The document outlines the definition, causes, symptoms, examinations, and management of intractable aspiration, emphasizing laryngeal penetration of gastric secretions. It discusses various conditions leading to aspiration, diagnostic methods, and treatment options, including conservative strategies and surgical interventions. Additionally, it addresses specific concerns regarding aspiration in neonates and related investigations.

1. Dr Zeeshan Ali
INTRACTABLE ASPIRATION

2. Definition
 Laryngeal penetration of gastric secretions below
the vocal cords
(40% have small aspirations often go
unnoticed: it’s the quantity of aspiration that
defines it)
low pH causes inflammatory response bringing
leukotriene induced damage to lung

3. Causes
 CNS – stroke,MS,parkinsons,head injury
 PNS – GB synd, polio,demylinating diseases
 NMJ – mysthenia gravis, lambert eaten synd
 Muscles– muscular dystrophy, polymyositis
 GIT – GERD, achlasia, pharyngeal pouch, tumour
 Mechanical – NG tubes,tracheostomy,ETT
 Misc – severe debilitation

4. Signs and symptoms
 No symptoms
 Coughing bouts
 Chowking during swallowing
 Dysphagia
 Regurgitation
 Dysphonia
 RECURRENT PNEUMONIA PLUS SEPSIS

5. Examination
 Complete head and neck exam
 Tongue movement
 Gag reflex
 Cough reflex
 IDL

6. Investigations
 CXR (no pattern) basal infiltrates
 Contrast swallow
 Rigid endoscopy
 Barium videoflouroscopy swallow test
 Fibreoptic endoscopic evaluation of swallowing
(FEES)
 Bronchio aveolar lavage for lipid laden
macrophages
Best contrast should be nonionic,low osmolar
having LMW

7. Current radiological method
 Barium and gastrograffin both poor materials as
cause chemical pneumonitis! OMNIPAQ ,DIONOSIL
are recommended
 What a radiologist should do! sequence
 Take history and examine patient
 Do Diluted barium test
 Do Barium puree in food test
 Use alternate contrast in children -Tc99 in milk
 see Change is neck positions on swallowing
 See Breath holding effect on swallowing
 Witness all on flouroscopy himself
 Or record it via videoflouroscopy
 Help swallowing pathologist suggest usefulness of
exercises

8. Management
 Specific surgeries
 Surgeries for persistent aspirators
 Conservative strategies

9. Specific surgeries
 VC medialization
 Cricopharyngeal myotomy (Heller’s)
 Nissen’s fundoplication
 Removal of tumour
 Pharyngeal pouch surgery
 TEF surgery

10. Persistent aspirators
 Principle
 Close or separate
 Divert
 Excise

11. Persistent aspirators
 Total / narrow field laryngectomy
 Endolaryngeal stents
 Epiglottopexy
 Vertical laryngoplasty
 Subperichondrium cricoidectomy
 Glottic closure
 Tracheo-oesopageal diversion
 Laryngotracheal seperation

12. Very effective ,irreversible , speech lost , preserves hyoid , strapes and pharyngeal mucosa
NARROW FIELD LARYNGECTOMY

13. Effective, Reversible ,
vented stents allow speech,
but compromises swallowing
ENDOLARYNGEAL STENT

14. 50% successful,
Allows speech,
reversible
EPIGLOTTOPEXY

15. Effective, irreversibe , allows speech,need cricopharyngeal myotomy
VERTICAL LARYNGOPLASTY

16. LA bed procedure, reversible,
sternohyoid interposition
SUBPERICHONDRIUM
CRICIODECTOMY

17. Effective, requires thyrotomy,reversible, loss of speeech
GLOTTIC CLOSURE

18. Effective,
Preferred in peads ,
Reversible,
Loss of speech,
Diversion done in low tracheostomy
Separation done in high tracheostom
TRACHEO-ESOPHAGEAL DIVERSION
VS
LARYNGOTRACHEAL SEPERATION

19. Conservative
 Treat lung disease
 Chest physiotherapy
 Swallow maneuvers
 NPO, Frequent suctioning, head elevation
,alternative route nutrition
 Tracheostomy (causes aspiration!! Evan blue
test)
 NG TUBE
 Gastrostomy
 Jejunostomy (best results)

20. Swallow maneuvres
 Reclining position at 30 degrees
 Seated position 60 degrees 2 hrs after eating
 Head rotation (opposite of what we think!! Tilting toward
paralyzed side reduces aspiration)
 Chin tuck method
 Side lying position
 Cervical excercises
 Thermal tactile stimulation
 Supraglottic swallowing
 Mandelsohn maneuvre
 Shaker exercise
 Balloon training
 Respiratory physiotherapy

21. ASPIRATION IN NEONATES

22.  Aspiration have infant reflux but not all reflux
have aspiration
 All infant have reflux but a minor event and
subsides later (physiological reflux)
 Short abdominal segment and hourly feeds is the
reason
 Preterm infant have more reflux problems
 More in formula fed infants ( causes more
bloating and lead to opening of LES earlier)
 Most reflux are asymptomatic
 Major cause of ALTE (apparent life threatening
events)
 Seen in laryngomalacia, subglottic stenosis,
laryngeal clefts and resp papillomatosis

23. Causes
 CP
 NM disorders
 Impaired esophageal motility and laryngeal
sensations
 Prematurity
 GERD
 Tracheostomy?
 Laryngeal clefts
 TEF
 VC palsy

24.  Presents as
 Apnea and bradycardia
 Chowking episodes
 ALTE
 Colicky pains , irritability and arching of back
(Sandifer synd)
 Recurrent pneumonia
 Recurrent hoarseness,croup like
symptoms,laryngitis
 Rhinosinusitis
 Otitis media

25. Investigations for reflux
 Trial of antireflux (diagnostic intervention)
 Barium swallow (good for structural problems)
 Radionucleotide scintigraphy(tc99 labelled milk)
 PH monitoring (gold std)
 Endoscopic findings
 Hypopharyngeal cobble stoning
 Oedema arytenoids
 Posterior commisure oedema
 Lingual tonsil hypertrophy
 Blunting carina
 Increased bronchial secretions
 Signs of oesophagitis

26. Investigations for aspiration
 FEES with a coloured liquid (allows wide range of
testing like nasal regurg , level of aspiration, witness
live swallowing at bed side)
 FEEST addition of sensory testing – for laryngeal
sensation
 Modified barium swallow videofluoroscopy
 Laryngoscopy and bronchoscopy to rule out clefts and
fistulas plus lavage for lipid laden macrophages
 Tc99 swallow than finding dye in lungs

27. Management
 Mild – no treatment
 Moderate – feed thickeners, positioning (left lateral
head up), antireflux
 Prolong NG feeds makes infant forget how to swallow
so not a good long term option
 Tracheostomy worsens aspiration!!
 Treat specific cause or Close, divert ,excise!!

28. THANK YOU