Speech-language pathologists are faced with a great deal of information about swallow interventions. This information comes to us from a wide variety of sources – websites, journals, blogs, and other clinicians – and can often be conflicting. Conventional wisdom is passed along from clinician to clinician, at times without regard for the accuracy of the information.
It is critical to separate evidence-based information from “swallow myths” because what we think we know might actually harm our patients.
Swallow Myth #1: Laryngeal Penetration is Abnormal
I have heard many clinicians report “my patient demonstrated laryngeal penetration on the instrumental assessment, so we’re recommending thickened liquids.”
Laryngeal penetration can be a normal finding across age groups, but it is particularly common in the elderly. The key to evaluating laryngeal penetration is to assess its depth. Shallow penetration that doesn’t approach the vocal folds is normal and typically doesn’t elicit a protective airway response such as a cough or throat clear. This can occur at any time, but is most often observed with serial swallows and with larger liquid boluses.
Swallow Myth #2: Thick Liquids Are Safer Than Thin Liquids
As dysphagia interventions have developed, this created an industry committed to altered diets. Products like texture-modified molded foods, pre-thickened liquids, starch thickeners, and xanthum gum thickeners came into existence due to dysphagia therapy growth. The belief that thick liquids are safer and less likely to cause aspiration has not only driven this product development, but has resulted in many more clients drinking thickened liquids than perhaps is necessary.
The potential effectiveness of thick liquids as an intervention depends on the specific swallow physiology disorder present in each patient, such as:
- Disorders of timing – including reduced oral containment, delayed swallow response, and slowed hyo-laryngeal excursion and laryngeal valve closure – may improve with thick liquids. Thick liquids slow the liquid flow rate and can result in safer, more efficient swallows.
- Disorders of motility – such as reduced tongue propulsion, impaired tongue base retraction, and limited pharyngeal stripping – are generally not improved with thickening. In fact, thick liquids in these patients may exacerbate the degree of impairment, pharyngeal retention, and aspiration risk.
Swallow Myth #3: Tube Feeding Eliminates Aspiration Pneumonia Risk
The use of percutaneous endoscopic gastrostomy (PEG) tubes has increased dramatically for the elderly in the last two decades. Tube feeding is not without drawbacks, including the need for medical oversight, an increased caregiver burden, and the medical complications (e.g. reflux, bleeding, and infection).
In patients with dementia, there is no evidence that tube feeding improves nutrition, life expectancy, functional status, or reduces aspiration risk. In many patients, tube feeding actually increases the risk of aspiration pneumonia, particularly when the tube feeding is combined with the poor oral care, which often accompanies non-oral feeding of institutionalized patients.
In conclusion, conventional wisdom for swallow interventions may not always be accurate. With large amounts of information available, it’s important for SLPs to separate hard facts from myths when prescribing an intervention. Doing so empowers clinicians to provide the highest level of care possible for their patient.
- Allen, J., et al, “Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia”,Otolaryngology, Head and Neck Surgery, 142, 208-13, 2010.
- Butler, S., et al, “Penetration and Aspiration in Healthy Older Adults as assessed During Endoscopic Evaluation of Swallowing”, Annals of Otology, Rhinology and Laryngology, 118(3), 190-98, 2009
- Choi, KH, et al, “Kinematic Analysis of Dysphagia: Significant Parameters of Aspiration Related to Bolus Viscosity”, Dysphagia, 26, 392-98, 2011.
- Finucane, T., et al, “Tube feeding in patients with advanced dementia: A review of the evidence”, Jnl American Medical Association, 282, 1365-70, 1999
- Kimyararov, S., et al, “Percutaneous endoscopic gastrostomy tube feeding of nursing home residents is not associated with improved body composition parameters”, J Nutr Health Aging, 17(2), 162-65, 2013
- Murphy, L., and Lipman, T., “Percutaneous Endoscopic Gastrostomy does not prolong survival in patients with dementia”, Archives of Internal Medicine, 163, 1351-53, 2003.
- Robbins, et al, “Differentiation of Normal and Abnormal Airway Protection During Swallowing Using the Penetration – Aspiration Scale”, 14, 228 – 232, 1999.
- Robbins, J., et al, “Comparison of two interventions for liquid aspiration in pneumonia incidence: a randomized trial”, Ann Internal Medicine, 148(7), 509-18, 2008.
- Verhoef, and Van Rosendaal, “Patient outcomes relate to percutaneous endoscopic gastrostomy placement”, Jnl Clinical Gastroenterology, 32, 49-53, 2001