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ASPIRATION:
RISKS,
RECOGNITION,
AND
PREVENTION
DANA BARTLETT, RN, BSN, MSN, MA
Dana Bartlett is a professional nurse and author. His clinical experience includes 16
years of ICU and ER experience and over 20 years of as a poison control center
information specialist. Dana has published numerous CE and journal articles, written
NCLEX material, written textbook chapters, and done editing and reviewing for
publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the
subject of toxicology and was recently named a contributing editor, toxicology
section, for Critical Care Nurse journal. He is currently employed at the Connecticut
Poison Control Center and is actively involved in lecturing and mentoring nurses,
emergency medical residents and pharmacy students.
ABSTRACT
Both national safety and health facility protocol guide nursing practice
in the area of aspiration risk precaution and treatment. Multiple factors
influence the potential for aspiration risk and complications stemming
from silent and major aspiration episodes. Nursing interventions in
acute care and long-term settings involve recognizing the potential for
aspiration and implementing preventive and timely treatment
measures when an issue of aspiration occurs, such as aspiration
pneumonia and its sequela.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 2.5 hours. Nurses may only
claim credit commensurate with the credit awarded for completion of
this course activity.
Statement of Learning Need
Risk factors for aspiration are a national safety concern in acute care
and long-term care facilities. Nurses provide the primary care for
patients at the bedside where the use of screening tools and protocol
to recognize patient risk and an aspiration event is most crucial.
Although aspiration can often be a benign event, the risk of aspiration
in elderly and acutely ill patients, such as those with mental status
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changes, poses a severe health concern with significant morbidity and
mortality if standards of care are not appropriately observed.
Course Purpose
To provide knowledge about aspiration risk, prevention and treatment
in acute care and long-term care settings.
Continuing Nursing Education (CNE) Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC -all have
no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 4/29/2016
Termination Date: 4/29/2019
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Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will
be provided at the end of the course.
1.
Aspiration is defined as
a.
b.
c.
d.
2.
The most important protection against aspiration is the
a.
b.
c.
d.
3.
epigastric reflex.
nasal reflex.
gag reflex.
Babinski reflex.
Which of these prevents foreign objects from entering the
larynx?
a.
b.
c.
d.
4.
infection of the lungs from nasal secretions.
movement of a foreign substance into the lungs.
abnormal or difficult swallowing.
the absence of a gag reflex.
The
The
The
The
uvula
pharynx
esophageal sphincter
epiglottis
True or False: Approximately 30% of people do NOT have a
functioning gag reflex.
a. True
b. False
5.
Which of the following are common causes of aspiration?
a.
b.
c.
d.
Myocardial infarction and hypertension
Diabetes and Alzheimer’s disease
Stroke and dysphagia
Irritable bowel syndrome and general anesthesia
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Introduction
Aspiration is defined as the movement of a foreign substance into the
lungs. Aspiration is very common and it can cause significant and
serious complications. All nurses working in acute and long-term care
settings need to be able to recognize factors that increase the risk for
aspiration, know which patients are most likely to aspirate, and to
understand the signs and symptoms of aspiration. These are essential
aspects of safe and appropriate nursing care to avoid an adverse
patient event.
Swallowing And The Gag Reflex
Aspiration is intimately related to swallowing and the gag reflex so to
understand aspiration the nurse must be familiar with these normal
physiological functions. The cough reflex is also involved in aspiration
and that will be discussed briefly in another section of this learning
module.
Upper Gastrointestinal Tract and Associated Structures
Swallowing is the coordinated movement of food or liquids from the
mouth to the stomach. It will be explained here in terms of swallowing
solid food but the process is essentially the same for liquids.
Swallowing can best be understood by dividing it into two phases:
voluntary and involuntary. These will be discussed in context of the
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upper gastrointestinal tract structures known to be involved during the
process of swallowing.1 Finally, aspiration prevention will be reviewed.
The Gastrointestinal Tract
The gastrointestinal tract starts with the mouth, which is also called
the oral cavity. It then descends into the pharynx, esophagus and into
the stomach as depicted in the following table.1
Table 1: The Upper Gastrointestinal Tract
Oral Cavity
↓
Pharynx
↓
Esophagus
↓
Stomach
The sections of the upper gastrointestinal tract are described in
greater detail in the following section.1
Oral Cavity
The oral cavity is the beginning of both the respiratory tract and the
gastrointestinal tract. In terms of swallowing the primary function of
the oral cavity is to begin the digestion of food and to break down food
into manageable sizes.
Pharynx
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The next section of the gastrointestinal tract is the pharynx, a
relatively short tube made of muscle and connective tissue that is
located behind the larynx. The pharynx connects the oral cavity to the
esophagus. The pharynx is further comprised of the nasopharynx, the
oropharynx, and the laryngopharynx. The primary functions of the
pharynx are to allow passage of food and liquid into the esophagus
and air into the trachea.
Esophagus
The esophagus is a thick-walled tube of muscle and cartilage that is
located behind the larynx and the trachea. The esophagus connects
the pharynx to the stomach and like the pharynx, its primary function
is to allow for the passage of food and liquids. The esophagus has two
sphincters, the upper and lower esophageal sphincters. A sphincter is
a ring of muscle that can open and close and there are many
sphincters throughout the body; the anal sphincter is an example.
The upper esophageal sphincter is located at the junction of the
pharynx, and the lower esophageal sphincter is located at the juncture
