I’ve had the privilege of getting to know the wonderful Ed Bice over the last year, and his comments are always just so objective and research based. Some people get offended because they think he is abrasive, but if you know him personally he is one of the kindest hearts on this earth, and he is basically a walking encyclopedia… of dysphagia research. He gets emotional when he’s sees other SLPs with a blatant disregard for the research, and “doing what they’ve always done.” However, he said something on one of my recent podcasts about how we need to take emotion out of the equation and begin treating dysphagia as a science, which I couldn’t agree with more. And while I thoroughly enjoy do writing these blog posts, and they’ve become rather cathartic for me, I do spend a whole crap ton of time mulling them over to make sure my research is completely on point or my inner New York girl doesn’t come out too abruptly. And then there’s Ed, who just decided on a random Sunday morning to vomit out a bunch of research on aspiration and slap it on a post and call it a day. So since I thought it was waaaaay too good to get lost in cyber space, and quite frankly my head is spinning from churning out podcasts at warp speed, I let Ed take the wheel here, and school us on the devil we know.. or maybe actually don’t know… aspiration!
Take it away Ed:
Sometimes, as I read posts on the SLP forums on Facebook, I get the impression that we envision ourselves as some sort of superhero fighting an evil enemy. Perhaps we think we are the mighty “Super Swallower” fighting to save the world from evil “Dr. Aspiration.” The issue with this type of thinking is we are trying to get a broad picture while viewing through a microscope. So, today, while the house is quiet and I have a few minutes to myself I thought I would share a few thoughts on this matter. I am not blogger. I have no desire to be one. If I have time I would rather be playing with my dogs or digging in my garden than sitting at a computer. Be aware that I am not witty like Theresa Richard and I do not have the power of analogies that is congruent with the thoughts of Dr. Ianessa Humbert. Consequently, the entertainment value of my writing is minimal. (Editor’s note: Theresa Richard begs to differ!)
First I want to say, the more I learn about swallowing and dysphagia, the more I doubt myself. Today I am on call. Literally, the first thing I thought when I woke up was, “Why do I do this? I have no idea how to help these people.” I guess I am saying, knowledge is required, confidence is optional.
At the risk of being stoned by my colleagues who understand the history of swallowing therapy, I am going to start off with a quote by a well known critic:
The most common misperception about swallowing treatment is that the primary purpose of intervention is to identify aspiration and that aspiration can and must be prevented. The overwhelming emphasis on the supposed negative effects of aspiration seems to have developed from the early literature on swallowing disorders in which it was repeatedly stated that all aspiration was probably lethal. These early publications relied on the seminal work of Bartlett, Cameron, and others who were writing of the hazards of aspiration of stomach contents including vomitus… (Campbell Taylor, 2008)
Although Campbell-Taylor often overstates her case, sometimes we need to allow her words to marinate in our minds. How are we going to identify and prevent ALL aspiration?
The answer is, we won’t and we can’t.
But the good news is: it isn’t necessary.
So, take off your superhero costume and save it for Halloween. The reality is that we have all experienced aspiration at some time and that 45% of healthy normal adults experience it during sleep (Ozcan 2003). Let me say it again, 45% of us reading this blog experienced aspiration last night. That did not merit a speech consult or require any change in our diet. We will go on with our daily activities unaware of the meanness lurking in our lungs.
Now Sherman, let’s take a trip in the “Wayback Machine.”
In 1996, Fienberg published Prandial aspiration and pneumonia in an elderly population followed over 3 years. What were the take aways?
- The study group consisted of 152 nursing home residents undergoing fluoroscopic swallowing examinations with an average age of 86.
- 100 of these patients were referred because of suspected dysphagia.
- 52 were referred as part of an upper gastrointestinal series. None of the 52 had a history of swallowing problems.
- The examinations revealed 50 non aspirators, 51 minor aspirators (aspirated occasionally or small amounts on some liquids/foods) and 51 major aspirators (aspirated consistently or large amounts). Some of the patients were subsequently given alternate means of nutrition.
- The 152 patients were followed for a total of 4,280 months.
- What happened to these patients?
|Feeding Status||Months||Developed PNA||Frequency||Statistically Significant|
|Major aspiration/ Oral feeding||
|Major aspiration/ Artificial feeding||
This is interesting. There was no statistical significance in the development of pneumonia until the feeding tube group! (Note that the minor aspirators were followed for many more months than the non-aspirators and only had pneumonia rate 0.3% higher than the non-aspirators. Also note that the feeding tube group was followed almost 2/3 fewer months but has a 3.8% higher occurrence of pneumonia.)
Now for some more interesting findings:
|Feeding Status||Deaths||PNA present||PNA considered cause of death||Statistically Significant|
|5 (71%)||3 (43%)||
|7 (78%)||3 (33%)||
|Major aspiration/ Oral feeding||
|10 (48%)||7 (33%)||
|Major aspiration/ Artificial feeding||
|15 (58%)||14 (54%)||
Spend a few minutes mulling over this chart. Note that that rate of pneumonia present at death in the non-aspiration group was 71% and that it was considered the cause of death more often than those who aspirated!
The conclusion of the study was “Theoretically, these patients (those who aspirate) should have been at particularly high risk for pulmonary infection by virtue of their advanced age and dependency requirements. We found that the frequency of pneumonia during months of major prandial aspiration, minor prandial, and no aspiration was not significantly different.”
