UNM COC:  Your Healthcare Primer for Long Term Care

 
Aspiration Pneumonia

Sharon Witemeyer MD (Pediatrician)

Definition

When the contents of the mouth (oral cavity) or stomach enter the airway and get into the lungs they can cause infection or inflammation which is called aspiration pneumonia.

Introduction

Particles from the mouth frequently dribble into the airways. It is a common occurrence in the average population. Usually they are cleared out by the body's defenses before they get into the lungs. Individuals with severe disabilities are at high risk for aspiration pneumonia due to a number of risk factors and associated conditions. The most common risk factors include:

1. Dysphagia (swallowing difficulties)

2. Gastro-esophageal reflux disease (GERD)

3. Periodontal (dental) disease

4. Altered level of consciousness

5. Neurological conditions such as stroke, seizures, etc

6. Other neuromuscular conditions

Aspiration pneumonia is also associated with a variety of associated conditions including:

1. Diabetes

2. Cancer

3. Congestive heart failure

4. Renal (kidney) failure

5. Chronic obstructive pulmonary disease (COPD)

6. Feeding tube

7. Xerostomia (dry mouth)

Diagnosis

Not all aspiration results in pneumonia. The risk of developing pneumonia rises when aspiration is frequent, the amount of material aspirated is large or acidic (such as stomach contents) or infected (as in periodontal/dental disease.) It is also more likely if solid material is aspirated. Symptoms of aspiration pneumonia may be obvious or subtle and include:

1. Coughing

2. Wheezing

3. Intermittent fevers

4. Weight loss

5. Dehydration

6. Rumination

The individual's physician will often make the diagnosis of pneumonia based on physical signs on examination of the chest. The diagnosis may be confirmed by chest X-ray. Silent or recurrent aspiration may require more detective work including modified barium swallow study, videoflouroscopy (a swallowing study) and evaluation by a feeding specialist (usually an OT or SLP with special expertise in the area of feeding disorders) or team of specialists (such as at the SAFE feeding clinic).

Prevention and Treatment

Treatment of aspiration pneumonia consists of antibiotics and supportive care. Antibiotic selection depends on which bacteria is most likely to have caused the pneumonia, whether the aspiration occurred in or out of a hospital setting and upon other individual conditions which might predispose to specific bacterial infections. The physician will prescribe antibiotics.

Supportive care may include:

1. Stopping feeding

2. Protection of the airway

3. Positioning

4. Oxygen if needed

5. Nebulization treatments if needed

6. Careful monitoring of the individual

Prevention may be accomplished using a variety of strategies that include: Follow mealtime programs which may include one or more of the following:

1. Changing the diet: consistency, texture, or temperature

2. Therapeutic positioning: correct neck position, seating support, and proper alignment

3. Adaptive eating equipment: spoons that make eating easier (as with built up handles or with angles) and safer (such as coated spoons to protect the teeth, heavy plastic spoons used in individuals with a bite reflex, spoons to regulate bite size)

4. Cups and glasses that increase safety (control the rate of flow of liquids) or promote correct head positioning (nosey cups)

5. Assisted eating techniques: position of the person assisting with the meal, spoon placement in the mouth, rate of food presentation, directions fluids are introduced into the mouth

6. Non-oral/Alternative eating techniques: tube feeding by nasograstic, gastric or jejunostomy tubes

7. Good oral hygiene

8. Appropriate choice of medications

Emergency Situations – What can go wrong?

Choking

An acute episode of choking is frightening to both the individual who is choking and those around him. Dozens of Americans die in choking accidents each year. In a true choking episode, food becomes trapped in the vocal cords so the individual cannot gag or cough or talk or even breathe. Unless the food is removed, the individual suffocates. The individual may clutch at his throat, look frightened and turn blue (cyanotic.) The Heimlich Maneuver is a rescue technique used to dislodge the food from the individual's airway.

Performing the Heimlich Maneuver:

1. If the individual can talk, cough, gag or breathe he is not choking and the maneuver is not indicated. Remember that many of our clients have osteoporosis. Performing the maneuver unnecessarily may lead to rib fractures and/or lung punctures which are at least extremely painful and at worst life threatening.

2. If the individual cannot talk, cough, gag or breathe, minimize panic, tell him you know what to do and can help.

3. Step behind the individual and clasp your hands around his abdomen below the ribcage.

4. Make a fist with one hand and hold the thumb side in against the person.

5. Then grasp the fist with your other hand and thrust your fist forcefully in and up.

6. If one forceful thrust does not restore free breathing, repeat the maneuver.

7. Have someone else call 911 for emergency medical help.

8. If the individual is still not breathing and has no pulse begin CPR.

Acute aspiration, the individual gagging and coughing without actual choking is still frightening to the individual and caretakers. It often occurs during or after mealtime or when an individual is taking a drink.

1. Stop the feeding.

2. Position the individual so that liquids and /or solids can drain out of the mouth.

3. Maintain a clear airway.

4. Notify agency nurse immediately so that the protocol for aspiration pneumonia can be instituted.

5. The individual must be observed closely over the next several days for signs of aspiration pneumonia (coughing, wheezing, or fever.)

6. If signs of pneumonia develop the individual must be taken to his physician for evaluation and treatment.

Conclusion

Aspiration of small amounts of oral contents is common in all populations of people. Individuals with developmental disabilities are at greater risk of aspiration than the average population because of associated risk factors and conditions. Not all episodes of aspiration result in pneumonia. However, aspiration is frequently related to the cause of death in person with developmental disabilities. Aspiration happens, but very often it does not have to. There are ways to prevent it by identifying risk factors, following the individual's meal-time program/meal plan, therapeutic positioning, adaptive eating equipment and techniques, and diet changes.

References

Simons, Anne MD, Hasselbring, Bobbie and Castleman, Michael : Before You Call the Doctor, Ballantine Books, 1992.

Langmore, SE et al "Predictors of Aspiration Pneumonia: How Important is Dysphagia?" Dysphagia 13:69-81 (1998)

Sharon Witemeyer MD (Pediatrician)