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Aspiration Pneumonia
(in head and neck cancer)
Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB (Gold Medalist),MNAMS
UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow
Physiology and anatomy of swallowing
Anatomy of swallowing
Aspiration
• Inhalation of oropharyngeal or
gastric content to the larynx or
lower respiratory tract
• Not uncommon in healthy
individuals (sleep)
• Protective mechanisms:
– Cough reflex (pharyngeal
sensitivity)
– Active ciliary mechanism
– Immunocompetent status
– Low burden of virulent bacteria
in normal pharyngeal
secretions
Aspiration
• Pneumonitis: chemical injury of
sterile contents
• Pneumonia: infectious process
from colonized content
• Altered protective mechanisms
• Altered microbial flora
• Submucosal effects, including
fibrosis, and vascular and nerve
(sensory and motor) injury
Long term functional deficits: head
and neck cancers
Swallowing dysfunction: Surgery or RT alone
• Surgery Alone
– Extent and site of the tumour
– Extent of surgical resection: Tongue, BOT, Arytenoids
– Type of reconstructive procedure (less role)
• RT alone
– Total radiation dose, fraction size, radiated volume
– Inter-fraction interval, treatment techniques, use of intensity-
modulated RT (IMRT) and tissue–dose compensation
– site and size of the primary tumour
– patient smoking during and after RT
• Surgery plus RT
– Additive effect
– Early and late components
Predictors of aspiration
• Primary site: Hypopharyngeal and Laryngeal primary, BOT
• Elderly age
• Baseline swallowing dysfunction
• Stage of disease: advanced T stage
• Habitual alcohol consumption, sleeping pill use, poor oral
hygiene, hypoalbuminemia, coexistence of other malignancies*
• Concurrent chemoradiotherapy
• Bilateral neck irradiation
• Weight loss
• Neck dissection after CTRT
*Kawai et al. BMC Cancer (2017) 17:59
Risk Factors for Aspiration
• Altered level of consciousness
* Alcohol
* Drugs
* Hepatic failure
* CVA
* Anesthesia
• Depressed cough or
gag reflex
• Esophageal disorders
* GERD
* Strictures
* Vomiting
• Disruption of glottic closure
* ET tube
* NG tube
* Endocopy/
Brochoscopy
• Neuro/muscular disorders
* Multiple sclerosis
* Parkinsons
* Myasthenia
* Seizures
* Stroke
• Scoliosis/ Kyphosis
• Dry Mouth
Incidence of aspiration rate
• Aspiration rate at diagnosis: 17% (10/63); 35-80% (Literature**)
• Aspiration prevalence CTRT: 33% (21/63)
Nguyen NP et al. Radiotherapy and Oncology 80 (2206) 302-306
**Stenson KM. Arch Otolaryngol Head Neck Surg 2000; 126:384-9
Aspiration and outcome
• The 1-year and 5-year cumulative incidence of aspiration
pneumonia was 15.8% and 23.8%
• The 30-day mortality rate after hospitalization for aspiration
pneumonia was 32.5%.
• Aspiration pneumonia was associated with a 42% increased risk of
death (hazard ratio, 1.42; P<.001) after controlling for confounders.
Xu B et al. SEER database Cancer 2015
Impact of aspiration on outcome
• Silent aspirators: Prolonged feeding tube dependence,
weight loss, reduced intake
• Impaired quality of life and failure of organ
preservation
• Cause of mortality (10-20%): Sepsis and respiratory
failure
Aspiration pneumonia: Clinical Symptoms
Symptoms can vary greatly
from asymptomatic to:
• Clearing throat
• Coughing
• Gurgling
• Wheezing
• Abrupt onset of dyspnea
• Chest pain
• Tachycardia
• Tachypnea
• Hypotension
•Fever
• Hypoxemia
• Diffuse crackles or decreased
breath sounds
Aspiration pneumonia: Diagnosis
• Symptoms: Wet cough, sputum, and fever.
