Explanation
Aspiration is not equal to pneumonia; it does not always lead to pneumonia. Whether pneumonia occurs depends on several factors: the amount, bacterial content, and pH of what is aspirated (eg, the aspiration of gastric juice can severely injure the lung due to its low pH); the presence/absence of the cough reflex and the degree of expectoration force; local immunocompetence in the lung; and the body's protective capabilities (ie, nutrition and immune status).
Explanation
Pneumonia is the third leading cause of deaths among Japanese, with the elderly accounting for 95% of all pneumonia-related deaths.
Food aspiration is among the types of aspiration that can lead to pneumonia. Food aspiration can occur with or without choking (the latter is referred to as subclinical aspiration). Another type is non-food aspiration, which includes aspiration of saliva, pharyngeal secretions, or retained objects. This type is also referred to as micro-aspiration. Saliva aspiration is usually not accompanied by choking, so it is often referred to as subclinical aspiration. (In general, physicians familiar with videofluoroscopy, such as otorhinolaryngologists and rehabilitation physicians, refer to all types of aspiration without coughing as subclinical aspiration, regardless of the involvement of saliva, whereas internal medicine physicians, who consider aspiration as a cause of pneumonia, tend to refer to saliva aspiration as subclinical aspiration.) Subclinical aspiration of saliva during the nighttime has been associated with pneumonia, especially in the elderly. Gastroesophageal reflux can also lead to aspiration causing pneumonia, and this condition produces fewer subjective symptoms in elderly or bedridden individuals.
Explanation
The 3 main symptoms of pneumonia are cough, sputum, and fever. In the elderly, not all of these symptoms are always observed, but symptoms of overall physical dysfunction, such as mild consciousness disturbance and urinary incontinence, are often observed. An infiltrative shadow on chest X-ray or CT leads to definitive diagnosis of pneumonia.
Aspiration pneumonia occurs most frequently in the right lower lung. This is because the right principal bronchus is anatomically more vertical than the left, making an aspirated object more likely to fall into the right lung. However, when we detect an abnormality in another part of the lung, this does not always rule out aspiration pneumonia because the upper lobe, into which inspired air is more likely to enter, can be affected in some patients and the back side of the lung can be affected in bedridden individuals.
White blood cell (WBC) count and C reactive protein (CRP) are laboratory markers of inflammation and increase not only in pneumonia, but also in various inflammatory diseases such as infections and rheumatism. WBC count, although varying depending on the measurement method, is about 3000-8000/μL in normal individuals and tends to decrease in elderly individuals. CRP is a protein produced from the liver in response to inflammation or tissue destruction and is used as a measure of the degree of inflammation. The normal level is around 0.4 mg/dL and levels ≥1 mg/dL can be considered high.
According to the diagnostic criteria proposed by the Study Group on Diagnosis and Treatment of Aspiration-induced Lung Diseases for the Research and Development Grants for Longevity Science, patients that meet both of the following criteria are diagnosed with pneumonia:
①A pulmonary alveolar shadow (infiltrative shadow) detected on chest X-ray or CT
②Two or more of the following: fever ≥ 37.5°C, abnormally high CRP level, increased peripheral WBC of ≥ 9000/μL, and airway symptoms such as expectoration
Explanation
Meanwhile, the criteria for diagnosing pneumonia caused by aspiration (ie, aspiration pneumonia) have not been established. In cases when dysphagia is the only clinical factor thought to be related to the pneumonia, the patient should be considered to have aspiration pneumonia and treated accordingly. Shown here is the diagnostic flow chart (developed by the Study Group on Aspiration Pneumonia).
The Clinical Diagnostic Criteria for Aspiration Pneumonia* proposed by the Study Group on Diagnosis and Treatment of Aspiration-induced Lung Diseases for the Research and Development Grants for Longevity Science, defines the following types of pneumonia:
I. Definitive cases
IA. Direct evidence of aspiration observed and followed by the development of pneumonia.
IB. Patients with pneumonia in whom an aspirated object was retrieved from the airway by suctioning or other methods.
II. Probable cases
IIA. Patients who repeatedly show clinical symptoms of dysphagia, such as a clearing cough, after eating or drinking and meet the diagnostic criteria for pneumonia.
IIB. Patients who meet either criterion IA or IB and meet only one of the diagnostic criteria for pneumonia.
Aspiration pneumonia does not always occur independently; it often occurs in patients with non-aspiration pneumonia (eg, influenzal pneumonia, pneumococcal pneumonia) who had aspiration due to disuse syndrome resulting from long-term bed rest or illness, or in patients with chronic inflammatory lung disease (eg, emphysema, interstitial pneumonia) who had aspiration.
*Note: "aspiration pneumonia" is a type of swallowing-associated pneumonia and corresponds to the normal type of aspiration pneumonia shown in this slide.
