Managing Chronic Aspiration in Adults
Understanding this life-threatening condition and the multidisciplinary approach needed to provide effective, patient-centered care.
Ozlem E. Tulunay-Ugur, MD, and Priya Krishna, MD
The Initial Evaluation: A Comprehensive Approach
The management of chronic aspiration, which comprises medical and surgical treatment options, aims to prevent recurrent pneumonias and weight loss, while maintaining the patient on an oral diet for as long as possible. The initial evaluation requires ample time, as it is important to understand the diet and nutritional intake of the patient, amount of weight loss, history of aspiration, case(s) of pneumonia, potential head and neck cancer, and neurological disorders. Assessing frailty, cognition, and comorbidities during an office visit guides the treatment planning. Cognition is a crucial aspect of the assessment, especially because patients with dementia will continue to increase as the population continues to age.
Cognitive Impairment and Goals of Care
Recognizing the degree of cognitive impairment is significant for multiple reasons. First, it will help determine if the patient can complete swallowing therapy, which is the mainstay of management. It should also generate a comprehensive discussion with the patient and family about goals of care, especially in patients suffering from Alzheimer’s Disease (AD). For example, it has been well documented that feeding tube placement does not prevent aspiration or prolong life in patients with AD. Despite this, it is common for patients to receive a feeding tube during hospitalization and usually when they can no longer voice their own opinions.1,2 Therefore, it is important to have these discussions with the patient while they can still participate to understand their wishes and lessen the burden on others involved.
During the initial patient encounter, it is also important to assess the patient’s cough thoroughly, as lack of cough is an important prognostic indicator.3 Management of chronic aspiration should include restoration of cough whenever possible, such as with vocal fold augmentation.
Dietary Modifications and Rehabilitation: Cornerstones of Care
It should be noted that the mainstay of treatment is diet modification and rehabilitation rather than surgical treatment. Patients are known to struggle both emotionally and functionally with modified diets when prescribed. It is always recommended that a patient keep trying to swallow and that every effort to rehabilitate swallowing is made.
Maneuvers used during therapy depend on the specific area of deficit in the swallowing mechanism. These may be maneuvers and exercises that improve laryngeal closure and elevation, such as coughing, sustained phonations, and/or Lee-Silverman voice treatment. Other maneuvers include chin tuck and head turns and tilts for oropharyngeal and pharyngeal phase weakness. Expiratory muscle strength training improves maximum expiratory pressure and, in turn, improved swallowing.
Dietary modifications are important but also must be evaluated repeatedly and frequently so that a patient is not left on a restricted diet longer than necessary. Dietary modifications may include thickeners and control of bolus sizes. Research shows, however, that patients do not usually like thickened liquids, and maintaining outpatient compliance with this modification is challenging.4 Cognitive function and patient motivation are important determinants for successful conservative management.
Surgical Management: When Conservative Measures Fail
Surgery can be successful if conservative measures fail as well as in a limited number of structural disorders. Surgical management aims to improve glottic closure and cough and lessen aspiration. Re-establishment of cough significantly aids in improving pulmonary toilet (pulmonary hygiene) and can reduce the incidence of aspiration pneumonia. One of the most common surgeries performed to improve cough is vocal fold augmentation. Injection laryngoplasty is performed by most otolaryngologists in various settings (i.e., clinic versus the operating room) and is advantageous in frail patients as it can be done without general anesthesia. Vocal fold augmentation is one of the initial steps in managing most patients with chronic aspiration due to various etiology.
Certain structural pathologies like cricopharyngeal dysfunction and Zenker’s diverticulum can lead to chronic aspiration and recurrent pneumonias along with weight loss. Patients in this group will likely see the most improvement, and surgery can alleviate their issues completely. There are many successful techniques to choose from, depending on the preference of the surgeon, along with the characteristics of the diverticulum and patient comorbidities.
Chronic Aspiration in Head and Neck Cancer Survivors
Head and neck cancer patients present with challenging needs and, along with aging patients, show a growing presence in our clinics. With vast advances in head and neck cancer treatment, survival rates have increased significantly, leading to more patients living with the life-altering side effects of treatments. Chemoradiation can result in significant fibrosis resulting in dysphagia, chronic aspiration, and airway compromise, often occurring many years after treatment has been completed. These patients present with a non-functional laryngopharynx and generally have already undergone swallowing therapy. Although cricopharyngeal dilation can be effective in some patients, it is not uncommon for patients to become feeding tube- and tracheotomy-dependent during treatment. Functional laryngectomy offers significant improvement in quality of life for these patients; it enables them to restart an oral diet, which results in being able to join family dinners again.
In addition, a laryngectomy stoma is generally easier to care for than a tracheotomy. Despite these advantages, this is a very difficult discussion to have with patients as it is not easy to appreciate the benefits that may ensue. Preparing a patient for a functional laryngectomy requires time and patience, repeated discussions with patients and families, and exhausting all other rehabilitative and surgical options. In head and neck cancer patients, the use of free flap reconstruction is common after a total laryngectomy. If a functional laryngectomy is being done for intractable aspiration in a stroke patient, narrow field laryngectomy is employed, with preservation of strap muscles.
Surgical options for chronic aspiration either aim to improve glottic closure and protection of the lower airways or seek to separate the airway and the swallowing system from each other. There are many surgeries intended to achieve glottic closure, but most of them have not gained widespread acceptance.5-7 For airway-deglutition separation, Lindeman described the first laryngeal diversion in 1975.8 There have been several modifications of the procedure, but laryngotracheal separation remains an effective and safe option in treating intractable aspiration. It is faster to perform than a total laryngectomy and is preferred in frail patients who require shortened anesthesia times.
In conclusion, treating a patient with chronic aspiration requires a well organized care team. The team should include not only otolaryngologists, but also geriatricians, neurologists, gastroenterologists, speech language pathologists, occupational therapists, nurses, and social workers. However, the most important part of the team is the patient and the caregivers. Management necessitates empathy and education, as well as understanding patient values and goals. It is a long road that requires patience and, at times, small steps toward healing.
References
- Zhu Y, Olchanski N, Cohen JT, et al. Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life. Alzheimers Dis. 2023;96:1183-93
- Goldberg LS, Altman KW. The role of gastrostomy tube placement in advanced dementia with dysphagia: a critical review. Clin Interv Aging. 2014;14;9:1733-9
- Darrock K, Wallace E, Hernandez EG, et al. The Influence of Cough Reflex Testing on Patient Management. J Speech Lang Hear Res. 2024;67:2987-96
- O’Keefe ST, Leslie P, Lazpeny-Paterson T, et al. Informed or misinformed consent and use of modified texture diets in dysphagia. BMC Medical Ethics 2023;24:7
- Ueha R, Magdayao R, Koyama M, et al. Aspiration prevention surgeries: a review Respir Res 2023;24:43
- Habal MB, Murray JE. Surgical treatment of life-endangering chronic aspiration pneumonia. Use of an epiglottic flap to the arytenoids. Plast Reconstr Surg. 1972;49:305–11
- Miller FR, Eliachar I. Managing the aspirating patient. Am J Otolaryngol. 1994;15:1–17
- Lindeman RC. Diverting the paralyzed larynx: a reversible procedure for intractable aspiration. Laryngoscope. 1975;85:157-80