[Dysphagia] Re: new list on Medicare holiday coverage

[vstefans at george.ach.uams.edu (Vikki Stefans)]

I basically agree that thickened liquids are helpful and use quite a bit 
of them. BUT, we don't just do it on general priniciples, we do it for 
individual patients whose swallowing studies suggest a definite decrease 
in the amount of liquids going into the trachea instead of the esophagus 
with thicker consistencies.

I have had a few patients who clinically cleared up respiratory problems 
while inpatients after we studied them and stopped thin liquids at least 
temporarily. The most memorable was a young man with C5 quadriplegia who 
could not be weaned from oxygen though we could get off the vent until 
this was done. He had what is commonly called "cervical dysphagia" and it 
did improve, so he went home without an Rx for thickener. On an outpatient 
basis, we have kids who stop "catching everything" and clear up chronic 
congestion once this is done.

Again, it *is* WRONG to just assume that all people with swallowing 
problems should have thickened liquids. Attention to nutrition and 
hydration is critical when this is done; many people do not drink much if 
they have to thicken. Others do fine.

In the real world which includes understaffing and undereducated staff, 
there is a tendency to view things as black and white, simple solution 
issues. People still have the misconception that if there is 10% (or 
less!) aspiration of thin liquid seen on a VFSS, the person could choke to 
death on a sip of water. And I still hear the phrase "passed their VFSS" 
or "failed their VFSS" way too often. Of course, there is also the 
converse misconception that patients in ICUs should all be started on thin 
liquids when they have a gag reflex or at least seem able to swallow. :-)

I think I should start adding "all the simple problems have been solved 
already" to my sig file.

Vikki Stefans, M.D., pediatric physiatrist (rehab doc for kids) at UAMS
and Arkansas Children's Hospital.  Working Mom of Sarah T. and Michael C.,
and wife of Henry Stefans. Every mom is a working mom!- OK, dads too.

On Wed, 2 Mar 2005 smilinggirl336@comcast.net wrote:

> I am new to this dysphagia list and I am questioning why SLP's would be 
> opposed to using thickened liquids.
>
> I am a proponent of using thickened liquids to reduce the risk of 
> aspiration of thin liquids.  I refrain from using the term "prevent" 
> when it comes to aspiration, as I feel it is impossible to "prevent" 
> aspiration, especially with saliva. I find that poor positioning in 
> hospital beds and poor feeding techniques can increase the risk of 
> aspiration with almost consistency.  I feel my job is useful to reduce 
> the risk of aspiration and to reduce the frequency of aspiration and I 
> may do this by altering the consistency of foods and liquids.  I think 
> it is also important to look at the nature of the aspirate.  I find that 
> some patients find it uncomfortable to have coughing episodes while 
> drinking and find swallowing thickened liquids to be more comfortable. 
> Are not these reasons to use thickened liquids?  Whenever possible, I 
> want people to be on a "normal" diet; it is equally important that 
> patient's will accept the consistencies and be able to meet their 
> nutrtional and hydration needs.  If these are not met, they will 
> develop other problems (i.e. dehyrdation, malnutrition, cognitive 
> changes, UTI).  There is so much more to look at when we treat a patient 
> than just aspiration risk.
>
> I also get upset when I see physician's (or others) document that they 
> inserted a PEG tube to prevent aspiration.  With the PEG tube, they have 
> just opened up another can of worms, and we can't prevent aspiration!
>
> Anyway, as I am new to the list, I hope I am not just restating what has 
> already been said - just trying to add my reasoning for using thickened 
> liquids.