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Clinical factors predicting risk for aspiration and respiratory aspiration among patients with Stroke1

Objective: to investigate the association of risk factors with the Risk for aspiration nursing diagnosis and respiratory aspiration. Method: cross-sectional study assessing 105 patients with stroke. The instrument used to collect data addressing sociodemographic information, clinical variables and risk factors for Risk for aspiration. The clinical judgments of three expert RNs were used to establish the diagnosis. The relationship between variables and strength of association using Odds Ratio (OR) was verified both in regard to Risk for aspiration and respiratory aspiration. Results: risk for aspiration was present in 34.3% of the patients and aspiration in 30.5%. The following stood out among the risk factors: Dysphagia, Impaired or absent gag reflex, Neurological disorders, and Impaired physical mobility, all of which were statistically associated with Risk for aspiration. Note that patients who develop such a diagnosis were seven times more likely to develop respiratory aspiration. Conclusion: dysphagia, Impaired or absent gag reflex were the best predictors both for Risk for aspiration and respiratory aspiration.


Introduction
Every year, 795 thousands people experience a new or recurrent episode of cerebrovascular accident (CVA) or stroke. Even though CVA is the second-leading cause of death around the world and is associated with the main cause of disability in many countries, the mortality rate decreased 34.8% from 1998 to 2008 and the real number of deaths caused by CVA decreased by 19.4% (1) .
Despite this decreased rate, patients may experience many complications with the potential to affect mobility, speech and swallowing; swallowing disorders have a prevalence from 18 to 81% in the acute phase of stroke and may persist up to six months after the event, which can lead to a worse prognosis (2)(3) .
Aspiration is the most severe aspect of dysphagia, defined as the entry of solids or fluids into airways below the vocal cords; it is more frequently observed when swallowing fluids (4)(5) . It is worth noting that the concept of respiratory aspiration is well-defined in the health field, thus its prevention requires the joint efforts of a multidisciplinary team caring for a CVA patient. This situation shows the need to focus on the assessment of the Risk for aspiration nursing diagnosis in order to reduce complications that may arise from a stroke.
According to NANDA International, Inc. (NANDA-I), the nursing diagnosis Risk for aspiration is defined as "the risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids or fluids into the tracheobronchial passages" (6) . After the clinical validation process of this diagnosis in CVA patients, the risk factors found were: dysphagia; impaired or absent cough reflex; neurological disorders; use of gastrointestinal tubes; impaired physical mobility; impaired or absent gag reflex; and low headboard (7) . Therefore, improved understanding of the Risk for aspiration nursing diagnosis and the development of respiratory aspiration among patients with stroke enables identifying some needs and frailties to which nurses should pay attention, elect priorities, and upon which focus their work. Even though there are studies addressing respiratory aspiration, only one study (7) was found that investigated this nursing diagnosis and its relationship with patients affected by CVA.
Additionally, note that knowledge of associated factors is essential to rapidly establish these phenomena, since the methods considered to be the gold standard for diagnosing this condition, such as videofluroscopy or even endoscopy by optical fiber, are expensive and not widely available in healthcare facilities (8)  Data were collected using a form based on the risk factors of the nursing diagnosis under study, which had been validated for CVA patients in a previous study (7) .
Additionally, sociodemographic (sex, education, marital status, and age) and clinical variables (comorbidities, use of vasoactive drugs, sedative, oxygen therapy, type of CVA, number of episodes, and time since the event) were also verified. disagreements during data collection were discussed together with the researcher so that the pair could reach consensus.
After a preliminary assessment, the presence of respiratory aspiration was verified using a test proposed by Daniels et al. (9)(10) that identified six clinical features: dysphonia, dysarthria, abnormal gag reflex, abnormal voluntary cough, cough after swallowing, and change of voice after swallowing. Aspiration was confirmed when at least two of the six clinical features were observed.
This clinical assessment was performed due to the unavailability of a videofluroscopy (the gold standard) to confirm respiratory aspiration. Note that studies (9)(10) that established these clinical signs presented specificity at 89% for the detection of respiratory aspiration when compared to the gold standard.
Afterwards, data concerning this assessment, without the information of whether there was the presence of respiratory aspiration or not, was submitted to three judges, who met the following criteria: having a Master's degree; academic and professional background in the field of nursing diagnoses; and having provided care to patients with CVA or critical patients. The purpose of having these experts was to avoid the influence of data collection in terms of diagnostic inference, because these professionals were not aware of which of the patients had experienced respiratory aspiration during hospitalization.
The judges received the instrument completed by the nurses during collection of each patient's data, presenting sociodemographic data, clinical variables, and risk factors for aspiration. The diagnosis under study was reported by most RNs. Hence, we decided to use the agreement reached by the experts to be the gold standard to identify the presence of this diagnosis, minimizing bias, considering the individual opinion of experts, as was performed in a prior study verifying accuracy (11) .
The results were organized in Excel 8. Pearson's Chi-square was used to analyze association among data in the occurrence of expected frequencies above five and below 20 and organized into 2x2 tables; Fisher's exact test was used when expected frequencies were below five. Odds Ratio (OR) was used to verify strength of association. OR was computed in the cells with frequency equal to zero. A level of significance of 5% was adopted. In regard to the characterization of patients, no patient was using vasoactive or sedative drugs during the assessment and none were receiving low-or high-flow oxygen therapy. The following comorbidities were found: hypertension (63.8%), diabetes mellitus (24.8%), heart diseases (14.3%), and dyslipidemia (13.3%).
In regard to the nursing diagnosis, the judges deemed that 34.3% of the patients affected by CVA presented the Risk for aspiration diagnosis, while 30.5% developed respiratory aspiration, which was confirmed by clinical assessment (Table 1). Additionally, most patients with CVA did not present risk factors for Risk for aspiration (31.4%) or one factor (29.5%), followed by those with two risk factors (16.2%), three (12.4%), four (7.6%), five (1.9%), and six factors (0.9%). In addition to associations presented in

