Change is never easy. Admitting that what we have been doing and thought was correct was actually very incorrect is not easy either. Convincing other health care workers and staff that we were wrong but here’s what we know now can be a challenge as well. But just because these things are hard, it doesn’t change the fact that we need to change our thinking and how we manage dysphagia. Below I have listed some hard truths that we all need to start implementing in our practice of dysphagia diagnosis and treatment.
1. No component or combination of components of the clinical swallow examination or bedside swallow examination have data to support their reliability and validity to diagnose dysphagia, determine whether aspiration is present or absent, or to make recommendations for diet and liquid consistencies (McCullough et al., 2005).
We need to start using instrumental assessments every time for diagnosis of pharyngeal dysphagia, to determine treatment techniques, and to recommend a diet. If you don’t, chances are you are wrong about some part. And even if you are lucky enough to guess the impairment, you have no idea what treatment or compensatory strategies will work.
2. Patients can cough in response to aspiration of thin liquids but silently aspirate thickened liquids. Miles et al., 2018 found that 20 patients who coughed in response to aspiration of 5 mL of thin fluid silently aspirated the same volume of thickened liquids.
We need to stop using presence or absence of a cough as an indicator of whether a liquid consistency is “safe” or not. If you only rely on a cough, you may be recommending thickened liquids when they actually make the swallow worse. The only way we know if someone is aspirating or not is to use instrumental evaluation. (Of course presence or absence of aspiration is not the main goal of instrumental evaluation or the CSE, however, it is important to identify).
3. Feeding tubes do not always eliminate aspiration pneumonia. In fact, rates of pneumonia have been shown to be the highest in patients with a feeding tube as compared to those with no aspiration, minor aspiration, and major aspiration (Feinberg, Knebl, &Tully, 1996).
This sheds light on the complex relationship, or lack of a relationship between prandial aspiration and pneumonia. When we only look at prandial aspiration, we neglect aspiration of gastrointestinal reflux which can cause pneumonia. We know that reflux is made worse with use of feeding tubes. The main takeaway here is that if our goal for recommending a feeding tube is to eliminate pneumonia, data show that we might be doing the opposite.
4. Thickened liquids are not harmless and should not be recommended without instrumental assessment and consideration for the whole picture.
Thickened liquids are usually prescribed to reduce or eliminate aspiration. Many times I hear things like, “Oh we just put him/her on thickened liquids for now because it is probably safer.” In truth, thickened liquids come with more negatives than positives:
- Thickened liquids have been associated with higher levels of dehydration (Cichero, 2013). Dehydration can lead to kidney failure, constipation, UTI, confusion or impaired mental status, hypotension, and poor recovery from other illness.
- Thickened liquids slow digestion (Cichero, 2013). Think slower gastric emptying means more risk for reflux. Aspiration of gastrointestinal reflux can lead to pneumonia.
- Thickened liquids can change the way medications are absorbed and dissolved (Cichero, 2013). Medications can be vital to the health of our patients. Medications are used to prevent and/or treat stroke, heart conditions, pain, infections, and neurological conditions among others.
- Thickened liquids decrease feeling of satiety (Cichero, 2013). When people consume thickened liquids they report reduced feeling that their thirst is quenched. Their mouths feel sticky instead of wet. Pair this with the slowed gastric emptying and now we are making people feel thirsty and full all at the same time. No wonder people report reduced quality of life.
- Thickened liquids are expensive (O’Keefe, 2018).
- More reasons than can be covered here. I think I will write a separate post about this.
So what do we need to do?
- Use instrumental assessment every time that pharyngeal dysphagia is suspected or the patient has risk factors for dysphagia.
- Stop relying on a cough to determine if aspiration is present or absent unless the cough response is confirmed on instrumental assessment.
- Remember that feeding tubes and thickened liquids are not without negative consequences and should not be recommended EVER without instrumental assessment.
I’d love to hear how people are changing the minds of nurses, doctors, CNA’s, administrators, and more about these facts. Let me know what you have done that worked or didn’t work in the comments. And as always..
Cichero J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition journal, 12, 54. https://doi.org/10.1186/1475-2891-12-54
Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104–109. https://doi.org/10.1007/BF00417899
Lippert, W. C., Chadha, R., & Sweigart, J. R. (2019). Things We Do for No Reason: The Use of Thickened Liquids in Treating Hospitalized Adult Patients with Dysphagia. Journal of hospital medicine, 14(5), 315–317. https://doi.org/10.12788/jhm.3141
McCullough, G. H., Rosenbek, J. C., Wertz, R. T., McCoy, S., Mann, G., & McCullough, K. (2005). Utility of clinical swallowing examination measures for detecting aspiration post-stroke. Journal of speech, language, and hearing research : JSLHR, 48(6), 1280–1293. https://doi.org/10.1044/1092-4388(2005/089)
Miles, A., McFarlane, M., Scott, S., & Hunting, A. (2018). Cough response to aspiration in thin and thick fluids during FEES in hospitalized inpatients. International journal of language & communication disorders, 53(5), 909–918. https://doi.org/10.1111/1460-6984.12401
O’Keeffe S. T. (2018). Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?. BMC geriatrics, 18(1), 167. https://doi.org/10.1186/s12877-018-0839-7