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