You Know Everything About Dysphagia, True or False?
I once heard a physician tell a story about his graduation from medical school. One of his professors addressed the graduating class and warned “Approximately half of what we’ve taught you will turn out to be wrong…” After a pause, he continued, “Unfortunately, we have no idea which half that is!”
Facts are facts, or so the saying goes. But in medicine, what is known to be true often changes in light of new evidence and information. Clinicians are faced with an often bewildering amount of information that comes to us from a variety of sources…journal articles, websites, fellow clinicians. Some of that information is accurate and reliable. Some of it may have been thought to be true at one time but has been proven to be wrong. Some of it is true for some of our patients but not for all. Some of it is just plain wrong. Perhaps our most challenging job as clinicians is to sort it all out…so let’s do some “fact-checking” on dysphagia.
True or False? Diet texture modification makes patients safer.
Reducing food texture to soft, ground, or pureed levels can be helpful in decreasing risk of choking, compensating for fatigue and low endurance, and in improving overall oral management. Dietary modifications have consequences, however. Not the least of which is a decrease in taste intensity, visual appeal, and palatability. There is increasing evidence to suggest that these often unpalatable diets result in low appetite, decreased intake, and nutritional compromise with subsequent immune compromise. (Dahl, et al, 2007; Bannerman and McDermott, 2011). In fact, many skilled nursing facilities, at the urging of Medicare and the American Dietary Association are moving toward diet liberalization in an attempt to improve nutrition in elderly residents. So are modified diets safer? Depends on your definition of safe…
True or False? Laryngeal penetration is evidence of dysphagia.
Answer= It depends.
Laryngeal penetration, or material that enters the laryngeal vestibule but does not move through the vocal folds into the trachea, is often used as evidence of dysphagia and rationale for dietary modifications including texture modifications and thickened liquids. But laryngeal penetration occurs in those of us with normal swallows too (Todd, et al, 2013; Daggett, et al, 2006; “Robbins, et al, 1999). So how can we tell normal laryngeal penetration from dysphagia? Normal laryngeal penetration is inconsistent, shallow (i.e. does not reach the level of the vocal folds), and clears spontaneously. Laryngeal penetration that occurs with most swallows, is deep in the larynx reaching the level of the vocal folds, and does not clear spontaneously would be considered symptomatic of a true swallow disorder.
True or False? Tube feeding prevents aspiration and its complications.
Dietary modifications, NPO status, and tube feeding can reduce risk of aspiration while eating and drinking, unfortunately, nothing can keep patients from aspirating their saliva. Dr. Susan Langmore’s important studies (Langmore, et al, 1998; Langmore, et al, 2002) demonstrated that tube feeding often increases a patient’s risk of aspiration and pneumonia. Patients who are not eating by mouth often experience significant dry mouth which increases the bacterial load in the oral cavity. Aspiration of even small amounts of saliva in that case can be extremely dangerous. Reflux often increases with tube feeding as well and aspiration of stomach acids is particularly toxic in the lungs.
True or False? Thick liquids are safer than thin liquids
Answer = Not necessarily
To answer this question, we have to first have some information about the patient’s specific swallow disorder. Aspiration doesn’t simply occur…it has to be caused by something. And understanding the cause of the dysphagia for each individual will help us to answer this question. If the underlying problem is one of timing – delayed swallow response, slow laryngeal closure, reduced oral containment, etc. – then thicker, slower liquids may indeed be safer. If the underlying issue is one of motility – reduced tongue base retraction, reduced pharyngeal stripping, incomplete pharyngeal clearance – then thicker, heavier liquids may in fact be harder to clear, may result in more residue, and may increase aspiration risk. (Choi, et al, 2011; Kuhlemeier, et al, 2001) There is also some evidence to suggest that if we do aspirate thicker liquids, they will be less efficiently cleared from our lungs and more likely to result in illness. (Robbins, et al, 2008) In short…we have to be sure we know why we’re doing whatever we’re doing. And, again, we need to evaluate our definition of “safe”.
True or False? Aspiration leads to aspiration pneumonia
Answer = Sometimes
We have all had clients we knew were aspirating…who chose to continue eating or drinking in a way that we felt was unsafe. Not all of those clients got sick. Some did develop respiratory complications and pneumonias, but some did not. The fact is, each individual’s propensity to aspiration pneumonia is dependent on their potential for pulmonary clearance. We all have the ability to clean out our lungs after aspirating…which is a good thing, since we all aspirate once in a while. Cough, muco-ciliary clearance, and cellular clearance mechanisms all work together to contribute to keeping material out of our airway…and getting material out of our airway. (Marik, 2001; Marik, 2011; Voynow and Rubin, 2009; Donnelly and Barnes; 2012) The aspirate itself is another important consideration – some things are more easily cleared from our lungs than other things. As noted above, thick liquids, if aspirated, may be much more difficult to clear from our lungs than thin liquids. (Robbins, et al, 2008).
It’s clear that there aren’t too many always “true” or always “false” answers in the work we do. It’s also becoming clear that some of the things we were taught during our training programs may no longer be accurate. It’s an ongoing learning process for us all as we try to sort out what’s best for our clients.
About the Author: Angela Mansolillo, MA/CCC-SLP
Angela Mansolillo is a Speech-Language Pathologist and board recognized specialist in swallowing disorders who has worked in a variety of clinical settings. She brings over twenty years of experience with children with dysphagia to her teaching. Her dynamic, interactive style, coupled with her ability to present complex material in a meaningful, practical way, enables her course participants to arm themselves with new successful strategies to apply immediately.
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Choi, KH, et al, “Kinematic Analysis of Dysphagia: Significant Parameters of Aspiration Related to Bolus Viscosity”, Dysphagia, 26, 392-98, 2011.
Daggett, A., et al “Laryngeal Penetration During Deglutition in Normal Subjects of Various Ages”, Dysphagia, 21(4), 270-74, 2006.
Dahl, W., et al, “Protein content of pureed diets: Implications for planning”, Can J Diet Pract Res, 68(2), 99-12, 2007.
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Kuhlemeier, K, et al, “Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients”, Dysphagia, 16(2), 119-22, 2001.
Langmore, Susan, et al, “Predictors of Aspiration Pneumonia: How Important is Dysphagia?” Dysphagia, 13, 69-81, 1998.
Langmore, S., et al, “Predictors of aspiration pneumonia in nursing home residents”, Dysphagia, 17(4), 298-307, 2002.
Marik, P., “Aspiration Pneumonitis and Aspiration Pneumonia”, New England Journal of Medicine, 344, 665-671, 2001.
Marik, P., “Pulmonary Aspiration Syndromes”, Current Opinions in Pulmonary Medicine, 17(3), 148-54, 2011.
Robbins, J., et al, “Differentiation of normal and abnormal airway protection during swallowing using the Penetration-Aspiration Scale”, Dysphagia, 14(4), 228-32, 1999.
Robbins, J., et al, “Comparison of two interventions for liquid aspiration in pneumonia incidence: a randomized trial”, Ann Internal Medicine, 148(7), 509-18, 2008.
Todd, J., et al, “Stability of aspiration status in healthy adults”, Ann Otol Rhinol Laryngol, 122(5), 289-93, 2013
Voynow, J., and Rubin, B.,”Mucins, Mucus, and Sputum”, Chest, 135, 505-12, 2009