Are you thirsty?Thick vs Thin Liquids

Carrie Pascale, MS CCC-SLP TSSLDSt. Charles Hospital

Disclosures

• Relevant Financial: I am employed by St. Charles Hospital and am receiving my salary for today’s talk.

• Relevant Non-Financial: I am a member of the American Speech-Language Hearing Association (ASHA)

What you will learn

• Understand the implications of dysphagia for the stroke population• Name 2 benefits and limitations of thickened liquids • Name 2 benefits and limitations of the Free Water Protocol• Identify 3 inclusion/exclusion criteria for the Free Water Protocol

Current Hot Topic

• For patients with pharyngeal phase dysphagia, there is often a decision that needs to be made by an SLP and the interdisciplinary team: their diet consistency and namely, the thickness of their liquids

• The debate over whether or not thick liquids are doing more harm than good and whether or not thin liquids, when provided to a patient with a known dysphagia, is beneficial

Start with the basics:What is dysphagia?

• Dysphagia is defined as a disorder or impairment in any phase of the swallow process

• Can occur in any or all of the 4 phases of the swallow:• oral preparatory phase• oral phase• pharyngeal phase (what we most often think of when we think of

“dysphagia”)• esophageal phase of the swallow

Stroke and Dysphagia

• Prevalence of dysphagia in stroke patients is highly variable• Numbers range from 20-80% across studies (Arnold et al, 2016)

• This large range is based on different studies having differing qualifying criteria for “dysphagia” as well as it being identified via subjective or objective assessments

• Studies that use objective assessments showed a higher incidence of some level of dysphagia in stroke patients

• It is widely discussed that the average prevalence for patients who have had a stroke and experience dysphagia = 50%

Location of Stroke Impact on Dysphagia

• It is known that strokes occurring in the cerebral cortex, cerebellum and the brain stem can all impair swallow physiology

• Cerebral lesions affect cognition which in turn impacts the voluntary mastication and oral phase anterior-posterior transit of bolus

• Cortical lesions may interrupt contralateral oral function (lip, tongue, buccal muscle control) as well as overall pharyngeal function (which may also be contralateral)

• Cerebellar lesions and brain stem infarcts, though less common, have the highest frequency of patients with dysphagia affecting lingual sensation, overall pharyngeal timing and constriction as well as airway protection

(Martino et al, 2005)

How is dysphagia diagnosed?

• A Speech-Language Pathologist (SLP) completes one, or more, of the following assessments:

• Clinical Swallow Assessment• Flexible Fiberoptic Endoscopic Evaluation of Swallowing and Sensory Testing

(FEESST)• Modified Barium Swallow Study (MBSS)

Objective Swallow Assessment: FEESST

• A flexible laryngoscope is passed through the nasopharynx during the swallow

• Allows for the assessment of the pharyngeal phase of the swallow• After the swallow is elicited, the scope is moved lower toward the

laryngeal vestibule so the vocal folds can be visualized in order to determine if any material has been aspirated

Objective Swallow Assessment: MBSS

• Most frequently utilized objective procedure to assess the oral, pharyngeal, and upper esophageal phases of swallow function: considered the Gold Standard

• Allows for both lateral and anterior-posterior view of the swallow; from oral prep all the way through the upper esophageal segment

• Assesses for abnormalities in the anatomy/physiology of the swallow

This is what a normal swallow should look like:

https://www.youtube.com/watch?v=6DdwhoWiPzE

This is what gross aspiration looks like:

https://www.google.com/url?url=https://www.youtube.com/watch%3Fv%3D1sFNMk87558&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwiov8_E6PXNAhUDph4KHcHJDkcQtwIIIDAA&sig2=qpBaA0oisDmFtWIKYkOh8A&usg=AFQjCNF4X49nf6O2ccaUh_SeBakrND-DnA

What is aspiration?

• Aspiration is defined as abnormal entry of fluid or particulate matter into the lower airway, below the level of the vocal fold

(Bartlett, 2012)

• Aspiration can be present either with or without a sensory response

• Aspiration without a sensory response is referred to as “silent aspiration”

Aspiration Pneumonia

• Just because a person aspirates, does not mean that it will result in a pneumonia!

