What is Aspiration Risk?
In simple terms, aspiration is a common occurrence, even in healthy individuals. It can become quite dangerous under certain conditions, leading to severe health problems or even death. The type of aspiration is determined by what kind of material is aspirated, or accidentally breathed in. If it involves throat secretions, food, or partially digested stomach contents, it’s likely to lead to a type of lung infection called infectious pneumonia. However, if pure stomach secretions are aspirated, it typically results in a condition known as chemical pneumonitis.
If a person aspirates both partially digested stomach contents and some stomach acid, a mix of chemical pneumonitis and harmful bacteria can infect the lungs. In reality, it’s wise to treat chemical pneumonitis with antibiotics as a preventive measure, since over 25% of cases end up with an additional infection. It’s usually hard to identify what exactly was aspirated in many cases, and it’s not uncommon for both bacterial and chemical injury to occur.
What Causes Aspiration Risk?
There are several risk factors that can increase the chances of aspiration (inhaling food or liquids into the lungs). They include:
1. Cognitive neurological issues: This includes conditions that affect thinking abilities, such as stroke, seizures, being intoxicated, developmental delays, or any other form of cognitive impairment.
2. Focal neurological problems: These are issues related to a previous stroke, injury to the nerves in the head, or an injury to the muscles in the throat.
3. Lung disease: This includes patients who need a respirator to breathe, patients who have difficulty coughing, or who do not have strong enough lungs to forcefully exhale.
4. Upper throat disease: These are conditions that cause irregular shapes in the back of the throat, poor dental hygiene, or diseases that cause the esophagus to move poorly and make swallowing difficult.
There are a few more conditions and situations that can also increase the risk of aspiration. For instance, changing positions can lead to aspiration even in healthy people. Studies show that half of healthy individuals subtly inhale food or drink during sleep without realizing it. Regularly vomiting a large amount is another possible risk factor. In addition, using medication that reduces stomach acid can change the stomach’s usual bacterial environment, which may allow harmful bacteria to thrive.
Finally, anything that numbs the throat or windpipe, any medical procedure involving the mouth, throat, or airway, any injury, and having certain medical devices, such as a nasogastric tube, tracheostomy, upper endoscopy, bronchoscopy, or a feeding tube going into the stomach, can all increase the risk of aspirating.
Risk Factors and Frequency for Aspiration Risk
Any age group can experience aspiration, but the risk is highest for the very young and the elderly because they have more risk factors. It affects men and women equally.
It’s unclear exactly how many people develop aspiration pneumonia, but the numbers are not small. In hospitals, patients can develop this condition as a result of a drug overdose, stroke, or other issues with the central nervous system.
Signs and Symptoms of Aspiration Risk
If a patient has breathing problems, there are several common signs that doctors look for. These may include rapid breathing, coughing, low oxygen levels, crackling sounds while breathing in, and no sound of breathing if the airways are blocked. It’s important to know the patient’s history as they might have been seen inhaling a foreign substance or they suddenly find it hard to breathe.
- Rapid breathing
- Coughing
- Low oxygen levels
- Crackling sounds while breathing in
- No sound of breathing if airways are blocked
- Patient history of inhaling a foreign substance
- Sudden trouble breathing
Testing for Aspiration Risk
If a doctor suspects a patient has aspirated, or breathed in a foreign substance into the lungs, they might order a chest x-ray. This image helps the doctor see how much material has entered the lung. For more severe cases, they might need to do procedures called bronchoscopy and bronchoalveolar lavage to remove any of the material that can be seen.
Patients at risk for aspiration should have a swallow evaluation and a barium swallow study, a type of x-ray for the throat and esophagus. These tests help doctors understand how well someone can swallow. Until these tests are completed, patients should not eat or drink anything. In children and some adults, these tests are performed under a special kind of x-ray called a fluoroscope. Adjustments to the patient’s diet, like eating pureed food or thick liquids, could help if swallowing is a problem.
Doctors may also do a blood gas test to check oxygen levels and if the body’s pH balance is normal. A high lactate level can mean that the body isn’t getting enough oxygen, which is commonly seen in people experiencing shock.
To check kidney function and hydration levels, doctors usually look at electrolytes, BUN (blood urea nitrogen), and creatinine. A complete blood count (CBC) could reveal whether there’s an infection, if the patient could be anemic, or if the blood is clotting more than usual.
Though doctors may do a sputum culture and gram stain, results are not usually very reliable because of contamination. Blood cultures are often not helpful for immediate management because they’re usually not positive.
