Aspiration: risk and prevention

Aspiration is the entry of food, fluid, saliva or stomach contents into the airway, and it happens to the patient whose protection against it has been lost -- a depressed level of consciousness from illness, sedation, anaesthesia or a seizure, a swallow weakened by stroke or neuromuscular disease, a tube through the mouth or nose that props the throat open and whose cuff does not seal the airway, a stomach that empties slowly or is distended, vomiting, and lying flat -- so the nurse first identifies that patient and then removes the openings: nothing by mouth, not even a sip or a tablet, until a swallow screen is passed and the diet and fluid consistency it prescribes are followed; meals eaten sitting fully upright with the patient staying up afterwards, in small mouthfuls, without talking while swallowing, supervised, with the chin tucked or the thickened fluids and altered textures the swallowing assessment ordered and the tablets given the way it directs, and a cough, a wet or gurgling voice, pocketed food, or a meal that keeps stopping treated as aspiration rather than as a slow eater; the mouth brushed regularly, including in the patient who takes nothing by mouth, because it is the bacteria in the mouth that turn an aspirated drop into a pneumonia; for the tube-fed patient the tube's position confirmed by imaging when it is first placed and by the external length and mark before every feed and every medication, never by listening for air over the stomach, the head of the bed kept raised during and after the feed and the feed stopped before the patient is laid flat for a turn or a procedure, and the feed held and reported when there is distension, nausea, vomiting or a new cough; the unconscious or vomiting patient turned on the side with suction at hand; sedation kept to the least that is needed and the patient sat out and walked as early as possible -- and when aspiration is seen or suspected, the feeding stops, the airway is suctioned and the patient positioned, oxygen is given and the team is told at once, remembering that much aspiration is silent and declares itself only later as a fever, a new crackle, a new oxygen requirement or an infiltrate in the patient nobody saw choke.