Aspiration Pneumonitis and Aspiration Pneumonia in Neurologically Impaired Children

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Volume 4 No.

3, September 2008 Review Ar ticle

Aspiration pneumonitis and aspiration pneumonia in


neurologically impaired children
Ping LAM

Department of Paediatrics, Caritas Medical Centre, Hong Kong

Introduction Aspiration is a relative common phenomenon even in


normal person. When radioactive substance was
Respiratory problems contribute significantly to the introduced into the naso-pharynx of healthy adults during
overall morbidity and mortality in neurologically impaired sleep, one study6 found that half of them will aspirate
children.1-3 Plioplys3 studied severely disabled children small amounts of the radioactive substance. There are
living in institution in United States and found that 77% various normal defense mechanisms against aspiration.
of deaths were result of pneumonia. Aspiration, either These include the closing of the larynx during
from secretions/food in the pharynx or from reflux of swallowing, the upper and lower oesophageal sphincter
gastric contents, is a very common phenomenon in this which protects against gastro-esophageal reflux, and
group of children.1,4 The true prevalence of aspiration cough reflex which expels the foreign material out of
pneumonia is difficult to determine because of the vague the respiratory tract when chemoreceptors of the
definitions and varying levels of clinical recognition. respiratory epithelium are stimulated. Aspiration will
Although aspiration syndrome is very common, there occur if these protective mechanisms are defective.
remain many pitfalls in its management, including failure Some of the conditions associated with increased risk
to distinguish aspiration pneumonitis from aspiration of aspiration include decreased level of consciousness,
pneumonia, failure to recognise the spectrum of neuromuscular disease with impaired swallowing,
pathogens, and the misconception that aspiration must structural abnormalities of the aerodigestive tract,
be witnessed. A physician survey in a university medical prolonged supine position, endotracheal intubation,
centre5 found out that there is divergent approach to nasogastric tube, and vomiting.7,8
the treatment of cases of aspiration with empirical
antibiotics frequently initiated to treat noninfectious In children with neurological impairment, several factors
stages of aspiration. This article will review on the coexist and contribute to the increased rate of aspiration.
pathophysiology, clinical features and management of Many of these children have oropharyngeal motor
aspiration pneumonitis and aspiration pneumonia, with problems and in-coordinated swallowing. Gastro-
special emphasis on aspects related to neurologically oesophageal reflux is also more common and severe
impaired children. in children with cerebral palsy. Refluxed material is more
likely to be aspirated because of disturbed esophageal
peristalsis and in-coordination between swallowing and
Pathophysiology breathing. Children with neurological impairment also
tend to have weak cough which offer poor protection to
Aspiration is defined as the inhalation of material into the lower airway when aspiration occurs.
the airway below the level of the true vocal cords. The
inhaled material can be antegrade from swallowed food/
nasopharyngeal secretions or retrograde from refluxed Aspiration pneumonitis
gastric content. Aspiration can lead to a group of
pulmonary conditions including pneumonitis, There is frequent confusion between the diagnosis of
pneumonia, airway obstruction, atelactasis, lung aspiration pneumonitis and aspiration pneumonia. 7
abscess, bronchiectasis, lipoid pneumonia, and acute Aspiration pneumonitis is defined as an acute
lung injury/acute respiratory distress syndrome (ARDS). inflammatory reaction to the aspirated material. It is
non-infectious and characterised by an infiltrate
on chest X-ray commonly in the dependent
Email: lamping@wingcheung.com.hk bronchopulmonary segment. Posterior segments of the

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Journal of Paediatric Respirology and Critical Care

