[Dysphagia] thickened liquids

[eripley at yahoo.com (Irene Campbell-Taylor)]

If the coughing presents a real problem for the patient or is a medical hazard then it must be avoided. The best way to do this is by the use of hypodermoclysis for hydration or by finding the appropriate position - sometimes side lying or recumbent- in which the patient can swallow water without coughing. And please remember that thickened liquids are still aspirated - if that is your concern.
 
Francesca Swift <FrancescaSwift@hmh.westsound.net> wrote:
I agree with this when it does not cause them distress. What are you
guys' feelings when ingestion of water causes explosive choking (with a
weak, non-productive cough), gurgling, discomfort and face turning red
etc. each sip. It can be quite uncomfortable for them and disruptive to
the meal process. (We've obviously all seen this regularly).

>>> "Chris and Claire Langdon" 1/25/2005
9:50:13 PM >>>
Are people on the listserv familiar with the study by Garon et. al.
from 1997? 
Garon BR, Engle M and Ormiston C (1997) A randomized control study to
determine the effects of unlimited oral intake of water in patients with
identified aspiration. J. Neuro Rehab 11(3):139-148

They conducted a study where acute stroke patients (mean 12.8 days
post) with documented aspiration on thin fluids were randomised to
receive (a) thickened liquids only (b) thickened liquids plus access to
water. The (b) group weren't allowed water with or within an hour of
meals and were required to rinse their mouths prior to any water intake
in order to minimise ingestion of bacteria or food stasis. Participants
in the group allowed access to water reported greater satisfaction as
thickened liquids were reportedly "not thirst quenching and were lacking
in taste and enjoyment". A significant difference in fluid intake per
day was found between the groups for the amount of thickened fluids
ingested; with participants in the (b) group ingesting less thickened
fluids.

Participants in group (b) had a mean intake of 1318cc fluid, of which
water comprised an average 463cc. Group (a) participants averaged
1210cc thickened liquids daily. The research team reported that
participants in the study group consumed considerably less water than
expected, but water was placed out of the patients' reach for control
purposes. Study participants reported they drank water for oral dryness
and to alleviate thirst. Being able to take small sips of cold water
during the day reportedly made a big difference to participants in terms
of thirst.

No patients in either group developed pneumonia or dehydration during a
30-day follow up period. Limitations - The study was of a small
population (10 participants in each group). Patients unable to "rinse
and spit" prior to a swallow and patients unable to hold a cup or self
feed were excluded, so probably the more severe strokes were excluded. 
Impulsive patients were excluded, as were patients with a severe cough
reaction to aspiration of thin fluids. 

Garon reported since completing the study that approximately 100
patients with thin liquid aspiration had been allowed access to water
and ice chips for hydration or thirst following the protocol of a
pre-ingestion rinse and spit and not allowing water with or within a
hour of meals. No patient had developed pneumonia.

I'm not sure if this study pre-dates the Frazier Free Water Protocol
(Kathy Panther).

Wishing you all a Happy Australia Day!

Claire 


----- Original Message ----- 
From: "Irene Campbell-Taylor" 
To: 
; 
Sent: Tuesday, January 25, 2005 10:15 PM
Subject: Re: [Dysphagia] thickened liquids


> Increasingly, physicians are realizing that thickened liquids tend to
produce not only dehydration but malnutririon as the recent literature
indicates. It is not possible to get enough water on thickened liquids
without compromising other intake. Also, there is NO evidence whatever
that thickeners achieve any positive result. Hydration requires adequate
intake of water, nit just any fluid : See
> 
> ASHA SID 13 Newsletter, Perspectives on Swallowing and Swallowing
Disorders, 11(2): 16-19, 2002
> 
> Defining Physical Properties of Fluids for Dysphagia Evaluation and
Treatment JoAnne Robbins; Wm. S. Middleton ;Mark Nicosia;Jacqueline A.
Hind; Gary D. Gill; Roberto Blanco, EZ-EM, Inc;Jed Logemann,
Northwestern University.
> 
> 
> Thickening liquids has been and continues to be one of the most
frequently used compensatory interventions in hospitals and long term
care facilities, the latter because liquid aspiration is most common in
elderly patients (Feinberg, Knebl, Tully, Segall, 1990; La Croix,
Lipson, Miles, White, 1989). Nonetheless, there are little (sic) extant
data that convincingly demonstrate that drinking thickened liquids has a
significant positive effect on health outcomes such as pneumonia,
hydration, nutrition, or quality of life. Bolus flow outcomes have long
served as surrogate indicators of health outcomes. They include
direction (aspiration or penetration), duration (transit times), and
clearance (residue). The generally accepted clinical notion that
manipulation of thicker (more viscous) substances reduces occurrence of
aspiration, or modifies other bolus flow characteristics in dysphagic
persons that produce an "improved swallow", has little support other
than anecdotal, in the li!
> terature. 
> And
> Whelan K. Inadequate fluid intakes in dysphagic acute stroke. Clin
Nutr 2001 Oct;20(5):423-8 Patients not on specialist stroke units who
received pre-thickened fluids drank almost 100% more than those on
powder-thickened fluids (Note: This was still only approximately 900ml
fluid/day.Fluid intakes in this patient group are insufficient to
achieve requirements. Hospital staff must ensure adequate fluid intakes
in patients at risk of dehydration, which should include both an
adequate prescription and provision of supplementary fluids
> 
> Finestone HM, Foley NC, Woodbury MG, Greene-Finestone L.. Quantifying
fluid intake in dysphagic stroke patients: a preliminary comparison of
oral and nonoral strategies. Arch Phys Med Rehabil 82:1744-6. 2001. 
> The authors examined thirteen dysphagic patients with acute strokes
for 21 days postadmission. Seven patients (group 1) were started on
enteral feeding and later progressed to oral diets and 6 patients (group
2) received oral dysphagia diets. Fluid intake of patients in group 1
significantly declined over the 21 days . Mean fluid intake of patients
in group 2 was approximately 33% of requirements. This volume was
significantly lower than the fluid intake of patients who received
nonoral feeding. The patients who received thickened-fluid dysphagia
diets failed to meet their fluid requirements whereas patients on
enteral feeding and intravenous fluid regimens received sufficient
fluid. It is not clear how much the intravenous fluid contributed to the
overall fluid intake and whether or not fluid intake would have been
sufficient without it.
> 
> 
> This practice requires significant reconsideration, at best.
> What is the general consensus out there: Do thickened liquids provide
as 
> much hydration as regular thin liquids? I work with a doctor who
feels that 
> anyone on thickened liquids is at risk for dehydration (even if they
take adequate 
> amounts).
> Thank you, Patti Banick, SLP
> Maryland
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Clinical Neuroscientist
Exclusive Distributor:
www.interactivetherapy.com