I recently started to do a peer review for the ASHA conference Complex Cases in Adult Dysphagia. One thing that really stuck in my mind during the first part of the conference is from Dr. Coyle talking about labeling a patient with “aspiration risk”.
When we label a patient with dysphagia or as an “aspiration risk” this becomes a part of that person’s medical file that will permanently remain in their file.
So, what is an “aspiration risk?”
Wikipedia defines aspiration as “Pulmonary aspiration is the entry of material (such as pharyngeal secretions, food or drink, or stomach contents) from the oropharynx or gastrointestinal tract into the larynx (voice box) and lower respiratory tract (the portions of the respiratory system from the trachea—i.e., windpipe—to the lungs).”
Typically when “aspiration risk” is scripted in the patient chart, the meaning is that the patient has a higher chance of aspirating food/drink because of a swallowing problem or dysphagia.
Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia after stroke incidence, diagnosis, and pulmonary complications. stroke, 36(12), 2756-2763:
- There is a high incidence of dysphagia and aspiration following acute stroke.
- The incidence of silent aspiration following acute stroke is high.
- The risk of developing pneumonia following stroke is proportional to the severity of aspiration.
“Neurologic dysfunction, decreased consciousness, advancing age, gastroesophageal reflux, and tube feeding are all potential risk factors for the development of aspiration.” DeLegge, M. H. (2001). Aspiration pneumonia: incidence, mortality, and at-risk populations. JPEN. Journal of parenteral and enteral nutrition, 26(6 Suppl), S19-24.
Which Came First
There is also an article published from James Coyle about aspiration and dysphagia. A Dilemma in Dysphagia Management: Is Aspiration Pneumonia the Chicken or the Egg? can be found here. If you take one message from that article this is probably the greatest. “Aspiration contributes to the pathogenesis of dysphagia-related pneumonia (Marik, 2001), but only as one of many pneumonia risk factors, and sometimes not even the greatest.”
Aspiration Pneumonia Risk
The 1998 study by Dr. Susan Langmore is one of the landmark studies of our profession. Why? She defined the greatest risk factors in aspiration pneumonia. The greatest risk factors found from this study for aspiration pneumonia included:
- Dependence on others for feeding
- Multiple medical conditions
- Tube feeding
- Dependence for oral care
- Number of decayed teeth
- Number of medications
You may notice that dysphagia is nowhere to be found on this list.
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia?. Dysphagia, 13(2), 69-81.
Consider those patients that are viewed via instrumental assessment with aspiration. Sometimes the study is halted at that point and sometimes the study continues. Then comes the decision to alter diet or to even allow the patient to eat.
We’ve all had that patient that per instrumental assessment should not be eating Per Os (po or by mouth). The patient refuses to be Nil Per Os (NPO or nothing by mouth.) As we watch them eat and drink we cringe and just wait for the pneumonia to set in. It doesn’t happen.
In the Skilled Nursing Facility (SNF)
Dr. Langmore also evaluated the risk factors for those patients in a SNF setting.
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.
A variety of conditions that increase the likelihood of aspiration and reduce the ability of the host to fight off an impending infection in nursing home residents:
- Dependent for feeding
- mechanically altered diet
- weight loss
- tube fed
- swallowing problem
- indicators of delirium/less alert
- advanced age
- multiple medications
- urinary tract infection
- dependent ADL status
Cognition and Aspiration Risk
Leder, Suiter and Warner found that patients not oriented x3 may be 31% more likely to aspirate.
The risk of liquid aspiration, puree aspiration and being deemed unsafe for any oral intake were, 57, 48 and 69% greater, respectively, for patients unable to follow single-step verbal commands.
Leder, S. B., Suiter, D. M., & Warner, H. L. (2009). Answering orientation questions and following single-step verbal commands: effect on aspiration status. Dysphagia, 24(3), 290-295.Aspiration Pneumonia
Aspiration pneumonia is a 3 phase process:
- Colonize pathogenic bacteria in the oropharynx
- Aspirate the bacteria into the airway
- Unable to clear the material and then develops a bacterial infection in the respiratory system
When we eat or drink, we have neutrophils present in the oral cavity that trap and fight pathogens. This is one of our bodies protective mechanisms that help to decrease the risk of an aspiration becoming a pneumonia. When there is an infection, such as a pneumonia, those neutrophils are needed elsewhere in the body and the protective mechanism is decreased.
Marik, P. E. (2001). Aspiration pneumonitis and aspiration pneumonia. New England Journal of Medicine, 344(9), 665-671.
Marik remarkably stated that “Approximately half of all healthy adults aspirate small amounts of oropharyngeal secretions during sleep.”
Also stated in that article: “The risk of aspiration pneumonia is lower in patients without teeth and in elderly patients in institutional settings who receive aggressive oral care than in other patients.”
Also: “otherwise healthy elderly patients with community-acquired pneumonia have a significantly higher incidence of silent aspiration than age-matched controls.”
A patient may be admitted to the hospital with pneumonia. They may have never had dysphagia. However, now their body is fighting infection, they are lying in bed, possibly on oxygen with respiratory compromise, they may have oral care that is lacking, they are probably on more medication than normal. All these factors may impact the swallow, but consider the fact that they may only impact the swallow during the progression of the illness.
Think Before you Label
Be cognizant when labeling your patient an “aspiration risk”. When you think about it, aren’t we all an “aspiration risk?”