Aspiration pneumonia is one of the more common infectious diseases in nursing homes and is a significant cause of mortality and morbidity among residents. In this week’s episode, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Dr. Susan Langmore of Boston University to discuss aspiration pneumonia in nursing homes, including common prevention methods and treatment.
Schenk: Hey out there and welcome back. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And we are your hosts for this extra special episode of the Nursing Home Abuse Podcast. We’re going to be talking about aspiration pneumonia. I’ve got to admit that before I got into this line of work, suing nursing homes for abuse and neglect, I don’t think I’ve ever heard of aspiration pneumonia.
Smith: Yeah, I mean I don’t know how to respond to that.
Schenk: That was a prompt for you to start talking.
Smith: Well what I was going to say is I don’t want to sound condescending but I have heard of it because I worked in nursing homes.
Schenk: But before you worked in nursing homes.
Smith: No, I hadn’t even heard the word “aspiration,” so I didn’t even know what that meant.
Schenk: Is that like a pill to take? Like aspirin?
Smith: No, it’s the inhalation of something other than air.
Schenk: No, I know that now. I’m saying like I know that it’s not aspirin.
Smith: Oh, right. Right, right, right.
Schenk: But as you can tell, Will and I might not be the most qualified two individuals to talk for 30 minutes about aspiration pneumonia in nursing homes, however, we have gone out again into the ether and brought back with us an exceptionally certified guest. Her name is Dr. Susan Langmore, PhD, board certified speech pathologist. Will? Tell us a little bit more.
Smith: I think most people in the healthcare industry who deal with patients who have an increased chance of aspiration pneumonia will be familiar with her because she wrote an article that is essentially a landmark article on predicting, predictors of aspiration pneumonia. Dr. Susan Langmore is a PhD, board certified speech pathologist and has worked in the field for 40 years as a clinician, a professor and a researcher.
Her specialty is dysphasia or swallowing disorders. She developed FEES, or Flexible Endoscopic Evaluation of Swallowing, and it’s a procedure that is used to evaluate swallowing function using a laryngoscope. She’s currently professor of otolaryngology – she’s going to have to pronounce a lot of these words for us – at Boston University doing research, but she lives in California. And like I said, her vast research led to the article in 1998, “Predictors of Aspiration Pneumonia: How important is dysphasia?” and she’s a member of American Speech Language Hearing Association, where she was awarded honors of the association, so we’re very privileged and pleased to have Dr. Langmore with us today.
Schenk: Dr. Langmore, welcome to the show.
Susan: Thank you. Thank you for having me.
Smith: So we were actually talking about this just before we gave your introduction is that before we started doing this or working in this area, I had never heard of the term aspiration, much less aspiration pneumonia. We’re all familiar with what pneumonia is basically, but what is aspiration pneumonia and what does it mean to aspirate?
Susan: Well I’ll tell you, there are two kinds of pneumonia. That’s viral pneumonia and bacterial pneumonia, and aspiration pneumonia is a bacterial pneumonia. So viral pneumonia is the kind that healthy people get – you’re exposed to a virus. You have a bad cough, a fever, etc. Aspiration pneumonia is – the term aspiration refers to anything that goes into the trachea and the lungs. So aspiration pneumonia is really bacteria that’s carried into the lungs on particles of food or liquid or saliva or secretions. You have this voice, these secretions that line your mouth and your throat. And so bacteria need to hook onto one of items, the food or other secretions, and the bacteria, along with whatever other it’s carried in goes into the lungs. And so aspiration pneumonia is a bacterial infection that develops in the lungs.
Smith: So can I say it’s when something goes down the wrong pipe as most of us typically say?
Susan: Yes. That’s aspiration. I’m sorry – aspiration means anything that goes into the airwaves and falls down to the level of the trachea and the lungs below those, below that.
Smith: So why is this a problem, more of a problem with nursing home residents. Why are they at a higher risk than say me or Rob or you?
Susan: Okay. Well they are at more, at greater risk for aspirating.
Susan: People who have a swallowing problem from a stroke or head-neck cancer or are just very weak or frail tend to have food or liquid go the wrong way more often. And then if you cannot clear it with a cough, a good cough, or if you’re immunocompromised, you don’t get rid of the stuff you aspirated. And so one reason nursing home residents are more at risk is because they tend to aspirate more than a healthy younger person.
