Aspiration occurs when material such as gastric contents, saliva, food, nasopharyngeal secretions are inhaled into the airway or upper respiratory tract. In a healthy population, micro aspiration is common and pulmonary secretions seldom occur. In the unhealthy population risk for pneumonia is higher due to levels of consciousness, altered airway defenses, and depressed immune function. Aspiration may be silent or with overt symptoms. How much is too much aspiration??
Not enough research exists to definitively answer this question. Until more research is available, the SLP should use clinical judgment and assume that the least amount of aspiration is safest for the patient (Hardy & Robinson, 1999). The amount of aspiration will also depend on the patient’s current medical condition and varying diagnosis’ involved.
Aspiration Pneumonia – Pneumonia occurs when bacteria that normally exist in the oral, nasopharyngeal and gastrointestinal tract or food and/or liquid are aspirate into the lungs. A chest X-ray that may show infiltrates or pneumonia confirms diagnosis of pneumonia, most consistently in the right lower lobe. A bronchoscopy can give a definitive diagnosis.
What one person considers “quality of life”, someone else may think differently. Artificial supplied nutrition and hydration are a medical treatment to be considered in the same light as other technological procedures and not considered life support in the medical field. Literature supports PEG placement in patients recovering from a traumatic accident or expected to make a recovery process. It is considered a medical intervention, not obligatory care. Tube feeding is an art and a science that is increasingly used in our aging society as more people become physically incapacitated or have dementia. Properly used it can be helpful.
Types of Nonoral Feeding
NG – Nasogastric Tube – thin flexible tube inserted into the nasal cavity through the pharynx, esophagus, down into the stomach. Usually consider a short-term alternative. The diameter of the tube varies, however a narrow tube is preferred to create minimal irritation in the pharynx. Disadvantages of the NG tube are the physical presence in the pharynx and esophagus and the potential for regurgitation. Dobhoff tube is designed to reduce the potential for reflux and aspiration by extending into the jejunum. Tracheal placement of the tube is common in patients with a reduced gag reflex. Nasogastric tubes are considered a temporary solution. Due to the fact that each anatomy is different the effect of the presence of an NG tube will vary patient to patient.
PEG – Percutaneous Endoscopic Gastrostomy – surgical procedure that creates an external opening in the abdomen that leads to the stomach. 125,000 procedures are performed annually. A soft flexible tube is inserted into this opening that leads into the stomach. It is performed under general anesthesia. Blended foods or other specially prepared nutritional supplements can be given with a catheter-tip syringe or feeding pump through G-tube or PEG. Consider more long term, but not permanent.
Tube Feeding Formulas – A variety of formulas from several manufactures are available; they differ in osmolarity, calories per milliliter, and amount of carbohydrate, protein, fat, and fiber. It is given in bolus or continuous infusion. Bolus feedings are for ambulatory patients and for convenience. Feedings can run over night to supplement partial oral daytime intake.
Isotonic formulas are usually tolerated at full strength
Hypertonic and elemental formulas are best initiated at half strength.
Medications – Numerous medications have to be crushed and mixed in solvents before administering thus altering their bioavailability and characteristic release properties. Feeding tubes should always be flushed with at least 30-60mL of water after administration of medications to prevent clogging.
Decreasing Risks of Aspiration with Tube Feeding – Despite multiple risk factors, enteral nutrition remains the safest and most cost effective means to promote nutritional requirements in the hospitalized patients who cannot take nutrition orally (Braunschweig et al, 2001). Implementation of prevention strategies is a key factor for improving safety if tube feeding and decreasing risk of aspiration.
· Maintain HOB above 30 degrees at all times
· Routinely verify tube placement
· Remove Naso/oroenteric tubes as soon as possible
· Clinical assessment of GI tolerance including Abdominal distention, Fullness, Discomfort, Excessive residual trends
MYTHS AND REALITIES
MYTH: Artificial feeding prolongs life
Reality: Patients with advance diseases do not necessarily live longer and may in fact suffer more. Artificial nutrition often brings additional medical complications. This true if the illness is cancer, chronic lung disease, dementia, kidney failure etc. There is evidence that cancer grows faster with nutrition by feeding the tumor. Artificial feeding is likely to extend life for those with neurological disorders such as stroke or coma.
MYTH: If a patient does not eat well they will die of starvation
Reality: Patient’s stop eating due to end stage disease and die of the illness, not lack of food. Patients can live for a month on a few bites and sips a day.
MYTH: Without nutrition the patient will suffer more
Reality: When the body no longer needs or benefits from nutrition there seems to be a natural mechanism that “turns off” the desire for food. At the same time the body seems to compensate for the lack of food by producing a chemical that acts as a buffer preventing hunger that healthy people experience when they do not eat.
MYTH: Dehydration causes suffering
Reality: In the end stages of life the body can simply not process all those fluids. Research has shown that many patients are actually more comfortable when the body does not have to struggle with fluid overload. IV fluids do not prevent dry mouth. Gradual dehydration is not painful!
MYTH: Artificial feeding is like eating
Reality: It is not natural. Patients loose the pleasure of eating that includes flavor and sharing meal times. Body image can cause distress after a stomach tube is placed. Also the body can not always regulate the amount of intake relative to the amount that is delivered. Where true hunger and thirst exists, quality of life may be enhanced (such as GI obstruction). Tube feeding can be a mixture of regular foods blended with liquid but nutritional balanced liquid products ensures proteins, fats, carbohydrates, vitamins, and minerals.
MYTH: Patients will become stronger if fed by a tube
Reality: It depends on the disease process and the expected progress.
MYTH: TF prevents pneumonia in those with dysphagia
Reality: There is a still a risk depending on care of the TF, gastric status including reflux, and positioning. No randomized controlled studies have been published, only observational studied have been published.
MYTH: TF prevents bedsores and other problems of malnutrition
Reality: TF may make it harder for the patient to move around depending on the disease process, causing more bedsores.
When it is time – LETTING GO – As death nears it is not depression we witness but a lessening of a desire to live longer. Some people had described it as a sense of profound tiredness that no longer goes a way with rest. Refusing to let go can prolong dying but will not prevent it. It is usually those still healthy who love the dying individual that prolong the struggle by emotionally distressing their loved one. A great act of kindness and love may be to say “You may go when you feel it is time. I will be okay”
A helpful publication that can guide families through some of these decisions can be found online at www.ohri.ca. It is titled Making Choices: Long Term Feeding Placement in Elderly Patients.