Risk Factors for Aspiration
- Debilitation
- History of Dysphagia
- Intubation: of any duration
- Swallowing difficulties exist in 50% of intubated patients for up to 1 week after
- No clinical factors reliably predict if patient will aspirate
- Muscle Weakness
- Older Age
- Oral/Nasal Enteral Feeding Tubes
- Tracheostomy (see Tracheostomy, [[Tracheostomy]])
Etiology
Upper Airway Structural/Functional
Gastrointestinal
- Esophageal Motility Disorder
Neurologic
- Obtundation/Coma with Inability to Protect Airway (see Obtundation-Coma, [[Obtundation-Coma]])
- Intoxication
- Withdrawal
- Sedative
- General Anesthesia (see General Anesthesia, [[General Anesthesia]])
- Neuromuscular Swallowing Dysfunction
Other
Diagnosis
- Assessment of Swallowing Function
- Bedside Swallowing Evaluation: relatively insensitive for evidence of aspiration in patients with tracheostomy, since up to 77% of aspiration was silent [MEDLINE] [MEDLINE]
- Gag Reflex: does not predict adequacy of swallowing function (as gag reflex uses different muscles than swallowing and many patients without gag can swallow normally)
- Modified Barium Swallow: best test
- Sputum Gram Stain/Culture and Sensitivity
- CXR/Chest CT Patterns
- Alveolar Infiltrate: often located in dependent lung region (particularly RLL-superior segment)
- Bibasilar Fibrosis: may be seen in cases of chronic aspiration
Clinical Presentations
Treatment
Measures To Decrease Risk of Aspiration
- NPO
- Nasogastric Feeding
- Gastrostomy Tube Placement
- Cuffed Tracheostomy
- Laryngeal-Tracheal Separation/Laryngectomy: last resort treatment
- Allows PO intake, but speaking is not possible
- Proven effective and beneficial to improve mood and clinical outcome
Treatment of Aspiration Pneumonia
- Antibiotics (per Infectious Disease Society of America/ISDA Recommendations): second agent for anaerobic coverage may be unnecessary, as Gatifloxacin/Moxifloxacin have adequate anaerobic coverage
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Piperacillin/Tazobactam (Zosyn) (see Piperacillin-Tazobactam, [[Piperacillin-Tazobactam]])
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Ampicillin/Sulbactam (Unasyn) (see Ampicillin-Sulbactam, [[Ampicillin-Sulbactam]])
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Metronidazole (Flagyl) (see Metronidazole, [[Metronidazole]])
- Newer Generation Fluoroquinolone (Levofloxacin/Gatifloxacin/Moxifloxacin) (see Fluoroquinolones, [[Fluoroquinolones]]) + Clindamycin (see Clindamycin, [[Clindamycin]])
References
- Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest. 1994 Feb;105(2):563-6 [MEDLINE]
- Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest. 1996 Jan;109(1):167-72 [MEDLINE]
- Satisfaction of patients treated surgically for intractable aspiration. Chest. 1999 Nov;116(5):1251-6 [MEDLINE]