COVID-19 and Aspiration: A Case Study
With help from Dr. James Coyle PhD, CCC-SLP, BCS-S, ASHA Fellow and Doreen Benson MS CCC-SLP
Meet Jacob. He is 82 years old. History of prostate cancer, gastroesophageal reflux disease (GERD), hypercholesterolemia, hyperlipidemia, chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD) s/p stent. In August of 2021, he was unfortunately exposed to the novel Coronavirus and was diagnosed with COVID-19. Already medically compromised, Jacob’s condition was at risk of growing severe from the disease process. And that’s exactly what happened. He later was found to exhibit “ground-glass opacities” in the right lower lobe and was diagnosed with pneumonia. Because of his compromised immune response, an opportunistic yeast infection (candida) in his sputum. For Jacob, things felt like they couldn’t possibly get any worse.
ARDS
Unfortunately, things did get worse. Jacob’s infection became so severe that he eventually developed acute respiratory distress syndrome (ARDS). It should be understood that half of patients that develop ARDS do not survive; therefore survivors are very different from their own baselines. ARDS is so terrible because it elicits an immune response that ultimately compromises the blood-gas barrier which quickly fills the lungs up with “stuff” (it’s a scientific term, just don’t question it). (See my ARDS blog with Dr. James Coyle and Kelsey Day to read more about this process). This “stuff” is essentially derived from immune and circulatory system byproducts, dead cells, leukocytes, and other contents/fluids leaking in from the blood vessels. This essentially “drowns” the lungs from inside the body while also making the lungs more difficult to inflate (i.e., less compliant). The problem with a serious and new infectious disease like COVID-19 is that the body’s immune system is “confused” because it’s never seen the virus before (like an SLP on their very first day of clinical externship- it doesn’t really know what it’s doing). Instead of acting like a sharp-shooter, it acts more like a grenade, destroying itself with its own defenses (which is why vaccines are so important because they prepare the immune system beforehand- like an SLP who takes a bunch of CEUs before they start their externship).
Free Fall
Jacob’s respiratory status continued to deteriorate and he was finally diagnosed with hypoxic respiratory failure. The alveoli were no longer allowing enough air in them to perform proper oxygen exchange to the blood vessels (the body is too busy bringing that extra “stuff” into the alveoli to leave room for silly ol’ air). In order to combat this, the patient was put on BiPAP which will provide air with high pressure and large amounts of oxygen in order to force open the lungs and promote oxygen exchange to the arterial blood circulating to the heart and the rest of the body. However, this backfired. The inflammation from the infection made the lungs hard and stiff (noncompliant). The high volumes and pressure delivered from the BiPAP into stiff lungs resulted in barotrauma (baro = pressure) leading to a pneumothorax (like a balloon that lost its elasticity and popped before fully inflated). This essentially makes the lung useless and requires weeks of intense intervention to heal. In the meantime, the patient is forced to breathe with one lung. We have officially hit rock bottom.
The Road to Recovery
About a week later Jacob ends up on my caseload in a critical illness recovery hospital after his acute hospitalization. To avoid another pneumothorax, the patient was switched from BiPAP to high-flow nasal cannula (HFNC) and kept on a relatively low level of flow in order to prevent further damage to an already terrible respiratory situation. This is in sync with a management approach called low tidal volume ventilation and is frequently used to prevent or manage ARDS from causing further inflammation to the lungs, another pneumothorax, and ultimately to improve the opportunity for recovery.
Two of the top four precipitating factors of ARDS are aspiration and pneumonia. Jacob has one already, and we want to mitigate the other. This tells us that we have a role to play here in maintaining clear lungs and promoting a healthy recovery. But we have to be careful. Very careful.
Asking “Why”
The first thing I do when I get a consult for the patient is to figure out why we are here (not in an existential sense, but in a “why we are being consulted” sense). I’m a detective. You’re a detective. And our jobs are to solve the mystery. But what is the mystery we are trying to solve? In other words, what question are we trying to answer? Hopefully, your doctor will have slipped this information into the order such as “assess candidacy for PO intake vs feeding tube” or “FEES to rule out silent aspiration.” I would love it if the specifics of a given order were written out so clearly. We should only be so lucky right? If the order was more general or unclear, talk to the MD or NP who wrote the order and any other team member who can help you answer the question of what question we are answering.
For Jacob, the order was for a swallow evaluation and the objective was to find out if the he was at a high risk for gross aspiration and, if so, can this factor be correlated with his abnormal chest x-rays, leukocytosis (increased WBC count), and slow recovery of the respiratory system? So we assess for dysphagia and the overall risk of developing aspiration pneumonia (or the risk of making a current infection worse via aspiration). Let’s organize all of the important information on the chart to find any clues that might tell us about Jacob’s risk for aspiration pneumonia.
Risk Review
As mentioned above, we have a complex case on our hands. However, it can be incredibly difficult to assess risk by taking one quick glance at the history. To obtain a better understanding of the risk (and how it can be managed), we must categorize the risk factors of pneumonia into 3 main categories:
Aspiration of harmful contents
Impaired respiratory status (pulmonary clearance and ventilatory capacity)
Impaired immune response.
In summary, we want to see if the patient is aspirating (and what contents they may be aspirating), if that aspiration can be coughed out or cleared out, and, if not, if the patient can fight off any infection that might result from that aspiration and if he has signs of breathing-swallow incoordination that may explain aspiration.
So let’s take a look at Jacob and see what the chart tells us.
(*Please note that the risk factors listed below are associated with the risk of aspiration pneumonia and do not necessarily imply causation especially as an independent factor. See sources cited below)
Aspiration of harmful contents
GERD
Tachypnea/swallow coordination
Dependence on HFNC (60 LPM with 50% FiO2)
Reduced pulmonary clearance
COVID-19 pneumonia
COPD
Supplementary oxygen
Impaired immune response
Medical complexity
Age
Polypharmacy
Nutrition risk
Current infection
As we move onto the bedside we get even more information to add to our list:
Aspiration of harmful contents
Poor oral health
Reduced pulmonary clearance
Decreased mobility
Weak cough
Impaired immune response
Generalized weakness
(Feinberg et al., 1996; Fukuba et al., 2020; Herzig et al., 2009; Kaneoka et al., 2017; Kollmeier & Keenaghan, 2022; Laheij, 2004; Langmore, et al., 1998; Langmore et al., 2002; Leder et al., 2013; Manabe et al., 2015; Marik, 2001; Nativ-Zeltzer et al., 2021; Taylor et al., 2013)
Risk in Real Life
Now that we know and understand the risk factors to provide a context for us, it’s time to do our swallow evaluation so we can get a clinical picture. Jacob was admitted on a diet of mechanical soft solids and thin liquids. Trials of the current diet were administered during lunch and a 3 oz water test was completed. No deficits were observed. I spoke to the patient, family, nurse, and respiratory therapist to determine if there were signs/symptoms of aspiration that I may have missed during my brief time with the patient. There weren’t. Aside from all of the risk factors present the patient appears to be tolerating PO without significant difficulty at this time.
Thankfully the risk is now A LOT lower knowing that the patient is not experiencing any difficulty swallowing. But that doesn’t mean the risk is 0%. In fact, it’s never that low (even healthy people aspirate with surprising frequency). So, the patient may still have an elevated risk of aspiration pneumonia even if we do everything we can to make sure the patient is safe with PO. So let’s recommend some management approaches to reduce the risk of aspiration pneumonia in the event that the patient does infrequently aspirate.
Managing Risk
Let’s look back at our list. Are we doing everything we can to mitigate risk? If so, how?
Increased risk of aspiration of harmful contents:
GERD: Proton-pump inhibitor and reflux precautions
Tachypnea: Breathing/swallowing coordination with slow pacing during meals, and diet modified to puree with ground meats to reduce fatigue factor during meals
Dependence on HFNC: Titration by respiratory as indicated
Poor oral health: On Valtrex with magic mouthwash
Reduced pulmonary clearance:
COVID-19 pneumonia: Infectious disease MD managing with steroids, anti-viral, and other medications as needed. Training on secretion management techniques provided.
COPD: On nebulizer treatments, undergoing chest physiotherapy, and deep breathing education
Supplementary oxygen: Titrating by respiratory as indicated
Decreased mobility: Undergoing rehab for mobilization and strengthening
Weak cough: Respiratory strength training
Impaired immune response
Medical complexity: Multidisciplinary approach
Age: Consider conservative approach and avoidance of aggressive measures with IDT as needed
Polypharmacy: Med list is regularly reviewed with physicians and pharmacists to determine if medications can be reduced or discontinued
Generalized weakness: Undergoing rehab for mobilization and strengthening
Nutrition risk: Registered dietician following to optimize caloric and nutritional intake
Current infection: Infectious disease MD managing current infections with antibiotics, anti-viral, and other medications
Placing the Pieces of the Puzzle
Thankfully most of Jacob’s risks can be managed through various forms of intervention. Management of this complex case takes a complex approach from multiple angles involving multiple disciplines. But it also requires each team member to know (or learn!) enough about other disciplines’ work and goals to align them all together. It’s a team approach. And we are essential members of that team, providing direct treatment in the form of an ongoing assessment of status and risk with training on compensatory strategies, instruction on secretion management techniques, and education on breathing techniques. Yes, the list of risks is long and intimidating and many of those risks cannot be managed by us because they are simply not within our scope of practice. But there is still SO much we can do to help this patient. The problems that we can’t help with directly are identified, documented, and an appropriate referral and follow-up can be managed by the SLP as well to make sure all pieces of the puzzle are falling into place. We continue to assess, educate/train, and provide any form of direct intervention we can to reduce risk and promote recovery.
