Aspiration

Author Credentials 

Ashli O’Rourke, MD
Associate Professor
Evelyn Trammell Institute for Voice and Swallowing
Otolaryngology – Head and Neck Surgery
Medical University of South Carolina
Charleston, South Carolina

Module Summary

Aspiration is commonly associated with dysphagia. The consequences of aspiration depend on patient comorbidities, the volume of aspirated material and the chronicity of symptoms. Early detection and appropriate management of aspiration may decrease complications. This module provides a comprehensive framework for the diagnosis and management of aspiration and its sequelae.

Module Learning Objectives 
  1. Define aspiration.
  2. Name the risk factors for developing aspiration.
  3. Identify appropriate testing to detect aspiration.
  4. Recognize the complications of aspiration.
  5. Employ appropriate treatment of aspiration related complications.
  6. Describe surgical procedures designed to lessen or prevent aspiration.

Anatomy

Learning Objectives 

Describe the structures involved in normal oropharyngeal swallowing.

References 
  1. Murry T, Carrau R. Anatomy and Function of the Swallowing Mechanism. In: Murry T, Carrau R. Clinical Management Of Swallowing Disorders. 3rd Edition. San Diego, CA: Plural Publishing, Inc; 2012:13–24.

Pathogenesis

Learning Objectives 
  1. Define aspiration.
  2. Explain the mechanisms responsible for airway protection during swallowing.
    1. Airway closure mechanisms
    2. Laryngeal adductor reflex
    3. Cough
  3. Differentiate between the types of aspiration.
    1. Choking
    2. Acute aspiration (i.e. altered consciousness or anesthesia associated)
    3. Chronic aspiration (i.e. dysphagia related)
  4. Explain the consequences of aspiration
    1. Hypoxia
    2. Pneumonitis
    3. Pneumonia
    4. Respiratory Failure
References 
  1. Shaker A, Shaker R. Airway protective mechanisms, reciprocal physiology of the deglutitive axis. In: Shaker R. Principles of Deglutition: A Multidisciplinary Text for Swallowing and Its Disorders. New York, NY: Springer; 2013. P. 35-51.
  2. Nason KS. Acute Intraoperative Pulmonary Aspiration. Thoracic surgery clinics. 2015;25(3):301-307.
  3. Marik PE . Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665-71.

Incidence

Learning Objectives 

Describe the incidence of aspiration in relation to risk factors.

  1. General anesthesia (acute surgical)
  2. Mechanical ventilation
  3. Altered mental status
  4. Neurological disorders
  5. Gastroesophageal reflux disease
  6. Head and neck cancer
References 
  1. Nason KS. Acute Intraoperative Pulmonary Aspiration. Thoracic surgery clinics. 2015;25(3):301-307.
  2. Reza Shariatzadeh M, Huang JQ, Marrie TJ. Differences in the features of aspiration pneumonia according to site of acquisition: community or continuing care facility. J Am Geriatr Soc. 2006 Feb;54(2):296-302.
  3. Armstrong JR, Mosher BD. Aspiration Pneumonia After Stroke: Intervention and Prevention. The Neurohospitalist. 2011;1(2):85-93.
  4. Kawai S, Yokota T, Onozawa Y, et al. Risk factors for aspiration pneumonia after definitive chemoradiotherapy or bio-radiotherapy for locally advanced head and neck cancer: a monocentric case control study. BMC Cancer. 2017 Jan 17;17(1):59.

Patient Evaluation

Learning Objectives 

Recognize the signs and symptoms of aspiration.

 

References 
  1. McCullogh GH, Wertz RT, Rosenbek JC. Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke. J of Comm Dis. 2001;34(1-):55-72.
  2. Denk-Linnert DM. Evaluation of Symptoms. In: Ekberg O. (eds) Dysphagia: Diagnosis and Treatment. Berlin, Springer: 2012:71-81.

Imaging

Learning Objectives 

Explain and contrast imaging techniques that may be used to detect aspiration.

  1. Flexible endoscopic evaluation of swallowing
  2. Videofluoroscopic swallowing studies
  3. Scintigraphy
References 
  1. Robinson CL. The radiographical evaluation of dysphagia: the modified barium swallow. In: Carrau R., Murry R, Howell R. Comprehensive Management of Swallowing Disorders 2nd Ed. San Diego: Plural Publishing; 2017:117-122.
  2. Weinstein D. Functional endoscopic tests of swallowing. In: Carrau R., Murry R, Howell R. Comprehensive Management of Swallowing Disorders 2nd Ed. San Diego: Plural Publishing; 2017:128.
  3. Collier BD. Detection of aspiration: scintigraphic techniques. Am J Med. 1997;103(5), Supplement 1:135s-137s.

