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Risk for Aspiration

By
Gil Wayne, RN
-
October 26, 2016

Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretion,
solids, or fluids into tracheobronchial passages.

Aspiration is breathing in a foreign object such as foods or liquids into the trachea and lungs and
happens when protective reflexes are reduced or jeopardized. An infection that develops after an
entry of food, liquid, or vomit into the lungs can result in aspiration pneumonia. Inhaling
chemical fumes or breathing in and choking on certain chemicals, even small amounts of gastric
acids can damage lung tissue, resulting in chemical pneumonitis. Many household and industrial
chemicals can produce both an acute and a chronic form of inflammation in the lungs which can
place patients at risk for aspiration. Acute conditions, like postanesthesia effects from surgery or
diagnostic tests, happen predominantly in the acute care setting. Chronic conditions, like altered
consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia, and
dysphagia from stroke, use of tube feedings for nutrition, and artificial airway devices such as
tracheostomies, may be experienced in the home, rehabilitative, or hospital setting.

Prevention is the main goal when caring for patients at risk for aspiration. Evidence shows that
one of the principal precautionary measures for aspiration is placing at-risk patients in a
semirecumbent position. Other measures include compensating for absent reflexes, assessing
feeding tube placement, identifying delayed stomach emptying, and managing effects of
prolonged intubation.

Contents [hide]

 1 Risk Factors
 2 Goals and Outcomes
 3 Nursing Assessment
 4 Nursing Interventions
 5 See Also
 6 Further Reading

Risk Factors

Here are some factors that may be related to Risk for Aspiration:

 Advanced age
 Anesthesia or medication administration
 Decreased gastrointestinal motility
 Delayed gastric emptying
 Depressed cough or gag reflex
 Drug or alcohol intoxication
 Facial, oral, or neck surgery or trauma
 Impaired swallowing
 Increased gastric residual
 Presence of gastrointestinal tubes
 Presence of tracheostomy or endotracheal tube
 Reduced level of consciousness
 Seizure activity
 Situations hindering elevation of upper body
 Tube feedings
 Wired jaws

Goals and Outcomes

The following are the common goals and expected outcomes for Risk for Aspiration:

 Patient is free of signs of aspiration and the risk of aspiration is decreased.


 Patient expectorates clear secretions and is free of aspiration.
 Patient maintains a patent airway with normal breath sounds.
 Patient swallows and digests oral, nasogastric, or gastric feeding without aspiration.

Nursing Assessment

Assessment is required in order to distinguish possible problems that may have lead to aspiration
as well as name any episode that may occur during nursing care.

Assessment Rationales
The primary risk factor of aspiration is
Assess level of consciousness.
decreased level of consciousness.
Monitor respiratory rate, depth, and effort. Note Signs of aspiration should be identified as soon
any signs of aspiration such as dyspnea, cough, as possible to prevent further aspiration and to
cyanosis, wheezing, or fever. initiate treatment that can be life-saving.
Evaluate swallowing ability by assessing for the
following: Impaired swallowing increases the risk for
aspiration. There remains a need for valid and
 Coughing, choking, throat clearing, easy-to-use methods to screen for aspiration
gurgling or “wet” voice during or after risk.
swallowing
 Residual food in mouth after eating
 Regurgitation of food or fluid through
the nares

For high-risk patients, performance of a


Review results of swallowing studies as videofluoroscopic swallowing study may be
ordered. indicated to determine the nature and extent of
any swallowing abnormality.
Nausea or vomiting places patients at great risk
for aspiration, especially if the level of
Assess for presence of nausea or vomiting. consciousness is compromised. Antiemetics
may be required to prevent aspiration of
regurgitated gastric contents.
Food should never be present in the
Observe for food particles in tracheal secretions
tracheobronchial passages. It signifies aspirated
in patients with tracheostomies.
material.
Reduced gastrointestinal motility increases the
risk of aspiration as fluids and food build up in
the stomach. Further, elderly patients have a
Auscultate bowel sounds to assess for
decrease in esophageal motility, which delays
gastrointestinal motility.
esophageal emptying. When combined with the
weaker gag reflex of older patients, aspiration is
at higher risk.
Aspiration of small amounts can happen with
Assess pulmonary status for clinical evidence of sudden onset of respiratory distress or without
aspiration. Auscultate breath sounds noting for coughing particularly in patients with
crackles and rhonchi. Monitor chest x-ray films diminished levels of consciousness. Pulmonary
as ordered. infiltrates on chest x-ray films indicate some
level of aspiration has already occurred.
An ineffective cuff can increase the risk of
Monitor the effectiveness of the cuff in patients
aspiration. Work together with the respiratory
with endotracheal or tracheostomy tubes.
therapist, as necessary, to verify cuff pressure.
In patients with nasogastric (NG) or gastrostomy tubes:
 Check placement before feeding, using A displaced tube may erroneously deliver tube
tube markings, x-ray study (most feeding into the airway. Chest x-ray verification
accurate), pH of gastric fluid, and color of accurate tube placement is most reliable.
of aspirate as guides. Gastric aspirate is usually green, brown, clear,
or colorless, with a pH between 1 and 5.
 Test sputum with glucose oxidase
Significant amounts of glucose in sputum may
reagent strips.
be indicative of aspiration.
 Check residuals before feeding, or every Large amounts of residuals indicate delayed
4 hours if feeding is continuous. Hold gastric emptying and can cause distention of the
feedings if amount of residuals is large, stomach, leading to reflux emesis. The amount
and notify the physician. of residuals may vary depending on the volume
and rate of infusion; however, the evaluation
can be unreliable. Feedings are often held if
residual volume is greater than 50% of the
amount to be delivered in 1 hour.
Food and feeding habits may be strongly tied to
Assess the patient and family for willingness
family cultural values. Acknowledgment and/or
and cognitive ability to learn and cope with
adjustment to cultural values can facilitate
swallowing, feeding, and related disorders.
compliance and successful family coping.

