How closely related are dysphagia and aspiration pneumonia?
Does your patient have aspiration pneumonia? Then they MUST have dysphagia. Right? Aspiration pneumonia is often attributed solely to swallowing difficulties, but that's incorrect. Yes, it may be caused by dysphagia and anterograde aspiration (that is, from the mouth to the lungs), but it's often the case that retrograde aspiration occurs (from the stomach or esophagus to the lungs). And unfortunately, the two are indistinguishable on chest x-ray.
Where does this leave us as speech pathologists focusing primarily on the oropharyngeal swallow? We must remember that the upper airway is not isolated from the rest of the body. We don't treat the swallow; we treat the patient, right? The oropharynx, or upper airway, doesn't magically float around disconnected from the rest of the body. It's connected to the lower airways, esophagus, and stomach. Think of it like one area of a city that sits within a vast transportation network. Just as traffic jams and road closures in one part of the network can disrupt the entire system, problems in other body parts can impact the aerodigestive tract and increase the risk of aspiration pneumonia.
Magic Tricks and Missing Puzzle Pieces
Do you know how magic tricks work? The magician forces you to focus on something other than where the trick occurs. For example, when they switch out your card, they tell a funny joke, compliment you, or create a visual distraction. The magic is in your failure to observe what's actually happening. With that definition, clinical mysteries are often nothing more than magic tricks.
I once saw a patient who was admitted with aspiration pneumonia. I did a clinical swallow evaluation and realized that the swallow was grossly intact. Yes, the patient was a little lethargic but did not appear to have any functional oropharyngeal deficits. However, the medical team (myself included) couldn't disconnect the concepts of anterograde aspiration, dysphagia, and aspiration pneumonia. We were convinced he had a swallowing problem, and somehow, we were just missing it at the bedside.
The next course of action was to do an instrumental swallow evaluation. However, it was an extremely busy time for the hospital, so scheduling was tricky. So, this poor man was NPO for two days until we could schedule a modified barium swallow study. The patient had some medications that couldn't be administered through IV, and the team was starting to get concerned about dehydration and malnutrition, so an NGT was placed in the meantime. Two days later, we found an intact oropharyngeal swallow, and the esophageal motility also looked functional. What was going on here?
Turns out, the patient had an episode of emesis the evening before he was admitted to the hospital and was too out of it to report it. The chest x-ray looked exactly like how aspiration pneumonia would look if the patient had severe dysphagia. But he didn't. He had acute alcohol intoxication, and his body was sending the liquor back from where it came with some leftovers to share with the lungs.
I’m sure many of you have similar cases where we mentally could not separate dysphagia from aspiration and, in turn, miss the broader context of what's really happening. By focusing solely on the swallow, we missed the true cause of the pulmonary issue and inadvertently recommended an unnecessary intervention- The nasogastric tube, which certainly didn't make the situation any better for him. That was a magic trick nobody was impressed with, especially not the patient.
Dysphagia: A Symptom, Not a Standalone Diagnosis
Remember that dysphagia is a symptom. It's not a diagnosis on its own. We need a solid understanding of anatomy, physiology, and disease processes that cause the symptoms to treat them effectively. It's similar to pain. We've learned that serious, life-changing outcomes occur when we focus solely on treating the pain and overlook the bigger picture of what's causing it. Let's not make that same mistake with dysphagia.
Think of us like a detective investigating a crime. Dysphagia is the clue, but we need to uncover the underlying causes and contributing factors to solve the case. Don't get me wrong, the clue is important. Without it, we don't have a chance at solving the mystery. But it's NOT the whole case. If you found an empty jar of cookies and a mound of cookie crumbs in the kitchen, you wouldn’t simply clean it up and call the case closed. You’d want to find out who stole those delicious cookies so you wouldn’t have to forgo your midnight snack again.
Surprising Research Findings: Challenging Assumptions
Research has revealed some surprising findings about dysphagia and aspiration pneumonia:
Dysphagia alone is not a significant risk factor for aspiration pneumonia. Other factors, such as dependence on feeding, play a more prominent role. Dependence on feeding increases the risk of aspiration pneumonia by 20 times! Whoa. And that's a standalone, independent risk factor. So, there's more to managing aspiration pneumonia than simply evaluating and treating the dysphagia. A lot more.
Think of it like this: if dysphagia is a leaky faucet, dependence on feeding is a burst pipe. Both can cause problems, but the scale of the issue isn't even comparable, and the management approaches will be totally different.
Feeding tubes do not reduce the risk of aspiration pneumonia and may actually increase it. This is a really important concept to grasp, but it's difficult for SLPs and other medical professionals who believe that we can eliminate the risks involved with aspiration by stopping the swallow completely. They may no longer be on a diet, but they're still on secretions. Placing a feeding tube solely because of the risk of aspiration is like trying to prevent flooding by building a dam around a single puddle while ignoring the overflowing river nearby. Multiple risk factors exist, and swallowing difficulty isn't even the most important.
Only 11% of patients with Parkinson's disease and dementia who were known aspirators developed pneumonia. That's about one in every ten patients. Not a huge number, right? This statistic underscores the complex interplay of factors involved in aspiration pneumonia and challenges the assumption that aspiration inevitably leads to pneumonia. It's like saying you’re guaranteed to catch a cold if you don't get 8 hours of sleep. Well, adequate sleep is important, but so is your diet, stress levels, and immune system health.
These important yet often overlooked findings directly challenge our assumptions. There is still a very fuzzy relationship between dysphagia, aspiration, and pneumonia. To bring clarity to this fuzziness, we need a team approach. We must collaborate with our patients, their families, and other healthcare professionals to develop individualized treatment plans that meet their needs and goals.
By understanding the whole patient, considering all contributing factors, and moving beyond our assumptions and knee-jerk reactions to dysphagia and aspiration, we can provide patient-centered care that improves quality of life and reduces the risk of aspiration pneumonia in a meaningful way.
What insights have you gained from your experiences with dysphagia and aspiration pneumonia? Share your thoughts and comments below.
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