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DISCLOSURES No
Preventing Aspiration Pneumonia: What Should I Be Considering Beyond Aspiration?
No
financial disclosures. non-financial disclosures.
Michelle Payne, MA, CCC-SLP Saint Louis University Department of Otolaryngology- Head & Neck Surgery
OBJECTIVES •
State risk factors for aspiration pneumonia.
•
State recommendations to prevent aspiration pneumonia.
ASPIRATION PNEUMONIA is the misdirection oropharyngeal or gastric contents into the larynx and lower respiratory tract.
ASPIRATION PNEUMONIA 13%
to 48% of all infections in nursing home residents Leading cause of death in long-term care patients Second most common type of nosocomial infection in hospitalized patients, after urinary tract infections Mortality rate ranges from 20% to 50%, with a rate as high as 80% reported in some studies
Colonization Altered oropharyngeal flora
Aspiration
¡
Aspiration
pneumonia results when the bacteria and other microorganisms become part of an infiltrate within the lung tissue, the resulting effect is an infection in the lung, either bilaterally or unilaterally. ¡
Aspiration into lungs
Marik & Kaplan, 2002
Host resistance
Pneumonia
Pace & McCullough, 2010
Adapted from Langmore et al., 2008
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DYSPHAGIA & ASPIRATION = ASPIRATION PNEUMONIA? Many
studies have not demonstrated a clear relationship between dysphagia and aspiration
SO IF NOT DYSPHAGIA RESULTING IN ASPIRATION PNEUMONIA…
PREDICTORS OF ASPIRATION PNEUMONIA
POOR MEDICAL STATUS
Poor
Multiple
medical/health status Poor functional status Dysphagia and reflux Feeding/mode of nutritional intake Poor oral/dental status ¡ Langmore
medical conditions Neurologic disease, COPD, GI disease, and CHF
Stroke,
¡ Combination
of 2 of these increases risk further
et al., 1998
POOR MEDICAL STATUS
FUNCTIONAL STATUS
Example:
Dependency
¡ Nursing
home patient ¢ Multiple medical conditions ¢ Multiple medications ¤ Xerogenic ¢
Dependency
for feeding for oral care
effects of medications
Poor functional status
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DYSPHAGIA of food > aspiration of liquid of dysphagia:
DYSPHAGIA
Aspiration
Aspiration
Aspects
Excess
of secretions secretions in the mouth
¡ Pharyngeal ¡ Excess
delay residue
GASTROESOPHAGEAL REFLUX
ESOPHAGEAL DYSPHAGIA
GE
Esophageal
reflux most dangerous to patients in intensive care unit or in postsurgical setting
dysmotility
¡ Slow
or incomplete esophageal assessment ¡ Co-occurrence of esophageal dysmotility and pharyngeal dysmotility
FEEDING/MODE OF NUTRITIONAL INTAKE
ORAL/DENTAL STATUS
Tube
Number
feeding
¡ NPO-
aspiration of secretions ¡ GE Reflux
of decayed teeth of brushing teeth Dependency for oral care Frequency ¡ Plaque
¡ Oral
and gingivitis
Vigilid, 1988
disease higher when dependent
Jette et al., 1993 Beck, 1992
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ORAL/DENTAL STATUS
ORAL/DENTAL STATUS
Oral/dental
Reduced
disease may result in:
¡ Increased
levels of oral bacteria in the saliva ¡ Change the composition of salivary flow Dental
decay
¡ Higher
levels of bacteria (mutans streptococci, lactobacilli, and yeast) in saliva
Salivary Flow
¡ Associated
with increased prevalence of decay, edentulousness, and salivary hypofunction ¡ Associated with: Systemic diseases/conditions Damage to salivary glands ¢ Interference with neural transmission ¢ ¢
¡ Xerogenic
¢
effects of medications
Loesche et al., 1995
MEDICATIONS WITH XEROGENIC EFFECTS
Anticholinergic drugs Tricyclics antidepressants Muscarinic receptor antagonists for treatment of overactive bladder Alpha receptor antagonists for treatment of urinary retention Antipsychotics such as phenothiazines Diuretics Antihistamines Sympathomimetic drugs Antihypertensive agents Antidepressants (serotonin agonists, or noradrenaline and/or serotonin re-uptake blockers)
Appetite suppressants Decongestants and ‘cold cures’ Bronchodilators Skeletal muscle relaxants Antimigraine agents Benzodiazepines, hypnotics, opioids and drugs of abuse H2 antagonists and proton pump inhibitors Cytotoxic drugs Retinoids Anti-HIV drugs Cytokines ¡
