What to do for an elderly patient who is profusely coughing and NPO (nothing by mouth) due to aspiration?

Management of an Elderly Patient with Profuse Coughing and NPO Status Due to Aspiration

For an elderly patient who is profusely coughing and NPO due to aspiration, immediate referral to a speech-language pathologist (SLP) for a comprehensive swallowing evaluation is essential, while maintaining NPO status until the evaluation is completed. 1

Initial Assessment and Management

• Maintain NPO status until a proper swallowing evaluation can be performed, as patients with reduced consciousness or inability to manage oral secretions are at high risk for aspiration 1
• Ensure proper positioning - keep the patient in an upright position (head elevated) to reduce risk of aspiration 1
• Assess the patient's level of consciousness, as extremely lethargic patients or those with inconsistent alertness should not be fed orally until consciousness improves 1
• Evaluate the need for oral/pharyngeal suctioning to manage secretions 1
• Order a chest radiograph to assess for evidence of aspiration pneumonia (patchy opacity, lower lobe infiltrate, air space disease) 1
• Request a nutritional assessment to evaluate the patient's nutritional status 1

Swallowing Evaluation

• Refer the patient to a speech-language pathologist (SLP) for a comprehensive oral-pharyngeal swallowing evaluation 1
• Consider videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) to identify appropriate treatment strategies 1
• Note that VSE or FEES are contraindicated if the patient has:
  • Lethargy
  • Absent swallow response on command
  • Inability to manage oral/pharyngeal secretions
  • Respiratory rate >35 breaths/min 1

Nutritional Support While NPO

• Consider enteral nutrition (EN) if oral intake is expected to be impossible for more than three days or below half of energy requirements for more than one week 1
• For short-term feeding (less than four weeks), a nasogastric tube is generally preferred 1
• For longer-term feeding, a gastrostomy may be considered, especially in patients with frequent tube dislodgement 1
• Parenteral nutrition (PN) should be offered if enteral nutrition is not possible and the patient has a reasonable prognosis 1

Respiratory Management

• For patients with profuse coughing, consider nebulized therapy to help manage respiratory symptoms:
  • For bronchodilation: salbutamol 5 mg or terbutaline 10 mg via nebulizer 1
  • For severe non-productive cough: consider nebulized lignocaine 2%, 2-5 ml or bupivacaine 0.25%, 2-5 ml (up to four hourly) preceded by a β-agonist 1
• Ensure adequate oxygenation - consider oxygen therapy if hypoxemic 1

Rehabilitation Approach

• Implement early rehabilitation to reduce mortality and facilitate earlier hospital discharge 2
• Include physical rehabilitation to maintain mobility and prevent hospital-acquired disability 2
• Incorporate pulmonary rehabilitation to improve respiratory function 2, 3
• Once swallowing evaluation is complete, implement dysphagia rehabilitation as recommended by the SLP 2

Transitioning from NPO Status

• Only resume oral feeding after a formal swallowing evaluation by an SLP 1
• If the patient is alert and deemed appropriate for a swallowing trial:
  • Begin with small amounts of water (3 oz) under supervision 1
  • Observe for signs of aspiration (coughing, wet voice, throat clearing, hoarse voice) 1
  • If the patient can safely swallow water, progress to appropriate diet textures as recommended by the SLP 1, 4
• Even when tube feeding is necessary, encourage safe oral intake as tolerated to maintain swallowing function and quality of life 1

Prevention of Recurrent Aspiration

• Maintain good oral hygiene to reduce pathogenic bacteria in the oropharynx 5, 6
• Review and minimize medications that affect salivary flow or cause sedation 5
• Limit use of H2 blockers and proton-pump inhibitors when possible 5
• Consider continuing ACE inhibitors in patients who tolerate them, as they may have protective effects against aspiration pneumonia 5
• Correct folate deficiency if present 5

Multidisciplinary Approach

• Manage the patient with an organized multidisciplinary team that may include:
  • Physician
  • Nurse
  • Speech-language pathologist
  • Dietitian
  • Physical and occupational therapists 1

By following this comprehensive approach, you can effectively manage the elderly patient with profuse coughing who is NPO due to aspiration, with the goals of preventing further aspiration events, ensuring adequate nutrition, and eventually restoring safe oral intake when appropriate.