Those Amazing Thickened Liquids

Warning... vent ahead!!!

So last week I had one of those situations that just makes you want to bang your head against the wall. Over and over. Or maybe throw things, but that can get you in trouble. But I digress...

Patient had an old stroke, but no significant residual dysphagia. After my initial eval, the patient was placed on a regular diet with thin liquids. I followed up for a meal monitor, just to make sure everything was okay... no problems.

A few days later, I was asked to see the patient again. Worsening medical status? New difficulty with meals? Pneumonia? Nope, the doctor heard "wheezing" during morning rounds and thought the patient "might have aspirated saliva," and so placed the patient on thickened liquids and asked for a reassessment. The reassessment is no problem, but how on earth does one expect thickened liquids to prevent the aspiration OF SALIVA? Never mind the completely erroneous assumption that thickened liquids are somehow inherently "safer".

So the patient is exactly the same as before, which is to say, not a significant prandial (mealtime) aspiration risk, so I recommend resuming the regular diet.

The next day I check the chart and discover that (1) the doctor is ticked that I didn't do a VFSS (hello, if you want that done, you have to WRITE AN ORDER FOR IT, or at least mention it in the progress notes so I know that's the "reassessment" you want!), and (2) the doctor knows I recommended the regular diet, but writes to continue thickened liquids to "make sure the patient doesn't aspirate gastric secretions."

So, not only do those amazing thickened liquids prevent the aspiration of saliva, they also prevent aspiration of reflux! Just wait til the surgeons find out! Never mind pre-op NPO status, just put patients on thickened liquids! (I'm sure the thickener companies wouldn't object...)

Gah. Anyways, I did correct the misinformation (there is NO EVIDENCE that thickened liquids prevent aspiration of gastric secretions, or aspiration of anything, really) and the patient was placed back on a regular diet at last (after a completely normal VFSS, no less). So all's well that ends well, but that reasoning was certainly a new one for me!

Do videofluoroscopic swallowing studies show what happens during a meal?

In a word: No.

Understanding this is crucial to managing dysphagia appropriately. I would be all for video-ing just about everyone with dysphagia or suspected dysphagia if VFSS showed what happens at a meal. However, it does not -- it cannot.

Why not?

Most SLP’s recognize that a number of factors may differ between the video swallowing study and normal mealtime circumstances. As such, they (rightly) attempt to adjust these to be as close to the patient’s usual mealtime situation as possible. These factors include patient positioning (including head and body positioning), the patient’s mental status, bolus size/volume, and feeding rate. Most clinicians also recognize that a VFSS provides just a “snapshot” of how a patient is doing at that particular time, with a limited number of food and liquid trials. Unfortunately, these factors are often the only ones taken into account, so there seems to be a widespread belief that if these factors can be controlled for, the VFSS will at least closely resemble what happens during a meal.

However, this doesn’t take into account another set of factors, which cannot be modified. These have to do with the nature of the VFSS itself. The major ones are the bolus characteristics of barium, which are vastly different than those of plain food or liquid. Adding barium to food does not make the results of the VFSS closer to “what happens at a meal”; it just tells you how that patient swallows barium plus food (at that moment in time). Barium is heavier and denser than regular food or liquids, both bolus characteristics which are known to affect the physiology of the swallow. Add to that a different taste, mouth feel, and often viscosity, and it should be readily apparent why the barium bolus cannot be expected to closely resemble a regular food or liquid bolus.

Although many clinicians realize that there may be discrepancies between the results of a VFSS study and what is actually occurring at mealtimes, it has not stopped a large number of clinicians from elevating VFSS results to a level of near-infallibility -- the be-all-end-all of swallowing evaluation. See, for example, the “swallow scores” utilized in much of the VitalStim research: a numerical scale based on which textures/consistencies are “safe” according to VFSS. Or clinicians who change a diet based solely on VFSS performance, without regard to the patient’s clinical presentation.

