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Case Study: Nutrition

Management of Aspiration
Pneumonia
Renee (Pik Shan) Fung
Dietetic Intern
ARAMARK Healthcare
Distance Learning Dietetic Internship
Maple Grove Hospital

Disease Description

Definitions
Aspiration- the inhalation of oropharyngeal
or gastric contents into the larynx and lower
respiratory tract
Aspiration Pneumonitis- Chemical injury
caused by the inhalation of sterile gastric
contents
Aspiration Pneumonia- Infectious process
caused by the inhalation of oropharyngeal
secretions that are colonized by pathogenic
bacteria

Aspiration
Aspiration can cause serious illnesses and even
death.
Four common problems of aspiration:
1. Failure to distinguish aspiration pneumonitis from
aspiration pneumonia
2. Tendency to consider all pulmonary complications
of aspiration as infectious
3. The failure to identify the spectrum of pathogens in
patients with infectious complications
4. Misconception that aspiration must be witnessed
for it to be dx.

Etiology
Half of all healthy adults aspirate.
The human body is capable of removing
foreign objects by coughing
Individuals who have problem with removing
foreign objects properly are at risk of
developing aspiration pneumonia/
pneumonitis

Pathophysiology
Common cause of aspiration pneumonia is
the inhalation of Haemophilus influenza and
Streptococcus Pneumonia.
They are colonized in the nasopharynx or
oropharynex before they are aspirated.

Pathophysiology
Since aspiration pneumonitis is the
inhalation of sterile gastric contents,
bacterial infection does not play an
important role at early stage.
At a later stage of aspiration pneumonitis,
bacterial colonization may occur if the
individual has gastroparesis, small-bowel
obstruction, receives enteral feedings, or has
higher pH gastric acids. In this case, the
individual has aspiration pneumonia.

Aspiration Pneumonia
Diagnosis
Signs/symptoms: (signs of aspiration)
Persistent cough and fever. However, many
times silent aspiration can develop. In
aspiration pneumonia, the episode of
aspiration is generally not witnessed.
Swallowing evaluation by an SLP
CT scan- radiographic evidence of foreign
material infiltrating in patients lungs (some
may be undetectable)

Individuals who are at risk of


aspiration pneumonia
Currently, there are no recognized guidelines for risk factors of
aspiration pneumonia
Elderly
Neurologic Dysphagia
Unconscious individuals
Individuals at hospitals
Disruption of the gastroesophageal junction
Abnormalities of the upper GI tract
Poor oral care individuals
Patients with stroke
After the removal of an endotracheal tube due to residual effects or
sedative drugs, the presence of an NG tube, and swallowing
dysfunction related to alterations of upper-airway sensitivity, glottic
injury, and laryngeal muscular dysfunction

Co-morbidity
Increased LOS
Increased cost
Increased morbidity and mortality

Decrease aspiration pneumonia


complication
Early detection of patents who are at risk of
or have aspiration pneumonia
SLP evaluation
Barium swallow

CT scan

Provide appropriate care

Evidenced Based Nutrition


Recommendations for
Aspiration Pneumonia

AND Evidence Analysis Library


and the A.S.P.E.N
30-45 degree head of bed elevation position
Promotility agents
AND: if >500 mL GRV
A.S.P.E.N: If >250 mL GRV

E.g. Metoclopramide and Erythromycin


Associated with reduced GRV in critically ill pts
Recommend to be used in critically ill pts who
experience feeding intolerance (high gastric
residuals, emesis)

Horiuchi A, et al (2013) Elemental diets


may reduce the risk of aspiration pneumonia
in bedridden gastrostomy-fed patients

Hypothesis: Elemental diets may be useful


for the prevention of aspiration pneumonia
possibly through more rapid gastric
emptying than standard liquid diets.
This study is separated into 2 different parts.

Horiuchi A, et al Elemental diets may reduce the risk of


aspiration pneumonia in bedridden gastrostomy-fed patients
PART 1

Participants:
128 Bedridden PEG participants
Age: Average 80 years old
Gender: 60 of the participants were male.
Method:
60 subjects were assigned to elemental diet group
67 subjects were assigned to the standard liquid diet
group.
Record subjects who experienced aspiration and
aspiration pneumonia

Horiuchi A, et al Elemental diets may reduce the risk of


aspiration pneumonia in bedridden gastrostomy-fed patients
PART 1

Result:
The number of patients who had diet
aspirated from the trachea or who developed
new aspiration pneumonias in the elemental
group was significantly less than the
standard liquid diet group.

