My colleagues often ask, “What’s one research article or paper that has changed the way you practice?” And my response is always the same: “This one’s easy - it’s the Three Pillars of Pneumonia, by Dr. John Ashford.”
NOTE: Yes, I'm aware it's not technically a research article, but I've never been much of a rule follower, so whatever. Moving on...
So why is this one so important?
Because SLPs are taught to be afraid of aspiration pneumonia.
And not just a little bit afraid, but more like “Holy sh*%, I’ll lose my license and end up homeless living under a bridge for the rest of my life if I screw this up,” full-on panic attack kind of terrorization. You're introduced to dysphagia in grad school and taught that your recommendations could "really hurt people" and you're probably thinking - WTF when did I sign up for this responsibility?! I'm here to work with the kids!
But then you graduate and quickly find out that a.) you either prefer working with adults, b.) that medical settings pay better, or c.) maybe the SNF job was the only position available for a CF, so you think, "Sure, I'll give this dysphagia thing a shot." But what happens when fear meets uncertainty? Well, then we tend to over-diagnose, over-treat, and over-restrict in order to “CYA” - cover our assets.
And you're doing it to benefit the patient, to prevent this dreadful thing - this "risk of aspiration."
But as with everything, the truth (and the swallowing process) is much more complex than that.
FIRST, LET'S DISPELL SOME MYTHS!
Dr. Ashford makes the mystery of aspiration pneumonia a little less, well, mysterious. His focus over the last decade has been on pneumonia and what creates the perfect storm for aspiration pneumonia to occur. He assures us that:
1. Aspiration pneumonia does not develop as a singular and independent disease entity. 2. Aspiration pneumonia can only develop within the context of a primary and serious illness. 3. Laryngeal aspiration is not the sole cause of aspiration pneumonia.
SO WHAT ARE THE FACTS?
So before we dive down the rabbit hole, let's review the literature and establish some solid facts about aspiration pneumonia:
1. What is pneumonia? Pneumonia is an acute infection, and as you know, infections develop when the immune defenses are insufficient to meet the challenge of bacterial or viral pathogens entering and colonizing - in this case - the lower respiratory system.
2. What's the difference between nosocomial ("hospital acquired") pneumonia and aspiration pneumonia? Nosocomial pneumonia has a bacterial origin and is a term for when the disease is developed while in a hospital or skilled nursing facility. Patients who have been intubated or in the ICU have a higher risk and anyone developing nosocomial pneumonia has an increased risk of death.
Aspiration pneumonia is defined as an infection that develops after inhaling oropharyngeal pathogens into the lungs that have first colonized in the oropharynx.
3. Why do some patients who aspirate develop pneumonia and others don't? This is a fair question. While the relationship between aspiration and pneumonia has been well recognized, laryngeal inefficiency is only one piece of the puzzle. Whether pneumonia develops from aspiration depends on the volume and characteristics of aspirated material, the frequency of aspiration events, and the integrity of the immune system.
So while some patients may develop aspiration pneumonia after one episode of aspiration, others may experience episodes of aspiration pneumonia after aspirating small amounts of material over a prolonged period.
LET'S FINALLY TALK ABOUT THE THREE PILLARS OF PNEUMONIA!
Armed with the above knowledge, Dr. Ashford designed the "Three Pillars of Pneumonia" to help determine who's at risk for developing the "dreadful disease" and this is what he found - three things must happen in conjunction for a patient to be considered “high risk.” They are as follows:
1. COMPROMISED IMMUNE SYSTEM This includes any previous and current co-morbities, old age, acute disease process, etc.
2. THE PRESENCE OF ASPIRATION (self explanatory, right?) Dr. Ashford stresses that clinical swallowing evaluations "should only be used to determine if the patient has overt signs of dysphagia, and, if so, to refer for an instrumental study. These tools [bedside swallowing exams] are too insensitive to detect aspiration."
3. POOR ORAL HEALTH SLPs can determine this by thoroughly examining the teeth, tongue, and mouth. Dr. Ashford endorses the use of Oral Health Assessment Tool (OHAT).
NOW BRACE YOURSELVES, BECAUSE HERE'S THE KICKER:
Even if TWO of the elements exist without the THIRD, the patient remains virtually at NO RISK for aspiration pneumonia!
Whoah, did you read that? Read it again!
Simply stated, that means - with the exception of compromised immune system in addition to aspiration, which still only results in a relatively low risk - a patient can have a poor oral health and documented aspiration of materials, but if he/she has an excellent immune system, then the risk is virtually NONE!!!
WHAAAT. THE. ACTUAL. F^%#. My head was SPINNING FOR DAYS!!
So after I caught my breath, what did I do? Well, first I panicked. Then I proceeded to read and re-read each of Dr. Ashford’s articles multiple times and spent several nights awake pondering how many nectar-thickened liquid diets I’ve unnecessarily put my patients on. How many clinical bedside swallow studies have I performed (complete with crappy non evidence-based recommendations) without knowing better? We’ve all heard the negative consequences of thickened liquids (e.g; dehydration, poor PO intake, increased chance of mortality if aspirated, etc) but what about the patient’s quality of life too?
The guilt is real, y’all.
To redeem for all those guilty feels, I decided that I would share dysphagia literature and research with any SLP who would listen! I understand there’s no possible way a busy SLP could read every single journal article available to our field, because that would be a ridiculous and unreasonable task. Combine that with a demanding work schedule, kids, and/or a spouse, and all you want to do is go home, sit on the couch, and ZONE OUUUUT.
I totally freakin' get it.
Unfortunately, with new research coming out that continues to challenge so much of what we've learned in grad school, we no longer have the luxury to just throw our hands in the air, shrug our shoulders and say, "Welp, I didn't know that!"
We chose to dedicate our careers to helping and rehabilitating people in their time of need, therefore, we entered an unspoken contract to always do what's best for our patients. And part of that is holding ourselves accountable for ongoing professional development and keeping up with the most current and up-to-date EVIDENCE BASED PRACTICES.
So I urge you, my wonderful, capable colleagues to please refer to the following chart (courtesy of Dr. Ashford) and keep these findings in mind before making those super restrictive, life-altering recommendations. Download and keep it with you everywhere you go!
Your patients will thank you.
Dr. John Ashford, Ph.D., CCC-SLP currently serves as the Education Director and Co-Owner of SASS. He is a retired Clinical Speech-Language Pathologist from the Veterans Administration Tennessee Valley Health Care System, and a retired Associate Professor of Speech-Language Pathology from Tennessee State University. For more of Dr. Ashford's research/literature and to view his upcoming CEU courses, please visit his company website at www.sasspllc.com.
This blog post is part of a multi-part series where I summarize articles and findings that have completely changed my way of thinking and altered the way I approach dysphagia treatment/management. Please subscribe to our mailing list for updates on future posts.