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]])

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Etiology

Upper Airway Structural/Functional

• Bilateral Vocal Fold Immobility (BVFI) (see Bilateral Vocal Fold Immobility, [[Bilateral Vocal Fold Immobility]]): of any etiology
• Cervical Spine Surgery

Gastrointestinal

• Esophageal Motility Disorder
  • Esophageal Achalasia (see Esophageal Achalasia, [[Esophageal Achalasia]])
    • Scleroderma (see Scleroderma, [[Scleroderma]])
  • Esophageal Stricture (see Esophageal Stricture, [[Esophageal Stricture]])
  • Gastroesophageal Reflux Disease (GERD) (see Gastroesophageal Reflux Disease, [[Gastroesophageal Reflux Disease]])
  • Mixed Connective Tissue Disease (MCTD) (see Mixed Connective Tissue Disease, [[Mixed Connective Tissue Disease]])

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
  • Intracerebral Hemorrhage (Hemorrhagic Cerebrovascular Accident) (see Intracerebral Hemorrhage, [[Intracerebral Hemorrhage]])
  • Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
  • Myasthenia Gravis (see Myasthenia Gravis, [[Myasthenia Gravis]])
  • Polydermatomyositis (see Polydermatomyositis, [[Polydermatomyositis]])
  • Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage, [[Subarachnoid Hemorrhage]])

Other

• Ankylosing Spondylitis (see Ankylosing Spondylitis, [[Ankylosing Spondylitis]])
• Near Drowning (see Near Drowning, [[Near Drowning]])

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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

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Clinical Presentations

• Acute Lung Injury-ARDS (see Acute Lung Injury-ARDS, [[Acute Lung Injury-ARDS]])
• Cryptogenic Organizing Pneumonia (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])
• Interstitial Pulmonary Fibrosis (see Interstitial Lung Disease-Etiology, [[Interstitial Lung Disease-Etiology]])
• Lung Abscess (see Lung Abscess, [[Lung Abscess]])
• Necrotizing Pneumonia/Pulmonary Gangrene (Necrotizing Pneumonia and Pulmonary Gangrene, [[Necrotizing Pneumonia and Pulmonary Gangrene]])
• Parapneumonic Pleural Effusion (see Pleural Effusion-Parapneumonic, [[Pleural Effusion-Parapneumonic]])
• Pneumonia (see Pneumonia, [[Pneumonia]])

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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]])

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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]