• Aspiration pneumonia generally refers to the pulmonary sequelae that occur in association with large volume aspiration (Bartlett, 2012)

Aspiration Pneumonia

• Risk factors associated with increased incidence of developing aspiration pneumonia

• Reduced consciousness• Decreased cough reflex• Dysphagia as a result of a neurologic deficit• Mechanical disruption of the integrity of the upper airways (i.e. tracheostomy, intubation,

NG tube feeding, protracted vomiting, & drowning) • Mobility• General health• Pulmonary health/toilet• Cognitive status• Oral hygiene

(Bartlett, 2012)(Ortega, 2014)

3 Pillars to Developing Aspiration Pneumonia

Impaired Health Status Presence of Dysphagia Poor Oral Hygiene

(Ortega, 2014)

Current Practice to Decrease Risk of Aspiration Pneumonia

• In terms of dysphagia, the most widely and currently used practice is diet modification

(Karagiannis, 2011)

• National Dysphagia Diets (NDD): current model of standardization of diets across facilities to ensure carryover of proper diet consistency between facilities

• Liquid consistencies as per the NDD• Thin• Nectar• Honey

Thick Liquid Overview

• Nectar and honey thick liquids are the current terms used as part of the NDD (though, there is a current shift for facilities to move toward the IDDSI- but that’s not part of today’s talk )

• Today we are going to talk about liquids in terms of THIN vs. THICK(to include both nectar and honey thick liquids)

Presenter

Presentation Notes

These are commonly available brands/products available to the general public. Both pre-thickened and powdered thickeners and gels

Benefit of Thickened Liquids

• Easy to make a diet recommendation/modification based on the results of the MBSS or FEESST to a consistency that the patient is NOT aspirating

• Readily available• Powder/gel can be mixed with nearly all thin liquid consistencies to

reach the desired thickness• Pre-thickened liquids come in a variety of flavors

Limitations of Thickened Liquids

• Not as desirable (don’t “quench” your thirst)• May result in overall decreased fluid intake which could result in:

• Dehydration/malnutrition• Slower rate of wound healing• Lower satisfaction scores

• Starch and/or sugar based which is often problematic for patients with diabetes • Are expensive: both for healthcare facilities, and those that are private paying

(O’Keeffee, 2018)

• Using powder thickener increases the chances of non-standardization across the board for liquid thickness

(Garcia et al, 2010)

• Shifting gears now to the other side of the aisle- if we don’t thicken the liquids, let the patients have thin liquids. But for purposes of today’s discussion, thin liquids refer to tap water only

Free Water Protocol

• Developed out of the Frazier Rehab Institute (Louisville, KY) in 1984 in response to patients who were non-compliant with thickened liquid recommendations

• However, these patients were not developing aspiration pneumonia despite evidence of aspiration on videoflouroscopy (MBSS)…but why???

Researching the Free Water Protocol

• “Dysphagia and aspiration are necessary, but not sufficient conditions for development of pneumonia.” (Langmore et al, 1986)

• Aspiration will result in pneumonia only if the aspirated material is pathogenic to the lungs and the host resistance to the aspirated material is compromised (Panther, 2012)

More support for the Free Water Protocol

• Aspiration of differing materials may not present an equal risk for the development of aspiration pneumonia

• What does this mean???• They found that water is “better” than aspirating any other thin liquid (i.e.

coffee, tea, soda, etc.) or even thickened liquids

• Schmidt (1994) reported aspiration of thicker fluids and semi-solids was predictive of aspiration pneumonia and death

(Panther, 2012)

But we know aspirating anything is bad! (or at least that’s what we’ve been taught)

• However, aspiration will only result in a pneumonia if the aspirated material is pathogenic to the lungs (Robbins et al, 2008)

• Aspiration of oro-pharyngeal pathogens is the dominant cause of hospital and nursing home acquired PNA (Rabbany et al, 2005)

• Poor oral health strongly correlates with an increased risk of developing PNA (O’Keeffe, 2018)

So why is not called the Free Soda Protocol?

