Aspiration pneumonia medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Medical Therapy
Management of patients with swallowing dysfunction is highly individualized based on the cause of the dysfunction and other patient characteristics identified by the multidisciplinary evaluation outlined above.
If there are primary anatomical abnormalities that predispose to aspiration, these should be surgically corrected, if possible. Total parenteral nutrition or nasogastric tube feeding may be necessary to safely meet caloric requirements during the recovery period after corrective surgery. The same methods for nutritional support should be considered when the patient's swallowing dysfunction is secondary to a transient disease, such as a critical illness.
Feeding decisions
The goals of therapy are safe and efficient nutrition that preserves stable respiratory function and appropriate growth. Oral feeding, while always desirable, is not always the most reasonable goal for patients with severe swallowing dysfunction because the risks of oral feeding may outweigh the psychosocial benefits to the patient and family [6,37,38]. On the other hand, for some patients with severe static encephalopathy or global delays, the family may choose to maintain oral feeds for pleasure despite the known risks of aspiration and pulmonary injury. These considerations require a clear and detailed discussion of goals and risks between the family and clinicians [39].
Techniques to enhance oral feeding
In children with functional abnormalities, treatment is often led by speech and occupational therapists that specialize in swallowing. The specialist selects specific techniques to improve swallowing function based on individual patient characteristics:
●In infants, change in the flow of liquids may significantly improve swallowing. These changes can be made by changing to a slow flow nipple.
●Other feeding techniques include changes in the infant or child's position and posture during feeding, modification of bolus size, and alterations of consistency, shape, texture, and temperature of food. These techniques should be selected based on the result of the videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) (image 1) [3,40].
●In children with delayed maturation, swallowing function may improve over time. In the interim, the techniques outlined above are used to support adequate nutrition and avoid aspiration. The type of feeding is then gradually advanced as the infant or child matures. Advances in feeding may be directed by repeat swallowing evaluation, including clinical assessment of feeding, with or without VFSS or FEES.
Gastrostomy feeds
Percutaneous gastrostomy tube placement should be considered for patients who are unable to safely consume enough calories by mouth. Some patients will require gastrostomy tubes to meet part or all of their nutritional needs. Oral-motor and swallowing therapy should be continued in patients in whom swallowing function is expected to improve, and gastrostomy tubes may be removed when no longer necessary.
Parents may initially be reluctant to have a gastrostomy tube placed because of concerns about losing pleasure of eating, discomfort, or cosmesis. The importance of preventing pulmonary aspiration, long-term benefits of improved nutrition, and reversibility of this procedure should be emphasized. In addition, gastrostomy tubes can be useful for administering medication and fluid, when needed.
General considerations about gastrostomy placement and enteral feeding are discussed in a separate topic review.
Management of salivary aspiration
Management techniques for patients with suspected salivary aspiration include:
●Providing small quantities ("tastes") of liquid or food, to assist purposeful swallowing and reduce the risk of aspiration from pooled saliva.
●Administration of anticholinergic agents, such as glycopyrrolate or scopolamine patches to inhibit salivation. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)
●Botulinum toxin injections to decrease salivation. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)
●Surgical removal of salivary glands or salivary duct ligation has had a beneficial effect in some individuals, although these surgeries are not without risk. (See "Management and prognosis of cerebral palsy", section on 'Drooling'.)
●In very rare instances, laryngotracheal separation with a permanent tracheostomy may be indicated.
Surgical approaches should be approached with caution because it is often difficult to predict whether or not these procedures will improve pulmonary symptoms.
Management of gastroesophageal reflux
Patients with swallowing dysfunction, especially those with neurologic impairment, may have increased frequency and volume of gastroesophageal reflux (GER).
Most patients with mild GER can be effectively managed without fundoplication, using dietary modification and positioning to reduce the frequency of GER, pharmacotherapy for acid suppression, and occasionally prokinetic agents.
