Physical Therapy for repeated aspiration pneumonia

Pneumonia is associated with a high mortality rate and is the fourth leading cause of death in Japan. With aging, reduced eating and swallowing functions cause pneumonia due to aspiration (aspiration pneumonia). There are many studies on physical therapy for disuse syndrome or dysphagia after having pneumonia; however, only a few studies have examined that for aspiration pneumonia. Physiotherapy intervention for dysphagia was performed in a patient who experienced repeated aspiration pneumonia and whose condition had been unstable for 2 weeks after the onset. We report the patient, who showed improved functional oral intake, with a discussion. The patient was a 66-year-old male. Since a chest CT scan showed infiltrates in the dorsal area, impaired oxygenation due to accumulated secretions was suspected. Regarding aspiration, continuous inspiratory rales (snoring-like sound) were heard, and crepitation rales were heard over the lower lobe of the lungs during breathing after aspiration. The respiratory rate was 20-30/min, which indicated tachypnea (use of an oxygen mask; oxygen flow rate, 3 L; percutaneous oxygen saturation, 97-99%). Activities of accessory muscles of respiration, such as sternocleidomastoid and trapezius muscles, were observed during inspiration and expiration, and they restricted cervical movements. Regarding the swallowing function, because bolus mastication was poor, a delay in the swallowing reflex was observed, and sometimes choking occurred, even with jelly. The oral cavity was often unsanitary; being dry and sputum was stuck to the tongue and teeth. Short-term goals were set to achieve early improvement and prevent the recurrence of aspiration pneumonia and disuse syndrome. The long-term goal was set to achieve a stable in-hospital life without recurrence. The intervention program consisted of the following: 1) respiratory physical therapy, 2) ROM exercises, 3) sitting exercises, and 4) hygiene practices. For the treatment of aspiration pneumonia, oral hygiene is considered important; therefore, hygiene practices (gargling and tooth brushing) were conducted in order to remove food residues as well as retain moisture in the oral cavity. The patient was at a high risk of swallowing toothpaste while brushing teeth due to various adverse conditions, such as a bad posture, tachypnea, reduced comprehension, reduced ability to swallow, and dry mouth. Hygiene practices were conducted considering the above risks regarding the posture, breathing, vision, amount of water, and coughing. At the final assessment, total body and nutritional conditions were stable without pneumonia recurrence. Regarding the behavior, sitting on a chair became possible, as well as tooth brushing with assistance. The cervical movement restrictions and unsanitary oral conditions observed in the early phase were improved, which favorably affected the swallowing function. The effectiveness of physical therapy for aspiration pneumonia was indicated as a one of the essential roles of the multidisciplinary team. The progression of physical therapy in this field is expected.