What is the treatment for aspiration of saliva into the respiratory system?

Management of Saliva Aspiration into the Respiratory System

The most effective treatment for aspiration of saliva into the respiratory system involves positioning the patient in a semi-recumbent position (30-45° head elevation), implementing compensatory swallowing maneuvers such as the chin-tuck posture, and ensuring proper oral hygiene to reduce bacterial load. 1, 2

Initial Management Approach

• Maintain the patient in a semi-recumbent position (30-45° head elevation) at all times to prevent further aspiration, especially during feeding 1
• Implement the chin-tuck posture (chin down) as it has proven useful in the majority of cases by offering valuable protection for the airways by opening the valleculae and preventing penetration into the larynx 2
• Ensure proper oral hygiene to reduce bacterial load in the oropharynx, as this can significantly decrease the risk of developing aspiration pneumonia 2, 3
• Consider throat clearing every three to four swallowing acts to prevent possible post-swallowing inhalation in cases of penetration without aspiration into the laryngeal inlet 2

Diagnostic Evaluation

• Refer patients with suspected saliva aspiration to a speech-language pathologist (SLP) for a comprehensive oral-pharyngeal swallow evaluation 2
• Consider videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) to directly visualize the anatomy and physiology of swallowing and identify appropriate treatment strategies 2
• Be aware that silent aspiration (aspiration without clinical signs) occurs in 20-30% of patients who aspirate, making instrumental evaluation crucial 4
• Recognize risk factors for silent aspiration, including cranial nerve paresis (IX and X), history of tracheostomy, and previous radiotherapy 4

Compensatory Strategies

• Adapt bolus characteristics by modifying food texture (soft, semisolid, or semiliquid states) to compensate for poor oral preparation and ease oral and pharyngeal transport 2
• For patients with delayed swallowing, use thicker liquids or semisolid foods with high water content (such as jellified water) as better alternatives to thinner liquids 2
• Consider postural maneuvers based on the specific mechanism of swallowing disorder:
  • Head rotation for hypertonicity, incomplete release, or premature upper esophageal sphincter closure 2
  • Hyperextended head posture in the absence of lingual pump (only if safe transit is ensured) 2

Multidisciplinary Approach

• Manage patients with dysphagia through organized multidisciplinary teams including a physician, nurse, SLP, dietitian, and physical and occupational therapists 2
• Implement a proactive team approach, as this has been shown to significantly decrease the rate of aspiration pneumonia from 6.4% to 0% in stroke patients 2
• Consider nutritional supplementation for patients who cannot cover their nutritional requirements with an enriched diet 2

Advanced Interventions

• For tracheostomized patients with chronic saliva aspiration, consider constant positive airway pressure (CPAP) via tracheostomy, which has been shown to decrease saliva aspiration and reduce respiratory complications 5
• In cases of intractable aspiration not responding to conservative measures, surgical intervention may be considered, though this should be a last resort 2

Special Considerations and Pitfalls

• Avoid feeding patients with a reduced level of consciousness as they are at high risk for aspiration 2
• Be aware that feeding tubes (nasogastric or gastrostomy) do not reduce the risk of aspiration pneumonia and may actually increase risk by reducing lower esophageal sphincter pressure 2, 3
• Recognize that adherence to recommendations for thickened liquids is generally low, which may compromise treatment effectiveness 2
• Monitor for signs of dehydration when using thickened liquids, as this is a common complication that can decrease quality of life 2
• Be vigilant about aspiration risk in elderly patients with cerebrovascular disease, as they often have dysphagia leading to an increased incidence of aspiration 6

Treatment of Complications

• If aspiration pneumonia develops, initiate prompt empiric antibiotic therapy based on local pathogen epidemiology and resistance patterns 1
• Distinguish between aspiration pneumonitis (chemical injury from gastric contents) and aspiration pneumonia (infection from aspirated bacteria), as the former does not require antibiotics 1, 7
• Limit antibiotic treatment to 7 days if there is good clinical response and no complications 1
• Monitor for failure to improve in clinical parameters such as oxygenation within the first 3 days of treatment, as this is associated with increased mortality 3