Explanation
Fever in dysphagia patients is not always attributable to aspiration pneumonia. We should be aware that patients can become febrile due to various other physical dysfunctions, even if we are not responsible for making the diagnosis.
Urinary tract infections (UTI) include cystitis and, less frequently, pyelonephritis. Although urinary catheter placement undoubtedly increases the risk of UTI, patients with independent urination or incontinence may also be at increased risk of UTI if they have residual urine (inability to remove all of the urine in the urinary bladder). Treatment for UTI consists of antibiotics and prevention or reduction of residual urine.
The incidence of cholecystitis is also increased by long-term bed rest. Cholecystitis as a disuse syndrome is likely to occur when someone resumes eating after a certain period of fasting, during which bile secretion was not necessary, and the digestive tract, including the gall bladder, needs to start working. So, fever from cholecystitis tends to occur when eating resumes and must be differentiated from fever from aspiration pneumonia. Not all individuals with cholecystitis complain of abdominal pain, and the diagnosis must be established by a combination of increased biliary enzymes (eg, ALP and gamma-GTP), increased inflammatory markers (eg, CRP and WBC), and a distended gallbladder on echography or CT. Treatments include fasting, antibiotics, drainage (tube placement), and surgery. Prolonged fasting due to cholecystitis leads to disuse atrophy of the muscles used in swallowing[[was this your intended meaning?]], creating a vicious cycle.
We should suspect intestinal infection if the patient has diarrhea, and confirmatory stool culture is needed. Treatments include antibiotics and fasting. Clostridium difficile (CD)-related colitis accounts for most cases of nosocomial infectious diarrhea. This hospital-acquired infection cannot be prevented by alcohol hand washing and requires specific infection control strategies.
Fever may occur when the upper airway or lung is infected. In patients with a history of tuberculosis or MAC lung disease, flare-up should be suspected.
Explanation
Contact the attending physician to discuss if the fever can be attributed to aspiration caused by direct training and if the patient should be fasted until test results are available. Even if fasting is decided, indirect training should be continued to prevent further impairment of swallowing function unless the patient is severely ill due to fever. Discuss this with the attending physician.
If fever is attributable to aspiration caused by direct training, re-evaluate food consistency, method of feeding assistance, and amount of food used in the direct training and consider the possibility of subclinical aspiration having been overlooked. Discuss with the attending physician whether to resume direct training and under what conditions to resume it. Consider whether there are any interventions other than direct training can be added or modified, such as reinforcement of sputum expectoration training or reinforcement of oral care and body positioning. Also consider how to manage the risk of worsening nutritional status due to fasting (eg, patients with pneumonia require additional nutrients).
For patients with poorly controlled pneumonia, the management goals may be changed to, for example, long-term fasting or gastrostomy. Also consider the psychological impact on patients of lowering their goals.
Explanation
The prevention of aspiration pneumonia requires not only swallowing training, but also multifaceted interventions.
For the prevention of food aspiration, provide training and treatment to improve the swallowing function as well as adjust food consistency and use compensatory techniques and appropriate assistance during eating. Fasting is another way to prevent food aspiration.
Consider measures to reduce the risk of saliva aspiration in parallel. Encourage patients to carry out oral care and encourage pharyngeal care for patients on mechanical ventilation. Also, consider drug therapy for improving swallowing function.
Reduced incidence of gastroesophageal reflux leads to reduced incidence of pneumonia. Maintaining a sitting position after meal and lying in a head-up position during the night or bed rest are effective, but care should be taken to minimize the risk of bed sores developing in the sacral region caused by slide-down. For patients on enteral nutrition, avoid overfeeding to prevent reflux, consider the use of semisolid nutrients, and adjust the rate and order of infusion.
At the same time, because it is impossible to completely eliminate the risk of aspiration, interventions should be made to improve the patient's ability to cough and expectorate. These include improving the cough reflex with oral medications, improving the ability to expectorate through training, educating patients on sputum expectoration techniques, and providing prophylaxis with medication and suctioning.
To improve general physical strength (which is required to recover from pneumonia and coughing multiple times a day) and improve immunocompetence, it is important to improve the patient's activities of daily living, activity level, and nutritional status. To do this, fluid replacement and enteral nutrition may also be used in patients whose ultimate goal is to eat orally. (see the slide)
Foods and situations that can cause choking
There were 9346 choking-related deaths in 2016, 8493 (90.9%) of which involved elderly people.
Choking can be caused not only by rice cake, but also by various other types of food such as meat and bread. In addition to reduced masticatory force, inappropriate ways of eating (eg, overfilling the mouth) are also risk factors for choking in the elderly. Elderly people who are not aware of dysphagia and appear to be independent in eating may also be at risk of choking. Because early detection and treatment of choking leads to better outcomes, elderly people eating independently in bed should also be monitored regularly.
Explanation
In the event of choking, actions taken by people who witnessed it (ie, by-standers) can play an important role in the outcome.
