Although we can’t predict who will or will not get sick, we do know that there are a number of factors that increase the risk of developing an aspiration pneumonia. I’ve created an easy-to-read handout that I’m finding useful in educating patients, families, and other medical staff.
In discussion with my patient and other team members, I highlight or circle which statements are true for them. This is intended to be a tool for medical professionals to use when working collaboratively with patients to determine treatment plans.
Free DIRECT download: Risk factors for developing aspiration pneumonia (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- What is aspiration pneumonia?
- Why is aspiration pneumonia so complicated?
- Risk factors for developing aspiration pneumonia.
- SLP’s role in dysphagia management is nuanced.
- References.
- Related Eat, Speak, & Think posts.
What is aspiration pneumonia?
Aspiration pneumonia can be a serious illness, especially for older adults or people with a compromised immune system. As Ed Bice, M.Ed., CCC-SLP and Angela Van Sickle, Ph.D., CCC-SLP recently wrote, “aspiration pneumonia” is actually an ambiguous diagnosis that covers at least 13 different conditions. Speech-language pathologists generally think of aspiration pneumonia as being the result of food, liquid, or saliva entering the lungs. However, aspiration pneumonia may also result from gastroesophageal reflux, vomiting, or a pulmonary infection.
Why is aspiration pneumonia so complicated?
I left graduate school with the understanding that my job was to prevent aspiration at all costs. Aspiration of food or liquid into the lungs would cause an infection known as aspiration pneumonia, which could be deadly to some people. It was a straightforward, easy-to-understand sequence of events. Aspiration led to aspiration pneumonia which could lead to death.
Imagine my fascination and dismay when faced early in my career with a resident of a skilled nursing facility who routinely aspirated large amounts of food and liquid but who never became ill. We knew this because he had participated in more than one instrumental swallow study, participated in speech therapy, and ended up declining to follow the recommended modified diet. He represented a clear signal that my understanding of aspiration pneumonia was faulty.
It turns out that the development of aspiration pneumonia is far more complicated, and not well-understood even today. This article is not meant to be a comprehensive review, so please check out the references for more reading. But I do want to share a couple of points.
The 3 pillars of aspiration pneumonia
John R. Ashford, Ph.D., CCC-SLP points out that three factors have to be present for aspiration pneumonia to develop.
- Poor oral health status.
- Impaired health status.
- Dysphagia (impaired laryngeal valve integrity).
Follow the link above to see a pneumonia risk prediction chart. He advocates that SLPs consider the whole person when judging the risk of them developing an aspiration pneumonia. We should also educate for developing the habit of routine daily oral care.
Serious illness changes how the body works
In 2005, Dr. Ashford wrote about factors that contribute to aspiration pneumonia outside of dysphagia. Specifically, he wrote about how the body changes in response to a serious disease or medical condition, and how that raises the risk of developing pneumonia.
Healthy people do not develop aspiration pneumonia, so it’s important to understand how the body responds to stress and illness. Not only do the immune system and muscle function change, but even the microbiome of the mouth, throat, lungs, and digestive tract change.
There are more questions than answers
Bice and Van Sickle (2020) have clearly the problems with the linear thinking that used to be so common in our field: that aspiration leads to aspiration pneumonia which can lead to death.
Instead, they highlight just how complex the whole problem is, down to the very definition and diagnosis of “aspiration pneumonia”. Here are some of the problems they highlight:
- Lack of a clear definition of aspiration pneumonia.
- Low accuracy of diagnosis.
- Research often conflates community-acquired pneumonia with aspiration pneumonia.
- Cough reflex isn’t reliably tested by SLPs.
- Lack of understanding the microbiome, and how altering diets and liquids may impact it.
Risk factors for developing aspiration pneumonia
In reading various research papers, it’s clear that there are many risk factors that seem to contribute to a higher risk for developing an aspiration pneumonia. This list of 10 factors comes from four primary sources: Ashford (2005), Bice & Van Sickle (2020), Langmore et al (2002), and Langmore et al (1998).
- Dependence for feeding.
- Dependence for oral care.
- Poor oral hygiene or poor oral health.
- Limited or infrequent ambulation.
- Compromised respiratory system.
- Impaired cough function.
- Previous aspiration pneumonia.
- Impaired health status (compromised immune system).
- Gastrointestinal disease.
- Currently a smoker.
You may notice that dysphagia is not on this list. Langmore et al (1998) found “to our surprise, all the factors that directly measured dysphagia were eliminated as significant predictors” (p. 76). They go on to explain that this likely means that dysphagia was “highly correlated with other risk factors that had better predictive value.”
SLP’s role in dysphagia management is nuanced
There may be something appealing in having a clear role (identify aspiration and eliminate it by any means necessary), but the true picture is much more complicated. We shouldn’t assume that our interventions don’t have possible negative consequences. We don’t have x-ray vision (i.e., get instrumental exams), and dysphagia can’t be treated in isolation (i.e., consider the whole person). It’s complicated and the final answers aren’t known, but we can keep reading to stay up-to-date. Please share this article with others, and please leave a comment with your recommended reading for me!
References
- Ashford, J. R. (2005, March). Pneumonia: Factors Beyond Aspiration. Perspectives in Swallowing and Swallowing Disorders (Dysphagia), 14, 10-16. https://doi.org/10.1044/sasd14.1.10
- Ashford, J. R. (n.d.). Three Pillars of Pneumonia. Retrieved October 31, 2020, from https://www.sasspllc.com/three-pillars-pneumonia/. In revision, retrieved December 2, 2023, from https://www.sasspllc.com/three-pillars-of-pneumonia?rq=pillars
- Bice, E., & Van Sickle, A. (2020, September 24). Aspiration Pneumonia: The More We Learn the Less We Know. Retrieved October 31, 2020, from https://dysphagiacafe.com/2020/09/17/aspiration-pneumonia-the-more-we-learn-the-less-we-know/
- Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298–307. https://doi.org/10.1007/s00455-002-0072-5
- Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia?. Dysphagia, 13(2), 69-81. https://doi.org/10.1007/pl00009559
Related Eat, Speak, & Think posts
- 9 free swallow assessment tools.
- Single-use swallow evaluation folders.
- Take the guesswork out of thickening liquids with the IDDSI flow test.
- ALS guide for SLPs.
Free DIRECT download: Risk factors for developing aspiration pneumonia (patient handout). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Negative Space from Pexels.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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