A Different Kind of Intervention
Even though Jacob is not experiencing significant signs or symptoms of aspiration, it doesn’t mean the risk is 0%. While the risk may be relatively low, we must still acknowledge his compromised respiratory status which should be managed to reduce his overall risk of choking and pneumonia, as well as to optimize nutrition and hydration so a feeding tube is not needed. Our role might be supportive in nature and may not require traditional forms of intervention, but it is no less important. It is the integrative and team-based management techniques that often make the most difference for the patient in the critical care setting. Jacob wasn’t ready for extended periods of rehabilitation yet, but with time and effort, unnecessary atrophy and a functional decline were averted. Once stable, he was admitted to an acute rehabilitation center where he would get involved in long periods of direct rehab to work on his functional abilities. He continues to work hard every day in order to accomplish the final task that he’s been thinking about for the last three and a half months: To go home.
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References
Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104-109. doi:10.1007/bf00417899
Fukuba, N., Nishida, M., Hayashi, M., Furukawa, N., Ishitobi, H., Nagaoka, M., Takahashi, Y., Fukuhara, H., Yuki, M., Komazawa, Y., Sato, S., & Shizuku, T. (2020). The relationship between polypharmacy and hospital-stay duration: A retrospective study. Cureus. https://doi.org/10.7759/cureus.7267
Herzig, S. J. (2009). Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA, 301(20), 2120. https://doi.org/10.1001/jama.2009.722
Kaneoka, A., Pisegna, J. M., Inokuchi, H., Ueha, R., Goto, T., Nito, T., Stepp, C. E., LaValley, M. P., Haga, N., & Langmore, S. E. (2017). Relationship between laryngeal sensory deficits, aspiration, and pneumonia in patients with dysphagia. Dysphagia, 33(2), 192–199. https://doi.org/10.1007/s00455-017-9845-8
Kollmeier, B. R. & Keenaghan, M. (2022). Aspiration risk. StatPearls Publishing. NBK470169. 29262188
Laheij, R. J. F. (2004). Risk of community-acquired pneumonia and use of gastric acid–suppressive drugs. JAMA, 292(16), 1955. https://doi.org/10.1001/jama.292.16.1955
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
Leder, S. B., Suiter, D. M., Murray, J., & Rademaker, A. W. (2013). Can an oral mechanism examination contribute to the assessment of odds of aspiration? Dysphagia, 28(3), 370-374. doi:10.1007/s00455-012-9442-9
Manabe, T., Teramoto, S., Tamiya, N., Okochi, J., & Hizawa, N. (2015). Risk Factors for aspiration pneumonia in older adults. PLOS ONE, 10(10), e0140060. https://doi.org/10.1371/journal.pone.0140060
Marik, P. E. (2001). Aspiration pneumonitis and aspiration pneumonia. New England Journal of Medicine, 344(9), 665–671. https://doi.org/10.1056/nejm200103013440908
Nativ‐Zeltzer, N., Nachalon, Y., Kaufman, M. W., Seeni, I. C., Bastea, S., Aulakh, S. S., Makkiyah, S., Wilson, M. D., Evangelista, L., Kuhn, M. A., Sahin, M., & Belafsky, P. C. (2021). Predictors of aspiration pneumonia and mortality in patients with dysphagia. The Laryngoscope, 132(6), 1172–1176. https://doi.org/10.1002/lary.29770
Taylor, J. K., Fleming, G. B., Singanayagam, A., Hill, A. T., & Chalmers, J. D. (2013). Risk factors for aspiration in community-acquired pneumonia: Analysis of a hospitalized UK cohort. The American Journal of Medicine, 126(11), 995–1001. https://doi.org/10.1016/j.amjmed.2013.07.012
