Vol. 19 • Issue 13 • Page 4
In the past 30 years speech-language pathologists have done an excellent job decreasing the risk of prandial aspiration, the aspiration of food and fluids. Our diagnostic tools and intervention techniques, though still being defined, have made this possible. However, this is not the only cause of aspiration pneumonia.
Non-prandial aspiration, or the aspiration of digesta from the stomach, and the aspiration of oral secretions also pose a significant risk to the fragile elderly in hospitals and extended care facilities. The newest challenges for speech-language pathologists are how to help prevent the aspiration of bacteria-laden saliva and foster better oral care in their settings and further reduce the incidence of aspiration pneumonia.
Microorganisms found it the lungs of elderly patients with pneumonia originate in the mouth and gingiva.1,2There is a link between poor oral hygiene and aspiration pneumonia.3-7
Even when we make patients NPO to prevent food and drink aspiration, they can become seriously ill because enteral and perenteral feedings cannot prevent the aspiration of bacteria-laden oral secretions. Oddly enough, interventions of diet modifications actually can make things worse for patients. Their refusal of pureed diets or thickened liquids can lead to dehydration and malnutrition, weakening the immune system and compromising lung health.
There are three categories of risk factors that lead to aspiration pneumonia:
•any factor that increases the bacterial load or colonization in the oral-pharyngeal cavity (e.g., lack of daily tooth brushing or xerostomia);
•any factor that decreases the patient's resistance to the inoculum (e.g., malnutrition or ventilator dependency); and
•any factor that increases the risk of aspiration (e.g., paralysis from stroke or chronic neurological disease affecting the muscles and nerves involved in swallowing).
Speech-language pathologists have been most successful in elucidating the last factor.
The oral cavity is a diverse and complex place where as many as 500 species of pathogens thrive in its warm, moist, dark environment. Through the interaction of saliva and soft and hard tissues such as your teeth and mucous membranes, we are able to prepare food for ingestion, begin digestion, and keep harmful bacteria under control. Saliva contains more than 135 constituents that help control bacterial colonization, prepare masticated food for swallowing, protect the surface of the teeth, and keep the mouth hydrated for speaking.
Without regular oral care or when oral care is suspended, as in a hospitalization for stroke or a surgical procedure, periodontal disease develops rapidly. Within just 48 hours the oral cavity becomes virulent and over-laden with gram-negative bacteria, staphylococcus aureus and yeast. Under stress the patient's immune system cannot sustain itself against this bacterial onslaught, and systemic disease will occur. When these bacteria are aspirated due to dysphagia, a decreased level of consciousness, poor positioning, etc., the immunocompromised person develops aspiration pneumonia.
Aspiration pneumonia ranks second in morbidity and first in mortality among nosocomial infections. Over time, particularly for those in long-term care, ongoing oral infections can lead to pain with chewing, refusal to eat, and loss of teeth, making it more difficult for patients to eat solid, high-protein foods. This further weakens the immune system, increasing the risk that pneumonia will develop from even small amounts of aspirated bacteria.
Oral care can decrease aspiration pneumonia rates, according to a growing body of evidence.8
Facilities and hospitals are providing evidence that these rates can decrease significantly with simple daily cleaning. Such programs can decrease morbidity, mortality, aspiration pneumonia rates, febrile days, length of stay, and health care costs.7,9-14
Physicians, nursing staff, patients and families do not understand the need for oral care. We must improve education, training and commitment from facility leadership to decrease the rate of aspiration pneumonia. Researchers have found this to be true, and there is a movement afoot to change.15
The speech-language pathologist usually is best equipped to meet this challenge and help to develop teams within settings. We have a unique knowledge of oral structures and functions and know how disease and trauma can change the status of the oral environment and how to combat aspiration pneumonia.
No one protocol meets the needs of patients in all settings. A team should develop a protocol in each setting. Ideally, the team should include speech-language pathologists, nurses, respiratory therapists, dietitians and nursing assistants, who most likely will perform the care. Physicians such as pulmonologists or internists would be helpful; and a dentist or dental hygienist, if available, would be very valuable. It is not the speech-language pathologist's responsibility to build and execute the protocol but to provide expertise, education and quality assurance support as a member of the team.
While all patients do not require the same interventions, general guidelines and practices can form the core of any oral hygiene program. Interventions include brushing, which removes dental plaque from teeth; swabbing, which removes oral debris and secretions and stimulates the oral mucosa; suctioning, which removes loosened dental plaque, debris and oral secretions; and moisturizing, which soothes and hydrates the lips and oral tissue.
