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Original Article
Neurology
Early assessment of aspiration risk in acute stroke by fiberoptic endoscopy in critically ill patients
Mohamed Saad Abdelaziz Elsyaad, Akram Muhammad Fayed, Mohamed Mostafa Abdel Salam Megahed, Nesrine Hazem Hamouda, Ahmed Moustafa Elmenshawy
Acute Crit Care. 2022;37(3):276-285.   Published online June 27, 2022
DOI: https://doi.org/10.4266/acc.2021.01375
  • 3,829 View
  • 215 Download
  • 2 Web of Science
  • 2 Crossref
AbstractAbstract PDF
Background
Fiberoptic endoscopic evaluation of swallowing (FEES) has been recommended to assess aspiration in stroke. This study aimed to determine the diagnostic and prognostic roles of FEES in the early assessment of aspiration, intensive care unit (ICU) stay and mortality in acute stroke patients.
Methods
Fifty-two patients with acute stroke admitted to the Alexandria Main University Hospital were included. Complete examinations and assessment of aspiration using the 8-point penetration-aspiration scale (PAS) with FEES protocol were performed.
Results
The patients were classified into three groups: normal with no or low risk of aspiration (n=15, 27.3%; PAS level 1), low to moderate risk (n=8, 14.5%; PAS level 2–4), and high risk (n=32, 58.2%; PAS ≥5). There was high incidence of aspiration pneumonia, prolonged ICU stay, and mortality in both moderate- and high-risk groups (P=0.001, P<0.001, and P<0.001, respectively). The PAS score predicted aspiration pneumonia (hospital-acquired pneumonia) with sensitivity and specificity of 80.0% and 76.0%, respectively (negative predictive value [NPV], 76.0; positive predictive value [PPV], 80.0; 95% confidence interval [CI], 0.706–0.940) and mortality with sensitivity and specificity of 88.46% and 68.97% (NPV, 87.0; PPV, 71.9; 95% CI, 0.749–0.951). The PAS score could predict the length of ICU stay with sensitivity and specificity of 70.21% and 87.50, respectively (NPV, 33.3; PPV, 97.1; 95% CI, 0.605–0.906).
Conclusions
The standard FEES protocol using PAS score is a useful tool to assess aspiration in acute stroke patients and could be used to predict length of ICU stay and mortality.

Citations

Citations to this article as recorded by  
  • Aspiration Pneumonia
    Di Pan, Samuel Chung, Erik Nielsen, Michael S. Niederman
    Seminars in Respiratory and Critical Care Medicine.2024; 45(02): 237.     CrossRef
  • The use of videofluoroscopy (VFS) and fibreoptic endoscopic evaluation of swallowing (FEES) in the investigation of oropharyngeal dysphagia in stroke patients: A narrative review
    K. Helliwell, V.J. Hughes, C.M. Bennion, A. Manning-Stanley
    Radiography.2023; 29(2): 284.     CrossRef
Case Reports
Pulmonary
Recurrent Aspiration Pneumonia due to Anterior Cervical Osteophyte
Jae Jun Lee, Ji Young Hong, Jun Han Jung, Jun Hyeok Yang, Jun-Young Sohn
Korean J Crit Care Med. 2017;32(1):74-78.   Published online February 28, 2017
DOI: https://doi.org/10.4266/kjccm.2016.00409
  • 9,495 View
  • 119 Download
  • 2 Web of Science
  • 2 Crossref
AbstractAbstract PDF
A 74-year-old man presented with recurrent vomiting and aspiration pneumonia in the left lower lobe. He entered the intensive care unit to manage the pneumonia and septic shock. Although a percutaneous endoscopic gastrostomy tube was implanted for recurrent vomiting, vomiting and aspiration recurred frequently during admission. Subsequently, he complained of neck pain when in an upright position. A videofluoroscopic swallowing study showed compression of the esophagus by cervical osteophytes and tracheal aspiration caused by an abnormality at the laryngeal inlet. Cervical spine X-rays and computed tomography showed anterior cervical osteophytes at the C3-6 levels. Surgical decompression was scheduled, but was cancelled due to his frailty. Unfortunately, further recurrent vomiting and aspiration resulted in respiratory arrest leading to hypoxic brain damage and death. Physicians should consider cervical spine disease, such as diffuse skeletal hyperostosis as an uncommon cause of recurrent aspiration pneumonia.

