eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Aspiration Syndromes: Treatment & Medication

Author: Cecilia P Mikita, MD, MPH, Associate Program Director, Allergy-Immunology Fellowship, Chief, Clinical Services, Allergy-Immunology Clinic, Walter Reed Army Medical Center
Coauthor(s): Charles Callahan, DO, Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Apr 21, 2008

Treatment

Medical Care

• Conservative therapy is the initial treatment of choice to prevent aspiration syndromes and often results in significant improvement in respiratory symptoms. Position infants in the prone or upright position. Avoid placing infants younger than 6 months in a seated position for approximately 90 minutes after a feed. Do not feed the infant within 90 minutes before bedtime. Elevation of the head of the bed approximately 30° may help, although young infants may slide down the bed during the night. Dietary modifications include thickening feeds for infants; breastfeeding; decreasing volume of feeds (10-20 mL/kg per feeding); and feeding small, frequent meals. Patients with swallowing dysfunction may benefit from certain food consistencies, positioning, and adaptive feeding equipment or utensils.
• The management of an acute aspiration event consists of conservative management, observation, and possible antibiotic therapy. Initially, the patient's upper airway should be cleared and endotracheal intubation should be considered if the patient is unable to protect his airway. Close monitoring in an inpatient setting is recommended for at least 48 hours. Initially, empiric antibiotic therapy is not recommended, even if fever, clinical, laboratory, or radiographic findings are present. Selection of resistant organisms with the use of empiric, broad-spectrum antibiotic therapy is always a concern, especially in an uncomplicated chemical pneumonitis picture. If the patient fails to improve after 48 hours, the addition of broad-spectrum antibiotics is recommended.
• A second or third generation cephalosporin is appropriate to cover potential gram-positive flora from the oropharynx and gram-negative organisms from the GI tract. Anaerobic coverage is not routinely required initially. Limited and controversial data on the role of corticosteroids in the management of acute aspiration events are available. Numerous animal studies and clinical trials fail to demonstrate a significant beneficial effect of corticosteroids after acute aspiration events. Based on these data, routine administration of systemic corticosteroids is not recommended.

Surgical Care

• Surgical management with Nissen fundoplication and/or gastrojejunostomy is generally not first-line therapy for gastroesophageal reflux (GER) lung disease but may be appropriate for some individuals with neurological impairment.¹⁴ Surgical treatment of curable anatomic disorders, such as malrotation, is paramount.
• Patients who are neurologically impaired, have GER, and require a feeding tube are usually initially treated with fundoplication and gastrostomy. However, a percutaneous endoscopic gastrojejunostomy may be an intermediate step before surgical intervention.
• Several surgical procedures have been tried as an adjunct to fundoplication and gastrostomy to prevent direct aspiration. Total laryngectomy, glottic closure, tracheostomy, and injection of Teflon into the vocal cords have all been tried in patients with persistent direct aspiration.
• Laryngotracheal separation, with or without end-to-side laryngoesophagectomy, has been tried more recently in children with neurological impairment who have intractable aspiration pneumonia as an adjunct to fundoplication and gastrostomy.¹⁵ In this procedure, the larynx and trachea are permanently divided; therefore, aspiration can never occur, but phonation is sacrificed.

Consultations

• A primary care provider can successfully provide routine medical care for children with aspiration syndromes.
• Consultation with a speech-language pathologist or occupational therapist is recommended to assess swallowing dysfunction. Oral structure and function, clinical signs of safe swallowing, and positioning should be assessed.
• Refer patients to a pediatric pulmonologist and/or pediatric gastroenterologist if the patient does not respond to conservative or simple medical therapy or if the ordered studies are equivocal.
• A pediatric neurologist should thoroughly evaluate patients with possible neuromuscular disorders.

Diet

• Several dietary modifications can be initiated to decrease the risk of aspiration. Decreasing volume and increasing frequency of feeds, breastfeeding, thickening feeds, and not feeding within 90 minutes of nap or bedtime may decrease GER and aspiration.
• Special feeding equipment or utensils and positioning may also help patients with swallowing dysfunction or anatomical defect.
• In certain cases, transpyloric feedings may be necessary to decrease the risk of aspiration.
• In addition, avoidance of certain foods (eg, caffeine, fatty meals, carbonated beverages, peppermint, citrus) may decrease GER in older children and adults.
• If the volume of aspiration is greater than 10% of the bolus feed, enteral feeds may not be appropriate.

Activity

• Simple modifications in activity help decrease incidence of physiologic and pathologic GER.
• Elevation of the head of the bed approximately 30° and avoidance of seated devices for approximately 90 minutes after feeding may decrease GER and aspiration.
• Avoidance of prolonged use of seated devices in very young infants may be beneficial.

Medication

Consider medical therapy if conservative therapies have failed. One may consider an upper GI before the administration of medications to rule out an anatomic abnormality.

Prokinetic agents

These agents are used to augment cholinergic activity and to improve motility in the GI tract.

Cisapride (Propulsid)

Increases LES tone, improves esophageal peristalsis, increases gastric contractions, and accelerates gastric emptying. Has been associated with serious, and sometimes fatal, cardiovascular toxicity. In the United States, only available through an investigational limited access program by Janssen Pharmaceutica (1-877-795-4247). May still be commercially available in other countries. Must obtain a 12-lead ECG before initiation of therapy. Do not give if QTc >450 ms.

Metoclopramide (Reglan, Clopra, Maxolon)

Increases resting esophageal sphincter tone, improves gastric tone and peristalsis, relaxes the pyloric sphincter, and augments duodenal peristalsis with the net effect of increasing GI motility and decreasing reflux potential. Dopamine antagonist that stimulates acetylcholine release in the myenteric plexus. Acts centrally on chemoreceptor triggers in the floor of the fourth ventricle, which provides important antiemetic activity.

Bethanechol (Urecholine)

Cholinergic agent that increases tone, amplitude of contractions, peristaltic activity, and secretions of the GI tract.

Histamine (H2) receptor antagonists

These agents do not reduce the frequency of reflux but decrease the amount of acid in the refluxate by inhibiting acid production. All are equipotent when used in equivalent doses and work best in nonerosive esophagitis. Because of the superiority of proton pump inhibitors (PPIs), H2 blockers may be reserved for use in patients unable to tolerate PPIs.

Cimetidine (Tagamet)

Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and reduced hydrogen concentrations.

Ranitidine (Zantac)

Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which, in turn, reduces gastric acid secretion, gastric volume, and reduced hydrogen concentrations.

Proton pump inhibitors

These agents act by blocking the enzyme system responsible for active transport of protons into the GI lumen (ie, hydrogen/potassium adenosine triphosphatase [H⁺/K⁺ ATPase]) of the gastric parietal cell, also known as the proton pump.

Administer with the first meal of the day; children with nasogastric or gastrostomy tubes may have granules mixed with an acidic juice, and then the tubes are flushed to prevent blockage.

Omeprazole (Prilosec)

Inhibits gastric acid secretion. Used for the short-term treatment (4-8 wk) of GER disease.

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