Extravaganza 2008Extravaganza 2008

Adult Swallowing EBP Group

Who are we?Who are we?

The Adult Swallowing EBP Group comprises both

metropolitan and rural members.

Formed in March 2007, following the division ofAdult Swallowing and Communication group

into 3separate groups (Adult swallowing, speech andlanguage).

We are all practicing Speech Pathologists with a

particular interest in the management of adultswallowing impairments.

We currently have 34 active members.

Inspiration for our clinical Inspiration for our clinical questionquestion

Most practicing speech pathologists have anecdotal

evidence that thickened fluids can reduce theincidence of aspiration. This is frequentlydemonstrated on objective assessment (eg.

MBSand FEES).

What we wanted to know was....Do thickened fluids

reduce the incidence of aspiration pneumonia?

Clinical QuestionClinical Question

In adults with dysphagia, do thickened fluids reduce the

incidence of aspiration pneumonia?

What is aspiration pneumonia?What is aspiration pneumonia?

Langmore et al 1998 defines aspiration pneumonia as:

elevated white blood cell count (12000 or above),fever, and new infiltrate on the chest radiograph.

Aspiration pneumonia is bronchopneumonia (infection of the bronchus/lung) thatdevelops due to the entrance of foreign materials that enter the bronchial tree, usually oral or gastric contents (including food, saliva, or nasal secretions).

Aspiration pneumonia can account for 13% -

48% of all infections in nursing home residents – Zimmer, 1986 & Crossley, 1989.

20%-50% mortality rate (as high as 80% in some studies) cited in Langmore et al 1998

Flow chart of pneumonia Flow chart of pneumonia developmentdevelopment

Dysphagia & pneumonia: a complex relationship

(Langmore 1998)

Colonisation (altered oropharyngeal flora):

Aspiration into lungs

Host resistance

Pneumonia

Predictors of aspiration pneumonia – how important is

dysphagia? (Langmore et al 1998)

Dysphagia (MBS,FEES) Dental/oral health Medical History Functional status Contraction of aspiration pneumonia or

death

Langmore et al (1998):

‘dysphagia and aspiration may not be critical risk factors in a person who is medically stable, has a clean, healthy mouth and/or is independent for daily activities, especially feeding. If a combination of these positive conditions are not met, pneumonia may develop.’

Depending on the acidity of the aspirate, a chemical pneumonitis can develop, and bacterial pathogens (particularly anaerobic bacteria) may add to the inflammation.

Aspiration pneumonia=infection of the lung.Aspiration of 'chunks' (e.g. food)=lobe or lung

collapseMaterial from decaying teeth = lung abscessesPneumonitis is…A sterile lung abscess and lung inflammation (a

'burn' of the lung), which is usually caused by aspiration of large amount of acidic material (e.g. gastric contents) however differential diagnosis is difficult because a clear history is the only way to tell.

PneumoniaPneumonia or Pneumonitis ???or Pneumonitis ???

Our search for evidenceOur search for evidence

Databases searched: Ovid (embase, Medline, Cinahl, PsychInfo, SpeechBITE, Google....)

Reference Lists: ASHA conference, references from other relevant articles

Critically Appraised PapersCritically Appraised Papers

Evaluated 14 articles 2 articles relevant to clinical question1) Robbins et al (2008)2) Groher (1987)

Article 1...Article 1...Robbins et al 2008Robbins et al 2008

Study Aim: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened fluids on the 3-month cumulative incidence of pneumonia.

Design/Method:o Randomised, controlled parallel design trialo 515 patients with dementia or Parkinson’s disease who aspirated on

thin fluids during MBS.o Patients were randomly assigned to two groups:

1. Chin tuck posture2. Thickened fluids group: this group were randomly assigned again

into nectar thick and honey thick groups.o Procedures put in place for adherence to the interventionso Followed up for 3 months or until deatho Adverse events including pneumonia, death, dehydration, UTI were

monitored.

Results:o Cumulative incidence of pneumonia was much lower

than expected overall.o The incidence of pneumonia was greater in the

chin down group compared to the thickened fluids group.

o The incidence pneumonia was greater in the honey thick fluids group compared to the nectar thick fluids group.

o Increased incidence of dehydration, UTI and fever in group receiving thickened liquids.

