Should the SLP trial thickened liquids without a swallow study?

This question keeps coming up again and again. So, should the SLP trial thickened liquids at bedside? What once seemed like a really easy answer for me (No), has turned into a more thoughtful response (Maybe). It’s not an easy answer and depends of course on many variables. So let’s get started…

Access to a swallow study

First things first, do you have access to a swallow study? No? Why not? When can you schedule one? Longer than 24 hours? What is the delay? Can this be changed? Why or why not? Do you like questions? Would you like me to write the rest of this article in question form because I can if that’s what you like?

The point here (Which has probably been drilled into your head as much as it has mine) is that we need an instrumental study to properly assess dysphagia. There are several reasons for this, but the most obvious is that we cannot rule out silent aspiration without visualization. To complicate things, thickened liquids may actually come with an increased risk of silent aspiration. There aren’t any clinical signs of silent aspiration. Which isn’t surprising because… well because it’s silent. A consecutive water swallow test such as with the Yale Swallow Protocol might be our best tool for improving the ability to detect aspiration clinically when the risk for silent aspiration is high, but still… If it’s silent, we won’t hear it.

Wait it out

Let’s assume that we don’t have access to an instrumental study for more than 24 hours. Should we then just wait it out until we DO have access? For some, this time frame could be days. For others, it could be weeks. And for a few, it could be never. Then we are essentially waiting for nothing and leaving the patient in limbo is not a very effective management approach. So, what can we do in the meantime?

Risk assessment

We know that a throat clear or a cough immediately after the swallow that is only occurring during PO intake is a decent enough clinical sign of aspiration at the bedside. We can at least agree on that. With this in mind let’s say your patient is coughing on thin liquids, but not on mildly thick liquids. While the risk is of silent aspiration increases with mildly thick liquids, the risk of aspiration overall is less with thick than it is with thin. OK, so the risk is lower, but we can’t accurately assess that risk. So recommending thickened liquids for this patient is sort of like sticking our heads in a slightly more pleasant sand. Not to say it’s the best option, but maybe it’s the least bad one.

Other risks

Of course looking for a cough is not a comprehensive assessment. A trained monkey can do that. We can’t see the whole “map” without zooming out a bit and looking at all the factors. What is the risk of aspiration pneumonia? How about the risk of weight loss? Dehydration? Decreased quality of life? Or the risks associated with being unable to take medications? And how about ALL of the risks associated with thickened liquids. The funny thing about reading this “map” is that it’s written in 8 different languages so you need at least that many people alongside you to help you read it and figure out what’s going on (Just a little interdisciplinary team analogy for ya). We simply can’t figure these things out by ourselves. You’d need to live 8 different lives to gain as much knowledge that your various colleagues can bring to the table. Since I’ve never met anyone who is 800 years old, let’s use our team to help us with some of these tough decisions.

Baseline status

Something else we should consider when making a recommendation at bedside is what the baseline status is. Was this a patient who was eating and drinking normally yesterday or a bed-bound patient in the nursing home who was diagnosed with dysphagia a decade ago? Were they already on thickened liquids before you saw them or is this just a temporary condition that should resolve in the coming days/weeks? This may help you determine if thickened liquids might only be used temporarily or if it’s more of a long term option (Which changes the risk profile). This reminds me, what is the prognosis anyway?

Prognosis

Knowing the prognosis of the condition may help us determine how long the patient will require thickened liquids. For example, is this an acute stroke or ALS? Alcohol withdrawal or Parkinson’s? If the patient is suffering from a temporary condition that is expected to resolve soon, then we can assume those long-term consequences of taking thickened liquids may not be as much of a concern if it’s only recommended for a couple of days. Compare this with a patient with a degenerative disorder who will have to decide whether the thickened liquid is something she might accept going forward?

Patient preferences

What does the patient want? This is usually not a single answer and often requires multiple discussions so the patient has time to understand and reflect on the different variables at play. What the patient wants often trumps any other factor. A patient or family member with a full understanding of the condition should be able to make up their own minds when it comes to their care. We are only the guides to help give them a detailed understanding of the condition and the various risk factors so they can make an informed decision. Some people don’t mind thickened liquids for a day, a week, or even forever. Others take a sip and make a face that looks like they ate a grape fruit. If a tree falls in the forest and nobody is there to hear it, did it make a sound? Similarly, if a patient is recommended thickened liquids and they don’t drink it, does it have any value?

Think outside the box of thickener

What if the question wasn’t black and white (hint hint: it’s not)? What if it wasn’t a question of thickened or thin, but a question of what works for this patient? Small amounts of water? Ice? How about starting on thickened liquids and gradually introducing thinner consistencies while monitoring closely? What about providing the patient with a limited amount of their targeted consistency (i.e. juice, coffee, soda, etc.) or freezing it and turning it into ice chips to make it even safer. This might help for practice and for pleasure. The point here is that there are options. Let’s expand our perspective and entertain any number of possibilities that might work for the patient by thinking outside the thickener packet.

So, should we recommend thickened liquids at bedside or not?

As you can see, the answer isn’t always that easy. If it was, nobody would hire us to make these decisions. In short, I can safely say that, yes, there are times a recommendation for thickened liquids after a clinical assessment is appropriate. Say a patient is incessantly coughing and super uncomfortable with thin liquids, is open to thickened liquids at least temporarily, and has a good chance of recovering from their dysphagia in the next few days. Thickened liquid has a place in many clinical scenarios such as this. It can reduce the risk of aspiration and thus the risk of aspiration pneumonia while improving comfort, quality of life, and even hydration in the short term. But we still need to acknowledge that without a swallow study our heads are always at least a little bit in the sand. Even if the sand is slightly more comfortable.

Enjoy learning about clinical decision making? Consider taking our short course, Complex Decision-Making in Dysphagia Management to learn more.