Aspiration occurs when foreign material enters the airway below the level of the true vocal cords. The video below shows aspiration of thin fluid during a videofluroscopy assessment.

Aspiration pneumonia is defined as inflammation of the lungs, and airways to the lungs resulting from the inhalation of foreign material. Frequently in the swallowing literature, dysphagia is identified as one of the leading causes of aspiration pneumonia, as impaired swallowing function can lead to fluids, solids, stomach contents and other secretions entering the airway.Langmore et al (1998) identified that although dysphagia was a predictor for the development of aspiration pneumonia, it was not the most significant predictor. Langmore et al (1998) identified the following factors as being the leading predictors for the development of aspiration pneumonia:
Leading Predictors for the Development of Aspiration Pneumonia

Dependency for feeding
Number of decayed teeth
Dependency for oral care
Tube feeding
More than one medical diagnosis
Number of medications

As patients with bilateral hemispheric stroke present with the most severe dysphagias and are likely to present with most or all of the factors above, these patients are of the highest risk for developing aspiration pneumonia post stroke.

Priorities for intervention to help reduce the risk of aspiration pneumonia in patients with bilateral hemispheric stroke during the acute stroke phase must therefore include:
Rigorous Oral and Dental Hygiene:
oor oral and dental hygiene can cause pathogenic bacteria to build up in the mouth and saliva. Acute phase patients with bilateral hemispheric stroke are often malnourished, dehydrated and have an immune system in a weakened state, thus if pathogenic material is aspirated along with their secretions, the likelihood of developing pneumonia is high. Healthy oral and dental hygiene can be maintained by:
· Aggressively brush the teeth at least once a day. Use small amounts water to reduce the foaming effects of toothpaste and reduce the chance of the patient aspirating dislodged bacteria.
· Use antimicrobial agents to help clean the teeth and mouth. · Ask patient to expectorate or use suction whilst brushing teeth/cleaning mouth to ensure secretions containing harmful bacteria are not swallowed.
Oral and Pharyngeal Suctioning of Excess Secretions:
Patients with bilateral hemispheric stroke and severe dysphagia are likely to aspirate their nasal and oral secretions due to the severity of their dysphagia and the high likelihood that they are being fed via a Nasogastric tube (Langmore et al., 1998). Excess secretions should be removed via oropharyngeal or nasopharyngeal suctioning and this task is usually carried out by nurses or other trained professionals in the acute care setting. Suctioning of secretions performed in conjunction with rigorous oral and dental care should effectively help to reduce the risk of aspiration occurring.

Training of Safe Feeding Techniques: if the patient is safe for oral intake

Early in intervention, an effort should be made to get the patient as mobile as possible as studies have shown that lack of movement can also lead to the development of pneumonia (Sahn 1991; Loeb, McGeer et al. 1999).This may be a significant implication for patients with bilateral hemispheric stroke as their second stroke may have left them severely physically impaired.

In cases where the risk of aspiration is so severe, tracheostomy tubes can be surgically placed which a) prevent secretions from entering the airway and b) provides the patient with an airway. Tracheostomy is generally only performed on the most severe stroke patients (Daniels & Huckabee, 2008).

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