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Dysphagia

, Volume 20, Issue 3, pp 218–225 | Cite as

Silent Aspiration: What Do We Know?

  • Deborah Ramsey
  • David Smithard
  • Lalit Kalra
Article

Abstract

Although clinically evident aspiration is common in subjects with dysphagia, a significant proportion may aspirate silently, i.e., without any outward signs of swallowing difficulty. This article reviews the literature on the prevalence, etiology, and prognostic significance of silent aspiration. An electronic database search was performed using silent aspiration, aspiration, dysphagia, and stroke as search terms, together with hand-searching of articles. Silent aspiration has been described in many conditions and subgroups of patients (including normal individuals), using a number of detection methods, making comparisons a challenge. The best data are for acute stroke, in which 2%–25% of patients may aspirate silently. Mechanisms associated with silent aspiration may include central or local weakness/incoordination of the pharyngeal musculature, reduced laryngopharyngeal sensation, impaired ability to produce a reflexive cough, and low substance P or dopamine levels. In terms of prognosis, silent aspiration has been associated with increased morbidity and mortality in many but not all studies. However, some degree of silent aspiration at night may be normal in healthy individuals. The phenomenon of silent aspiration is poorly understood and further research is needed to improve methods of detection and thereby better define its prevalence and prognostic significance.

Keywords

Dysphagia Aspiration Deglutition disorders Stroke 

Notes

Acknowledgment

The authors gratefully acknowledge support from Action Medical Research and The Stroke Association.

