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• W2000872647 abstract "Chronic or recurrent aspiration of gastric contents or ingested material may result in significant pulmonary morbidity in infants and children. There are certain conditions, including disorders of neuromuscular weakness or developmental abnormalities, that may predispose some children to oral aspiration. In other cases, an anatomic defect, such as a laryngeal cleft, is the culprit. The association between gastroesophageal reflux (GER) disease and the development of chronic respiratory symptoms is well established. The recognition of oil aspiration as a cause of pneumonia in 6 infants was first described by Pinkerton in 1927.1 Several articles followed that shared a common histologic theme: the presence of lipid-laden alveolar macrophages (LLAMs). The diagnosis of aspiration in children may be elusive, because many children will have nonspecific chronic respiratory complaints, such as recurrent cough and wheezing. Other diagnoses are often considered first, unless an association of the respiratory symptoms with eating or drinking is suggested by history. Radiographic findings also are nonspecific, with findings that range from normal to diffuse interstitial or peribronchial inflammatory changes. Since the advent of pediatric flexible bronchoscopy more than 3 decades ago, further diagnostic testing has become possible. Examination of bronchoalveolar lavage (BAL) fluid in children has produced further insight into the pathophysiology of aspiration. Oil Red O (1-[2,5-dimethyl-4-(2-5-dimethylphenyl) phenyldiazenyl] azonapthalen-2-ol) staining of alveolar macrophages has allowed for the calculation of a lipid-laden macrophage index (LLMI) that quantifies the number of alveolar macrophages with lipid staining and the relative abundance of fat within the macrophages. Several studies have examined the LLMI as a clinical tool. However, even the test itself has been under increased scrutiny, and it has been suggested that interobserver and intraobserver variability associated with the use of LLMI may have an impact on its clinical utility.2 Two primary questions have been examined with regard to the LLMI: 1) can the LLMI detect chronic or recurrent aspiration, and 2) is there a correlation between GER and elevated LLMI? It has been demonstrated that lipid-laden macrophages from BAL are elevated in adults with lung disease, although values were higher in aspirating patients.3 An LLMI > 100 was consistent with patients who were aspirating. A prospective study that examined the LLMI in children with respiratory disorders was published by Colombo and Hallberg in 1987.4 They observed a strong correlation between an LLMI > 90 and recurrent aspiration of food or liquid compared with lower indices for those children in whom aspiration was excluded: all had an LLMI < 72. However, those results have not been validated. More recently, a higher cutoff value of an LLMI > 165 was suggested to diagnose aspiration.5 The presence of a laryngeal cleft may predispose certain children to aspiration during swallowing. A larger defect would be expected to result in more significant pulmonary aspiration. Indeed, higher LLMI scores have been observed in children with more severe laryngeal clefts.6 Despite these findings, other investigators have reported a lack of sensitivity and specificity of the LLMI for aspiration, with significant overlap of values in various pediatric pulmonary diseases as well as for healthy children. In addition, the use of a modified LLMI lacked specificity to diagnose aspiration in children and was elevated in many respiratory conditions.7 Although respiratory symptoms are frequently reported in children and adults with GER, it has been difficult to establish causality in many disease processes. Two mechanisms have been proposed for GER-triggered respiratory symptoms: vagally mediated bronchoconstriction and microaspiration of gastric contents. Again, the utility of the LLMI as a marker for GER in respiratory disorders has been controversial. In 1 study, LLAMs were much more prevalent in children who had respiratory disease and GER compared with those who had respiratory disorders without GER.8 Other studies have failed to demonstrate an association between LLMI and either biopsy-diagnosed reflux esophagitis or GER that was diagnosed through impedance testing.9, 10 The lack of a clear indication for the LLMI in patients with GER is not surprising. The gold standard for GER diagnosis in adults has traditionally included pH probe testing. However, there is a lack of consensus for abnormal pH probe results in infants and children, particularly because impedance testing has become more widely used in the diagnosis of GER. If indeed an elevated LLMI is a marker of aspiration, then the lack of a positive association with GER may merely reflect that many children with GER do not aspirate. The lack of an established “gold standard” for the detection of pulmonary aspiration in children has been problematic. Clinicians continue to rely on a combination of historic factors along with clinical, radiographic, and laboratory findings to support the diagnosis. Although barium esophagrams and videofluoroscopic swallow evaluations may provide clear documentation of discrete aspiration events, these tests are notoriously insensitive and nonspecific, because they represent a “snap shot in time” and may miss aspiration during swallowing or from severe GER at any particular moment. In consideration of the available evidence, the LLMI may continue to be used judiciously by clinicians as an adjunct investigation for children whose symptoms are suspicious for aspiration and warrant flexible bronchoscopy with BAL. When the diagnosis of aspiration is made, several treatment strategies may be attempted, including acid suppression, thickening of feedings or liquids, or surgical intervention. Dr. Thomas Lahiri is the Director of Pediatric Pulmonology at Vermont Children's Hospital at Fletcher Allen Health Care in Burlington, Vermont. He is Professor of Pediatrics at the University of Vermont College of Medicine and serves as Director of the Vermont Cystic Fibrosis Center. He also leads the Pediatric Aerodigestive Program at Fletcher Allen Health Care. In this capacity, he has extensive experience in flexible bronchoscopy and the evaluation of infants and children with feeding and swallowing disorders." @default.
• W2000872647 created "2016-06-24" @default.
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• W2000872647 date "2013-12-02" @default.
• W2000872647 modified "2023-09-26" @default.
• W2000872647 title "The utility of the lipid-laden macrophage index for the evaluation of aspiration in children" @default.
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• W2000872647 doi "https://doi.org/10.1002/cncy.21365" @default.
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