Horiuchi A, et al Elemental diets may reduce the risk of


aspiration pneumonia in bedridden gastrostomy-fed patients
PART 2

Randomized, crossover trial which focused


on identifying the gastric emptying velocity
differences between the two diets via PEG
Participants:
19 PEG subjects

Horiuchi A, et al Elemental diets may reduce the risk of


aspiration pneumonia in bedridden gastrostomy-fed patients
PART 2

Result:
Elemental diets were associated with more
rapid gastric empting.
Possibly due to:
Fatty diet takes longer time to empty and is
associated with gastroesophageal
regurgitation. Standard liquid diet has higher
fat content than elemental diet.

Horiuchi A, et al Elemental diets may reduce the risk of


aspiration pneumonia in bedridden gastrostomy-fed patients

Limitation:
Study 1 had increased risk of bias because it
was neither randomized nor blinded
Study 2 could not prove the hypothesis by itself
Participants in study 1 included those who had
pervious experience of aspiration which
suggested that they can be generalized.
Study 2 might have carry-over issues between
treatments.

Horiuchi A, et al Elemental diets may reduce the risk of


aspiration pneumonia in bedridden gastrostomy-fed patients

In summary, this study found elemental


diets to be associated with reduced episodes
of aspiration and more rapid gastric empting
among bedridden PEG patients.
Nevertheless, further research is needed to
prove whether or not there is a causation
effect existing between rapid gastric
empting and reduced episodes of aspiration
and aspiration pneumonia.

Jiyoung J, et al (2013) - Effect of gastric versus postpyloric feeding on the incidence of pneumonia in
critically ill patients: observations from traditional
and Bayesian random-effects meta-analysis.

Examined the effect of gastric versus post-pyloric feeding on the


incidence of pneumonia in critically ill patients.
Method:
2 reviewers reviewed and selected studies searched from MEDLINE,
EMBASE, Web of Science, and CCTRD. The reviewers then compared
gastric and post-pyloric feeding in critically ill patients.
Selection Criteria:
Trails should report at least one of the following outcomes: incidence of
pneumonia, vomiting, or aspiration, and studies that were published in
any language. Selected studies were all published in English and were
from Canada, Australia, Italy, Spain, Taiwan, and the USA. The selected
studies included patients from general ICUs, pediatric ICU, neurological
ICU, and severe acute pancreatitis from gastroenterology.

Jiyoung J, et al - Effect of gastric versus post-pyloric


feeding on the incidence of pneumonia in critically
ill patients: observations from traditional and
Bayesian random-effects meta-analysis.

Result:
The incidences of pneumonia were 16.3% in the postpyloric feeding group and 26.1% in the gastric feeding
group (P = 0.001).
There was no significant differences in the beneficial
effect of the post-pyloric feed location (duodenum
(P=0.03) versus jejunum (P= 0.07).
there was no significant difference between post-pyloric
feeding group and gastric feeding group in the amount of
aspiration (P= 0.55) and vomiting (P = 0.56) incidence.

Jiyoung J, et al - Effect of gastric versus post-pyloric


feeding on the incidence of pneumonia in critically
ill patients: observations from traditional and
Bayesian random-effects meta-analysis.

Limitation
Not all outcomes in the selected studies were reported.
Many of the studies were not good qualities.
For example, potential biases may exist in the selected
studies, clinical heterogeneity in the studies that may
account for the statistical heterogeneity that were found in
this study which could have affected the result, and not all
studies reported adequate concealment, blinding of
participants, and outcome assessment.

The amount of eligible studies was relatively small.


(757 pts; 15 studies)

Jiyoung J, et al - Effect of gastric versus post-pyloric


feeding on the incidence of pneumonia in critically
ill patients: observations from traditional and
Bayesian random-effects meta-analysis.

In summary, Jiyong J, et al suggested that


critically ill patients with post-pyloric feeding is
associated with reduced incidence of
pneumonia when compared with gastric
feedings. Meanwhile, there is no significant
difference in incidence of neither aspiration
nor vomiting between the two groups. Finally,
no significant beneficial difference was found
between post-pyloric feeds to the jejunum or
duodenum.

