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8 July 2014


 July 8, 2014
Category Dysphagia, Research
The Most Important Aspiration Pneumonia Article…Ever
This month I am going old school.  Waaay old school.  I’m talking 1998 old school, which in the world of research is basically primitive and never encouraged by professors or important research-reading people. Oh well.  Sometimes we need to go back to the basics – to the seminal articles which help us understand why we do what we do, and that which has been shown time and again to be truth in our practice.  My trip to the past was motivated by my selection of this 2014 article as my original Research Tuesday post.  Its a lovely article showing how NPO status and presence of a NG tube were significant predictors of aspiration pneumonia in acute stroke management, but as I read it and attempted to write about it, I kept thinking about this beauty.  I had to share.  I couldn’t resist the antique, and I love that the shiny new article I was attempting to write about was another article that supported a lot of the information from this old faithful.  Whether its news to you or old hat, I hope you enjoy it!
Langmore SE, Terpenning MS, Schork A, Chen YL, Murray JT, Lopatin D, Loesche WJ. Predictors of Aspiration Pneumonia: How Important is Dysphagia? Dysphagia. 1998;13:69–81.
This prospective outcome study, brought to us by Dr. Langmore, Dr. Terpenning and a before-he-completed-his-PhD Joseph Murray, looked at a variety of possible predictors for aspiration pneumonia.  The authors followed 189 subjects for 4 years (!!!) to determine who got aspiration pneumonia and what predictive factors the patients had in common.  The subjects were all male and had a variety of medical diagnoses (CVA, neurologic disease, COPD) and were followed in acute care, nursing homes and as outpatients.  Each participant was given a clinical swallowing evaluation, a FEES, a MBSS, three scintigraphy exams to assess esophageal clearance and reflux, a dental exam, saliva & throat samples, a thorough chart review and an interview to gather pertinent information.  The exams and interview were repeated annually unless a status change occurred, and the patients were followed until death, an occurrence of pneumonia or till they failed to return.  A panel of physicians was established to create a consensus as to when pneumonia was present.  The features used to diagnose pneumonia were “elevated white blood cell count (12,000 or above); fever (temperature >100.5 F); and new infiltrate on the chest radiograph, with the most weight given to the radiographic evidence.”   Risk factors for aspiration pneumonia were identified in the following categories: functional status, medical/health status, oral/dental status, and swallowing/feeding status.  Here are some of the most interesting results from each category:
  1. Functional status: Dependence for feeding and oral care were associated with a high level of pneumonia.
  2. Medical/Health Status: The highest incidence of pneumonia was found in nursing home patients (44%).  Patients with COPD, GI disease, and CHF experienced pneumonia at a similarly high rate as those with neurological diagnoses, and patients with both COPD & GI disease had the highest rate of pneumonia (50%).
  3. Oral/Dental Status: Number of decayed teeth, frequency of brushing teeth, and dependence for oral care were significantly associated with pneumonia.
  4. Swallowing/Feeding Status: Aspiration of food was found to have a higher association with aspiration pneumonia than aspiration of liquids.  Pharyngeal delay, premature spillage, and excess pharyngeal residue were the physiologic swallowing parameters most linked with aspiration pneumonia. Aspiration of secretions and excess secretions in the mouth were both significantly associated with pneumonia in dentate subjects, as was reduced esophageal motility.  And of the upmost importance was this quote, one that we all shake our heads at in dismay and disbelief: “In our study, tube feeding was significantly associated with aspiration pneumonia, which is consistent with the findings of others [19,28,31–34,38,40]. Because our patients were usually not taking any food or liquid by mouth, aspiration presumably occurred with secretions.”
The authors found that the best predictors of pneumonia were:
  1. dependent for feeding
  2. dependent for oral care
  3. number of decayed teeth
  4. tube feeding
  5. more than one medical diagnosis
  6. number of medications
  7. smoking status
And then they created this awesome flow chart to show how all of the factors are linked to result in aspiration pneumonia. (click on the image to make it bigger)
predictors of pneu
WOW.  Just wow.  Its almost an entire dysphagia course in one single journal article.  I reference it at least once a week, and it is on my mind during every chart review and every evaluation I complete.  At SASS, we have taken this article to heart so much that our FEES report and oral mechanism templates cover almost all of those 7 predictors (we don’t actually sit down and count decayed teeth, but we do note oral condition). SLPs will never truly be able to identify every single patient who will get aspiration pneumonia, but with a good instrumental evaluation and these factors in mind, we can provide the patient and staff some good information as to their risk.
May I take a quick moment on my soap box?…Please?… How often do we harp about oral care only to get brushed off by family or the patient or nursing staff?  A lot.  This is the article to show directors of nursing everywhere when patients aren’t getting their teeth cleaned or are getting food administered too quickly.  Those dinky green spongy things and mouthwash don’t cut it.  Patients need friction and abrasion to get plaque off teeth and they need a toothbrush to do it.  If teeth aren’t present, gums should be brushed and dentures appropriately cleaned.  Bacteria lives in those places, too.  Dr. Ashford always says the best tools to combat pneumonia are a teaspoon, a toothbrush and a thermometer – use them! SASS has created an amazing oral care presentation designed for CNA inservices that should be available soon.  If you need help in this battle, please let us know!  Phew, ok, rant over.
There are many other articles out there that elaborate on the findings of this article in single studies (such as the one I started to write about for this post), but this one is so thorough and covers so much information about the multifactorial nature of aspiration pneumonia – it should be in everyone’s “dysphagia” file.  At the end, the authors note “ a major conclusion was that dysphagia and aspiration are necessary but not sufficient conditions for development of pneumonia.”  That is such an important take-away from this study.  There is no cookbook for dysphagia evaluation and treatment.  We have to lean on our training, experience, and articles like this one to help us best treat our patients. Never stop reading and never stop learning, and, occasionally, go back and look at some of these ancient artifacts of dysphagia research…there is much to gain from it!

Kelley Babcock, MS, CCC-SLP, BCS-S, is a voice and swallowing therapist from Nashville, Tennessee.  She works as a clinician and educator for SA Swallowing Services which provides basic, advanced and custom FEES courses for SLPs across the country.  For more information on FEES and dysphagia, check out or connect with Kelley on Twitter or LinkedIn.

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