Aspiration Syndromes Treatment & Management

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.

Patients should be seen by their primary care manager for routine well-child visits and regularly for follow-up care.

Admit infants and children with aspiration syndromes if a documented oxygen requirement is noted, if the patient has altered mental status, or if adequate medical care is unable to be met in the outpatient arena.

Admit to the intensive care unit if the patient requires intubation, shows signs of impending respiratory failure, or shows instability on the ward with requirement of closer monitoring.

Conservative measures are the best deterrence against gastroesophageal reflux (GER). Attention to feeding volumes, positioning, and encouragement of breastfeeding may be helpful to decrease GER signs and symptoms in infants.

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 or patients with respiratory complications or recurrent aspiration that have failed medical therapy. ^{[1, 19]} Surgical treatment of curable anatomic disorders, such as malrotation, is paramount. A systematic review of the surgical treatment of gastroesophageal reflux disease reported that fundoplication did not affect the rate of hospitalization for aspiration pneumonia or apnea. ^[20]

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. ^[21] In this procedure, the larynx and trachea are permanently divided; therefore, aspiration can never occur, but phonation is sacrificed.

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.

Diet

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. Infants who are breastfed are less likely to have GER than formula-fed infants. ^[22]

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. Other nonpharmacologic measures for older children and adults include weight reduction for persons who are overweight and avoidance of overfeeding, active/passive smoking, alcohol, and food consumption before bedtime. ^[22]

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.