The First Thing….
When I assess a patient with dysphagia, my first plan of attack is to teach the patient about oral care and start an oral care plan with that patient!
Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways, that is, the act of taking foreign material into the lungs. (http://emedicine.medscape.com/article/296198-overview)
What Causes the Pneumonia?
At one time, we thought the food/liquid that was aspirated was the most important factor in those who end up with aspiration pneumonia. I remember being told early in my career to avoid foods/drinks with high sugar content because they will cause the person to develop pneumonia.
Even recently, I was told that patients were ok to aspirate any liquid as long as it is clear. Any liquid that you can see through.
There are many factors in developing aspiration pneumonia. There are people walking around that aspirate on a daily basis that never develop pneumonia. Others simply look at a piece of pizza and bam, pneumonia. Health status, respiratory status, activity level, medications can all play a factor in the development of aspiration pneumonia. A major factor is oral care.
Bacteria from the oral cavity and nares are the main culprits in causing aspiration pneumonia including: Streptococus pneumoniae,Haemophilus influenza, Staphlococcus aureus, and gram-negative bacteria (Bacteroides, Prevotella, Fusobacterium).
Oral colonization of bacteria worsens with (Gomes et al 2003):
- Antibiotic use
- Oral disease
- Presence of teeth
- Patients who are dependent for oral care
- Have large numbers of missing teeth
- Have limited hand dexterity Decreased mental capacity Multiple medical co-morbidities Immunosuppressed
- Ventilator dependant
- Receive non-prandial feedings Have had a stroke
- Neurologically impaired Xerostomia
- Known dysphagia
- Poor access to professional dental care
- Active smoking
- Use of sedative medicine
- Use of gastric acid-reducing medication
- Use of ACE inhibitor
- Poor feeding position
Aspiration pneumonia is a 3 phase process:
- Colonizes pathogenic bacteria in the oropharynx
- Aspirates the bacteria into the airway
- Unable to clear the material and then develops a bacterial infection in the respiratory system
(Langmore S, Terpenning M., Schork A., Chen Y., Murray J., Lopatin D., Loesche W. Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 1998; 13: 69-81)
Proper oral care is essential in the elimination/reduction in this harmful bacteria. Oral care consists of brushing with a toothbrush and a toothpaste containing fluoride. Rinsing with a non-alcohol based mouthwash may also help with oral care.
Lemon glycerine swabs are not made for oral care and can, in fact, be very drying to the oral mucosa. They have no cleaning agent in them and can actually cause erosion to the enamel of the teeth, not to mention that they can irritate the mucosal membranes of the mouth an become very painful.
Toothette swabs do not create adequate friction to clean the oral cavity.
Improper oral care can be linked to increased risk of stroke.
Oral Care Assessment:
The Oral Health Assessment Tool (OHAT) is a tool that is great for use in the SNF setting. The user is able to rate the oral cavity condition and assign severity to oral care or lack of. It also prompts for an admission rating and quarterly ratings.
The Necessity of Oral Care
Oral care is an absolute necessity during a bedside evaluation. Have you ever tried to chew and swallow a cracker with a severely dry mouth or after you have not brushed your teeth for days? It’s not easy. While helping the patient or performing oral care, you have a great opportunity to educate the patient/family member/caregivers on oral care and its importance. Oral care is a great tool for patients that refuse an NPO status or for patients that are not compliant with diet recommendations. It’s an absolute essential for everyone.
Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., Hoshiba, K., … & Mizuno, Y. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of the American Geriatrics Society, 50(3), 430-433.
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.
Gomes, G. F., Pisani, J. C., Macedo, E. D., & Campos, A. C. (2003). The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Current Opinion in Clinical Nutrition & Metabolic Care, 6(3), 327-333.
Seedat, J., & Penn, C. (2016). Implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a South African setting. South African Journal of Communication Disorders, 63(1), 1-11.
Watando, A., Ebihara, S., Ebihara, T., Okazaki, T., Takahashi, H., Asada, M., & Sasaki, H. (2004). Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest, 126(4), 1066-1070.