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Aspiration

Background

Medical Management Considerations

References

Resources for Families

Advisory Committee

Publication Information

BACKGROUND

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Description

Aspiration is the inhalation of food, fluids, medications, saliva, gastric contents, bacteria or other foreign objects into the lungs or upper respiratory tract. Aspiration can occur when materials are on their way to the stomach or when stomach contents flow back up the esophagus (gastroesophageal reflux). The consequences of aspiration depend on the type of material aspirated, its volume and its pH. Aspiration is a rarely diagnosed problem that often goes unrecognized. It is more common among people with developmental disabilities than the general population, in part because of some of the influencing factors listed below.

Influencing Factors

  • Long term use of nasogastric feeding tubes
  • Tracheostomy
  • Poor oral motor skills, depressed cough and gag reflexes
  • Dysphagia
  • Delayed gastric emptying
  • Colectomy
  • Disorders of the esophagus or GI tract (stricture, gastroesophageal reflux (return to the index for documents on reflux and gastrointestinal disorders))
  • Immobility
  • Poor body and head alignment
  • Vomiting
  • Decreased respiratory function
  • History of pneumonia
  • Stroke
  • Seizures
  • Mealtime or medication administration techniques
  • Consistency/texture of food and fluids
  • Altered level of consciousness
  • Medications or substances affecting nervous system (sedatives, anesthesia, alcohol/drugs)
  • Trauma/pain/stress
  • Dental problems
  • Increased age

Signs and Symptoms

  • Coughing and gagging during or after meals
  • Whistling cough, wheezing
  • Choking, inability to speak
  • Gurgling sounds from throat or lungs
  • Foul-smelling sputum
  • Breathing difficulty, noisy breathing
  • Chest pain
  • Rapid heartbeat
  • Low grade fever
  • Weight loss
  • Fatigue
  • Blue coloring, especially lips and nail beds
  • Blood-streaked mucus
  • Increased mucus production
  • Increased white blood cell production
  • Tachypnea
  • Tachycardia
  • Transient hypoxemia with cyanosis

Possible Complications

Note: The lower the pH of aspirated contents, the more severe the respiratory distress.

  • Aspiration pneumonia
  • Lung abscess
  • Pulmonary hypertension
  • Pulmonary tree damage
  • Decline in arterial blood oxygen tension
  • Damage to alveolar-capillary membrane
  • Interstitial edema
  • Intraalveolar hemorrhage
  • Bronchospasm
  • Empyma
  • Atelectasis
  • Hypoxia
  • Decrease in intravascular volume
  • Gas exchange abnormalities
  • Tracheal mucosal desquamation
  • Pneumothorax
  • Septicemia
  • Low blood pressure
  • Shock
  • Adult respiratory distress syndrome (ARDS)
  • Respiratory failure
  • Death

MEDICAL MANAGEMENT CONSIDERATIONS

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Note: These considerations are in addition to the normal medical care provided to an individual without aspiration. All recommendations can be addressed through clinical examination by the primary care provider, unless otherwise noted.

Diagnostic Procedures

  • Physical examination
  • CBC
  • Arterial blood gas
  • Blood culture
  • Bronchoscopy
  • Chest X-ray
  • Lung needle biopsy with culture
  • Open lung biopsy
  • Sputum culture

Ongoing Management

  • Monitor for all influencing factors (above)
  • Maintain history of aspiration and pneumonia
  • Monitor growth
  • Educate caregivers in emergency treatment of aspiration: align head, finger sweep throat, Heimlich maneuver, suction the oropharynx
  • Advise caregivers to have wire cutters available for possibility of vomiting in patient whose jaw has been wired
  • Work to wean from tracheostomy (if applicable)
  • Refer to nutritionist as needed
  • Refer for oral sensorimotor therapy as needed
  • Recommend measures to avoid constipation and impactions (see index for document on GI disorders)
  • Encourage use of loose-fitting clothing
  • In cases of aspiration pneumonia, use chest physiotherapy (deep breathing, coughing) and supplemental oxygen, if necessary
  • Patients should take nothing by mouth if recently extubated until the ability to cough, gag and swallow is elicited
  • Manage ARDS with oxygen, Positive End Expiration Pressure (PEEP) and ventilators
  • Consider surgery as an option

Mealtime Interventions

  • Check nasogastric tube placement (if applicable)
  • Encourage oral feeding whenever possible
  • Provide postural drainage before meals
  • Encourage patient to eat slowly
  • Avoid fatty foods
  • Avoid overfilling stomach (smaller meals)
  • Advise to eat and digest either while lying on right side or in upright position with head above hips by 30-45 degrees
  • Provide adequate head and trunk support
  • Assure body, head and jaw alignment
  • Use small-bore feeding tubes when possible