Discussion
In general, the sociodemographic profile of the 105 patients with CVA assessed in this study was similar to that reported by international studies, i.e., mostly men, married, with a low level of education, and not currently employed (12)(13)(14) .
Note that age may influence swallowing because many changes occur in the masticatory apparatus (e.g., lips, tongue, cheeks), which may change mastication, swallowing, breathing, voice, speech and increase the risk for respiratory aspiration (15)(16)(17) . Additionally, such changes may also gradually decrease oropharyngeal and  (18) .
Most participants lived with a partner (67.6%), which is important because a caregiver, often the wife, generally appears in family relationships and helps the individual impaired due to a CVA (19) . Therefore, it is essential that the caregiver be trained by nurses to recognize the risk factors for respiratory aspiration, because it contributes to malnutrition, dehydration, and respiratory infections, among other problems that worsen the patient's condition.  (20) . Another study reports that ischemic stroke were more common, though hemorrhagic events most frequently resulted in negative changes in swallowing (21) . increase the risk of a CVA (12) .
In regard to the Risk for aspiration nursing diagnosis and respiratory aspiration, this study's results are similar to those reported by another study (7) that assessed 24 patients in the acute phase of stroke. The study reports a prevalence of 58.3% for the Risk for aspiration diagnosis and 37.5% of the patients developed respiratory aspiration after 72 hours. Note that the occurrence of silent aspiration was not verified, which may have decreased the prevalence of the phenomenon in the studied population.
The incidence of respiratory aspiration among patients affected by a stroke is approximately 50% and about half of those patients experience silent aspiration (5,21) . Even though the prevalence found in this study was lower, it does not diminish the clinical relevance of this problem because there is a clear relationship between respiratory aspiration and an increased number of complications, longer hospitalizations, higher mortality rates, higher hospital costs, and more frequent use of gastrostomy feeding tubes.
Authors state that the assessment of patients with CVA to verify whether they present aspiration should be performed early, within 72 hours at most from the beginning of treatment in order to identify patients at risk and plan care to be implemented (22) . This study's participants assessed within 72 hours were less likely to develop Risk for aspiration, corroborating these findings.
In regard to the number of risk factors, we observed that the presence of one factor increased the likelihood of developing Risk for aspiration and the presence of two or more factors increased the likelihood of respiratory aspiration. Studies associating the number of risk factors with the development of these phenomena were not found; however, many studies show the relevance of these factors to the development of both Risk for aspiration (7) and respiratory aspiration (4)(5)(21)(22) .
Risk for aspiration and the presence of respiratory aspiration were assessed simultaneously and the following factors contribute to these clinical conditions: Dysphagia, Impaired or absent gag reflex, and Impaired physical mobility. In this study, these were good predictors for both phenomena.
Note that in this study we found an association between the risk factor Neurological disorders and the nursing diagnosis Risk for aspiration. This risk factor, however, behaved as a protective factor. This may have been a spurious result since the literature shows that the type and localization of CVA, as well as the existence of another neurological disease, may impact the swallowing process and lead to respiratory aspiration (4,23) .
According to conceptual analysis, these disorders are linked to the stroke severity (hemorrhagic, bilateral and/or brainstem), may or may not be associated with diseases and prior conditions such as brain injury or Alzheimer's (7,18,24) . assessment and an increase of 10 times when the exam was performed by videofluroscopy (OR 10.50) (25) .

