Pneumonia is a common disease in the elderly, and its incidence is 10 to 20 times higher than that of young people. Statistics show that pneumonia is the first cause of death in the elderly over 80 years of age, and half of the elderly over 90 years of age die from senile pneumonia, while aspiration pneumonia is a common type of pneumonia in the elderly, which is mainly caused by aspiration of oral contents or gastric or esophageal reflux.
The elderly are prone to cerebral infarction, Alzheimer’s disease, Parkinson’s disease and other cardiovascular and neurological diseases, resulting in impaired consciousness and swallowing difficulties, which are the main risk factors for aspiration. Other risk factors include vomiting, inactivity, inability to cough, inattention to posture after feeding or irritation of the pharynx.
Early prevention, recognition and management of swallowing problems and misaspiration in patients can have significant benefits in preventing aspiration pneumonia – reducing patient suffering, lowering patient costs, shortening patient length of stay and facilitating early recovery. Here we summarize the matters that need attention for the prevention of aspiration pneumonia in the elderly as follows.
1. Matters to be noted for patients who eat through the mouth.
(1) Water, tea and other thin liquids are most likely to lead to accidental inhalation, generally using soft food, paste or frozen sticky food.
Minimize the consumption of rice, bread, pastries and other hard-to-swallow foods to prevent inhalation of rice grains, bread crumbs, etc.
(2) Small amount and multiple meals, usually 5-6 meals per day, less than 300ml per meal. After each feeding, ask the patient to swallow several times repeatedly to make all the food pass through the pharynx, and then feed again only after the patient swallows completely to avoid choking and coughing that may lead to aspiration pneumonia caused by food accidentally entering the trachea.
To prevent swallowing food from accidentally entering the trachea, ask the patient to inhale enough air when feeding, hold the breath before and during swallowing, so that the vocal cords can be closed to close the larynx before swallowing, and cough after swallowing to remove the gas from the lungs to spray out the food residue left in the throat. When oxygen is available, it should be removed before feeding. The patient should not be fed or watered while coughing.
(3) When feeding plant survivors, the pills should be mashed and fed with warm boiled water.
(4) Feeding and watering should be done in sitting or semi-sitting position. Patients who cannot sit or stand should elevate the head of the bed at least 45 degrees and feed slowly.
(5) To prevent esophageal reflux, the position should be kept in place for more than 0.5 to 1 hour after feeding.
(6) If drinking from a cup, keep at least half a cup of water in the cup, because when there is less than half a cup of water in the cup, the patient lowers his head for drinking, and this position increases the risk of accidental aspiration.
(7) Because drinking through a straw requires more complex oral muscle function, patients with swallowing difficulties should not use a straw to drink.
2.Nasal feeding and percutaneous gastrostomy patient care considerations.
(1) Make sure that the gastric tube is in the stomach and maintain a sitting position. Those who cannot sit up should change position before nasal feeding and raise the head of the bed at least 45 degrees.
(2) 4-6 times a day, 200-300ml each time, finished in 15-20min, too much too fast may lead to stomach cramps and vomiting.
(3)Try not to change the position during and 30-60 minutes after nasal feeding, and avoid back patting as much as possible (because vomiting is easily induced under satiety) and observe closely, and deal with misaspiration promptly once it occurs.
3.Other precautions.
(1) The appropriate position should be used to keep the airway open when lying down, and generally the side lying position can be used. The head is tilted to the side in the horizontal position to prevent the tongue from falling back and secretions from obstructing the airway. Elderly people with gastroesophageal reflux disease in particular need to maintain a lateral position. In addition, the patient’s position in bed should be changed frequently, and patients who cannot turn over should be assisted to turn over 2 hours.
(2) Sleeping on the side is appropriate. Note that aspiration pneumonia mostly occurs during sleep. The ability to swallow during sleep is reduced, the cough reflex is weakened, oral secretions flow into the trachea, and pathogenic bacteria can migrate to the lower respiratory tract and cause infection. Therefore, the patient should sleep in a right-sided or semi-recumbent position with a slightly elevated head to facilitate the flow of oral secretions. Help patients rinse their mouths before going to bed, and when there is a lot of oral secretions, they should be sucked out and cleaned at any time.
(3) Do not talk during feeding to prevent choking and coughing. If choking occurs, stop eating immediately, lie on your side, encourage coughing, and cough up food particles by gently pressing the back of the chest. If necessary, remove the food from the mouth, larynx and trachea by hand or suction or tracheoscope.
(4) Patients should turn their heads to the side when vomiting, and have aspirators at the bedside to remove vomit at any time to prevent aspiration pneumonia caused by inhalation of the trachea.
(5) the elderly oral cavity due to age-related changes, large gaps between teeth, often cause food embedding, plus saliva secretion is reduced, sticky, etc., are conducive to bacterial growth. Inhalation of bacteria in oral and pharyngeal secretions is an important risk factor for nosocomial pneumonia in the elderly, and poor oral hygiene can contribute to pneumonia in the elderly. Those who can rinse their own mouths should be assisted to rinse their mouths and moisten their mouths at all times. Those who cannot take care of themselves should do oral care regularly and remove oropharyngeal secretions in time to reduce the production of bacteria in the oral cavity.
For critically ill and fasting patients, the oropharynx should be swabbed two to three times a day, and for those who can eat, help patients rinse their mouths or brush their teeth after each meal, which is necessary to prevent aspiration pneumonia.
(6) Instruct and encourage patients to cough effectively to avoid sputum retention. Specific method: Let the patient take a sitting position as far as possible, take several deep breaths, then inhale deeply and then keep the mouth open, and forcefully perform 2 short coughs to cough out the sputum from the deep part. For patients who have been bedridden for a long time and have a weak cough, they should be assisted to change position frequently. After each position change, tap the patient’s back with both hands alternately to improve local blood circulation and make the sputum adhering to the tracheal wall move and be easily coughed out.
When tapping, the shoulders, elbows and wrists are relaxed, the back of the hand is hollowed out, and the space between the palm of the hand and the back is preserved to enhance pressure transmission to the deeper part. Tapping should be rhythmic, from the bottom up, encouraging the patient to cough up sputum while tapping. Be careful not to tap on the spine and kidney area. For elderly people who cannot excrete sputum, the sputum can be suctioned out with a suction device in the hospital depending on their condition.