Patients at risk include those who are dependent for oral care, have large numbers of missing teeth or dentures, have limited hand dexterity or decreased mental capacity, have multiple medical co-morbidities, are immunosuppressed or ventilator dependent, receive non-prandial feedings, have had a stroke or are neurologically impaired, have severe xerostomia, and have known dysphagia.
An oral hygiene program must begin with a good assessment tool. Some are available commercially, and others can be found on the Internet.16Any protocol should first identify the usual care practices of patients and then identify those most at risk and those that will need assistance.
An examination should be performed upon admission and at least once a day. Using a flashlight and tongue depressor, examine the oral mucosa, the lips and corners of the mouth, the tongue and teeth/dentures. Look for signs of candidasis or signs of xerostomia and check chewing and swallowing ability. Remember that the
environment of the oral cavity can change very quickly when health status, medications or dependency change.
A good program includes brushing at least twice daily, suctioning oral secretions to decrease the bacterial load, and keeping the oral mucosa moist with adequate hydration or saliva substitutes and moisturizers. Tools should be available in a place near the patient to allow for convenient cleansing.
Brushing with simple non-detergent toothpaste or baking soda is most effective. The antiseptic cetylpyridinium is available in most kits. Only swab with dental sponges between brushings to mop up secretions and other oral contaminants. Suction toothbrushes are available for known aspirators. While there is some evidence that electric rotary toothbrushes are more effective than manual brushes, the cost is prohibitive for most settings. A method for deep cleaning should be available when needed. Chlorhexidine can be prescribed for this. Dentures require the same care as teeth.
The oral care team must develop a policy and procedures for changing out and replacing suction equipment, using soft-tipped yankauer catheters, implementing special cleaning techniques for ventilators, and looking at ways to improve overall health in the at-risk patient.
1.Smith, D.T. (1927). Experimental aspiratory abscess. Archives of Surgery, 14: 231-39.
2.Smith, D.T. (1928). Fuso-spirochaetal diseases of the lungs. Tubercle, 9: 420-37.
3.Langmore, S.E., et al. (1998). Predictors of aspiration pneumonia. Dysphagia, 13 (2): 69-81.
4.Palmer, L.B. (1987). Bacterial colonization: Pathogenesis and clinical significance. Clinics in Chest Medicine, 8 (3): 455-66.
5.Scannapieco, F.A., et al. (1992). Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Critical Care Medicine, 20 (6): 740-45.
6.Marik, P.E. (2001). Aspiration pneumonitis and aspiration pneumonia. New England Journal of Medicine, 344 (9): 665-71.
7.Garcia, R. (2005). A review of the possible role of oral and dental colonization on the occurrence of health care-associated pneumonia. American Journal of Infection Control, 33: 527-41.
8.Sole, M.L., et al. (2003). STAMP study: ET/oral care and suctioning practices. American Journal of Critical Care, 12: 220-30.
9.Orr, J.C., et al. (2008). Health care associated pneumonia prevention using a comprehensive oral hygiene protocol. American Journal of Infection Control, 36 (5): e73-74.
10.Mori, H., et al. (2006). Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Medicine, 32: 230-36.
11.Yoneyama, T., et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of the American Geriatrics Society, 50: 430-33.
12.Adachi, M., et al. (2002). Effects of professional oral health care on the elderly living in nursing homes. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Edentonics, 94: 191-95.
13.Garrouste-Orgeas, M., et al. (1997). Oropharyngeal or gastric colonization and nosocomial pneumonia in adult intensive care unit patients. American Journal of Respiratory Critical Care Medicine, 156: 1647-55.
14.Scannapieco, F.A. (2006). Pneumonia in nonambulatory patients: The role of bacteria and oral hygiene. Journal of the American Dental Association, 137: 21-25s.
15.Munro, C.L., et al. (2004). Oral health and care in the intensive care unit. American Journal of Critical Care, 13 (1): 25-33.
16.Chalmers, J.M., et al. (2005). The Oral Health Assessment Tool: Validity and reliability. Australian Dental Journal, 50 (3): 191-99.
Tom Franceschini is clinical coordinator of the Heartburn and Swallowing Disorders Center at Hancock Regional Hospital in Greenfield, IN. He can be reached at (317) 468-4660 or http://firstname.lastname@example.org.