Quick action prevents life-threatening outcome.
- Aspiration can lead to hypoxia and airway obstruction.
- Airway obstruction can lead to respiratory acidosis and cardiac arrest.
You’re caring for Steven Tanner*, a 75-year-old man admitted to your unit with a diagnosis of ischemic stroke, left-sided weakness, and dysphagia. He receives continuous feedings via a small-bore tube through his right nare. Aspiration precautions include keeping the head of the bed at 30 degrees.
Telemetry monitors Mr. Tanner’s vital signs. He’s in normal sinus rhythm with an HR of 74 to 92 bpm. His BP is 140/76 mmHg and RR 24 breaths per minute. Pulse oximetry (SpO2) shows 98% on room air.
Enteral feeding: Indications, complications, and nursing care
Mr. Tanner’s cardiac monitor alarms. His HR is now 42 bpm and his SpO2 74%.
Taking action
As you enter Mr. Tanner’s room, you note his labored breathing (RR 42 breaths per minute) and that his feeding tube has become dislodged. You call for help and activate a rapid response.
You raise the head of the bed to avoid further suspected aspiration, turn off the feeding pump, and remove his feeding tube. While orally suctioning the patient’s mouth and oropharynx, you draw out suspected feeding material.
The rapid response team places Mr. Tanner on 100% oxygen via nonrebreather mask. A chest x-ray shows patchy infiltrates (white spots); the full extent of aspiration pneumonia may take up to 24 hours to appear on a chest x-ray. Auscultation reveals coarse crackles.
All ABG results are out of normal range: pH 7.12, PaCO2 61 mmHg, PaO2 55 mmHg, SpO2 79%, and bicarbonate 12 mEq/L, indicating respiratory acidosis with hypoxia. Mr. Tanner’s HR is now 56 bpm with a SpO2 of 82%.
Despite aggressive suctioning and 100% oxygen, Mr. Tanner remains hypoxic with labored breathing. He doesn’t have a gag reflex and he can’t remove his own mask, so he isn’t a candidate for noninvasive ventilation. The team decides to intubate Mr. Tanner. During intubation, the anesthesiologist notes suspected tube feeding aspirate in the patient’s lungs. A chest x-ray confirms endotracheal tube placement and he’s transferred to the intensive care unit.
Outcome
The provider prescribes antibiotics for aspiration pneumonia. The ICU nurses suction the patient and perform chest physiotherapy. After a swallowing evaluation, the speech therapist recommends a percutaneous endoscopic gastrostomy (PEG). After PEG surgery the following day, Mr. Tanner is discharged to an acute rehabilitation facility.
Education and follow-up
A debriefing with the rapid response team and nursing staff includes discussion of aspiration risks and signs and symptoms. While reviewing Mr. Tanner’s telemetry strips, the team and nurses note a gradual decrease in his HR. As he aspirated the tube feedings, he couldn’t oxygenate or expire CO2, which led to respiratory acidosis.
Respiratory acidosis occurs when a disease process or the inability to breath prevents the body from adequately performing gas exchange; CO2 increases and pH decreases. Acidosis can lead to bradycardia (slow heart rate) due to slowing of electrical conduction in the heart’s atrio-ventricular node.
Quick intervention
The gradual decrease in Mr. Tanner’s HR was a symptom of aspirate blocking his airway and preventing adequate gas exchange. Fortunately, telemetry monitoring alerted you to a change in his condition. Your quick intervention resulted in appropriate care. Without this intervention, Mr. Tanner may have gone into cardiac arrest.
*Names are fictitious.
Elizabeth Avis is a clinical practice lead for nursing support services (rapid response team, CWOCN, and nutrition) at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania.
References
Almirall J, Boixeda R, de la Torre M, Torres A. Aspiration pneumonia: A renewed perspective and practical approach. Respir Med. 2021;185:106485. doi:10.1016/j.rmed.2021.106485
Fulks LE, Nguyen BN. Dysphagia and aspiration. Brain Injury Med. 2021;219-26. doi:10.1016/B978-0-323-65385-5.00040-8
Kogo M, Nagata K, Morimoto T, et al. Enteral nutrition is a risk factor for airway complications in subjects undergoing noninvasive ventilation for acute respiratory failure. Respi Care. 2017;62(4):459-67. doi:10.4187/respcare.05003
Palmer PM, Padilla AH. Risk of an adverse event in individuals who aspirate: A review of current literature on host defenses and individual differences. Am J Speech Lang Pathol. 2022;31(1):148-62. doi:10.1044/2021_AJSLP-20-00375
Sidhu S, Marine JE. Evaluating and managing bradycardia. Trends Cardiovasc Med. 2020;30(5):265-72. doi:10.1016/j.tcm.2019.07.001
Waseem MH, Lasi FF, Valecha J, Samejo B, Sangrasi SA, Ali SM. Effectiveness of chest physiotherapy in cerebrovascular accident patients with aspiration pneumonia. J Mod Rehabil. 2021;15(1):47-52. doi:10.32598/JMR.15.1.7
Key words: aspiration, respiratory acidosis, bradycardia