But it’s also what they aspirate. And so food and liquid have some bacteria in them, but they’re relatively clean, especially water is pretty clean. But saliva has a lot of bacteria, so if I can continue in that vein, saliva in healthy persons has a certain makeup of bacteria that is actually benign, and if you or I aspirate saliva, the lungs aren’t particularly bothered, and if it’s some saliva, it’s fairly easy to clear it. But in nursing homes and in hospitalized patients, they have a different kind of bacteria growing in their mouth – it’s in their mouth and their throat, on their teeth and their gums. That bacteria is more – it’s called pathogenic. It’s harder for the lungs to clear and it’s like bad bacteria. And if their cough is weak, which it often is, then they don’t clear that.
So why is the bacteria different in a nursing home patient than in a healthy person? Because they’re immunocompromised, and bad bacteria is more prevalent in a nursing home environment. There’s all kinds of germs, bacteria, in a nursing home or hospital environment that a healthy person can resist. But if you are, again, immunocompromised, the nursing home resident won’t be able to resist it, and that’s the kind of bacteria that’s prevalent in their saliva, mouth and throat.
So they have a different makeup of bacteria called a colony of bacteria. If you were to culture their saliva or the cheek, anywhere, a different kind of bacteria would grow out from the resident than from you or I.
So the bad bacteria is prevalent and they can’t resist it, so when they aspirate their saliva, it contains a lot of bacteria that the lungs really don’t like, have a hard time doing, more likely to cause infection. And again, if they can’t cough or clear it, it starts an infection.
Smith: Right. So explain dysphasia – am I pronouncing that correct?
Susan: Dysphasia is the preferred pronunciation.
Susan: Dysphasia is disordered swallowing. So dysphasia can take many forms, but the problem that’s most relevant to this is they aspirate, which means they don’t protect their airways, they don’t cover their airway as they swallow either quickly enough or completely enough and whatever they’re swallowing, a little bit of it or a lot of it goes into the airway, goes into the lungs.
There are other problems with dysphasia, like not being able to clear food, something’s stuck in the throat, that kind of problem, but for our purposes, it’s aspiration that causes the pneumonia.
Smith: I got you. And can you talk about bad oral hygiene? Because this is something we see a lot is just not – dentures aren’t cleaned, people, their teeth aren’t brushed, they’re not flossed. How does that lead to this?
Susan: Well that’s sort of jumping ahead. It’s because if they don’t – if they have poor oral health, they’re more likely to develop decay and periodontal disease, and those bacteria are pathogenic to the lungs. That means it’s dangerous for the lungs. If they just don’t have their teeth brushed, bacteria grows in the mouth, and whenever you aspirate food, liquid or just saliva, that bacteria will get in there because saliva is mixed with anything that you can put in your mouth and swallow. So I’d like to sort of lead up to that if I could.
Smith: Sure, please. Yeah, go ahead, Doctor.
Susan: Okay, because what we’re interested in is how to prevent pneumonia and treat it, right?
Susan: So the treatment for pneumonia is antibiotics. But the problem is pneumonia will just recur unless it’s prevented, so prevention is really the key. And what do we want to prevent? Well we want to prevent aspiration in everything. And how do you do that? Well one solution, although it’s a bad one, is feeding tubes. That comes with a whole set of other problems that we don’t need to get into, but feeding tube is one way to prevent someone who aspirates everything.
Altering the diet to find foods or liquids that the person is less likely to aspirate is another solution, and that’s where thick liquids come into play, because there have been some studies that show that people who are weak or have dysphasia, many of them are less likely to aspirate thickened liquids than thin liquids. By thin liquids, I mean water or juice or coffee. Thicker liquids is more like nectar thick or smoothies or something that’s not thin. Thicker liquids are sometimes easier to swallow for some people because they move more slowly down the throat. So if the person takes a while to close off the airway as the food goes down the throat, because the airway and the food passage share this common area in the throat, so you have to close off the airway when you swallow, otherwise the food and liquid will end up in the airway rather than going down into the esophagus. So thick liquids are sometimes, and I would say often, recommended as a preventative measure.
The problem is thick liquids have their own problems. First of all, people don’t like them. They’re fine with a smoothie, but they want some water. They want – they mainly want water. They want something nice and clear that will quench their thirst. So thick liquids, if that’s part of a person’s diet, often the resident doesn’t drink enough of it because they don’t like it. That leads to dehydration, and dehydration can give you infections, can lead to a whole lot of problems. And if they are aspirated, it’s harder for the lungs to clear thickened liquids. It’s very easy for the lungs to clear water. It just goes right into the bloodstream. But it’s harder for the lungs to clear thick liquids. So you have to be sure that the thick liquids are really necessary before you would say, “Stick with thick liquids.”
And there are many people with dysphasia who do fine with thin liquids. Thick liquids are not better. So that gets into a big controversy about how do you evaluate someone, how do you know they need thick liquids. I don’t think we want to get into that. That’s something that a speech pathologist would do when she or he is evaluating a patient.
