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Swallowing Difficulties and Aspiration Pneumonia

Aspiration is caused by stomach contents and food being misdirected from the esophagus and stomach into the throat and lungs. Studies have shown that dysphagia carries a sevenfold increased risk of aspiration pneumonia and is an independent predictor of death (Singh & Hamdy, 2006).

What are the risk factors for dysphagia and subsequent aspiration pneumonia?

  • Stroke
  • Parkinson’s disease
  • Dementia
  • Conditions that suppress the cough reflex (such as sedation), which may be caused by infection or inappropriate medication use

What are the symptoms of aspiration?

  • Sudden appearance of respiratory symptoms (such as severe coughing and blue skin) associated with eating, drinking, or regurgitation of gastric contents
  • Voice change (such as hoarseness or a gurgling noise) after swallowing
  • There may be no symptoms. Small-volume aspirations are common and are often not discovered until the condition progresses to aspiration pneumonia.

What are the symptoms of aspiration pneumonia?

Elders with aspiration pneumonia have fewer symptoms than those who are younger, making it under diagnosed. Delirium (acute confusion associated with hyperactivity or sedation) may be the only sign. Symptoms may include an elevated respiratory rate, fever, chills, pleuritic chest pain, and lung congestion.

What should the nursing home be doing to prevent aspiration in those with swallowing difficulties?

  • Observation for aspiration pneumonia should be ongoing in high-risk persons.
  • Have the speech therapist evaluate and treat the resident for swallowing difficulties.
  • Provide a 30-minute rest period prior to feeding time; a rested resident will likely have less difficulty swallowing.
  • Sit the resident upright in a chair; if confined to bed, elevate the head of the bed to a 90-degree angle.
  • Adjust rate of feeding and size of bites to the resident’s tolerance.
  • Avoid rushed or forced feeding.
  • Alternate solids and liquids when feeding.
  • Vary placement of food in the resident’s mouth according to the type of deficit. For example, food may be placed on the right side of the mouth if left facial weakness is present.
  • Determine the food thickness that is best tolerated by the resident. For example, some residents swallow thickened liquids more easily than thin liquids.
  • Ensure proper dental care. Missing teeth and poorly fitted dentures increase the risk for aspiration by interfering with chewing and swallowing.
  • Administer proper oral care if aspiration does occur. Infected teeth and poor oral hygiene predispose to pneumonia following the aspiration of contaminated oral secretions.
  • Proper oral care should be maintained in those who are being tube fed. It has been suggested that tube feedings are associated with increased bacteria in the mouth more so than that observed in those who received oral feedings.
  • Cleaning the resident’s teeth with a toothbrush after each meal has been shown to lower the risk of aspiration pneumonia.
  • Minimize the use of sedatives and hypnotics since these agents may impair the cough reflex and swallowing.

Persons who aspirate oral feedings are also likely to aspirate tube feedings. The following are ways aspiration might be prevented in those with tubes.

  • Keep the bed’s backrest elevated to at least 30º during continuous feedings.
  • When the tube-fed person is able to communicate, ask if any nausea, feeling of fullness, abdominal pain, or cramping are present. These signs are indicative of slowed gastric emptying that may, in turn, increase the probability for regurgitation and aspiration of gastric contents. High feeding volumes that remain in the stomach should be measured in elders who cannot communicate to assess risk.

What else should I know?

If your loved one has swallowing difficulties in which repeated aspirations occur, you may need to make some difficult choices if your loved one cannot make his or her own. You may need to make a decision about a tube feeding, the use of antibiotics, and repeated hospitalizations to treat aspiration. If a tube feeding is not desired, some opt to continue to allow their loved one to eat even if the risk of choking and aspiration is high because the resident desires to eat. The facility may ask you to sign a waiver of responsibility if this situation arises. It is important that you act in the best interest of your loved one and what he or she would have wanted if able to make his or her own decisions.

Resources

NursingCenter.com

Quagliarello, V., Ginter, S., Lan, L., Van Ness, P., Allore, H., Tinetti, M. (2005). Modifiable risk factors for nursing home-acquired pneumonia. Clinical Infectious Diseases, 40(1), 1-6.

Siddique, R., Neslusan, C.A., Crown, W.H., Crystal-Peters, J., Sloan, S., & Farup, C. (2000). A national inpatient cost estimate of percutaneous endoscopic gastrostomy associated aspiration pneumonia. American Journal of Managed Care, 6(4), 490-496.

Singh, S., & Hamdy, S. (2006). Dysphagia in stroke patients. Postgraduate Medical Journal. 82(968), 383-391.

Terpenning M. (2005). Geriatric oral health and pneumonia risk. Clinical Infectious Diseases, 40(12), 1807-1810.

 

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