Aspiration among critically ill patients may often be subtle or even silent, but that doesn't mean it's insignificant. The condition contributes to an increased risk of pneumonia and other serious complications, and the lack of a bedside diagnostic test makes it difficult to detect.
Recognizing the importance of preventing this common problem, the American Association of Critical-Care Nurses (AACN) has updated its AACN Practice Alert, Prevention of Aspiration in Adults, outlining the most current bedside practice supported by the latest evidence.
The AACN Practice Alert offers a detailed checklist for aspiration prevention, including head-of-bed elevation, assessment of sedation levels and feeding-tube placement. Known internationally for her feeding tube and aspiration-related research, Norma Metheny, RN, PhD, FAAN, associate dean of research at Saint Louis University School of Nursing, authored this Practice Alert for AACN.
"Preventing or minimizing aspiration takes on added importance due to the lack of a bedside test to identify when it's occurring," she said. "Microaspirations may be difficult to detect and can lead to serious complications."
Microaspirations are small-volume, clinically silent aspirations of gastric content and are far more common than noticeable large-volume incidents. According to one study, approximately half of critically ill, mechanically ventilated, tube-fed patients experienced frequent microaspirations. The study also found these patients had a four times greater risk of developing pneumonia.
This alert is the latest in a series of advisories issued by AACN to standardize practice and update nurses and other healthcare providers on new clinical advances and trends. All Practice Alerts are available on the AACN website, www.aacn.org/practicealerts and can be downloaded free of charge.
Based on the latest available evidence, the expected practice to prevent aspiration is to:
•Maintain head-of-bed elevation at an angle of 30 to 45 degrees, unless contraindicated
•Use sedatives as sparingly as feasible
•For tube-fed patients, assess placement of the feeding tube at four-hour intervals
•For patients receiving gastric tube feedings, assess for gastrointestinal intolerance to the feedings at four-hour intervals
•For tube-fed patients, avoid bolus feedings at high risk for aspiration
•Consult with physician or other provider about obtaining a swallowing evaluation before oral feedings are started for recently extubated patients who have been intubated for more than two days
•Maintain appropriate endotracheal cuff pressures, and ensure secretions are cleared from above the cuff before above the cuff before it is deflated
Supported by authoritative evidence, each AACN Practice Alert seeks to ensure excellence in practice along with promotion of a safe and humane work environment. Topics address both nursing and interprofessional activities of importance to patients in acute and critical care environments. Some alerts include additional resources for staff education and performance-improvement activities.
Additional alerts address verification of feeding-tube placement, noninvasive blood pressure monitoring, dysrhythmia monitoring, pulmonary artery pressure monitoring, ST segment monitoring, family presence during CPR and invasive procedures and prevention of catheter-associated urinary tract infections.
American Association of Critical-Care Nurses (AACN)