Preventing aspiration pneumonia in at-risk residents.

Aspiration pneumonia is an infection in the lungs commonly perceived to be caused by food or liquid that goes down the windpipe (trachea) into the lungs, rather than into the stomach. However, aspirated bacteria are the true culprits. Which residents of your nursing home are at risk for aspiration pneumonia? The answer may surprise you. The resident who is diagnosed with aspiration pneumonia is often referred to the Speech-Language Pathologist (SLP) for evaluation of a swallowing problem, or dysphagia, but this is just one of several risk factors for aspiration pneumonia. Indeed, residents who do not have swallowing disorders also can fall prey to this illness. Formerly perceived as a simple cause-effect diagnosis, aspiration pneumonia is more correctly viewed as a multifactor disorder.

Who else is at risk?

The following categories describe other residents who are vulnerable to this illness.

Category 1: Anyone with a mouth, especially those with teeth or dentures, because of the presence of oral bacteria. Aspiration pneumonia can result when these bacteria enter the airway. (1) When teeth or dentures are not brushed, the bacteria quickly multiply, potentially to the point where they completely fill the space they occupy. When a resident has dental cavities, bacteria multiply even faster. These bacteria can migrate to the pharynx, sinus, larynx and, finally, the trachea, bronchi, and lungs. They can enter the lungs by aspiration regardless of whether swallowing problems are present. In fact, most healthy adults aspirate small amounts of their own saliva during deep sleep, setting up the potential for pneumonia to develop. Those with dysphagia may aspirate even greater amounts of oral bacteria, as well as food and liquid, compounding their risk.

Category 2: Anyone who has an acute illness or who has experienced brain injury, surgery, or trauma--which are among the chief reasons for admission to nursing homes. One consequence of trauma is altered immune response, resulting in an inability to fight infection. (2) The healthy person with mild to moderate sleep aspiration and a normal immune response does not develop pneumonia. However, victims of fractures, stroke, heart attack, and other traumatic occurrences suffer from a complex stress response that reduces energy expenditures but compromises respiratory immune function. Further, this response reduces saliva production, alters the normal oral chemical balance, and allows for growth of gram-negative bacteria. Combine that with three days of minimal oral hygiene, and nosocomial (facility-originated) pneumonia can arise.

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Category 3: Anyone who is classified as "NPO" (nothing by mouth). (3) Is that surprising? Although tube feeding and NPO are established treatment regimens for individuals in whom aspiration of food and beverages has been identified, researchers reviewing this practice have found that people receiving tube feedings are as likely to develop pneumonia as those with moderate aspiration.

When the mouth is not used for food and fluid intake, the natural process of washing down contaminated secretions to the sterile stomach does not occur. Also, oral care often is not perceived as needed for residents who do not eat and, as a result, bacteria grow rapidly in their mouths. Add to that the stress of the condition that precipitated placement of the feeding tube, and you have a resident with a compromised immune response. Aspiration of oral flora occurs and pneumonia follows.

Cumulative risks

Oropharyngeal bacteria, illness, trauma, and tube feeding are priority conditions that set the stage for pneumonia. Concern is heightened for residents with the added complications of:

* Dehydration (inadequate salivary flow)

* Malnutrition (altered immune response)

* Chronic respiratory disease, such as chronic obstructive pulmonary disease (higher susceptibility to further insult)

* Low mobility (poor pulmonary clearance and circulation)

* Gastroesophageal reflux disease (GERD) (risk of aspirating stomach contents, especially if tube fed)

* Diabetes (slow gastric emptying)

Team Approach to Prevention

In long-term care, preventing aspiration pneumonia requires a team approach. Physicians, nurses, dietitians, rehab professionals, and nursing assistants all will have roles in the plan of care, although--as previously indicated--the SLP still must evaluate residents' swallowing ability and determine their potential for safe, adequate intake of food and liquids.

Nursing staff should perform a thorough oral evaluation for every resident and develop a care plan that addresses specific needs. Residents should see a dentist for immediate concerns and should have routine visits to the dentist thereafter. Also, clinicians should consider the possibility of periodontal infection in all residents who have fevers.

Daily oral hygiene is of the utmost importance, as follows:

* Brush teeth with toothpaste after meals.

* Floss at least once a day.

* Brush dentures after meals and remove at night to soak in an appropriate solution.

* Rinse mouths (with or without teeth) with antiseptic mouthwash.

* Inspect mouth frequently for sores, bleeding, or signs of infection.

* Treat existing conditions with appropriate medication.

Assessments of nutritional status, hydration, and respiratory function via lab values are also important preventive measures, because they provide crucial insight into residents' ability to fend off infection.

Interventions for those found to be at risk should focus on supporting the immune system. For example:

* Encourage food and fluid intake at meals.

* Offer between-meal snacks for residents with GERD or gastrointestinal (GI) conditions that limit bulk intake.

* Support efforts to stop smoking.

* Treat GI conditions that may hinder absorption of nutrients.

* Decrease medications that promote anorexia, dry mouth, diuresis, dysphagia, or lethargy, or those that alter gustatory sensation (e.g., diuretics, antihistamines, antidepressants, antipsychotics, and anticholinergics).

* Avoid NPO restrictions whenever possible.

Mobility and positioning of residents, both while they're eating and while in bed, are 24-hour concerns. Staff should:

* encourage residents to be up in a chair for all meals and for 30 to 60 minutes after meals;

* use an upright position for all food, beverage, and medication presentations;

* elevate the head of the bed at all times for residents with GERD and/or those receiving tube feedings; and

* encourage sedentary residents to stand, walk, or propel their wheelchairs.

Of course some residents will refuse or be unable to benefit from these interventions. If that is the case, documentation and the resident's prognosis should indicate that this refusal or inability is a constant, unavoidable situation resulting from the resident's diagnosis (e.g., late-stage dementia with agitation).

Conclusions

Aspiration pneumonia does not have a single cause. In fact, a chain of events begins with major medical stress followed by altered immune response, rapid growth of oral bacteria, and aspiration of oropharyngeal secretions; these events conclude with pneumonia. This illness also does not resolve by means of a single intervention. Residents at risk of developing aspiration pneumonia often remain at risk to varying degrees, depending on fluctuations in their heath and nutritional status. Preventing aspiration pneumonia demands constant vigilance by all members of the care team. Although skilled assessment and treatment are necessary to recovery, basic care, as outlined in this article, is the most effective preventive measure.

References

1. Marik PE. Aspiration pneumonitis and aspiration pneumonia. New England Journal of Medicine 2001;344:665-71.

2. Ashford JR. Aspiration pneumonia: Factors beyond just laryngeal aspiration. Short Course Presentation: Convention of the American Speech-Language Hearing Association, 2003.

3. Langmore SE, Terpenning MS, Schork A, et al. Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 1998; 13:69-81.

BY BRENDA K. LOGSDON, MA, CCC/SLP

Brenda K. Logsdon, MA, CCC/SLP, has been practicing in skilled nursing and long-term care for 12 years. She is a CE instructor with Dynamic Learning Online (www.dynamic-online.com). For more information, send e-mail to [e-mail]. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].