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ACQ
uiring knowledge
in
sp eech
,
language and hearing
, Volume 11, Number 1 2009
39
MULTICULTURALISM AND DYSPHAGIA
defences may be overwhelmed and pneumonia develops
(Cassiere, 1998; Finucane et al., 1999; Mojon, 2002). If the
aspirate is large in volume, but small in contagion, then
pneumonia results only if the aspirated organisms are highly
virulent or host defences severely compromised (Cassiere,
1998). A direct association between pulmonary infection and
oral diseases seems to only occur in patients with severely
compromised health, such as frail elderly and patients with
chronic pulmonary diseases (Mojon, 2002), with pneumonia
occurring due to the inability of lung defences to clear or kill
aspirated challenge (Gibson & Barrett, 1992).
Risk factors
Tube feeding
Tube feeding in elderly patients is associated with
pathogenic colonisation of the oropharynx. A study of 215
patients demonstrated oropharyngeal colonisation rates of
81% in nasogastric tube-fed patients, 51% of patients fed by
be particularly important in maintaining residents’ health,
due to a link between poor oral health and increased risk of
stroke (Joshipura, Hung, Rimm, Willett, & Ascherio, 2003).
In a case-control study comparing residents of a chronic
care facility with age-, race- and gender-matched dental clinic
outpatients, chronic care patients had fewer teeth, but much
higher plaque levels than outpatients. Chronic care patients
took a greater number of medications, were more often cur
rent or ex-smokers and were more likely to have COPD. Twenty
five percent of chronic care subjects carried respiratory
pathogens in their dental plaque, and 57% of these subjects
were found to be colonised. While a similar percentage of the
control group carried respiratory pathogens in plaque, none
of the controls were colonised (Russell, Boylan, Kaslick,
Scannapieco & Katz, 1999).
If the aspirated material is small in volume, but highly
contaminated with bacteria, even relatively strong host
Table 2. 2005 Survey of facilities using a free water protocol (continued)
Facility
Started Modified Notes on participants and Who they
Is it
More
protocol? program
exclude
working? pneumonia?
Archibold Memorial Sept. 2004 Yes, oral Eliminated all thickened
Exclude those
Yes
No
Hospital, Thomasville,
care
liquids. Insist on strict oral
with excessive
Georgia
care. Use ice chips if patient
discomfort/
has marked coughing
coughing
Kindred HealthCare, Sept. 2004 Yes, oral As above
Trached or vent
Yes
No
Atlanta, Georgia
care
patients with
(trach/vent)
history of pul-
monary disease
Cape Fear Valley
1999
Yes,
Strict oral care mandatory.
Significant
Yes
No
Health System,
limited Increased compliance,
coughing,
Fayetteville,
the
improved hydration,
decreased
North Carolina
amount
increased patient satisfaction pulmonary status
3x/day
or history of
and oral
aspiration
care
pneumonia; also
very poor oral care
San Antonio, Texas
2000
Yes, case Strict oral care – written
Non-compliant,
Yes
No
(long-term acute
by case orders for staff compliance;
“super-coughers”
hospital)
imple-
have noted increased speed or those who
mentation of improvement, cognitive
demonstrate no
improvement and decreased real pleasure from
dehydration
free water protocol
Moncton Hospital,
2003
Yes
Use neon yellow signs at
Compromised Yes
No
New Brunswick,
bedside and in chart; watch respiratory status
Canada (acute &
COPD patients carefully;
or immune
rehab)
patients are much happier;
suppression; those
most tolerate protocol well
with severe
coughing
Missouri Rehab
2002
Yes, oral Use antibacterial mouthwash Significant
Yes
No
Centre, Mount
care
in addition to oral care. ICU respiratory issues,
Vernon
patients watched carefully.
non-ambulatory,
Improvement noted in
bedridden
pneumonia incidence,
dehydration, cognition, speed
of improvement; people much
more compliant
Caulfield General
2003
Yes, oral Strict oral hygiene; include Unstable patients Yes
No
Medical Centre,
care
medically stable patients –
Melbourne, Australia
mainly in residential care; no
negative outcomes thus far
Note.
Compiled by Janis Lorman, MA CCC/S&A, Senior Lecturer, The University of Akron, Ohio.