What to do with an aspirating, bedbound pt?

[inthedistrict]

At clinical the other day, we had an aspiration-precaution pt. have some dinner go down the wrong pipe. The student working with her was watching her like a hawk, doing everything right, and the pt. was fine-- coughed it back up.

I wasn't working with the pt, I was was the pt. in the adjacent bed. However, the other student called to me because I was a tech before school. I hopped over the chairs, sat the pt. up, and since she started a productive cough I didn't need to do much more than that.

I'd had this situation happen when I was a tech, and at the time asked the nurses what I should do. I didn't get a good answer. When I asked the instructor after this, I didn't get a good answer either.

"Well...you'd do the heimlich, like on anyone else."

"But what if the patient is bed bound, in a soft bed? Drag them down?"

"Yeah...you just...you know. You do what you can."

"What about the morbidly obese?" (We see a LOT of them in our hospital)

"You just have to do what you can."

Is that really the answer???? Our instructor is great, so this really surprised me. Is there a source where I can learn what to do in this situation? I have to imagine someone has protocol in place for a bed-bound, aspirating patient. Is there a way to help clear the airway while keeping them in bed??? I just don't think in an emergency situation, alone, I'd have the time to get the patient safetly out, bear their weight to hold them up, and then be able to perform thrusts. OF course, call for someone, etc, but....in some situations even additional hands wouldn't be enough, fast enough, to do anything. I wouldn't forgive myself if I lost a patient this way, especially for lack of knowledge!

Thanks so much for any help! Articles or websites with the answer would be great, too, so I have some EBP materials to back me up.

[AgentBeast, MSN, RN]

The Heimlich is only useful if the patient is actively choking. Once whatever food/water get's into the lungs there isn't much you are going to be able to do other than encouraging coughing. The best thing to do is to prevent stuff from getting into the trachea/lungs to begin with. A patient like this should be in high Fowler's position, and you should be feeding a patient like this mechanical soft food and thickened liquids in small increments.

[Been there,done that, ASN, RN]

Have suction equipment available at all times.

If the patient is coughing.. STOP feeding them.

Give small bites, encourage thorough chewing..end with chin tuck swallowing.

Consult your speech/swallow technologist for your facilities protocol.

[PeepnBiscuitsRN]

Didn't the patient have a suction cath hooked up and ready to go? Were they on a modified diet/liquid like soft/pureed/or nectar thick liquids? I guess in our hospital, if there's the slightest inkling they have trouble swallowing, we call for a swallow study and do the aspiration precautions...and get a suction cath ready in case. Generally Speech Therapy can then determine their ability to swallow. I don't recall if the patient is NPO before a swallow study though...does anyone know about this, or is it facility specific? To me I'd be more comfortable if they were NPO, just in case (but I'm a night person, so generally patients aren't asking for food at that time).

[inthedistrict]

Per protocol, they must have cleared a swallow test to get a diet (that's where I worked as a tech, so I know that much is done). She was in high fowler, soft mechanical.. There wasn't suction in the room, which was a problem, especially since this was only the 3rd or 4th hour we'd been on the floor as students. I've operated suction before, but I doubt anyone else in my class has. Sorry, I should have added those details.

I understand that if they are coughing, they aren't choking, so no heimlich :)-- but, theoretically, what if they ARE choking? Sometimes, we can take all precautions and something still goes wrong. Or, the situation has changed and we don't learn we need extra precautions until it is too late.

In that case-- what should we do???? I would think suction wouldn't be of much help-- can't get it down far enough to clear something deep in the throat, and don't want to push it further in.

thanks so much for all of your help. I'm clear on prevention, just not clear on a plan B if prevention doesn't work. I'm big on always knowing my plan b! :)

[nurseprnRN, BSN, RN]

one other thing that is often overlooked, especially by newer nurses, is that the patient should always be bolt upright, all the way up, with the head forward a bit.

why? well, how do you position somebody if you have to open an airway? right, head tipped back. for feeding, you don't want it like that, because you want to totally minimize the chance that the airway will be vulnerable to incursion.

alas, the instructor is correct. have your suction handy and know how to do nasotracheal suctioning properly, do a chest thrust (which you can do from the front without getting behind the patient as in a classic heimlich), encourage deep coughing ... and do the best you can.