WATER:• The body is approximately 60% water• Tap water is a near neutral pH and is compatible with other bodily

fluids• Water does not obstruct the airway• Lung mucosa can absorb small amounts of aspirated water without

harm

Which is why Oral Care is so important!

Oral Care…

• This is really the crux of being able to provide any known aspirator with water

• Think about this: if we know the patient is aspirating, why would we allow them to aspirate all of their oral/pharyngeal bacteria when we know that that’s what is most likely causing a pneumonia

• If the mouth is free of bacteria, then when the water is aspirated, it can easily be re-absorbed without incident. (O’Keeffe, 2018)

The Idea Behind Providing Free Water is to:

• Increase compliance with modified diets• Increase overall quality of life/patient satisfaction (Langmore, 2011)

• Decrease length of stay• Decrease risk of dehydration

So how does it work?

• Patients who are on modified diet, or who are NPO, are allowed unrestricted water throughout the day, with the exception of during meals, during med passes, and 30 minutes after meals

• So if nectar thick liquids were recommended, they only have to drink that at mealtimes and then they can have water throughout the rest of the day.

• The patient is not allowed water with meds/meals for the same reason as to why oral care is so important: If the patient is aspirating water, we don’t want them to aspirate food particles as well during their meals

Inclusion/Exclusion Criteria (at St. Charles Hospital)

• Cognitive status• Be able to participate in a strict oral hygiene program• Must not be bed-bound• Not have an active pneumonia• Not be an excessive cougher after known aspiration (too much strain

on the body)• No oral/dental pathogens (namely = thrush)

More Support for a Free Water Protocol

• Additionally, there is a school of thought that essentially looks at the principle of specificity: that the best exercise for swallowing is swallowing

• If the ultimate “end goal” is for our patients to be able to tolerate thin liquids, then they should be practicing how to swallow thin liquids (Crary, 2014)

Limitations of Free Water

• The idea behind Free Water is essentially a theoretical hypothesis that water is, in essence, inert when absorbed in small amounts into the lungs (Wagner, 2005)

• There is lack of strong evidence to support the Free Water Protocol (Langmore, 2011)

• Why a patient does not develop pneumonia when provided Free Water is multi-factorial, and there are many variables that could alter the outcomes as to how well a patient tolerates the protocol (McGrail, 2016)

Is thicker/thinner really better?

Thickened Liquids• Limited evidence to support

whether or not thickened liquids decreases the risk of developing aspiration pneumonia in patients with a known dysphagia (specifically aspiration) (O’Keeffe, 2018)

Thin Liquids• Limited evidence to support that

it is completely safe to provide thin liquids to patients who are known aspirators (Coyle, 2011)

What do we actually know?

Thickened Liquids• Readily available (either pre-

thickened or powder/gel based)• Patient is not aspirating this

consistency• Decreased fluid intake may lead to

increased risk for dehydration• Decreased compliance

w/recommendations• Limited evidence to support a

decreased risk of developing aspiration pneumonia

Thin Liquids• Readily available• Water, when clean and in small

amounts, can be easily re-absorbed by the lungs

• Not all patients are candidates for free water protocols

• Increased compliance with other diet modifications

• Limited evidence to support the safety of a free water protocol

St. Charles Hospital Data

• We, at St. Charles, have been collecting data on our patients since the implementation of our free water protocol’s inception in 2013

• When the numbers are pulled for just stroke patients who were put on the free water protocol, there were no new diagnosis of pneumonia during the course of their rehabilitation

So how do we decide?