of the esophagus, where it meets the stomach to complete the
passage of food or fluids. The esophageal sphincters are not under
voluntary control and except during swallowing, they are normally
closed.
Gastrointestinal Tract and Associated Structures
The associated structures to the upper gastrointestinal tract are
described below in greater detail.
Epiglottis
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The epiglottis is a flap of cartilage that is attached to the upper part of
the larynx. One end of the epiglottis is attached to the larynx (this
attachment can be thought of as a hinge) and the other end projects
backwards up and behind the tongue. The epiglottis has a vital role in
normal swallowing and the prevention of aspiration, and this will be
discussed later on in this module. The epiglottis is above the glottis,
which is the opening between the vocal cords.
Larynx
The larynx is the initial section of the respiratory tract. It is a short
tube of muscle and cartilage that begins in the oral cavity and
connects to the trachea (commonly known as the windpipe). The
larynx is relevant to this module because the larynx is where coughing
is initiated and coughing is an important protective reflex that keeps
foreign bodies from entering the lungs.
Swallowing
As mentioned above, swallowing can best be understood by dividing it
into two phases: voluntary and involuntary, which are explained
further here.
Voluntary Phase
Swallowing is for the most part an automatic process; we do not have
to think about swallowing as it happens. However, the initial phase of
preparing the food for swallowing and the beginning of swallowing is
under voluntary control.
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The voluntary phase (also called the oropharyngeal phase) of
swallowing begins in the oral cavity by lubrication of the food with
saliva and digestive juices and chewing the food into small pieces that
can pass through the upper parts of the gastrointestinal tract; these
small pieces of food are called boluses.
Involuntary Phase
After food has been chewed and lubricated, the lips close to seal the
mouth and the tongue moves the bolus to the back of the oral cavity
and into the oropharynx. At this point the involuntary phase (also
called the esophageal phase) of swallowing begins.
As the food bolus or liquid reaches the oropharynx a series of
coordinated movements begin to push the food or liquid smoothly
through the upper gastrointestinal tract and into the stomach. When
examined closely, this process has many steps but it can be explained
quite simply. Although the swallowing process is presented here stepby-step, all of these actions happen essentially at the same time.
Table 2: The Process of Swallowing
1.
The pressure of the food bolus in the pharynx causes the
muscles of the pharynx to contract and to move the food away
from the mouth and into the pharynx.
2.
The uvula contracts and covers the opening of the
nasopharynx, preventing food from entering the nasal
passages.
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3.
Laryngeal movement: Once the food bolus or liquid reaches
the back of the oral cavity, the larynx moves upward. This
helps close the glottis and prevents food from passing
through the vocal cord and into the trachea.
4.
Epiglottis movement: At the same time that the larynx is
moving upward to close the glottis, the epiglottis swings
down and covers the opening of the larynx, acting like a
cover. This prevents food or liquid from entering the trachea.
5.
Sphincter relaxation: The esophageal sphincter relaxes,
providing access to the esophagus.
6.
Peristaltic action: Once the food or liquid enters the
esophagus it is moved along by involuntary rhythmic muscles
actions called peristalsis.
Because the esophagus is essentially a closed tube, pressure
on any part of the esophagus will move food or liquid in the
direction of least resistance - in this case, towards the lower
esophageal sphincter and the stomach. A useful way to think
of this is to imagine squeezing an open tube of toothpaste;
when you do so the contents will be moved out through the
opening and peristaltic contractions in the esophagus function
in the same way.
7.
The lower esophageal sphincter relaxes and allows for
passage of the food bolus or liquid into the stomach.
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During the process of swallowing, other physiological actions that
involve the oral cavity, the pharynx, the larynx, or the esophagus
cannot be done. When a person is swallowing he or she cannot inhale,
exhale, talk, vomit, or cough.
When the process of swallowing is reviewed, two things are prominent
and have particular relevance to the topic of aspiration.
1. The gastrointestinal tract and the respiratory tract are in close
proximity; at certain points there is very little that separates them.
2. Swallowing requires the coordinated action of many muscles,
nerves, and reflexes; it is a relatively complicated act.
Given these two points, it becomes apparent that there is considerable
potential for food or liquid to be aspirated, and that there are many
steps in the process of swallowing that can break down and put a
patient at risk of aspiration.
Gag Reflex And Cough Reflex
The gag reflex and the cough reflex protect the lungs from aspiration
and entry of foreign objects. The gag reflex involves the oral cavity
and the upper part of the gastrointestinal tract; the cough reflex
involves the upper part of the respiratory tract. The gag reflex, which
is more formally called the pharyngeal reflex, is the most important
protective mechanism for the prevention of aspiration and it will be
discussed in detail here.1
The gag reflex occurs when a foreign object touches the roof of the
mouth, the back of the tongue, the areas around the tonsils or the
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uvula, or the oropharynx. When a person swallows, food and liquids
contact these areas but the automatic closing of the epiglottis prevents
aspiration from occurring. This protective mechanism is absent during
a potential aspiration situation but the gag reflex takes over and stops
foreign objects from entering the lungs.
Nerve endings located in the roof of the mouth, the back of the
tongue, etc., are stimulated by the physical contact with food or fluid
and this stimulation initiates very strong, forceful contractions of the
pharynx, which expels the foreign object. The patient experiences the
gag reflex as coughing, choking, and gagging.
Learning Break:
An easy way to imagine the gag reflex is to think about an
