Are you thirsty? Thick vs Thin Liquids Carrie Pascale, MS CCC-SLP TSSLD St. Charles Hospital
Discl closures • 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 • The debate over whether or not phase dysphagia, there is often a thick liquids are doing more decision that needs to be made harm than good and whether or by an SLP and the not thin liquids, when provided interdisciplinary team: their diet to a patient with a known consistency and namely, the dysphagia, is beneficial thickness of their liquids
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/w atch%3Fv%3D1sFNMk87558&rct=j&frm=1&q=&esrc=s&sa=U& ved=0ahUKEwiov8_E6PXNAhUDph4KHcHJDkcQtwIIIDAA&sig2= qpBaA0oisDmFtWIKYkOh8A&usg=AFQjCNF4X49nf6O2ccaUh_S eBakrND-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 (Ortega, 2014) Impaired Health Status Presence of Dysphagia Poor Oral Hygiene
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)
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!
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