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Patel N, Lin P, Stack M, Conrad JM, Fakioglu H, Abomoelak B, Horvath K, Mehta DI. Oral Care Associated With Less Microaspiration in Ventilated Cardiac Patients. JPGN REPORTS 2023; 4:e290. [PMID: 37181916 PMCID: PMC10174743 DOI: 10.1097/pg9.0000000000000290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 09/08/2022] [Indexed: 05/16/2023]
Abstract
Aspiration is common in mechanically ventilated patients and may predispose patients to aspiration pneumonia, chemical pneumonitis, and chronic lung damage. Pepsin A is a specific marker of gastric fluid aspiration and is often detected in ventilated pediatric patients. We investigated the effect of oral care and throat suctioning in the detection of pepsin A in tracheal aspirates (TAs) up to 4 hours after these procedures. Methods Twelve pediatric patients between age 2 weeks to 14 years who underwent intubation for cardiac surgery were enrolled in this study. Six of the 12 patients were consented before their surgery with initial specimen collected at the time of intubation and last one shortly before extubation (intubation duration < 24 hours). The remaining 6 patients were consented after cardiac surgery. All specimens were collected per routine care per respiratory therapy protocol and shortly before extubation (intubation duration > 24 hours). Tracheal fluid aspirates were collected every 4 to 12 hours in the ventilated patients. Enzymatic assay for gastric pepsin A and protein determination were performed. The time of oral care and throat suctioning within 4 hours prior was recorded prospectively. Results A total of 342 TA specimens were obtained from the 12 intubated pediatric patients during their course of hospitalization; 287 (83.9%) showed detectable total pepsin (pepsin A and C) enzyme activity (> 6 ng/mL) and 176 (51.5%) samples had detectable pepsin A enzyme levels (>6 ng/mL of pepsin A). Only 29 samples of 76 samples (38.2%) had evidence of microaspiration after receiving oral care, while 147 of 266 (55.3%) samples were pepsin A positive when no oral care was provided. Odds ratio is 0.50 (Cl 0.30-0.84), and the number needed to treat is 5.8 (Confidence interval 3.4-22.3). Testing air filters for pepsin was not beneficial. Conclusion Oral care is a highly effective measure to prevent microaspiration of gastric fluid in ventilated pediatric patients. The number needed to treat (5.8) suggests this is a very effective prevention strategy. Our study suggests that pepsin A is a useful and sensitive biomarker that allows identification of gastric aspiration.
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Affiliation(s)
- Nishant Patel
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Philip Lin
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Michael Stack
- Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA
| | - Janet M. Conrad
- Pediatric Gastroenterology and Translational Research Laboratory, Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Harun Fakioglu
- Department of Pediatric Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Bassam Abomoelak
- Pediatric Gastroenterology and Translational Research Laboratory, Cardiology Arnold Palmer Hospital for Children, Orlando, FL
| | - Karoly Horvath
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
| | - Devendra I. Mehta
- From the Center for Digestive Health and Nutrition, Arnold Palmer Hospital for Children, Orlando, FL
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Torous VF, Ly A. Correlation between cytology Oil Red O staining and lung biopsy specimens: utility of the lipid-laden macrophage index. J Am Soc Cytopathol 2022; 11:226-233. [PMID: 35597768 DOI: 10.1016/j.jasc.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Oil Red O staining is used for enumeration of the lipid-laden macrophage index (LLMI) as a surrogate for aspiration. As part of quality improvement efforts aimed at optimizing resource utilization, the utility of this stain in current cytopathology practice was re-evaluated. The objective of this study was to explore the clinical utility of Oil Red O staining in bronchoalveolar lavage (BAL) samples by correlating the LLMI with findings in concurrent histologic tissue samples. MATERIALS AND METHODS Lung transbronchial biopsy specimens that suggested aspiration that were submitted with concurrent BAL cytology samples were retrieved. Lung tissue biopsies were reviewed for the presence of foamy alveolar macrophages (graded as 0, 1+, and 2+), foreign material, and giant cells. The concurrent BAL was reviewed with consensus determination of the LLMI. RESULTS A total of 53 cases were identified. On histology, 13 cases (24.5%) were found to have no foamy alveolar macrophages, 23 cases (43.4%) were found to have 1+ foamy alveolar macrophages, and 17 cases (32.1%) were found to have 2+ foamy alveolar macrophages. Six cases (11.3%) were found to have foreign material, and 10 cases (18.9%) were found to have multinucleated giant cells. The average LLMI score was 16, with 44 (83.0%) in the low range (LLMI <40) and 9 (17.0%) in the intermediate range (LLMI of 40-90). CONCLUSIONS None of the cases in our study had an LLMI that exceeded the cutoff value for which aspiration would be suspected. We found no correlation of the LLMI with lung biopsies that suggested aspiration.
