pulmonary considerations

involves the entry of material (food, liquid, secretions, gastric contents) into the airway

aspiration

Aspiration can:

• cause or worsen _______, particularly in children with underlying _________

• lead to _________ with ______ and impaired _________. Even minimal aspiration may be harmful in children with respiratory disease

• respiratory disease; pulmonary condition

• chronic lung disease with lung scarring; gas exchange

Infants have:

• Higher _________ time for safe swallowing

• _________ increase risk of infections and inflammation

• ________ (________ most active before age 2) are more vulnerable

• respiratory rates limit

• Immature immune systems

• Developing lungs (alveolar growth)

additional risk factors of aspiration:

• High _________ (e.g., ________)

• Uncoordinated _____________

• __________ response

• _____________

• _____________

• High respiratory rates (e.g., >60 breaths/min)

• Uncoordinated swallow–breath timing

• Immature immune response

• Gastroesophageal reflux

• congenital anomalies (TEF)

Respiratory status must be closely monitored in infants with _______ or _________

dysphagia or at risk of aspiration

Special consideration is needed for children with ________—even _________ aspirated can be clinically significant

pre-existing lung disease; small volumes

Aspiration is underrecognized and understudied; there’s a need for more __________ to guide diagnosis and treatment

pediatric- specific evidence

Most common reasons/occurrences of aspiration:

• Oral feeds (solids/liquids)

• Secretions (in non-oral feeders)

• Refluxed gastric contents

• Structural anomalies (e.g., TEF)

Can some aspiration be "safe"?

Generally, avoid assuming any aspirated texture or volume is “safe,” especially in medically fragile infants.

however, clinically you may have to make a decision if they are pretty stable and very little aspiration in order to keep the skin-to-skin and mother-bonding

Shown to cause airway inflammation in animal models.

Risks of varied substances: milk

Considered potentially less harmful in adults with dysphagia but lacks pediatric trial data

Risks of varied substances: water

Particularly harmful due to acidity → causes bronchoconstriction, coughing, and excess mucus.

Risks of varied substances: gastric contents

Can introduce aerobic/anaerobic bacteria, leading to infections like bronchitis or pneumonia

Risks of varied substances: oral/nasal secretions

Symptoms vary based on ______, ____, ________, and __________

frequency, type, volume of aspiration, and host factors (e.g., anatomy, neurology, inflammation, genetics).

acute symptoms

Coughing, choking, stridor, wheezing, oxygen desaturation, fever, respiratory distress

chronic symptoms

Stridor, persistent cough, wheezing, recurrent pneumonia, increased respiratory effort, but often nonspecific and can mimic other diseases (e.g., asthma)

what is common—no obvious symptoms during feeding?

Silent aspiration

what happens once there is aspiration?

• RSV (transient)

• aspiration pneumonia

typically involves dependent lung lobes like posterior/lower or right lung due to anatomy

aspiration pneumonia

effect of pneumonia?

longer hospital stays, higher ICU admission, more gram-negative bacteria

aspiration may require…

broader-spectrum antibiotics

Post-aspiration, inflammation may lead to what?

bronchitis, wheezing, desaturation, and fever within 72 hours.

what may worsen pulmonary hypertension (PH), especially in infants with severe lung disease (e.g., BPD, congenital diaphragmatic hernia)

chronic aspiration

aspiration increases morbidity and mortality of what?

lung disease

aspiration can be misdiagnosed as _______ or other chronic respiratory illnesses

asthma

how do we diagnose aspiration?

• Thorough history and physical exam (respiratory, GI, and feeding symptoms).

• Observation of feeding in clinic settings when applicable.

• Tailored diagnostic testing to avoid over-testing and complications.

• Modified Barium Swallow Study (MBSS)

• Chest X-Ray/CT

• Upper GI series

what do you look for in an MBSS

• Timing

• Fatigue

• Participation

Chest X-Ray/CT looks at what two findings?

chronic vs acute

• A "snapshot" in time

• Primarily for reflux and GI anomalies

upper GI series

Office-based, useful for upper airway inspection

flexible laryngoscopy

Requires anesthesia, allows for diagnosis and potential intervention

Rigid Bronchoscopy (DLB)

Combines upper airway, lower airway, and GI tract evaluation under one anesthesia—efficient for complex cases

Triple Endoscopy

• Assesses breathing-swallowing coordination and salivary control.

• Requires trained personnel and video recording.

• Equipment expense

FEES

Useful for direct visualization of airway inflammation or malacia

flexible broncoscopy

aspiration feeding modifications:

• Always aim for the least restrictive diet

  • Changing feeding position or utensils (e.g., nipple types, straws, cups).

• Diet texture modifications:

  • Restricting certain food or liquid consistencies.

• If ineffective and aspiration leads to respiratory decompensation, escalate to:

  • Nasogastric tubes (NGTs)

  • Gastrostomy tubes (GTs) for long-term feeding

How do we manage? GERD & Aspiration

• Feeding modifications

• Pharmaceuticals

• Advanced Interventions

Restricting feeding volumes may reduce ____

reflux

Pharmaceuticals:

• Histamine-2 blockers and proton pump inhibitors (PPIs): Reduce acid content, not volume, of refluxed material.

  • May reduce __________.

  • Risks of long-term PPI use:

    • ↑ Risk of _______.

    • ↑ Risk of ________, ____________

• Motility agents (e.g., metoclopramide): Enhance ___________.

  • May cause extrapyramidal side effects, particularly in children

• Histamine-2 blockers and proton pump inhibitors (PPIs): Reduce acid content, not volume, of refluxed material.

  • May reduce airway/lung inflammation.

  • Risks of long-term PPI use:

    • ↑ Risk of pneumonia.

    • ↑ Risk of enteric infections, notably Clostridium difficile.

• Motility agents (e.g., metoclopramide): Enhance gastric emptying.

  • May cause extrapyramidal side effects, particularly in children

advanced interventions

• Post-pyloric feeding

• Surgical fundoplication (e.g., Nissen fundoplication)

Post-pyloric feeding

Nasoduodenal, nasojejunal, or jejunostomy tubes.

• Intended to reduce GER and aspiration.

• Evidence is limited regarding its impact on respiratory outcomes.

• Can loosen over time; imaging may be needed if symptoms worsen

Surgical fundoplication (e.g., Nissen fundoplication)

what should be approached conservatively in patients requiring respiratory support due to higher risks associated with aspiration?

Oral feeding

Each modality poses unique risks and benefits regarding _______, _____, _________, and ______

swallow safety, fatigue, secretion management, and pulmonary reserve

• Used in infants with chronic lung disease (e.g., BPD).

• Does not directly affect swallowing. (Exception: NICU)

• Oxygen may help prevent desaturation during feeds by improving pulmonary reserve.

• Fatigue during prolonged feeding can increase aspiration risk; oxygen may reduce this risk

Nasal Cannula (Standard Flow)

Noninvasive Positive Pressure Ventilation (NIPPV) includes…

CPAP, nasal CPAP (NCPAP), BiPAP

Feeding while on NCPAP:

• Increases risk of ________ or _______.

• May delay_______, but _______ may remain intact

• laryngeal penetration or aspiration

• feeding milestones, but airway protection

may not alter swallowing, but underlying conditions (e.g., neuromuscular disorders) often do

tracheostomy

Abnormal swallowing is present in _____% of children with tracheostomies

45-80%

tracheostomy related risks:

• Cuffed tracheostomy tubes do not prevent aspiration.

• Inflated cuffs may cause tracheal damage.

• Speaking valves (e.g., Passy-Muir) may reduce aspiration in adults, but not consistently in children