Extravaganza 2008

1. Extravaganza 2008 Adult Swallowing EBP Group

2. Who are we? The Adult Swallowing EBP Group comprises both metropolitan and rural members. Formed in March 2007, following the division of Adult Swallowing and Communication group into 3 separate groups (Adult swallowing, speech and language). We are all practicing Speech Pathologists with a particular interest in the management of adult swallowing impairments. We currently have 34 active members.

3. Inspiration for our clinical question Most practicing speech pathologists have anecdotal evidence that thickened fluids can reduce the incidence of aspiration. This is frequently demonstrated on objective assessment (eg. MBS and FEES). What we wanted to know was....Do thickened fluids reduce the incidence of aspiration pneumonia?

4. Clinical Question In adults with dysphagia, do thickened fluids reduce the incidence of aspiration pneumonia?

5. What is aspiration pneumonia? Langmore et al 1998 defines aspiration pneumonia as: elevated white blood cell count (12000 or above), fever, and new infiltrate on the chest radiograph. Aspiration pneumonia is bronchopneumonia (infection of the bronchus/lung) that develops due to the entrance of foreign materials that enter the bronchial tree, usually oral or gastric contents (including food, saliva, or nasal secretions).

6. Aspiration pneumonia can account for 13% - 48% of all infections in nursing home residents – Zimmer, 1986 & Crossley, 1989. 20%-50% mortality rate (as high as 80% in some studies) cited in Langmore et al 1998

7. Flow chart of pneumonia development • Dysphagia & pneumonia: a complex relationship (Langmore 1998) • Colonisation (altered oropharyngeal flora): • Aspiration into lungs • Host resistance • Pneumonia

8. Predictors of aspiration pneumonia – how important is dysphagia? (Langmore et al 1998) • Dysphagia (MBS,FEES) • Dental/oral health • Medical History • Functional status • Contraction of aspiration pneumonia or death

9. Langmore et al (1998): ‘dysphagia and aspiration may not be critical risk factors in a person who is medically stable, has a clean, healthy mouth and/or is independent for daily activities, especially feeding. If a combination of these positive conditions are not met, pneumonia may develop.’

10. Pneumoniaor Pneumonitis ??? Depending on the acidity of the aspirate, a chemical pneumonitis can develop, and bacterial pathogens (particularly anaerobic bacteria) may add to the inflammation. Aspiration pneumonia=infection of the lung. Aspiration of 'chunks' (e.g. food)=lobe or lung collapse Material from decaying teeth = lung abscesses Pneumonitis is… A sterile lung abscess and lung inflammation (a 'burn' of the lung), which is usually caused by aspiration of large amount of acidic material (e.g. gastric contents) however differential diagnosis is difficult because a clear history is the only way to tell.

11. Our search for evidence Databases searched: Ovid (embase, Medline, Cinahl, PsychInfo, SpeechBITE, Google....) Reference Lists: ASHA conference, references from other relevant articles

12. Critically Appraised Papers Evaluated 14 articles 2 articles relevant to clinical question Robbins et al (2008) Groher (1987)

13. Article 1...Robbins et al 2008 Study Aim:To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened fluids on the 3-month cumulative incidence of pneumonia. Design/Method: • Randomised, controlled parallel design trial • 515 patients with dementia or Parkinson’s disease who aspirated on thin fluids during MBS. • Patients were randomly assigned to two groups: • Chin tuck posture • Thickened fluids group: this group were randomly assigned again into nectar thick and honey thick groups. • Procedures put in place for adherence to the interventions • Followed up for 3 months or until death • Adverse events including pneumonia, death, dehydration, UTI were monitored.

14. Results: • Cumulative incidence of pneumonia was much lower than expected overall. • The incidence of pneumonia was greater in the chin down group compared to the thickened fluids group. • The incidence pneumonia was greater in the honey thick fluids group compared to the nectar thick fluids group. • Increased incidence of dehydration, UTI and fever in group receiving thickened liquids.

15. Level of Evidence: II • Strengths: • Statistical Analysis • High level of evidence • Limitations: • Adherence to interventions problematic (although this probably reflects real life!!) • Patients for whom one or two interventions worked were excluded from the 3 month follow-up with regard to adverse outcomes. This means we do not know if patients who had not aspirated with honey thick, for example (when they were still aspirating nectar and thin with chin down), would have been less likely to experience adverse outcomes if treated with this, than those who were still aspirating. • Use of chin-down posture with patients with dementia (? Difficulty learning and remembering the technique) • No comment as to severity of PD or dementia in patients.