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Affiliation(s)
- Vanda F Torous
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Amy Ly
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Hysinger E, Friedman N, Jensen E, Zhang H, Piccione J. Bronchoscopy in neonates with severe bronchopulmonary dysplasia in the NICU. J Perinatol 2019; 39:263-268. [PMID: 30518799 DOI: 10.1038/s41372-018-0280-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/05/2018] [Accepted: 10/22/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To describe the findings, resulting changes in management, and safety profile of flexible bronchoscopy in the neonates with severe bronchopulmonary dysplasia. STUDY DESIGN This was a retrospective case series of twenty-seven neonates with severe bronchopulmonary dysplasia who underwent flexible bronchoscopy in the neonatal intensive care unit. RESULTS Flexible bronchoscopy revealed airway pathology in 20/27 (74%) patients. Tracheomalacia 13/27 (48%), bronchomalacia 11/27 (40.7%), and airway edema 13/27 (48%) were the most common findings. Bronchoalveolar lavage (BAL) was performed in 17 patients. BAL culture revealed a microorganism in 12/17 (70.5%) cases. Findings from bronchoscopy resulted in change in clinical management in 17/27 (63%) patients. Common interventions included initiation of antibiotics (37%) and treatment of tracheobronchomalacia with bethanechol (22.2%), atrovent (18.5%), and PEEP titration (18.5%). Bronchoscopy was performed without significant complication in 26/27 (97%) patients. CONCLUSION Flexible bronchoscopy can be a safe and useful tool for the management of neonates with severe bronchopulmonary dysplasia.
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Affiliation(s)
- Erik Hysinger
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nicholas Friedman
- Department of Pediatrics, Madigan Army Medical Center, Tacoma, WA, USA
| | - Erik Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Huayan Zhang
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Piccione
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Faro A, Wood RE, Schechter MS, Leong AB, Wittkugel E, Abode K, Chmiel JF, Daines C, Davis S, Eber E, Huddleston C, Kilbaugh T, Kurland G, Midulla F, Molter D, Montgomery GS, Retsch-Bogart G, Rutter MJ, Visner G, Walczak SA, Ferkol TW, Michelson PH. Official American Thoracic Society Technical Standards: Flexible Airway Endoscopy in Children. Am J Respir Crit Care Med 2015; 191:1066-80. [DOI: 10.1164/rccm.201503-0474st] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Abstract
The term aspiration lung disease describes several clinical syndromes, with massive aspiration and chronic lung aspiration being at two extremes of the clinical spectrum. Over the years, significant advances have been made in understanding the mechanisms underlying dysphagia, gastroesophageal function, and airway protective reflexes and new diagnostic techniques have been introduced. Despite this, characterizing the presence or absence of aspiration, and under what circumstances a child might be aspirating what, is extremely challenging. Many children are still not adequately diagnosed or treated for aspiration until permanent lung damage has occurred. A multidisciplinary approach is mandatory for a correct diagnosis in addition to timely and appropriate care.
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Affiliation(s)
- Fernando M de Benedictis
- Division of Pediatric Medicine, Department of Pediatrics, Salesi Children's University Hospital, Ancona, Italy.
