Preventing aspiration pneumonia in at-risk residents Aspiration pneumonia is an infection in the lungs commonly perceived to be caused by food or liquid that goes down the windpipe (trachea) into the lungs, rather than into the stomach. However, aspirated bacteria are the true culprits. Which residents of your nursing home are at risk for aspiration pneumonia? The answer may surprise you. The resident who is diagnosed with aspiration pneumonia is often referred to the Speech-Language Pathologist (SLP) for evaluation of a swallowing problem, or dysphagia, but this is just one of several risk factors for aspiration pneumonia. Indeed, residents who do not have swallowing disorders also can fall prey to this illness. Formerly perceived as a simple cause-effect diagnosis, aspiration pneumonia is more correctly viewed as a multifactor disorder.
Who else is at risk?
The following categories describe other residents who are vulnerable to this illness.
Category 1: Anyone with a mouth, especially those with teeth or dentures, because of the presence of oral bacteria. Aspiration pneumonia can result when these bacteria enter the airway.1 When teeth or dentures are not brushed, the bacteria quickly multiply, potentially to the point where they completely fill the space they occupy. When a resident has dental cavities, bacteria multiply even faster. These bacteria can migrate to the pharynx, sinus, larynx and, finally, the trachea, bronchi, and lungs. They can enter the lungs by aspiration regardless of whether swallowing problems are present. In fact, most healthy adults aspirate small amounts of their own saliva during deep sleep, setting up the potential for pneumonia to develop. Those with dysphagia may aspirate even greater amounts of oral bacteria, as well as food and liquid, compounding their risk.
Category 2: Anyone who has an acute illness or who has experienced brain injury, surgery, or trauma-which are among the chief reasons for admission to nursing homes. One consequence of trauma is altered immune response, resulting in an inability to fight infection.2 The healthy person with mild to moderate sleep aspiration and a normal immune response does not develop pneumonia. However, victims of fractures, stroke, heart attack, and other traumatic occurrences suffer from a complex stress response that reduces energy expenditures but compromises respiratory immune function. Further, this response reduces saliva production, alters the normal oral chemical balance, and allows for growth of gram-negative bacteria. Combine that with three days of minimal oral hygiene, and nosocomial (facility-originated) pneumonia can arise.
Category 3: Anyone who is classified as "NPO" (nothing by mouth).3 Is that surprising? Although tube feeding and NPO are established treatment regimens for individuals in whom aspiration of food and beverages has been identified, researchers reviewing this practice have found that people receiving tube feedings are as likely to develop pneumonia as those with moderate aspiration.
When the mouth is not used for food and fluid intake, the natural process of washing down contaminated secretions to the sterile stomach does not occur. Also, oral care often is not perceived as needed for residents who do not eat and, as a result, bacteria grow rapidly in their mouths. Add to that the stress of the condition that precipitated placement of the feeding tube, and you have a resident with a compromised immune response. Aspiration of oral flora occurs and pneumonia follows.
Oropharyngeal bacteria, illness, trauma, and tube feeding are priority conditions that set the stage for pneumonia. Concern is heightened for residents with the added complications of:
- Dehydration (inadequate salivary flow)
- Malnutrition (altered immune response)
- Chronic respiratory disease, such as chronic obstructive pulmonary disease (higher susceptibility to further insult)
- Low mobility (poor pulmonary clearance and circulation)
- Gastroesophageal reflux disease (GERD) (risk of aspirating stomach contents, especially if tube fed)
- Diabetes (slow gastric emptying)
Team Approach to Prevention
In long-term care, preventing aspiration pneumonia requires a team approach. Physicians, nurses, dietitians, rehab professionals, and nursing assistants all will have roles in the plan of care, although-as previously indicated-the SLP still must evaluate residents' swallowing ability and determine their potential for safe, adequate intake of food and liquids.
Nursing staff should perform a thorough oral evaluation for every resident and develop a care plan that addresses specific needs. Residents should see a dentist for immediate concerns and should have routine visits to the dentist thereafter. Also, clinicians should consider the possibility of periodontal infection in all residents who have fevers.
Daily oral hygiene is of the utmost importance, as follows: