Aspiration of pharyngeal or gastric material into the lungs is a significant risk for many patients in the ICU. This may lead to the development of aspiration pneumonia, which can cause serious complications.
The American Association of Critical Care Nurses recently released a Practice Alert called “Prevention of Aspiration in Adults”. By implementing measures nurses can use to keep patients’ airways clear, reduce the risk of aspiration, and prevent subsequent pneumonia, the goal is to improve patient outcomes and reduce hospital costs.
Let’s take a closer look at some of the proposed practice recommendations:
- Elevate patient’s head of bed between 30 and 45 degrees: Laying supine increases reflux and potential for aspiration. Barring any contraindications, patients who are at high risk for aspiration, such as those with a feeding tube or who are ventilated, should have the head of the bed elevated to decrease this risk.
- Reduce the use of sedatives when possible: When a patient is sedated, they may be less likely to clear their own airway by coughing or gagging. Limiting the use of sedatives will allow these reflexes to stay intact.
- Check feeding tube placement every 4 hours: Even when properly placed, the position of the feeding tube can change over time. It is important that nurses regularly assess where the end of the feeding tube is located. If it moves too high, the patient is at a higher risk for aspiration.
- Assess for signs of feeding intolerance every 4 hours in tube-fed patients: Regularly checking gastric residuals (the amount of a tube feeding that has not been digested), gastric distention, and complaints of gastric pain are all good indicators of how well a patient is tolerating feedings. Intolerance can lead to vomiting and possible aspiration.
- Avoid bolus feedings: There are no specific recommendations, but it appears from a small study that patients at high risk for aspiration are less likely to aspirate when receiving continuous feedings versus receiving a larger food bolus over a short period of time.
- Consider swallow studies for recently extubated patients: When patients are intubated, they experience some decrease in swallowing ability. Patients who have been intubated for longer than 2 days should have a formal evaluation of their swallowing function.
- Keep endotracheal cuff pressures at proper levels and suction secretions from the hypopharynx: It is recommended that cuff pressures be kept between 20 and 30 cm H2O to prevent secretions from leaking into the lower airways, while still minimizing damage to the trachea. Before the cuff is deflated, the patient should be suctioned to remove secretions from the hypopharynx so that they are not aspirated.
Additionally, nurses are patient advocates. Even though they aren’t directly responsible for a patient prior to admission, critical care nurses should recognize the importance of and advocate for the best possible treatment of their patients before they arrive in the ICU. A recent article, “Aspiration Pneumonitis and Pneumonia”, discussed the value of suctioning to remove aspirate when stabilizing patients’ airways in the field and in the ER, so as to avoid developing aspiration pneumonia days later.
Nurses should always stay abreast of the newest guidelines and recommendations so that they are certain provide the highest quality care for their patients. Reducing the prevalence of aspiration pneumonia will lead to shorter hospital stays, less use of antibiotics, and a decrease in mortality for their patients.
Methany, N. E., RN, PhD, FAAN. (2016). Prevention of Aspiration in Adults. Critical Care Nurse, 36(1), 20-24. Retrieved March 20, 2016, from http://www.aacn.org/wd/practice/docs/practicealerts/aspiration-pa-feb2016ccn-pages.pdf
Swaminathan, A., MD, MPH, Varkey, B., MD, FCCP, Stearns, D. A., MD, & Varkey, A. B., MD. (n.d.). Aspiration Pneumonitis and Pneumonia . Retrieved March 20, 2016, from http://emedicine.medscape.com/article/296198-overview#a1