Primary prevention
Patients with comorbidities or neurologic disorders, or in critical care
Measures to identify gastroesophageal reflux disease, oropharyngeal dysphagia, gastrointestinal motility, and metabolic disorders (including diabetes mellitus) and to reduce oropharyngeal load of pathogenic organisms, particularly in patients with neurologic disease, patients with comorbidities, and those who are intubated, can potentially help to reduce aspiration and associated complications such as aspiration pneumonia.[54][55]
Patients with stroke or other disorders who have impaired swallowing should be managed using a multidisciplinary approach.[56] Patients thought to have any risk factors for aspiration should be carefully evaluated before attempting feeding. This includes neurologic evaluation with assessment of cortical function, bulbar muscle gag, and cough reflex. A speech pathologist should evaluate swallowing in unclear cases.[48] Modified diets (nectar-thick instead of thin liquids) may be easier to swallow. These patients may benefit from swallow rehabilitation, including training like upright posture, chin tuck, and slow swallowing.
Keeping the head of the patient's bed higher than 30° to 45° reduces the risk of aspiration, especially in critically ill or mechanically ventilated patients.[57][58] Other potentially useful measures to prevent aspiration in critically ill patients include oral decontamination with antiseptic solutions; a chin-down position while feeding for patients with dysphagia; percutaneous endoscopic gastrostomy tube or percutaneous endoscopic jejunostomy tube for feeding chronically debilitated patients; feeding by hand rather than inserting feeding tubes for geriatric patients; feeding a soft mechanical diet and thickened liquids; using capsaicin to sensitize the gag reflex; suctioning subglottic secretions in patients with endotracheal tubes; suppressing gastric acid with drugs; minimizing use of sedative drugs; monitoring gastric residual volumes as a marker of aspiration risks; and placing a postpyloric feeding tube.[37][59]
Anesthesia
Anesthesia-related aspiration of gastric contents can be prevented by identifying patients susceptible to vomiting, minimizing gastric contents before surgery, minimizing emetic stimuli, and avoiding complete loss of protective reflexes from oversedation.[37] Antiemetics may be considered for patients at increased risk of postoperative nausea and vomiting.[54]
Aspiration of gastric contents during anesthesia can be prevented by adhering to national anesthesiology societies' guidelines. Water and other clear liquids (e.g., tea, coffee, soda water, apple juice, pulp-free orange juice) are allowed up to 2 hours before anesthesia in otherwise healthy adults (including pregnant women not in labor) and children who are scheduled for elective surgery.[54][60] The fasting period after intake of solids should not be less than 6 hours. However, in the emergency procedural setting when the opportunity to use preventive strategies may not be available, there are no data to suggest that the risk of aspiration is increased due to lack of fasting.[61] Cricoid pressure (Sellick maneuver) is commonly employed to minimize the risk of aspiration during endotracheal intubation in patients at high risk of aspiration; however, its routine use is of uncertain benefit.[62][63]
A nasogastric tube is commonly inserted prophylactically in patients at high risk for aspiration during general anesthesia.[8]
Gastrointestinal stimulants or proton-pump inhibitors (or nonparticulate antacids) may be given to patients preoperatively only if they are at increased risk of aspiration.[54] Use of perioperative H2 antagonists may maintain gastric pH >2.5 in unfasted patients, providing a theoretical benefit in preventing lung injury from aspiration.[64][65][66] However, no data exist that demonstrate improvement in outcome with this approach. One meta-analysis comparing the effectiveness of H2 antagonists with proton-pump inhibitors (PPIs) concluded that a single oral dose of an H2 antagonist before surgery is more effective than PPI. However, when given as two oral doses preoperatively or using the intravenous route, both classes are equally effective.[67] Pregnant patients requiring anesthesia should receive a preoperative H2 antagonist to increase gastric pH and undergo early intubation with cricoid pressure.[38] Routine preoperative use of H2 antagonists, PPIs, antacids, antiemetics, or anticholinergics is not recommended for patients with no apparent increased risk for pulmonary aspiration.[54]
Pharmacologic management options to prevent aspiration are limited, and depend on the mechanism of aspiration risk. ACE inhibitors have been shown to increase the cough reflex in Chinese and Japanese patients at risk of aspiration after stroke.[68]
Barium studies
Postural techniques during barium studies can reduce or eliminate the risk of aspiration when small volumes of barium sulfate are used.[69] Radiologists should try to avoid barium entering the tracheobronchial tree by assessing the likelihood of aspiration in patients at risk before starting the exam.[4] Patients at high risk should swallow a contrast medium such as iopydol that is less likely to harm the lungs. Gastrografin can cause pulmonary edema and should be avoided if aspiration is suspected.[24]
Secondary prevention
Patients with ≥2 risk factors or with documented aspiration, persistent feeding intolerance, or both can be treated with a prokinetic drug and/or fed with tubes placed with the tip at or below the ligament of Treitz (suspensory ligament of the duodenum).[44][116][117] Relatively small, single-center trials have suggested reduction in pneumonia with both metoclopramide and postpyloric feeding.[116][117] These findings need to be confirmed in larger randomized controlled studies. Improved oral hygiene may also decrease the risk of aspiration pneumonia.[16][118]
Patients with stroke or other disorders who have impaired swallowing should be managed using a multidisciplinary approach.[56] Although swallowing function may return in most patients within 6 months of a stroke, tube feeding may be indicated in the acute phase. The Feed or Ordinary Diet (FOOD) study, a 3-part randomized controlled trial, found no significant benefit from nutritional supplements in patients with stroke.[119][120] Early nutrition within the first week decreased mortality. In this study, percutaneous endoscopic gastrostomy tubes, when compared with nasogastric tubes, were associated with higher mortality or adverse outcomes at 6 months. The data available on the optimal type of feeding tube are conflicting. Postpyloric placement of feeding tubes has been shown to decrease pneumonia risk in small, single-center studies, though no difference has been shown in other outcomes such as the duration of mechanical ventilation, vomiting, or mortality.[116][121][122][123][124]
Tracheostomy or laryngectomy may be options to be considered in highly select cases such as patients with neurodegenerative disorders (e.g., amyotrophic lateral sclerosis), or those with irreversible dysphagia and recurrent aspiration (e.g., previous radiation and surgery for throat cancer).
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