Chest pearls – Well being and Way of life

Almost 10% of adults who suck in foreign bodies do not survive

By Ed Susman

When foreign objects such as groceries or other shopping malls “get into the wrong pipe” and sucked into the lungs, most people – especially children – survive, but a surprising number of adults die from such incidents, researchers reported at the virtual CHEST meeting 2020, sponsored by the American College of Chest Physicians.

In the first nationwide analysis of foreign body aspiration, Dr. Rodrigo Garcia Tome, a third-year fellow at the University of Southern California at Los Angeles, found all hospital mortality from these events to be 7.6% – but there were big differences between those under 18 and adults.

The adult mortality rate in the 3-year retrospective analysis of the statewide inpatient sample was 9.6%, while that of children was 1.4%, as stated in his poster presentation.

“Foreign body aspiration can be a potentially life-threatening event,” reported Dr. Garcia Tome. “There are thousands of emergency room admissions and hospital admissions in the US every year. While most of these events are not fatal, they cause significant morbidity and contribute to significant health care expenditures. “

Dr. Garcia Tome and his colleagues analyzed records for the years 2012-2014. They found:

– In 2012, there were 6,490 foreign body aspiration admissions in the US, resulting in a 7.2% mortality rate.

– In 2013, there were 5,780 foreign body aspiration admissions in the US, resulting in a 6.9% death rate.

– In 2014, there were 5,760 admissions for foreign body aspiration in the US, resulting in a death rate of 8.7%.

A total of 1,375 people died in the hospital from foreign body aspiration.

In total, foreign bodies in the trachea or bronchus accounted for 10,265 patients who had to be hospitalized – 56.9% of the cases during the three-year study period. The rest of the foreign objects occurred in the pharynx or larynx, reported Dr. Garcia Tome.

“This study provides novel epidemiological and resource use data on this potentially life-threatening event,” he noted. “It also emphasized the key role of the pulmonologist in diagnostic and therapeutic management.” The researchers found that the nationwide inpatient sample is the largest public database of inpatients with all payers, representing an approximately stratified sample of 20% of hospitals in the United States, including data on more than 7 million hospital stays.

These hospital stays to treat foreign body aspiration weren’t cheap, the researchers reported. The average cost per case was $ 11,469.80, reported Dr. Garcia Tome. This included the cost of performing 1,590 laryngoscopies and 3,165 bronchoscopies, or a total of 4,755 diagnostic procedures. “Bronchoscopy appears to be a diagnostic and therapeutic cornerstone in these patients,” he noted. “The total annual inpatient cost of aspirating foreign objects is approximately $ 70 million.

In the study, the mean age of the patients was 51.9 years; 63.4% of the patients in the study were Caucasian; About 48.4% of the patients in the analysis were women, the researchers reported.

Commenting on the study, Len Horovitz, MD, lung specialist at Lenox Hill Hospital in New York City, “Aspiration in childhood occurs primarily because children put objects in their mouths with great frequency. Since adults are aware of this, they tend to suck in small objects like toys and are not necessarily life threatening.

“In adults,” he said, “aspiration from food occurs and can be exacerbated by impaired consciousness from the use of sleeping pills or alcohol.” In comorbid conditions, especially heart disease, this can lead to a higher incidence of death. “

Dr. Horovitz also said, “Children who aspirate foreign objects are often watched by caregivers and action is taken. Adults are more likely to be alone when aspiration occurs. “

COVID-19 complicates cancer

In another presentation at the meeting, held online or using teleconferencing technology, patients undergoing cancer treatment appear to be at greater risk of death if they have a severe case of SARS-CoV-2 infection – COVID-19 disease – develop.

Of 38 cancer patients admitted to intensive care because of COVID-19, 18 died, a death rate of 47%, reported Dr. Michael Dang, an intensive care fellow at Memorial Sloan Kettering Cancer Center in New York City.

“The landscape of COVID-18 data is constantly changing,” said Dr. Dang in his oral presentation. “Mortality rates are typically higher than general medicine, but cancer with COVID-19 is viable.”