Citations

Citations to this article as recorded by  
  • Diffuse idiopathic skeletal hyperostosis of the cervical spine causing dysphagia and airway obstruction: an updated systematic review
    Netanja I. Harlianto, Jonneke S. Kuperus, Firdaus A.A. Mohamed Hoesein, Pim A. de Jong, Jacob A. de Ru, F. Cumhur Öner, Jorrit-Jan Verlaan
    The Spine Journal.2022; 22(9): 1490.     CrossRef
  • An unusual presentation of thoracic diffuse idiopathic skeletal hyperostosis (DISH) and video-assisted thoracoscopic surgery (VATS)
    Suthipas Pongmanee, Borvornsake Rojdumrongrattana, Noparoot Kritworakarn, Peem Sarasombath, Wongthawat Liawrungrueang
    International Journal of Surgery Case Reports.2022; 93: 106993.     CrossRef
Pulmonary/Thoracic Surgery
Extracorporeal Membrane Oxygenation Therapy for Aspiration Pneumonia in a Patient following Left Pneumonectomy for Lung Cancer
Jangwhan Jo, Yang Gi Ryu
Korean J Crit Care Med. 2016;31(2):156-161.   Published online May 31, 2016
DOI: https://doi.org/10.4266/kjccm.2016.31.2.156
  • 7,941 View
  • 114 Download
  • 1 Crossref
AbstractAbstract PDF
A patient had undergone left pneumonectomy for lung cancer and had an increased risk of fatal complications such as pneumonia, including acute respiratory distress syndrome (ARDS). The treatment effects of veno-venous extracorporeal membrane oxygenation (VV-ECMO) for ARDS of postpneumonectomy patient are uncertain. A 74-year-old man with one lung experienced aspiration pneumonia while swallowing pills after the operation, and his condition progressed to ARDS within a day. He was successfully treated with VV-ECMO support and intensive care unit care.

Citations

Citations to this article as recorded by  
  • The Future of Research on Extracorporeal Membrane Oxygenation (ECMO)
    Ji Young Lee
    Korean Journal of Critical Care Medicine.2016; 31(2): 73.     CrossRef
Anesthesiology/Pediatric
Aspiration Pneumonia in a Pediatric Patient under General Anesthesia despite Adequate Preoperative Fasting
Sang-Il Yoon, Jong-Man Kang
Korean J Crit Care Med. 2015;30(4):313-317.   Published online November 30, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.4.313
  • 65,535 View
  • 195 Download
  • 1 Crossref
AbstractAbstract PDF
Aspiration pneumonia rarely occurs during general anesthesia; however, it can result in fatal pulmonary complications. To reduce aspiration pneumonia, a preoperative fasting time of 8 hours is recommended. A 4-year-old boy with ankyloglossia was scheduled for frenotomy. He completed preoperative fasting time and had no digestive symptoms. Pulmonary aspiration due to unexpected massive vomiting occurred during anesthesia induction. The patient’s airway was immediately secured by endotracheal tube. The vomitus in the airway tract was removed by fiberoptic bronchoscopy. Abdomen radiograph taken after this event showed paralytic ileus which can cause aspiration of gastric contents. We describe a case of pneumonia caused by aspiration of gastric contents in a pediatric patient who followed fasting instructions and who was scheduled for outpatient surgery.

Citations

Citations to this article as recorded by  
  • Factors associated with bronchopulmonary aspiration: a national-based study
    Jaqueline Helena Tanner, Cristina Mara Zamarioli, Magda Machado de Miranda Costa, Heiko Thereza Santana, Ana Clara Ribeiro Bello dos Santos, Cleide Felicia de Mesquita Ribeiro, Fernanda Raphael Escobar Gimenes
    Revista Brasileira de Enfermagem.2022;[Epub]     CrossRef
Cardiology/Anesthesiology
Early Extracorporeal Membrane Oxygenation for Massive Aspiration during Anesthesia Induction
Namo Kim, Kwan Hyung Kim, Jeong Min Kim, Su Youn Choi, Sungwon Na
Korean J Crit Care Med. 2015;30(2):109-114.   Published online May 31, 2015
DOI: https://doi.org/10.4266/kjccm.2015.30.2.109
  • 7,045 View
  • 92 Download
  • 2 Crossref
AbstractAbstract PDF
Although the incidence is not high in the general surgical population, pulmonary aspiration of gastric contents can result in serious long-term morbidity and mortality. We report a case of early use of extracorporeal membrane oxygenation (ECMO) to correct severe hypoxemia refractory to conventional mechanical ventilation in a patient with massive aspiration of gastric contents immediately followed by acute lung injury during general anesthesia induction. A 64-year-old woman diagnosed with stomach cancer was scheduled for elective diagnostic laparoscopy. Although there was no sign of gastrointestinal tract obstruction and midnight Nil per Os (NPO) was performed before the operation, pulmonary aspiration occurred during the induction of anesthesia. Despite the endotracheal intubation with mechanical ventilation, severe hypoxemia with hypercapnea persisted. Medical team agreed with applying veno-venous (VV) ECMO, and her blood gas analysis results became stable. ECMO was weaned successfully 9 days after the first aspiration event had occurred. Based on this case, early application of extracorporeal life support can have survival benefits.

