History
Clinical signs of acute versus chronic lung aspiration can vary dramatically. Acute aspiration may manifest as coughing, wheezing, fever, and chest discomfort. In the setting of massive aspiration, the patient may present with cyanosis and/or pulmonary edema, which may progress to severe respiratory distress syndrome. [2] Occasionally, aspiration may be silent with no overt signs or symptoms.
The 4 syndromes that may be associated with chronic lung aspiration are recurrent wheezing, apnea, chronic cough, and recurrent pneumonia. Recurrent wheezing and asthma symptoms can be related to aspiration of gastric contents. Evaluate patients for aspiration who have asthma symptoms unresponsive to standard therapy; unexplainable or nocturnal symptoms; or whose symptoms are not associated with allergens, upper respiratory tract infection (URTI) symptoms, or exercise.
Recurrent pneumonia is often observed in infants who are neurologically challenged and in children who chronically aspirate who may be neurologically healthy. These children often have impaired airway protection mechanisms and are noted to both directly and indirectly aspirate. Apneic episodes, both obstructive and central in nature, may be associated with aspiration in young infants and children. Obstructive apnea secondary to laryngospasm is observed in infants who are awake or asleep.
Microaspiration from indirect reflux causes laryngeal inflammation and bronchorrhea, manifested as hoarseness and cough. Chronic cough, defined as a cough that lasts 3 or more weeks, may be the only manifestation of recurrent aspiration. Failure to thrive (FTT) is also associated with gastroesophageal reflux (GER) and can be caused by a wide variety of factors, including cystic fibrosis.
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Patients often have a latent period after the aspiration event and the onset of symptoms. Symptoms usually occur within the first hour of aspiration, but almost all patients have symptoms within 2 hours of aspiration. Elicit a history of recurrent pulmonary symptoms from the parents and patient, including the following:
Wheezing, bronchospasm
Noisy breathing
Choking, gagging, coughing, and/or spitting during feeds
Recurrent vomiting
Apnea, bradycardia, cyanotic episodes
Recurrent stridor, hoarseness, sore throat
Chest discomfort
Unexplained nocturnal fevers
Night sweats
Purulent sputum
Chronic cough (at least 4 wk in duration)
Nocturnal wheezing or cough
Excessive salivation
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Other associated findings or conditions include the following:
Failure to thrive (secondary to calorie wasting)
Apnea and bradycardia (especially in young infants)
Hiccups
Recurrent episodes of pneumonia or bronchitis
Cystic fibrosis
Pulmonary abscess
Pulmonary fibrosis
Chronic bronchitis
Obliterative bronchiolitis
Interstitial lung disease
Other chronic lung diseases
Physical Examination
Physical findings may include the following:
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Dysmorphic features (cleft palate, micrognathia, macroglossia)
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Fever
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Tachypnea
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Heterophonous wheezing versus homophonous wheezing: Heterophonous wheezing is noted with small airway obstruction, whereas homophonous wheezing is noted with central airway involvement
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Crackles
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Noisy breathing
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Cough (characteristics, timeframe, triggers)
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Congestion
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Clubbing associated with chronic lung disease
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Increased work of breathing; grunting, flaring, retractions
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Cyanosis
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Hypoxemia
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Weak suck
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Shock
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Stridor
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Hoarse voice or cry
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Irritability
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Excess drooling
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Dental erosions
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Globus hystericus
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Chest radiograph of a child with a tracheostomy and recurrent aspiration reveals patchy infiltrates and increased interstitial markings.
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Lateral chest radiograph of the same child as in the previous image reveals increased interstitial markings and patchy and perihilar infiltrates.
