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Ann Thorac Surg 2007;83:193-196
© 2007 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Routine Evaluation for Aspiration After Thoracotomy for Pulmonary Resection

^a Division of Cardiothoracic Surgery, University of South Florida, Florida
^b H. Lee Moffitt Cancer and Research Institute, Tampa, Florida

Accepted for publication August 2, 2006.

^_* Address correspondence to Dr Sommers, Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr, Tampa, FL 33612. (Email: sommerek{at}moffitt.usf.edu).

General thoracic surgery: The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.

 

	Abstract

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BACKGROUND: The purpose of this study was to evaluate the role of a routine protocol for evaluation of oropharyngeal aspiration after thoracotomy for pulmonary resection.

METHODS: Demographic, operative, and outcomes data were collected prospectively for consecutive patients undergoing thoracotomy for pulmonary resection starting in April 2005. Starting on postoperative day one, patients underwent evaluation by a licensed speech therapist before per os intake. Patients failing clinical examination were referred for radiographic evaluation. Diets were advanced on the basis of results from both clinical and radiographic evaluation. Data analysis included descriptive statistics, Student’s t test, and ² test when appropriate.

RESULTS: One hundred forty patients were prospectively evaluated during this period. Thirty-two patients (22.9%) failed initial clinical swallowing evaluation and were referred for dynamic videofluoroscopic esophagram. Twenty-five patients (17.8%) had evidence of potential oropharyngeal aspiration on videofluoroscopic esophagram. Only 1 patient (0.7%) aspirated after a negative clinical evaluation. Univariate risk factor analysis revealed that patients demonstrating aspiration were older (67.7 ± 1.6 years versus 64.4 ± 1.1 years; p = 0.10) and had a higher incidence of head and neck malignancy (p < 0.001). Patients without radiographic aspiration had a shorter median hospital stay when compared with those who did (6 days versus 5 days).

CONCLUSIONS: Aspiration after thoracotomy for pulmonary resection may affect nearly 20% of patients and is likely underrepresented in the surgical literature. The institution of a protocol to evaluate risk of aspiration has characterized patients at high risk and led to an increased awareness of the potential for aspiration after thoracotomy.

Aspiration is a common and potentially fatal complication often encountered in certain hospitalized populations. Research on aspiration has largely focused on patients with a prior cerebral vascular accident. Nearly half of all cerebral vascular accident patients show clinical signs of aspiration when studied using clinical testing [1]. Additionally, patients who undergo cervical spine surgery also demonstrate a significant rate of aspiration [2]. Because of the recognition of high rates of aspiration in certain populations, the American College of Chest Physicians recently issued a position statement with regard to the management of patients who are at high risk for aspiration. In it, they advocate a multidisciplinary approach with early evaluation by a speech pathologist, and they assert that this approach is associated with improved outcomes [2].

Aspiration after thoracotomy for pulmonary resection has not been comprehensively studied. Aspiration is frequently overlooked and omitted from multicenter trials as a complication after major surgical procedures excluding upper gastrointestinal surgery. When reported in the thoracic surgical literature, the incidence of aspiration is low. A 2004 manuscript detailing outcomes of 328 extrapleural pneumonectomies cites an incidence of aspiration of 3% [3]. We have found that aspiration occurs much more often after major pulmonary resection, and this may potentially contribute to a significant portion of in-hospital morbidity. We hypothesized that a clinical protocol designed to detect patients at risk for aspiration would better characterize the true incidence and risk factors of aspiration after thoracotomy for pulmonary resection.

	Material and Methods

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Before the initiation of the study, Institutional Review Board at the University of South Florida approval was sought and granted. Informed consent for access to protected health information was obtained. All patients in the study underwent thoracotomy for pulmonary resection by a single surgeon (K.E.S.) at a single institution from February to November 2005. Double-lumen endotracheal tubes were routinely but not exclusively used. All patients underwent placement of an epidural catheter preoperatively. Patients were kept nothing per os until postoperative day one when a certified speech pathologist performed a bedside clinical swallowing evaluation. All patients were assessed for level of consciousness on postoperative day one by both the speech pathologist and the surgeon, and a decreased level of consciousness warranted postponement of the clinical and radiographic examinations. This number represented only a small minority of patients. The bedside evaluation involved completion of an oral mechanism examination and observation of swallowing trials with thin liquids as well as pureed and solid foods. If clinical signs of aspiration were noted, patients were referred for radiographic evaluation. If no signs were evident, the patients’ diet was advanced as tolerated. Radiographic evaluation consisted of a diagnostic video evaluation of swallowing (DVE). This test was performed under fluoroscopy, and patients were asked to swallow barium-enriched materials including thin liquid, nectar-thick consistency liquid, pudding, and a barium-covered cracker to evaluate for the presence of oropharyngeal aspiration. A radiologist assisted with the performance and interpretation of the DVE (Fig 1).