16. Therefore… Clinical Bottom Line: • Too difficult to make any definitive conclusions as to whether thickened fluids reduce the risk of aspiration pneumonia. It appears that the rate of pneumonia was lower than expected for this population…we are unable to say if one treatment was responsible for this above the others. • Further research into the merits of neck flexion and nectar-thick fluids combined is needed. • Recommending thickened fluids for patients who are aspirating thin and thick fluids should be carefully considered.

17. Article 2 …Groher 1987 Study Aim:To study the effect of bolus manipulation on the recurrence of aspiration pneumonia in patients with pseudobulbar dysphagia. Design/Method: • Randomised controlled trial • 56 patients with histories of pseudobulbar dysphagia from chronic care facilities. • Selection criteria included a history of one or more episodes of aspiration pneumonia that had resolved at least one month before the study and oral intake of a puree diet and fluids. • Study went over three years and patients followed up for six months

18. Subjects randomly assigned into two groups: • Pureed foods and thin fluids • Soft mechanical diet with altered fluids such as half-frozen juices, thickened nectars and milk products and jello prepared with excess water. • Monthly examinations and bi monthly CXR’s Results: • After 6 months there were 28 incidences of aspiration pneumonia in group 1 and 5 incidences in group 2. The difference was statisticallysignificant.

19. Level of Evidence:II • Strengths: • High level of evidence • Statistical analysis • Limitations: • Lack of instrumental assessment (e.g. MBS) prior to study – what was their swallowing status/aspiration risk? • Unclear as to what types of fluids the patients were on prior to entering the study. • Unclear as to what contributed to the reduction of pneumonia in group 2 Description of the thickened liquids used is unclear. • The use of half frozen juices and jello in group 2

20. Therefore… Clinical Bottom Line: The incidence of pneumonia was significantly less in patients given a mechanical soft diet and thickened fluids, however it is unclear as to how much the use of thickened fluids contributed to this decreased incidence.

21. CAT: Clinical Bottom Line Question: In adults with dysphagia do thickened fluids reduce the incidence of aspiration pneumonia? Answer: Dysphagia management appears to reduce the likelihood of aspiration pneumonia however more research is needed to determine the exact role that thickened fluids play.

22. Discussion • Limited number of relevant articles – Did we need to broaden our clinical question? • Most articles looked at aspiration and not aspiration pneumonia. • Articles looked at combinations of thickened fluids and compensatory strategies • Methodological limitations created by: • Ethical issues in conducting this type of research -Unable to have a control group in some instances as it is not ethical to provide no treatment for patients with known dysphagia and aspiration. • Poor description of diets, particularly thickened fluids.

23. Where to from here? Possible topics/areas of interest for 2009? Hydration and thickened fluids Aspiration of food vs. liquids, and associated risk of pneumonia Free water protocols

24. Questions?

25. References • Robbins J. Gensler, G., Hind, J., Logemann, JA., Lindblad, AS., Brandt, D. Baum, H., Lilienfeld, D., Kosek, S., Lundy, D., Dikeman, K., Kazandjian, M., Gramigna, GD, McGarvey-Toler S. & Miller-Gardner, PJ. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized Trial. Annals of Internal Medicine, 148(7): 509-518. • Groher, M.E. (1987). Bolus Management and Aspiration Pneumonia in Patients with Pseudobulbar Dysphagia. Dysphagia, 1, 215-216. • Campbell-Taylor I, Panther K. Should patients who aspirate thin liquids be given water? ASHA 1998; 40:12-13. • Langmore, S.E., Terpenning, M.S., Schork, A., Chen, Y., Murray, J.T., Lopatin, D. & Loesche, W.J. (1998). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia, 13(2), 69-81. • www.patient.co.uk • www.sklung.ca/graphics/anatomy • www.americandysphagianetwork.org • www.medkast.libsyn.com

26. Contacts Dysphagia EBP group leaders 2008 Lisa Howard lisa.howard@sesiahs.health.nsw.gov.au Eva Katalinic eva.katalinic@sesiahs.health.nsw.gov.au