Silent microsuction

Specialty: Geriatrics.

• asymptomatic tracheobronchial aspiration
• chronic microaspiration in the elderly
• silent passage of digestive contents into the airway

Why it occurs

• Loss of the protective cough reflex and the swallowing reflex due to peripheral or central neurological aging
• Sequelae of repetitive strokes or presence of advanced neurodegenerative dementia (especially Alzheimer's or Parkinson's type)
• Gastroesophageal reflux disease (GERD) with upper esophageal sphincter dysfunction while lying down at night
• Autonomic neuropathy that causes severe gastroparesis and generalized slowing of the upper digestive tract
• Chronic use of sedative, muscle relaxant or anticholinergic drugs that depress alertness and reduce the tone of the esophageal sphincters

Initial workup

Videofluoroscopy of swallowing (considered the reference test to document aspiration into the airway without triggering cough); clinical evaluation of swallowing at the bedside using the volume-viscosity clinical examination method (MECV-V); PA and lateral chest x-ray looking for infiltrates in posterior or basal lung segments; 24-hour esophageal pH-metry or impedanciometry if predominantly nocturnal silent gastroesophageal reflux is suspected.

Standard management

• Omeprazole — 20 mg to 40 mg orally daily in the morning to reduce the acidity of the aspirate and mitigate pulmonary chemical pneumonitis [Mendelson syndrome]
• Metoclopramide — 5 mg to 10 mg orally or intravenously administered 15 to 30 minutes before main meals to accelerate gastric emptying, restricting its use to a maximum of 5 days due to the risk of extrapyramidalism and tardive dyskinesia in the elderly
• Domperidone — 10 mg orally up to three times a day with prior electrocardiogram to monitor that the QTc interval is not prolonged
• Systematic use of commercial food thickeners (xanthan gum-based) to modify the viscosity of liquids.