Chronic Recurrent Aspiration

1. Clinical evaluation

• History and observation: Careful review of symptom timing and feeding-related triggers can help distinguish between swallowing-related aspiration (above) and reflux-related aspiration (below).
• Feeding observation: Direct observation of feeding is essential to assess for nasopharyngeal reflux, difficulty with sucking or swallowing, and other swallowing abnormalities.
• Oral cavity examination: Inspection for anatomic abnormalities and assessment of the gag reflex.

2. Imaging and diagnostic studies

 2-1. Radiographic studies

• Chest radiographs or CT scans may show segmental or lobar infiltrates in dependent lung regions, bronchial wall thickening, or bronchiectasis. These findings are not specific but may support the diagnosis.

 2-2. Contrast studies

• Modified barium swallow or videofluoroscopic swallowing study are considered the gold standard for diagnosing aspiration.
• These tests visualize the swallowing process under fluoroscopy, identifying penetration or aspiration and evaluating the anatomy and function of the esophagus.

There is no single specific treatment for aspiration. Management focuses on preventing or minimizing complications and is tailored according to aspiration severity and the underlying cause.

1. Mild Aspiration

Examples: Oropharyngeal incoordination due to prematurity

 1-1. Feeding modifications

• Adjusting food consistency (e.g., thickened liquids, pureed foods).
• Adapting feeding techniques (semi-upright positioning, using special nipples, limiting food amounts).

These approaches are used for immature swallowing mechanisms (e.g., in premature or term infants) or for reversible causes such as GER or laryngomalacia, and after surgical correction of structural issues (e.g., cleft lip/palate).

2. Moderate Aspiration

Examples: Difficulty swallowing due to chronic lung disease, neuromuscular disorders, tracheostomy

 2-1. Nasogastric tube feeding

• Used temporarily during transient dysphagia.
• Minimally invasive but may cause GER or aspiration if misplaced.

 2-2. Gastrostomy

• Recommended for patients unlikely to regain oral feeding ability in the near term.
• Postpyloric feeding (duodenal or jejunal):
• Reduces, but does not fully eliminate, GER.
• Delivered via nasoduodenal/nasojejunal tubes or gastrojejunal (G-J) tubes (easily placed through an existing gastrostomy).
• Often used in patients with neuromuscular disorders and severe motility problems.

3. Severe Aspiration

 3-1. Surgical repair

• Required for structural abnormalities such as tracheoesophageal fistula or laryngeal cleft, once the patient is medically stable.

 3-2. Nissen fundoplication

• Reserved for cases of refractory GER-related aspiration not responding to medical or conservative therapy.
• Decreases, but does not eliminate, GER.
• May cause severe retching in patients without muscle weakness if performed too tightly.