• Objective findings:
– Coarse crackles in the chest, elevated inflammatory
markers (e.g. white blood cell count or C-reactive
protein), or image findings (e.g. infiltration on a chest X-
ray or consolidation in chest computed tomography)
• Aspiration was suspected clinically (choking or delayed
swallowing) or by endoscopic or video-fluorographic
examinations.
• No evidence of atypical pneumonia: Legionella and
Mycoplasma
Swallowing studies
• Video-fluoroscopic/Modified barium swallow
– Analysis of phases of swallowing
– Amount of aspiration and penetration, Laryngeal sensation,
residue/pooling after swallow
– Penetration: Portion of bolus entering laryngeal vestibule to
the level of vocal folds
– Oropharyngeal swallowing efficiency
• Flexible endoscopic evaluation of swallowing safety
(FESS)
• Esophagogram/Manometry/Biplane Fluoroscopy
*Eisbruch A et al. IJROBP 2002
Aspiration pneumonia in head and neck cancer patients
Aspiration pneumonia in head and neck cancer patients
Triggers for dysphagia evaluation
PAS: Penetration Aspiration Scale
Swallowing scales
Grade 1-5: Swallowing therapy
Grade 6-7: Tube feeding
Handling aspiration pneumonia
Preventive strategies
• Pre-treatment counselling
– Dietary and postural strategies
– Preventive exercises: Early vs. Late
– Dental prophylaxis
• Encourage enteral feeding as long as appropriate even with NJ
tubes
• Prophylactic PEG vs NJ tube
• Treatment modifications
– Surgical planning
– Radiation beam modulation:
• Reduce unnecessary doses to DARS : DARS sparing IMRT
• Minimize Xerostomia
Swallowing exercises
Aspiration pneumonia in head and neck cancer patients
Aspiration pneumonia in head and neck cancer patients
Aspiration pneumonia in head and neck cancer patients
Aspiration pneumonia in head and neck cancer patients
Aspiration pneumonia in head and neck cancer patients
Aspiration pneumonia in head and neck cancer patients
Aspiration pneumonia in head and neck cancer patients
Aspiration Pneumonia:
Therapeutic
• Acute phase treatment
• Compensatory meal alterations
– Posture: head back, chin down, head tilt etc.
– Bolus volume and consistency
• Therapy exercises directed to dysfunction of patients
• Swallowing manoeuvres
• Pharyngeal/cervical oesophagus dilatation
• Prosthetics
• Neuromuscular electrical stimulation (NES) has been used as
an adjunct to swallowing therapy
Aspiration pneumonia in head and neck cancer patients
Swallow Challenge
• Have the patient brush their
teeth and rinse their mouth
• Have suction equipment available
• Instruct the patient to drink a full
glass of water WITHOUT stopping
Take home message
• Aspiration pneumonia is underreported in head and neck
cancers and oncology as such!!
• Patient, tumor characteristics and treatment parameters help
predict patients at high risk of aspiration
• Objective tests: MBS and FESS are useful investigations and
triggers may help in optimizing it`s use
• Swallowing maneuvers and exercises are both preventive and
therapeutic: Need to adapt to patients needs
• DARS optimized IMRT is promising: Needs further follow up
Thank you
Patient and care giver awareness is one of the
important keys!!

