Aspiration occurs when food, secretions, fluids, or other substances enter the airways of the lungs. When swallowing, the epiglottis should close over the trachea which prevents food or fluids from entering the trachea (often called the windpipe). If this mechanism fails, substances can end up in the lungs, which can cause complications such as aspiration pneumonia. Sometimes gastric contents can also reflux, which causes stomach contents to regurgitate into the esophagus.
People who have dysphagia, which is difficulty swallowing, are at the highest risk for aspiration. Older adults, those with a compromised airway or impaired gag reflexes, or the presence of oral, nasal, or gastric tubes are at an increased risk. Aspiration can cause choking, respiratory complications, infections, and can be fatal if not quickly recognized and treated. Prevention is the first step, and the nurse should assess risk factors before feeding the patient or providing oral medications to patients. For people with known dysphagia, aspiration precautions should be implemented.
In this article:
- Risk Factors (Related to)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Risk Factors (Related to)
The following are common risk factors for aspiration:
- Presence of tracheostomy or endotracheal tube
- Tube feedings
- Reduced level of consciousness
- Depressed cough or gag reflex
- Impaired swallowing
- Oral/facial/neck trauma or surgery
- Inability to maintain upright body posture
- Gastrointestinal disorders: hiatal hernia, delayed gastric emptying, gastroesophageal reflux disease (GERD), etc.
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for risk for aspiration:
- Patient will not experience aspiration, as observed by clear lung sounds, unlabored breathing, absence of coughing, and oxygen saturation within normal limits.
- Patient and/or caregiver will demonstrate appropriate techniques to prevent aspiration.
- Patient and/or caregiver will verbalize potential risk factors for aspiration.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to risk for aspiration.
1. Identify patients at an increased risk for aspiration.
Patients with impaired swallowing (dysphagia) from a stroke, Parkinson’s disease, spinal cord injury or neurological damage with the inability to clear secretions require assessment and monitoring when providing anything by mouth.
2. Determine the level of consciousness.
Patients who are sedated either intentionally or unintentionally are at risk for aspiration. Patients with reduced consciousness may not be able to clear secretions themselves.
3. Assess gag reflex and ability to safely swallow.
The nurse should first assess the patient’s speech and any difficulty in speaking which may signal risk for aspiration. Assess dentition and the patient’s ability to close the lips, control tongue movement, the presence of facial symmetry, and the ability to cough. The nurse can assess the gag reflex by touching the back of the patient’s throat with a tongue blade or cotton swab. The patient may cough or initiate swallowing as a positive response. If not, do not provide anything by mouth and request further evaluation. It may also be useful to have a speech-language pathologist do a formal assessment of the patient’s swallowing ability.
4. Monitor for signs of aspiration after oral intake.
If a patient is pocketing food in the mouth/cheeks, clearing the throat or coughing while eating, drooling, or displaying any difficulty breathing while eating or drinking, these may be indicators of aspiration.
5. Monitor for tubes that increase aspiration risk.
An overinflated or underinflated tracheostomy or endotracheal cuff can increase the risk of aspiration. A nasogastric tube dislodged from the stomach can cause aspiration if gastric contents get into the lungs. Tube feedings with a large residual signal ineffective digestion and increase the risk of reflux and aspiration.
6. Auscultate lung sounds and assess respiratory status.
Adventitious lung sounds such as crackles or rhonchi may be heard with aspiration pneumonia. Any change in respiratory status such as an increased rate, effort, or declining SaO2 level needs immediate attention.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a risk for aspiration.
1. Keep suctioning equipment at the bedside.
Patients at an increased risk for aspirating should have functioning suctioning equipment at the bedside for immediate use.
2. Performing suctioning as necessary.
Patients with a large amount of secretions or who cannot clear the secretion themselves may require frequent suctioning.
3. Keep the head of the bed elevated after feeding.
Whether self-feeding, assisting with feeding, administering medications or tube feedings, the head of the bed should remain elevated for 30 minutes to one hour after oral intake.
4. Implement other feeding techniques.
Patients who require assistance with feeding should be fed small bites slowly. Some patients may require coaching to remind them to chew and swallow. Allow rest before feeding times, as this may decrease the patient’s difficulty with swallowing. Do not distract or allow the patient to talk while chewing or swallowing.
5. Consult with speech therapy.
If swallowing is impaired, the patient requires further screening. A speech-language pathologist (SLP) can test swallowing with different foods and liquids. They can also teach the patient techniques to reduce swallowing such as the “chin-tuck” maneuver.
6. Follow diet modifications.
Use thickening agents as ordered and ensure proper diet modifications such as pureed or mechanical soft foods if these are specified. Thicker foods and liquids are less likely to be aspirated so diet recommendations should be instituted for people at high risk of aspiration.
7. Position properly.
Patients with drooling or uncontrolled secretions should be placed side-lying to allow secretions to drain and not pool in their mouths. Patients on continuous tube feeds should always have the head of the bed elevated at least 30 degrees.
8. Educate about conditions that can cause aspiration.
Esophageal strictures (narrowing of the esophagus) can trap food. Gastroesophageal reflux disease (GERD) is a condition that causes gastric acid to back up into the esophagus which can cause damage and lead to strictures. Delayed gastric emptying doesn’t empty food as quickly as it should which can cause reflux, vomiting, and other problems.
9. Request medication formulation changes.
Patients who cannot swallow pills may need medications to be administered in liquid, IV, or powder form. Some pills cannot be crushed and may not come in other forms. In these situations, the nurse should consult a pharmacist. Some patients may also be able to tolerate swallowing pills by placing the pill in applesauce or pudding.