Streckfaus, 1995
Colonization Altered oropharyngeal flora
PATIENT 1 85
Aspiration into lungs
year old male with history of tonsil cancer s/p chemoradiation in 2011 and base of tongue resection in 2013
Host resistance
PATIENT 2 Pneumonia
64
year old male with moderately advanced Parkinson’s disease
Adapted from Langmore et al., 2008
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CASE PRESENTATION
CASE PRESENTATION
Colonization/Altered
Oral Flora
Aspiration
1 (85 y/o M with head and neck cancer)
¡ Patient
¡ Patient ¢
Independent for oral care, no decayed teeth although ill fitting dentures, 3 medications, feeding tube was removed in 2013
¡ Patient ¢
2 (64 y/o M with Parkinson’s Disease)
Dependent for oral care and often refused oral care by his wife, missing many teeth and teeth in fair condition, 12 medications, no feeding tube in place
¢ ¢
into the lungs
1 (85 y/o M with head and neck cancer)
Large volume aspiration of liquid, food, and likely saliva Independent for feeding
¡ Patient
2 (64 y/o M with Parkinson’s Disease)
Small volume aspiration of liquid during multiple consecutive sips, suspected microaspiration of saliva with evidence of aspiration of saliva on FEES ¢ Dependent for feeding, wife states she often has to force feed him ¢
CASE PRESENTATION
CASE PRESENTATION
Host
Pneumonia
Resistance
¡ Patient
1 (85 y/o M with head and neck cancer)
Not a current smoker, although former smoker ¢ Only other medical condition ¢
¡ Patient ¢
¡ Patient ¡ Patient ¢
2 (64 y/o M with Parkinson’s Disease)
Small volume aspiration of liquid during multiple consecutive sips, however evidence of aspiration of saliva on FEES
¢
1 (85 y/o M with head and neck cancer)
No pneumonia
2 (64 y/o M with Parkinson’s Disease)
Multiple bouts of pneumonia consistent with aspiration pneumonia
PREVENTING ASPIRATION PNEUMONIA More
PREVENTING ASPIRATION PNEUMONIA
than treatment for swallow function!
Safe
feeding strategies care Pulmonary clearance Monitoring of health Oral
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SAFE FEEDING STRATEGIES
ORAL HYGIENE
Adequate
Brush
training to nurses, family members
¡ Rate ¡ Positioning ¡ Volume ¡ Observe
for signs and symptoms of dysphagia, provide feedback or alternations
teeth, tongue and gums for 2 minutes at least twice per day Floss daily Regular dental cleanings
PULMONARY CLEARANCE
MONITORING HEALTH
Encourage
Signs
physical activity and time spent
and symptoms of pulmonary complications:
out of bed Cessation of smoking Remain upright when consuming eating or drinking and 30-60 minutes after a meal
WATER PROTOCOL Allow
water by mouth Oral hygiene prior to consuming Sit upright and use appropriate swallowing strategies
¡ Fever ¡ Productive
cough with greenish or rust-colored mucus ¡ Shortness of breath
REFERENCES
Langmore, S. E., Terpenning, M. S., Schork, A., & Yinmiao, C. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia,13(2), 69–81. Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298–307. Loesche, W. J., Bromberg, J., Terpenning, M. S., Bretz, W. A., Dominguez, M. S., Grossman, M. A., & Langmore, S. E. (1995). Xerostomia, xerogenic medications and food avoidances in selected geriatric groups. Journal of the American Geriatrics Society, 43(4), 401–407. Marik, P. E., & Kaplan, D. (2002). Aspiration Pneumonia and dysphagia in the elderly. Chest, 124(1), 328-336. Pace, C. C., & McCullough, G. H. (2010). The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: Review and recommendations. Dysphagia, 25, 307-322. Sreebny, L. M., & Schwartz, S. S. (1997). A reference guide to drugs and dry mouth. Gerodontology, 14(1), 33-47. Sreebny, L. M., & Valdini, A.: (1987). Xerostomia. A neglected symptom. Archives of Internal Medicine 147(7), 1333–1337.
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QUESTIONS? Contact information: Michelle Payne, MA, CCC-SLP
[email protected]
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