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Farhath S, He Z, Nakhla T, Saslow J, Soundar S, Camacho J, Stahl G, Shaffer S, Mehta DI, Aghai ZH. Pepsin, a marker of gastric contents, is increased in tracheal aspirates from preterm infants who develop bronchopulmonary dysplasia. Pediatrics 2008; 121:e253-9. [PMID: 18245400 DOI: 10.1542/peds.2007-0056] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to study the association between pepsin in tracheal aspirate samples and the development of bronchopulmonary dysplasia in preterm infants. METHODS Serial tracheal aspirate samples were collected during the first 28 days from mechanically ventilated preterm neonates. Bronchopulmonary dysplasia was defined as the need for supplemental oxygen at 36 weeks' postmenstrual age. An enzymatic assay with a fluorescent substrate was used to detect pepsin. Total protein was measured by the Bradford assay to correct for the dilution during lavage. Immunohistochemistry using antibody against human pepsinogen was performed in 10 lung tissue samples from preterm infants. RESULTS A total of 256 tracheal aspirate samples were collected from 59 preterm neonates. Pepsin was detected in 234 (91.4%) of 256 of the tracheal aspirate samples. Twelve infants had no bronchopulmonary dysplasia, 31 infants developed bronchopulmonary dysplasia, and 16 infants died before 36 weeks' postmenstrual age. The mean pepsin concentration was significantly lower in infants with no bronchopulmonary dysplasia compared with those who developed bronchopulmonary dysplasia or developed bronchopulmonary dysplasia/died before 36 weeks' postmenstrual age. Moreover, the mean pepsin level was significantly higher in infants with severe bronchopulmonary dysplasia compared with moderate bronchopulmonary dysplasia. The mean pepsin level in tracheal aspirate samples from the first 7 days was also lower in infants with no bronchopulmonary dysplasia compared with those who developed bronchopulmonary dysplasia or developed bronchopulmonary dysplasia/died before 36 weeks' postmenstrual age. Pepsinogen was not localized in the lung tissues by immunohistochemistry. CONCLUSION The concentration of pepsin was increased in the tracheal aspirate of preterm infants who developed bronchopulmonary dysplasia or died before 36 weeks' postmenstrual age. Recovery of pepsin in tracheal aspirate samples is secondary to gastric aspiration, not by hematogenous spread or local synthesis in the lungs. Chronic aspiration of gastric contents may contribute in the pathogenesis of bronchopulmonary dysplasia.
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Affiliation(s)
- Sabeena Farhath
- Division of Gastroenterology and Nutrition and Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
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Furuya MEY, Moreno-Córdova V, Ramírez-Figueroa JL, Vargas MH, Ramón-García G, Ramírez-San Juan DH. Cutoff value of lipid-laden alveolar macrophages for diagnosing aspiration in infants and children. Pediatr Pulmonol 2007; 42:452-7. [PMID: 17427898 DOI: 10.1002/ppul.20593] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Chronic passage of gastric and/or alimentary material into the airways is a frequent and difficult-to-diagnose condition. Because alveolar macrophages phagocytose aspirated material, it has been suggested that their identification is a useful diagnostic method. To know the usefulness of the lipid-laden alveolar macrophages (LLAM) index as a diagnostic tool for aspiration, children from 1 month to 16 years of age were included in three groups: G-I, children with pulmonary pathology and suspicion of aspiration by clinic or image evaluation; G-II, with pulmonary pathology without suspicion of aspiration; and G-III, without respiratory symptoms nor suspicion of aspiration. Bronchoalveolar lavage was obtained through bronchoscopy in G-I and G-II, and through endotracheal tube in G-III, and the LLAM index (0-400) was determined. A total of 112 patients (41, 30, and 41 in G-I to III, respectively) were studied. LLAM index (mean +/- SEM) was highest in G-I (233.2 +/- 5.5), as compared with G-II (187.8 +/- 11.6, P < 0.05), and G-III (108.5 +/- 13.5, P < 0.001). However, notable overlap of LLAM values was observed between G-I and G-II, and between G-II and G-III. When patients from G-I and G-III were jointly analyzed, the area under the ROC curve for diagnosing aspiration was 0.92, with a best cutoff value of >165 (98.6% sensitivity, 78.0% specificity, 87.8% overall accuracy). LLAM index, with a cutoff value of >165 is a useful diagnostic test for aspiration when there is suspicion of this condition. However, due to its low specificity, it does not discriminate other causes of chronic lung disease.
