Serious Illness Changes How The Body Works
In 2005, Dr. Ashford wrote about factors that contribute to aspiration pneumonia outside of dysphagia. Specifically, he wrote about how the body changes in response to a serious disease or medical condition, and how that raises the risk of developing pneumonia.
Healthy people do not develop aspiration pneumonia, so its important to understand how the body responds to stress and illness. Not only do the immune system and muscle function change, but even the microbiome of the mouth, throat, lungs, and digestive tract change.
Ology And Principal Findings
We conducted an observational study using data from a nationwide survey of geriatric medical and nursing center in Japan. The study subjects included 9930 patients who were divided into two groups: those who had experienced an episode of aspiration pneumonia in the previous 3 months and those who had not. Data on demographics, clinical status, activities of daily living , and major illnesses were compared between subjects with and without aspiration pneumonia. Two hundred and fifty-nine subjects were in the aspiration pneumonia group. In the univariate analysis, older age was not found to be a risk factor for aspiration pneumonia, but the following were: sputum suctioning , daily oxygen therapy , feeding support dependency , and urinary catheterization . In the multiple logistic regression analysis, the risk factors associated with aspiration pneumonia after propensity-adjustment were sputum suctioning , deterioration of swallowing function in the past 3 months , dehydration , and dementia .
Pneumonia After Cardiovascular Surgery: Incidence Risk Factors And Interventions
- 1Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- 2Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- 3China Medical University-The Queen’s University of Belfast Joint College, China Medical University, Shenyang, China
- 4Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- 5Department of Vascular and Endovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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General And Clinical Characteristics Of Subjects
A total of 9930 subjects from 1121 participating geriatric facilities throughout Japan were eligible for the present study. Two hundred and fifty-nine subjects had an episode of aspiration pneumonia in the 3 months prior to the observation period. The general characteristics, functional impairment status, clinical assistance requirements, and comorbidities of the subjects were compared between those with and without aspiration pneumonia .
Factors Associated With Hospital Readmission
The factors associated with 30-day hospital readmission for pneumonia-related and -unrelated reasons are listed in Tables 3 and and4,4, respectively. In the multivariable analysis, pneumonia-related readmission was associated with para/hemiplegia, malignancy, PSI class 4 and clinical instability 1 at hospital discharge . Comorbidities such as chronic lung disease and chronic kidney disease, treatment failure, and decompensation of comorbidities were associated with the pneumonia-unrelated 30-day readmission rate .
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Slps Role In Dysphagia Management Is Nuanced
There may be something appealing in having a clear role , but the true picture is much more complicated. We shouldnt assume that our interventions dont have possible negative consequences. We dont have x-ray vision , and dysphagia cant be treated in isolation . Its complicated and the final answers arent known, but we can keep reading to stay up-to-date. Please share this article with others, and please leave a comment with your recommended reading for me!
What Is Aspiration Pneumonia
Aspiration pneumonia can be a serious illness, especially for older adults or people with a compromised immune system. As Ed Bice, M.Ed., CCC-SLP and Angela Van Sickle, Ph.D., CCC-SLP recently wrote, aspiration pneumonia is actually an ambiguous diagnosis that covers at least 13 different conditions. Speech-language pathologists generally think of aspiration pneumonia as being the result of food, liquid, or saliva entering the lungs. However, aspiration pneumonia may also result from gastroesophageal reflux, vomiting, or a pulmonary infection.
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Why Is Aspiration Pneumonia So Complicated
I left graduate school with the understanding that my job was to prevent aspiration at all costs. Aspiration of food or liquid into the lungs would cause an infection known as aspiration pneumonia, which could be deadly to some people. It was a straightforward, easy-to-understand sequence of events. Aspiration led to aspiration pneumonia which could lead to death.
Imagine my fascination and dismay when faced early in my career with a resident of a skilled nursing facility who routinely aspirated large amounts of food and liquid but who never became ill. We knew this because he had participated in more than one instrumental swallow study, participated in speech therapy, and ended up declining to follow the recommended modified diet. He represented a clear signal that my understanding of aspiration pneumonia was faulty.
It turns out that the development of aspiration pneumonia is far more complicated, and not well-understood even today. This article is not meant to be a comprehensive review, so please check out the references for more reading. But I do want to share a couple of points.
How Is Aspiration Pneumonia Diagnosed
Generally, the first thing your provider will do in any situation is take a complete medical history and perform a physical examination. Theyll ask you about your current signs and symptoms. One thing that is a little tricky about aspiration pneumonia is that often no one actually sees you breathe in an object or food or saliva.
In addition to taking note of your symptoms, your provider will order tests such as:
- Chest X-ray and/or a computed tomography scan. In cases of aspiration pneumonia, inflammation is often seen at the bottom of your lungs.
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What Causes Aspiration Pneumonia
Pneumonia from aspiration can occur when your defenses are impaired and the aspirated contents have a large amount of harmful bacteria.
