An important point is that all three factors–impaired health status (body condition & immune status), dysphagia, and poor oral health–must be considered together each with their presence and severity integrated into determining if your patient is at risk for pneumonia from aspiration or not.
Health Status, or severity of illness, is determined from the medical record for age, current medical diagnoses, level of frailty or debility, labs values (albumin & RBC count), and the status of the immune system (WBC, Neutrophils, & Lymphocytes).
Oral Health Status is determined overtly by examining the teeth, tongue, lips, and mouth. Look for signs of red, swollen gingiva, yellow shiny teeth surfaces, receding gingiva, tooth cavities, plaque, and dry mouth surfaces. The Oral Health Assessment Tool (OHAT) is a recognized, proven screening tool for just such purposes. The mouth is a reservoir of bacteria populating the lungs and gastric system.
Swallowing Safety should only be determined using instrumental studies–FEES or VFSS. These important tools must be administered using established standard clinical protocols and procedures. In-depth analyses and interpretations by trained and experienced SLPs provide high-quality useful results needed to make decisions. Screening tests and “clinical bedside assessments” should only be used to determine if the patient has overt signs of dysphagia, and, if so, to refer for an instrumental study. The Yale Swallow Protocol provides very good sensitivity and specificity. Screening tools are too insensitive to detect aspiration, complex swallowing impairment, and explain the underlying biomechanical reasons for the dysphagia. Dysphagia is the direct result of muscle weakness associated with frailty (acquired or aging), sarcopenia, and/or malnutrition.
Below is a chart to assist with making decisions regarding possible pneumonia risks.
Below are publications that may assist you in your understanding of this concept and how to use it effectively in your clinical practice.
Ashford, J. R. (2005, March). Pneumonia: Factors Beyond Aspiration. Perspectives in Swallowing and Swallowing Disorders (Dysphagia), 14, 10-16.
Ashford, J. R. & Skelley, M. L. (2008, March). Oral Care and the Elderly. Perspectives in Swallowing and Swallowing Disorders (Dysphagia), 17, 19-26.
Ashford, J. R. (2012, March). Oral Care Across Ages: A Review. Perspectives in Swallowing and Swallowing Disorders (Dysphagia), 21, 3-8.
Mills, R. H. & Ashford, J. R. (2008, December). A Methodology for the Inclusion of Laboratory Assessment in the Evaluation of Dysphagia. Perspectives in Swallowing and Swallowing Disorders (Dysphagia), 17, 128-134.
SA Swallowing Services, PLLC