1. Complete an objective assessment2. Look at the whole patient, not just the dysphagia alone

• And consider your recommendations in terms of the whole patient

3. Determine short and/or long term recommendations to best meet the needs of the patient and to put them at the lowest risk for developing a pneumonia

Case Study- Patient Comparison:Patient A• 75 year old male• Chief complaint: coughing when

drinking• Clinical swallow eval: outward s/s

aspiration w/cough ~50% of the time w/thin liquids

• Recommend: MBSS• MBSS: aspiration w/thin liquids

~75% of the time w/intermittent sensory response. No aspiration w/nectar thick liquids and no other noteworthy findings

Patient B• 75 year old male• Chief complaint: coughing when

drinking• Clinical swallow eval: outward s/s

aspiration w/cough ~50% of the time w/thin liquids

• Recommend: MBSS• MBSS: aspiration w/thin liquids

~75% of the time w/intermittent sensory response. No aspiration w/nectar thick liquids and no other noteworthy findings

Patient A• Recommendations??

• Other PMH and pertinent info:• Dementia• Bed-bound• Rotten/decaying teeth• Admitted for Right Lower Lobe

pneumonia

Patient B• Recommendations??

• Other PMH and pertinent info:• Outpatient/ambulatory• History of TIA’s with recent CVA ~6

months ago• Back to work• Otherwise “healthy”

Now what?

References• Arnold M, Liesirova K, Broeg-Morvay A, et al. Dysphagia in acute stroke: incidence,

burden and impact on clinical outcome. Public Library of Science. 2016: 11 (2): e0148424.

• Bartlett J. Aspiration pneumonia. Netter’s Infectious Diseases. 2012; 29: 153-156.• Coyle J. Water, water everywhere, but why? Argument against free water protocols.

Perspectives on swallowing and swallowing disorders (dysphagia). Dec 2011.• Crary M, Carnaby G. Adoption into clinical practice of two therapies to manage

swallowing disorders: exercise based swallowing rehabilitation and electrical stimulation. Current Opinion in Otolaryngology & Head and Neck Surgery. 2014, Jun: 22 (3): 172-180.

• El-Rabbany M, Zaghlol N, Bhandari M, Azarpazhoch A. Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: a systematic review. International Journal of Nursing Studies. 2015; Jan: 52 (1): 452-464.

• Frey K, Ramsberger G. Comparison of outcomes before and after implementation of a water protocol for patients with cerebrovascular accident and dysphagia. Journal of Neuroscience Nursing. Jun 2011; 43 (3): 165-171.

• Garcia J, Chambers IV E, Clark M, et al. Quality of care issues for dysphagia: modifications involving oral fluids. Journal of Clinical Nursing. 2010; 19: 11-12.

• Gillman A, Winkler R, Taylor NF. Implementing the free water protocol does not result in aspiration pneumonia in carefully selected patients with dysphagia: a systematic review. Dysphagia. 2017: Jun: 32 (3) 345-361.

• Karagiannis MJ, Chivers L, Karagiannis TC. Effects of oral intake of water in patients with oropharyngeal dysphagia. BMC Geriatrics. 2011.

• Langmore S. Why I like the free water protocol. Perspectives on swallowing and swallowing disorders (dysphagia). 2011.

• Martino R, Foley N, Bhogal S, et al. Dysphagia after stroke: incidence, diagnosis and pulmonary complications. Stroke. 2005; 36: 2756-2763.

• McGrail A. Thickened liquids= substandard oral fluid intake= dehydration: is it really that simple? Perspectives of the ASHA Special Interest Groups. Mar 2016.

• O’Keeffe S. Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified? BMC Geriatrics. 2018; 18:167.

• Ortega O, Parra C, Zarcero S, et al. Oral health in older patients with oropharyngeal dysphagia. Age and Ageing. 2014; 43: 1: 132-137.

• Panther, K. Free water protocols. 2012. Power Point slides from lecture.• Robbins J, Gensler G, Hind J, Logeman J, et al. Comparison of 2 interventions for liquid

aspiration on pneumonia incidence: a randomized trial. Annals of Internal Medicine. 2008; 148 (7): 509-518.

• Tablan O, Anderson L, Besser R. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the healthcare infection control practices advisory committee.

• Wagner L. Ethical and legal implications of the Frazier free water protocol. Perspectives on swallowing and swallowing disorders (dysphagia). Mar 2005.

Thank you!