Chest
Recent Advances in Chest MedicineAspiration-Related Pulmonary Syndromes
Section snippets
Epidemiology
Aspiration-related pulmonary syndromes are encountered in subjects of any age, from infancy to the aged. However, specific pulmonary syndromes are more likely to be encountered in certain age groups or in clinical contexts in which there are risk factors for aspiration. For example, foreign body aspiration is encountered most commonly in young children and the elderly, particularly those with impaired mental status or swallowing mechanism.14, 15 Aspiration pneumonitis typically occurs in the
Risk Factors for Aspiration
Major risk factors for aspiration include depressed consciousness, compromised airway defenses, dysphagia, gastroesophageal reflux disease (GERD), and recurrent vomiting (Table 2).13, 16 States of depressed consciousness include general anesthesia, alcohol intoxication, and drug overdose. Under these conditions, swallowing mechanisms and airway defenses are impaired. Airway defenses are also impaired in subjects with vocal cord immobility, oropharyngeal deformities caused by surgery or
Pathophysiology
When aspiration occurs in healthy subjects, the amount of aspirated material is usually minimal and cleared without clinical sequelae. When aspiration results in adverse clinical consequences, the character of the evolving illness is determined by the nature and volume of the aspirated material, the chronicity, and the host responses.
In patients with GERD, laryngeal injury with mucosal damage results from direct exposure to refluxed gastroduodenal contents that include acid, pepsin, and bile
Diagnostic Evaluation
Evaluation of a patient suspected of having an aspiration-related pulmonary syndrome is tailored to the individual context and the specific syndrome (based on clinical and radiologic features) being addressed. Several modalities are available to evaluate subjects with dysphagia. Videofluoroscopic swallow study (performed by a speech therapist or radiologist) is generally considered to be the procedure of choice and should assess oral, pharyngeal, and esophageal phases.9, 12, 17 Other methods of
Vocal Cord Dysfunction
Several laryngeal manifestations have been associated with GERD; these include chronic laryngitis, laryngospasm, vocal fold granuloma, and vocal cord dysfunction.26, 27 The most relevant of these entities to pulmonologists is vocal cord dysfunction, which is commonly misdiagnosed as asthma. Vocal cord dysfunction is characterized by episodes of airflow obstruction due to true vocal cord adduction during inspiration, occasionally during expiration, or both.27 Vocal cord dysfunction is thought to
Aspiration Pneumonitis
Two aspiration-related pulmonary syndromes that are most familiar to physicians are aspiration pneumonitis and aspiration pneumonia. Aspiration pneumonitis refers to acute lung injury occurring after inhaling a large volume of regurgitated gastric contents.16 This syndrome typically occurs in patients who have altered consciousness, such as that resulting from sedation, general anesthesia, drug overdose, seizure, massive stroke, or traumatic brain injury.13, 52 Although the initial lung injury
Conclusions
Aspiration can be clinically occult and elicits a broad spectrum of pulmonary syndromes. Integration of the clinical context (including risk factors for aspiration) and awareness of clinicoradiologic findings associated with these disorders will facilitate recognition of these diverse syndromes, which often go undiagnosed.
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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