Pathology

Learning Objectives 

List the most common pathogens in aspiration related pneumonia.

References 
  1. Bartlett JG. How important are anaerobic bacteria in aspiration pneumonia: when should they be treated and what is optimal therapy. Infect Dis Clin North Am. 2013;27(1):149-55.

Treatment

Learning Objectives 

Describe the immediate management of acute intraoperative aspiration.

References 
  1. Nason KS. Acute Intraoperative Pulmonary Aspiration. Thoracic surgery clinics. 2015;25(3):301-307.

Surgical Therapies

Learning Objectives 

Describe the surgical options available to address aspiration.

  1. Bronchoscopy
  2. Gastrostomy tube placement
  3. Injection medialization for glottal incompetence
  4. Tracheostomy
  5. Laryngohyoid suspension
  6. Narrow field laryngectomy
  7. Laryngotracheal separation
References 
  1. Graboyes EM, Bradley JP, Meyers BF, Nussenbaum B. Efficacy and safety of acute injection laryngoplasty for vocal cord paralysis following thoracic surgery. Laryngoscope. 2011;121(11):2406-10.
  2. Takano S, Goto T, Kabeya M, Tayama N. Surgical closure of the larynx for the treatment of intractable aspiration: surgical technique and clinical results. Laryngoscope. 2012;122(6):1273-8.
  3. Yen KL, Farwell DG. Surgical management of life-threatening aspiration. In: Shaker R. Principles of Deglutition : A Multidisciplinary Text for Swallowing and Its Disorders. New York, NY: Springer; 2013:945-954.

Rehabilitation

Learning Objectives 
  1. Demonstrate several swallowing exercises aimed at preventing aspiration.
  2. Demonstrate several compensatory swallowing strategies aimed at preventing aspiration.
References 
  1. Murry T, Carrau R. Non-surgical management of swallowing disorders. In: Murry T, Carrau R.  Clinical Management Of Swallowing Disorders. 3rd Edition. San Diego, CA: Plural Publishing, Inc; 2012:99-120.
  2. National Foundation of Swallowing Disorders. Swallowing Exercises. http://swallowingdisorderfoundation.com/oral-swallowing-exercises/.

Case Studies

  1. A 55-year-old obese female presents for a gastric fundoplication. Following induction of anesthesia, direct laryngoscopy reveals gastric contents within the oropharynx. What patient factors increase the risk of aspiration during general anesthesia? What immediate interventions would you consider? What are some possible complications for this patient and how would you manage them?
  2. An 82-year-old male presents with the complaint of feeling that foods are sticking in his throat for the past year. His symptoms are worsening. He also reports occasional coughing with liquids and a feeling of persistent phlegm that he tries to constantly clear throughout the day. He denies weight loss or shortness of breath. What is your differential diagnosis? What initial testing would you perform?

Complications

Learning Objectives 
  1. List the possible complications of acute and chronic aspiration.
  2. Recognize appropriate antibiotic therapy for aspiration related pneumonia.
  3. Differentiate between the treatment recommendations for aspiration pneumonitis versus aspiration pneumonia.
References 
  1. Allewelt P, Schuler PL, Boleskei, et al. Ampicillin + sulbactam vs. clindamycin +/− cephalosporin for the treatment of aspiration pneumonia and primary lung abscess. Clin Microbiol Infect. 2004 Feb;10(2):163-70.
  2. Lascarrou JB, Lissonde F, Thuaut AL, et al. Antibiotic Therapy in Comatose Mechanically Ventilated Patients Following Aspiration: Differentiating Pneumonia From Pneumonitis. Crit Care Med. 2017 Aug;45(8):1268-1275.
  3. Bartlett JG. How important are anaerobic bacteria in aspiration pneumonia: when should they be treated and what is optimal therapy. Infect Dis Clin North Am. 2013;27(1):149-55.

Review

Review Questions 
  1. Which populations are at highest risk for aspiration?
  2. What are three diagnostic tests used to evaluate for aspiration?
  3. What are two surgical procedures that may alleviate intractable aspiration?
  4. What are the potential consequences of chronic aspiration?
  5. How is aspiration pneumonia appropriately treated?
References 
  1. Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med. 2001;344(9):665-71.
  2. Yen KL, Farwell DG. Surgical management of life-threatening aspiration. In: Shaker R. Principles of Deglutition : A Multidisciplinary Text for Swallowing and Its Disorders. New York, NY: Springer; 2013:945-954.
Resources 

Learner must Sign In to access AAO-HNSF education activities.

  1. Annual Meeting Webcasts (AMW):