References

  1. 1.
    Horner J, Massey EW: Silent aspiration following stroke. Neurology 38:317–319, 1988PubMedGoogle Scholar
  2. 2.
    Amberson JB: Aspiration bronchopneumonia. Int Clin 3:126–138, 1937Google Scholar
  3. 3.
    Culver GA, Makel HP, Beecher HK: Frequency of aspiration of gastric contents by the lungs during anesthesia and surgery. Ann Surg 133: 289–292, 1951PubMedGoogle Scholar
  4. 4.
    Gardner AMN: Aspiration of food and vomit. QJM 27:227–245, 1958PubMedGoogle Scholar
  5. 5.
    Linden P, Siebens AA: Dysphagia: predicting laryngeal penetration. Arch-Phys Med Rehabil 64:281–284, 1983PubMedGoogle Scholar
  6. 6.
    O’Donoghue S, Bagnall A: Videofluoroscopic evaluation in the assessment of swallowing disorders in paediatric and adult populations. Folia Phoniatr Logop 51:158–171, 1999PubMedGoogle Scholar
  7. 7.
    Ramsey DJC, Smithard DG, Kalra L: Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke 34(5):1252–1257, 2003CrossRefPubMedGoogle Scholar
  8. 8.
    Splaingard ML, Hutchins B, Sulton LD, Chaudhuri G: Aspiration in rehabilitation patients: videofluoroscopy vs bedside clinical assessment. Arch Phys Med Rehabil 69:637–640, 1988PubMedGoogle Scholar
  9. 9.
    Garon BR, Engle M, Ormiston C: Silent aspiration: results of 1,000 videofluoroscopic swallow evaluations. J Neurol Rehabil 10:121–126, 1996 Google Scholar
  10. 10.
    Smith CH, Logemann JA, Colangelo LA, Rademaker AW, Pauloski BR: Incidence and patient characteristics associated with silent aspiration in the acute care setting. Dysphagia 14:1–7, 1999PubMedGoogle Scholar
  11. 11.
    Horner J, Massey EW, Riski JE, Lathrop DL, Chase KN: Aspiration following stroke: clinical correlates and outcome. Neurology 38:1359–1362, 1988PubMedGoogle Scholar
  12. 12.
    Holas MA, DePippo KL, Reding MJ: Aspiration and relative risk of medical complications following .stroke. Arch Neural 51:1051–1053, 1994PubMedGoogle Scholar
  13. 13.
    Collins MJ, Bakheit AMO: Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Stroke 28(9):1773–1775, 1997PubMedGoogle Scholar
  14. 14.
    Arvedson J, Rogers B, Buck G, Smart P, Msall M: Silent aspiration prominent in children with dysphagia. Int J Pediatr Otorhinolaryngol 28:173–181, 1994CrossRefPubMedGoogle Scholar
  15. 15.
    Elpern EH, Scott MG, Petro L, Ries MH: Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest 105:563–566, 1994PubMedGoogle Scholar
  16. 16.
    Hiss SG, Postma GN: Fiberoptic endoscopic evaluation of swallowing. Laryngoscope 113(8):1386–1393, 2003PubMedGoogle Scholar
  17. 17.
    Leder SB, Sasaki CT, Burrell MI: Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia 13:19–21, 1998PubMedGoogle Scholar
  18. 18.
    Leder SB: Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheotomy. Chest 122:1721–1726, 2002CrossRefPubMedGoogle Scholar
  19. 19.
    Huxley EJ, Viroslav J, Gray WR, Pierce AK: Pharyngeal aspiration in normal adults and patients with depressed consciousness. Am J Med 64:564–568, 1978CrossRefPubMedGoogle Scholar
  20. 20.
    Gleeson K, Eggli DF, Maxwell SL: Quantitative aspiration during sleep in normal subjects. Chest 111:1266–1272, 1997PubMedGoogle Scholar
  21. 21.
    Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H: High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med 150:251–253, 1994PubMedGoogle Scholar
  22. 22.
    Nakagawa T, Sekizawa K, Aral H, Kikuchi R, Manabe K, Sasaki H: High incidence of pneumonia in elderly patients with basal ganglia infarction. Arch Intern Med 157:321–324, 1997CrossRefPubMedGoogle Scholar
  23. 23.
    Ozcan M, Ortapamuk H, Naldoken S, Olcay I, Ozcan KM, Tuncel U: Pulmonary aspiration of nasal secretions in patients with chronic sinusitis and asthma. Arch Otolaryngol Head Neck Surg 129:1006–1009, 2003CrossRefPubMedGoogle Scholar
  24. 24.
    Balan KK, Vinjamuri S, Maltby P, Bennett J, Woods S, Playfer JR, Critchley M: Gastroesophageal reflux in patients fed by percutaneous endoscopic gastrostomy (PEG): detection by a simple scintigraphic method. Am J Gastroenterol 93: 946–949, 1998CrossRefPubMedGoogle Scholar
  25. 25.
    Silver KH, Van Nostrand D: The use of scintigraphy in the management of patients with pulmonary aspiration. Dysphagia 9:107–115, 1994CrossRefPubMedGoogle Scholar
  26. 26.
    Lim SHE, Lieu PK, Phua SY, Seshadri R, Venketasubramanian N, Lee SH, Choo PWJ: Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients. Dysphagia 16(1):1–6, 2001CrossRefPubMedGoogle Scholar
  27. 27.
    Smith HA, Lee SH, O’Neill PA, Connolly MJ: The combination of bedside swallowing assessment and oxygen saturation monitoring of swallowing in acute stroke: a safe and humane screening tool. Age Ageing 29:495–499, 2000CrossRefPubMedGoogle Scholar