A chest x-ray can give information on where the patient was when the aspiration occurred. The lower right lung is usually where aspiration happens because of its upright orientation. If someone aspirated while standing, we could see changes in both lower lungs, while if a person was laying on their left side, we might see changes in the left lung. If a patient was face down when they aspirated the top part of lung may be affected. This scenario usually happens in people who drink a lot of alcohol. Some people can develop fluid around their lungs that can be tested.
Although not usually needed, a CT scan could be used if a patient isn’t adjusting well or if the doctor thinks an infection or a soft, hollow area of dead tissue could be present.
Bronchoscopy is usually necessary in cases of chemical pneumonitis, a type of lung irritation. This situation arises when food or foreign objects are aspirated. This technique can also help get samples for testing and can locate any blockages in the breathing tubes.
Treatment Options for Aspiration Risk
Determining the type of aspiration, or inhalation of foreign material into the lungs, is crucial. If chemical pneumonitis, a type of lung irritation, is suspected, supportive treatments should be started. Depending on the patient’s overall health, breathing tubes might be necessary – decided on a case-by-case basis. Be aware that this condition can get worse very quickly, often leading to severe breathing difficulties.
It’s important to note that cases aren’t typically just chemical or bacterial, so preventative antibiotics should be used until it’s confirmed there’s no bacterial infection involved.
If large food particles or other material from the mouth or stomach block the airway, a procedure called a bronchoscopy might be needed to remove it. Any blockage should be cleared quickly so the lungs can deal with any remaining secretions or infectious material normally.
If the aspiration leads to bacterial pneumonia, cultivation of samples should be done to pinpoint the responsible bacteria, and broad-spectrum antibiotics started. Once the specific bacteria are identified, a more targeted antibiotic treatment can be given.
For those at elevated risk of aspiration, measures can be put in place to lower this risk. The approach depends on each person’s unique risk factors. For those who can’t manage their own oral hygiene, a mouth cleansing program, using chlorhexidine oral swabs twice a day, is recommended, particularly for patients who need long-term breathing tubes.
Patients with breathing tubes should ideally be positioned in a semi-upright position to reduce the risk of aspiration, provided there’s no medical reason not to do this. If the breathing tube is likely to be needed for more than two to three days, a specialized tube should be used that allows for continuous or intermittent suction to help clear secretions.
Also, problems with blood pressure and heart function are common in aspiration pneumonia, so patients may require close monitoring in an intensive care unit and medication to improve their heart function.
Particularly vulnerable patients, including those with debility or neurological impairment, should eat in an upright position. An evaluation by a speech therapist or nutritionist should be done to determine the best food and liquid consistency. For those who can’t eat or drink ordinarily, a percutaneous endoscopic gastrostomy tube (PEG tube), or a tube inserted into the small intestine (J-tube), should be considered if the patient’s recovery is expected to take a long time.
What else can Aspiration Risk be?
When a doctor is working to diagnose lung-related issues, they may consider a variety of conditions that can cause similar symptoms. These could include:
- Pneumonia (which can be caused by bacteria or viruses)
- A pulmonary embolism, or a sudden blockage in a lung artery
- Acute Respiratory Distress Syndrome (ARDS), a life threatening lung condition
- Heart failure, a chronic condition where the heart doesn’t pump blood as well as it should
- Lung cancer
- Tuberculosis, an infectious disease that mainly affects the lungs
- Gastroesophageal reflux disease (GERD), a chronic disease where stomach acid frequently flows back into the tube connecting your mouth and stomach (the esophagus)
Each of these conditions requires a different treatment approach, so it’s important for the doctor to carefully review the patient’s symptoms and medical history, and may need to order additional tests to ensure they make the correct diagnosis.
What to expect with Aspiration Risk
The outcome of aspiration, which is when something enters the airway or lungs, can vary widely and depends on several factors. Those who were in good health before the event, aspirated a small amount, and have a robust lung capacity generally have a better prognosis. However, those with weak immune systems, frequent aspiration events, aspiration of large amounts of acid, and existing lung disease may struggle more.
The key aspect of treating aspiration in the hospital is prevention whenever possible. The death rate for aspiration pneumonia, a specific complication, can range between 10% to 50%. Any delay in identifying or treating this condition usually results in a higher death rate.
Possible Complications When Diagnosed with Aspiration Risk
Possible complications of lung conditions:
- Lung abscess
- Empyema (an infection in the space between the lung and the chest wall)
- Bronchopleural fistula (an abnormal connection between the bronchial tubes and the space around the lungs)
- ARDS (Acute Respiratory Distress Syndrome, which causes fluid to build up in the lungs, making it difficult to breathe)