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Aspiration pneumonia in head and neck cancer patients

  • 1. Aspiration Pneumonia (in head and neck cancer) Dr Ajeet Kumar Gandhi MD (AIIMS), DNB (Gold Medalist),MNAMS UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow
  • 2. Physiology and anatomy of swallowing
  • 4. Aspiration • Inhalation of oropharyngeal or gastric content to the larynx or lower respiratory tract • Not uncommon in healthy individuals (sleep) • Protective mechanisms: – Cough reflex (pharyngeal sensitivity) – Active ciliary mechanism – Immunocompetent status – Low burden of virulent bacteria in normal pharyngeal secretions
  • 5. Aspiration • Pneumonitis: chemical injury of sterile contents • Pneumonia: infectious process from colonized content • Altered protective mechanisms • Altered microbial flora • Submucosal effects, including fibrosis, and vascular and nerve (sensory and motor) injury
  • 6. Long term functional deficits: head and neck cancers
  • 7. Swallowing dysfunction: Surgery or RT alone • Surgery Alone – Extent and site of the tumour – Extent of surgical resection: Tongue, BOT, Arytenoids – Type of reconstructive procedure (less role) • RT alone – Total radiation dose, fraction size, radiated volume – Inter-fraction interval, treatment techniques, use of intensity- modulated RT (IMRT) and tissue–dose compensation – site and size of the primary tumour – patient smoking during and after RT • Surgery plus RT – Additive effect – Early and late components
  • 8. Predictors of aspiration • Primary site: Hypopharyngeal and Laryngeal primary, BOT • Elderly age • Baseline swallowing dysfunction • Stage of disease: advanced T stage • Habitual alcohol consumption, sleeping pill use, poor oral hygiene, hypoalbuminemia, coexistence of other malignancies* • Concurrent chemoradiotherapy • Bilateral neck irradiation • Weight loss • Neck dissection after CTRT *Kawai et al. BMC Cancer (2017) 17:59
  • 9. Risk Factors for Aspiration • Altered level of consciousness * Alcohol * Drugs * Hepatic failure * CVA * Anesthesia • Depressed cough or gag reflex • Esophageal disorders * GERD * Strictures * Vomiting • Disruption of glottic closure * ET tube * NG tube * Endocopy/ Brochoscopy • Neuro/muscular disorders * Multiple sclerosis * Parkinsons * Myasthenia * Seizures * Stroke • Scoliosis/ Kyphosis • Dry Mouth
  • 10. Incidence of aspiration rate • Aspiration rate at diagnosis: 17% (10/63); 35-80% (Literature**) • Aspiration prevalence CTRT: 33% (21/63) Nguyen NP et al. Radiotherapy and Oncology 80 (2206) 302-306 **Stenson KM. Arch Otolaryngol Head Neck Surg 2000; 126:384-9
  • 11. Aspiration and outcome • The 1-year and 5-year cumulative incidence of aspiration pneumonia was 15.8% and 23.8% • The 30-day mortality rate after hospitalization for aspiration pneumonia was 32.5%. • Aspiration pneumonia was associated with a 42% increased risk of death (hazard ratio, 1.42; P<.001) after controlling for confounders. Xu B et al. SEER database Cancer 2015
  • 12. Impact of aspiration on outcome • Silent aspirators: Prolonged feeding tube dependence, weight loss, reduced intake • Impaired quality of life and failure of organ preservation • Cause of mortality (10-20%): Sepsis and respiratory failure
  • 13. Aspiration pneumonia: Clinical Symptoms Symptoms can vary greatly from asymptomatic to: • Clearing throat • Coughing • Gurgling • Wheezing • Abrupt onset of dyspnea • Chest pain • Tachycardia • Tachypnea • Hypotension •Fever • Hypoxemia • Diffuse crackles or decreased breath sounds
  • 14. Aspiration pneumonia: Diagnosis • Symptoms: Wet cough, sputum, and fever. • Objective findings: – Coarse crackles in the chest, elevated inflammatory markers (e.g. white blood cell count or C-reactive protein), or image findings (e.g. infiltration on a chest X- ray or consolidation in chest computed tomography) • Aspiration was suspected clinically (choking or delayed swallowing) or by endoscopic or video-fluorographic examinations. • No evidence of atypical pneumonia: Legionella and Mycoplasma
  • 15. Swallowing studies • Video-fluoroscopic/Modified barium swallow – Analysis of phases of swallowing – Amount of aspiration and penetration, Laryngeal sensation, residue/pooling after swallow – Penetration: Portion of bolus entering laryngeal vestibule to the level of vocal folds – Oropharyngeal swallowing efficiency • Flexible endoscopic evaluation of swallowing safety (FESS) • Esophagogram/Manometry/Biplane Fluoroscopy *Eisbruch A et al. IJROBP 2002