upper lobes and apical segments of the lower lobes are occurs in many healthy adults.5 However, the protective
commonly involved when a patient aspirate in mechanisms of forceful coughing and ciliary movement,
recumbent position while basal segments of the lower the low burden of virulent bacteria and normal immune
lobes are commonly affected if a patient aspirate in mechanisms made aspiration pneumonia infrequent in
upright position. healthy persons. Aspiration pneumonia usually refers
specifically to patients who are at increased risk for
Historically aspiration pneumonitis was described as oropharyngeal aspiration.
Mendelson’s syndrome in obstetric patients who
aspirated while receiving general anesthesia during In patients with aspiration pneumonia, the episode of
obstetrical procedures. The severity of lung injury aspiration is generally not witnessed. The diagnosis is
depends on the nature of the aspirate: high vs. low considered when a patient at high risk of aspiration
volume, acidic vs. neutral pH, particulate vs. non- developed radiographic evidence of pneumonia in a
particulate, contaminated vs. non-contaminated, and characteristic bronchopulmonary segment. Its diagnosis
virulence of the organism. Usually a pH of 2.5 or less is confirmed when a protected brush specimen/bronchial
together with volume of gastric aspirate of 0.3 ml/kg is alveolar lavage specimen yield pathogenic organism in
required for the development of aspiration pneumonitis.7 significant concentration.
However, particulate aspiration can cause severe
pulmonary damage even if pH of the aspirate is above Anaerobes are believed to be the commonest organisms
2.5. Gastric contents are sterile under normal conditions in aspiration pneumonia in adults and children.10-12 Two
because of the acidic environment which prevents recent adult studies using protected brush specimen in
bacterial growth. Colonisation of gastric contents by intensive care setting found that aerobic organisms are
pathogenic organisms may occur if the pH in the more common.13,14 However, anaerobic conditions were
stomach is increased, e.g., in patients taking antacids not preserved during transport in both studies. Also in
or proton pump inhibitors. one study14 all patients were given Penicillin G before
sampling with a protected specimen brush was
If the aspiration is witnessed, patient should be put into performed. In community-acquired aspiration
lateral position and the upper airway should be suctioned pneumonia, aerobic organisms commonly isolated
immediately. In patients who are unable to protect their include Strep pneumoniae, Staph aureus, and gram
airways, e.g., patients with impaired consciousness, negative bacilli.15 If the patient comes from institution
endotracheal intubation should be considered. Since or long stay care facility, Pseudomonas aeruginosa is
aspiration pneumonitis is the result of a non-infectious also a common organism.16 A study in children11 using
inflammatory process, most authorities agree that percutaneous transtracheal specimens found that
prophylactic antibiotics are not indicated.7,9 Overuse of multiple organisms are involved in aspiration pneumonia
antibiotics may select for more resistant organisms in with mixed aerobes and anaerobes present in 90% of
patients with uncomplicated chemical pneumonitis. tracheal aspirates. The common anaerobic organisms
Antibiotics should be considered when there is likely to involved in these children include Bacteroides
be bacterial infection, e.g., when aspiration pneumonitis melaninogenicus, Peptococcus, Peptostreptococcus,
worsens or fails to resolve within 48 hours after Fusobacterium, Bacteroides fragiliis, Veillonella, and
aspiration. Prophylactic corticosteroids were commonly Bacteroides oralis while the common aerobic bacteria
used to treat pneumonitis in the past but studies found include Alpha-hemolytic strep, Pseudomonas
that they have no significant effect on patients’ outcome aeruginosa, Strep Pneumoniae, E. coli, Klebsiella and
and complication rates and is therefore not Staph aureus.
recommended.7,9
In one retrospective study17 on antimicrobials treatment
of aspiration or tracheotomy-associated pneumonia in
Aspiration pneumonia neurologically impaired children, three groups of
antibiotics were used, namely: iv ticarcillin-clavulanate
Aspiration pneumonia is an infectious process that followed by oral amoxicillin-clavulanate, iv followed by
develops after aspirating colonised oropharyngeal or oral clindamycin, and iv ceftriaxone followed by oral
gastric material. As we have seen, aspiration of small cefixime. Ceftazidime was added if previous tracheal
amounts of oropharyngeal secretions during sleep aspirate culture reviewed Pseudomonas. A satisfactory

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Volume 4 No. 3, September 2008 Review Ar ticle

