Aspiration, swallowing dysfunction and chronic lung injury — formative SAQs

SAQ 1 (10 marks)

A 4-year-old boy with severe cerebral palsy is referred with his third pneumonia this year, each affecting the right lower zone. His carer reports long, messy mealtimes and a rattly chest, but says he "never coughs" on his feeds. He is below the second centile for weight. [1] [3]

1. Explain why the absence of coughing on feeds does not exclude aspiration. (3) [1]
2. Outline how you would confirm and characterise the problem. (4) [2]
3. State the main components of your management plan. (3) [5]

Model answer — SAQ 1

(1) Silent aspiration (3). In a child with severe cerebral palsy, laryngeal sensation is often blunted, so material can enter the airway without triggering a protective cough. This silent aspiration means a cough-free feed is falsely reassuring, and recurrent pneumonia in the same dependent region — here the right lower zone — is itself a presentation of chronic aspiration. I would therefore treat the recurrent chest disease and weight faltering as evidence of aspiration until proven otherwise, rather than relying on the carer's report of a normal-looking swallow. [1]

(2) Confirm and characterise (4). I would start with a clinical feeding assessment by a speech pathologist, observing an actual feed for coughing, wet voice, effort and fatigue, while recognising that this bedside evaluation can miss silent aspiration. I would add an instrumental study — a videofluoroscopic swallow study or fibreoptic endoscopic evaluation of swallowing — to detect aspiration, define which textures are unsafe, and identify the dominant route. I would image the lung with a chest radiograph, and consider chest computed tomography to assess for bronchiectasis given recurrent disease, and assess for contributing reflux. [2] [3]

(3) Management plan (3). Management is a multidisciplinary bundle. I would modify feeding with thickened fluids, texture change, upright positioning and pacing, and secure nutrition and airway safety with nasogastric then gastrostomy feeding if oral feeding cannot be made safe. I would control saliva, treat reflux, and protect the lung with airway clearance, prompt antibiotics for wet cough and exacerbations, and surveillance for bronchiectasis, all coordinated across respiratory, ENT, gastroenterology, speech pathology, dietetics and the family. [5] [1]

SAQ 2 (10 marks)

A 6-year-old girl with a neurodevelopmental disability drools continuously, has a persistently rattly chest, and has had two admissions with pneumonia. Her swallow of solids is safe, but she pools saliva and cannot clear it. [1] [4]

1. Which aspiration route is most likely responsible, and why? (3) [1]
2. Describe your stepwise approach to controlling this problem. (4) [4]
3. State two adverse effects of anticholinergic therapy you would monitor for. (3) [4]

Model answer — SAQ 2

(1) Route (3). The most likely route is chronic salivary aspiration. She has continuous drooling with pooled secretions she cannot clear, a rattly chest at rest and recurrent pneumonia, but a safe swallow of solids, which points away from antegrade aspiration of feeds and toward the slow, continuous aspiration of saliva. Chronic salivary aspiration tracks closely with the drooling of neurodisability. [1]

(2) Stepwise approach (4). I would begin with behavioural and positioning measures and secretion management. Next I would use an anticholinergic — glycopyrronium or a hyoscine patch — titrated to effect, noting that the DRI trial found hyoscine patches caused more adverse effects and discontinuation than glycopyrronium liquid. If medication is insufficient or poorly tolerated, I would move to botulinum toxin injection into the salivary glands, and reserve salivary duct ligation or relocation for refractory drooling. Throughout, I would continue airway clearance and prompt treatment of chest infection. [4] [1]

(3) Anticholinergic adverse effects (3). I would monitor for anticholinergic side effects, which commonly include constipation, urinary retention, dry mouth that can become excessive, flushing, blurred vision and behavioural change or irritability. These effects are a leading reason for discontinuation and must be balanced against the benefit in drooling, with the dose titrated and reviewed regularly. [4] [1]