Positioning

  • Advise to change position every few hours
  • Elevate head of bed 30-45 degrees
  • Maintain internal and external alignment
  • If patient must lie flat or is unconscious, position on right side and keep airway clear

Medications

  • Consider antibiotics (penicillin, clindamycin, ticarcillin-clavulanate)
  • Consider low-dose methylprednisolone
  • Consider gastrokinetic medications (metoclopramide, sodium citrate)
  • Consider H2 receptor antagonists (famotidine, ranitidine)
  • Avoid or reduce medications that increase gastroesophageal reflux
  • Avoid or reduce medications that decrease ability to swallow, gag and cough (alcohol, sedatives, anticholinergics, anesthesia)

Emergency Care

  • Lateral/head down position
  • Suction oropharynx
  • Endotracheal intubation
  • Respirator as needed
  • Ventilate with 100% oxygen
  • Positive end-expiratory pressure (PEEP
  • Endotracheal suctioning
  • Monitor cardio/respiratory
  • Bronchoscopy to remove foreign bodies
  • Chest tube to drain infection as needed

Possible Surgical Procedures

  • Endoscopic capping
  • Closure of the larynx (administer botulinum toxin A preoperatively)
  • Laryngotracheal separation (very effective)
  • Transthyrotomy closure of the supraglottic larynx
  • Epiglottoplasty procedure
  • Laryngeal diversion procedure
  • Tracheotomy (not always effective)
  • Tracheo-esophageal diversion
  • Surgical modification of vocal cords

Note: It has recently been suggested that treatment of Helicobacter pylori may reduce aspiration pneumonia and some gastrointestinal disorders in patients with developmental disabilities.

REFERENCES

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Peer-reviewed Journal Articles/Academies

Brook, I. (1996). Treatment of Aspiration or Tracheostomy-associated Pneumonia in Neurologically Impaired Children: Effect of Antimicrobials Effective Against Anaerobic Bacteria. International Journal of Pediatric Otorhinolaryngology, 35(2) 171-177.

Finucane, T.E. & Bynum, J.P.W. (1996). Use of Tube Feeding to Prevent Aspiration Pneumonia. Lancet 348(9039) 1421-1424.

Gisel, E.G. et al. (1995). Effect of Oral Sensorimotor Treatment on Measures of Growth, Eating Efficiency and Aspiration in the Dysphagic Child with Cerebral Palsy. Developmental Medicine and Child Neurology, 37(6) 528-543.

Projansky, R. et al. (1994). Symptomatic H. Pylori: Infection in Young Patients with Severe Neurologic Impairment.” Journal of Pediatrics, (125), 750-752.

Special Interest Groups/Other Publications

Goodwin, R.S. (1996). Prevention of Aspiration Pneumonia: A Research-Based Protocol. Dimensions of Critical Care Nursing. Hall Johnson Communications.

Kastner, T. (1997). Helicobacter Pylori: Infection in Institutional Settings. Exceptional Health Care, (November).

Prazeres, G.A., Pulmonary Aspiration. Med Students – Anesthesiology. Retrieved April 17, 2006 from http://www.medstudents.com.br/anest/anest2.htm

Smith Consultant Group & McGowan Consultants. (1998). In (Ed.) Sigon Snyder M, Aspiration. Health and Wellness Reference Guide. Neri Productions, State of Tennessee Commission on Compliance (July), (pp. 151-157).
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RESOURCES FOR FAMILIES

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American Association for Respiratory Care,

http://www.aarc.org

American Gastroenterological Association (AGA), 301-654-2055

http://www.gastro.org

American Lung Association, 800-LUNG-USA,

http://www.lungusa.org

American Thoracic Society, 212-315-8700,

http://www.thoracic.org

California Department of Developmental Services, 916-654-1690,

http://www.dds.ca.gov

California Regional Centers, 916-654-1958,

http://www.dds.ca.gov/rc/RCInfo.cfm

International Society for Respiratory Protection,

http://www.isrp.com.au

National Board for Respiratory Care,

http://www.nbrc.org

National Digestive Diseases Clearinghouse, 212-685-3440

National Institute of Allergy and Infectious Diseases,

http://www.niaid.nih.gov

ADVISORY COMMITTEE

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Theodore A. Kastner, M.D., M.S.

Felice Weber Parisi, M.D., M.P.H.

Patrick J. Maher, M.D.

PUBLICATION INFORMATION

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Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.