experience we have all had, one that is commonly called “having
something go down the wrong way.” A piece of food or some liquid
reaches the back of your mouth and you begin to gag and cough.
An intact functioning gag reflex is essential to prevent aspiration.
However, it has been estimated that the gag reflex is absent in almost
30% of the population and some people may have a gag reflex but it is
not very strong. In addition, there are many diseases and medical
conditions that can temporarily or permanently damage the gag reflex,
making that person susceptible to aspiration. The cough reflex is also
important for preventing aspiration. The primary function of the larynx
and trachea is to move air into the lungs and the respiratory tract and
any foreign substance that enters the airways interferes with
respiration and is a potential cause of infection. Nerve endings located
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on the larynx and the trachea becomes stimulated when a foreign
body enters the larynx or trachea. A forceful cough is produced, which
aids the foreign object to be expelled.
Aspiration: Causes, Signs, Symptoms, Consequences
Aspiration occurs when the gag reflex and the cough reflex fail to
prevent a foreign substance from entering the lungs. The common
conception of aspiration is that it is an abnormal and dramatic
pathologic event that causes coughing, choking, and a serious
complication such as pneumonia. This is certainly true for some
aspiration events but aspiration is actually a common occurrence and
it may not result in harm.
Studies have shown that at least one-half of all adults aspirate during
sleep and the aspiration does not wake them up or cause signs or
symptoms. Aspiration happens to normal, healthy adults who have a
functioning gag reflex. They aspirate very small amounts of saliva,
mucous, and possibly gastric juices. The aspirations that result in
serious harm occur in a very different population, under very different
circumstances, and with potentially serious consequences. Why and
how these aspirations become harmful are highlighted below.3,4,7,8
Volume
In patients who may suffer a harmful aspiration there is often a large
volume that enters the lungs. An example of this would be the patient
who has aspirated tube feedings. A milliliter or two would be tolerated
but 30 ml or more, for example, would cause signs and symptoms.
However, serious aspiration can occur from a small volume or amount.
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Substance
If the aspirate contains infectious bacteria the patient may develop
aspiration pneumonia.
Frequency
Aspirations occurring repeatedly expose the respiratory tract/lungs to
more frequent stress and the patient has less time to recover.
Patient Issues
There are many individual factors that influence how often aspirations
occur and whether such events cause complications. For example,
patients with a decreased level of consciousness, compromised
immune system, or a respiratory illness, i.e., pneumonia or chronic
obstructive pulmonary disease (COPD) that decreases the blood
oxygen level. In all of these situations, aspiration and/or harm from
aspiration is more likely to occur. There are many causes of aspiration,
as shown in Table 3 below; however, this list is not all-inclusive.
Table 3: Causes of Aspiration
Cerebral vascular accident (Stroke)
Drug or alcohol overdose
Dysphagia
Excessive production of oral secretions
General anesthesia
Grand mal seizure
Mechanical ventilation
Nasogastric feedings
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Neurologic diseases
Prolonged vomiting
Sedative, hypnotic, or opioid medications
Tracheostomy
Traumatic brain injury
In addition to the above list of identified causes of aspiration being not
all-inclusive, there is also some overlap; for example, many people
who have a stroke develop dysphagia. This list can certainly be studied
and referred back to from time-to-time, however, it is more useful to
view these causes of aspiration as having similarities. Understanding
these similarities will help to identify patients who are at risk for
aspiration. These similarities are elucidated below.
 The patient has a depressed level of consciousness. Someone who
has a depressed level of consciousness often has a weak or absent
gag reflex. Often, in such a scenario the patient is described as
someone not having the ability to “protect the airway.” This can
happen to a patient who has had a stroke, experienced a seizure,
or following a drug overdose.
 Protective reflexes are absent or compromised. Examples of this
would include a patient who 1) has been endotracheally intubated
or who has a tracheostomy, 2) had placement of a nasogastric
feeding tube, or 3) has dysphagia. (Dysphagia will be discussed
later in the module).
Experienced nurses know that when patients have a depressed level of
consciousness there is also a loss of protective reflexes; the two
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frequently go together. For example, a patient who has had a stroke
may be comatose and have a damaged gag reflex.6
Learning Break:
Dysphagia is a medical term that means difficulty in swallowing.
Common neurological problems such as Alzheimer’s disease,
stroke, and traumatic brain injury frequently cause dysphagia and
dysphagia is a significant risk factor for aspiration. Dysphagia is
very common; the authors of a recent article in the medical journal
Chest noted that dysphagia is present in at least 30% of all
hospitalized patients. Unfortunately, dysphagia often goes
unrecognized.
Aspiration Signs And Symptoms
The signs and symptoms of aspiration can be subtle and very clear or
some patients can aspirate and initially be asymptomatic. The obvious
signs and symptoms of aspiration are coughing, choking, and difficulty
breathing and they often occur after a situation that puts the patient
at risk. For example, a patient who recently had a stroke and is taking
fluids by mouth for the first time begins to cough and gasp.
Experienced nurses recognize this as a situation with the potential for
aspiration risk and of course coughing and gasping cannot be missed.
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It is difficult to recognize aspiration when aspiration is slight, if the
signs and symptoms are minor, or if the patient is initially
asymptomatic.12 In these situations the nurse must remember who is
at risk for aspiration and be on the alert for clues that an aspiration
has happened. Signs and symptoms of aspiration are listed in Table 4
below.
Table 4: Signs and Symptoms of Aspiration