Another conclusion: “Compared with the other three groups, pneumonia frequency was significantly higher during months of artificial feeding.” It is time to drop the notion that feeding tubes are a “safe” alternative for those with dysphagia.
A few years later Susan Langmore (1998) publish a seminal work concerning aspiration and the development of pneumonia. Let’s take a look at some of her publication:
- 189 subjects were followed for up to four years
- All of the subjects had:
- CSE (repeated annually)
- 3 scintigraphy examinations to assess esophageal clearance, GERD, and pulmonary aspiration of gastric material
- A thorough dental exam
- Throat cultures (repeated annually)
- In-depth interview covering medical and dental conditions (repeated annually)
- Half of the subjects also had a FEES
There are many important findings of this study. I am only going to report the ones that are germane to my blog.
- Of the 189 subjects followed to outcome, 41 developed aspiration pneumonia for an incidence rate of 21.7%
- Average age of the subjects who developed aspiration pneumonia was 71 years compared with 69.5 years for those who did not develop pneumonia
- The highest incidence aspiration pneumonia occurred in nursing home patients (44%).
- 19% of inpatients developed pneumonia
- 9% of outpatients developed pneumonia
- 32% of the subjects who developed pneumonia smoked and averaged 10 medications compared to 7.6 in subjects without pneumonia
- Of the subjects with aspiration pneumonia
- 81% had dysphagia (that means 19% did not)
- 58% aspirated liquid
- 27% aspirated food
- 27% were tube fed
The conclusion of the study: “…dysphagia and aspiration are necessary but not sufficient conditions for develop of pneumonia.”
What were the predictors of aspiration pneumonia?
- Dependent for oral care (Listen to Dr. Ashford’s podcast on the importance of oral care)
- Dependent for feeding
- Number of medications
- Multiple medical diagnoses
- Number of decayed teeth
The question is: Are these the issues that are being considered during a CSE before a diet change is recommended or is it simply a cough, throat clear, or some other extraneous measure?
I want to say, what I have written is a simplification of this study. Nothing that I have written is misleading, nor does it misrepresent the truth. I recommend you read the study in its entirety to realize all the implications.
In 2002, Langmore conducted a retrospective study with only nursing home patients. She reviewed 102,842 MDS evaluations. She found the following to be predictors of aspiration pneumonia (in order of correlation):
- Feeding tube
- Case mix index (meaning highly complex patient)
- Indicators of delirium
- Weight loss
- Swallowing problems
Note that there are 7 items more predictive of the development of aspiration than dysphagia. Are these items ones that are considered when conducting a CSE?
I am NOT trying to minimize aspiration pneumonia. The point is, aspiration is a multifactorial process that requires more than aspiration to occur. We MUST consider the whole person.
I (Theresa) am going to cut this post off here. My brain is mush. Ed presented us with quite a bit of research to mull over before we start recommending a PEG for anyone that presents with aspiration. We’ve got to start using that pink, mushy thing between our ears, and realize that there are so many moving parts when treating patients with dysphagia. We have an extremely powerful profession, and we owe it to our patients to pay homage to the research, arrange for instrumental assessments, and therapize the swallow, not just slap a band-aid on it and get home in time for the Real Housewives.
I know, I know, now you’re all like, “OMG Theresa I know exactly what NOT to do with my patients, but what the heck DO I do?!?” Believe me, I LOVE giving out cheese to go with your w(h)ine, but pump the breaks. This is a nice segway in to the next series which will be all about evidence based treatment strategies. So enter your email in the green box below if you want to know when I get around to diving in to all of that.
In Part 2 of this post, we’ll discuss more of the ramifications of diet modifications and thickened liquids, and learn why, just why, aspiration is the devil we should know.
P.S. If this stuff is all brand new to you, and you have so many dysphagia questions you’re head is about to pop off but you’re way to embarrassed to ask on a public forum, please join our Facebook group “MedSLP Newbies.” It’s a completely safe ‘no bullies allowed’ zone where you can openly ask any questions, and we will guide you in the right direction so that you can use best practice with your patients.
P.P.S. Shameless self promotion 101: My new podcast “Swallow Your Pride” dropped Sept. 1st on iTunes, Stitcher, Google Play, Android, and at www.swallowyourpridepodcast.com! Be sure to SUBSCRIBE now, or sign up here to get the latest podcasts sent to your inbox.
Campbell-Taylor, I. (2008). Oropharyngeal dysphagia in long-term care: misperceptions of treatment efficacy. Journal of the American Medical Directors Association, 9(7), 523-531.
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.
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307.
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: how important is dysphagia?. Dysphagia, 13(2), 69-81.
Ozcan M, Ortapamuk H, Naldoken S, Olcay I, Ozcan KM, Tuncel U. Pulmonary Aspiration of Nasal Secretions in Patients With Chronic Sinusitis and Asthma. Arch Otolaryngol Head Neck Surg. 2003;129(9):1006–1009. doi:10.1001/archotol.129.9.1006
Vivanti AP, Campbell KL, Suter MS, Hannan-Jones MT, Hulcombe JA. Contribution of thickened drinks, food and enteral and parenteral fluids to fluid intake in hospitalised patients with dysphagia. J Hum Nutr Diet. 2009;22:148–55.