Level of Evidence: II o Strengths:

- Statistical Analysis- High level of evidence

o Limitations:- Adherence to interventions problematic (although this

probably reflects real life!!)- Patients for whom one or two interventions worked

were excluded from the 3 month follow-up with regard to adverse outcomes. This means we do not know if patients who had not aspirated with honey thick, for example (when they were still aspirating nectar and thin with chin down), would have been less likely to experience adverse outcomes if treated with this, than those who were still aspirating.

- Use of chin-down posture with patients with dementia (? Difficulty learning and remembering the technique)

- No comment as to severity of PD or dementia in patients.

Therefore…Clinical Bottom Line: Too difficult to make any definitive conclusions as to

whether thickened fluids reduce the risk of aspiration pneumonia. It appears that the rate of pneumonia was lower than expected for this population…we are unable to say if one treatment was responsible for this above the others.

Further research into the merits of neck flexion and nectar-thick fluids combined is needed.

Recommending thickened fluids for patients who are aspirating thin and thick fluids should be carefully considered.

Article 2Article 2 ……Groher 1987Groher 1987

Study Aim: To study the effect of bolus manipulation on the recurrence of aspiration pneumonia in patients with pseudobulbar dysphagia.

Design/Method:o Randomised controlled trialo 56 patients with histories of pseudobulbar dysphagia

from chronic care facilities.o Selection criteria included a history of one or more

episodes of aspiration pneumonia that had resolved at least one month before the study and oral intake of a puree diet and fluids.

o Study went over three years and patients followed up for six months

Subjects randomly assigned into two groups:1) Pureed foods and thin fluids2) Soft mechanical diet with altered fluids such as

half-frozen juices, thickened nectars and milk products and jello prepared with excess water.

Monthly examinations and bi monthly CXR’s

Results:o After 6 months there were 28 incidences of

aspiration pneumonia in group 1 and 5 incidences in group 2. The difference was statistically significant.

Level of Evidence: II o Strengths:

- High level of evidence- Statistical analysis

o Limitations:- Lack of instrumental assessment (e.g. MBS) prior to

study – what was their swallowing status/aspiration risk?

- Unclear as to what types of fluids the patients were on prior to entering the study.

- Unclear as to what contributed to the reduction of pneumonia in group 2 Description of the thickened liquids used is unclear.

- The use of half frozen juices and jello in group 2

Therefore…

Clinical Bottom Line:The incidence of pneumonia was significantly

less in patients given a mechanical soft diet and thickened fluids, however it is unclear as to how much the use of thickened fluids contributed to this decreased incidence.

CAT: Clinical Bottom LineCAT: Clinical Bottom Line

Question: In adults with dysphagia do thickened fluids reduce the incidence of aspiration pneumonia?

Answer:Dysphagia management appears to reduce

the likelihood of aspiration pneumonia however more research is needed to determine the exact role that thickened fluids play.

DiscussionDiscussion

Limited number of relevant articles – Did we need to broaden our clinical question?

- Most articles looked at aspiration and not aspiration pneumonia.

- Articles looked at combinations of thickened fluids and compensatory strategies

Methodological limitations created by:- Ethical issues in conducting this type of research

-Unable to have a control group in some instances as it is not ethical to provide no treatment for patients with known dysphagia and aspiration.

- Poor description of diets, particularly thickened fluids.

Where to from here?Where to from here?

Possible topics/areas of interest for 2009?

Hydration and thickened fluids Aspiration of food vs. liquids, and

associated risk of pneumonia Free water protocols

Questions?Questions?

ReferencesReferences

Robbins J. Gensler, G., Hind, J., Logemann, JA., Lindblad, AS., Brandt, D. Baum, H., Lilienfeld, D., Kosek, S., Lundy, D., Dikeman, K., Kazandjian, M., Gramigna, GD, McGarvey-Toler S. & Miller-Gardner, PJ. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized Trial. Annals of Internal Medicine, 148(7): 509-518.

Groher, M.E. (1987). Bolus Management and Aspiration Pneumonia in Patients with Pseudobulbar Dysphagia. Dysphagia, 1, 215-216.

Campbell-Taylor I, Panther K. Should patients who aspirate thin liquids be given water? ASHA 1998; 40:12-13.

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.

www.patient.co.uk www.sklung.ca/graphics/anatomy www.americandysphagianetwork.org www.medkast.libsyn.com

ContactsContacts

Dysphagia EBP group leaders 2008

Lisa Howard

lisa.howard@sesiahs.health.nsw.gov.au

Eva Katalinic

eva.katalinic@sesiahs.health.nsw.gov.au