Smith: Got you.
Susan: So let me get back to the thin liquids. Thin liquids may be more likely to be aspirated, but they’re easier for the lungs to clear. There have been a few studies, and there was a review done by someone who I know – her name is Osako Konioka. She compared all the studies that were large and had two groups of patients that they were studying. One group of patients had thick liquids. The other group of patients were allowed thin liquids like water. And so even though they were known to aspirate the thin liquids – now they weren’t given it just any time, there were ways to make it a little bit safer, but basically, people have looked at groups of patients that are on thick liquids and compared to patients who were allowed to take thin liquids like water, even though they aspirate. And surprisingly enough, all of those studies came to the conclusion that there was no difference in pneumonia, that the group that got only thin liquids and aspirated thin liquids did just as well as the group that got thick liquids. So it’s really uncertain when thick liquids have a role.
Smith: Oh, I got you. I know that when I was working in several homes, I felt like thickened liquids were extremely prevalent. Is that still the case today?
Susan: It is. It is. It’s one of the banes of my existence. It is very common because there’s still this idea out there that thick liquids are safer, and so to be sure, let’s just put everyone on thick liquids.
Susan: And first of all, half the people may not need it at all. They do fine with thin liquids. And the other half don’t drink them, and what you can do, like what’s been suggested as what may be the safest way to allow someone to have thin liquids even though you think sometimes they’re aspirating it is to not have thin liquids during the meal, because you don’t want food carried into the lungs. That could occlude the lungs, it could – it’s more likely to have bacteria and cause pneumonia. Don’t give them water with their meal, so that they get through their meal with either thickened liquids or no liquids at all. But then between meals when they’re just drinking, they have water, and so they’re not carrying food particles in. If they do aspirate, they’re only carrying water in and their saliva. Anyways, it’s called the free water protocol and it’s been shown to be very effective. Now we haven’t talked about oral care.
Smith: Yes, please do.
Susan: So the most – the treatments, the preventative treatments that have been tried is, first of all, the one we just talked about – give them thick liquids, they’re less likely to aspirate it. The most effective treatment that has the most number of studies that has the best evidence for it is to provide good oral care. And by that, I just mean brushing a person’s teeth – either they brush their own or someone else brushes their teeth, because what you do when you brush the teeth is you reduce the number and the kind of bacteria that are being aspirated. And by cleaning the mouth, brushing the teeth, you reduce the bacteria, and then if you do aspirate, you don’t aspirate so many, the quantity of bacteria is much reduced because when you brush the teeth, you clean the mouth and you brush away a lot of that bacteria. The bacteria is on the surface. So that has been proven to be the most effective treatment we know for minimizing the risk of pneumonia.
Smith: Got you.
Susan: And it’s something that’s neglected.
Susan: It’s not being given enough – people, I think, still most nurses and families think brushing the teeth is just to make your mouth feel better, but more important than that is you’re getting rid of all the bacteria that could be aspirated. You’re cleaning the mouth. So I guess ideally you’d brush the teeth before the person ate, but you know you don’t have to brush someone’s teeth before or after every meal six times a day. It’s been shown if you just brush the teeth twice a day, you will reduce the incidence of pneumonia. There have been many studies in hospital patients, ICU patients and nursing home patients, long-term care, and this treatment will reduce pneumonia.
Smith: So speaking of this, in the time that we have left, about five or six minutes, what are some other things that families should be aware of if their loved one is at risk. We were just talking about brushing teeth isn’t just a comfort measure, but also you don’t need to do it a dozen times a day. What are some other things they need to be aware of?
Susan: Well that’s the most important thing, is the most effective thing you can do. Secondly, if they’re feeding the patient or they’re observing the staff feed the patient, the patient should be upright as much as possible in a good position. If you’re fed lying flat on your back, it’s more likely to go the wrong way. So upright, head neutral, not falling back, not chin up but chin down or chin neutral. Feed slowly. Be sure that the person swallows everything you’ve given them before you give the next bite.
Smith: Well that would make sense, just taking it slow, not trying to – and I’ve seen that before. There’s not enough staff and they just want them to eat, and if they don’t do it – that leads to another thing. If they can’t do it quick enough, sometimes they don’t get fed.
Schenk: Can you believe I was investigating a case the other day and I was reading a survey of that nursing home, and the surveyor observed the CNA feeding the resident flat. And when the surveyor came over and said, “Hey, raise the bed up,” the CNA said, “I don’t know how to do it.” And that was in the survey.