I suspect that this underlying assumption -- that what happens on VFSS is equivalent to what happens when the patient is really eating/drinking -- is a large part of the heavy emphasis on obtaining VFSS on most (if not all) patients with suspected pharyngeal swallowing dysfunction. However, it has the potential to lead to inappropriate treatment decisions.

What's wrong with this statement?

"Electric stimulation hastens recovery from dysphagia in patients with Polymyositis thereby reducing morbidity and mortality, and improving quality of life."

Sounds authoritative, right?

But here we have yet another instance of some members of the VitalStim camp not understanding (or perhaps, disregarding) basic research principles.

This statement comes from an abstract recently posted on the VitalStim website. This abstract is listed as a "peer-reviewed poster presentation" on the online version of Archives of Physical Medicine and Rehabilitation. The abstract is entitled "Effect of Electric Stimulation on Swallow Function in Patient with Polymyositis: A Case Report." It describes a case study of a 62-year-old male with Polymyositis who was treated with VitalStim.

So the problem with the statement above?

You cannot make sweeping statements about the value and efficacy of a particular intervention in an entire patient population based on a SINGLE CASE.

Nor can you say the "electric stimulation accounted for earlier and quicker recovery from dysphagia in this subject," as is stated elsewhere in the abstract, when you have nothing to compare the recovery time to!

C'mon people, this is Research 101. Or really, just Logic 101.

Case studies are a good thing -- we can certainly use more of these in our (fairly sparse) literature on swallowing disorders. But we need to be cautious and realize that their results do not necessarily hold true for every similar case.

You would think that some of the "peers" doing the peer-reviewing would have caught that.

A Cleft Palate Case

Not my usual area of practice, but one I find very interesting, is cleft palate. In adults, I've seen one case of an unrepaired cleft palate, and a couple bifid uvulas -- none of which really affected speech or swallowing much, but which were pretty cool to see!

Check out this interesting account by a pediatrician of diagnosing a submucosal cleft in a 4-day-old infant -- it's a good illustration of the importance of using the patient's history to guide the physical examination, in order to avoid missing potentially subtle findings.

Contraindications

Contraindication (noun): something (as a symptom or condition) that makes a particular treatment or procedure inadvisable

From Wikipedia: In medicine, a contraindication is a condition or factor that increases the risk involved in using a particular drug, carrying out a medical procedure or engaging in a particular activity.

VitalStim has a list of oft-repeated contraindications for their their therapy:

The contraindications for VitalStim Therapy are specific to patients suffering from dysphagia. Caution should be used with patients who have cardiac demand pacemakers. Its use is contraindicated with patients who are severely demented and exhibit non-stop verbalization. Constant verbalization could result in aspiration during trials of oral intake. VitalStim Therapy is also contraindicated in patients with significant reflux due to use of a feeding tube. Such patients are prone to repeated cases of aspiration pneumonia, and the VitalStim Therapy device has not been studied in this population. Use of the VitalStim Therapy device is contraindicated in patients with dysphagia due to drug toxicity. Patients suffering from drug toxicity could aspirate during trials of oral intake.

Quite an odd assortment of “contraindications,” if you ask me. Let’s look at them individually:

Its use is contraindicated with patients who are severely demented and exhibit non-stop verbalization. Constant verbalization could result in aspiration during trials of oral intake.
You think??! How about, “VitalStim would not be effective since the primary cause of aspiration in these patients is most likely decreased oral control due to nonstop verbalization, which VitalStim cannot fix”!

VitalStim Therapy is also contraindicated in patients with significant reflux due to use of a feeding tube. Such patients are prone to repeated cases of aspiration pneumonia, and the VitalStim Therapy device has not been studied in this population.
Only due to a feeding tube? What about severe reflux, period? And, yes, these patients are prone to repeated pneumonia/pneumonitis due to the reflux, but that is because of aspirating acidic gastric secretions. And the device “hasn’t been studied in this population”? Well, neither has it in many of the rest of the populations it’s claimed to work for.