  • 20. Swallowing scales Grade 1-5: Swallowing therapy Grade 6-7: Tube feeding
  • 21. Handling aspiration pneumonia Preventive strategies • Pre-treatment counselling – Dietary and postural strategies – Preventive exercises: Early vs. Late – Dental prophylaxis • Encourage enteral feeding as long as appropriate even with NJ tubes • Prophylactic PEG vs NJ tube • Treatment modifications – Surgical planning – Radiation beam modulation: • Reduce unnecessary doses to DARS : DARS sparing IMRT • Minimize Xerostomia
  • 30. Aspiration Pneumonia: Therapeutic • Acute phase treatment • Compensatory meal alterations – Posture: head back, chin down, head tilt etc. – Bolus volume and consistency • Therapy exercises directed to dysfunction of patients • Swallowing manoeuvres • Pharyngeal/cervical oesophagus dilatation • Prosthetics • Neuromuscular electrical stimulation (NES) has been used as an adjunct to swallowing therapy
  • 32. Swallow Challenge • Have the patient brush their teeth and rinse their mouth • Have suction equipment available • Instruct the patient to drink a full glass of water WITHOUT stopping
  • 33. Take home message • Aspiration pneumonia is underreported in head and neck cancers and oncology as such!! • Patient, tumor characteristics and treatment parameters help predict patients at high risk of aspiration • Objective tests: MBS and FESS are useful investigations and triggers may help in optimizing it`s use • Swallowing maneuvers and exercises are both preventive and therapeutic: Need to adapt to patients needs • DARS optimized IMRT is promising: Needs further follow up
  • 34. Thank you Patient and care giver awareness is one of the important keys!!

Editor's Notes

  1. There are four stages of swallowing that involve a series of coordinated events involving more than 30 pairs of muscles and six cranial nerves
  2. Oropharyngeal swallow efficiency (OPSE) is a global measure of the safety and speed of the swallow. OPSE is calculated by measuring the total oral and pharyngeal transit time of the bolus divided by the percentage of bolus swallowed. The latter measure is an approximation, because the measurement of the volume cannot be made during the swallow with VFG. The OPSE scores typically range from 100, meaning that 100% of the bolus is swallowed in 1 s, to 140 in normal subjects. In patients, the OPSE often drops to 50 or 40, as the percentage of bolus swallowed reduces and the time increases
  3. Fig 3. (A) Normal hyolaryngeal motion (elevation plus anterior excursion); (B) reduced hyolaryngeal motion. Arrow indicates hyoid. Fig 2. Base of tongue in opposition to posterior pharyngeal wall. (A) Normal; (B) reduced after chemoradiotherapy. Arrows indicate tongue base
  4. Pharyngeal residue on modified barium swallow (MBS); (B) pharyngeal residue on fiberoptic endoscopic evaluation of swallowing; (C) aspiration on MBS. Arrow indicates tracheal aspiration
  5. Penetration aspiration scale
  6. Patients with abnormal swallow (grade 3–7) underwent swallowing therapy immediately following the MBS. The swallowing therapy was individualized for each patient. They were taught various maneuvers to improve swallowing efficiency like chin tuck (postural technique) or supraglottic swallow (voluntary swallowing maneuver) to protect the airway during swallow. Patients identified to have an anatomic abnormality during the MBS also required range of motion (ROM) exercises which were dependent on the specific defect observed (tongue, larynx, upper esophageal sphincter). For therapeutic purposes, patients with grade 5 have trace aspiration. Swallowing therapy was frequently effective to stop their aspiration. They were able to maintain adequate nutrition with oral feeding. Patients with grade 6–7 have severe aspiration and require tube feeding. Patients with grade 6 are allowed to have oral feeding for psychological reasons but most of their nutrition comes from tube feedings. Patients with grade 7 are not allowed to have oral feeding. All patients with grade 5 or less after treatment will have their PEG tubes removed unless they still have severe weight loss