View larger version (10K): [in this window] [in a new window]   Fig 1. Flow chart depicting the assessment of patients after the operation. (DVE = diagnostic video evaluation of swallowing; NPO = nothing per os.)

Demographic, operative, and outcome data were gathered prospectively and assembled into a database. Univariate statistical analysis including Student’s t test, ² test, and descriptive statistics were undertaken. All results were expressed as mean ± standard error of the mean when appropriate. Preoperative data were gathered by patient self-reporting. All outcomes measures were collected for the hospital stay of the original operation only. Respiratory complications were defined as pneumonia as evinced by laboratory and radiographic data requiring antibiotic therapy or by reintubation.

	Results

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Consecutive patients numbering 140 underwent evaluation for aspiration after thoracotomy for pulmonary resection. Demographic data regarding the entire cohort are highlighted in Table 1. Thirty-two patients (22.9%) failed initial bedside evaluation and were referred for DVE. Of these 32 patients, 25 (17.8% of total, 78.1% of positive clinical evaluations) had evidence of oropharyngeal dysphagia with aspiration on DVE. Preoperative and operative risk factors for failure of DVE are highlighted in Table 2. Important risk factors reaching statistical significance included head and neck cancer and neoadjuvant chemotherapy (p < 0.05).

	Comment

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Aspiration is a serious complication after pulmonary resection, and pneumonia or pneumonitis as a result of aspiration is potentially fatal. In spite of the serious nature of this complication, little attention has been paid to aspiration in the thoracic literature. To illustrate, recent manuscripts addressing respiratory complications after pulmonary resection have failed to mention aspiration [4, 5]. When included in an inventory of complications, the incidence of aspiration has been described as less than 5% [3]. This is the first study to attempt to quantify the incidence of dysphagia and aspiration in patients undergoing pulmonary resection.

The exact pathophysiology of aspiration and dysphagia is multifactorial and poorly understood. Abnormalities in lingual propulsion, vallecular stasis, and laryngeal elevation among others have been cited in prior studies [6]. The pathophysiology is also complicated by multifocal cerebral control of the aspiration reflex. Experimental evaluation of neurons involved in the aspiration reflex demonstrated that this reflex is controlled in multiple bilateral levels of the brain including the mesencephalon, the pons, and the medulla oblongata [7]. These authors concluded that the aspiration reflex is not centered in any one portion of the brain but is rather controlled by a long loop control circuit instead. Aspiration can therefore occur as a result of an insult occurring at any number of places both intracerebral and extracerebral.

To more accurately evaluate the true incidence of aspiration after pulmonary resection, we have established a multidisciplinary approach that includes speech therapy as well as surgery and radiology to detect and possibly prevent aspiration as a result of oropharyngeal dysphagia. Our results show that aspiration is a more frequent complication than has been previously appreciated after pulmonary resection. Whether an increased awareness of the risk of aspiration can be translated into better outcomes remains to be seen.

We consider it an important goal to identify risk factors for aspiration in our patients. Although not statistically significant in this group of patients, age has been correlated with an increased incidence of dysphagia after stroke [8]. Given further accrual, we would expect this fact to be borne out for patients undergoing thoracotomy for pulmonary resection as well. Another preoperative risk factor for dysphagia in our cohort was either prior or current head and neck cancer. Head and neck cancers are often seen in concert with non–small-cell cancer of the lung, and these malignancies have been implicated as risk factors for pneumonia after pulmonary resection [9]. Our data reveal that patients with prior or current head and neck cancers are at a significantly higher risk of aspiration than patients without. Although patients who presently have head and neck cancers or have had treatment for head and neck cancer do not possess a normal swallowing mechanism preoperatively, their dysphagia worsens and their risk for aspiration increases significantly after thoracotomy for pulmonary resection. A small number of these patients underwent preoperative swallowing evaluations, and their dysphagia worsened considerably after their respective procedures.