  28. 28.
    Smithard DG, O’Neill PA, Park C, England R, Renwick DS, Wyatt R, Morris J, Martin DF: Can bedside assessment reliably exclude aspiration following acute stroke? Age Ageing 27:99–106, 1998PubMedGoogle Scholar
  29. 29.
    Daniels SK, Brailey K, Priestly DH, Herrington LR, Weisberg LA, Foundas AL: Aspiration in patients with acute stroke. Arch Phys Med Rehabil 79:14–19, 1998CrossRefPubMedGoogle Scholar
  30. 30.
    Kidd D, Lawson J, Nesbitt R, MacMahon J: Aspiration in acute stroke: a clinical study with videofluoroscopy. QJM 86:825–829, 1993PubMedGoogle Scholar
  31. 31.
    Mann G, Hankey GJ, Cameron D: Swallowing disorders following acute stroke: prevalence and diagnostic accuracy. Cerebrovasc Dis 10:380–386, 2000CrossRefPubMedGoogle Scholar
  32. 32.
    Stanners AJ, Chapman AN, Bamford JM: Clinical predictors of aspiration soon after stroke. Age Ageing 2(Suppl 2): A47, 1993Google Scholar
  33. 33.
    Ishizuka C: [Videofluorographic study of swallowing in patients with severe motor and intellectual disabilities—II. Impairment of oral phase.] No to Hattatsu 32(5):390–394, 2000 JapanesePubMedGoogle Scholar
  34. 34.
    Mathisen B, Worrall L, Masel J, Wall C, Shepherd RW: Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study. J Pediatr Child Health 35(2):163–169, 1999Google Scholar
  35. 35.
    Sheikh S, Alien E, Shell R, Hruschak J, Iram D, Castile R, McCoy K: Chronic aspiration without gastroesophageal reflux as a cause of chronic respiratory symptoms in neurologically normal infants. Chest 120(4):1190–1195, 2001CrossRefPubMedGoogle Scholar
  36. 36.
    Morgan A, Ward E, Murdoch B, Bilbie K: Acute characteristics of pediatric dysphagia subsequent to traumatic brain injury: videofluoroscopic assessment. J Head Trauma Rehabil 17(3):220–241, 2002PubMedGoogle Scholar
  37. 37.
    Leder SB: Fiberoptic endoscopic evaluation of swallowing in patients with acute traumatic brain injury. J Head Trauma Rehabil 14(5):448–453, 1999PubMedCrossRefGoogle Scholar
  38. 38.
    Tolep K, Getch CL, Criner GJ: Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest 109:167–172, 1996PubMedGoogle Scholar
  39. 39.
    Leder SB, Ross DA: Investigation of the causal relationship between tracheotomy and aspiration in the acute care setting. Laryngoscope 110:641–644, 2000PubMedGoogle Scholar
  40. 40.
    Harrington OB, Duckworth JK, Starnes CL, White P, Fleming L, Kritchevsky SB, Pickering R: Silent aspiration after coronary artery bypass grafting. Ann Thor Surg 65(6):1599–1603, 1998Google Scholar
  41. 41.
    Hughes PJ, Scott PMJ, Kew J, Cheung DMC, Leung SF, Ahuja AT, Van Hasselt CA: Dysphagia in treated nasopharyngeal cancer. Head Neck 22(4):393–397, 2000CrossRefPubMedGoogle Scholar
  42. 42.
    Lefton-Greif MA, Crawford TO, Winkelstein JA, Loughlin GM, Koerner CB, Zahurak M, Lederman HM: Oropharyngeal dysphagia and aspiration in patients with ataxia–telangiectasia. J Pediatr 136(2):225–231, 2000PubMedGoogle Scholar
  43. 43.
    Kluin KJ, Bromberg MB, Feldman EL, Simmons Z: Dysphagia in elderly men with myasthenia gravis. J Neural Set 138(1-2):49–52, 1996Google Scholar
  44. 44.
    Fuh J-L, Lee R-C, Wang S-J, Lin C-H, Wang P-N, Chiang J-H, Liu H-C: Swallowing difficulty in Parkinson’s disease. Clinic Neurol Neurosurg 99(2):106–112, 1997Google Scholar
  45. 45.
    Frazier JB, Friedman B: Swallow function in children with Down syndrome: a retrospective study. Dev Med Child Neurol 38:695–703, 1996PubMedGoogle Scholar
  46. 46.
    Perie S, Laccourreye O, Bou–Malhab F, Brasnu D: Aspiration in unilateral recurrent laryngeal nerve paralysis after surgery. Am J Otolaryngol 19(1):18–23, 1998PubMedGoogle Scholar
  47. 47.
    Tonshoff G, Stock U, Bohuslavizki KH, Brenner W, Costard–Jaekle A, Cremer J, Clausen M: Scintigraphic diagnosis of silent aspiration following double-sided lung transplantation. Nuklearmedizin 35(4):140–142, 1996PubMedGoogle Scholar
  48. 48.
    Garcia PE, Arzuaga EM, Perez SP, Arizaga MA: [Silent pulmonary aspiration of barium after esophagogastroduodenography and subtotal gastrectomy.] Rev Esp Anestesiol Reanim 45(7):298–300, 1998 SpanishGoogle Scholar
  49. 49.
    Lim–Dunham JE, Narra J, Benya EC, Donaldson JS: Aspiration after administration of oral contrast material in children undergoing abdominal CT for trauma. AJR Am J Roentgenol 169(4):1015–1018, 1997PubMedGoogle Scholar
  50. 50.
    Alessi DM, Hanson DG, Berci G: Bedside videolaryngoscopic assessment of intubation trauma. Ann Otol Rhinol Laryngol 98:586–590, 1989PubMedGoogle Scholar