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Affiliation(s)
- María E Y Furuya
- Unidad de Investigación Médica en Enfermedades Respiratorias, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
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Krishnan U, Mitchell JD, Messina I, Day AS, Bohane TD. Assay of tracheal pepsin as a marker of reflux aspiration. J Pediatr Gastroenterol Nutr 2002; 35:303-8. [PMID: 12352517 DOI: 10.1097/00005176-200209000-00012] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Aspiration of gastric contents is a relatively common cause of acute and chronic pulmonary disease. However, a reliable method of diagnosing recurrent aspiration is currently lacking. The aim of this study was to determine whether the presence of gastric pepsin in tracheal aspirates of infants and children might be used as a reliable marker of the microaspiration of refluxed gastric contents. METHODS Ninety-eight children undergoing general anesthesia and tracheal intubation participated in the study. Sixty-four of 98 children underwent endoscopy for clinically significant gastroesophageal reflux. Thirty-four children from routine operative lists were nonreflux controls. These two groups were further subdivided based on the presence or absence of associated respiratory symptoms. After endotracheal intubation, tracheal aspirates were obtained and subsequently assayed for gastric pepsin using a fluoroscein isothiocyanate casein. RESULTS Pepsin was detected in 7 of 27 children with reflux symptoms alone and in 7 of 8 of those with chronic respiratory symptoms. In addition, pepsin was present in 31 of 37 children with a history of both reflux and chronic respiratory symptoms. Tracheal pepsin was not detected in any of the 26 children without gastroesophageal reflux or respiratory symptoms. Tracheal pepsin was found significantly more frequently in children with reflux symptoms than in those without, particularly in children with both reflux and respiratory problems. CONCLUSION Tracheal pepsin assay as a reliable marker of gastroesophageal reflux aspiration.
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Affiliation(s)
- Usha Krishnan
- Division of Pediatric Gastroenterology, Sydney Children's Hospital, High Street, Randwick, New South Wales, Australia 2031.
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10
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Krishnan U, Mitchell JD, Tobias V, Day AS, Bohane TD. Fat laden macrophages in tracheal aspirates as a marker of reflux aspiration: a negative report. J Pediatr Gastroenterol Nutr 2002; 35:309-13. [PMID: 12352518 DOI: 10.1097/00005176-200209000-00013] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Refluxed gastric material aspirated into the lungs is an important cause of acute and chronic pulmonary disease. Currently, the presence of fat-laden macrophages (FLM) in tracheobronchial secretions of children is a conventional marker for reflux aspiration. However, this assay is limited by its apparent lack of specificity. The aim of this study was to reevaluate the role of this assay in diagnosing reflux aspiration. METHODS The tracheal aspirates of sixty-four consecutive children with clinically significant gastroesophageal reflux undergoing upper gastrointestinal endoscopy under general anesthesia, and 34 other children from the routine operative schedule were evaluated. Both groups were further subdivided on the basis of presence or absence of associated respiratory symptoms. After intubation, tracheal aspirates were collected, fixed, and stained for FLM. By grading the amount of intracellular fat present, a semiquantitative lipid index was computed. Tracheal aspirates with a lipid index of 100 or greater were considered positive. RESULTS Twenty-four of the 64 children with reflux symptoms and 14 of 34 children without reflux symptoms were positive for FLM. Sixteen of 37 children with both gastroesophageal reflux and respiratory symptoms and 10 of 26 children negative for both tested positive for FLM. The mean lipid index of the subgroup of children with both reflux and respiratory symptoms was not significantly different from that of the subgroup that was negative for both conditions. Despite computing a semiquantitative lipid index, an index of 100 or greater only had a sensitivity of 38% and specificity of 59%. CONCLUSION Assay of FLM in the tracheal aspirates of children considered at risk of reflux aspiration is not a sensitive or specific as a marker for reflux aspiration.
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Affiliation(s)
- Usha Krishnan
- Division of Pediatric Gastroenterology, Sydney Children's Hospital, High Street, Randwick, New South Wales, Australia 2031.
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11
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Bibi H, Khvolis E, Shoseyov D, Ohaly M, Ben Dor D, London D, Ater D. The prevalence of gastroesophageal reflux in children with tracheomalacia and laryngomalacia. Chest 2001; 119:409-13. [PMID: 11171716 DOI: 10.1378/chest.119.2.409] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE We conducted a retrospective study to determine the relationship between gastroesophageal reflux (GER) and large airways malacia in infancy. METHODS One hundred sixteen children referred for chronic respiratory problems who were between the ages of 3 and 28 months were investigated. All of them underwent flexible bronchoscopy and chest radiography. Eighteen children had laryngomalacia, 13 had tracheomalacia, and 23 had combined laryngotracheomalacia. During bronchoscopy, BAL was performed. An analysis of macrophages in the BAL fluid for lipid content was performed. Fifty-four children with laryngomalacia and tracheomalacia constituted the study group, and 62 children were in the control group. Reflux studies were obtained for 40 children from the study group and 41 from the control group. RESULTS In the study group, 28 children (70%) had GER documented by reflux studies compared with 16 children (39%) in the control group (p < 0.01). In the control group, GER was found mainly among those with recurrent bilateral pneumonia. The lipid-laden macrophage score was correlated with the documented GER. CONCLUSION GER is prevalent among infants with large airways malacia, and treatment of this group with antireflux therapy should be considered.
