Aspiration

Definition: the passage of secretions beyond the V.C

Few notes on aspiration:
 50% of Normal healthy patient aspirate during sleeping but
without clinical significant
 Most patients with chronic aspiration have severe underlying
medical condition
 CVA is the most common underlying medical condition in adult
that cause chronic aspiration
 Chronic aspiration may have severe long term pulmonary consequences
 The volume and the character of the aspirated material has marked impact on the clinical
impact of aspiration
 Aspiration in the supine position is more in the RT lower lobe
 No place for prophylactic antibiotic
 Aspiration is more likely if the superior laryngeal nerve is affected
 Lower motor neuron Bilateral recurrent laryngeal nerve paralysis not upper because :
o Lower motor neuron paralysis: flaccid paralysis
o Upper motor neuron paralysis: spastic paralysis
Barrier for aspiration:
a. Reflex:
1. Cough reflex
2. Swallowing reflex
b. Mechanical factors:
1. Epiglottis
2. Aryepiglottic fold
3. Vocal cords apposition
Source of aspiration:
1. Oral intake
2. Pharyngeal secretions (the most source cause)
3. Reflex of the gastric content ( 2nd source cause)
Tracheostomy and aspiration:
 No definitive causal relationship between aspiration and tracheostomy
 Tracheostomy does not prevent aspiration
 But it allows pulmonary toilet and decrease the dead space for pt with chronic aspiration
Effects of tracheotomy tube:
 interferes with anterior displacement and elevation of larynx during swallowing
 FB that promotes crust formation and pooling of secretions
 compromises normal cough mechanisms (inability to produce adequate subglottic pressure)
 disrupts normal laryngeal reflexes, such as vocal cord adduction during swallowing
 cuff may compress esophagus, hindering bolus transport
 interferes with ciliary motion

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal reading only.
Investigations:
a) Functional (Fiberoptic) Endoscopic Evaluation of Swallowing (FEES):
 Allows bedside evaluation of swallowing function
 nasopharyngoscopy utilized to visualize swallowing phases
 may assess for aspiration, penetration, and pharyngeal and laryngeal function
 Sensitivity is improved with sensory assessment by including pharyngeal squeeze:
 the patient is instructed to deliver a voluntary, forceful, high-pitched /eee/ and
the pharyngeal muscular contraction is evaluated by assessing the motion of the
lateral hypopharyngeal walls and corresponding narrowing of the pyriform
sinuses
 Disadvantage: can’t assess the oral and pharyngeal phase of the swallowing
b) Videofluoroscopic Swallow study (VFSS)/modified barium swallow
Utilizes:
Varying bolus amounts and consistencies
Visualizes:
1. oral Phase
2. pharyngeal phases
Determines:
1. oral motility
2. pharyngeal motility
3. laryngotracheal elevation
4. laryngeal penetration aspiration
Note:
 FEES & VFSS: have similar sensitivity and
specificity and may be used according to
hospital availability and preference
 So if the patient is critically ill and cannot be
transferred into radiological unite: do FEES
because it can be done bedside
c) Esophagram (Barium Swallow):
Evaluates: Esophageal phase of swallowing
Determine:
1. Motility
2. luminal integrity (large ulcers, intrinsic/extrinsic masses, strictures, webs)
3. reflux
d) Manometry:
Measures:
1. peristaltic waves: Duration; Amplitude; velocity
2. pressure:
a) esophageal sphincter (UES) pressure
b) lower esophageal sphincter (LES)
c) Esophageal body.

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal reading only.
e) Laryngoscopy and Esophagoscopy: Indicated if suspect malignancy, for uncertain etiology, to
evaluate esophagus, to remove foreign Bodies, and to biopsy a mass or lesion
f) Bed side swallow evaluation:
 Used in critically ill patients
 Depends on history and examination:
1. cough post swallowing
2. repeated swallowing
3. wet voice post swallowing
4. voice change post swallowing
5. desaturation post swallowing
 Limitations: misses silent aspiration cases
Note: Silent aspiration are detected via direct observation of the pharyngeal phase as in
Videofluoroscopic swallow study + FEES
Management:
Initial Non-surgical Management of chronic aspiration:
1. Discontinuation of all oral intake
2. alternative route of alimentation is provided:
a. NG tube
b. gastrostomy
c. jejunostomy
3. Special positioning
4. Swallowing therapy including chin tuck

 Reversible procedures
 Can be done bedside
 Can be done in the presence of previous
tracheostomy
 Can be done in children
 The stasis of secretions in the laryngeal pouch in
laryngotracheal separation does not cause irritation

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal reading only.
Aspiration in children

 patients with confirmed aspiration and/or refractory dysphagia and no obvious cause (eg, vocal
fold immobility after PDA ligation) may undergo microlaryngoscopy and bronchoscopy to evaluate
for a structural abnormality of the aerodigestive tract such as a
a) laryngeal cleft
b) H-type tracheoesophageal fistula
Laryngeal cleft grading:
I: interarytenoid defect
II: cricoid involvement
III cervical trachea involvement
IV thoracic trachea involvement
Treatment:
 goal is securing airway and avoiding chronic aspiration;
 symptomatic type I–II and certain type III clefts can be repaired endoscopically
 most type III and all type IV require open repair

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal reading only.
 Tracheoesophageal fistula occur due to failure of tracheoesophageal septum formation
 The most common type is proximal atresia with distal fistula
 If esophageal atresia is suspected the first feed should be hold
 The risk of aspiration due to:
1. overspill into the trachea
2. fistula between the airway and the GI system
 Symptoms:
 Aspiration
 cough
 Recurrent pneumonitis with purulent pus
 Dysphagia
 GERD

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal reading only.