Change in consciousness, especially depressed consciousness

Decreased oxygen saturation as measured by pulse oximetry

Excessive drooling

Fatigue

Fever

Increased sputum production

Persistent, mild cough

Rapid breathing

Tachycardia

Vomiting soon after meals
Of course, signs and symptoms of aspiration listed above are nonspecific. There are many reasons why a patient may have a fever or a
rapid pulse. If these signs are present in a patient who has risk factors
for aspiration, then the possibility should be investigated.
Learning Break:
Asymptomatic aspiration is also called silent aspiration, and it is
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especially worrisome. It cannot be detected without specialized
testing, and patients who have silent aspirations are much more
likely to develop aspiration pneumonia. Silent aspirations are not
rare. One study found that 25% of all patients who had a confirmed,
documented aspiration had experienced a silent aspiration.
The Consequences Of Aspiration
Aspiration can cause airway obstruction and interfere with ventilation.
It can also cause an inflammation of the lungs called chemical
pneumonitis, aspiration pneumonia, or a combination of these
conditions. This section discusses known risks and complications of
aspiration.10,11,12
Aspiration pneumonia is perhaps the most common complication of
aspiration. It occurs when a patient aspirates bacteria or other
microorganisms from his or her oral cavity, nasal passages, or upper
stomach. These microorganisms are part of the normal flora of the
upper respiratory tract and the gastrointestinal tract, but if they enter
the lungs they can multiply and then are not benign. Aspiration
pneumonia can develop if these oral, nasal, or gastric nasal secretions
contain a large number of microorganisms, if the aspirations are
frequent, or if the patient is susceptible to a respiratory infection.
It is important to remember that the size of the aspiration is not
important. Aspiration pneumonia can occur even after a very small
aspiration, and aspirations can be silent. Just as importantly, nurses
should be aware that pneumonia occurs in approximately one-third of
all patients who aspirate. The exact incidence of aspiration pneumonia
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is not known but it is a relatively common problem. It is especially
prevalent in the elderly population; quite commonly in the elderly who
have dysphagia and in elderly people who are hospitalized. For elderly
who are hospitalized, aspiration pneumonia is also very dangerous.
One study found the mortality rate of hospital-associated aspiration
pneumonia to be almost thirty percent.
The signs and symptoms of aspiration pneumonia vary considerably
and depend on how recently the aspiration happened, the patient’s
basic state of health, and the virulence of the microorganism. Common
clinical problems that are seen are drowsiness, fever, rapid breathing,
and tachycardia. If the patient is elderly and dehydrated, he or she
may be hypotensive, as well. It is also possible for the patient to have
relatively mild signs and symptoms for a few days as the aspiration
pneumonia develops.
Aspiration pneumonia is diagnosed by examining the patient, by
recognizing risk factors for aspiration, and most definitively by chest
x-ray. Laboratory studies, including culture of sputum have limited
usefulness in diagnosing aspiration pneumonia. Aspiration pneumonia
is treated with antibiotics and fluids.
Prevention Of Aspiration
As with any medical problem, disease prevention is far better than
treatment. Aspiration prevention is considered to be a key component
of safe and appropriate healthcare, and it involves identifying patients
who are at risk and then using practical methods to ensure that
patients do not aspirate.10,11,12
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Identifying Risk for Aspiration: Screening Methods
Aspiration prevention is considered to be a key component of good
healthcare. The Agency for Healthcare Research and Quality (AHRQ) is
an agency of the National Institutes of Health, and the AHRQ
recommends as one of its 30 Safe Practices for Better Health Care that
all patients be screened for aspiration. To quote the AHRQ: “Upon
admission, and regularly thereafter, evaluate each patient for the risk
of aspiration.”2 Evaluating stroke patients within 24 hours of admission
for their risk of aspiration and the presence of dysphagia is also
typically recommended.
Prevention of aspiration begins with recognizing patients who are at
risk for this problem and this has been shown to be both simple and
difficult. The simple part is identifying which patients are likely to
suffer an aspiration (as covered earlier on in this learning module). If
the answer is Yes to any of the screening questions highlighted in the
table below then the patient is at risk for aspiration.
Table 5: Basic Screening for Aspiration Risk

Is the patient elderly?

