What is the cause of aspiration in this patient?

Causes of Aspiration in This Patient

Aspiration in patients with bronchiectasis or chronic respiratory symptoms is most commonly caused by recurrent gastroesophageal reflux disease (GERD) with or without dysphagia, affecting 1-11.3% of adults with bronchiectasis. 1

Primary Etiologies to Investigate

Gastroesophageal Reflux Disease (GERD)

• GERD is the leading cause of recurrent aspiration in adults, occurring through two mechanisms: direct aspiration of refluxed gastric contents into the airways and reflux-related laryngeal irritation. 1
• GERD can be completely asymptomatic in terms of gastrointestinal symptoms (silent reflux), yet still cause significant aspiration and bronchiectasis. 1
• Delayed gastric emptying is present in 26-33% of GERD patients and contributes to increased reflux episodes and aspiration risk. 2, 3
• The pathophysiology involves transient lower esophageal sphincter relaxations (TLESRs), decreased LES pressure, and reflux of acid, bile, pepsin, and pancreatic enzymes. 4, 3

Dysphagia-Related Causes

• Neurological disorders (stroke, Parkinson's disease, dementia, neuromuscular diseases) impair swallowing coordination and increase aspiration risk. 1
• Oesophageal dysmotility causes delayed esophageal clearance and is strongly associated with reflux aspiration, independent of gastric emptying. 1, 5
• Anatomical disorders including tracheoesophageal fistula (TEF), pharyngeal pouch, previous head/neck surgery, or late effects of radiotherapy. 1
• Vocal cord dysfunction or paralysis increases aspiration likelihood by impairing airway protection. 1

Esophageal Atresia-Tracheoesophageal Fistula (EA-TEF) Related

If the patient has a history of EA-TEF repair, multiple contributing factors exist: 1

• Oesophageal dysfunction from dysmotility, GERD, and delayed oesophageal clearance. 1
• Post-surgical effects including strictures, myenteric dysfunction, altered sensation, or recurrent laryngeal nerve injury. 1
• Recurrent fistula at the original repair site or new lesion in a different location. 1
• Congenital or acquired co-existing gastrointestinal and/or airway pathology. 1
• Delayed oral-motor development and persistent feeding difficulties. 1

Diagnostic Approach

Clinical History Assessment

• Obtain detailed gastrointestinal history focusing on heartburn, regurgitation, dysphagia, food impaction, and timing of symptoms relative to meals. 1
• Assess for neurological symptoms including history of stroke, progressive weakness, speech changes, or cognitive decline. 1
• Review surgical history for previous esophageal, gastric, or head/neck procedures. 1
• Evaluate medication history particularly for agents that delay gastric emptying (GLP-1 receptor agonists can cause delayed gastric emptying and retained gastric contents even 10-14 days after discontinuation). 1

Diagnostic Testing Selection

The British Thoracic Society recommends tailoring investigations to clinical features, as sensitivity and specificity for aspiration assessment in bronchiectasis patients have not been established: 1

• Videofluoroscopic swallow study for suspected oropharyngeal dysphagia or neurological causes. 1
• Flexible endoscopic evaluation of swallow (FEES) for direct visualization of swallowing mechanics and aspiration. 1
• Upper gastrointestinal endoscopy to assess for esophagitis, strictures, hiatal hernia, or anatomical abnormalities. 1
• Ambulatory esophageal pH monitoring and manometry to document acid reflux episodes and assess esophageal motility. 1
• Bronchoscopy with bronchoalveolar lavage when pathogenic bacteria in lower airways are found, strongly suggesting chronic aspiration. 1
• CT chest to evaluate for bronchiectasis, particularly in the presence of chronic wet cough, persistent atelectasis, or recurrent pneumonias. 1

Key Diagnostic Findings

• Laryngoscopy may reveal posterior laryngitis with red arytenoids and interarytenoid mucosa consistent with reflux laryngitis. 1
• Bronchoscopy may show subglottic stenosis, hemorrhagic tracheobronchitis, or erythema of subsegmental bronchi consistent with aspiration. 1
• Upper GI contrast study with "pull-back" technique can identify small tracheoesophageal fistulas by forcing contrast through under pressure. 1

Common Pitfalls to Avoid

• Do not assume GERD is causal simply because it is common—prevalence in the general population means it can be coincidentally present rather than causative. 1
• Do not overlook silent GERD—up to 75% of patients with GERD-related cough have no gastrointestinal symptoms. 1
• Do not attribute laryngeal inflammation solely to reflux—coughing itself from other causes can produce similar laryngoscopic findings. 1
• Do not miss recurrent TEF in patients with prior EA-TEF repair—combined bronchoscopy and endoscopy is the gold standard for diagnosis. 1
• Do not ignore severe ineffective esophageal motility—this is strongly associated with reflux aspiration independent of gastric emptying delays. 5