Modified Monday: The importance(?) of aspiration
Aspiration gets a lot of attention, maybe even more than the epiglottis (see recent MM for more on that flashy show off). Significant decisions are made based on the presence or absence of aspiration, patients with dysphagia dread being told that aspiration was seen on an instrumental, and it can literally change a patient's life. But...how important is it really? What really gets people worked up about aspiration are two things: pneumonia and choking.
Looking first at pneumonia, we have two really great resources below that should be considered. Firstly, Ashford's "Three Pillars of Pneumonia from Aspiration" in which three (obviously) things should be considered by clinicians in determining aspiration pneumonia risk: impaired health status (med hx, comorbidities, immunocompromise, etc.), impaired airway protection (aspiration seen on instrumental), and impaired oral environment (oral hygiene). Dr. John Ashford found that only by putting these three factors together can we make an accurate prediction about risk of developing pneumonia. He goes on to say that "Assessment and treatment should move beyond observations of potential aspiration events and their causes and place these findings within the context of the patient’s total medical condition." Our second resource is the 1998 Langmore et. al study in which 189 subjects were followed for four years to determine the most significant risks for developing aspiration pneumonia which were identified as: dependence on others for feeding, dependence for oral care, a number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. In this study, dysphagia was not found to be significant enough by itself to lead to aspiration pneumonia.
Choking risk gets less clear. We do know that some age-related changes like tooth loss, sarcopenia resulting in decreased tongue strength and overall increased frailty can put patients at an increased risk. Here we as SLPs should also be looking at the total picture of the patient, including the instrumental assessment, to make these recommendations.
Our patient this week highlights both of these concerns and alllll of these considerations. Our Ohio team was at a facility in the Cincinnati area (have you tried the chili there? Amazing! Also the Bengals were robbed.) with a patient. He had a diagnosis of Parkinson's, and was in the SNF to recover from post-COVID complications. Overall was doing very well medically and physically-and although his ordered diet was nectar and puree due to aspiration and "lack of mastication" on a prior MBS, he was very clear with our team that he was "always sneaking good drinks and real food". Looking at his past three months, he had no lung infiltrates or pneumonias, and his general medical status had continued to improve. He did have a two instances of documented "choking", which he was pretty clear about ("Bit off more than I could chew"). Our study found aspiration (with no cough or throat clear or other overt signs) with thin before the swallow, but only when the patient was fed and when he took large continual swallows-when he took a small sip independently, his airway closure timing improved and no aspiration was noted. For the solids, he did struggle with mastication, and swallowed a rather large piece whole, and decided to spit out the other piece. For this fella, we recommended thin liquids (with some strategies and recommendations for oral care), and after discussion with the patient, he decided to continue with puree foods.
Aspiration (and the reason for the aspiration) is important to look at, but we as SLPs cannot have a hyper focus on it's presence or absence when making recommendations for a plan of care. Rather, by looking at the patient through the lens of the total picture of history, health, choices, and quality of life, we get a different picture than when we look at aspiration alone. The Bengals were still robbed.
Age-Related Changes to Eating and Swallowing Impact Frailty: Aspiration, Choking Risk, Modified Food Texture and Autonomy of Choice - PMC (nih.gov)
Predictors of Aspiration Pneumonia: How Important Is Dysphagia? | SpringerLink
Three Pillars of Pneumonia From Aspiration - SA Swallowing Services, PLLC (sasspllc.com)