Aspiration Syndromes Treatment & Management
- Author: Cecilia P Mikita, MD, MPH; Chief Editor: Michael R Bye, MD more...
See the list below:
- 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.
See the list below:
- The American Gastroenterological Association has published clinical practice guidelines regarding surgical intervention for oral pharyngeal dysphagia.
- 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. 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. In this procedure, the larynx and trachea are permanently divided; therefore, aspiration can never occur, but phonation is sacrificed.
See the list below:
- 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. Compensatory feeding strategies should be implemented to protect the airway.
- 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.
- A pediatric allergist/immunologist and/or pediatric gastroenterologist should be consulted if eosinophilic esophagitis is considered.
See the list below:
- Several dietary modifications can be initiated to decrease the risk of aspiration. Restricting fluids, decreasing volume and increasing frequency of feeds, breastfeeding, providing texture-modified diets, 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.
See the list below:
- 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.
Rudolph CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001. 32 Suppl 2:S1-31. [Medline].
de Benedictis FM, Carnielli VP, de Benedictis D. Aspiration lung disease. Pediatr Clin North Am. 2009 Feb. 56(1):173-90, xi. [Medline].
Callahan CW. Increased gastroesophageal reflux in infants: can history provide an explanation?. Acta Paediatr. 1998 Dec. 87(12):1219-23. [Medline].
Callahan CW, Sisler C. Use of seating devices in infants too young to sit. Arch Pediatr Adolesc Med. 1997 Mar. 151(3):233-5. [Medline].
Callahan CW. The diagnosis of gastroesophageal reflux in hospitalized infants: 1971-1995. J Am Osteopath Assoc. 1998 Jan. 98(1):32-4. [Medline].
Orenstein D. Aspiration pneumonias and gastroesophageal reflux - related respiratory disease. In: Nelson Textbook of Pediatrics. 15th ed. Elsevier Science. 1996:1213-1215.
Orenstein SR. Gastroesophageal reflux. Pediatr Rev. 1999 Jan. 20(1):24-8. [Medline].
Orenstein SR, Orenstein DM. Gastroesophageal reflux and respiratory disease in children. J Pediatr. 1988 Jun. 112(6):847-58. [Medline].
Nelson SP, Chen EH, Syniar GM, Christoffel KK. One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatric Practice Research Group. Pediatrics. 1998 Dec. 102(6):E67. [Medline].
Richter JE. Extraesophageal presentations of gastroesophageal reflux disease. Semin Gastrointest Dis. 1997 Apr. 8(2):75-89. [Medline].
Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). J Allergy Clin Immunol. 2004 Jan. 113(1):11-28; quiz 29. [Medline].
Sheikh S, Allen E, Shell R, Hruschak J, Iram D, Castile R, et al. Chronic aspiration without gastroesophageal reflux as a cause of chronic respiratory symptoms in neurologically normal infants. Chest. 2001 Oct. 120(4):1190-5. [Medline].
Yoshikawa H, Yamazaki S, Abe T. Acute respiratory distress syndrome in children with severe motor and intellectual disabilities. Brain Dev. 2005 Sep. 27(6):395-9. [Medline].
Kohda E, Hisazumi H, Hiramatsu K. Swallowing dysfunction and aspiration in neonates and infants. Acta Otolaryngol Suppl. 1994. 517:11-6. [Medline].
Carre IJ. The natural history of the partial thoracic stomach (hiatus hernia) in children. Arch Dis Child. 1959 Aug. 34:344-53. [Medline].
Model J, Boysen P. Pulmonary aspirations of stomach contents. In: The Society of Critical Care Medicine Textbook of Critical Care. Philadelphia, Pa:. WB Saunders Co. 1984:272-274.
Albanese CT, Towbin RB, Ulman I, Lewis J, Smith SD. Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux. J Pediatr. 1993 Sep. 123(3):371-5. [Medline].
Takamizawa S, Tsugawa C, Nishijima E, Muraji T, Satoh S. Laryngotracheal separation for intractable aspiration pneumonia in neurologically impaired children: experience with 11 cases. J Pediatr Surg. 2003 Jun. 38(6):975-7. [Medline].
Campanozzi A, Boccia G, Pensabene L, Panetta F, Marseglia A, Strisciuglio P. Prevalence and natural history of gastroesophageal reflux: pediatric prospective survey. Pediatrics. 2009 Mar. 123(3):779-83. [Medline].
Chang AB. Cough: are children really different to adults?. Cough. 2005 Sep 20. 1:7. [Medline].
Darrow DH, Harley CM. Evaluation of swallowing disorders in children. Otolaryngol Clin North Am. 1998 Jun. 31(3):405-18. [Medline].
Derkay CS, Schechter GL. Anatomy and physiology of pediatric swallowing disorders. Otolaryngol Clin North Am. 1998 Jun. 31(3):397-404. [Medline].
Goldsobel AB, Chipps BE. Cough in the pediatric population. J Pediatr. 2010 Mar. 156(3):352-8. [Medline].
Harding SM, Richter JE. The role of gastroesophageal reflux in chronic cough and asthma. Chest. 1997 May. 111(5):1389-402. [Medline].
Irwin RS, Boulet LP, Cloutier MM, et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest. 1998 Aug. 114(2 Suppl Managing):133S-181S. [Medline].
Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001 Mar 1. 344(9):665-71. [Medline].
Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 2000 Feb. 154(2):150-4. [Medline].
Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during infancy. A pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 1997 Jun. 151(6):569-72. [Medline].
Nelson W, Behrman RE, Kliegman RM. Nelson Textbook of Pediatrics. 15th ed. Elsevier Science; 1996. 1052-4.
Sheikh S, Stephen T, Howell L, Eid N. Gastroesophageal reflux in infants with wheezing. Pediatr Pulmonol. 1999 Sep. 28(3):181-6. [Medline].
Shepherd RW, Wren J, Evans S, et al. Gastroesophageal reflux in children. Clinical profile, course and outcome with active therapy in 126 cases. Clin Pediatr (Phila). 1987 Feb. 26(2):55-60. [Medline].
[Guideline] Smith Hammond CA, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan. 129(1 Suppl):154S-168S. [Medline].
Spitzer AR, Boyle JT, Tuchman DN, Fox WW. Awake apnea associated with gastroesophageal reflux: a specific clinical syndrome. J Pediatr. 1984 Feb. 104(2):200-5. [Medline].
Strople J, Kaul A. Pediatric gastroesophageal reflux disease--current perspectives. Curr Opin Otolaryngol Head Neck Surg. 2003 Dec. 11(6):447-51. [Medline].
Ward C, Forrest IA, Brownlee IA et al. Pepsin like activity in BAL is suggestive of gastric aspiration in lung allografts. Thorax. 2005. 60:872-874.
Young MA, Reynolds JC. Respiratory complications of gastrointestinal diseases. Gastroenterol Clin North Am. 1998 Dec. 27(4):721-46. [Medline].