Susan: Oh my god. Didn’t know how to do it? You know, raising the bed also helps reflux. I didn’t even mention, but people who reflux, that means something from the stomach is coming back up, that can be aspirated.
Smith: Oh, man.
Schenk: Oh, yeah.
Susan: If it gets up to the throat, it can fall into the airway. And so elevating the head of bed is a good precaution for that, as much as possible and as often as possible, if the person refluxes.
Smith: I can’t imagine eating lying down anyways. That’s just absurd. I think I would choke.
Susan: Well try taking some pills with a glass of water flat on your back.
Smith: Oh, good God.
Susan: It’s really hard.
Smith: No, yeah. Gravity’s your friend.
Susan: So in my study in ’88, dependent for oral care was a risk, and that was mainly because they ended up, if a person can’t brush their own teeth, then no one else does, and so that was the reason for that. Dependent for feeding, because people weren’t being fed carefully. Having tooth decay or periodontal disease was another risk factor.
Feeding tubes, and we didn’t get into that, but the feeding tube, especially if you’re not fed anything by mouth but you just have a feeding tube, then you can imagine the amount of bacteria that grow in the mouth. And they often have their oral care neglected more than someone who’s eating who’s taking something by mouth because they figure, “Well he’s not eating anything, not going to have bacteria.” No, that’s not true. Someone who has a feeding tube in their stomach or the nose down the throat, if they don’t have water or something by mouth to help wash that bacteria away, it proliferates. It grows by tenfold. They really need their teeth brushed.
Smith: Yeah. Well all right, Dr. Langmore, that’s the end of our episode. This is extremely informative.
Susan: Oh, thank you.
Schenk: Very good job, yeah.
Smith: So we really appreciate you coming on here and educating, like I said, it’s a lot of family members and advocates and ombudsmen – this is a very important issue because oral healthcare, I think we were talking about this at the Consumer Voice Conference last year, oral healthcare is a poor state in our state and across the nation, and aspiration pneumonia, I assume just based on the things I’ve seen, can be fatal, right?
Susan: Oh, yes. Depending on who you read, it’s either the most common or second most common infection acquired in the hospital for nursing home, and the mortality is pretty high.
Smith: Yeah. Yeah.
Susan: So it’s a serious issue. If someone thinks their loved one is coughing or choking while they eat or drink, they should get a speech pathologist there to evaluate and let’s just hope that that speech pathologist doesn’t recommend thick liquids. There’s also pureed food.
Smith: Oh yeah.
Susan: You look at diets, pureed food is also just thrown in there preventatively because they think that’s easier to swallow, whereas people who can chew some soft food would much prefer to have food that hasn’t been blended.
Susan: Quality of life should be a priority.
Smith: Amen, I’m with you.
Susan: Quality of life, not just try to prevent something you think might become a problem.
Smith: Right. All right, well Dr. Langmore, we really appreciate it.
Susan: Thank you, I enjoyed it.
Schenk: Yeah, a lot of good information.
Smith: This podcast is one of those podcasts that shines a light on an issue in nursing homes that most people don’t even think about. It’s oral healthcare, oral hygiene in your grandmother or grandfather or loved one’s case, and it’s so important, because like she said, aspiration pneumonia, if it’s not number one, it’s number two infection in a nursing home, and infections can be fatal. So brushing their teeth, making sure they’ve got all that bacteria, it’s not just food particles, but cleansing that bacteria, it’s just as important as preventing bedsores or anything else.
Schenk: So if you’re on this long holiday weekend coming up, if you’re going to visit your loved one in a nursing home, check out how their oral hygiene is coming along because it could save their life. All right, so that is actually going to bring this episode to an end. Will, this holiday weekend or the long weekend because the 4th is on Thursday – are we working Thursday and Friday? We’re off Thursday because it’s the Fourth, but you’re not coming in on Friday, I guess. Probably not. So Thursday, you’re eating ribs, all right? Maybe some pulled pork?
Smith: All right.
Schenk: Corn on the cob. There are fireworks going on.
Smith: Got you.
Schenk: Somebody walks up to you wherever you’re at, the party you’re at…
Smith: And they go, “Hey, where can I watch the video version of your podcast?” And I would say, “Well if you want to watch the video, you can go to NursingHomeAbusePodcast.com. If you want to download the audio and listen to it, you can go anywhere that MP3 or podcasts are available, Stitcher, iTunes, Spotify – Spotify has our podcasts on there as well.”
Schenk: And then he said, “Well I was just going to ask where did you get the ribs and the pulled pork.”
Smith: Yeah, and then I go, “Oh, my bad.”
Schenk: But those are all true answers. And with that…
Smith: Have a happy Independence Day and we will see you next time.
Schenk: See you next time.