I realize I’ve got this aspiration thing all wrong, please send me the PDF handout so that I can get my mind right, and improve the quality of life of my patients!
So welcome back to Part 2 of “Aspirations” (that just sounds so dreamy and whimsical) with our most favorite guest blogger (and well only so far) Mr. Ed Bice. Hopefully Ed was able to grind in to your little brain how significant or dare I say: insignificant aspiration can be when looking at the ENTIRE picture (aka a person.) Here’s a link to Part 1 if you missed it.
Now in this second part, we are going to discuss why just simply knowing that a patient aspirates is not helpful. We *MUST* know the “why”, and we *MUST* answer that gigantic question before even dreaming up a treatment plan. This means exactly what you think it means, and also what so many of you are so resistant to: Imaging!
Imaging is REQUIRED, and not just any imaging, VFSS and FEES are both the gold standard in dysphagia diagnostics. (Cervical auscultation is NOT imaging no matter which way you turn the stethoscope, or how many clings, clangs, or clunks you think you heard.) The report *MUST* include information concerning the characteristics of the dysfunction. Otherwise, we do not know what needs to be treated, and as dreamy and whimsical as the title of this post may be, we are not just going to dream up a treatment plan and compensatory strategies, click our heels together, wave our magic wand, and tell our DOR that poof the aspiration is gone. That’s not how this works. That’s not how ANY of this works.
Now Dr. Peabody and Sherman set the time machine forward several years.
Suppose imaging has been completed and the patient aspirates. They come from the study with a report. Inevitably, the report will indicate that the patient has decreased hyo-laryngeal elevation, it appears that 100% of patients who have had an MBSS do (that is a whole different Oprah episode). In addition, the patient aspirates and pureed diet with nectar thick liquids has been recommended. What do we know about these decisions? This has been the subject of a great deal of research. I am only going to mention a few papers here.
To lay the foundation for the development of the International Dysphagia Diet, Dr. Catriona Steele et. al. (2015) performed a systematic literature review to determine what we know about modifying food and liquid. The team found 10,147 articles on this subject (So, it has been reviewed a few times.). A full text review was conducted on 488 articles (I would venture to say that is more than any of us have read on this subject.) Only 36 articles were found to contain specific information comparing oral processing or swallowing behaviors for at least two liquids consistencies or food textures.
After all that work, here is what we know:
- Thicker liquids reduce the risk of penetration-aspiration.
- Thicker liquids increase the risk of post-swallow residue in the pharynx.
- “We found very little evidence to guide practice with respect to different degrees of modifying solid foods for patients with dysphagia.”
There you have it. Now you know, “the rest of the story.” In a world where diet alternation seems to be a “go to” resolution, there is not much to know. What we do know is not extremely encouraging. Aspirate now or aspirate later. Perhaps before your hair catches on fire because someone gave a patient something “not on their diet,” consider what our field ACTUALLY knows about this subject.
So, undaunted, we move ahead with decreasing penetration/aspiration (a.k.a. “making our patient safe”) and increasing pharyngeal residue. What happens to our patient?
Vivanti (2009) monitored the daily fluid intake of 25 patients on thickened liquid for a mean of 10 days. Their conclusion:
“…findings demonstrate that individuals with dysphagia requiring thickened fluids, are unlikely to meet any published estimated minimum fluid requirements. Poor total daily oral fluid intake was apparent across all categories regardless of age group, diagnosis, fluid thickness and whether assistance was required.”
Further, Crary et al. published “Clinical Variables Associated with Hydration Status in Acute Ischemic Stroke Patients with Dysphagia” in 2016. This retrospective study reviewed lab values of 67 ischemic stroke patients during their acute stay. They found:
- Patients on modified solid diets had significantly higher mean BUN/Cr values at discharge (27.12 vs. 17.23) as did tube fed patients (28.94 vs. 18.66)
- No difference was noted between these subgroups at baseline.
