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​Prevention of aspiration pneumonia and pneumonitis in patients who aspirate

(Marik, 2011)

  1. Good oral hygiene and tongue cleaning.
  2. Providing regular dental care and cleaning teeth with a toothbrush after each meal lowers the risk of aspiration pneumonia (Metheny, 2011).
    1. The upper airway should be suctioned following a witnessed aspiration.
  3. Endotracheal intubation should be considered in patients who are unable to protect their airway.
  4. Although common practice, the prophylactic use of antibiotics in patients with suspected or witnessed aspiration is NOT recommended. However, antimicrobial therapy should be considered in patients with an aspiration pneumonitis that fails to resolve within 48 hours.
  5. Tube feeding is not essential in all patients who aspirate. Short-term tube feeding, however, may be indicated in elderly patients with severe dysphagia and aspiration in whom improvement of swallowing is likely to occur.  Those patients whose dysphagia does not resolve may be candidates for placement of a PEG tube.
  6. Sedative medication has been demonstrated to increase the risk of pneumonia in residents of long-term care facilities and should, therefore, be avoided.
  7. The use of phenothiazines and haloperidol should be very carefully considered, as they reduce oropharyngeal swallow coordination, causing dysphagia.
  8. Medications that dry up secretions, including antihistamines and drugs with anticholinergic activity, make it more difficult for patients to swallow and should, therefore, also be avoided.
  9. Implement additional strategies to reduce aspiration in specific patient groups (see below)

Preventing aspiration in the critically ill

(American Association of Critical-Care Nurses, 2016)

  1. Maintain head-of-bed elevation at an angle of 30° to 45°, unless contraindicated.
  2. Use sedatives as sparingly as feasible.
  3. For tube-fed patients, assess placement of the feeding tube at four-hour intervals.
  4. For patients receiving gastric tube feedings, assess for gastro–intestinal intolerance to the feedings at four-hour intervals.
  5. For tube-fed patients, avoid bolus feedings in those at high risk for aspiration.
  6. Consult with provider about obtaining a swallowing assessment before oral feedings are started for recently extubated patients who have been intubated for more than two days.
  7. Maintain endotracheal cuff pressures at an appropriate level, and ensure that secretions are cleared from above the cuff before it is deflated. (American Association of Critical-Care Nurses, 2016)

Preventing aspiration in the older adult with dysphagia

(Metheny, 2011)

  1. Risk Assessment – Patients should be screened for risk factors for aspiration or dysphagia, and evaluated for dysphagia if risk factors are present. Screening should be performed by a speech-language pathologist when possible.
  2. Prevention of aspiration during hand feeding:
  1. Provide a 30-minute rest period prior to feeding time; a rested person will likely have less difficulty swallowing.
  2. Sit the person upright in a chair; if confined to bed, elevate the backrest to a 90-degree angle.
  3. The chin-down or chin-tuck maneuver is widely used in dysphagia treatment although it does not have a precise anatomical definition. The extent to which this maneuver is effective is unclear. Swallowing studies may be needed to determine which individuals are most likely to benefit from this position.
  4. Adjust rate of feeding and size of bites to the person's tolerance; avoid rushed or forced feeding.
  5. Alternate solid and liquid boluses.
  6. Vary placement of food in the person's mouth according to the type of deficit. For example, food may be placed on the right side of the mouth if left facial weakness is present.
  7. Determine the food viscosity that is best tolerated by the individual. For example, some people swallow thickened liquids more easily than thin liquids.
  8. Be aware that some patients may find thickened liquids unpalatable and thus drink insufficient fluids.
  9. Minimize the use of sedatives and hypnotics since these agents may impair the cough reflex and swallowing.
  10. Medications that dry up secretions should be avoided since they make it more difficult for patients to swallow.
  11. Evaluate the effectiveness of cueing, redirection, task segmentation and environmental modifications (minimizing distractions).
  12. Oral care after meals and snacks. (Clayton, 2012; Eisenstadt, 2010)

Preventing aspiration during tube feedings

(Metheny, 2012; American Association of Critical-Care Nurses, 2016)

  1. Keep the bed's backrest elevated to at least 30-degrees during continuous feedings.
  2. Assess placement of the feeding tube at four-hour intervals.
  3. Avoid bolus feedings in those at high risk for aspiration.
  4. Ask patients able to communicate if any of the following signs of gastrointestinal intolerance are present: nausea, feeling of fullness, abdominal pain, or cramping. These signs are indicative of slowed gastric emptying that may, in turn, increase the probability for regurgitation and aspiration of gastric contents.
  5. Measure gastric residual volumes every four to six hours during continuous feedings and immediately before each intermittent feeding. There is no convincing research-based information regarding how much gastric residual volume is 'too much'.
  6. Use of a promotility agent should be considered when an adult patient has two or more gastric residual volumes ≥ 250 ml.

Note: The incidence of pneumonia is not different in patients with nasogastric tubes and percutaneous feeding tubes. However, a gastrostomy tube is more comfortable for the patient than is prolonged use of a nasogastric tube.

Preventing aspiration in the pediatric population

(Dodrill & Gosa, 2015)

  1. Modified fluids – adding thickening agents or using naturally thick fluids (i.e., nectar).
  2. Modified foods – adjusting the texture or size of solid foods.
  3. Special feeding equipment - using different bottles, nipples, spoons, cups.
  4. Altering positioning and/or seating equipment.
  5. Altering pace of delivery of food.
  6. Swallowing maneuvers (i.e., chin tuck).

A multidisciplinary approach to assessment and management of dysphagia and aspiration pneumonia prevention in the pediatric population is important. (Dodrill & Gosa, 2015)

Note: See also Hospital Harm Improvement Resource - Healthcare Associated Pneumonia for details regarding Ventilator-Associated Pneumonia.

Conduct Clinical and System Reviews (see details below)

Given the broad range of potential causes of this clinical group, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.
  2. Use appropriate analytical methods to understand the contributing factors.
  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.

Useful resources for conducting clinical and system reviews: