Pa Patient Saf Advis 2009 Dec;6(4):115-21.
Does Your Admission Screening Adequately Predict Aspiration Risk?
Emergency Medicine; Internal Medicine and Subspecialties; Nursing
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Abstract

The National Quality Forum and the Agency for Healthcare Research and Quality identified aspiration risk assessment as a practice to reduce the risk of harm to patients. Pennsylvania healthcare facilities submitted 133 nonanesthesia aspiration event reports to the Pennsylvania Patient Safety Authority from June 2004 through January 2009. Seventy-three (55%) of these event reports indicated that swallowing or aspiration assessments had been completed before the event occurrence. The remaining 60 (45%) reports of nonanesthesia aspiration indicated patients had not received aspiration risk screenings or assessments before the aspirations. Thirty-eight (29%) of the nonanesthesia aspiration reports describe instances in which barriers were identified during aspiration risk screening and as aspiration precautions were implemented. While video fluoroscopic swallow evaluation is considered the “gold standard” for predicting aspiration, aspiration screening of patients on admission can help determine whether a more detailed aspiration assessment and fluoroscopic swallow evaluation are indicated and help to identify dysphagia and patients at risk for aspiration.

The Problem

The National Quality Forum and the Agency for Healthcare Research and Quality (AHRQ) identified the aspiration risk evaluation of each patient upon admission and regularly thereafter as a suggested patient care practice.1 Patients who aspirate are at greater risk of developing serious respiratory complications such as airway obstruction or aspiration pneumonia. Aspiration pneumonia is one of the most common forms of hospital-acquired pneumonia among adults and occurs in 4 to 8 of every 1,000 admitted U.S. patients.2 Patient conditions that present a high risk for aspiration include stroke or other neurologic impairment that affects swallowing, tracheostomy or endotracheal intubation, advanced age, changes in the oropharyngeal anatomy due to trauma, surgery complications, neoplasm, pneumonia, unexplained weight loss, or even body position.3 Routine bedside aspiration risk assessments are noninvasive, typically evaluate patient symptoms, and are designed to be administered quickly. Invasive diagnostic procedures such as the fiberoptic endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallow evaluation (VSE) visualize the anatomy and physiology of a patient’s swallowing and are frequently used when a suspected swallowing disorder has been identified by a routine bedside aspiration screening. Many aspiration risk assessment tools are already available to assist anesthesia providers with aspiration prescreening criteria for patients receiving anesthesia, but there are few such tools for the newly admitted hospital patient. The benefit of adopting aspiration risk screening tools will provide organizations with the ability to promptly identify those patients who are experiencing dysphagia and may be at risk for aspiration. This screening may also provide healthcare providers with baseline information to complete a more detailed aspiration assessment to assist in the identification and treatment of patients with aspiration, to prevent aspiration events, to provide optimal patient care, and to ensure accurate patient information exchange through all levels of care.

Pennsylvania Patient Safety Authority Reports

Of the 133 nonanesthesia aspiration Incidents and Serious Events reported to the Pennsylvania Patient Safety Authority’s reporting system from June 2004 through January 2009, 73 (55%) of the events indicated that patients had been assessed for aspiration risk before the nonanesthesia aspiration event. Fifteen (11%) of the aspiration events required transfers to a higher level of care, and 7 (5%) resulted in patient death.

Events that resulted in transfer to higher levels of care include the following:

The patient began to cough, followed by vomiting, developed worsening respiratory symptoms, and was transferred to the ICU [intensive care unit] with shortness of breath and aspiration.

The patient was found with cyanotic face and lips upon entering the room to complete an assessment. The rapid response team was called. The patient began coughing up whole pieces of chicken. The patient was transferred to the ICU.

The patient was eating a sandwich and began to choke. Heimlich attempts were unsuccessful. The food particles [were manually] removed, and the patient [was transferred to the ICU] and intubated.

Events that resulted in patient deaths include the following:

A patient vomited during the night and [the order to administer the patient nothing by mouth] NPO [was written]. In the morning [the patient was] found unresponsive. Despite aggressive resuscitation [efforts], the patient ceased to breathe. Silent aspiration is considered the cause of death.

A patient had moderate to severe dysphagia [following a] stroke. Family [members] brought in solid food, which the patient ate and [immediately began] to choke. Despite immediate resuscitation efforts, the patient expired.

A patient with recent history of stroke was placed on pureed dysphagia diet after nutrition and speech evaluations. After being fed [a meal] by [a family member], the patient became [short of breath]. Suctioning [the patient] produced the [meal] contents. The patient was intubated, transferred to the cardiac care unit, [and died as a result] of aspiration.

The remaining 60 (45%) reports of nonanesthesia aspiration indicated patients had not received aspiration risk screening or assessments before the aspiration events.

Of the 55% of reports indicating patients had been assessed for aspiration risk before a nonanethesia aspiration event, analysis identified the following contributing factors:

  • Patients received inappropriate nutrition in 28 (38%) of the events, including delivery of incorrect nutrition to patients who were NPO (nothing by mouth), family members who fed patients who were NPO, or missed patient bedside NPO alerts.
  • Miscommunication occurred between healthcare providers and departments in the hospital in four (5%) of the events (e.g., NPO notification between patient care areas and the dietary department).
  • Medication-related issues were evident in three (4%) of the events, including some patients who received unauthorized medication doses and incidence of staff knowledge deficit (e.g., NPO clarification between prescribers and nurses when patients are NPO except for medications versus exclusively NPO).
  • Tubing insertion misplacement issues occurred in three (4%) of the events involving endotracheal, nasogastric, or gastrostomy tubes.

The Complexity of Swallowing

It is important for healthcare providers to understand the complexity of normal swallowing in order to recognize, identify, and treat patients with swallowing difficulties and aspiration. Furthermore, provider knowledge will assist in prevention efforts, help provide optimal patient care, ensure accurate communication and patient information exchange through all levels of care, and aid in educating patients and family members about abnormal swallowing.

Normal Swallowing

Normal swallowing is a complicated act that relies on independent cognition, upper extremity mobility, oral mobility, taste, smell, and vision capabilities. It involves more than 26 muscles that control facial, palatal, suprahyoid, and pharyngeal structures, whose actions are coordinated by the cerebellum.4,5 Normal swallowing also depends on the intact function of the trigeminal, facial, glossopharyngeal, vagus, and hypoglossal cranial nerves.5 Successful swallowing occurs with the completion of the oral preparatory, oral propulsive, pharyngeal, and esophageal phases of swallowing.2,3,4

Impairment to the oral phase of swallowing may result in difficulty retaining the food or liquid bolus in the oral cavity or chewing or moving the material toward the oropharynx. Associated symptoms with impairment in the oral phase of swallowing may include drooling, pocketing of food in the buccal cavity, poor tongue movement, leakage of food or liquid from the mouth, or difficulty initiating the swallowing process.5

The pharyngeal phase of swallowing is under involuntary neuromuscular control and triggers the swallowing reflex as the food or liquid moves with a progressive contraction wave from top to bottom. Impairment to the pharyngeal phase of swallowing can result in the food or liquid material being retained in the oropharynx and overflow aspiration after swallowing. Associated symptoms with impairment in the pharyngeal phase of swallowing include nasal regurgitation, coughing, choking, hoarseness, or food sticking in the throat.5

The esophageal phase of swallowing begins after the food or liquid passes through the upper esophageal sphincter.1,5 Impairment to the esophageal phase of swallowing may result in ineffective movement and retention of the bolus of food or liquid in the esophagus. Associated symptoms with impairment in the esophageal phase of swallowing may include burping, indigestion resulting from esophageal reflux, heartburn, chest pain, or silent aspiration.5

Anything that interferes or impairs with any of the normal swallowing phases is defined as dysphagia, which may cause morbidity and mortality.4

Dysphagia

Dysphagia, or difficulty swallowing, may cause problems that range from symptoms of mild throat discomfort to an inability to eat.1 Dysphagia may be a symptom of one or more underlying pathologies and may include complications related to age, structure, neurologic and neuromuscular impairment, medication side effects, surgery, infections, iatrogenic conditions, and irradiation effects of the head and neck. Fifty percent of adult patients in acute care facilities are reported to experience dysphagia, while 66% of those in long-term care facilities have swallowing difficulties.7 Dysphagia makes a patient more prone to malnutrition, dehydration, aspiration, aspiration pneumonia, subsequent respiratory failure, and possible death.8 Normal aging has subtle effects on all four stages of swallowing.5 Presbyphagia, or normal changes in the swallowing mechanism secondary to aging, compounds the risk for aspiration.9,10 Aging causes changes in the structure, motility, coordination, and sensitivity of the swallowing process.5,9,11

McCullough et al. used an 8-point penetration-aspiration scale incorporating thin liquid, puree, and solid and bolus sizes from 5 mL to 3 ounces in 79 normal adults ranging in age from 21 to 103 years old. This study found that laryngeal penetration is common for older individuals, often resulting in retained material in the laryngeal vestibule after swallowing, which is consistent with changes in the swallowing physiology that occur with the aging process. Increase in the time to swallow has the potential to create problems, including aspiration. Penetration-aspiration was more common with older participants. Over- or undermanaging these changes may present unnecessary restrictions on nutritional intake or negative consequences that affect the quality of life, even though this study provided some data that supports that aspiration in small quantities is normal for some older adults.11 This makes it even more difficult for healthcare providers to assess aspiration risk for these patients.

Common presenting symptoms of oral or pharyngeal dysphagia include coughing or choking with swallowing, difficulty initiating swallowing, food sticking in the throat, drooling, unexpected weight loss, change in dietary habits, recurrent pneumonia, change in voice or speech, and nasal regurgitation. Signs of esophageal dysphagia include the sensation of food sticking in the chest, oral or pharyngeal regurgitation, food sticking in the throat, drooling, unexpected weight loss, change in dietary habits, and recurrent pneumonia.4,5,10

Aspiration

Aspiration is the passage of food or liquid through the true vocal cords and is often caused by impaired laryngeal closure but may also occur because of the overflow of food or liquids retained in the pharynx. Cervical spine surgery increases aspiration risk by more than 40%.2 Factors that influence aspiration include quantity, depth (material in the distal airways is more dangerous than aspirating material in the pharynx), physical properties of the aspirate, and pulmonary clearance mechanisms.4 The bedside swallowing assessment provides the early identification of those patients at greatest risk for dysphagia and aspiration. The VSE is the “gold standard” for predicting aspiration, and aspiration screening of patients on admission can help determine whether a more detailed aspiration assessment and fluoroscopic swallow evaluation are indicated; therefore, an accurate and valid risk assessment tool is vital.2,4,12 This will help identify dysphagia and patients at risk for aspiration.

Sitoh et al.’s prospective study of 65 geriatric patients used a bedside swallowing assessment that incorporated criteria known to be associated with aspiration risk, including cough upon swallowing, delay in swallowing, and drooling. The study found the simple assessment swallowing protocol was useful in helping to identify patients at risk for swallowing dysfunctions and those at risk for developing chest infections. Fourteen of the 65 patients subsequently contracted hospital-acquired pneumonia; 13 of those had been identified as having swallowing dysfunctions, based on the bedside swallowing assessments. One limitation to the study was the lack of video-fluoroscopic or endoscopic confirmation of aspiration.13

Overt aspiration may occur with patients who have dysphagia. Aspiration pneumonia is the second most common healthcare-acquired infection in hospitalized patients.3,14 Patients with endotracheal tubes have a high risk for aspiration and may also experience prolonged swallowing dysfunction after extubation.3 The presence of a nasal or oral feeding tube, gastroesophageal reflux, or those patients tube fed in the supine position may have increased swallowing dysfunction, thereby increasing aspiration risk.3,14 The right lower lobe is the most frequent site of aspiration due to its larger caliber and straighter orientation of the right mainstem bronchus. The left lung is more difficult to suction secondary to the fact that the left bronchus is narrower, longer, and has a more horizontal angle than the right lung, making it more difficult to suction the intubated patient.3 There are also patients who may regularly experience silent aspiration when food or liquid material is inhaled without a discernable gag reflex, cough, or other identifiable apparent difficulties.10,12

Silent Aspiration

Silent aspiration is the occurrence of aspiration before, during, or after swallowing in the absence of cough or other apparent signs of distress.2,12,15 Patients with silent tracheobronchial aspiration have a 13-fold increased risk for developing pneumonia.2,12 Silent aspiration cannot be diagnosed without the aid of instrumentation, since patients do not display overt signs (coughing) and often deny swallowing difficulty; thus, silent aspiration requires a higher index suspicion. As a result, the healthcare prescriber may elect to incorporate the assistance of a speech language pathologist (SLP) who may recommend performing a modified barium swallow study or FEES to rule out silent aspiration in these at-risk patients. At-risk patients who have been found to silently aspirate include those with altered mental status and decreased awareness; decreased sensation due to stroke, neurological disorders, or head and neck cancers; gastrointestinal problems; and those who are generally weak or deconditioned. Researchers have found that very young and elderly patients are more susceptible to silent aspiration.11,12

Contraindication for use of VSE includes lethargy, absent swallow response, abnormal upper airway sounds, need for frequent oral/pharyngeal suctioning, those patients unable to cooperate, tachypnea, and some critically ill patients.2 Clinical identifiers that may predict the need for a swallowing evaluation include a new cough, sputum, fever, rigors, breathlessness, wheezing, pleuritic chest pain, sore throat, and head cold symptoms. However, classic symptoms are often absent, diminished, or nonspecific in the elderly and may include tachypnea, lethargy, functional decline, incontinence (new onset), alteration in sleep-wake cycles, loss of appetite, and increased confusion or agitation.

Due to the high incidence of silent aspiration in acute care settings, SLPs do not rely solely on the absence of signs or symptoms to rule out silent aspiration. Patients determined to be at risk, but who are without cough or complaint, warrant further evaluation. Many factors predispose patients to silent aspiration, including altered level of consciousness, enteral feeding, cerebral vascular accident, increased age, gastroparesis, gastrophageal reflux, seizure, neurologic dysfunction, structural lesions, psychiatric disorder, connective tissue diseases, iatrogenic causes, neurologic disorders, and medication side effects.2,3,4,10,12  Ramsey et al. suggest that silent aspiration likely occurs in healthy individuals during sleep and in many disease states.12 This make it more difficult for healthcare providers to assess aspiration risk for these patients.

Smithard et al.’s prospective study concluded that bedside assessment alone lacks the necessary sensitivity to use as the sole screening tool in predicting acute stroke complications such as aspiration. In this study, 94 patients who had been admitted to 1 of 2 hospitals with a diagnosis of stroke underwent video-fluoroscopy, medical bedside assessments by physicians, and bedside assessments by SLPs. Twenty patients were identified to be aspirating on video-fluoroscopy. Twenty-one percent of these patients had not been recognized as actively aspirating from their medical bedside assessments. The medical bedside assessment sensitivity was 70% compared to the SLPs’ bedside assessment of 47%. VSE is considered the gold standard in identifying aspiration risk, and the video-fluoroscopy is one portion of this assessment but may be cost prohibitive for predicting acute stroke complications such as aspiration. The study results suggest that the hospitals involved revise and simplify their aspiration bedside assessments to adequately predict aspiration risk following acute stroke diagnosis.16

Guidelines

In 2006, the American College of Chest Physicians (ACCP) developed 15 evidence-based clinical practice guidelines for cough and aspiration of food and liquid due to oral-pharyngeal dysphagia.2 These guidelines address conditions that have a high risk for aspiration and silent aspiration. The conditions include neurologic impairment (e.g., cerebrovascular disease, head trauma, cervical spine injury, anoxia, seizure disorder, Parkinson’s disease, Alzheimer’s disease); surgery related (e.g., vocal fold paralysis, brain surgery, coronary artery bypass grafting, cervical spine surgery); structural (e.g., glossectomy); gastrointestinal problems; pulmonary problems (e.g., bronchitis); intubation for greater than 48 hours; ventilated patients; and medication side effects (e.g., sedatives, neuroleptics).2

The guidelines suggest that those patients with high-risk conditions be referred for an oral-pharyngeal swallowing evaluation. Patients experiencing cough should be questioned regarding their perception of choking or fear of choking while eating or drinking and a chest x-ray, and a speech assessment may be considered to rule out aspiration. The evaluation of those patients with oral-pharyngeal dysphagia, cough, and those conditions associated with aspiration may include an oral-pharyngeal swallow evaluation. Those patients at high risk for aspiration, with reduced level of consciousness, should be kept NPO until there is an increase in sensorium. The guidelines also suggest that alert patients with medical diagnosis and conditions associated with aspiration be assessed while drinking small sips of water. If the patient exhibits clinical signs of aspiration, the patient may be referred for a detailed swallowing evaluation. These guidelines suggest that those patients with dysphagia have VSE or FEES evaluation of their swallowing ability to determine appropriate treatment. An aspiration assessment relies on the clinician’s subjective evaluation, while the VSE and FEES provide direct visualization of the anatomy and physiology of swallowing. Limited economic and staffing resources make the regular use of VSE and FEES nearly impossible on every admitted patient, so dependence on the bedside aspiration assessment alone becomes essential when determining aspiration risk.2

The guidelines also suggest that the management of patients with dysphagia be the responsibility of an organized multidisciplinary team, including a physician, nurse, an SLP, dietitian, and physical and occupational therapist. The goals of this team include focusing on aspiration reduction, improving swallowing ability in order to optimize the patient’s nutritional status and quality of life, determining compensatory strategies for those at high risk for aspiration patients to enable safe swallowing, and providing dietary recommendations.2

Mitigation Strategies

The development of mitigation strategies continues to be a priority when identifying patients with swallowing difficulties and those at risk for aspiration and silent aspiration upon admission. These strategies may include bedside swallowing screening and assessment, radiologic swallowing assessment, individualized swallowing treatment plan, and assessment for medications that affect swallowing.

Bedside Swallowing Screening and Assessment

Aspiration screening and assessment are two distinct procedures, conducted at separate times by different healthcare providers. The preliminary aspiration screening is typically performed by a nurse during the patient admission assessment. The full bedside swallowing assessment is typically conducted by the SLP after the preliminary screening identified the patient as high risk for aspiration.15,17 There are various types of full bedside swallowing assessments in the clinical literature, but the literature reports very few preliminary bedside screening tools. Many of the preliminary bedside swallowing screening tools do not contain the sensitivity and specificity to identify dysphagia or aspiration.7,10,15,18 A preliminary swallowing screening performed at the admission assessment can be an effective tool to determine whether additional swallowing evaluations are warranted.10

Hinchey et al. conducted a prospective study of 15 acute care hospitals in which 6 of the hospitals had formal dysphagia screening protocols. The hospitals’ adherence rate to the screening protocols rate was 78% compared with 57% for the other 11 acute care facilities that lacked formal dysphagia screening. The dysphagia screening was defined as a checklist that assessed patients for previous and current risk factors for aspiration, based on clinical findings. If the patient passed the initial screening, a water challenge followed, and the patient was observed. If the patient failed the initial screening, an NPO order was initiated, followed by further evaluation by an SLP. Dysphagia screens were performed before any oral intake by the patient. The results for pneumonia rates at the hospitals with a formal dysphagia screen were 2.4% versus 5.4% for the hospitals that did not have formal dysphagia screening. Patients who experienced a stroke and had received a formal screening that were used to treat the patient were found to have significantly decreased odds (three-fold) of developing pneumonia after consideration for stroke severity.19

A preliminary bedside swallowing screening tool may be in checklist or algorithm formats, which may be easily conducted with the patient admission assessment.10,18 The Massey bedside swallowing screen is an example of such a tool (a reprinted copy is available online from the Authority). This particular tool has content that has been shown to have predictive validity and interrater reliability. Sensitivity and specificity were determined by retrospective chart analysis to determine postscreening evidence of dysphagia.8 All preliminary bedside tools screen a patient’s swallowing abilities through a series of questions, the presence of a variety of symptoms, and the use of clinical indexes to identify patients with dysphagia, at risk of aspiration, or who have no prior history of dysphagia but meet the criteria for a full bedside swallowing assessment.4,8,13,17-19

While AHRQ identified a suggested patient care practice to include the evaluation of each patient for aspiration risk upon admission and regularly thereafter, the use of preliminary bedside screening tools can provide facilities the minimum requirements and key elements needed to identify patients with dysphagia and those at greater risk for developing aspiration. While AHRQ has not recommended any single screening tool, the agency suggests a formal dysphagia screening protocol may decrease the risk of pneumonia by three-fold.19 The Joint Commission dysphagia screening requires that patients who have experienced a stroke be assessed for dysphagia before any food, fluids, or medications are administered orally. A preliminary bedside swallowing screening will promptly identify those patients at high risk for dysphagia, developing aspiration, or those experiencing silent aspiration, so a timely full bedside swallowing assessment can be provided.1

Several forms of full bedside swallowing assessments may be used to evaluate patients at high risk for aspiration or for those who have swallowing difficulties. Full bedside swallowing assessments typically involve a questionnaire that includes care history information; review of auditory, visual, and motor status; screening of cognitive/communications skills; a noninvasive oral-pharyngeal exam that includes the oral cavity; evaluation of oral motor skills and laryngeal function for phonation; observation of respiratory function; and functional swallowing trials.1,18 Various acceptable methods are included in a full bedside swallowing assessment, including a simple standard bedside swallowing assessment and formal evaluation by an SLP.17 The Joint Commission excludes the National Institutes of Health Stroke Scale rating and the documentation of a gag reflex or positive gag as the full evaluation for screening dysphagia. The dysphagia screening may include the minimum of a formal bedside swallowing assessment.18,20 Patients who are waiting for the completion of the full bedside swallowing assessments are typically kept NPO until the testing is conducted so an individualized patient treatment plan may be developed. Full bedside assessments may also include the patient’s health history, nutritional status, medications, physical examination, and diagnostic evaluation.6 A diagnostic evaluation may be conducted through the VSE.

Radiologic Swallowing Assessment

ACCP practice guidelines identify VSE screening as beneficial for those patients with medical conditions or diagnosed as being at high risk for developing aspiration or those with silent aspiration. Penetration occurs when food or liquid material enters the laryngeal area to the level of the true vocal cords. Aspiration occurs when the food or liquid material moves below the true vocal chords and enters the trachea.3 Silent aspiration is often not recognized and therefore is not treated.

A FEES is used by the SLP for the functional evaluation of the oropharyngeal stage of swallowing. The FEES does not replace the fiberoptic examination performed by an otolaryngologist, which assesses the integrity of the laryngeal and pharyngeal structures. The FEES is a comprehensive assessment of swallowing and includes the following components:

  • Observation of the anatomy involved in the oropharyngeal stage of swallowing
  • Observation of the movement and sensation of critical structures within the hypopharynx
  • Observation of secretions
  • Direct assessment of swallowing function for food and liquid
  • Response to therapeutic maneuvers and interventions to improve swallowing

The FEES frequently guides prescribers regarding the adequacy of the swallow, the advisability of oral feeding, and the use of appropriate interventions to facilitate safe and efficient swallowing. The observations of structure or function of the larynx and pharynx through a fiberoptic examination may suggest the possibility of an undiagnosed medical condition.18,21

Medications Affecting Swallowing

The review of the patient’s current medication list may reveal some drugs that can exacerbate dysphagia and aspiration. Some of these side effects include central nervous system depression, increased salivation, drooling, myopathy, poor tongue movement, xerostomia, inability to initiate the swallowing process, coughing, burping, and esophageal sphincter dysfunction. These side effects may predispose a patient to exhibit aspiration symptoms (see “Medications That Increase Aspiration Risk”). The medication review should also include any over-the-counter, supplemental, and herbal formulations the patient may be taking.2,4,5,6,10

