Prevention of Aspiration and the Development of Pneumonia

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 isusually the second most common nosocomial infection after urinary tractinfections. Mortality from pneumonia is also very high; it is the fifth leadingcause 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 personinhales a foreign item such as saliva and oral secretions, refluxed gastriccontents, food and/or liquid. It can happen during or after swallowing. Commonrisk factors for patients with potential for aspiration are altered mentalstatus, post anesthetic recovery, weakness or frailty, sedation, tracheostomyand recumbent position.

Dysphagia, which is difficulty with chewing and swallowing, can also causethe devastating consequences of choking and aspiration. Frequently, dysphagia isa clinical manifestation resulting from neurologic disorders such ascerebrovascular 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 aspirationand the development of pneumonia. They must be knowledgeable not only aboutpatient populations at risk but also aware of early signs and symptomsindicating dysphagia. Patients should be observed for and or questioned aboutthe 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 thefollowing:

• 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 inapproaches 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 ofaspiration and the potential development of pneumonia, implementing timely andindividualized interventions is crucial.

Diane Baranowsky, RN, BSN, MS, CIC, is nurse epidemiologist at TheStamford Hospital in Stamford, Conn.