Aspiration, swallowing dysfunction and chronic lung injury — branching viva

Opening

Examiner: This 3-year-old with cerebral palsy has recurrent right-lower-lobe pneumonia, long messy meals, a wet voice after feeds and constant drooling, and is losing weight. How do you approach her? [1]

Candidate: I would frame this as likely chronic aspiration in a high-risk child, and my first task is to work out whether she is aspirating, by which route, and how injured her lung is. The recurrent pneumonia anchored to one dependent region, the wet voice and the drooling all point to aspiration, probably by more than one route. My plan is a multidisciplinary feeding-and-airway assessment, and I would not simply treat each pneumonia in isolation. [1] [6]

Branch 1 — confirming and characterising

Examiner: Her carer says she does not cough on feeds. Does that reassure you? [1]

Candidate: No. In cerebral palsy laryngeal sensation is often blunted, so aspiration can be silent with no cough at all. The absence of coughing does not exclude aspiration, and her chronic chest disease is itself the clue. I would arrange a clinical feeding assessment and, because the bedside evaluation can miss silent aspiration, add an instrumental study. [1] [3]

Examiner (probe): Which instrumental study, and what does it add? [2]

Candidate: A videofluoroscopic swallow study or fibreoptic endoscopic evaluation of swallowing. The videofluoroscopic study watches her swallow different textures under fluoroscopy and shows aspiration and its timing, while endoscopy views the pharynx and larynx directly. Both reveal silent aspiration the bedside assessment misses and tell me which textures are unsafe, so I can modify feeding rather than guess. [2] [3]

Branch 2 — the management bundle

Examiner: The study shows aspiration of thin fluids but a safe swallow of purees. What now? [1]

Candidate: I would modify feeding: thicken fluids, keep her on safe textures, position her upright and pace her feeds, with speech-pathology strategies. Because she is losing weight, I would involve dietetics and consider nasogastric then gastrostomy feeding to secure nutrition and airway safety. In parallel I would treat her drooling and assess for reflux, and protect the lung with airway clearance and prompt antibiotics for wet cough. [1] [6]

Examiner (probe): How would you manage the drooling? [4]

Candidate: Stepwise: behavioural and positioning measures first, then an anticholinergic — glycopyrronium or a hyoscine patch — titrated to effect. The DRI trial found hyoscine patches caused more adverse effects and discontinuation than glycopyrronium, so I often prefer glycopyrronium and monitor for anticholinergic effects. If that fails, I would move to botulinum toxin into the salivary glands, then salivary surgery for refractory drooling. [4] [1]

Branch 3 — reflux and surgery

Examiner: The family asks whether she needs a fundoplication. What do you say? [5]

Candidate: I would treat reflux first with feed changes and acid suppression, and reserve fundoplication for selected neurologically impaired children in whom reflux is clearly contributing and conservative measures fail. The Cochrane review of gastrostomy with or without fundoplication in neurologically impaired children shows genuine uncertainty about who benefits, so I would make the decision jointly with gastroenterology, surgery and the family rather than routinely. [5] [1]

Examiner (probe): Why does stopping the aspiration matter so much for her lungs? [6]

Candidate: Because continuing aspiration drives recurrent infection and airway inflammation that, over time, produce bronchiectasis and chronic suppurative lung disease. If I only treat each pneumonia and never address the route, the lung damage becomes structural and irreversible. Stopping the aspiration is what changes her long-term respiratory prognosis. [6] [1]

Close

Examiner: Summarise your safe approach in one line. [1]

Candidate: Suspect aspiration in the at-risk child despite silent presentations, confirm and characterise the route with a feeding assessment and instrumental study, run the multidisciplinary bundle of feeding modification, saliva control and reflux management, and protect the lung before it scars into bronchiectasis. [1] [6]