BTS clinical statement on aspiration pneumonia

Summary of clinical practice points
The following key points represent an executive summary for clinicians drawn from the sections that follow, in which greater detail is provided.

General
Aspiration pneumonia (AP), and risk factors for AP, are common. AP is particularly common in people with a learning disability, in older people and in patients with neurological or upper gastrointestinal conditions.

Prevention, identification and treatment of AP requires a multidisciplinary team approach.

Every hospital and care home should have at least one oral health ‘champion’ promoting good oral healthcare.

Pathogenesis of AP
AP is usually characterised by microaspiration of bacteria-rich secretions from the oropharynx into the lungs and is very frequently accompanied by swallowing difficulties.

Swallowing impairment may be ‘silent’ (not apparent to an observer) in patients with reduced laryngopharyngeal sensation or reduced conscious level, and in such patients a high index of suspicion for aspiration is needed.

Abnormal swallowing commonly improves/recovers spontaneously or with treatment, particularly after a stroke.

AP is also commonly caused by reflux of material from the gastrointestinal tract.

Prevention of AP
Good oral hygiene appears to reduce the rate of AP.

For patients in hospital or care homes, oral hygiene should include brushing of the teeth, tongue and palate with a soft toothbrush, using non-foaming toothpaste, at least two times per day.

Oral examination should be performed in all hospitalised patients at risk of AP or with suspected AP, and at least weekly in care home residents, checking for infection (eg, candidiasis), quality of dentition, food residue and cleanliness of mucosal surfaces. Any abnormalities should be treated.

People with swallowing difficulties should be referred to a speech and language therapist (SLT).

Whenever feasible, patients with mild swallowing problems who are not considered at high risk of AP after a bedside swallow assessment should be fed orally and observed carefully.

When consuming food and liquid as normal is felt to present a high risk of AP, cold carbonated drinks may be trialled; alternatively, thickened fluids or feeds may be trialled.

In patients approaching the end of life and/or with moderate–severe dementia, a best interests discussion should take place prior to a ‘nil by mouth’ instruction.

When an SLT considers a patient’s swallow presents a high and imminent risk of AP and a ‘nil by mouth’ instruction is issued, a plan should be formulated (a) seeking to restore effective swallow and (b) arranging further assessment of swallow. A ‘nil by mouth’ instruction should be considered temporary, and steps taken to minimise duration where possible.

In patients with a newly diagnosed abnormality of swallowing that presents a high risk of AP, who are not felt to be approaching the end of life, early nasogastric feeding (within 3 days of presentation with swallowing difficulties) improves nutritional status and outcomes. Attempts to improve swallow, with a view to restoring eating and discontinuing nasogastric feeding, must be continued.

Percutaneous endoscopic gastrostomy (PEG) should be considered when abnormal swallow presents a continuing high risk of AP and when nasogastric tubes are either poorly tolerated or fail to provide adequate nutrition.

PEG tubes should not always be considered permanent. If safe swallow returns PEG tubes can be removed.

In Chinese and Japanese patients at risk of AP after stroke, and in the absence of contraindications, angiotensin-converting enzyme (ACE) inhibitors should be prescribed to reduce the risk of AP. Insufficient evidence currently exists to support this practice in other ethnic groups.

Diagnosis of AP
A careful history is key to increasing the likelihood of an accurate diagnosis of AP. In patients presenting with suspected community-acquired pneumonia (CAP), risk factors and features of the history suggestive of aspiration, should be covered.

Chest X-ray fails to detect AP in up to 25% of cases, when compared with thoracic CT scans.

Older patients may have a blunted systemic inflammatory response compared with younger patients.

Management of AP
For patients being managed for AP in a hospital the antibiotic regimen should be informed by Medical Microbiology guidance on local epidemiology, taking into account recent antibiotic exposure, recent microbiology results when available, and where the patient was when the pneumonia began.

A 5-day course of antibiotics is considered adequate for AP unless there is failure to improve, in which case alternative sources of illness, complications of AP and/or an alternative antibiotic regimen should be sought.

Patients being managed for AP should receive thromboprophylaxis (unless contraindicated), adequate hydration and (if required) supplemental oxygen.

Patients hospitalised with AP should have early access to physiotherapy (to reduce the risk of sputum retention or atelectasis), with early referral for general, respiratory or neurorehabilitation as appropriate.

Palliative care
The palliative care needs of patients who may be approaching the end of life, and their families should be addressed, including advance care planning and referral to specialist palliative care services as appropriate.