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==Overview==
==Overview==
==Medical Therapy==
==Medical Therapy==
* Management of patients with swallowing dysfunction is highly individualized based on the cause of the dysfunction.
* Management of patients with swallowing dysfunction is individualized based on the cause of the dysfunction.
* Total parenteral nutrition or nasogastric tube feeding may be necessary to safely meet caloric requirements when the patient's swallowing dysfunction is secondary to a transient disease, such as a critical illness.
* Oral feeding is not always the most reasonable goal for patients with severe swallowing dysfunction. Patients with swallowing dysfunction is secondary to a transient disease need [[total parenteral nutrition]] or [[Nasogastric intubation|nasogastric tube]] to meet the caloric requirements.
'''Feeding decisions'''
* The benefits from the feeding plan is to provide efficient nutrition with preserved stable respiratory function.
* The goals of therapy are safe and efficient nutrition that preserves stable respiratory function and appropriate growth.  
* Oral feeding, while always desirable, is not always the most reasonable goal for patients with severe swallowing dysfunction because the risks of oral feeding may outweigh the psychosocial benefits to the patient and family [6,37,38].  
* On the other hand, for some patients with severe static encephalopathy or global delays, the family may choose to maintain oral feeds for pleasure despite the known risks of aspiration and pulmonary injury. These considerations require a clear and detailed discussion of goals and risks between the family and clinicians [39].
'''Techniques to enhance oral feeding'''
* In children with functional abnormalities, treatment is often led by speech and occupational therapists that specialize in swallowing. The specialist selects specific techniques to improve swallowing function based on individual patient characteristics:
* In infants, change in the flow of liquids may significantly improve swallowing. These changes can be made by changing to a slow flow nipple.
* Other feeding techniques include changes in the infant or child's position and posture during feeding, modification of bolus size, and alterations of consistency, shape, texture, and temperature of food. These techniques should be selected based on the result of the videofluoroscopic swallowing study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) (image 1) [3,40].
* In children with delayed maturation, swallowing function may improve over time. In the interim, the techniques outlined above are used to support adequate nutrition and avoid aspiration. The type of feeding is then gradually advanced as the infant or child matures. Advances in feeding may be directed by repeat swallowing evaluation, including clinical assessment of feeding, with or without VFSS or FEES.
'''Gastrostomy feeds'''
 
Percutaneous gastrostomy tube placement should be considered for patients who are unable to safely consume enough calories by mouth. Some patients will require gastrostomy tubes to meet part or all of their nutritional needs. Oral-motor and swallowing therapy should be continued in patients in whom swallowing function is expected to improve, and gastrostomy tubes may be removed when no longer necessary.
 
Parents may initially be reluctant to have a gastrostomy tube placed because of concerns about losing pleasure of eating, discomfort, or cosmesis. The importance of preventing pulmonary aspiration, long-term benefits of improved nutrition, and reversibility of this procedure should be emphasized. In addition, gastrostomy tubes can be useful for administering medication and fluid, when needed.
 
General considerations about gastrostomy placement and enteral feeding are discussed in a separate topic review.
 
'''Management of gastroesophageal reflux'''
 
'''Aspiration Pneumonia'''
 
Antibiotic therapy is unequivocally indicated in patients
 
with aspiration pneumonia. The choice of antibiotics
 
should depend on the setting in which the
 
aspiration occurs as well as the patient’s general health
 
(Table 2). However, antibiotic agents with activity
 
against gram-negative organisms, such as third-generation
 
cephalosporins, fluoroquinolones, and piperacillin,
 
are usually required. Penicillin and clindamycin,
 
which are often called the standard antibiotic agents
 
for aspiration pneumonia, are inadequate for most patients
 
with aspiration pneumonia.78 Antibiotic agents
 
with specific anaerobic activity are not routinely warranted
 
and may be indicated only in patients with severe
 
periodontal disease, putrid sputum, or evidence
 
of necrotizing pneumonia or lung abscess on radiographs
 
of the chest.78,79
 
'''Aspiration Pneumonitis'''
 
The upper airway should be suctioned after a witnessed
 
aspiration of gastric contents. Endotracheal intubation
 
should be considered for patients who are
 
unable to protect their airway (for example, those with
 
a decreased level of consciousness). Although it is
 
common practice, the prophylactic use of antibiotics
 
in patients in whom aspiration is suspected or witnessed
 
is not recommended. Similarly, the use of antibiotics
 
shortly after aspiration in patients in whom
 
a fever, leukocytosis, or a pulmonary infiltrate develops
 
is discouraged, since the antibiotic may select
 
for more resistant organisms in patients with an uncomplicated
 
chemical pneumonitis. However, empirical
 
antibiotic therapy is appropriate for patients who
 
aspirate gastric contents and who have small-bowel
 
obstruction or other conditions associated with colonization
 
of the gastric contents. Antibiotic therapy
 
should be considered for patients with aspiration
 
pneumonitis that fails to resolve within 48 hours after
 
aspiration. Empirical therapy with broad-spectrum
 
agents is recommended (Table 2); antibiotics with
 
anaerobic activity are not routinely required. Sampling
 
of the lower respiratory tract (with a protected
 
specimen brush or by bronchoalveolar lavage) and
 
quantitative culture in intubated patients may allow
 
targeted antibiotic therapy and, in patients with negative
 
cultures, the discontinuation of antibiotics.
 