Citations

Citations to this article as recorded by  
  • Massive aspiration syndrome: a possible indication for “emergent” veno-venous extracorporeal membrane oxygenation?: a case report
    Emiliano Gamberini, Venerino Poletti, Emanuele Russo, Alessandro Circelli, Marco Benni, Giovanni Scognamiglio, Domenico Pietro Santonastaso, Costanza Martino, Linda Domenichini, Romina Biondi, Giorgia Bastoni, Etrusca Brogi, Luca Ansaloni, Federico Coccol
    Journal of Medical Case Reports.2021;[Epub]     CrossRef
  • Extracorporeal Membrane Oxygenation Therapy for Aspiration Pneumonia in a Patient following Left Pneumonectomy for Lung Cancer
    Jangwhan Jo, Yang Gi Ryu
    Korean Journal of Critical Care Medicine.2016; 31(2): 156.     CrossRef
Five Successful Experiences in the Treatment of Charcoal Aspiration with Bronchoscopic Toilet: A Case Report
Young Il Kim, Jae Seok Park, Jae Sung Choi, Sung Shik Jou, Hyo Wook Gil, Sae Yong Hong
Korean J Crit Care Med. 2012;27(3):202-206.
DOI: https://doi.org/10.4266/kjccm.2012.27.3.202
  • 3,068 View
  • 46 Download
AbstractAbstract PDF
Although activated charcoal is an effective treatment for most toxic ingestions, aspiration of activated charcoal can be fatal. Here, we report that in 5 charcoal aspiration cases, bronchoscopy with suction and lavage was an effective way to remove charcoal from the lungs. Patients showed high APACHE II scores (range: 10-29), and either low PO2 levels, or low CO2 retention. After bronchoscopic removal of the aspirated charcoal, symptoms of hypoxia, CO2 retention, localized wheezing, and pneumonic infiltration as determined by chest radiography, improved in most patients. We report 5 cases of successful treatment of charcoal aspiration with bronchoscopic toilet.
Massive Diffuse Alveolar Hemorrhage Caused by the Aspiration of Gastric Contents during Induction of Anesthesia in Patients with Adhesive Ileus: A Case Report
Ji Seon Jeong, Jong Hun Jun, Hyo Jin Song, Hee Koo Yoo
Korean J Crit Care Med. 2012;27(2):115-119.
DOI: https://doi.org/10.4266/kjccm.2012.27.2.115
  • 3,506 View
  • 54 Download
AbstractAbstract PDF
Aspiration pneumonitis is best defined as an acute lung injury, following the aspiration of regurgitated gastric contents. Major cause of pulmonary aspiration, during anesthesia, is gastric contents. Pulmonary aspiration can present symptoms of wheezing, coughing, dyspnea, cyanosis, pulmonary edema, hypotension, and hypoxemia, which may progress rapidly to severe acute respiratory distress syndrome (ARDS). However, there was no report of massive alveolar hemorrhage associated with aspiration pneumonitis. A 63-year-old man, who had undergone a total gastrectomy and received adjuvant chemotherapy, four months ago, was scheduled for adhesiolysis of the small bowel. The patient occurred aspiration of gastric contents, during induction of anesthesia, and subsequently, hypoxia developed during surgery. The patient moved to an intensive care unit (ICU), without extubation. Mechanical ventilation with PEEP was performed in an ICU. However, the patient died by ARDS and massive alveolar hemorrhage.
Neurogenic-stunned Myocardium and Pulmonary Edema Following a Ruptured Cerebral Aneurysm: A Case Report
Sung Ha Mun, Won Joon Choi, Jeong Min Mok, Jae Young Yang, Chul Ho Woo
Korean J Crit Care Med. 2010;25(2):93-97.
DOI: https://doi.org/10.4266/kjccm.2010.25.2.93
  • 2,487 View
  • 22 Download
  • 1 Crossref
AbstractAbstract PDF
We report a case of neurogenic cardiopulmonary instability with pulmonary edema occurring after an aneurysmal subarachnoid hemorrhage. The patient's pre-operative Glasgow coma scale score was 6 and the PA chest radiograph showed increased diffuse haziness in the right lung field. The patient presented with severe hypotension and low oxygen saturation during surgery. Cardiac damage was documented by increased CK-MB troponin-T levels, and ischemic ECG findings. Reversible cardiac failure associated with subarachnoid hemorrhage may be due to a neurogenic-stunned myocardium. The patient underwent clipping of the aneurysm and recovered with minimal neurologic impairment and normal cardiac function.