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Affiliation(s)
- H Bibi
- Department of Pediatrics, Barzilai Medical Center, Ashkelon, Israel
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12
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Abstract
Gastro-oesophageal reflux (GOR) is an extremely common paediatric problem that often runs a harmless and self-limited course. Physiological GOR however can lead to marked parental anxiety, many unnecessary investigations and often unwarranted and potentially harmful therapeutic interventions. Our ability to better define GOR and gastro-oesophageal reflux disease (GORD) has improved in the past 15 years with a better understanding of the pathophysiology in infants and children due to the development and wider use of flexible endoscopy, 24-hour oesophageal pH monitoring and, more recently, the use of micromanometric methods for studying oesophageal motility. This will be further enhanced in the future with the development of non-invasive breath testing to study gastrointestinal motility and the use of electrical impedance to study fluid movement. Our therapeutic interventions have also improved particularly in the areas of acid suppression, improved surgical techniques and most recently laparoscopic fundoplication. This chapter reviews these advances in the paediatric area especially with regard to pathophysiology, diagnostic testing and therapeutic intervention.
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Affiliation(s)
- G P Davidson
- Gastroenterology Unit, Women's and Children's Hospital, 72 King William Road, North Adelaide, Adelaide, SA, 5006, Australia
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Kajetanowicz A, Stinson D, Laybolt KS, Resch L. Lipid-laden macrophages in the tracheal aspirate of ventilated neonates receiving Intralipid: A pilot study. Pediatr Pulmonol 1999; 28:101-8. [PMID: 10423309 DOI: 10.1002/(sici)1099-0496(199908)28:2<101::aid-ppul5>3.0.co;2-g] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lipid-laden macrophages (LLM) in tracheal aspirates are reported to be pathognomonic findings in exo- and endogenous lipoid pneumonia in adults. A pilot study was carried out to evaluate the effect of lipid infusion on the LLM index of the tracheal aspirates from ventilated neonates. All intubated infants were eligible for the study. Infants receiving parenteral nutrition had intravenous (IV) lipid introduced by 4-7 days of age; most samples after 7 days were from infants receiving IV lipid. Four infants received minimal gastric feeding; none had evidence of aspiration pneumonia. Tracheal aspirates from 28 infants were analyzed for the LLM index. Alveolar macrophages were graded 0-4 in direct relation to the amount of lipid per cell. One hundred macrophages were graded; the maximum possible LLM index was 400. Two hundred forty-five of 387 tracheal aspirate samples were acceptable for analysis. LLM indices increased during the first week after birth; the mean LLM index then continued in the same range, but with a wide distribution of individual values. The mean LLM index from infants receiving an IV lipid infusion during days 4-7 was 87.9 (SD = 44.8), and was significantly higher compared to 58.7 (SD = 40.8) in infants receiving no IV lipid (P < 0. 003). Tracheal aspirates from infants with and without IV lipid infusion yielded many LLM index values >100. These observations invalidate the use of the LLM index >100 as proof of aspiration pneumonia in this group of infants.
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Affiliation(s)
- A Kajetanowicz
- Department of Neonatal Pediatrics, I.W.K. Grace Health Centre, Dalhousie University, Halifax, Nova Scotia, Canada.