Case Presentation

Case Presentation
58 yrs old F
Lives at group home
Aspiration noted by group home manager.
Patient had continuous coughing and
developed a fever. Patient was admitted to
the ER the next day

Nutrition Care ProcessAssessment


Client Hx
Mental Retardation
Epilepsy
Schilders cataract
Hypothyroidism
Family Hx
Unknown; pt was in foster care since the age of 2

DNR status

Nutrition Care ProcessAssessment


Food/ Nutrition-Related Hx
Patient consumes a ground diet (Dysphagia 2)
with honey thickened liquids for the past 15
yrs due to recurrent aspirations
NKFA
Upon admission, patient was provided with
calcium + vit D pills, D5W NS @ 125 mL/hr,
Colace, Synthroid, Protonix, Miralax, and
Propofol ranging 7-10 mL/hr

Nutrition Care ProcessAssessment


Nutrition-Focused Physical Findings

Patient had gained 14 lbs in 2 days.


Patient has fluid retention.
Skin integrity: minor impairment
Appetite: Fine prior to aspiration episode
SLP recommended patient to be NPO besides
medications are crushed into applesauce.
Patient unable to self-feed

Nutrition Care ProcessAssessment


Anthropometric Measurements
UBW: Unable to obtain d/t patients mental
state
Height: 410
IBW: 95 lbs +/- 10%
BMI: 28.5 overweight
*Patient is retaining fluid, weight may not be
a good indicator for nutrition status

Nutrition Care ProcessAssessment


Biochemical Data, Medical Tests, and
Procedures
A swallowing evaluation was performed by
the SLP. The SLP noted signs and symptoms
of aspiration
The patient will have an OJ tube placed for
short-term nutrition support.
A chest x-ray was done before patient being
intubated.

Lab Results
Component Valu Nor Date
Rationale
e
mal

ALBUMIN 3.0* 3.5- 9/25/2013 Malnutrition, acute inflammation


g/dL
5
GLUCOSE 94 70- 9/27/2013
mg/dL
110
9/27/2013
GLUCOSE 91
9/26/2013 Elevation due to stressed state
GLUCOSE 116*

SODIUM

139 136- 9/27/2013 Check for hydration status


mEq/L
145
POTASSIUM 3.2* 3.5- 9/27/2013 GI loss, malabsorption
mEq/L
5.5
9/25/2013 Check for re-feeding syndrome risk
PHOSPHOR 3.1
US

MAGNESIU 2.0 1.8- 9/25/2013 Check for re-feeding syndrome risk

M mg/dL
CHLORIDE 106
mEq/L
CALCIUMSE 7.6*
RUM mg/dL
BUNUREAN 19*
RO
CREATININE 1.15
mg/dL

3
95- 9/27/2013 Check for fluid/ acid-base imbalances
105
9-11 9/27/2013 Low serum calcium; Corrected Ca: 8.4*

9/27/2013 Malnutrition

0.6- 9/27/2013 Check for kidney function


1.2

Nutrition Care ProcessAssessment


Nutrition Need
Calories: 1300 kcal (30kcal/kg IBW)
Protein: 65-86 gm (1.5-2 gm/kg IBW)
Fluids: 1300 mL
Nutrition Classification:
Severely Compromised, Will follow up every 1-3
days
New TF (+4), Low Albumin (+2), Swallowing
Problems (+3), Dysphagia (+3)

Nutrition Care Process: Nutrition Diagnoses

#1 Swallowing difficulty (NC-1.1) related to


respiratory status as evidenced by NPO
status, need for dysphagia diet, and
aspiration history.

Nutrition Care Process: Nutrition


Intervention
#1 Enteral Nutrition (ND-2.1).
Recommend initiate enteral nutrition via OJ tube or NJ tube,
once placement verified start Isosource 1.5 at rate of 15
mL/hr x 8 hrs; if tolerating advance by 10 mL every 8 hrs to
current goal rate of 30 mL/hr x 24 hrs/day. No current free
water flushes until IVF addressed. (Table 5)

#2 Collaboration and Referral of Nutrition Care:


Collaboration with other providers (RC-1.4).
No residual checks with Jejunal feeding

Nutrition Care Process: Nutrition


Intervention

Short-term Goal/ Expected Outcome :


Maximize nutrient intake: Patient receives more
than 75% of recommended nutritional needs via
PO or nutrition support.
Patient maintains admission weight.