10. Monitor tube-feeding patients closely.
Check residuals as ordered, often every 4 hours. Facility policy will dictate when residuals are too high. Always alert the provider if residuals are increasing, bowel sounds are hypoactive or absent, if there is any vomiting or frequent diarrhea, and if abdominal distention is observed.
11. Provide mouth care.
Mouth care prior to meals increases the desire to eat, while oral care following meals removes any residual food that could cause aspiration.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for risk for aspiration.
Care Plan #1
Diagnostic statement:
Risk for aspiration as evidenced by a reduced level of consciousness secondary to coma.
Expected outcomes:
- Patient will maintain a patent airway.
- Patient will not manifest signs of aspiration, such as:
- Dyspnea
- Cough
- Cyanosis
- Wheezing
- Hoarseness
- Foul-smelling sputum
- Fever
Assessment:
1. Confirm placement of enteral feeding tubes in the stomach.
Misplacement of feeding tubes may result in the aspiration of enteral formula. Patients who are intubated have a decreased level of consciousness, and those who have had a neurological injury or head, neck, and upper GI surgery have an increased risk for aspiration.
Confirm placement of enteral feeding tubes by:
- X-ray
- pH of 0 to 5 for the gastric fluid withdrawn through the tube
- Note that this test may not be fully unreliable if antacids were given within 4 hours.
- Auscultate injected air before intermittent feedings
- This may have reduced reliability as a malpositioned tube in the lungs or proximal jejunum may still be transmitted in the epigastrium.
- Observe the ability to speak and cough.
2. In patients with endotracheal or tracheostomy tubes, monitor the effectiveness of the cuff.
Collaborate with the respiratory therapist, as needed, to determine cuff pressure. An ineffective or overinflated cuff can increase the risk of aspiration. Properly inflated cuffs are the best protection.
3. Monitor for signs and symptoms of aspiration.
Common signs and symptoms include:
- Dyspnea
- Cough
- Cyanosis
- Wheezing
- Hoarseness
- Foul-smelling sputum
- Fever
Early detection of aspiration will facilitate urgent lifesaving interventions. If there is a new onset of symptoms, perform oral suction and notify the provider immediately.
4. Auscultate lung sounds frequently before and after feedings; Note any new onset of crackles or wheezing.
An increased respiratory rate and crackles may be the first signs of pneumonia in a patient who is intubated.
Interventions:
1. Keep suction setup available and use as needed.
Tracheal suction may be necessary to maintain a patent airway. Accumulation of secretions in the posterior pharynx and upper trachea increases the risk of aspiration.
2. If the patient has a tracheostomy or endotracheal tube:
- Inflate cuff:
- During continuous mechanical ventilation
- During and after eating
- During a 1-hour after-tube feeding
- During intermittent positive-pressure breathing treatments
- Suction every 1 to 2 hours and as needed
- Provide oral care.
Tracheostomy tubes interfere with the synchrony of the glottic closure. Inadequate cuff inflation may cause enteral materials to enter the lungs.
3. If the patient has a gastrointestinal tube:
- Elevate the head of the bed for 30 to 45 minutes during feeding periods and 1 hour after. This helps to prevent reflux using reverse gravity.
- Aspirate for residual contents before each feeding for gastric tubes.
- Administer feeding if residual contents are less than 150 mL during intermittent feeding.
Regulating gastric feedings at an intermittent schedule allows time for stomach emptying between feeding intervals.
Care Plan #2
Diagnostic statement:
Risk for aspiration as evidenced by impaired swallowing.
Expected outcomes:
- Patient will be free from aspiration.
- Patient will demonstrate techniques to improve swallowing and prevent aspiration.
Assessment:
1. Assess for sudden changes in respiratory signs and symptoms.
Sudden respiratory symptoms (e.g., severe coughing and cyanosis, wet phlegmy voice quality, new onset of crackles) indicate potential aspiration.
2. Assess the patient’s ability to swallow and cough. Note the voice quality.
Abnormal voice and speech patterns are signs of motor dysfunction in oral and pharyngeal swallowing structures.
3. Obtain medical history to identify factors contributing to impaired swallowing.
Individuals with impaired or absent cough reflexes (e.g., patients who had a stroke, those who have Parkinson’s disease, or those under sedation) are at high risk for aspiration.
Interventions:
1. Offer thick semi-solid foods or any food with a consistency that is tolerable by the patient.
Speech pathologists recommend using thickening agents for thickened semisolid foods (e.g., pudding and hot cereal) because they are easier to swallow and reduce the chances of aspiration. Liquids and thin foods are harder for patients with impaired swallowing. The patient should have a recommended food consistency ordered.
2. Advise the patient to eat slowly and chew food thoroughly during meals.
Cutting food into smaller pieces allows easier chewing and swallowing.
3. Provide meticulous oral care, including brushing of teeth at least two times per day.
Good oral care can prevent bacterial or fungal contamination of the mouth, which can be aspirated and lead to pneumonia.
4. Consult a speech therapist for an evaluation and recommended care plan.
A speech pathologist has the expertise needed to perform the dysphagia evaluation indicated to prevent aspiration pneumonia.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Aspiration from Dysphagia. (n.d.). Cedars-Sinai. Retrieved December 7, 2021, from https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/aspiration-from-dysphagia.html
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Clark Tippett, D. (n.d.). Dysphagia: What Happens During a Bedside Swallow Exam. Johns Hopkins Medicine. Retrieved December 7, 2021, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dysphagia-what-happens-during-a-bedside-swallow-exam
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