  51. 51.
    Pannunzio TG: Aspiration of oral feedings in patients with tracheostomies. AACN Clin Issues 7(4):560–569, 1996PubMedGoogle Scholar
  52. 52.
    Aviv JE, Sacco RL, Thomson J, Tandon R, Diamond B, Martin JH, Close LG: Silent laryngopharyngeal sensory deficits after stroke. Ann Otol Rhinol Laryngol 106:87–93, 1997PubMedGoogle Scholar
  53. 53.
    Aviv JE, Martin JH, Jones ME, Wee TA, Diamond B, Keen MS, Blitzer A: Age-related changes in pharyngeal and supraglottie sensation. Ann Otol Rhinol Laryngol 103:749–752,1994PubMedGoogle Scholar
  54. 54.
    Harraf F, Man WD, Rafferty GF, Polkey MI, Moxham J, Kalra L: Impairment of respiratory muscle function in acute stroke patients. Cerebrovasc Dis 16(suppl 4): O227, 2003Google Scholar
  55. 55.
    Horner J, Massey EW, Brazer SR: Aspiration in bilateral stroke patients. Neurology 40:1686–1688, 1990PubMedGoogle Scholar
  56. 56.
    Addington WR, Stephens RE, Gilliland K, Rodriguez M: Assessing the laryngeal cough reflex and the risk of developing pneumonia after stroke. Arch Phys Med Rehabil 80:150–154, 1999PubMedGoogle Scholar
  57. 57.
    Horner J, Brazer SR, Massey EW: Aspiration in bilateral stroke patients: a validation study. Neurology 43(2):430–433, 1993PubMedGoogle Scholar
  58. 58.
    Daniels SK, Me Adam CP, Brailey K, Foundas AL: Clinical assessment of swallowing and prediction of dysphagia severity. Am J Speech Long Pathol 6(4):17–24, 1997Google Scholar
  59. 59.
    Nakazawa H, Sekizawa K, Ujiie Y, Sasaki H, Takishima T: Risk of aspiration pneumonia in the elderly. Chest 103(5):1636–1637, 1993PubMedGoogle Scholar
  60. 60.
    Niimi A, Matsumoto H, Ueda T, Takemura M, Suzuki K, Tanaka E, Chin K, Mishima M, Amitani R: Impaired cough reflex in patients with recurrent pneumonia. Thorax 58:152–153, 2003CrossRefPubMedGoogle Scholar
  61. 61.
    Stephens RE, Addington WR, Widdicombe JG: Effect of acute unilateral middle cerebral artery infarcts on voluntary cough and the laryngeal cough reflex. Am J Phys Med Rehabil 82:379–383, 2003PubMedGoogle Scholar
  62. 62.
    Nakagawa T, Ohrui T, Sekizawa K, Sasaki H: Sputum substance P in aspiration pneumonia. Lancet 345:1447, 1995Google Scholar
  63. 63.
    Arai T, Yasuda Y, Takaya T, Toshima S, Kashiki Y, Yoshimi N, Fujiwara H: ACE inhibitors and symptomless dysphagia: Lancet 352:115–116, 1998PubMedGoogle Scholar
  64. 64.
    Aral T, Yoshimi N, Fujiwara H, Sekizawa K: Serum substance P concentrations and silent aspiration in elderly patients with stroke. Neurology 61(11):1625–1626, 2003PubMedGoogle Scholar
  65. 65.
    Arai T, Yasuda Y, Takaya T, Toshima S, Kashiki Y, Yoshimii N, Fujiwara H: Angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, and symptomless dysphagia. Chest 117(6):1819, 2000CrossRefGoogle Scholar
  66. 66.
    Kobayashi H, Nakagawa T, Sekizawa K, Arai H, Sasaki H: Levodopa and swallowing reflex. Lancet 348:1320–1321, 1996CrossRefPubMedGoogle Scholar
  67. 67.
    Arai T, Sekizawa K, Yoshimi N, Toshima S, Fujiwara H: Cabergoline and silent aspiration in elderly patients with stroke. J Am Geriatr Soc 51:1815–1816, 2003CrossRefPubMedGoogle Scholar
  68. 68.
    Bartlett JG, Gorbach SL: The triple threat of aspiration pneumonia. Chest 68:560–566, 1975PubMedGoogle Scholar
  69. 69.
    Cameron JL, Reynolds J, Zuidema GD: Aspiration in patients with tracheostomies. Surg Gynecol Obstet 136:68–70, 1973PubMedGoogle Scholar
  70. 70.
    Taenaka N, Fukumitsu K, Takezawa J, Shimada Y, Yoshiya I: [Pneumonia during long term mechanical ventilatior]. Masui 34(2):189–193, 2000 JapanesePubMedGoogle Scholar
  71. 71.
    Pikus L, Levine MS, Yang Y-X, Rubesin SE, Katzka DA, Laufer I, Gefter WB: Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia. AJR Am J Roentgenol 180:1613–1616, 2003PubMedGoogle Scholar
  72. 72.
    Meguro K, Yamagauchi S, Doi C, Nakamura T, Sekizawa K, Sasaki H: Prevention of respiratory infections in elderly bed-bound nursing home patients. Tohoku J Exp Med 167(2):135–42, 1992PubMedCrossRefGoogle Scholar
  73. 73.
    Anonymous: Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke patients. Evid Rep Technol Assess (Summ) 8:1–6, 1999Google Scholar
  74. 74.
    Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D, Loesche WJ: Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 13:69–81, 1998PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2005

Authors and Affiliations

  1. 1.Guy’s, King’s and St. Thomas’ School of MedicineKing’s CollegeLondon
  2. 2.Health Care of Older People DepartmentWilliam Harvey HospitalAshfordUnited Kingdom

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