Citations

Citations to this article as recorded by  
  • A Retrospective Study about Characteristics of Out-of-hospital Cardiac Arrest Caused by Non-traumatic Subarachnoid Hemorrhage
    Min Seob Sim, Ki Dong Sung, Mun Ju Kang, Ji Ung Na, Tae Gun Shin, Ik Joon Jo, Hyoung Gon Song, Keun Jeong Song, Yeon Kwon Jeong
    The Korean Journal of Critical Care Medicine.2011; 26(3): 151.     CrossRef
Original Articles
Clinical Outcomes of Early Vancomycin Administration before Identification of Methicillin-resistant Staphylococcus aureus in Patients with Nosocomial Pneumonia
Yong Woo Seo, Jung Eun Lee, Bo Ram Min, Jae Seok Park, Jeong Eun Kim, Young Yun Jang, Hun Pyo Park, Nam Hee Ryoo, Won Il Choi
Korean J Crit Care Med. 2007;22(1):1-6.
  • 1,543 View
  • 14 Download
AbstractAbstract PDF
BACKGROUND
The aim of this study is to determine the clinical outcomes of early vancomycin administration before identification of methicillin-resistant Staphylococcus aureus (MRSA) in patients with nosocomial pneumonia on a ventilator. METHODS: We retrospectively reviewed patients with nosocomial pneumonia in a 20-bed medical ICU during a period of 2 years and 2 months. This study included 52 inpatients, who were admitted for more than 72 hr and had a new or progressive lung infiltrate plus at least two of the following three criteria for pneumonia: abnormal body temperature (>38oC or <35oC), abnormal leukocyte count (>10,000/mm3 or <3,000/mm3), and purulent bronchial secretions. All of the MRSA were identified in tracheal aspirates during mechanical ventilation. RESULTS: A total of 23 patients who received vancomycin prior to identification of MRSA exhibited a 28-day mortality rate of 60%, while 29 patients who received vancomycin after identification of MRSA showed a 28-day mortality rate of 40% (p=0.17). There was no statistically significant difference in severity index and routine laboratory findings between the two groups. CONCLUSIONS: Early vancomycin administration before identification of MRSA does not appear to affect the mortality rate for patients with nosocomial pneumonia.
Incidence of Pulmonary Aspiration in Patients with Tracheostomy
Keon Sik Kim, Dong Soo Kim, Wha Ja Kang, Young Kyu Choi, Ok Young Shin, Doo Ik Lee, Moo Il Kwon
Korean J Crit Care Med. 1999;14(2):161-166.
  • 1,928 View
  • 16 Download
AbstractAbstract PDF
BACKGOUND: Patients with tracheostomy tubes have altered glottic closure in deglutition that may result in aspiration and may cause dangerous pulmonary complication including bronchopneumonia and atelectasis. The incidence of pulmonary aspiration in patients with tracheosomy may be high but difficult to determine because investigators often apply different criteria. The present study was prepared to document the incidence of aspiration in patients with tracheostomy using a simple dye-marker test.
METHODS
Thirty six surgical and medical patients (14 male and 22 female) in ICU with tracheostomy tube (high volume, low pressure cuffed tube) were included in this study. Mental status (presence of response to verbal command), the presence of nasogastric tube and the presence of ventilatory support were recorded in each patients to evaluate the effect of these factors on the incidence of aspiration. 1% solution of methylene blue dye was applied on the both side of posterior tongue and then any evidence of the blue dye-marker obtained microscopically on secretion through the tracheostomy tube at every 2 hours during 72 hours was considered the positive evidence of aspiration.
RESULTS
Aspiration was detected by a positive methylene blue dye test in 11 of the 36 patients (30.5%) and average length of time before blue dye was obtained on tracheal secretion was 8.2 7.3 hours.The presence of response to verbal command, nasogastric tube and ventilatory support had no apparent effect on the incidence of aspiration.
CONCLUSIONS