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Ahrens P, Noll C, Kitz R, Willigens P, Zielen S, Hofmann D. Lipid-laden alveolar macrophages (LLAM): a useful marker of silent aspiration in children. Pediatr Pulmonol 1999; 28:83-8. [PMID: 10423306 DOI: 10.1002/(sici)1099-0496(199908)28:2<83::aid-ppul2>3.0.co;2-a] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
At present there is no test available which identifies children suffering from silent aspiration due to gastroesophageal reflux (GER). The purpose of this study was to determine whether lipid-laden alveolar macrophage (LLAM) scoring is a useful method to arrive at the diagnosis. We evaluated bronchoalveolar lavage fluid (BALF) from 68 children aged 6 months to 14 years (median 3.75 years) for the presence of lipid-laden alveolar macrophages. We compared children with chronic chest disease (CCD) and GER to healthy surgical controls without known lung disease, and to children with recurrent pneumonia without GER. By grading the amount of intracellular Sudan Red-positive material, we determined a semiquantitative lipid-laden macrophage (LLAM) score for each patient. Patients with chronic chest disease suspected to be caused by silent aspiration secondary to GER had a significantly higher LLAM score (median, 117; range, 10-956) than children with recurrent pneumonia due to other reasons (median, 29; range, 5-127; P < 0.01) and healthy controls (median, 37; range, 5-188; P < 0.01). We believe that simply observing lipid-laden macrophages is nonspecific, but quantitation of these cells is a useful method for diagnosing silent aspiration in children, especially when the score exceeds 200.
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Affiliation(s)
- P Ahrens
- Department of Pediatrics, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany.
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16
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Abstract
Cough is an uncommon sign in infants. Cough may result from the presence of abnormal secretions in the airway or abnormalities of the central airways that affect the infant's ability to clear normal secretions. Tracheomalacia (TM) and gastroesophageal reflux (GER) can both cause cough in infants. Four infants whose cough began in the newborn period were diagnosed with TM and GER. Symptoms of central airway obstruction (homophonous wheeze or tracheal cough) suggested the diagnoses. In three patients, the diagnosis was made by barium esophagraphy and airway fluoroscopy. The infants responded to conservative and medical therapy for GER and to nebulized bronchodilators. Tracheomalacia and GER cause cough in infants that begins in the newborn period. The diagnosis can often be made with studies available to the primary care provider, and the conditions are often responsive to medical management.
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Affiliation(s)
- C W Callahan
- Tripler Army Medical Center, (MCHK-PE), Honolulu, HI 96859-5000, USA
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17
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Abstract
Gastroesophageal reflux is a common pediatric complaint and a frequent reason for pediatric patients to be referred to a gastroenterologist. The pathophysiology and clinical manifestations of this disorder differ according to patient age. The diagnosis is suggested by the history and can be confirmed by a pH probe. In the appropriate clinical setting, anatomic obstruction may need to be ruled out by contrast study. Endoscopy is used to assess associated complications, including esophagitis, esophageal strictures, Barrett's transformation, and failure to thrive. Other complications are controversial, including pulmonary disease, apnea, and sudden infant death syndrome. Treatment depends on the severity of disease. Conservative therapy includes behavorial modifications, prokinetic agents, and H2 antagonists. Proton pump inhibitors are generally reserved for refractory esophagitis. Surgical treatment may be necessary for gastroesophageal reflux resistant to medical management or for severe complications. Gastroesophageal reflux beyond infancy tends to be chronic; therefore, lifelong behavioral modifications or repeated courses of medical therapy may be necessary. An algorithm for the suggested diagnostic approach to gastroesophageal reflux is presented herein.
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Affiliation(s)
- W A Faubion
- Section of Pediatric Gastroenterology, Mayo Clinic Rochester, Minnesota 55905, USA
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Badellino MM, Buckman RF, Malaspina PJ, Eynon CA, O'Brien GM, Kueppers F. Detection of pulmonary aspiration of gastric contents in an animal model by assay of peptic activity in bronchoalveolar fluid. Crit Care Med 1996; 24:1881-5. [PMID: 8917040 DOI: 10.1097/00003246-199611000-00019] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether peptic activity in bronchoalveolar fluid, due to the presence of the gastric proteolytic enzyme pepsin, could serve as a biochemical marker for pulmonary aspiration of gastric contents. DESIGN Prospective, experimental trial. SETTING A university animal research laboratory. SUBJECTS Thirty-six New Zealand rabbits, weighing 2 to 4 kg. INTERVENTIONS New Zealand rabbits were anesthetized, intubated via tracheostomy, and mechanically ventilated. Pulmonary aspiration was induced by the intratracheal instillation of 2 mL/kg human gastric juice (pH 1.2 +/- 0.2; pepsin activity 0.02 +/- 0.006 microgram/mL; human gastric juice group, n = 24) or normal saline solution (pH 5.2 +/- 0.2; normal saline solution group; n = 12). Mechanical ventilation was