Aspiration Syndromes Workup

  • Author: Cecilia P Mikita, MD, MPH; Chief Editor: Michael R Bye, MD   more...
 
Updated: Apr 26, 2012
 

Laboratory Studies

  • Laboratory studies in a thorough evaluation should include the following:
    • CBC count with manual differential
    • ABG or pulse oximetry
    • Sweat chloride
    • Pulmonary function test
    • Serum immunoglobulin G (IgG) and subclasses, immunoglobulin M (IgM), immunoglobulin A (IgA), and immunoglobulin E (IgE) levels (possibly)
  • Skin prick testing, allergen-specific serum IgE, and/or food atopy patch testing to common foods may be performed if eosinophilic esophagitis is considered in the differential diagnosis.
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Imaging Studies

  • Chest radiography may reveal hyperinflation; marked diffuse interstitial or perihilar infiltrates, unilateral or bilateral; peribronchial thickening; pleural effusion; lobar or segmental consolidation; bronchiectasis; or atelectasis. Chest radiograph of a child with a tracheostomy anChest radiograph of a child with a tracheostomy and recurrent aspiration reveals patchy infiltrates and increased interstitial markings. Lateral chest radiograph of the same child as in tLateral chest radiograph of the same child as in the previous image reveals increased interstitial markings and patchy and perihilar infiltrates.
  • High-resolution chest CT scanning may reveal bronchial thickening, bronchiectasis, ground-glass opacities, tree-in-bud centrilobular opacities, and air trapping.
  • Barium esophagram is used to evaluate for anatomic or physiologic abnormalities of the upper GI tract, to quantify the degree of aspiration during swallowing, and to assess texture-specific foods and swallowing. Anatomic abnormalities, including a hiatal hernia, malrotation, pyloric stenosis, and antral or duodenal webs, may be diagnosed and may predispose an individual to gastroesophageal reflux (GER). These tests are neither sensitive nor specific in the diagnosis of GER.
  • Gastroesophageal scintigraphy, also referred to as a milk scan, is a radionuclide study that provides a more functional or physiologic assessment for GER. This test also lacks sensitivity and specificity in the diagnosis of pathologic GER.
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Procedures

  • Pulse oximetry
  • Videofluoroscopic swallow study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES): VFSS is the criterion standard for assessing the 4 phases of swallowing using various consistencies of food. FEES may be used to assess the oral propulsive and pharyngeal phases of swallowing only. The VFSS and FEES are often complementary studies in the assessment. Recommendations for determining compensatory swallowing strategies and liquid consistency can be made based on the results of the VFSS and/or FEES.
  • Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) with staining for lipid-laden macrophages: Some have found evaluation for pepsin in BAL fluid to be helpful.
  • Esophageal pH monitoring for 24 hours: This is a reliable measure to evaluate acid reflux, but the level may be normal in some patients with GER and the test does not document nonacid reflux. Multichannel intraluminal impedance and pH monitoring (MII-pH) may detect anterograde and retrograde passage of refluxate, irrespective of pH. This can measure both acid and nonacid reflux and evaluates the change in intraluminal electrical resistance that occurs with advancement of a bolus. Normal values for impedance have not been established for pediatric age groups.
  • Esophagogastroduodenoscopy (EGD) with biopsies to assess eosinophilic infiltration: GER disease may be represented with distal esophageal erythema, erosions, ulcers, and mucosal friability. Characteristics of eosinophilic esophagitis include linear furrowing, mucosal granularity, scattered exudates, and concentric esophageal rings. A normal appearance of the esophagus does not exclude eosinophilic esophagitis and biopsies are recommended when endoscopy is performed.
  • Radionuclide salivagrams: These may be used in patients with possible salivary aspiration.
  • Immunocytochemical staining of alveolar macrophages for milk proteins (experimental)
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Histologic Findings

  • Bronchoscopy may reveal airway mucosal desquamation, mononuclear cell inflammation with granuloma formation, bacterial invasion, and cell damage.
  • Lipid laden macrophages may be identified with oil red O stain on bronchoalveolar lavage samples.
  • Eosinophilic esophagitis can be distinguished from GER if the inflammatory infiltrate has more than 15-20 eosinophils per high-power field.
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Contributor Information and Disclosures
Author

Cecilia P Mikita, MD, MPH  Associate Program Director, Allergy-Immunology Fellowship, Associate Professor of Pediatrics and Medicine, Uniformed Services University of the Health Sciences; Staff Allergist/Immunologist, Walter Reed National Military Medical Center

Cecilia P Mikita, MD, MPH is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, and Clinical Immunology Society

Disclosure: Nothing to disclose.

Coauthor(s)

Charles Callahan, DO  Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Thomas Scanlin, MD  Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Heidi Connolly, MD  Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center; Professor of Clinical Pediatrics, State University of New York at Stony Brook

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD  Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

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Chest radiograph of a child with a tracheostomy and recurrent aspiration reveals patchy infiltrates and increased interstitial markings.
Lateral chest radiograph of the same child as in the previous image reveals increased interstitial markings and patchy and perihilar infiltrates.
 
 
 
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