Can a broken hip cause aspiration pneumonia?

Meet Norma. 84 year old female admitted with initial hospital admission for a Broken hip s/p open reduction fixation (ORIF) which evolved into a medically complex status including left sided atelectasis, pleural effusion, pneumonia, respiratory failure, urinary tract infection, acute kidney failure. Norma was stable on 2L of o2 via n/c with a nasogastric tube (NGT) in place as she arrived at the hospital. She was awake, alert, and oriented. But she was visibly weak and in a lot of pain upon any type of movement (even when adjusting herself in bed). She self-feeds a diet of pureed solids and nectar thick liquids with no prior instrumental study conducted (Not sure why she was recommended for such a restricted diet without imaging, but I’ve seen stranger things). I do an in-depth chart review to determine why I am seeing the patient, what question(s) I am answering, what the risks of pneumonia are, and how we are going to manage the overall risk. Let’s get right to it.

What can I do with all of this information?

Knowing and understanding the risk and how it’s managed gives me a clearer picture of how and why I’m conducting a clinical swallow evaluation. The team wants to see if aspiration is an issue given Norma’s recent pneumonia, if there’s potential for diet advancement given her poor appetite with her current diet, and if the NGT can be removed. Oral motor examination is normal. No cranial nerve abnormalities. Clean and moist oral mucosa. Strong cough observed subjectively. Since the patient is clearly at a high risk of developing aspiration pneumonia given her current risk factors, I start with the patient’s current diet which she’s been on for 9 days. Only problem is, she barely eats any of it. I have to give her max encouragement just to take a couple of bites and sips of the puree and nectar thick liquid. How good is a diet consistency if it’s left on the plate untouched? From what she did take, I can see she is tolerating without any overt s/s of aspiration or distress. Let’s move on to less restrictive trials. I work my way up slowly from ice chips, to teaspoon volumes of thin, to small cup and straw sips to independent drinking to 3 oz water test to soft solids then regular solids. No issues. At all.

I couldn’t get through to the SLP from the hospital and (of course) no transfer records were provided on the patient’s previous swallow evaluation, but according to the patient she coughed on some water right after extubation and was put on this diet ever since with no follow-up. Now is my chance to do right by this patient. I recommend a FEES to rule out silent aspiration.

I explain the situation to her: Her high risks of developing another infection, but that with a safe swallow the concern is relatively low. Further, if we can get her eating more, removing the NGT alone will reduce her risk of pneumonia significantly and hopefully offset any other small risk of trace amounts of aspiration that occur due to her poor positioning, weakness, and age. But the safest way to get her eating a regular diet again is to get a visual before we do so. She isn’t budging. She’s had two bronchoscopies in the hospital and doesn’t feel she has a problem swallowing. She wants a chance to eat and drink first before we assume she’s having trouble. It’s an understandable position and since I’ve already educated her on the risks, benefits, and my recommendations, I won’t push any further. She looked great in my clinical swallow evaluation- there’s little reason to think she’s at a high risk of frequent and/or high volume aspiration at this time. She agrees to all the other management suggestions for her risk factors noted above. We get her into a good position for her meals, and she begins eating a regular solid and thin liquid diet. After showing a good appetite, the NGT was moved two days later.

Complications

Five days after this, Norma’s chest x-ray shows worsening opacity on the left side. No other changes and patient remains stable and tolerating her diet. Though discouraging, there doesn’t seem to be any reason to change course at this time. During the next meeting one of the pulmonologists expresses concern of aspiration and makes an association between her recent diet upgrade and the worsening chest x-ray and recommends the patient maintain NPO status until the opacity clears. I review the chart again and look at all of the risk factors. It’s possible. The patient remains at a high risk for pulmonary infection and her positioning hasn’t been perfect. Plus, I don’t have imaging to rule out silent aspiration because Norma chose not to pursue this route. There’s a chance that it could be worsening pneumonia from aspiration, but there’s also a chance it’s not.

Clinically, she continues to tolerate her meals without difficulty. No changes there. We have removed her NGT so she has a reduced risk of retrograde aspiration now. She’s been following all other management recommendations and strategies so the risk theoretically should be decreasing, not increasing. I ask the pulmonologist if there are any other plausible explanations for her worsening chest x-ray. This starts a discussion between the house doctor and the pulmonologist where they go back and forth, considering different factors and possibilities and conclude that it’s certainly possible that it’s mucus build up from her the pneumonia she has not yet fully recovered from. It would be unusual for aspiration pneumonia to develop only on the left side due to the trajectory of the carina and angle at which it bifurcates into the two lungs, but she is often left leaning due to her hip. It’s all speculation until we find out for sure. And the only way to find out for sure is another bronchoscopy…

A Win for Norma

I feel so badly that Norma has to go through another bronchoscopy procedure, but it could mean the difference between putting an NGT back in her nose and making her NPO or resuming a regular diet. Thankfully, she agrees. The test is completed and only pulmonary mucus is observed and subsequently suctioned out. No definitive signs of aspiration according to the pulmonologist. She needs more time on antibiotics before we get too concerned about this and it truly is a good sign that she can resume eating and drinking. She’s still got a long way to go, but I’m calling it a win.

Norma’s last day

Two weeks later on the day of her discharge we have an entirely different clinical picture...

Recovery

What started as a fall ended up in a life or death situation with many twists and turns. What’s clear now is that she is on the mend. Most risk factors are improving and Norma is looking forward to a discharge to a rehabilitation center where she is expected to soon have clearance for limited mobility. She is on her way home to a more independent life away from hospital where she has spent far too much time. I’m just glad I had the opportunity to play a small part in her recovery.