What are evidence-based methods for preventing aspiration?

From the Guidelines

Aspiration prevention strategies should prioritize identifying at-risk patients and implementing evidence-based interventions, focusing on elevating the head of the bed, verifying feeding tube placement, and using continuous feeding, as well as oral care with chlorhexidine and medication adjustments to reduce aspiration risk and associated complications like pneumonia. The most effective interventions include:

• Elevating the head of the bed to 30-45 degrees, especially during feeding and for 30-60 minutes afterward, to reduce regurgitation risk 1
• Verifying feeding tube placement before each use, monitoring gastric residual volumes, and using continuous rather than bolus feeding when possible, to minimize the risk of aspiration 1
• Oral care with chlorhexidine 0.12% solution twice daily to reduce bacterial colonization and subsequent aspiration pneumonia risk, particularly in ventilated patients [@Example@]
• Medication adjustments, such as avoiding sedatives when possible and considering prokinetic agents like metoclopramide 10mg IV/PO every 6 hours for patients with delayed gastric emptying, to improve gastric emptying and reduce aspiration risk [@Example@]
• Implementing swallowing evaluations before oral intake, modifying food textures as needed, and considering speech therapy consultation for dysphagia management, to ensure safe swallowing mechanics and reduce aspiration risk 1 These interventions work by reducing regurgitation risk, minimizing oropharyngeal colonization with pathogenic bacteria, improving gastric emptying, and ensuring safe swallowing mechanics, collectively decreasing aspiration risk and associated complications like pneumonia. Key patient populations at highest risk for aspiration include those with altered mental status, impaired swallowing, decreased gag reflex, or those receiving enteral feeding, and these patients should be prioritized for intervention 1. Surgical interventions, such as cricopharyngeal myotomy or petiole supraglottopexy, may be considered for patients with intractable aspiration, but these procedures should be approached with caution and thoroughly evaluated for cost and outcomes 1.

From the Research

Aspiration Prevention Strategies

• Aspiration prevention surgeries can be categorized into three approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx 2
• These surgeries can prevent aspiration and increase oral intake in 50-80% of patients, although most patients lose vocal function after the surgery 2
• Implementation of evidence-based feeding protocols and aspiration risk reduction algorithms can decrease aspiration pneumonias and ventilator-associated pneumonia rates 3

Pharmacologic Interventions

• Angiotensin-converting enzyme inhibitors, capsaicin, and other pharmacologic interventions may be beneficial in preventing aspiration pneumonia, although more research is needed to guide an evidence-based approach 4
• Certain medications, such as amantadine, cabergoline, and theophylline, may cause serious adverse events and are not recommended for routine use in preventing aspiration pneumonia 4

Risk Assessment and Prevention

• Implementation of a risk assessment tool to identify patients at risk of aspiration pneumonia can lead to a decrease in aspiration pneumonia rates 5
• Use of polyurethane-cuffed endotracheal tubes, taper-shaped cuffs, and subglottic secretions drainage can help reduce microaspiration and prevent ventilator-associated pneumonia 6
• Continuous cuff pressure monitoring and control, as well as minimum positive end-expiratory pressure, can also reduce the risk of microaspiration and ventilator-associated pneumonia 6