Assessment of the relationship between dysphagia and
Risk for aspiration showed that dysphagia is accurate in determining the diagnosis (specificity at 88.8% and a positive predictive value of 90.9%) (7) . Therefore, an early assessment of this clinical indicator is essential so that nurses can detect clinical signs, or through screening results, to investigate for swallowing difficulties.
Dysphagia is very common among patients who suffered a stroke. Statistical differences concerning its prevalence depend of the diagnostic method used, time since the event occurred, and site of the lesion. This event contributes to the use of enteral feeding tubes, which increase the duration of hospitalizations (5) and interfere in the patients' independence to feed him/ herself and perform activities of daily living (15) .
Another factor that may lead patients with CVA to need enteral feeding support is a lack of gag reflex, which produces severe disruption of the reflex of the pharyngeal phase of swallowing, resulting in persistent dysphagia (3) . This situation also contributes to respiratory aspiration and aspiration pneumonia, which is evidenced by a persistent cough with sputum or by other signs such as fever, tachypnea, or focal consolidation confirmed by radiographic imaging (23) .
Impaired physical mobility was observed in 21.9% of the patients. Even though it is not listed in NANDA-I for the diagnosis under study, Impaired physical mobility was proposed in a clinical validation study and presented good accuracy (sensitivity at 80%, specificity at 77.7%, a positive predictive value of 85.7% and a negative predicative value of 70%) (7) . In this study, this risk factor doubled the likelihood of patients presenting Risk for aspiration and developing respiratory aspiration.
Even though the other risk factors observed in the population under study were not associated with the diagnosis or with the development of respiratory aspiration, much has been discussed in the literature about association with these events; thus, it is essential that nurses continuously assess these risk factors (5,7,9) .
Finally, the results presented reinforce the importance of clinically assessing these patients with a focus on swallowing, as well as a respiratory assessment to provide early identification of the factors that have been shown to be the best predictors for the phenomena, or the consequences of these phenomena, in order to favor accuracy of nurses' diagnostic process.

Conclusion
The risk factors that better predicted the phenomena under study include: Impaired or decreased gag reflex; Dysphagia; and Impaired physical mobility. Additionally, the patients with the diagnosis Risk for aspiration were at an increased risk of developing respiratory aspiration.