Preventing Pneumonia and Choking


Cases, Myths, Misconceptions, and Management
For The HDC Teleconference March 22, 2005

  1. If a VFSS shows 10% aspiration of thin liquids, the patient could die if they get a glass of unthickened water
  2. All pneumonia is aspiration-related and all aspiration is due to problems with swallowing food or liquid
  3. We can prevent all aspiration pneumonia by ensuring compliance to dietary recommendations
  4. We can prevent all surveyors from making recommendations by using lots of thickened liquids and putting PEG tubes in everybody who fails their VFSS
  5.   is this a human body design flaw?? How is it supposed to work: Our airways and foodways cross, but the larynx shuts during the swallow and the cough reflex and ciliary action of the lungs prevent injury to lung tissue from foreign substances. The UES stays tonically closed except during the swallow, and the stomach empties pretty well within an hour. (less than 50% at 90 min abnormal - depends on substance used, volume, etc.). Lungs are fully and evenly aerated and expanded by sigh breaths and secretions are effectively cleared.

    (this image stolen from the
    NIDCD Dysphagia Page)

    SO, what could possibly go wrong?
     


    CASES


    The school will not feed a young boy with cerebral palsy because they heard the swallow study was abnormal and they are afraid the child will choke to death at school. They are aware the family is feeding the child orally at home. The child has stopped gaining weight. The parents really don't want a tube. They feel that lack of weight gain during growth spurts is normal and have been told children with cerebral palsy should not gain too much weight and are expected to be small.

    Considerations and Resources for this case:

    • Misconceptions about feeding tubes
    • Misconceptions about acute catastrophic versus chronic aspiration events
    • Foods and choking in children - AAP site re prevention policy
    • Objective evaluation of nutritional status
    • Special growth charts for CP


    A twenty year old recently admitted to the HDC has decreased appetite and is losing weight. There have not been any pneumonias, but he is sick or congested more often. His respite forms indicated he has eaten orally lifelong, though with a modified diet.

    Considerations and Resources for this case:


    A teenager who is two weeks post complete cervical spinal cord injury absolutely will not take enough liquids orally if they have to be thickened, but the VFSS showed significant aspiration with thin liquids. He came off the ventilator earlier, but was not weanable from oxygen before the diagnosis was made and they were stopped.

    Considerations and Resources for this case:


    A fourteen year old girl, ambulatory, with cerebral palsy, starts having tremendous problems with respiratory illnesses. Her family denies problems with eating or swallowing, she does not cough with meals, only when she is ill and then more at night.
    Severe chronic injury with empyhsematous blebs, RML scarring
    Several years later, after having a PEG placed, this young woman continues to have problems despite being NPO. She is admitted from the HDC to an acute care hospital ICU with severe pneumonia with ARDS associated with hematemesis and is transferred to the rehabilitation unit when she has sufficiently recovered.

    Considerations and Resources for this case:

    • Evaluation options
    • Other causes of pneumonia? - asthma, irritant exposure
    • Silent aspiration
    • Treating GER, PUD and gastric emptying
    • PPIs may increase the risk of pneumonia?


    A thirty four year old woman with very severe cerebral palsy and scoliosis handles secretions poorly and continues to have frequent pneumonias despite having a GT with fundoplication, remaining NPO, and observing reflux precautions. Feeding tolerance is poor at times.

    Considerations and Resources for this case:

    • Oral care program
    • Barrett's esophagus
    • H. pylori
    • Types of feeding tubes and interventions
      • OGT
      • NGT
      • GT - "PEG" vs with fundoplication
      • G-JT
      • JT
      • Laryngeal procedures

    Related Illustrations:

    Infant with severe secretions problems Young man, age 14 with Duchenne's muscular dystrophy and pneumonia Young boy, age 8 with SMA
    Positive radionuclide salivagram
    See CXR also
    Predominant RML airspace disease, atelectasis vs pneumonia
    Left sided atelectasis and empyema

    An adult with mild mental retardation has newly identified pharyngeal dysphagia but does not want to eat a modified diet and his family concurs with this choice.

    Considerations and Resources for this case:

    • Ethics
    • Therapies, Manuevers (compensatory strategies) - some passive, some require cooperation


    Since my M.D. also stands for Messy Desk, please use my e-mail! Write me anytime at vstefans@george.ach.uams.edu