Use of the VitalStim Therapy device is contraindicated in patients with dysphagia due to drug toxicity. Patients suffering from drug toxicity could aspirate during trials of oral intake.
Couldn’t most patients who are VitalStim candidates aspirate? I mean, that’s usually a large part of why they’re getting the therapy, right? Why separate out “due to drug toxicity”? And do they mean “due to a drug side effect” or actual toxicity (e.g., digitalis toxicity)?

So everybody else is guaranteed not to aspirate during po trials?

The word contraindication means that there will likely be negative effects if a particular treatment is used. For instance, nitroglycerin is contraindicated in patients with low blood pressure as it will drop blood pressure even further, potentially causing severe hypotension (with all its accompanying adverse effects). None of these “contraindicated” things listed above are really contraindications to VitalStim therapy itself -- they are more “who is a good candidate?” The only two that are even halfway decent are the pacer precaution and the contraindication to passing current through an area of active neoplasm (not listed in the blurb above, but found elsewhere in the VitalStim literature). Those two make sense. The others appear to have been cobbled together to give the impression of a responsible company -- see, it’s not for everyone, there *are* contraindications. Really, a clinician with even a marginal amount of critical thinking should be able to determine that those patients listed above may require alternate approaches besides “swallowing therapy.” Nothing about these diagnoses suggests that e-stim would be particularly appropriate or effective in decreasing aspiration for these patients.

Are all these videos really necessary?

I have been pondering recently the increasing reliance on instrumental assessment (especially videofluoroscopic swallowing studies/modified barium swallows) in dysphagia evaluations. I get phone calls every so often from SLP’s in long-term care/skilled nursing facilities incensed that I did not do a VFSS on their patients. Never mind that I always have a reason for not performing a video -- most commonly because either (a) the patient was not appropriate (remember, I work in acute care; I like to wait until the patient is reasonably stable to do a video, otherwise the patient may change so rapidly after the video is done that the results no longer reflect the patient’s current swallowing status. Unfortunately, by the time the patient is stable, he is often on his way out the door already!) or (b) results of the video would not change management (e.g., a 92-year-old with dementia who has occasional throat clearing with thin liquids and no history of pneumonia). To some of these SLP’s, the fact that a pharyngeal phase dysphagia was suspected or signs of aspiration were observed but a video was not done is automatic proof of incompetence, laziness, negligence, or all three -- an attitude which tends to drive me up the wall (go figure!).

What are the reasons behind the heavy reliance on VFSS or other instrumental assessments? They are numerous and interrelated. The ones I’ve come up with so far:
(1) Lack of training or experience in thorough clinical assessment;
(2) Characterization of clinical dysphagia assessment as “subjective” -- and therefore falliable and unreliable -- while instrumental assessment is “objective”;
(3) Viewing clinical dysphagia assessment as merely a “screening” procedure;
(4) Fear of litigation;
(5) Overemphasis on prevention of prandial aspiration (aspiration occurring during meals);
(6) Belief that “silent aspiration” is common and frequently harmful;
(7) Belief that VFSS reflects what happens during a meal; and
(8) Belief that only instrumental assessment can yield information about the physiology of the pharyngeal swallow.

I would like to talk about each of these in more detail, but for now let’s focus on the last one -- the belief that instrumental assessment is required to gain any reliable information about the physiology of a patient’s swallow.

This is a pervasive belief, espoused by some of the most influential people in the profession, as in the following pronouncement:

“…the physiology of the pharyngeal swallow is not observable at the bedside, and the reason for any aspiration cannot be defined.” Logemann, J. After the Clinical Bedside Swallowing Examination: What Next? American Journal of Speech-Language Pathology 1991; 1: 13-20.

One book (The Source for Dysphagia by Nancy Swigert) gives the example that a dysphagic patient could have poor airway closure, causing aspiration during the swallow; poor tongue base movement and premature posterior spillage, causing aspiration before the swallow; or poor hyolaryngeal movement, causing pharyngeal residue and aspiration after the swallow, and asserts that it is impossible to tell which of these scenarios is occurring (and therefore plan appropriate treatment) without an instrumental assessment.

