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.
- Total parenteral nutrition or nasogastric tube feeding may be necessary to safely meet caloric requirements 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 gastroesophageal reflux
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