Aspiration in Neurological Injury

Introduction to Aspiration

• At least 50% of stroke patients and approximately 60% of traumatic brain injury patients experience oropharyngeal dysphagia (OD), leading to aspiration, with impaired swallowing physiology, disruption of protective reflexes, and impaired consciousness contributing to a high risk of aspiration pneumonia and increased mortality 1

Risk Factors for Aspiration

• High NIHSS score in stroke patients, decreased level of consciousness, multiple strokes or large hemispheric lesions, advanced age, and immobility increase the risk of aspiration in neurologically injured patients 2, 3, 4, 5
• Abnormal gag reflex, impaired voluntary cough, dysphonia, and incomplete oral-labial closure also increase the risk of aspiration in neurologically injured patients 2

Complications of Aspiration

• Aspiration in neurological injury leads to a three-fold increased risk of early aspiration pneumonia in stroke patients, with dysphagic stroke patients having significantly higher mortality rates compared to non-dysphagic stroke patients 1
• Aspiration also leads to prolonged artificial respiration and nutrition requirements, malnutrition, dehydration, and reduced quality of life in neurologically injured patients 1, 2

Clinical Assessment and Management

• The American Academy of Neurology recommends regular screening for dysphagia in all patients with Hoehn & Yahr stage above II, and in any patient with warning signs such as weight loss, low BMI, drooling, dementia, coughing during meals or drinking, and history of pneumonia 1, 6
• Screening methods include PD-specific questionnaires, water swallow test with measurement of average volume per swallow, and volume-viscosity swallow test 1, 6
• For patients who screen positive for dysphagia, instrumental assessment with FEES (preferred) or VFSS is recommended, as well as optimization of dopaminergic medication for fluctuating dysphagia 1, 6
• Swallowing therapy with Expiratory Muscle Strength Training (EMST), Shaker Head Lift Exercise, Oral Motor Exercise Program, and Lee Silverman Voice Treatment may be beneficial, along with dietary modifications such as thickened liquids and chin-down posture for specific swallowing problems 6

Recommendations and Guidelines

• Regular reassessment of swallowing function is necessary as the disease progresses to prevent complications and maintain quality of life, with the European Society for Swallowing Disorders and the American Academy of Neurology providing guidelines for management 6, 1
• Not monitoring for aspiration pneumonia, relying on patient self-reporting of dysphagia, waiting until advanced stages to screen, using standard water swallowing tests without volume measurement, and failing to perform assessments during medication ON-phase are not recommended 1, 6
• The following table summarizes the risk factors for dysphagia in Parkinson's disease:

1