clinical and microbiological response was observed in not recognised. In a study on videofluoroscopic
89% and 91% in the first two groups respectively assessment of dysphagia in children with severe spastic
compared with in only 50% in the third group. It was cerebral palsy, Mirrett et al 4 found that the overall
concluded that ticarcillin-clavulanate and clindamycin incidence of aspiration was 77% while incidence of silent
treated groups had significantly better outcome than the aspiration only is 68%.
ceftriaxone treated group in these neurologically
impaired children. The improved efficacy of clindamycin Assessment of the cough and gag reflexes is unreliable
as well as ticarcillin-clavulanic acid, as compared to in identifying patients at risk of aspiration. The clinically
ceftriaxone, may be due to their excellent antibacterial observable oral phase of swallowing also does not
activity against penicillin-resistant anaerobic bacteria as provide reliable clues as to whether or not the patient is
over 40% of the common pigmented Prevotella sp and swallowing safely.4 A videofluoroscopic swallowing study
Fusobacterium can resist beta-lactam antibiotics by performed by a speech therapist can provide a clear
producing beta-lactamase. 17,18 Common antibiotics picture of the entire swallowing process and its safety.
effective against beta-lactamase producing anaerobes During the study patient is given liquid or solid in different
include clindamycin, metronidazole, chloramphenicol, texture in different position. Videofluoroscopic images
combination of penicillin and a beta-lactamase inhibitor, are taken and analysed to assess the various stages of
and imipenem while antibiotics generally not effective swallowing, including oral preparation, pharyngeal
against beta-lactamase-producing anaerobes include triggering, and pharyngeal clearing/peristalsis. Presence
beta-lactam resistant penicillins, and second and third of aspiration and gastro-esophageal reflux can be seen
generation cephalosporins.17 from the images. If a patient is found to have swallowing
dysfunction, individualised early intervention can be
Antimicrobial therapy is directed at the major pathogens introduced with the help from the speech therapist. This
encountered in different patient groups. In community- could be choosing the appropriate texture of food for
acquired pneumonia, the usual oropharyngeal flora is the patient, reducing the bite size, positioning like
most likely involved and treatment with penicillin with or keeping the chin tucked and the head turned while
without beta-lactamase inhibitor is a good choice.18,19 If feeding etc. Alternative form of feeding like gastrostomy
aspiration pneumonia occurs in hospitalised or feeding is required in patients who continue to aspirate
institutionised children with neurological impairment or despite training and using of specific feeding strategies.
tracheotomy, a different spectrum of organisms will be
involved because of the modified oral flora and
prevalence of gram-negative rods in hospital patients. Gastrostomy feeding and aspiration
We should take into account of previous culture results
which may reveal colonisation by pathogens like Gastrostomy is frequently done for patients with oral-
Pseudomonas and Klebsiella. Because multiple motor dysfunction and poor oral intake with resultant
organisms may be involved in these groups of under-nutrition. Studies have demonstrated that
hospitalised patients, final antibiotic choice needs to rely gastrostomy tube feeding has resulted in increased
on culture results. Pending culture results, a penicillin weight gain and subcutaneous fat deposition, reduction
with beta-lactamase inhibitor plus coverage for gram in time spent feeding and improved quality of life for
negative organisms or Pseudomonas in previously carers and is superior to nasogastric tube feeding in
colonised patient is probably appropriate.18,19 delivering nutrition.20,21

However, there is much controversy on the effects of


Assessment and management for recurrent/ gastrostomy feeding on respiratory symptoms and
intractable aspiration gastro-esophageal reflux.21 Although patients on tube
feeding will not aspirate food while eating, they can still
Swallowing difficulties are common in neurologically aspirate colonised oral secretions or refluxed gastric
impaired children, especially in children with spastic contents. Two randomised studies22,23 have shown that
cerebral palsy. However, evaluation and management the incidence of aspiration pneumonia was similar when
of their feeding problem is typically delayed, partly nasogastric feeding was compared with gastrostomy
because many of the aspirations are silent aspirations feeding. In a prospective cohort study, Sullivan et al24
not accompanied by cough or choking and therefore found no evidence for an increase in respiratory

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Journal of Paediatric Respirology and Critical Care