Individualized Treatment Plan

Development of an individualized patient treatment plan occurs following the bedside and radiologic assessments so the patient can receive safe and adequate nutrition. This treatment plan is developed by an interdisciplinary team and may include the physician, SLP, individual nurse and nurse manager for the patient care area, clinical nurse specialist, dietitian, respiratory therapist, physical therapist, pharmacist, patient, and family who determine patient-specific interventions.2,5 These interventions may include exercises, indirect therapy (strengthening exercises for swallowing muscles), and direct therapy (exercises to perform effects of swallowing difficulties).2,10 These interventions may also consist of rehabilitative measures that incorporate swallow therapy, compensatory strategies for patients to implement while swallowing, and dietary modifications that are directly related to the patient’s swallowing capabilities.2,4

Conclusion

There continues to be a need to optimize a preliminary bedside aspiration screening that accurately predicts patients who need further testing to diagnosis dysphagia, aspiration, and/or silent aspiration.16,17 The need for organizations to have more standardized aspiration screening and assessments continues to be a priority when identifying patients with swallowing difficulties and those at risk for aspiration and silent aspiration upon admission.5,15,19

Notes

  1. Agency for Healthcare Research and Quality. 30 safe practices for better health care [fact sheet online]. 2005 Mar [cited 2009 Feb 13]. Available from Internet: http://www.ahrq.gov/qual/30safe.pdf.
  2. Smith Hammond CA, Goldstein LB. Cough and aspiration of food and liquids due to oral-pharyngeal dysphagia: ACCP evidence-based clinical practice guidelines. Chest 2006;129(1 Suppl):154S-68S.
  3. Delegge MH. Aspiration pneumonia: incidence, mortality, and at-risk populations. JPEN J Parenter Enteral Nutr 2002 Nov-Dec;26(6 Suppl):S19-25.
  4. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swallowing impairments. Am Fam Physician 2000 Apr 15;61(8):2453-62.
  5. Wieseke A, Bantz D, Siktberg L, et al. Assessment and early diagnosis of dysphagia. Geriatric Nurs 2008 Nov-Dec;29(6):376-83.
  6. Werner H. The benefits of the dysphagia clinical nurse specialist role. J Neurosci Nurs 2005 Aug;37(4):212-5.
  7. Ramsey DJ, Smithard DG, Kalra L. Can pulse oximetry or a bedside swallowing assessment be used to detect aspiration after stroke? Stroke 2006 Dec;37(12):2984-8.
  8. Massey R, Jedlicka D. The Massey Bedside Swallowing Screen. J Neurosci Nurs 2002 Oct;34(5):252-9.
  9. Leslie P, Drinnan MJ, Ford GA, et al. Swallow respiratory patterns and aging: presbyphgia or dysphagia? J Gerontol A Biol Scie Med Sci 2005 Mar;60(3):391-5.
  10. Robbins J, Kays S, Mccallum S. Team management of dysphagia in the institutional setting. J Nutr Elder 2007;26(3-4):59-104.
  11. McCullough GH, Rosenbek JC, Wertz RT, et al. Defining swallowing function by age: promises and pitfalls of pigeonholing. Topics Geriatr Rehab 2007 Oct-Dec;23(4):290-307.
  12. Ramsey D, Smithard D, Kalra L. Silent aspiration: what do we know? Dysphagia 2005 Summer;20(3):218-25.
  13. Sitoh YY Lee A, Phua SY, et al. Bedside assessment of swallowing: a useful tool for dysphagia in an acute geriatric ward. Singapore MedJ 2000 Aug;41(8):376-81.
  14. Metheny NA. Risk factors for aspiration. JPEN J Parenter Enteral Nutr 2002 Nov-Dec;26(6 Suppl):S26-33.
  15. Ramsey DJ, Smithard DG, Kalra L. 2003. Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke 2003 May;34(5):1252-7.
  16. Smithard DG, O’Neill PA, Park C, et al. Can bedside assessment reliably exclude aspiration following acute stroke? Age Ageing 1998 Mar;27(2):99-106.
  17. Perry L. Screening swallowing function of patients with acute stroke. Part two: Detailed evaluation of the tool by nurses. J Clin Nurs 2001 Jul;10:474-81.
  18. Swigert NB. Update on current assessment practices for dysphagia. Topics Geriatr Rehab 2007 Jul-Sep;23(3): 185-96.
  19. Hinchey JA, Shephard T, Furie K, et al. Formal dysphagia screening protocols prevent pneumonia. Stroke 2005 Sep;36(9):1972-6.
  20. The Joint Commission. Dysphagia screen data element [online]. 2008 Aug 18 [cited 2009 May 27]. Available from Internet: http://manual.jointcommission.org/bin/view/Manual/DataElem0205.
  21. American Speech-Language-Hearing Association. The role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing: technical report [online]. 2005 [cited 2009 Jul 1]. Available from Internet: http://www.asha.org/docs/html/TR2005-00155.html.