Is she or he receiving any medications that can cause sedation?

Does the patient have a neurological disease or disorder?

Does the patient have excess secretions?

Was general anesthesia recently used?

Does the patient have obvious difficulty eating/swallowing?

Is he or she unable to sit upright?

Has the patient has a prior aspiration?

Does she or he have a history of dysphagia?

Does the patient have a depressed level of consciousness?
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This basic assessment should be done for all patients, and for patients
who are especially susceptible to aspiration it should be repeated from
time to time. Most healthcare facilities will have an aspiration
screening tool and a protocol for how and when to use it. There are
bedside and technical-based screening methods that can be used for
detecting aspiration, evaluating aspiration risk, and for detecting one
of its most common causes, dysphagia. Unfortunately, there is no
universal agreement as to which one is best and when they should be
used and that is the part of aspiration and dysphagia screening that is
difficult. Explaining all of these screening methods is beyond the scope
of this learning module but commonly used ones are listed in Table 6.
The EAT-10 can be done at the bedside without specialized equipment
and is briefly discussed here.
Table 6: Screening Methods for Detecting Aspiration/Dysphagia
Barium swallow test
EAT-10
Endoscopy
Video-fluoroscopic evaluation (VSE)
Water swallow test
All of the screening methods listed in Table 6 (except the EAT-10) are
technical tests while the EAT-10 is a questionnaire that can be used to
determine the need for more complicated screening. The EAT-10 asks
the patient to respond to these 10 statements.
Table 7: The EAT-10 Questionnaire
1.
My swallowing problem has caused me to lose weight.
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2.
My swallowing problem interferes with my ability to go out for meals.
3.
Swallowing liquids takes extra effort.
4.
Swallowing solids takes extra effort.
5.
Swallowing pills takes extra effort.
6.
Swallowing is painful.
7.
The pleasure of eating is affected by my swallowing.
8.
When I swallow food sticks in my throat.
9.
I cough when I eat.
10. Swallowing is stressful.
The answers to the questions are scored on a scale from 0 – 4 (0 = no
problem to 4 = severe), and if the total score is 3 or higher the patient
may have a swallowing problem and more aggressive evaluation
should be considered.
Practical Methods For Aspiration Prevention
If a patient has been identified as being at risk for aspiration or if the
patient has aspirated, then practical methods designed to prevent this
from happening should be started. Basic steps to prevent aspiration
are reviewed are highlighted here.14,15 The first step nurses should
follow is to use the aspiration evaluation protocol that their healthcare
facility has adopted. Nurses should also keep in mind the screening
questions that are listed above. Specific measures for preventing
aspiration include: 1) patient positioning, 2) oral care; 3) assessment
of nasogastric tube placement; 4) tube feeding technique;
5) measuring residual gastric volume; and, 6) avoiding the use of
sedating drugs.
Each healthcare facility will use these preventive measures in a
different way and some of them may not be used at all, so it is not
possible to provide strict, definitive guidelines for their use. Nurses
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should follow the protocols established for their workplace and when in
doubt they should review facility protocols with a nursing supervisor.
Nurses are also key agents in their workplaces to advocate for best
practice protocols and improved standards of safe and appropriate
practice relative to aspiration risk precaution. The following patient
care interventions are recommended practice to prevent aspiration in
acute care and long-term care health facilities.
Positioning
Elevating the head of the bed is a very effective method for preventing
aspiration. Lying flat or with the head slightly elevated increases the
possibility of aspirating, especially so if a patient has an absent or
weak gag reflex or is receiving feedings by a nasogastric tube. Keep in
mind that one of the first things people do when food or liquid “goes
down the wrong way” is to stand up. Elevating the head of the bed at
30°-45° for patient safety is typically recommended, however the
exact degree to which the head of the bed should be elevated is also
generally determined by health facility protocol.10
Oral Care
Entry of oral, nasal, and gastric secretions into the lungs cause
aspiration pneumonia. Rigorous attention to oral care and possibly the
use of antiseptic mouth rinses that contain chlorhexidine are often
used as ways to reduce the number of microorganisms in the oral
cavity and prevent aspiration pneumonia. Chlorhexidine is an
antibacterial agent and a 0.12%-0.2% solution can be applied to a
sponge to swab the patient’s mouth four times a day. The frequency of
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chlorhexidine use and the protocol may vary from hospital to
hospital.13,16
Assessment of Nasogastric Tube Placement