morbidity following insertion of gastrostomy tube in morbidity and mortality in neurologically impaired
children with cerebral palsy and there was a reduction children. Early assessment for risk of aspiration, including
in chest infections in those who had a proven unsafe the use of videofluoroscopic swallow study, is useful in
swallow. A systemic review21 on gastrostomy feeding setting specific treatment goals for each patient.
and cerebral palsy found that there is little evidence to Aspiration should be suspected in a patient with
conclude whether gastro-oesophageal reflux was dysphagia and an infiltration in a dependent
increased or decreased with gastrostomy feeding. bronchopulmonary segment. Although there is some
overlap between aspiration pneumonitis and aspiration
pneumonia, they are two different clinical entities
Surgical manag ement for intractable requiring different treatment. Aspiration pneumonitis is
pulmonary aspiration a noninfectious inflammatory process and does not need
antibiotic treatment. On the other hand, aspiration
Intractable or chronic pulmonary aspiration is a life- pneumonia should be treated with antibiotics covering
threatening problem. Initial management for recurrent common aerobic and anaerobic organisms according to
aspiration includes swallowing training, positioning, food the prevalence of pathogens in different patient groups.
texture changes, alternative feeding route like
gastrostomy feeding and medications such as anti-
emetics, anti-reflux drugs and antibiotics. If all the initial References
management fails, surgical procedures can be done to
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Tracheotomy is useful in improving pulmonary toilet in
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of the tube in the trachea may in itself compromise J 1998;91:161-72.
laryngeal elevation during swallowing. For more severe 4. Mirrett PL, Riski JE, Glascott J, Johnson V. Videofluoroscopic
assessment of dysphagia in children with severe spastic
aspiration, more definitive and aggressive surgical
cerebral palsy. Dysphagia 1994;9:174-9.
intervention, including glottic closure, laryngeal closure, 5. Rebuck JA, Rasmussen JR, Olsen KM. Clinical aspiration-
total laryngectomy and laryngo-tracheal separation had related practice patterns in the intensive care unit: a physician
been tried with some success. survey. Crit Care Med 2001;29:2239-44.
6. Gleeson K, Eggli DF, Maxwell SL. Quantitative aspiration
Takamizawa et al 26 reported their experience of during sleep in normal subjects. Chest 1997;111:1266-72.
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and treatment of aspiration pneumonia in children. J Ped 1980;
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96:1000-4.
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Conclusions
14. Mier L, Dreyfuss D, Darchy B, Lanore JJ, Djedaïni K, Weber
P, et al. Is penicillin G an adequate initial treatment for
aspiration pneumonia? A prospective evaluation using a
Aspiration and its complications cause significant protected specimen brush and quantitative cultures. Intensive

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Volume 4 No. 3, September 2008 Review Ar ticle

Care Med 1993;19:279-84. 21. Sleigh G, Brocklehurst P. Gastrostomy feeding in cerebral


15. Leroy O, Vandenbussche C, Coffinier C, Bosquet C, Georges palsy: a systematic review. Arch Dis Child 2004;89:534-9.
H, et al. Community-acquired aspiration pneumonia in 22. Baeten C, Hoefnagels J. Feeding via nasogastric tube or
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1922-9. J Gastroenterol Suppl 1992;194:95-8.
16. Shariatzadeh MR, Huang JQ, Marrie TJ. Differences in the 23. Park RH, Allison MC, Lang J, Spence E, Morris AJ, Danesh
features of aspiration pneumonia according to site of BJ, et al. Randomized comparison of percutaneous
acquisition: community or continuing care facility. Geriatr Soc endoscopic gastrostomy and nasogastric tube feeding in
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17. Brook I. Treatment of aspiration or tracheostomy-associated 304:1406-9.
pneumonia in neurologically impaired children: effect of 24. Sullivan PB, Morrice JS, Vernon-Roberts A, Grant H, Eltumi
antimicrobials effective against anaerobic bacteria. Int J M, Thomas AG. Does gastrostomy tube feeding in children
Pediatr Otorhinolaryngol 1996;35:171-7. with cerebral palsy increase the risk of respiratory morbidity?
18. Brook I. Anaerobic pulmonary infections in children. Pediatr Arch Dis Child 2006;91:478-82.
Emerg Care 2004;20:636-40. 25. Hafidh MA, Young O, Russell JD. Intractable pulmonary
19. Dreyfuss D, Mier L. Aspiration pneumonia. N Engl J Med; aspiration in children: which operation? Int J Pediatr
344:1868-70. Otorhinolaryngol 2006;70:19-25.
20. Sullivan PB, Juszczak E, Bachlet AM, Lambert B, Vernon- 26. Takamizawa S, Tsugawa C, Nishijima E, Muraji T, Satoh S.
Roberts A, Grant HW, et al. Gastrostomy tube feeding in Laryngotracheal separation for intractable aspiration
children with cerebral palsy: a prospective, longitudinal study. pneumonia in neurologically impaired children: experience
Dev Med Child Neurol 2005;47:77-85. with 11 cases. J Pediatr Surg 2003;38:975-7.

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