I don’t buy this. I’m not sure where we speech pathologists got the notion that the pharyngeal swallow is some mysterious process, revealing its secrets only to high-tech instrumental assessment (primarily VFSS/MBS). I can’t even remember the last time I saw something on VFSS that surprised me, based on the findings from my clinical evaluation. Are there times when instrumental assessment is important and necessary? Absolutely. Does it provide helpful information? Sure. Is it essential? I would say, not usually.

In the example above, I would argue that in most cases, we can know which physiological abnormalities are occurring based on clinical examination alone. A patient with poor airway closure will exhibit abnormalities in voicing -- e.g., hoarseness, breathiness, difficulty changing pitch. Patients with poor oral control will show oral (especially lingual) weakness and/or discoordination. And hyolaryngeal movement can be judged by palpation. Combine these observations and the rest of the physical examination with knowledge of the patient’s medical history, the nature of the swallowing complaint, and observations of the patient with food and liquid trials, and an experienced SLP (or other swallowing specialist) is in a good position to determine clinically what is occurring pharyngeally.

Families

Working in acute care I run into all different types of families. I like dealing with families and I especially like doing patient/family education. Observing different family dynamics and seeing how different patients and families relate to each other fascinates me. Some of the family types I've seen in the past couple weeks:

• The Hoverers -- Most have a different definition of "personal space" than I do. They stand at my elbow while I'm evaluating a patient, forcing me to remember not to turn around suddenly or else they'll be wearing applesauce. They jump in to answer questions directed at the patient, which often yields helpful information, but then the patient usually clams up, eliminating the first-hand info. There are two subtypes of Hoverers: Concerned Hoverers (who only want the best for the patient and are usually just overwhelmed by the hospital setting) and Paranoid Hoverers (who think that hospital staff need to be kept in check before they adversely affect the patient through laziness, incompetence, not caring, or all three).
• The Notetakers -- Sit in the corner and scribble furiously as soon as staff walks in the room. These are the ones who ask to see your name badge and double-check the spelling of your name and your exact title. They often write down everything you say verbatim. Two subtypes: Perfectionist Notetakers (admittedly rare, these are the ones who want all the staff's names so they can send thank-you notes to each department head, and want all the patient's diagnoses with the correct spellings so they can look them up and addd them to the typewritten list of medical history and current medications the patient keeps on his/her person at all times) and Legal-Minded Notetakers (waiting for mistakes and want the evidence to back them up. If you listen closely, you can hear the faint ka-ching of a cash register after every question). Perfectionist Notetakers mean well and try not to be annoying. Legal-Minded Notetakers usually belong to families of Paranoid Hoverers.
• The Name-Droppers -- Often associated with Paranoid Hoverers, these are the ones who make it a point to inform you (usually within 30 seconds of entering the room) of their exact relationship to the president of the hospital. Or a hospital board member. Or a local politician. Or some random celebrity. The purpose, of course, is to demand special treatment and to give vague hints of dire consequences if that special treatment isn't immediately forthcoming. Funny thing is, the couple of times that I've had actual VIP's, they were the most unassuming, least demanding patients I'd seen in a long time. Go figure.
• The Musketeers -- Close-knit extended families who are easily recognized by the presence of at least five family members in the patient's room from dawn until well after visiting hours. Usually very concerned for the patient's welfare, but often so involved in ever-running conversations that they are oblivious to staff attempts to care for the patient. These are the ones you try to send to the lounge/waiting room area, or else you'll be tripping over them and having to constantly interrupt their conversations with the patient so you can finish your eval.
• The Researchers -- Reveal themselves by the phrase "I looked it up on the internet..." These ones are usually fun because they generally ask good questions and are interested in more detailed information about the patient's diagnoses than just prognosis and recommendations. There is a small subset who question everything you do because "the internet said xyz" (these are the ones who don't get the concept of "reliable" vs. "not-so-reliable" sources of info), but for the most part Researchers respond well to patient/family education.