Chronic Recurrent Aspiration

Etiology

Repeated aspiration of even small quantities of gastric, nasal, or oral contents can lead to recurrent bronchitis or bronchiolitis, recurrent pneumonia, atelectasis, wheezing, cough, apnea, and/or laryngospasm. Pathologic outcomes include granulomatous inflammation, interstitial inflammation, fibrosis, lipoid pneumonia, and bronchiolitis obliterans. Most cases clinically manifest as airway inflammation and are rarely associated with significant morbidity. Table 426.1 lists underlying disorders that are frequently associated with recurrent aspiration. Oropharyngeal incoordination is reportedly the most common underlying problem associated with recurrent pneumonias in hospitalized children. In 2 reports, between 26% and 48% of such children were found to have dysphagia with aspiration as the underlying problem. Lipoid pneumonia may occur after the use of home/folk remedies involving oral or nasal administration of animal or vegetable oils to treat various childhood illnesses. Lipoid pneumonia has been reported as a complication of these practices in the Middle East, Asia, India, Brazil, and Mexico. The initial underlying disease, language barriers, and a belief that these are not medications may delay the diagnosis (see Chapter 11 ).

Gastroesophageal reflux disease ( GERD ; see Chapter 349 ) is also a common underlying finding that may predispose to recurrent respiratory disease, but it is less frequently associated with recurrent pneumonia than is dysphagia (see Chapter 349 ). GERD is associated with microaspiration and bronchiolitis obliterans in lung transplant recipients. Aspiration has also been observed in infants with respiratory symptoms but no other apparent abnormalities. Recurrent microaspiration has been reported in otherwise apparently normal newborns, especially premature infants. Aspiration is also a risk in patients suffering from acute respiratory illness from other causes, such as respiratory syncytial virus infection (see Chapter 287 ). Modified barium swallow and videofluoroscopy may reveal silent aspiration in these patients. This finding emphasizes the need for a high degree of clinical suspicion for ongoing aspiration in a child with an acute respiratory illness, being fed enterally, who deteriorates unexpectedly.