Nasogastric tubes can easily become misplaced, putting the patient at
risk for aspiration. Frequent assessment of the proper position of
nasogastric tube placement is a responsibility of the nurses in terms of
preventative technique and long-term management. The management
of tube feeding and aspects of the nursing assessment to prevent
aspiration are reviewed below.5,6,9
Tube Feeding Technique
If a patient is receiving tube feedings and is at risk for aspiration, tube
feedings should be given at the prescribed rate. The nurse should not
increase the tube-feeding rate unless there is a specific order to do so
and should never administer a tube feeding as a bolus. Bolus feeding
increases the risk for aspiration.
Measuring Residual Gastric Volume
A technique that has traditionally been used to prevent aspiration in
patients who are receiving nasogastric feedings is measuring residual
gastric volume. After a tube feeding, the amount of enteral nutrition
liquid that is still in the stomach is measured. If the residual is above a
certain amount then it is assumed that the patient’s gastrointestinal
tract is not properly absorbing the liquid nutrition and the excess
volume puts the patient at risk for aspirating. This technique may be
helpful for certain patients but recent research has questioned its
usefulness.
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Avoid Sedating Drugs
The use of sedating drugs increases the risk of aspiration.
Administering these medications is a nursing responsibility.
Additionally, the nurse should be assessing patients for excessive
drowsiness caused by sedatives, analgesics, and other drugs that can
cause central nervous system depression and reporting these adverse
effects if they occur to the patient’s primary medical provider.
Case Scenario: Aspiration Pneumonia
Mrs. B is an 86-year-old female who has just been discharged from the
hospital and admitted to a long-term care facility. She recently suffered a
stroke that left her with significant weakness of her left arm and leg. She is
unable to walk but with some assistance she can perform some simple
activities of daily living and her mental status and speech are completely
intact.
The patient has been depressed and occasionally mildly agitated as she
tries to adjust to her limitations. In addition her appetite has been poor
and for the past two days she has refused to eat, telling the staff that food
“makes me sick.” She also complains of persistent pain in her left side.
Because of these developments the physician ordered the patient to be
given a low dose of fluoxetine, a commonly used anti-depressant.
The physician also requested an orthopedic and physical therapy consult
and while awaiting the results of those evaluations, she prescribed a nonnarcotic analgesic, tramadol.
Finally, after extensive discussions with the patient and with her
acceptance, a small nasogastric tube was inserted and enteral tube
feedings were begun. It was understood that the feeding tube would be in
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place for only a short period of time. Several days after the fluoxetine,
tramadol, and tube feedings were started the patient’s condition was
improved. Her mood was brighter, her pain was decreased, and she
seemed to have more energy. Mrs. B’s pain was diagnosed as
osteoarthritis, she was able to start physical therapy.
Plans were made for to move Mrs. B (within a few weeks) to a relative’s
house, albeit with the support of visiting nurses. However, after a week of
clinical gains the staff began to notice some mild regressions.
The patient was sleeping more and had less energy during the day,
although there were periods of time in which she seemed normal. She also
had a fever of 100.1° F, but this only occurred once and the fever
responded to fluids and a dose of acetaminophen.
On the seventh day of her tube feedings, Mrs. B was noted to have a fever
of 102.7° F and her respiratory rate was 24. Shortly after being assisted
from her bed to a chair, Mrs. B had several forceful, productive coughs and
the nurse saw undigested tube feeding residue in the patient’s sputum. The
physician was notified, a chest x-ray was done, and it was clear that Mrs. B
had aspirated and had pneumonia.
In the above scenario, the patient had obvious risk factors for an
aspiration. She had recently had a stroke, was prescribed several
medications that are known to cause central nervous system
depression, a nasogastric tube was in place, and she was receiving
enteral tube feedings. The clinical course the patient experienced was
fairly typical, with some subtle signs of silent aspiration being present
before it became clear that some of the tube feeding and gastric juices
had entered her lungs.
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Summary
Episodes of aspiration can be sudden and dramatic, but aspirations can
also be very minor and the patient may remain asymptomatic, the socalled silent aspiration. The causes of aspiration are many, and some
of the common ones have been reviewed here. Although the causes of
aspiration are all distinct, separate problems they share two common
characteristics: the patient is likely to have a depressed level of
