Reduction of Risk for Aspiration Pneumonia

...why the goal of "reducing the risk of pneumonia caused by aspiration of colonized oral secretions" (should) not be considered a legitimate therapeutic goal. I use it as one of my goals in the acute care setting. Patients known to aspirate (as so many have cited in this thread) are already at increased pneumonia risk due to dysphagia, and have a greater risk due to colonized oral secretions. As we all know Langmore et al. (1998) concluded that dysphagia alone was insufficient to predict risk of morbidity and mortality but when combined with other risk factors including periodontal disease and dependency for feeding (odds ratio of almost 20 - that is a twenty-fold increase in risk) and oral care, dysphagia became an important risk factor for pneumonia.
Some additional evidence to support this include the recommendation from the Centers for Disease Control and Prevention that secretions lying above an endotracheal tube cuff should be removed prior to extubation, to reduce risk of health-care associated pneumonia - a category II recommendations (Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or by strong theoretical rationale) (CDC, 2003), as well as the natural history of oral colonization and biofilm development seen in a number of studies in the oral health literature.
Adachi et al, (2007) found a high prevalence of oral pathogens (staph. aureus, pseudomonas species, and yeast (candida albicans) in nursing home patients, and showed a significant decrease in incidence of "fatal aspiration pneumonia" in patients receiving professional oral hygiene (by dental hygienists) than in those that did not (I cannot get the actual article so this is cited only from their abstract; the methods are not detailed enough in the abstract to allow critical appraisal. Likewise Azarpazhooh et al. (2006) conducted a systematic review that is well designed, on the association between oral health and respiratory infections. This study identified "fair evidence (II-2, grade B recommendation) of an association of pneumonia with oral health", and "good evidence (I, grade A recommendation) that improved oral hygiene and frequent professional oral health care reduces the progression or occurrence of respiratory diseases among high-risk elderly adults living in nursing homes and especially those in intensive care units". This evidence might help justify these clinical procedures by SLP's however appropriate training should precede such programs.
In the School in which I teach, faculty in the Clinical Dietetics program (and I understand this is an institutionalized professional initiative in their field) are teaching their students to conduct "physical examinations" including oral inspections to identify risks associated with oral intake. Dental hygienists are not ordinarily seen in nursing homes yet SLP's are, so perhaps as front-line observers of oral condition in these patients, SLP's are justified in performing at least screenings. Either we need dental hygienists in nursing homes or SLP's need to learn this important skill (or at least advocate for support to train (on an ongoing basis) the CNA's in these facilities).
Adachi, M., Ishihara, K., Abe, S., & Okuda, K. (2007). Professional oral health care by dental hygienists reduced respiratory infections in elderly persons requiring nursing care. International Journal of Dental Hygiene, 5(2), 69-74.
Azarpazhooh, A., & Leake, J. L. (2006). Systematic review of the association between respiratory diseases and oral health. Journal of Periodontology, 77(9), 1465-1482.
Centers for Disease, C., & Prevention (2003). Guidelines for preventing health-care associated pneumonia, 2003 (No. MMWR, 53 (RR-3)).
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., et al. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81.
Cheers,
James L. Coyle, Ph.D., CCC-SLP; BRS-S
Assistant Professor, Communication Science and Disorders University of Pittsburgh

Risks for Dehydration and/or Pneumonia

In the coming year the data from the Protocol 201 study, some of which was presented at the 2006 ASHA meeting, will be published. This study randomized aspirating Parkinson’s and dementia patients to either thin liquid using a chin-down posture, or thickened liquids (nectar or honey) for either three months follow up, or primary clinical end point (outcome of interest) of pneumonia, but hydration and nutritional parameters were also followed.



At the time of the ASHA meeting in 06, one interesting result presented was that patients in this study randomized to the “honey” thickened liquids intervention for managing aspiration of thin liquids, compared to the “nectar” thick and chin-down posture interventions, had significantly longer hospitalizations for pneumonia, than the pneumonia hospitalization durations for the other two interventions. I hope that the authors will clarify this with some data in their manuscripts and discuss this, as this “gel” discussion relates to the exact nature of the 201 finding: does aspirated thick liquid produce worse adverse outcomes than aspirated thin liquid.



The gel discussion aside, another important consideration is whether the patient drinks sufficient liquids once they are prescribed in their thick form. If we shift the risk from a potential respiratory adverse outcome (pneumonia) to a metabolic adverse outcome (inadequate hydration), there may be no net gain.

James L. Coyle

University of Pittsburgh

Estimating Risk of Pneumonia

James L. Coyle of the University of Pittsburgh wrote on the Dysphagia List-Serve:

"Eisenhuber et al (2002) developed a three point scale, using the height of retention in the vallecular and pyriform sinuses, as scale values.

A score of 1 corresponded to “less than 25% of the height” of the cavity described, 2 to “25-50% height”, and 3 to “>50% height”. They adapted a rating system published earlier by Perlman et al. (1994) by taking the published height values and attributing the values in the 3 point scale to the three measures created by Perlman.

They then used videofluoroscopy to determine whether pharyngeal retention seen on fluoroscopic images was predictive of laryngeal penetration or aspiration. They did not differentiate between the two (penetration, aspiration), instead lumping them together. This makes it difficult for the reader to know with certainty which outcome (penetration, aspiration) should be expected. They also lumped vallecular and pyriform sinus retention together in the attribution of aspiration/penetration risk however 83% of their patients had retention in both.

At any rate, The score “3” for pharyngeal retention was significantly more likely (about 4 to 1 odds of higher likelihood) to be followed by laryngeal penetration or aspiration than scores of 1 or 2. One finding that is a bit easier to swallow (ha ha) was that 93% of patients with pharyngeal retention (valleculae or pyriform sinuses or both) exhibited laryngeal penetration or aspiration whereas only 33% of patients without retention exhibited penetration or aspiration.

Robbins et al. (1999) used the penetration aspiration scale to differentiate between normals, and two groups of disordered swallowers (stroke, head and neck cancer). They found that 21% of normals exhibited high laryngeal penetration (no deeper than the vestibule-PAS scores of 2 or 3). Therefore deep penetration (to vocal folds) is not normal (nor is aspiration).

Combining the two measures, one can attribute risk of laryngeal penetration or aspiration to the height of pharyngeal retention, and the risk of inhalation of swallowed material to the severity of laryngeal penetration and aspiration. Added to the other host risk factors predisposing a patient to pneumonia, the clinician can generate a reasonable likelihood of pneumonia.

We use the two scales together to attribute risk associated with the dysphagia and discuss the additional risk factors to estimate pneumonia risk."

James L. Coyle

University of Pittsburgh

Reference List

Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., Scharitzer, M. et al. (2002). Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration. American Journal of Roentgenology, 178, 393-398.

Perlman, A. L., Booth, B. M., & Grayhack, J. P. (1994). Videofluoroscopic predictors of aspiration in patients with oropharyngeal dysphagia. Dysphagia, 9, 90-95.

Robbins, J. A., Coyle, J. L., Rosenbek, J. C., Roecker, E. B., & Wood, J. L. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14, 228-232.