- Any modification of solid diets (31.11 vs. 17.23) or thickened liquids (28.50 vs. 17.81) resulted in significantly elevated BUN/Cr values at discharge.
Conclusion “Liquid or diet modifications prescribed for acute stroke patients with dysphagia may impair hydration status in these patients”
(Editor’s note: Because I (Theresa) am anticipating what my inbox will look like for the next month, and unfortunately not many of us had a class in grad school on lab values, but fortunately we all have access to Google, so here’s a live demonstration, watch with me: Go to google.com, type in: “What are BUN/Cr lab values?” Good job! Google tells us that it means “Blood Urea Nitrogen/ Creatinine Ratio which is useful in the differential diagnosis of acute or chronic renal disease. Reduced renal perfusion, e.g., congestive heart failure, or recent onset of urinary tract obstruction will result in an increase in BUN/Creatinine ratio. A BUN test can reveal whether your urea nitrogen levels are higher than normal, suggesting that your kidneys or liver may not be working properly.”)
And here’s further clarification since I expect a flurry of emails from that response also: No, Google is not the best place to be seeking professional advice and medical answers for our patients, however it gives us a good place to start, and now we actually understand that there are dangers involved when we just willy nilly modify our patient’s diet without ANY medical reasoning or imaging to prove that it is in fact necessary, and that the benefits may not outweigh the risks of other potential medical complications.) End Editor’s Note.
There are many other studies related to thickened liquids and dehydration. In addition, see Theresa Richard’s other blog on this topic.
If you have hung with me this long, keep reading, we’re almost there, I promise.
One more question: What about changing diet texture? The results of two studies give us some insight (Wright 2015 and Vigano 2011):
- The Wright study evaluated dietary intake of hospitalized patients older than 60 years comparing intake in patients consuming a regular diet to those consuming a texture modified diet:
- Patients on the modified diet had a significantly lower nutritional intake in terms of energy and protein.
- 54% of patients on a texture modified diet were recommended a nutritional supplement, compared with 24% of patients on a regular diet.
- The Vigano study found that compared with the normal diet the puréed diets provided reduced nutritional benefit:
- “Energy” value was reduced by 31.4%
- Available protein was reduced by 45.4%
- Available lipids content was reduced by 41.0%
With just this thimble full of information, I would consider changing diets to have an overall negative outcome. Malnutrition and dehydration lead to poor recovery from all illnesses. Changing diets is not a decision without consequences.
So, in actuality, the devil is in the details, not the obvious. Aspiration is a problem but it is not THE PROBLEM. It is not equivalent to King Kong holding Faye Ray hostage atop the Empire State Building. There is no need to call in the military. Perhaps we need to pay more thought and attention to the devil we don’t know (malnutrition, dehydration, residue, pneumonia, etc.) than the devil we do know (aspiration).
“So Theresa and Ed, you gave us all of this information, but what do I do when my DOR tells me I have to put my patient who is “aspirating” on an altered diet?”
Good question, Sally. This is all part of the puzzle. Now you have all of this ammo to go back to Debbie DOR or Davey DOR, and tell her or him, that since Gertrude does have a diagnosis of chronic kidney disease, that you don’t feel comfortable altering her diet, when in fact, it may make her condition worse. You have no problem scheduling a VFSS or FEES to determine if in fact Gertrude is aspirating, or if she just likes to clear her throat, but you should speak with the family and the physician to lay out all of the possibilities. Sometimes, it is the lesser of 2 evils that we have to choose from, but the patient and their family deserve to make that call after being educating by you and being made aware of the risks of every scenario. Additionally, if your facility insists that you should just have the patient “sign a waiver if they don’t want to comply,” please listen to Episode 004 of the Swallow Your Pride podcast with Nannette Crawford regarding waivers, patient’s rights, and informed consent.
And if you do still have further questions, please feel free to reach out (after you google it of course 😉
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.