Long-term Goal/ Expected Outcome:


Patient will be able to meet more than 75% of
recommended nutritional needs via PO intake or
long-term tube placement in place for feeding.
Patient reduces aspiration incidence.

Nutrition Care Process: Monitoring


and Evaluation
Monitor and Evaluation (Nutrition Intervention
Performed):
#1Enteral nutrition intake (FH). Formula/ solution (1.3.1).
Patient was receiving enteral support via OJ tube with Isosource 1.5
formula at 30 mL/hr x 24 hours. Patient tolerated tube feeding at goal
rate. The patient is receiving 100% of recommended kcal and protein
needs via nutrition support.

#2 Micronutrient Intake (1.6) Mineral/ element intake (2)


Calcium (1). Patients corrected calcium is WNL. Phosphorus (6).
Patient is on phosphorus replacement protocol.

#3 Biochemical data, medical tests and procedures (BD).


Glucose/ endocrine profile (1.5).
Glucose, fasting(1). Glucose continues to be high. High glucose
possibly due to stress since Hgb A1c is WNL. Electrolyte and renal
profile (1.2). Continued to monitor patients renal lab.

#4 Anthropometric Measurements (AD). Weight change

Nutrition Care Process: Monitoring


and Evaluation

Short-term goal:
(Achieved) Short-term goal: Maximize nutrient intake:
Patient receives more than 75% of recommended
nutritional needs via PO or nutrition support.
(Not Achieved) Patient maintain current weight.
Long-term goal:
(Not Achieved) Patient will be able to meet more than
75% of recommended nutritional needs via PO intake or
long-term tube placement in place for feeding.
(Not Achieved) Patient reduces aspiration incidence.

Nutrition Care Process: Monitoring


and Evaluation
The patient was admitted to the hospital from 9.27 to 10.14. The
patient was followed up everyday by a dietitian. Meanwhile, the
patient had developed acute respiratory failure and was at
critical condition. Her tube feeding formula was switched from
Isosource 1.5 to Impact Peptide 1.5 which is an elemental
formula for patients who are in stressed condition. The patient
then became more stable, and had a PEG placement for longterm nutrition support. The patient was discharged with
nocturnal feeds Isosource 1.5 65 mL/hr x 12 hours/day. The
reason why she was discharged with Isosource 1.5 instead of
Impact Peptide 1.5 was because her insurance company would
not cover Impact Peptide 1.5 since it is an elemental formula
and is more expensive.

Patients Progress after Discharge

The patient was re-admitted to the hospital 4 days after


being discharged. The patient was re-admitted for aspiration
because she was having PO intake. The patient is on DNR
status. The RD recommended modifying the PEG tube to a
PEG-J tube, however, IR stated that PEG needed to be in
place for 3-4 weeks prior to adjust tube. During her second
admission, the tube feeding was either running at a low rate
or on hold for a few times due to reoccurring emesis. Finally,
the patient was able to tolerate tube feeding with bolus
feeds. The patient was discharged on 10/26/2013 with the
same recommendation of tube feeding regimen as previous
time.

Evidence-based recommendation
implemented on this case
30-45 degrees head of bed position
Enteral nutrition support to decrease risk of
aspiration
Jejunal feeds rather than gastric feeds
Elemental formula was used

Conclusion
The current recommendation for Aspiration
Pneumonia care is to feed patients who are receiving
tube feeding in a 30-45 degree elevation of head of
bed position. Promotility agents are also encouraged
to use. There are controversial in whether or not
jejunal feeding is more beneficial over gastric feeding;
More research need to be done to confirm this finding.
Further more, research suggest that elemental
formula may be a better choice than standard
formula, however, elemental formulas are more
expensive and many insurance do not cover it.

References
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may reduce the risk of aspiration pneumonia in bedridden gastrostomy-fed
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2. Jiyong J, Tiancha H, Huiqin W, Jingfen J. Effect of gastric versus post-pyloric feeding
on the incidence of pneumonia in critically ill patients: observations from traditional
and Bayesian random-effects meta-analysis. Clin Nutr. 2013; 32: 8-15.
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prevention of aspiration pneumonia in high-risk patients on a medical-surgical unit.
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community-acquired pneumonia and healthcare-associated pneumonia: A
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Nurs. 2010; 110(11): 26-33
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