continued. Bronchoalveolar lavage was performed at 15 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), 30 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), or 60 mins (human gastric juice group, n = 8; normal saline solution group, n = 4) postaspiration. MEASUREMENTS AND MAIN RESULTS Peak airway pressure and PaO2 values were measured at baseline and 15 and 30 mins after aspiration. The pH of retrieved bronchoalveolar lavage fluid was measured and pepsin activity in sample fluid was determined. Changes from baseline in peak airway pressure and PaO2 were significant in human gastric juice animals at 15 and 30 mins when compared with normal saline solution animals (PaO2 -4% vs. -44%, peak airway pressure 20% vs. 36% at 15 mins; PaO2 -16% vs. -79%, peak airway pressure 28% vs. 69% at 30 mins; normal saline solution group vs. human gastric juice group, p < .02). Bronchoalveolar lavage fluid pH was not significantly different between groups at any time postaspiration (6.6 +/- 0.7 vs. 6.0 +/- 0.4 at 15 mins; 7.4 +/- 0.9 vs. 6.5 +/- 0.4 at 30 mins; 7.2 +/- 0.5 vs. 6.4 +/- 0.4 at 60 mins, normal saline solution group vs. human gastric juice group, p = NS). No peptic activity was present in bronchoalveolar lavage fluid from normal saline solution animals at any time. In the human gastric juice group, peptic activity was detected in postaspiration bronchoalveolar lavage fluid in eight of eight animals at 15 mins, six of eight animals at 30 mins, and five of eight animals at 60 mins (normal saline solution group vs. human gastric juice group; p < .001 at 15 mins, p < .01 at 30 mins, p = NS at 60 mins). Peptic activity of bronchoalveolar lavage fluid varied; mean values were greater at 15 mins than at 30 or 60 mins (pepsin activity: 0.004 +/- 0.002 microgram/mL vs. 0.002 +/- 0.001 microgram/mL vs. 0.0006 +/- 0.0001 microgram/mL, respectively, p < .05). CONCLUSIONS The results of this study suggest that peptic activity in bronchoalveolar lavage fluid can be detected up to 60 mins after induced, experimental gastric juice aspiration and may prove a clinically useful biochemical marker for episodes of occult pulmonary aspiration of gastric contents.
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Affiliation(s)
- M M Badellino
- Department of Surgery, Temple University School of Medicine, Philadelphia, PA, USA
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19
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Abstract
The clinical challenge of determining the medical conditions that are associated with obvious symptoms of gastroesophageal reflux and what diagnostic tests are appropriate to define this relationship is substantial. To determine which infants may be suffering from pathologic conditions associated with subtle signs of gastroesophageal reflux is even more challenging. This determination is essential to avoid subjecting many healthy infants to costly and potentially invasive testing. This article focuses on the physiology, clinical presentations, diagnosis and evaluation, and therapy of gastroesophageal reflux.
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Affiliation(s)
- A C Hillemeier
- Division of Pediatric Gastroenterology, University of Michigan, Ann Arbor, Michigan 48109-0200, USA
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20
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Bauman NM, Sandler AD, Smith RJ. Respiratory manifestations of gastroesophageal reflux disease in pediatric patients. Ann Otol Rhinol Laryngol 1996; 105:23-32. [PMID: 8546421 DOI: 10.1177/000348949610500105] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Respiratory manifestations of gastroesophageal reflux disease (GERD) are being recognized with increasing frequency. We present the evaluation and management of four infants and children with unusual respiratory symptoms attributed to GERD. The advantages and disadvantages of diagnostic studies of GERD are discussed, and an evaluation and treatment protocol is presented. Treatment must be tailored to the nature and severity of the patient's presenting symptoms and includes conservative, pharmacologic, and/or surgical management.
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Affiliation(s)
- N M Bauman
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa College of Medicine, Iowa City, USA
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21
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Waki EY, Madgy DN, Belenky WM, Gower VC. The incidence of gastroesophageal reflux in recurrent croup. Int J Pediatr Otorhinolaryngol 1995; 32:223-32. [PMID: 7665269 DOI: 10.1016/0165-5876(95)01168-b] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The incidence of gastroesophageal reflux in recurrent croup was evaluated by a retrospective analysis of patients at the Children's Hospital of Michigan from 1986 to 1991. Sixty-six patients required hospitalization for recurrent croup during this 6-year period. Of the patients evaluated, 47% with recurrent croup had an additional diagnosis established of gastroesophageal reflux. In patients with three or more hospitalizations for croup, there was a 63% association with gastroesophageal reflux. Compared to all patients with recurrent croup, the patients with gastroesophageal reflux tended to be younger and had a shorter interval between episodes of croup. A prospective series of six cases of recurrent croup was seen in consultation. The diagnostic procedures involving lipid-laden macrophage quantitation, endoscopy, and gastroesophageal reflux scintiscans were utilized to establish the diagnosis of gastroesophageal reflux with tracheal aspiration. The results of these studies and the follow-up is discussed.
