Aspiration Pneumonia: The Whole Story
By George Barnes MS CCC-SLP
What comes to mind when you think of aspiration pneumonia (AP)? Something pretty straight forward right? There’s a cause (aspiration) and effect (pneumonia). Simple enough- let’s end things right here and call it a day then, shall we?
I remember when I was in my CF I would actually get upset with myself and even embarrassed when one of my patients would be diagnosed with AP. I failed her. I failed everybody. I...am...a… failure (insert inconsolable hysterics). I later learned that the term itself is often misused and the differential diagnosis often over-simplified.
What is aspiration?
Aspiration is the sucking in of food/liquid into the lungs. But how did it get there? What direction did it come from: anterograde (top-down) or retrograde (bottom-up)? What was it? Secretions? Food/liquid (If so, what type?)? Pneumonia (pna) can be defined by an infection in the lungs. But was it viral, bacterial, or fungal? Which part of the lungs was the infection in? Did the patient have it before or after the dysphagia started (The ol’ chicken or the egg phenomenon)?
Understanding the whole story:
So now that I’ve sprinkled doubt on everything you thought you knew about AP with a lot of rhetorical questions (Let’s be honest, probably too many), I’ll open up this oversimplified version of the term so we can see what’s inside. Just because our patient is aspirating and has pna, doesn’t mean it is AP. Many of us aspirate in our sleep every night and are none the wiser (Gleeson et. al., 2007). When we see AP, we often zero in on the swallowing and forget about all the other risk factors for pna. This would be like watching a movie trailer and pretending you watched the whole film. You wouldn’t know the storyline, the underlying moral message, or the complex interplay between the characters (quick pause while I Netflix and ponder).
So why focus on dysphagia?
This of course doesn’t mean it’s not important to assess and manage dysphagia. Dysphagia is a key component of consideration in the assessment of pna (not to mention the impact it has on quality of life- see prior blog on the importance of food in our lives) (Langmore et al., 1998). Further, aspiration can make a current infection worse, even if it wasn’t the original cause (Herrero et al., 2018; Lucas et al., 2009). Confused yet? Good. Because it’s complicated. And it should be. This is the human body we are talking about.
Moving forward:
What I think we should be doing is assessing the patient as a whole by answering two simple questions: What is being aspirated (contents and volume determined by an MBSS/FEES) and who is aspirating it (what’s the patient’s ability to clear the aspirate or forge an immune response?) (Hibberd et al., 2013; Langmore et al., 1998; Loeb et al., 1999; Quagliarello, 2005; Yu et al., 2018). Two people walk into a bar: One is a healthy 25 year-old with trace aspiration on thin and the other an 85 year-old with cardiopulmonary disease and a weak cough with gross aspiration on everything. Who has the higher risk?
So once we establish that there is aspiration and why it’s happening, we need to quantify the risk of developing pna before we laser in on the dysphagia and start draconian measures to manage it. A close colleague of mine, Doreen Benson MS CCC-SLP and I are in the midst of developing a tool that would allow us to calculate this risk based on the patient’s medical comorbidities. This way we can actually place a probability to the risk and modify that probability based on our intervention (i.e. thickened liquids, improved oral care, feeding strategies, etc.).
We believe this will get us to the root of the problem. Not the dysphagia, but the effects of the dysphagia. Because we are getting sick of watching the trailer. We want to understand the whole story.
If you’re interested in finding out more about this tool please subscribe to this blog as I will be discussing it in more detail soon.
References:
Gleeson, K., Maxwell, S. L., & Eggli, D. F. (1997). Quantitative Aspiration During Sleep in Normal Subjects. Chest, 111(5), 1266– 1272. https://doi.org/10.1378/chest.111.5.1266
Herrero, R., Sanchez, G., & Lorente, J. A. (2018). New insights into the mechanisms of pulmonary edema in acute lung injury. Annals of Translational Medicine, 6(2), 32. https://doi.org/10.21037/atm.2017.12.18
Hibberd, J., Fraser, J., Chapman, C. et al. Can we use influencing factors to predict aspiration pneumonia in the United Kingdom?. Multidiscip Respir Med 8, 39 (2013). https://doi.org/10.1186/2049-6958-8-39
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
Loeb, M., McGeer, A., McArthur, M., Walter, S., & Simor, A. E. (1999). Risk Factors for Pneumonia and Other Lower Respiratory Tract Infections in Elderly Residents of Long-term Care Facilities. Archives of Internal Medicine, 159(17), 2058. https://doi.org/10.1001/archinte.159.17.2058
Lucas, R., Verin, A. D., Black, S. M., & Catravas, J. D. (2009). Regulators of endothelial and epithelial barrier integrity and function in acute lung injury. Biochemical Pharmacology, 77(12), 1763–1772. https://doi.org/10.1016/j.bcp.2009.01.014
Quagliarello, V., Ginter, S., Han, L., Van Ness, P., Allore, H., & Tinetti, M. (2005). Modifiable Risk Factors for Nursing Home-Acquired Pneumonia. Clinical Infectious Diseases, 40(1), 1–6. https://doi.org/10.1086/426023
Yu, K. J., Moon, H., & Park, D. (2018). Different clinical predictors of aspiration pneumonia in dysphagic stroke patients related to stroke lesion. Medicine, 97(52), e13968. https://doi.org/10.1097/md.0000000000013968
About George:
George Barnes MS CCC-SLP has clinical experience in a variety of settings including acute care, acute rehab, skilled nursing, and critical illness recovery. This variety has developed his specialization in dysphagia management with a focus on diagnostics through instrumental swallow evaluations. His concentration is on geriatric patients with complex medical status. He is co-founder of FEESible Swallow Solutions, a mobile speech pathology company dedicated to improving access to high-quality dysphagia services for patients in the skilled nursing setting.
George has a track record of supporting the field of speech pathology by paying his knowledge forward to other professionals via graduate-level education, clinical fellowship and student supervision, the Student to Empowered Professional (STEP) mentorship program, The Medical SLP Collective mentorship service, ASHA special interest groups, peer review for ASHA course material, the SIG13 dysphagia editorial committee, and participation in various interdisciplinary teams and committees in the hospital setting. He is a multiple ASHA ACE Award recipient for his dedication to continuing education. George actively conducts and supports new research aimed to improve efficiency and accuracy in dysphagia diagnostics, management, and care.