You can aspirate and develop pneumonia if your food or drink goes down the wrong way. This may happen even if you can swallow normally and have a regular gag reflex. In that case, most of the time youll be able to prevent this by coughing. Those who have impaired coughing ability, however, may not be able to. This impairment may be due to:
- neurological disorders
Risk Factors For Aspiration Pneumonia In Older Adults
Affiliations Department of Pulmonary Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Ibaraki, Japan, Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba Ibaraki, Japan
Affiliations Department of Pulmonary Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Ibaraki, Japan, Hitachinaka Medical Education and Research Center, University of Tsukuba, Hitachinaka, Ibaraki, Japan
Affiliation Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba Ibaraki, Japan
Affiliations Tatsumanosato Geriatric Health Service Facility, Tatsuma, Daitou, Osaka, Japan, Japanese Association of Geriatric Health Services Facilities, Tokyo, Japan
Affiliation Department of Pulmonary Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Study Design Data Sources And Study Population
We carried out an observational and cross-sectional study, using secondary data from a nationwide questionnaire survey conducted by the Japanese Association of Geriatric Health Services Facilities in October 2010. JAGHSF has more than 3500 geriatric health services facilities in its membership, which provide medical, nursing, and rehabilitation services for elderly under the long-term care insurance in Japan for people aged over 65 years.
The questionnaire survey was conducted at 3800 randomly selected GHSFs and associated health facilities receiving elderly care. The study subjects were aged 65 years and older, and lived in 1121 GHSFs at the time of observation. People aged less than 65 years were excluded from the survey. We collected data on general characteristics of subjects, the duration of years from admission, dysfunction and clinical supports, comorbidities, and deterioration of health condition on subjects in 3 months including standing, moving and walking, and swallowing function. Data on activities of daily living were collected from the data of International Classification System of Functioning, Disability and Health staging, the assessment method for ADL condition of patients, which was modified by the JAGHSF from the ICF, standardised by the World Health Organization . Using ICF staging , the level of ADL concerning mobility, walking, recognition , eating , toileting, bathing, and dressing were collected.
Factors That Increase Risk Of Aspiration Pneumonia
Although we cant predict who will or will not get sick, we do know that there are a number of factors that increase the risk of developing an aspiration pneumonia. Ive created an easy-to-read handout that Im finding useful in educating patients, families, and other medical staff.
In discussion with my patient and other team members, I highlight or circle which statements are true for them. This is intended to be a tool for medical professionals to use when working collaboratively with patients to determine treatment plans.
Free DIRECT download: Risk factors for developing aspiration pneumonia .
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What Is The Outlook If I Have Aspiration Pneumonia
Most people who get aspiration pneumonia and get treatment will survive. The prognosis for aspiration pneumonia also depends on your overall health and other conditions that you may have and how sick you were when you started treatment.
Untreated aspiration pneumonia can be dangerous, resulting in things like lung abscesses or lung scarring. In fact, it can result in death.
Suffering From Gastroesophageal Reflux Disease
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Strategies For Preventing Aspiration Pneumonia
Health providers can adopt a number of strategies to reduce the risk of aspiration. Those include:
- Avoid the use of medications that may affect swallowing or saliva flow.
- Provide prompt and evidence-based treatment for medical conditions that increase the risk of aspiration, such as emphysema.
- Refer for a swallowing evaluation of swallowing therapy when a patient has dementia or a stroke history and shows signs of dysphagia.
- Avoid unnecessary medical interventions, particularly tube feeding. Hand feeding is a safer alternative, so try other alternatives first.
- Consider liquid diets for dementia and stroke patients with swallowing disorders.
- Suction patients during medical procedures that increase the risk of aspiration. Medical suction during dental procedures, for example, lowers aspiration risk, increases patient comfort, and may prevent choking.
There Are More Questions Than Answers
Bice and Van Sickle have clearly the problems with the linear thinking that used to be so common in our field: that aspiration leads to aspiration pneumonia which can lead to death.
Instead, they highlight just how complex the whole problem is, down to the very definition and diagnosis of aspiration pneumonia. Here are some of the problems they highlight:
- Lack of a clear definition of aspiration pneumonia.
- Low accuracy of diagnosis.
- Research often conflates community-acquired pneumonia with aspiration pneumonia.
- Cough reflex isnt reliably tested by SLPs.
- Lack of understanding the microbiome, and how altering diets and liquids may impact it.
You may notice that dysphagia is not on this list. Langmore et al found to our surprise, all the factors that directly measured dysphagia were eliminated as significant predictors . They go on to explain that this likely means that dysphagia was highly correlated with other risk factors that had better predictive value.
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Causes And Risk Factors
Aspiration pneumonia often occurs if a person has a compromised immune system and inhales an object containing a lot of germs.
In many cases, the person will cough automatically, which will expel these unwanted particles and prevent aspiration pneumonia from developing.
