phenylephrine-hydrochloride and Pneumonia--Aspiration

In the patient obtunded by drug intoxication, the optimal method of airway protection prior to gastric emptying is not clear. We report a prospective randomized trial of two methods of intubation in this patient population. Fifty-two overdose patients with Glascow Coma Scale scores of 12 or less were intubated either orotracheally after succinylcholine administration or nasotracheally. Success rate, time to intubate, difficulty, and complications of intubation were compared for the two groups. We found a success rate of 100% (23 of 23) for succinylcholine assisted intubation (SAI) versus 65% (19 of 29) success with blind nasotracheal intubation (BNI). Mean time to intubate was 64 seconds and 276 seconds in the SAI and BNI groups, respectively. Eighty-six percent (19 of 22) of patients were intubated successfully in less than 120 seconds in the SAI group versus 37% (10 of 27) in the BNI group (P less than .005). In the SAI group, the mean number of attempts was 1.3 per patient, (range, one to three) with 96% (22 of 23) having two or fewer attempts. No complications were identified. In the BNI group, the mean number of attempts was 3.7 per patient, (range, one to 13) with 45% (13 of 29) having two or fewer attempts (P less than .005). Sixty-nine percent of the BNI group experienced epistaxis, 17% had vomiting, and 10% aspirated. We conclude that SAI is a safe and effective method of airway protection in the obtunded poisoned patient. Complications and difficulty in intubation were significantly less with SAI than with blind nasotracheal intubation.

Topics: Adult; Humans; Intubation, Intratracheal; Mouth; Nose; Pneumonia, Aspiration; Poisoning; Prospective Studies; Random Allocation; Succinylcholine

Aspiration pneumonia (AP) is caused by dysfunctional swallowing resulting in aspiration of material colonized by respiratory pathogens. The aim of this study was to assess and compare the swallowing physiology, health status, oral health status, and oral/nasal microbiota in frail older patients (FOP) with oropharyngeal dysphagia (OD) and a control group.. We studied 47 FOP (>70 year) with OD by videofluoroscopy (17 with acute pneumonia -APN-, 15 with prior pneumonia-PNP- and 15 without) and 14 older controls without OD (H). Oral/nasal colonization by five respiratory pathogens was evaluated by qPCR, whereas commensal microbiota composition was assessed by pyrosequencing.. (i) Frail older patients with OD presented similar comorbidities, poor functionality, polymedication, and prevalent videofluoroscopic signs of impaired safety of swallow (33.3-61.5%). However, patients with OD-APN also presented malnutrition, delayed laryngeal vestibule closure (409.23 ± 115.6 ms; p < 0.05), and silent aspirations (15.6%). (ii) Oral health was poor in all groups, 90% presented periodontitis and 72%, caries. (iii) Total bacterial load was similar in all groups, but higher in the oropharynx (>10(8) CFU/mL) than in the nose (<10(6) CFU/mL) (p < 0.0001). Colonization by respiratory pathogens was very high: 93% in OD patients (p < 0.05 vs H); 93% in OD-PNP (p < 0.05 vs H); 88% in OD-APN (p = 0.07 vs H), and lower in controls (67%).. Frail older patients with OD had impaired health status, poor oral health, high oral bacterial load, and prevalence of oral colonization by respiratory pathogens and VFS signs of impaired safety of swallow, and were therefore at risk for contracting AP.

Topics: Aged; Aged, 80 and over; Deglutition Disorders; Female; Frail Elderly; Humans; Male; Mouth; Nose; Pneumonia, Aspiration; Prevalence

To examine the role of disturbed upper airway reflexes in aspiration, we administered 20 microliters of the adenovirus (Ad) vector Ad-CMV-LacZ or 20 microliters of phosphate buffered saline (PBS) intranasally to C57 black mice. We investigated expression of the LacZ gene by this Ad vector in the nostrils of each mouse, with or without anesthesia. Under anesthesia, LacZ gene expression was detected in the lungs of every mouse given the Ad vector. However, no LacZ gene expression was found in the trachea or lungs of mice given the Ad vector without anesthesia. In mice given PBS or wild-type adenovirus transnasally during anesthesia, there was no LacZ gene expression in the nostrils, trachea, or lungs, suggesting that with 5-bromo-4-chloro-3-indolyl-beta-D-galactopyranoside (X-gal) staining, blue-stained cells indicated transferred LacZ gene expression. These results suggested that aspiration of intranasal solution into lower airways was caused by disturbed upper airway reflexes during anesthesia. This process can be analyzed by the distribution of LacZ gene expression in airways. We next examined the effect of age on anesthesia-induced aspiration. Twenty-six-mo-old mice exhibited more LacZ gene expression in their lungs than did 6-mo-old mice at a concentration of 0.5 to 4.0% halothane in 100% oxygen. This suggests that light anesthesia may depress upper airway reflexes and cause aspiration in older animals. This novel model of aspiration, generated with the Ad-CMV-LacZ vector, may be useful for elucidating the mechanism of development of aspiration pneumonia in relation to age-related impairment of upper airway reflexes.

Topics: Adenoviridae; Age Factors; Anesthetics, General; Anesthetics, Inhalation; Animals; beta-Galactosidase; Chromogenic Compounds; Coloring Agents; Disease Models, Animal; DNA, Recombinant; Galactosides; Gene Expression Regulation, Viral; Gene Transfer Techniques; Genetic Vectors; Halothane; Indoles; Lac Operon; Lung; Male; Mice; Mice, Inbred C57BL; Nose; Oxygen; Pneumonia, Aspiration; Reflex, Abnormal; Trachea

Respiratory distress, apnea, and chronic pulmonary disease since birth were identified in 14 infants who also had symptomatic gastroesophageal reflux. Birth weights varied from 760 to 4,540 gm. All infants had radiographic changes similar to those in bronchopulmonary dysplasia. Cessation of apnea and improvement of pulmonary disease occurred only after medical (8) or surgical (6) control of gastroesophageal reflux. Simultaneous tracings of esophageal pH, heart rate, impedance pneumography, and nasal air flow in five infants demonstrated that reflux preceded apnea. Apnea could be induced by instillation of dilute acid, but not water or formula, into the esophagus. Prolonged monitoring of esophageal pH more than two hours after feeding in 14 other infants less than 6 weeks of age (birth weight 780 to 3,350 gm) without a history of recent vomiting indicated that reflux was not greater than in normal older children.

Topics: Apnea; Chronic Disease; Gastroesophageal Reflux; Heart Rate; Humans; Hydrogen-Ion Concentration; Infant, Newborn; Infant, Newborn, Diseases; Lung Diseases; Nose; Pneumonia, Aspiration; Pulmonary Ventilation; Respiratory Distress Syndrome, Newborn

Topics: Accidents, Traffic; Facial Bones; Fracture Fixation; Fractures, Bone; Humans; Immobilization; Mandibular Fractures; Maxillary Fractures; Maxillofacial Injuries; Nose; Pneumonia, Aspiration; Radiography; Respiratory Insufficiency; Transportation of Patients