consciousness and the protective mechanisms that prevent aspiration
are absent or compromised. Dysphagia in particular is very common
and a significant cause of aspiration.
Aspirations can cause serious medical problems, especially if there is a
large volume that has been aspirated and when the aspirate contains a
large number of infectious bacteria. When aspirations occur repeatedly
the patient is more predisposed to pulmonary complications. Nurses
need to be informed of the most common complication of aspiration aspiration pneumonia - as well as protocol to prevent its occurrence,
common signs and symptoms, and treatment. Screening for aspiration
is a vital part of care that every nurse working in acute and long-term
care facilities should implement in their work settings. Both national
standards of safe and appropriate practice and health facility protocol
to prevent, recognize and treat aspiration should guide nursing actions
during the course of patient care.
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Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
article, and providing feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
1. Aspiration is defined as
a.
b.
c.
d.
infection of the lungs from nasal secretions.
movement of a foreign substance into the lungs.
abnormal or difficult swallowing.
the absence of a gag reflex.
2. The most important protection against aspiration is the
a.
b.
c.
d.
epigastric reflex.
nasal reflex.
gag reflex.
Babinski reflex.
3. Which of these prevents foreign objects from entering the
larynx?
a.
b.
c.
d.
The
The
The
The
uvula
pharynx
esophageal sphincter
epiglottis
4. True or False: Approximately 30% of people do NOT have a
functioning gag reflex.
a. True
b. False
5. Which of the following are common causes of aspiration?
a. Myocardial infarction and hypertension
b. Diabetes and Alzheimer’s disease
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c. Stroke and dysphagia
d. Irritable bowel syndrome and general anesthesia
6. An aspiration that does not cause obvious signs or
symptoms is known as a
a.
b.
c.
d.
silent aspiration.
benign aspiration.
minor aspiration.
simple aspiration.
7. Which of the following is a common complication of
aspiration?
a.
b.
c.
d.
Hyperglycemia
Pulmonary edema
Fever
Pneumonia
8. Common signs and symptoms of aspiration may include:
a.
b.
c.
d.
Bradycardia and drowsiness.
Fever and rapid breathing.
Hypertension and hypoglycemia.
Hypotension and agitation.
9. Patients should be screened for aspiration risk
a.
b.
c.
d.
on admission and the as needed.
when they are being discharged.
if they have signs and symptoms of aspiration.
if they are elderly females (elderly males don’t need screening).
10. Which of the following is a recommended method for
preventing aspiration?
a.
b.
c.
d.
Keeping the head of the bed level
Administering tube feedings as a bolus
Keeping the head of the bed elevated
Deep breathing exercises
11. In addition to the gag reflex, the __________ is also
important for preventing aspiration.
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a.
b.
c.
d.
cough reflex
nasal reflex
pharyngeal reflex
Babinski reflex
12. Swallowing is the voluntary coordinated movement of food
or liquids from the mouth to the stomach.
a. True
b. False
13. The oral cavity is the beginning of
a.
b.
c.
d.
the gastrointestinal tract.
the respiratory tract.
the respiratory tract and gastrointestinal tract.
None of the above
14. The _____________ is a thick-walled tube of muscle and
cartilage that is located behind the larynx and the trachea.
a.
b.
c.
d.
gastrointestinal tract.
esophagus
epiglottis
duodenum
15. The ________________ is located at the juncture of the
esophagus, where it meets the stomach to complete the
passage of food or fluids.
a.
b.
c.
d.
lower esophageal sphincter
trachea
upper esophageal sphincter
uvula
16. The voluntary phase of swallowing is also known as the
a.
b.
c.
d.
oral phase
esophageal phase
automatic phase
oro-pharyngeal phase
17. During the swallowing process, the uvula contracts and
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covers the opening of the nasopharynx, preventing food
from entering
a.
b.
c.
d.
the
the
the
the
lungs.
trachea.
larynx.
nasal passages.
18. At the same time that the larynx moves upward to close the
glottis, the __________ swings down and covers the
opening of the larynx, acting like a cover.
a.
b.
c.
d.
esophageal sphincter
trachea
epiglottis
uvula
19. Once the food or liquid enters the esophagus it is moved
along by the action of involuntary rhythmic muscles, which
is called
a.
b.
c.
d.
involuntary swallowing.
peristalsis.
pharyngeal reflex.
esophageal reflex.
20. A person cannot inhale, exhale, talk, vomit, or cough when
he or she is swallowing.
a. True
b. False
21. The gag reflex occurs when a foreign object touches the
a.
b.
c.
d.
roof of the mouth or the back of the tongue.
oropharynx.
areas around the tonsils or the uvula.
All of the above
22. Aspiration occurs when the gag reflex and the cough reflex
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fail to prevent a foreign substance from entering
a.
b.
c.
d.
the
the
the
the
nasal passages.
uvula.
lungs.
glottis.
23. If the aspirate contains _________________ the patient
may develop aspiration pneumonia.
