting (IPW) method based on the logistic regression model. The mean age of the participants was 75.2 ± 6.5 years; 48.3% were male. Overall, 4.6% of the participants did not clean their dentures daily; 2.3% and 3.0% who did and did not clean their dentures daily, respectively, experienced pneumonia. After IPW, infrequent denture cleaning was significantly associated with pneumonia incidence (OR = 1.30, 95% CI = 1.01–1.68)). This study suggests that denture cleaning could prevent pneumonia among community-dwelling older adults.

Pilot study for risk assessment of aspiration pneumonia based on oral bacteria levels and serum biomarkers

Background

Aspiration pneumonia is a serious problem among elderly patients; it is caused by many risk factors including dysphagia, poor oral hygiene, malnutrition, and sedative medications. The aim of this study was to define a convenient procedure to objectively evaluate the risk of aspiration pneumonia in the clinical setting.

Methods

This prospective study included an aspiration pneumonia (AP) group, a community-acquired pneumonia (CAP) group, and a control (Con) group (patients hospitalized for lung cancer chemotherapy). We used the Oral Health Assessment Tool (OHAT), which assesses oral hygiene, and evaluated performance status, body mass index, serum albumin levels, substance P values in plasma, and oral bacterial counts.

Results

The oral health as assessed by the OHAT of the aspiration pneumonia group was significantly impaired compared with that of the CAP group and the control (5.13 ± 0.18, 4.40 ± 0.26, 3.90 ± 0.22, respectively; p < 0.05). The oral bacterial count in the aspiration pneumonia group (7.20 ± 0.11) was significantly higher than that in the CAP group (6.89 ± 0.12), consistent with the OHAT scores. Oral bacterial count was significantly reduced by oral care.

Conclusions

OHAT and oral bacterial counts can be a tool to assess the requirement of taking oral care and other preventive procedures in patients at high risk of aspiration pneumonia.

A Model of Self-limited Acute Lung Injury by Unilateral Intra-bronchial Acid Instillation

Selective intra-bronchial instillation of hydrochloric acid (HCl) to the murine left mainstem bronchus causes acute tissue injury with histopathologic findings similar to human acute respiratory distress syndrome (ARDS). The resulting alveolar edema, alveolar-capillary barrier damage, and leukocyte infiltration predominantly affect the left lung, preserving the right lung as an uninjured control and allowing animals to survive. This model of self-limited acute lung injury enables investigation of tissue resolution mechanisms, such as macrophage efferocytosis of apoptotic neutrophils and restitution of alveolar-capillary barrier integrity. This model has helped identify important roles for resolution agonists, including specialized pro-resolving mediators (SPMs), providing a foundation for the development of new therapeutic approaches for patients with ARDS.

Lung Ultrasound for Initial Diagnosis and Subsequent Monitoring of Aspiration Pneumonia in Elderly in Home Medical Care Setting

The number of aspiration pneumonia cases has increased in recent times. A definitive diagnosis of aspiration pneumonia is difficult in resource-limited settings where radiological equipment is unavailable. We report the initial diagnosis and subsequent monitoring of aspiration pneumonia in a home medical care setting. An 88-year-old Japanese male presented an acute onset of dyspnea, fever, and productive cough. At home, lung ultrasound displayed pleural effusion along with B-lines and subpleural consolidations. Upon admission, tests revealed increased total leucocyte counts with left-shifted neutrophils, elevated C-reactive protein levels, and positive sputum Gram stain. Chest X-ray imaging and computed tomography (CT) showed bibasilar infiltrates and wall thickening in the left S10 bronchi. The patient was diagnosed with aspiration pneumonia and treated with an antibiotic. After a 10-day hospitalization, lung ultrasound showed some remaining B-lines and disappearance of pleural effusion and subpleural consolidation. Chest X-ray image was normal, and CT revealed pleural abnormality and disappearance of bibasilar infiltrates, consistent with the ultrasound findings. Aspiration pneumonia develops with various clinical signs. However, diagnosis using chest X-ray imaging or CT in resource-limited settings is difficult. Ultrasound might allow physicians to make more accurate judgments, particularly while monitoring aspiration pneumonia following initial diagnosis in resource-limited settings.