Chronic Recurrent Aspiration

Chronic recurrent aspiration refers to the repeated entry of food, liquid, or gastric contents into the airway (trachea and lungs), which can lead to respiratory complications such as recurrent pneumonia.

Normal Swallowing Mechanism: 

Swallowing is a complex process designed to move food and liquids safely from the mouth to the esophagus while preventing them from entering the airway. It consists of four phases:

• Oral preparatory phase (voluntary): Chewing and preparing the food bolus.
• Oral phase (voluntary): Moving the bolus to the back of the throat.
• Pharyngeal phase (involuntary): Brief pause in breathing, closure of the vocal cords, movement of the arytenoid cartilages, and flexion of the epiglottis to cover the airway.
• Esophageal phase (involuntary): Peristaltic movements and gravity transport the bolus to the stomach.

Chronic recurrent aspiration may present with subtle or persistent symptoms related to swallowing difficulties and airway involvement:

• Coughing or choking during feeding (especially when drinking liquids quickly).
• Frequent throat clearing or wet-sounding voice after swallowing.
• Difficulty coordinating swallowing and breathing during meals.
• Recurrent respiratory symptoms, such as chronic cough, wheezing, or shortness of breath.
• Recurrent lung infections (pneumonia), sometimes leading to hospitalization.
• Poor weight gain or feeding difficulties in children.

Chronic recurrent aspiration can result from a combination of gastrointestinal, anatomical, functional, and respiratory factors that disrupt normal swallowing coordination:

1. Gastroesophageal reflux (GER/GERD)

Physiologic reflux is common from birth, but severe GER can predispose to aspiration if airway protective reflexes are impaired. GERD may cause pharyngeal and laryngeal swelling or vocal cord nodules, interfering with swallowing and increasing aspiration risk. Chronic microaspiration related to GERD has been linked to lung injury, such as bronchiolitis obliterans in transplant recipients.

2. Anatomic and functional abnormalities

Cleft lip/palate, micrognathia, macroglossia, and laryngomalacia can impair proper bolus formation and swallowing.

3. Neuromuscular factors

Hypotonia (as seen in trisomy 21 or prematurity) can cause oropharyngeal discoordination, increasing aspiration risk.

4. Respiratory conditions

Significant nasal obstruction or tachypnea increases the work of breathing, leading infants to breathe and swallow simultaneously, particularly during acute respiratory illness or enteral feeding.