"But she aspirated!"

A few months ago, I got an order for a bedside swallowing evaluation on an elderly woman who was admitted with pneumonia. Her doctor wanted to rule out aspiration -- of food or liquids -- as the cause of the pneumonia (a whole 'nother issue I won't go into now), so he ordered the eval.

Practically shouting (so much for HIPAA when you have a very hard-of-hearing patient!), I asked if she had trouble swallowing. No, no trouble at all, she answered, looking at me like I'd just asked her something outrageous. I explained the reason the doctor ordered the evaluation, then continued with my questioning. Do you ever cough or choke with meals? Have trouble chewing your food? Does food ever feel stuck? Does food or liquid ever "go down the wrong pipe"? No, no, no, and no, she replied. Her oral motor exam was negative. No neuro signs. Swallowing looked okay. Good oral control. Adequate hyolaryngeal movement. A timely swallow. No signs/symptoms of aspiration -- no coughing, throat clearing, change in vocal quality, nothing. "Oral/pharyngeal swallow appears WFL," I wrote on my report, and recommended continuing her current diet, regular food with thin liquids. (Now, I can just hear some speech pathology types muttering, "but what if she's silently aspirating? Shouldn't you do a videofluoroscopic swallowing study (VFSS)?" See my thoughts here).

The next day after the bedside eval, I got a VFSS order for the patient. "I still think she's aspirating," he wrote in his progress note. So I did the video.

Her swallow was picture-perfect. Coordinated, good airway protection, no penetration (entrance of contrast into the laryngeal vestibule, but above the level of the vocal cords), no aspiration . . . except for on the very first swallow, with thin liquid barium. With that swallow, she was just a little discoordinated (possibly due to the initial tasting of the barium, or to being not quite prepared for that first sip), and she aspirated a trace amount, barely a drop, to just below the vocal cords. It wasn't there for long, as she had an immediate coughing fit which promptly expelled that tiny drop of barium from her airway. She coughed and coughed and coughed some more before we could continue with the study. I certainly didn't need to worry about silent aspiration with her! Every other swallow on the study was perfect, including several more with thin liquids. Given the absence of coughing fits during her bedside eval, I was confident that the aspiration on the video was just a fluke. And, at any rate, the aspiration of a trace amount of liquid which was immediately cleared from the airway with a strong cough would not be contributing to her pneumonia.

So I dutifully recorded the events of the video in my report, along with my impressions of an oral/pharyngeal swallow WFL (yes, despite the aspiration, as that was an isolated incident which can happen even to someone with a completely normal swallow) and a recommendation to continue regular consistency foods and thin liquids. When the doctor saw the report, he flipped. "But she aspirated! How can you recommend thin liquids?! That's what she aspirated!" No amount of explaining -- about the discrepancy between the bedside eval and the VFSS, the strong cough and good airway protection, the lack of a cough (and, by extension, lack of aspiration) on bedside evaluation, the far greater risks of thickened liquids as opposed to thin liquids for this patient -- nothing could sway him. He looked me up and down as though appalled that I would dare to suggest continuing a regular diet when the patient clearly aspirated on the VFSS, unmoved by my reasoning, my evidence, my suggestions. And then he changed the patient's diet to pureed with nectar consistency liquids. And changed her diagnosis from "community-acquired pneumonia" to "aspiration pneumonia." Never mind the fact that unnecessarily putting the patient on a modified diet and thickened liquids would greatly increase her risk of malnutrition and dehydration, and that those risks were far, far greater than the minimal, if any, risk from rare trace aspiration with an intact cough response. Argh.

And whatever happened to the patient? I called the nursing home speech pathologist when the patient was discharged and told her what had happened and what my recommendations were. She evaluated the patient at bedside. When I saw the patient on a subsequent admission (not for pneumonia, still with a swallow WFL, this time with a different attending doctor), she had been switched back to a regular diet with thin liquids at the nursing home. Thankfully.