People who have an impaired ability to cough may be more at risk of developing an infection from inhaling something, particularly if the object was large or was a source of infectious germs.
Other risk factors for aspiration pneumonia include:
- esophageal disorders or dysfunction
Anyone with these symptoms should contact their doctor immediately for a proper diagnosis and treatment.
Signs such as colored phlegm and high fever in children or older adults justify a trip to urgent care.
What Are The Early Symptoms Of Aspiration Pneumonia’
- You may feel generally unwell, with a high temperature , headache, sickness and muscle aches. You might go off your food and lose a little bit of weight.
- A cough is the key feature, sometimes with yellow or green phlegm.
- Your breathing rate and pulse may become rapid.
- Other symptoms you may notice include breathlessness and chest pain which is worse when you breathe in deeply.
- A doctor listening to your chest with a stethoscope might hear that your breathing sounds muffled and that the covering of your lungs makes a sound when you breathe in and out .
- If your chest wall is tapped, the doctor may find an area of dullness.
- Untreated, pneumonia can make you feel very ill. The oxygen you breathe in may have difficulty getting to parts of your body distant from your lungs and may develop a blue tinge.
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The 3 Pillars Of Aspiration Pneumonia
John R. Ashford, Ph.D., CCC-SLP points out that three factors have to be present for aspiration pneumonia to develop.
- Poor oral health status.
- Impaired health status.
- Dysphagia .
Follow the link above to see a pneumonia risk prediction chart. He advocates that SLPs consider the whole person when judging the risk of them developing an aspiration pneumonia. We should also educate for developing the habit of routine daily oral care.
How To Reduce The Risk Of Aspiration Pneumonia
Aspiration pneumonia is common among seniors, people with dysphagia, and people with chronic breathing disorders. It can also occur during or following surgery, or subsequent to a sudden trauma. Mortality rates vary greatly, and rise with patient age and comorbidities, as well as the total volume of aspirated fluids. Among those with emphysema, it may be as high as 20 percent. Reducing the risk of aspiration pneumonia can save lives, reduce healthcare expenditures, and prevent health system crowding.
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How Can I Prevent Aspiration Pneumonia Or Reduce My Risk Of Getting Aspiration Pneumonia
Things that you can do to reduce your risk of aspiration pneumonia include the following:
- Avoid drinking alcohol to excess and using recreational drugs. These can affect your ability to swallow.
- Stay upright when you are eating.
- Chew slowly and completely.
- If you have problems swallowing , talk to your healthcare provider. They might need to change or adjust your diet or medication. They can also order tests or refer you to a speech professional or swallowing specialist.
- Dont smoke or use nicotine products.
- Take good care of your teeth.
Data Collection And Definitions
Patient electronic medical records were reviewed by two physicians . Clinical data included age, gender, comorbidities, vital signs, feeding status, mental status, ambulatory status and laboratory findings. We assessed disease burden using the Charlson comorbidity index 9, which assigns a weighted score to each comorbid condition depending on the risk of 1-year mortality.
Medical Aid beneficiaries were considered to have a lower socioeconomic status than National Health Insurance beneficiaries. The severity of pneumonia was assessed using the pneumonia severity index 10 and CURB-65 score11 on day 1 of hospitalization.
Inappropriate initial antibiotic therapy was defined as non-susceptibility to the initially prescribed empirical antibiotic by in vitro antibiotic susceptibility testing.
Treatment failure was defined as clinical deterioration during hospitalization with any of the following: progression of pneumonia on radiographs, respiratory failure, need for mechanical ventilation, hemodynamic instability, or development of a new infection focus12. Patients were defined as having decompensation of comorbidity if the medical records suggested exacerbation of one or more comorbidities during hospitalization that required intensification of treatment13, such as exacerbation of chronic lung disease, acute kidney injury in the presence of chronic kidney disease, or a rapid ventricular response in the form of atrial fibrillation.
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Assessing Risk Of Bias
The risk of bias in the included studies was assessed according to the recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. and MOOSE guidelines for the following items: selection, performance, detection, attrition, and publication bias. Each study included in this review was assessed for quality as good, moderate, or poor based on biases using the modified Haydens criteria. Disagreements among the investigators were resolved by review of the assessments to reach consensus.
Choosing The Right Aspiration Pneumonia Equipment
The right equipment can both prevent and treat aspiration pneumonia. In the operating room and among patients who cannot clear their airway secretions, suction is the primary weapon in the fight to prevent aspiration. When a patient begins aspirating, prompt suctioning can save their life. Aspiration mortality directly correlates with the volume of aspirate a patient inhales.
Portable emergency suction empowers health providers to act quickly no matter where they encounter patients and regardless of which medical procedures they assist with. For help choosing the right machine for your agency, download our free e-book, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.
Editor’s Note: This blog was originally posted in May of 2020 and has since been updated with newer content.
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