a.
b.
c.
d.
bolus
fluids
infectious bacteria
saliva
24. Dysphagia is a medical term that means
a.
b.
c.
d.
difficulty in swallowing.
decreased level of consciousness.
excessive production of oral secretions.
prolonged vomiting.
25. A serious aspiration can only occur from a large volume or
amount of a foreign substance entering the lungs.
a. True
b. False
26. Which of the following screening methods is a
questionnaire, not a technical test for detecting aspiration
or dysphagia?
a.
b.
c.
d.
Barium swallow test
EAT-10
Water swallow test
Video-fluoroscopic evaluation (VSE)
27. Specific measures for preventing aspiration include:
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a.
b.
c.
d.
use of sedative drugs to relax the patient.
avoiding the use of antibacterial medications.
eliminating liquids from diet.
measuring residual gastric volume.
28. If a patient is receiving tube feedings and she or he is at
risk for aspiration, tube feedings should be
a. administered as a bolus.
b. increased based on the CNA’s observations.
c. given at the prescribed rate.
d. given with sedative medication.
29. Typical signs or symptoms of aspiration include:
a.
b.
c.
d.
persistent, mild cough.
increased oxygen saturation.
decreased sputum production.
All of the above.
30. Which of the following questions is useful for performing a
basic aspiration risk assessment?
a.
b.
c.
d.
Is patient unable to sit upright?
Is the patient elderly?
Was general anesthesia recently used?
All of the above.
Correct Answers:
1. b
11. a
21. d
2. c
12. b
22. c
3. d
13. c
23. c
4. a
14. b
24. a
5. c
15. a
25. b
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6. a
16. d
26. b
7. d
17. d
27. d
8. b
18. c
28. c
9. a
19. b
29. a
10. c
20. a
30. d
References Section
The reference section of in-text citations include published works
intended as helpful material for further reading. Unpublished works
and personal communications are not included in this section, although
may appear within the study text.
1.
2.
3.
4.
5.
Gastroenterology Nursing: A Core Curriculum Fifth Edition (2013).
Society of Gastroenterology Nurses And Associates.
AHRQ. 30 Safe Practices for Better Health Care. Accessed April
19, 2016 from.
http://archive.ahrq.gov/research/findings/factsheets/errorssafety/30safe/30-safe-practices.html.
Blaser AR, Starkopf J, Kirsimägi Ü, Deane AM. Definition,
prevalence, and outcome of feeding intolerance in intensive care:
a systematic review and meta-analysis. Acta Anaesthesiol Scand.
2014;58(8):914-22.
Chen S, Xian W, Cheng S, et al. Risk of regurgitation and
aspiration in patients infused with different volumes of enteral
nutrition. Asia Pac J Clin Nutr. 2015;24(2):212-218.
Chen W, Cao Q, Li S, Li H, Zhang W. Impact of daily bathing with
chlorhexidine gluconate on ventilator associated pneumonia in
intensive care units: a meta-analysis. J Thorac Dis.
2015;7(4):746-753.
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6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Elke G, Felbinger TW, Heyland DK. Gastric residual volume in
critically ill patients: a dead marker or still alive? Nutr Clin Pract.
2015;30(1):59-71.
Eom CS, Jeon CY, Lim JW, Cho EG, Park SM, Lee KS. Use of acidsuppressive drugs and risk of pneumonia: a systematic review
and meta-analysis. CMAJ. 2011;183(3):310-319.
Khorvash F, Abbasi S, Meidani M, Dehdashti F, Ataei B. The
comparison between proton pump inhibitors and sucralfate in
incidence of ventilator associated pneumonia in critically ill
patients. Adv Biomed Res. 2014 Jan 27;3:52. doi: 10.4103/22779175.125789. eCollection 2014.
Kuppinger DD, Rittler P, Hartl WH, Rüttinger D. Use of gastric
residual volume to guide enteral nutrition in critically ill patients:
a brief systematic review of clinical studies. Nutrition.
2013;29(9):1075-9.
Li Bassi G, Torres A. Ventilator-associated pneumonia: role of
positioning. Curr Opin Crit Care. 2011;17(1):57-63.
McClave SA, Lukan JK, Stefater JA, Lowen CC, Looney SW,
Matheson PJ. Poor validity of residual volumes as a marker for
risk of aspiration in critically ill patients. Crit Care Med.
2005;33(2):324-330.
Metheny NA, Clouse RE, Chang YH, Stewart BJ, Oliver DA, Kollef
MH. Tracheobronchial aspiration of gastric contents in critically ill
tube-fed patients: frequency, outcomes, and risk factors. Crit
Care Med. 2006;34(4):1007-1015.
Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing
and health care-associated infections: a randomized clinical trial.
JAMA. 2015;313(4):369-378.
Reignier J, Mercier E, Le Gouge A, http://www-ncbi-nlm-nihgov.online.uchc.edu/pubmed/?term=Boulain
T%5BAuthor%5D&cauthor=true&cauthor_uid=23321763et al. Effect of
not monitoring residual gastric volume on risk of ventilatorassociated pneumonia in adults receiving mechanical ventilation
and early enteral feeding: a randomized controlled trial. JAMA.
2013;309(3):249-56.
Scolapio JS. Decreasing aspiration risk with enteral feeding.
Gastrointest Endosc Clin N Am. 2007;17(4):711-6.
Shi Z, Xie H, Wang P, et al. Oral hygiene care for critically ill
patients to prevent ventilator-associated pneumonia. Cochrane
Database Syst Rev. 2013 Aug 13;8:CD008367. doi:
10.1002/14651858.CD008367.pub2. Review.
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