Interestingly, neoadjuvant chemotherapy was identified as a risk factor. Most patients undergoing neoadjuvant chemotherapy at our institution receive two cycles of gemcitabine and pemetrexed as therapy before operation. Those patients undergoing neoadjuvant chemotherapy were more likely to demonstrate radiographic dysphagia than patients who did not. This finding is independent of pathology and staging results, which did not reach statistical significance. These patients routinely underwent staging mediastinoscopy and had higher preoperative staging, and perhaps these factors contributed to this finding. In all likelihood, an increase in dysphagia and aspiration in patients undergoing neoadjuvant therapy is the result of a combination of an increased rate of preoperative mediastinoscopy, an increased rate of peripheral neuropathies as a result of preoperative chemotherapy, and a higher stage and more extensive lymphadenopathy.

The hospital charge for a speech pathology clinical evaluation at our institution is $246.00. For those patients who require DVE, a further charge of $473.00 is assessed. A recent publication described the hospital charges associated with an episode of pneumonia to be at $65,000.00 [10]. To achieve putative cost-effectiveness, one pneumonia would have to be avoided for every 90 patients who undergo routine evaluation with DVE. In our current series, approximately 1 in 5 patients underwent DVE. If that trend were to continue, one case of pneumonia would have to be prevented for every 190 patients evaluated. Given that the incidence of radiographic dysphagia with aspiration approaches 20%, we have inferred that this protocol may prove to be cost-efficient.

This study is not without limitations. It was performed at a single institution by a single surgeon on consecutive patients. To confirm the findings, a multicenter, multiple surgeon trial should be undertaken. Additionally, this was an observational study—there were no controls nor was there a randomization process. This, however, was appropriate as we were attempting to define a potential complication of pulmonary resection that has yet to be completely delineated. With that concept in mind, it is possible that we have overestimated the clinical import of aspiration in this cohort of patients. As this manuscript and protocol represent a novel approach to a heretofore underrecognized complication, we would prefer to pursue a conservative course of evaluation and treatment as per our protocol.

Aspiration after pulmonary resection is underappreciated as a complication after thoracotomy for pulmonary resection. Our protocol has identified patients at risk for complications. Further accrual of patients will prove improved outcomes and cost-efficiency using a multidisciplinary approach for the evaluation for aspiration.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Terre R, Mearin F. Oropharyngeal dysphagia after the acute phase of stroke: predictors of aspiration Neurogastroenterol Motil 2006;18:200-205.[Medline]
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3. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies J Thorac Cardiovasc Surg 2004;128:138-146.[Abstract/Free Full Text]
4. Schussler O, Alifano M, Dermine H, et al. Postoperative pneumonia after major lung resection Am J Respir Crit Care Med 2006;173:116-119.
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7. Jakus J, Halasova E, Poliacek I, Tomori Z, Stransky A. Brainstem areas involved in the aspiration reflex: c-Fos study in anesthetized cats Physiol Res 2004;53:703-717.[Medline]
8. Chen SY, Chie WC, Lin YN, Chang YC, Wang TG, Lien IN. Can the aspiration detected by videofluoroscopic swallowing studies predict long-term survival in stroke patients with dysphagia? Disabil Rehabil 2004;26:1347-1353.[Medline]
9. Licciardello JT, Spitz MR, Hong WK. Multiple primary cancer in patients with cancer of the head and neck: second cancer of the head and neck, esophagus, and lung Int J Radiat Oncol Biol Phys 1989;17:467-476.[Medline]
10. Kollef MH, Shorr A, Tabak YP, et al. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia Chest 2005;128:3854-3862.

This article has been cited by other articles:

				A. Terzi, L. Luzzi, A. Campione, and A. Gorla Postoperative Pneumonia After Major Pulmonary Resections: The Importance of Gastrointestinal Tract Management Ann. Thorac. Surg., September 1, 2008; 86(3): 1059 - 1060. [Full Text] [PDF]

				M. F. Ismail, R. I. El-Refael Hammad, S. I. El-Sayed Sersar, and Y. A. F. El-Ghoneimy Aspiration After Thoracotomy Ann. Thorac. Surg., April 1, 2008; 85(4): 1501 - 1501. [Full Text] [PDF]

				W. B. Keeling and K. E. Sommers Reply Ann. Thorac. Surg., April 1, 2008; 85(4): 1501 - 1502. [Full Text] [PDF]

				M. Allen Invited commentary Ann. Thorac. Surg., January 1, 2007; 83(1): 196 - 196. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Thomas S. Maxey Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Keeling, W. B. Articles by Sommers, K. E. Search for Related Content PubMed PubMed Citation Articles by Keeling, W. B. Articles by Sommers, K. E. Related Collections Lung - other Related Article