Chronic pulmonary aspirations

Chronic pulmonary aspirations may present with chronic cough or wheeze, thus mimicking asthmatics.
May present with intermittent fevers, consistent with recurrent pneumonia.

Chronic aspiration can occur in patients with any one or combination of the following predisposing conditions:
Dysphagia
    Discoordinated swallow
    Weakness of pharyngeal muscles
    Developmental delay
    Hypotonia
Anatomic abnormality with loss of airway protection
Vocal cord paresis/paralysis
Laryngeal cleft
TEF
Tracheostomy

Chronically aspirated saliva, food particles, and/or stomach acid
Causes 

      inflammation of small airways
      Airway remodeling
      bronchiectasis

Clinical Presentation of 
May present with chronic cough or wheeze, thus mimicking asthmatics.
May present with intermittent fevers, consistent with recurrent pneumonia.
Patients may also be asymptomatic.
Over time, patients can develop bronchiectasis and demonstrate a gradual decrease in pulmonary function.

Diagnosis and Evaluation

History and physical examination are the most important things for timely diagnosis.

Pulmonology referral may help determine the next best steps of evaluation:

Chest radiograph to identify inflammation and severity of disease

Modified barium swallow study with the speech pathologist to diagnose dysphagia

Esophagram to identify fistulae or strictures.

Flexible bronchoscopy with bronchoalveolar lavage Can visualize

        Airway erythema,

        Edema, and 

        Secretions

Bronchoalveolar lavage

       1. culture can pathogenic bacteria.

       2. Cytology can show lipid-laden macrophages.

Pulmonary function testing can be done for capable patients.

Therapy for chronic pulmonary aspirations

A topical anti-inflammatory such as inhaled corticosteroids (ICS) 

Trial of bronchodilators and other airway clearance therapies for respiratory symptoms, especially for patients with neuromuscular disease or scoliosis

Dubious treatments that may help curtail upper respiratory secretions comprise anticholinergic agents or salivary botulinum toxin injections.

Assess and treat comorbid GERD and dysphagia (e.g., speech/feeding therapy, feed thickening, percutaneous gastric feeds)

Anatomic anomalies of the upper airway may require surgical intervention

Antibiotics during acute bacterial cases of pneumonia, with the appreciation of anaerobic coverage.