Mortality appeared to be higher in patients with hematologic cancer, he said. Mortality was 27% – 14 of 51 patients with solid tumors; 47% –18 of 38 patients with hematologic cancer.

Of the 59 patients who were mechanically ventilated, 32 died, which corresponds to a mortality rate of 54%. If the patient was neutropenic, the mortality was very high – 6 out of 9 of these patients died (75%).

In his study, Dr. Dang 89 patients treated for cancer and seriously ill due to severe acute respiratory syndromes due to COVID-19 infection and treated in 2 intensive care units from March 16, 2020 to June 30, 2020 units.

The study only included those patients who were being treated for cancer and were seriously ill in a single center. The patients were approximately 64 years old, 58% were men, 66% were white, 18% were black, and 10% were Asian / Indian. Of the 89 patients in the study, 40 died, said Dr. Dang.

In addition to being treated for cancer, the patients had multiple comorbidities. About 51% of the patients have been diagnosed with high blood pressure. 28% were diagnosed with diabetes; 12% had cardiovascular disease and 12% had a history of deep vein thrombosis or pulmonary embolism; 53% had a history of cigarette smoking; Asthma or chronic obstructive pulmonary disease was diagnosed in 9%.

Dr. Dang said that 57% of the patients enrolled in the study had been diagnosed with solid tumors, while the others had hematological conditions such as leukemia, lymphoma, and plasma cell dyscrasia.

About half of people had received active cancer therapy in the previous 90 days, but Dr. Dang said that upon admission to the intensive care unit, all cancer therapies were suspended.

After admission to the intensive care unit, 59 of the patients received mechanical ventilation. They were treated with a variety of therapies including hydroxychloroquine, azithromycin, as well as experimental therapies including remdesivir, convalescent plasma, N-acetylcsytin, and tocilizumab. About 75% of the patients also received steroids.

Delirium in the intensive care unit

In another study, patients treated for psychiatric disorders before being admitted to the intensive care unit for episodes of acute respiratory distress syndrome were at greater risk of developing delirium during their hospital stay.

“In patients with acute respiratory distress syndrome with pre-existing psychiatric illnesses, delirium was found in the intensive care unit in 48.3%, compared with 32.6% of patients without a pre-existing psychiatric illness [OR =1.93 (95% CI 0.98-3.79. P=0.055)]said Dr. Saminder Kalra, a fellow in pulmonary and critical care medicine at the University of Florida, Gainesville.

In particular, Dr. Kalra and colleagues found that with a pre-existing diagnosis of generalized anxiety disorder and / or depression, the risk of delirium was higher after intensive care therapy.

“In particular, both pre-existing depression and anxiety have nearly doubled the chances of developing delirium,” he said. The odds ratio was 1.86 for depression (P = 0.03) and the odds ratio was 1.83 for anxiety (P = 0.05).

Dr. Kalra and colleagues conducted a retrospective study in patients with acute respiratory distress syndrome treated from January 2016 to December 2018. The patients had to be supported by mechanical ventilation for more than 48 hours. The team defined psychiatric illness as the presence of major depression, generalized anxiety disorder, bipolar disorder, schizophrenia, or post-traumatic stress disorder (PTSD) prior to admission.

The results examined in 150 patients who met their inclusion criteria. In patients with acute respiratory distress syndrome and delirium in the intensive care unit, 22.1% of patients received anxiolytic support prior to admission, compared with 7.6% of patients without delirium.

“One possible explanation for the higher rate of delirium in patients with pre-existing psychiatric illnesses could be the need to use higher doses of benzodiazepines,” suggested Dr. Kalra before. “The elevation is required to achieve adequate sedation, which puts you at greater risk of withdrawal symptoms.

“In addition, home psychotropic drugs are often withheld in ventilated patients,” he said. “They are often given other sedatives that may predispose them to withdrawal symptoms, which often manifest as delirium.”

While previous studies linked a higher incidence of psychiatric illness in survivors of acute respiratory distress syndrome, little is known about the impact of pre-existing psychiatric illness on the hospital course of these patients, said Dr. Kalra. He found that these patients are often exposed to long periods of ventilation and often require deep sedation.

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