2021_Book_TextbookOfPatientSafetyAndClin

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Table 17.14 Risk factors for aspiration pneumonia
[103–105]
Impaired swallowing
Impaired
consciousness
Increased amount of
gastric content
reaching the lungs
Conditions impairing
the cough reflex
Others
Esophageal disease, including
dysphagia, head/neck cancer,
stricture, achalasia,
scleroderma, polymyositis
Chronic obstructive
pulmonary disease
Neurologic diseases, including
seizures, multiple sclerosis,
Parkinson’s disease and
parkinsonism, stroke,
dementia
Extubation from mechanical
ventilation
Stroke or intracerebral
hemorrhage
Cardiac arrest
Drug overdose and
medications, such as narcotic
agents, general anesthetic
agents, and some
antidepressant agents
Alcohol abuse
Percutaneous enteral tube
feeding, especially when
associated with gastric
dysmotility and cognitive
impairment
Gastro-esophageal reflux
Gastroparesis
Stroke
Medications
Alcohol
Degenerative neurologic
diseases
Male sex
Smoking
Diabetes mellitus
and swallowing reflexes showed more consisting
results [106–108].
Oral hygiene may represent an important preventive
action in non-ventilated patients: it has
been demonstrated that chlorhexidine or mechanical
oral cleaning reduce up to 60% risk of aspiration
pneumonia [109]. However, it is important to
remember that chlorhexidine can be toxic if aspirated
into the lungs, especially by ventilated
patients. The association of oral care to supplemental
nutrition also demonstrated to lower aspiration
pneumonia [110]. Anyway, a
M. L. Regina et al.
comprehensive oral care program (manual tooth,
gum brushing, chlorhexidine mouthwashes, and
upright positioning during feeding) evaluated in a
cluster-randomized controlled trial conducted
among nursing home residents showed a higher
number of pneumonias/lower respiratory tract
infections in the intervention group [111]. On the
other hand, a short course (≤24 h) of prophylactic
β-lactam antibiotics was shown to reduce the
risk of aspiration around the time of endotracheal
intubation [112].
Delirium is a neuropsychiatric syndrome
characterized by altered consciousness and attention
with cognitive, emotional, and behavioral
symptoms. It occurs among hospitalized
patients—mainly in elderly frail people—at a
rate from 14% to 56% and increases morbidity
and mortality [113]. In this condition, multiple
risk factors have been identified so that suggested
intervention is obviously multicomponent.
Evidence shows that they are effective in preventing
delirium onset in at-risk patients in a hospital
setting, without significant associated harms but
it is insufficient to identify which multicomponent
interventions are the most beneficial, and
which components within a program provide the
most benefit [114, 115]. The aim of primary prevention
is to prevent physiological derangements
by early mobilization, good hydration, sleep
enhancement, family and caregiver involvement,
in addition to physiotherapy and rehabilitation, as
summarized in Table 17.15.
Since it is usually triggered by different factors,
prevention strategies need to be reassessed
during hospital stay [114].
Approaches including the education of nursing
aides and caregivers, music therapy and psychotherapy
gave no definitive results [114].
The main recently published studies on pharmacological
approach are summarized in a
review by Oh et al. [114]. In general, antipsychotic
drugs did not demonstrate any clear benefit
in preventing delirium [116], similarly to
cholinesterase inhibitors, ketamine, melatonin,
and melatonin-receptor agonist (ramelteon) [117,
118]. Hence, there is a lack of support in using
drugs for prevention or treatment of delirium,
especially when considered as a unique entity.