When food can be seen in the mouth, the first thing to do is to pull it out with fingers, with care taken not to push it further back and understanding that it can't be taken out completely.
Heimlich maneuver: Stand behind the patient and hold the patient's upper body with both arms. Close the fist of one hand, place it between the patient's xiphoid process and navel, and put the other hand over the fist to join hands. Pull up the arms sharply to have them dig into the patient's abdomen and tighten and squeeze the patient's body upward.
The Japanese version of Emergency Resuscitation Guidelines developed by the Resuscitation Committee of the Japan Emergency Medical Foundation recommend the use of back blows or the Heimlich maneuver for people who are conscious (responsive) when choking and cardiopulmonary resuscitation for patients who have collapsed unresponsive. A foreign object may be removed by sternal compression performed for cardiopulmonary resuscitation.
The ambulance crew and medical doctors can use Magill forceps (and a laryngoscope) to remove a foreign body. In a hospital or other well-equipped facilities, suctioning is another effective means to remove a foreign body. For healthcare professionals who do not routinely perform suctioning, mastering the basic use of suction machines is useful for performing suctioning in emergency situations and for properly assisting in suctioning performed by multidisciplinary staff in emergency situations.
Although sputum suctioning used to be categorized as a medical act, the MHLW Health Policy Bureau Notification 0430 No. 1 allows physical, occupational, and speech-language-hearing therapists to perform sputum suctioning and other procedures under certain conditions. The same permission is granted to care workers and other care staff who have received certain training, under the Act for Partial Revision of the Long-Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure (Law No. 72 of 2011).
Explanation
First, shout for help while checking the patient's response (consciousness), respiration, and pulse. Call an ambulance if at home. Try to remove the object that the patient is choking on and start resuscitation if the patient is unconscious. Once people have gathered around, ask doctors, nurses, and/or the ambulance crew to take over treating the patient and help by, for example, gathering necessary supplies and preparing for transportation.
The person who found the patient choking should tell the doctors or nurses that the patient appeared to be choking when found and provide necessary information, such as what is the patient is choking on (if known), duration of choking, and time that the patient lost consciousness. Recording information is also important.
The time course of events should be briefly recorded and, after things have settled down, written up as a formal record or report (eg, incident report) in a specified format.
These incidents (regardless of any possible negligence) should be shared and discussed by the entire organization in order to prevent other occurrences.
To ensure that these actions can be taken immediately, the location of supplies should be routinely checked and training and other preparatory activities regularly carried out.
Explanation
One of the goals of treating dysphagia is to correct malnutrition caused by the dysphagia. So, the proper evaluation and management of malnutrition is important in dysphagic patients. They initially become nutritionally deficient due to reduced food intake, and then they take a longer time to swallow food and consume more energy for ingestion- and aspiration-related events, such as expectoration and protective responses to micro-aspiration. Because some dysphagia diets have high moisture content to ensure a soft texture, intake of the same amount of a different type of dysphagia diet may result in lower energy intake (eg, rice gruel vs rice). Moreover, malnutrition can cause muscle atrophy, muscle weakness, and peripheral neuropathy and prevent swallowing function from improving. Malnutrition is also a complicating factor of aspiration pneumonia, which is a complication of dysphagia.
When it is unlikely that malnutrition will be corrected soon by oral feeding, consider the use of parenteral nutrition to improve nutritional status.
Explanation
Dysphagia patients tend to become dehydrated because of insufficient water intake. As well as reduced intake of water by drinking, reduced oral intake of food also results in reduced intake of water. Patients taking thickened water for safety reasons can also have reduced water intake due to its poor taste or feelings of abdominal bloating.
Elderly people, even those without dysphagia, are at increased risk of dehydration because their reduced bodily water content makes them prone to the effects of insufficient water intake, and the signs of dehydration signs, such as thirst, are less likely to manifest, leading to delayed diagnosis. Some elderly patients refrain from drinking water to avoid waking up or going to the toilet during the night.
Explanation
Dehydration manifests as thirst and decreased amounts of urine, as well as more important symptoms including a dry tongue, dry skin, and consciousness disturbance. Patients presenting with all of these symptoms are likely to have a water deficit of about 3000 mL (10% of the body's water content).
Suspect dehydration with laboratory findings of increased blood urea nitrogen (BUN) with a minimal increase in creatinine (Cre). A BUN/Cre ratio of ≥ 25 indicates dehydration. Increased hematocrit (also observed in polycythemia) and increased uric acid also support the diagnosis.
A person weighing 50 kg loses about 20 mL/kg of water from the body surface and requires about 500 mL for waste excretion and therefore needs a total of 1500 mL of water. Because 200-300 mL is produced in the body, he or she needs an intake of at least 1200 mL of water. Although the basic approach is to set hydration at several different times, hydration through a non-oral route may also be required in certain circumstances.
