Primary prevention

The majority of hospital-acquired pneumonia and a significant proportion of community-acquired pneumonia in older people occur from microaspiration of infected oropharyngeal contents. Measures to identify oropharyngeal dysphagia and reduce oropharyngeal load of pathogenic organisms, particularly in patients with neurologic disease, nursing-home patients with comorbidities, and intubated or tube-fed patients, can potentially help reduce aspiration pneumonia.[24]

Vigilant care is necessary to prevent aspiration of oropharyngeal material. Older or neurologically impaired people should eat or be fed small meals at a slow pace and of an appropriate consistency to prevent choking or regurgitation. Good oral hygiene is recommended, although it is still uncertain whether oral hygiene will reduce incidence of infection.[25] Oral care, including a combination of professional cleaning of the oral cavity once a week, tooth brushing after each meal, cleaning dentures once a day, and gargling of disinfectant solution, can reduce the number of pathogenic bacteria in the oropharyngeal secretions and has the potential to reduce the occurrence and mortality from aspiration pneumonia, although the supporting studies may have limited methodological validity.[26][27][28][29] Nonrestorable teeth should be extracted.

Oral care extends beyond oral decontamination and emphasizes the need for improving motility of oropharyngeal secretions by dysphagia treatment (swallowing training, dietary management, and positioning). While reduction in incidence of pneumonia has not been established, there is a potential to reduce aspiration in patients with impaired swallowing abilities.[30] It appears that the greatest benefit from oral care is when it is provided by dental professionals; oral care provided by nurses had no appreciable reduction in mortality from pneumonia.[31]

Postural maneuvers and exercises to strengthen swallowing musculature may be necessary to retrain a debilitated patient with swallow dysfunction.

The patient should remain in an upright or elevated position at least 1 to 2 hours after meals. Feeding tubes require regular adjustment to prevent misplacement. Tube feeding residual volume in the stomach should be monitored, and tube feedings should be withheld if the residual volume exceeds 50 mL. Continuous pump nasogastric feeding does not reduce the incidence of pneumonia compared with bolus feeding. In critically ill patients, there is moderate-quality evidence that postpyloric feeding compared with gastric feeding is associated with a 30% lower rate of pneumonias.[32] Aspiration pneumonias are reduced in gastrostomy patients with elemental diets and mosapride.[33][34]

Prophylactic antibiotic therapy after a recognized episode of aspiration may not prevent the subsequent development of bacterial pneumonia; rather, it may select for resistant organisms. No evidence-based recommendations can currently be made for any pharmacologic intervention for prevention of aspiration pneumonia.[35]

There is little evidence that preoperative fasting reduces the risk of perioperative aspiration.[36] The routine preoperative use of antacids or medications that block gastric acid secretions is not recommended in patients who have no apparent increased risk for pulmonary aspiration (conditions that increase risk include gastroesophageal reflux disease, hiatal hernia, ileus or bowel obstruction, enteral tube feeding, pregnancy, and obesity).[19] One systematic review showed benefit from use of histamine-2 receptor antagonists in reducing gastric volume and increasing pH, thus reducing the number of patients at risk of acid aspiration.[37] Despite this, there is insufficient evidence to justify suppressing gastric acid, as administration of a proton-pump inhibitor or histamine-2 receptor antagonist may be associated with an increased risk of pneumonia.[38]

Similar trends for reducing risk of aspiration pneumonitis were noted in women undergoing cesarean section under general anesthesia with usage of H2 receptor antagonists, although quality of evidence was poor.[39]

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