Fundoplication
Fundoplication is a surgical procedure to reduce the risk of GER. It should be considered only in patients with GER that is strongly suspected to be contributing to pulmonary disease. When evaluating the severity of GER, a gastroenterologist classically focuses on the percent of time that gastric contents spend in the esophagus, which correlate with the risk for peptic esophagitis. From a pulmonary point of view, the number and duration of episodes may be less important than whether the reflux occurs during sleep, when the patient is horizontal and less likely to protect the larynx. Clinical judgment must be applied to individual patients when judging whether they are likely to benefit from fundoplication. Complications after fundoplication include retching, esophageal obstruction, intrathoracic herniation, and recurrence of GER due to breakdown of the wrap. Complications of fundoplication are most common in patients with neurologic impairment [42,43]. Failure rates (variously defined) of antireflux surgery range from 2 to 50 percent and are generally higher in children with neurological impairment [44].
Jejunal feeds
For patients with GER who are dependent on enteral feeds, an alternate strategy to reduce GER and the associated risks of aspiration is to place the feeding tube in the jejunum rather than in the stomach; this tends to reduce but not eliminate GER. Disadvantages of jejunal feeds include intolerance of rapid feeding infusions (such that continuous rather than bolus feeds must be used), and a tendency for accidental displacement (except with permanent, surgically placed jejunal tubes). A retrospective study in a group of children with neurological impairment found that the rates of aspiration pneumonia and mortality were similar among those treated with jejunal feeding as compared with those treated with fundoplication [45]
Aspiration Pneumonia
Antibiotic therapy is unequivocally indicated in patients
with aspiration pneumonia. The choice of antibiotics
should depend on the setting in which the
aspiration occurs as well as the patient’s general health
(Table 2). However, antibiotic agents with activity
against gram-negative organisms, such as third-generation
cephalosporins, fluoroquinolones, and piperacillin,
are usually required. Penicillin and clindamycin,
which are often called the standard antibiotic agents
for aspiration pneumonia, are inadequate for most patients
with aspiration pneumonia.78 Antibiotic agents
with specific anaerobic activity are not routinely warranted
and may be indicated only in patients with severe
periodontal disease, putrid sputum, or evidence
of necrotizing pneumonia or lung abscess on radiographs
of the chest.78,79
Aspiration Pneumonitis
The upper airway should be suctioned after a witnessed
aspiration of gastric contents. Endotracheal intubation
should be considered for patients who are
unable to protect their airway (for example, those with
a decreased level of consciousness). Although it is
common practice, the prophylactic use of antibiotics
in patients in whom aspiration is suspected or witnessed
is not recommended. Similarly, the use of antibiotics
shortly after aspiration in patients in whom
a fever, leukocytosis, or a pulmonary infiltrate develops
is discouraged, since the antibiotic may select
for more resistant organisms in patients with an uncomplicated
chemical pneumonitis. However, empirical
antibiotic therapy is appropriate for patients who
aspirate gastric contents and who have small-bowel
obstruction or other conditions associated with colonization
of the gastric contents. Antibiotic therapy
should be considered for patients with aspiration
pneumonitis that fails to resolve within 48 hours after
aspiration. Empirical therapy with broad-spectrum
agents is recommended (Table 2); antibiotics with
anaerobic activity are not routinely required. Sampling
of the lower respiratory tract (with a protected
specimen brush or by bronchoalveolar lavage) and
quantitative culture in intubated patients may allow
targeted antibiotic therapy and, in patients with negative
cultures, the discontinuation of antibiotics.
81,82
Corticosteroids have been used for decades in the
management of aspiration pneumonitis.
83
However,
there are limited data on the role of these agents. In
a prospective, placebo-controlled study, Sukumaran
and colleagues found that radiographically evident
lung injury improved more quickly in the patients given
corticosteroids than in those given placebo; however,
the patients given corticosteroids had a longer
stay in the intensive care unit, and there were no significant
differences between the two groups in the
incidence of complications or the outcome.
84,85
In a
case–control study, Wolfe and colleagues found that
pneumonia due to gram-negative bacteria was more
frequent after aspiration among patients treated with
corticosteroids than among those who were not.
86
Similarly, studies in animals have failed to demonstrate
a beneficial effect of corticosteroids on pulmonary
function, lung injury, alveolar–capillary permeability,
or outcome after acid aspiration.
87,88 Furthermore,
given the failure of two multicenter, randomized,
controlled trials to demonstrate a benefit of high-dose
corticosteroids in patients with the acute respiratory
distress syndrome, the administration of corticosteroids
cannot be recommended.89,90