[Dysphagia] thickened liquids

[chris_claire at bigpond.com (Chris and Claire Langdon)]

>From the Garon article.....

"We allow sips of water and ice chips for pleasure to reduce momentary
thirst.  In each case we follow the protocol of explaining the risks to
patients and families, obtaining approval for intake from patients, families
and physicians, not allowing water with meals and requiring a pre-rinse.
None of these patients have developed pneumonia.  Severe tracheal coughing
spasms affected four of the patients (all of whom refused to drink thickened
liquids).  Two of the patients returned to thickened liquids and two chose
to continue, even with severe coughing as they aspirated water."

My take on this is that being able to make the choice is important for
patients.  If I was told that I could never have a drink of water under any
circumstances, I'm sure that would be the only thing I would want!  I would
also like to reserve the right to change my mind if I experienced coughing
and distress at every mouthful.

Claire
----- Original Message -----
From: "Francesca Swift" <FrancescaSwift@hmh.westsound.net>
To: <Plbanick@aol.com>; <dysphagia@b9.com>; <chris_claire@bigpond.com>;
<eripley@yahoo.com>
Sent: Thursday, January 27, 2005 7:49 AM
Subject: Re: [Dysphagia] thickened liquids


> 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" <chris_claire@bigpond.com> 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" <eripley@yahoo.com>
> To: <Plbanick@aol.com>; <dysphagia@b9.com>
> 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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> >
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> > Clinical Neuroscientist
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