Prevention of Aspiration and the Development of Pneumonia
By Diane Baranowsky, RN, BSN, MS, CIC
Pneumonia is a serious infection occurring in hospitalized patients and is usually the second most common nosocomial infection after urinary tract infections. Mortality from pneumonia is also very high; it is the fifth leading cause of death in elderly patients.
Many cases of nosocomial pneumonia are aspiration related.
Aspiration pneumonia is a type of pneumonia that can occur when a person inhales a foreign item such as saliva and oral secretions, refluxed gastric contents, food and/or liquid. It can happen during or after swallowing. Common risk factors for patients with potential for aspiration are altered mental status, post anesthetic recovery, weakness or frailty, sedation, tracheostomy and recumbent position.
Dysphagia, which is difficulty with chewing and swallowing, can also cause the devastating consequences of choking and aspiration. Frequently, dysphagia is a clinical manifestation resulting from neurologic disorders such as cerebrovascular accident, traumatic brain injury, Parkinson's disease, Alzheimer's disease and Guillain-Barré syndrome.
Nursing staff members play an integral role in the prevention of aspiration and the development of pneumonia. They must be knowledgeable not only about patient populations at risk but also aware of early signs and symptoms indicating dysphagia. Patients should be observed for and or questioned about the following factors, for example:
- Food remaining on the tongue after swallowing
- Pocketing of food on side of mouth
- Excessive drooling
- Coughing or choking while eating or drinking
- Gargly-sounding voice after eating or drinking
Relevant history taking and physical assessment skills should include the following:
- Past and present eating habits
- Any history of aspiration pnuemonia
- Poor appetite which may stem from fear of choking
- Poorly fitted or damaged dentures
- Neglected oral care
An individualized patient care plan should then be developed which addresses:
- The patient's specific problem or need (i.e. pocketing food; history of aspiration)
- Realistic and measurable goals or expected behaviors (i.e., patient will protect airway during swallowing)
- Specific actions/interventions to solve the problems/satisfy needs (i.e. sit upright when eating, head slightly flexed forward; when recumbent, change position at least every two hours)
- Reviewing and assessing the patient's progress is an essential part of the care plan as is discharge planning which should include communication of the successful, implemented approaches to prevent aspiration.
Lastly, the patient's care should also include patient/family education in approaches to prevent aspiration such as:
- Feed small amounts
- Put food on one's unaffected strong side
- Allow a 30-minute rest period before meals
- Avoid excessive sedation
- Select thickened liquids such as nectars, instant breakfast drinks
- Provide oral care before and after meals and more frequently if needed
In order to have better clinical outcomes, being aware of who is at risk of aspiration and the potential development of pneumonia, implementing timely and individualized interventions is crucial.
Diane Baranowsky, RN, BSN, MS, CIC, is nurse epidemiologist at The Stamford Hospital in Stamford, Conn.