Supplemental Material

Medications That Increase Aspiration Risk

  • Benzodiazepines
  • Neuroleptics
  • Anticonvulsants
  • Corticosteroids
  • Lipid-lowering drugs
  • Anticholinergics
  • Antihistamines
  • Antipsychotics
  • Narcotics
  • Anticonvulsants
  • Antiparkinson agents
  • Antineoplastics
  • Antidepressants
  • Anxiolytics
  • Muscle relaxants
  • Diuretics
  • Antibiotics
  • Iron preparations
  • Quinidine
  • Nonsteroidal anti-inflammatory drugs
  • Potassium
  • Anticholinergics
  • Calcium channel blockers
  • Theophylline
  • Corticosteroids

Sources:

Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swallowing impairments. Am Fam Physician 2000 Apr 15;61(8):2453-62.
Robbins J, Kays S, Mccallum S. Team management of dysphagia in the institutional setting. J Nutr Elder 2007;26(3-4):59-104.
Wieseke A, Bantz D, Siktberg L, et al. Assessment and early diagnosis of dysphagia. Geriatric Nurs 2008 Nov-Dec;29(6):376-83.


Self-Assessment Questions

The following questions about this article may be useful for internal education and assessment. You may use the following examples or come up with your own.

  1. Risk reduction strategies to prevent aspiration include all of the following EXCEPT:
    1. Perform strengthening exercises for swallowing muscles.
    2. Implement dietary modifications related to swallowing capabilities
    3. Perform videofluoroscopic swallowing evaluation upon admission.
    4. Review medication list that includes all over-the-counter and supplemental drugs.
  2. Clinical manifestations of silent aspiration include all of the following EXCEPT:
    1. Altered mental status and decreased awareness
    2. Gastrointestinal problems
    3. Rib fractures
    4. Generalized weakness or deconditioning
  3. Which of the following should not be implemented when aspiration is suspected based on the admission screening?
    1. The physician limits the patient to a full-liquid diet.
    2. The speech-language pathologist conducts a formal evaluation.
    3. The dietitian performs a comprehensive nutritional assessment.
    4. The pharmacist assesses the patient for medications that affect swallowing.
  4. The goals of the multidisciplinary team that manages patients with dysphagia include all of the following EXCEPT:
    1. Optimize the patient’s quality of life.
    2. Eliminate any movement deficit caused by stroke.
    3. Determine compensatory strategies to ensure safe swallowing.
    4. Reduce aspiration risk.
  5. A previously healthy 78-year-old female is admitted to the hospital with unexplained shortness of breath. Upon examination, she is found to be lethargic and wheezing with a pulse oximetry of 86%. Examination of her chest radiograph reveals right lower lobe infiltrates. There is no previous history of any respiratory problems, chronic obstructive pulmonary disease, or asthma. The patient is a nonsmoker. Her caregiver reports that she is drowsy and confused while awake.

    Select the intervention that is appropriate for this patient upon admission.
    1. Obtain a formal evaluation by a speech-language pathologist.
    2. Restrict dietary intake until there is an increase in sensorium.
    3. Develop an individualized swallowing treatment plan.
    4. Perform videofluoroscopic swallowing evaluation.
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