81,82
 
Corticosteroids have been used for decades in the
 
management of aspiration pneumonitis.
 
83
 
However,
 
there are limited data on the role of these agents. In
 
a prospective, placebo-controlled study, Sukumaran
 
and colleagues found that radiographically evident
 
lung injury improved more quickly in the patients given
 
corticosteroids than in those given placebo; however,
 
the patients given corticosteroids had a longer
 
stay in the intensive care unit, and there were no significant
 
differences between the two groups in the
 
incidence of complications or the outcome.
 
84,85
 
In a
 
case–control study, Wolfe and colleagues found that
 
pneumonia due to gram-negative bacteria was more
 
frequent after aspiration among patients treated with
 
corticosteroids than among those who were not.
 
86
 
Similarly, studies in animals have failed to demonstrate
 
a beneficial effect of corticosteroids on pulmonary
 
function, lung injury, alveolar–capillary permeability,
 
or outcome after acid aspiration.
 
87,88 Furthermore,
 
given the failure of two multicenter, randomized,
 
controlled trials to demonstrate a benefit of high-dose
 
corticosteroids in patients with the acute respiratory
 
distress syndrome, the administration of corticosteroids
 
cannot be recommended.89,90


* The preferred treatment for infants and children with swallowing dysfunction is speech and occupational therapies to improve swallowing function.
* Other feeding techniques to prevent aspiration in infants include changes in the infant or child's position and posture during feeding, modification of bolus size, and alterations of consistency, shape, texture, and temperature of food. In children with delayed maturation, swallowing function may improve over time.
* Some patients will require [[percutaneous]] [[Gastrostomy|gastrostomy tubes]] to meet part or all of their nutritional needs for patients who are unable to safely use oral feeding.
* Parents may initially be reluctant to have a gastrostomy tube placed because of concerns about losing pleasure of eating, discomfort, or cosmesis. The importance of preventing pulmonary aspiration, long-term benefits of improved nutrition, and reversibility of this procedure should be emphasized. In addition, [[Gastrostomy|gastrostomy tubes]] can be useful for administering medication and fluid, when needed.
* Antibiotic agents with activity against [[Gram-negative bacteria|gram-negative organisms]], such as [[Cephalosporin|third-generation cephalosporins]], [[fluoroquinolones]], and [[piperacillin]], are usually required.
* '''Penicillin and [[clindamycin]]''', which are often called the standard antibiotic agents for aspiration pneumonia, are inadequate for most patients with aspiration pneumonia.
* [[Endotracheal intubation]] should be considered for patients who are unable to protect their airway.
* The prophylactic use of antibiotics in patients in whom aspiration is suspected or witnessed is not recommended.
* [[Empirical]] antibiotic therapy is appropriate for patients who aspirate gastric contents and who have [[Small bowel obstruction|small-bowel obstruction]] or other conditions associated with colonization of the gastric contents.
* Antibiotic therapy should be considered for patients with aspiration pneumonitis that fails to resolve within 48 hours after aspiration.
* [[Corticosteroids]] have been used for decades in the management of aspiration pneumonitis but there is no strong evidence about its benefit.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 20:22, 25 March 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Medical Therapy

  • Management of patients with swallowing dysfunction is individualized based on the cause of the dysfunction.
  • Oral feeding is not always the most reasonable goal for patients with severe swallowing dysfunction. Patients with swallowing dysfunction is secondary to a transient disease need total parenteral nutrition or nasogastric tube to meet the caloric requirements.
  • The benefits from the feeding plan is to provide efficient nutrition with preserved stable respiratory function.
  • The preferred treatment for infants and children with swallowing dysfunction is speech and occupational therapies to improve swallowing function.
  • Other feeding techniques to prevent aspiration in infants include changes in the infant or child's position and posture during feeding, modification of bolus size, and alterations of consistency, shape, texture, and temperature of food. In children with delayed maturation, swallowing function may improve over time.
  • Some patients will require percutaneous gastrostomy tubes to meet part or all of their nutritional needs for patients who are unable to safely use oral feeding.
  • Parents may initially be reluctant to have a gastrostomy tube placed because of concerns about losing pleasure of eating, discomfort, or cosmesis. The importance of preventing pulmonary aspiration, long-term benefits of improved nutrition, and reversibility of this procedure should be emphasized. In addition, gastrostomy tubes can be useful for administering medication and fluid, when needed.
  • Antibiotic agents with activity against gram-negative organisms, such as third-generation cephalosporins, fluoroquinolones, and piperacillin, are usually required.
  • Penicillin and clindamycin, which are often called the standard antibiotic agents for aspiration pneumonia, are inadequate for most patients with aspiration pneumonia.
  • Endotracheal intubation should be considered for patients who are unable to protect their airway.
  • The prophylactic use of antibiotics in patients in whom aspiration is suspected or witnessed is not recommended.
  • Empirical antibiotic therapy is appropriate for patients who aspirate gastric contents and who have small-bowel obstruction or other conditions associated with colonization of the gastric contents.
  • Antibiotic therapy should be considered for patients with aspiration pneumonitis that fails to resolve within 48 hours after aspiration.
  • Corticosteroids have been used for decades in the management of aspiration pneumonitis but there is no strong evidence about its benefit.

References

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