1 Preventing Aspiration Pneumonia Dorothea Devanna MS, ACNS-BCwith the help of Speech Pathologists from Mt Auburn
2 Objectives Define Aspiration Pneumonitis vs PnuemoniaIdentify 3 symptoms of aspiration Identify 3 patients populations at risk for Aspiration State how to perform a swallow screen Identify 3 important measures to prevent aspiration
3 Aspiration Inhalation of gastric contents into the larynx and lower respiratory tracts Pneumonitis: chemical injury of sterile contents Pneumonia: infectious process from colonized content
4 Is Aspiration Pneumonia a big issue?Prevalence: extremely variable, ranging from 10% to 70%. - post-extubation dysphagia ranges from % -62% Mortality: as high as 70% R/T volume and content of aspirate Skoretz,S.A.,Flowers, H.L>. & Martino,R (2010) The incidence of dysphagia following endotracheal intubation,: A systematic review. CHEST, 137(3) Delugge, MH (2002) Aspiration Pneumonia: Incidence, mortality, and at risk populations,Journal of Parenteral Enteral Nutrition Nov-Dec2002, R
5 The Processes used in Swallowingv the liquid bolus is held in the anterior part of the floor of the mouth or on the tongue surface against the hard palate surrounded by the upper dental arch (upper teeth). The oral cavity is sealed posteriorly by the soft palate and tongue contact to prevent the liquid bolus leaking into the oropharynx before the swallow. There can be leakage of liquid into the pharynx if the seal is imperfect, and this leakage increases with aging oral propulsive stage, the tongue tip rises, touching the alveolar ridge of the hard palate just behind the upper teeth, while the posterior tongue drops to open the back of the oral cavity. The tongue surface moves upward, gradually expanding the area of tongue-palate contact from anterior to posterior, squeezing the liquid bolus back along the palate and into the pharynx. When drinking liquids, the pharyngeal stage normally begins during oral propulsion.
6 Symptoms of AspirationSymptoms can vary greatly from asymptomatic to: Clearing throat Coughing Gurgling Wheezing Abrupt onset of dyspnea Chest pain Tachycardia Tachypnea Hypotension Fever Hypoxemia Diffuse cracklesor decreased breath sounds
7 Risk Factors for AspirationAltered level of consciousness * Alcohol * Drugs * Hepatic failure * CVA * Anesthesia Depressed cough or gag reflex Esophageal disorders * GERD * Strictures * Vomiting Disruption of glottic closure * ET tube * NG tube * Endocopy/ Brochoscopy Neuro/muscular disorders * Multiple sclerosis * Parkinsons * Myasthenia * Seizures * Stroke Scoliosis/ Kyphosis Dry Mouth
8 History that might be a clue to Risk of AspirationPresence of any condition listed earlier Unexplained weight loss Fear of eating or refusal to eat of drink Difficulty with pills or certain foods (rice) Cutting food unusually small
9 Interventions to Prevent AspirationOral Assessment Oral Care Screening: NEW to be done on all general anesthesia patients Positioning Be prepared for Aspiration in AT RISK patients
10 Oral Assessment Check dentition Check for edema of structuresCheck moisture of mouth Check for Thrush
11 Positioning Acceptable Not Acceptable Recliners SupineSeated as upright whenever possible If cannot get OOB, elevate HOB at least 45 degrees Not Acceptable Recliners Supine Goodwin, R ( 2009) Prevention of Aspiration Pneumonia: A research-based protocol from
12 RN Swallow Screening Is the patient ready for a swallow challenge?If you say NO to any of the following questions, keep the patient NPO including medications til they meet criteria and notify MD Is the patient alert and able to participate in a po trial? Is the patient able to maintain an upright position? Is the patient able to safely manage his/her oral secretions? Patients with Head & Neck Cancers should be referred directly to Speech Therapy
13 Swallow Challenge Have the patient brush their teeth and rinse their mouth Have suction equipment available Have patient hold a 3 oz cup of water, if unable provide a straw so they can control volume Instruct the patient to drink all 3oz WITHOUT stopping. If any symptoms or unable to complete without stopping, keep NPO and notify MD for further evaluation
14 Documentation of Swallow ChallengeThis test can be done on other patients you identify as being at risk Complete the Nursing Swallow Screen Form and file it in the H&P section of the patient’s chart This test is not a bedside swallow eval or a speech and swallow eval which is done by speech therapy
15 Oral Care Oral care and a variety of interventions to decrease bacteria in the mouth have been thought to be effective in preventing aspiration pneumonia. Yoneyama (1999) did a study of 141 residents who received oral care after each meal and another group that received no active treatment showed bordeline significance p= While more research is needed, this is a standard intervention used to prevent aspiration pneumonia R/T cleaner mouth moister mouth Yoneyama, T, Yoshida,M, Matsui, T et.al. Oral care and pneumonia. Lancet 1999; 3.54;515
16 When you must feed a patientAssist patient to a chair when possible. If not, elevate HOB to a 90 degree angle Provide oral care before meals to lubricate mouth Adjust rate of feeding and size of bites to patient’s tolerance Alternate solids and fluids Vary placement of food in the mouth based on deficits
17 When tube feeding is neededMark tube site at exit from nose once placement is confirmed by x-ray Before giving meds or starting feeding, confirm tube aspirate pH <5.0 Keep HOB elevated degrees Turn tube feeding off 30-60minutes prior to supine or recumbent positioning is recommended Monitor residual every 4 hours. Hold feeding for aspirate >100ml
18 Be Prepared
19 Case Study RC is a 56 year old admitted for a TKRPMH: CAD with unsuccessful PTCA to LAD, COPD, Bipolar PTSD, Alcohol and Substance abuse, GERD, HTN, and Hypercholesteremia Meds: Prilosec, Lithium, Lipitor, Zyprexa, Effexor, Clonidine Proair, Advair, and Nortriptyline RC experienced a Respiratory arrest on Post-op Day 2 What made him at risk for aspiration?
20 Hints from the Medication listSide Effect Lithium Dry mouth, muscle weakness Nortriptyline Dry mouth, confusion, hoarseness Zyprexa Dry mouth, drowsiness, trouble speaking/swallowing Effexor Dry mouth, weakness, loss of coordination Prilosec GERD is a risk factor Clonidine Drowsiness, dry mouth,
21 Case Study # 2 FW is an 86 year old admitted for a THR.PMH: Atrial fibrillation, HTN, ↑ Cholesterol, OA, BPH →TURP, CVA Meds: Amlodipine, Diltiazem, Labetolol, Lidocaine patch, Lisinopril. Lorazepam, Simvastin, MOM, Bisodyl, and Colace FW did well intra-operatively but on Post op Day 2 While on Dilaudid PCA he aspirated on this eggs. This led to a respiratory arrest. He was bronched in the ICU to remove the eggs. Ultimately he was discharged to rehab What hints might we identify now that this patient was at risk
22 Putting pieces of a Patient’s story togetherWhy are you taking so many medications for your bowels? How have you been eating? Constipation → Change in diet → Difficulty chewing Prior stroke: Any problems with eating since your stroke? Dilaudid PCA What was his sedation scale? Did he get his usual Lorazepam?