Nursing Interventions

The following are the therapeutic nursing interventions for Risk for Aspiration:

Interventions Rationales
Keep suction machine available when feeding A patient with aspiration needs immediate
high-risk patients. If aspiration does occur, suctioning and will need further lifesaving
suction immediately. interventions such as intubation.
Early intervention protects the patient’s airway
Inform the physician or other health care and prevents aspiration. Anyone identified as
provider instantly of noted decrease in being at high risk for aspiration should be kept
cough/gag reflexes or difficulty in swallowing. NPO (nothing by mouth) until further
evaluation is completed.
Maintaining a sitting position after meals may
Keep head of bed elevated when feeding and
help decrease aspiration pneumonia in the
for at least a half hour afterward.
elderly.
This positioning (rescue positioning) decreases
the risk for aspiration by promoting the
Position patients with a decreased level of
drainage of secretions out of the mouth instead
consciousness on their side.
of down the pharynx, where they could be
aspirated.
Supervision helps identify abnormalities early
Supervise or aid the patient with oral intake. and allows implementation of strategies for safe
Never give oral fluids to a comatose patient. swallowing. Withholding fluids and foods as
needed prevents aspiration.
Thickened semisolid foods such as pudding and
Provide foods with consistency that the patient
hot cereal are most easily swallowed and less
can swallow. Use thickening agents if
likely to be aspirated. Liquids and thin foods
recommended by a speech pathologist or
(e.g., creamed soups) are most difficult for
dietician.
patients with dysphagia.
Allow the patient to chew thoroughly and eat Well-masticated food is easier to swallow, food
slowly during meals. cut into small pieces may also be easier to
swallow.
Abdominal distention or rigidity can be
Note new onset of abdominal distention or associated with paralytic or mechanical
increased rigidity of abdomen. obstruction and an increased likelihood of
vomiting and aspiration.
Concentration must be focused on chewing and
For patients with reduced cognitive abilities,
swallowing. There is a higher risk for the
eliminate distracting stimuli during mealtimes.
airway to be opened when talking and eating at
Tell the patient not to talk while eating.
the same time.
During enteral feedings, position patient with Keeping patient’s head elevated helps keep
head of bed elevated 30 to 40 degrees; maintain food in stomach and decreases incidence of
for 30 to 45 minutes after feeding. aspiration
Place medication and food on the strong side of
Careful food placement promotes chewing and
the mouth when unilateral weakness or paresis
successful swallowing.
is present.
Ingesting food and fluids together increases
Offer liquids after food is eaten.
swallowing difficulties.
Place whole or crushed pills in soft foods (e.g.,
Mixing pills with food helps reduce risk for
custard). Verify with a pharmacist which pills
aspiration.
should not be crushed.
When turning or moving a patient, it is difficult
Stop continual feeding temporarily when
to keep the head elevated to prevent
turning or moving patient.
regurgitation and possible aspiration.
Oral care before meals reduces bacterial counts
in the oral cavity. Oral care after eating removes
Provide oral care before and after meals.
residual food that could be aspirated at a later
time.
In patients with artificial airways:
Suctioning reduces the volume of
 Perform oral suctioning as needed.
oropharyngeal secretions and reduces aspiration
risk.
 Brush teeth twice a day, and swab Oral care reduces the risk for ventilator-
mouth with sponge applicators every 2 associated pneumonia by decreasing the number
to 4 hours between brushing. of microorganisms in aspirated oropharyngeal
secretions.
In patients with NG or gastrostomy tubes:
 If ordered by physician, put several
drops of blue or green food coloring in
tube feeding to help indicate aspiration.
Colored secretions suctioned or coughed from
In addition, test the glucose in
the respiratory tract indicate aspiration.
tracheobronchial secretions to detect
aspiration of enteral feedings.
 Elevate the head of bed to 30 to 45
degrees while feeding the patient and for
30 to 45 minutes afterward if feeding is
intermittent. Turn off the feeding before Upright positioning reduces aspiration by
lowering the head of bed. Patients with decreasing reflux of gastric contents.
continuous feedings should be in an
upright position.

A speech pathologist can be consulted to


perform a dysphagia assessment that helps
determine the need for videofluoroscopy or
Consult a speech pathologist, as appropriate.
modified barium swallow and to establish
specific techniques to prevent aspiration in
patients with impaired swallowing.
Continuity of care can prevent unnecessary
For patients at high risk for aspiration, obtain
stress for the patient and family and can
complete information from the discharging
facilitate successful management in the home
institution regarding institutional management.
setting.
Establish emergency and contingency plans for Clinical safety of patient between visits is a
care of patient. primary goal of home care nursing.
Educate the patient and family the need for Upright positioning decreases the risk for
proper positioning. aspiration.
Information helps in appropriate assessment of
Instruct in signs and symptoms of aspiration. high-risk situations and determination of when
to call for further evaluation.
Demonstrate on suctioning techniques to Respiratory aspiration requires prompt action to
prevent accumulation of secretions in the oral maintain the airway and promote effective
cavity. breathing and gas exchange.
Refer the patient to a home health nurse,
Use of consultants may be required to ensure
rehabilitation specialist, or occupational
outcomes are achieved.
therapist as indicated.

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