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Affiliation(s)
- E Y Waki
- Department of Pediatric Otolaryngology, Children's Hospital of Michigan, Detroit 48201, USA
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22
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Abstract
The purpose of this study was to study the relationship of aspiration with ongoing respiratory difficulties in infants with bronchopulmonary dysplasia (BPD). Twelve infants with BPD were identified out of 314 children who had flexible bronchoscopy between 1987 and 1990; 11 of 12 had bronchoalveolar lavage (BAL). The lipid index (LI) was used to quantify the degree of lipid-laden macrophages in the BAL fluid as a marker of aspiration. The age range at the time of bronchoscopy was 3 months to 5 years. The LI was considered positive in 6 of 11 subjects. A pH probe study was done on seven subjects with concordant findings in five. Other findings included dynamic or structural airway abnormalities in 10 of the 12 subjects. These data suggest that aspiration frequently is associated with BPD in addition to the previously recognized dynamic and structural airway problems. The predisposition to gastroesophageal reflux and laryngeal injury probably accounts for the increased aspiration risk in children with BPD.
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23
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Burton DM, Pransky SM, Katz RM, Kearns DB, Seid AB. Pediatric airway manifestations of gastroesophageal reflux. Ann Otol Rhinol Laryngol 1992; 101:742-9. [PMID: 1514751 DOI: 10.1177/000348949210100905] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastroesophageal reflux (GER) in children may be classified as physiologic or pathologic, depending on its degree and consequences. There are many head and neck complications of GER in pediatric patients, but most numerous are the airway manifestations, including stridor, recurrent croup, exacerbation of subglottic stenosis, laryngeal irritation with or without laryngospasm, chronic cough, and obstructive apnea. Diagnosis may be difficult unless there is a high index of suspicion for GER and awareness of the concept of "silent" GER. We present the common pediatric airway manifestations of GER, illustrated by case reports, and provide a paradigm to assist in the diagnosis and management of children with airway compromise associated with GER.
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Affiliation(s)
- D M Burton
- Department of Pediatric Otolaryngology, Children's Hospital and Health Center, San Diego, California
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24
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Wolfson BJ, Allen JL, Panitch HB, Karmazin N. Lipid aspiration pneumonia due to gastroesophageal reflux. A complication of nasogastric lipid feedings. Pediatr Radiol 1989; 19:545-7. [PMID: 2797940 DOI: 10.1007/bf02389570] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The development of lipid aspiration pneumonia after chronic nasopharyngeal installation of mineral oil was first described in 1925 by Laughlin. Since that time this entity has been well recognized and numerous substances have been identified or implicated as the aspirated material. The classic radiographic appearance of severe chronic lipid aspiration pneumonia has been described as consisting of intense perihilar infiltrates. However, the radiographic findings are more often non-specific and usually consist of varying degrees of diffuse interstitial infiltrates that tend to be more prominent in the perihilar regions and the right lung. We are reporting a case of biopsy-proven lipid aspiration pneumonia in an infant with known gastro-esophageal reflux (GER) who had medium-chain triglyceride oil administered via nasogastric tube. Serial roentgenograms demonstrated a changing pulmonary pattern from diffuse bilateral interstitial infiltrates initially to a diffuse alveolar pattern at the time of the lung biopsy. Modern medicine has developed new methods for providing nourishment to sick newborns and infants to improve their nutritional status and help them to grow. One such method involves the administration of medium-chain triglycerides (MCT oil) into the GI tract via a nasogastric or nasoenteral tube. The purpose of this report is to describe a significant complication of this method of providing nutrition to an infant with gastroesophageal reflux (GER) and the diagnostic dilemma it presented.
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Affiliation(s)
- B J Wolfson
- Department of Radiology, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
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