This observation suggests that a simple test using dye-maker is helpful to detect aspiration in patients with tracheostomy. Tracheostomy should be done under discreet decision because the high incidence of aspiration in trcheostomized patients.
Case Reports
Atelectasis Due to Epistaxis Aspiration during Awake Fiberoptic Nasotracheal Intubation
Ju Tae Sohn, Sang Jung Lee, Kyung Il Hwang, Heon Keun Lee, Sang Hwy Lee, Young Kyun Chung
Korean J Crit Care Med. 1998;13(1):91-96.
  • 1,537 View
  • 11 Download
AbstractAbstract PDF
Indication for fiberoptic intubation in an awake patient include almost any abnormality that may hinder the expeditious placement of an endotracheal tube during anesthetic induction. An epistaxis is the most frequent complication of nasotracheal intubation. The patient was admitted for open reduction and internal fixation due to severe mandible fracture. We experienced a case of atelectasis due to epistaxis aspiration during awake fiberoptic nasotracheal intubation in the conscious patient regionally anesthetized by both superior laryngeal nerve block and translaryngeal anesthesia, which is treated by saline irrigation, suction, active coughing and chest percussion.
A Case of Pulmonary Aspiration during the Anesthetic Induction in the Post Total Gastrectomy Patient
Yoon Hee Kim, Sang Soo Kim, Moon Hee Park, Seok Hwa Yoon
Korean J Crit Care Med. 1998;13(1):85-90.
  • 2,066 View
  • 39 Download
AbstractAbstract PDF
Pulmonary aspiration of gastric contents is a feared complication of anesthetic procedures. But aspiration of intestinal contents is rare, the influences of the aspirated contents and/or the consequnt events in the airway have not been fully settled in its provacative role for causing an acute pulmonary reaction. We experienced a case of pulmonary aspiration of intestinal content. The patinet who had undergone previous total gastrectomy was planed emergency operation due to intestinal obstructon. Aspiration during anesthetic induction occurred accidentally. Immediate endotracheal intubation and suction were followed. Right chest breathing sound was coarse and then it was getting better. Although supplement of O2 by Y-piece, arterial blood gas analysis of patient revealed pH 7.30, PaCO2 36 mmHg, PaO2 58 mmHg after emegence from anesthesia in the recovery room. Chest X-ray showed the focal air space consolidation in right lower lung and ill defined pulmonary opacity in left mid lung and retrocardiac area. The measured pH of aspiration content was 7.8 and nonpathogenic Gram negative bacilli species were cutured. Frequent suction, encouraging expectoration, antimicrobial agents therapy and O2 supplementation by Y-piece were performed in the ICU. Patient normalized following 24 hrs after the episode of aspiration.
Anesthesia for Cesarean Section in Two Pregnant Women with Peripartum Cardiomyopathy: A report of two cases
Yong In Kang, Kyung Sook Cho, Su Yeon Kim, Myoung Hee Kim, Hyun Sook Lee
Korean J Crit Care Med. 1997;12(2):177-182.
  • 1,357 View
  • 23 Download
AbstractAbstract PDF
Peripartum cardiomyopathy (PPCM) is defined as the onset of acute heart failure without demonstrable cause in the last trimester of pregnancy or within the first 6 months after delivery. Mortality from PPCM ranges from 25% to 50% and cause of death is usually chronic congestive heart failure or thromboembolic complications. We experienced 2 patients with PPCM. One was a twin pregnant woman and PPCM was developed after cesarean section. In the other case, PPCM was combined with aspiration pneumonia in the preterm labor patient. They were treated with diuretics and cardiotonic drugs and recovered to normal cardiac function within 7 to 10 days. Prognosis is related to recovery of left ventricular function, which usually occurs within 6 months postpartum. Early diagnosis and appropriate treatment of PPCM improve outcome.

ACC : Acute and Critical Care