Dysphagia Myths – Busted!

Written by Leon and Athanasia Daley, co-owners of Daley Dysphagia Diagnostics, LLC.

Dysphagia, or a swallowing disorder, can lead to serious affects that could impact someone’s
nutrition status, overall well-being, and quality of life. As medical professionals, it is important
that we stay up to date with what the evidence suggests to provide the most effective care
possible. There are many myths floating around and Speech-Language Pathologists have to
educate patients, families, and other medical staff to combat the spread of misinformation.
Through proper education and collaboration, we can all work to improve patient outcomes,
reduce risk of hospitalization, and promote quality of life in our patients living with dysphagia.
Here are some myths that we busted!

Myth #1:
The Thicker the Liquid, the Better the Swallow!

• FICTION:
  • Thickener always prevents aspiration. If someone coughs with thin liquid, give them
    nectar (mildly thick) or honey (moderately thick) thickened liquids.
• FACT:
  • Thickened liquids do not prevent aspiration in all people with dysphagia (Kaneoka et al,
    2017; Vilardell et al, 2016).
  • Studies have shown that up to 40% of individuals aspirate nectar thickened liquids
    (Vilardell et al, 2016).
  • Pulmonary injury is worse in individuals aspirating cornstarch-based thickeners. Xanthan
    gum-based thickeners, though better than cornstarch-based thickeners, are worse for the
    lungs than thin water (Nativ-Zeltzer et al., 2018).
  • Thickened liquids have been associated with dehydration, which can also lead to negative
    health outcomes such as UTI, electrolyte imbalance, constipation, fecal impaction,
    cognitive impairment, failure to thrive, and even death (Langmore, 2002; Panther, 2016).
  • In 2008, 150,000 elderly adults were admitted to the hospital for dehydration, costing
    more than $2 billion (Panther, 2016).
  • No significant difference was noted regarding the appreciation of aspiration pneumonia
    between individuals on thin and thickened liquids in low-risk patients (Kaneoka et al,
    2017; Panther, 2016).

Myth #2:
A Chin Tuck Fixes Everything

• FICTION:
  • If any person has trouble swallowing, using a chin down or chin tuck maneuver will
    improve the swallow and mitigate aspiration.
• FACT:
  • While the chin tuck maneuver can be helpful for some individuals, it can decrease
    swallow safety or have no benefit at all in others (Logemann, 1993; Sheffler, n.d.).
  • Only a FEES or MBSS can tell us if a chin tuck is effective by assisting in redirecting the
    bolus away from the airway, thus improving swallow safety.
  • Terre & Mearin (2012) found the chin tuck maneuver to be effective in only 55% of
    individuals with dysphagia.

Myth #3:

PEG Tubes = NPO

• FICTION:
  • Patients only have PEG tubes if there is a severe dysphagia present. In which case, these
    patients should be kept strictly NPO because there is little to no chance of the patient
    being able to tolerate a PO diet.
• FACT:
  • Although PEG tubes are frequently placed due to severe dysphagia, the presence of a
    PEG tube does not necessarily mean that the patient is not safe to accept solids/liquids by
    mouth.
  • PEG tubes are often placed due to significantly reduced oral intake or an inability to
    achieve adequate nutrition/hydration by mouth.
  • Most often this is secondary to head/neck cancer or acute illness/injury resulting
    in decreased alertness or ability to eat (Shaw et al., 2015)
  • Frequently, patients significantly improve functioning in post-acute care settings,
    meaning they can participate in therapeutic exercises for dysphagia (which often involves
    trials of PO intake) and work towards weaning from the PEG (Mittal et al, 2015).

Myth #4:
Break The Silence!

• FICTION:
  • If a patient does not cough while eating/drinking, they don’t have dysphagia.
• FACT:
  • Silent aspiration (aspiration with no overt cough or other sensory response) occurs in as
    many as 25-52% of patients in the acute care setting (Leder et al, 2011).
  • Although a cough or throat clear doesn’t necessarily mean dysphagia or that
    someone is aspirating either!
  • Oral dysphagia may not result in aspiration but can have a profound negative effect on an
    individual’s health status.
  • Decreased mastication may lead to decreased appetite and reduced food intake
    (Hollis, 2018).
  • Presence of oral dysphagia doubles the likelihood of depression in elderly adults
    (Shin et al., 2016).

Myth #5:
Sponge Swabs are Effective and Adequate for Oral Care

• FICTION:
  • Using a sponge swab dipped in mouthwash is adequate for oral care.
• FACT:
  • Sponge swabs are not successful in removing built-up plaques and biofilm that manifest
    pathogenic microorganisms (which contributes to the development of aspiration
    pneumonia) (Sheffler, 2018).
  • Nothing is more effective at decreasing the development of gram-negative bacteria than
    thorough cleaning with a toothbrush and toothpaste! (Sheffler, 2018)
  • For tube fed patients, Maeda & Akagi (2014) found that pneumonia was twice as likely in
    the group that had no oral care protocol as compared to those getting oral care. They
    additionally found that standard oral care given twice daily resulted in a 40% decrease in
    hospitalizations.

Myth #6:

Aspiration Always Leads to Pneumonia

• FICTION:
  • If a patient is seen to aspirate on an instrumental assessment, they will get pneumonia
    unless they are recommended thickened liquids, altered diet consistencies, or NPO.
• FACT:
  • We know there are 3 main factors that contribute to the development of aspiration
    pneumonia (Ashford, n.d.):
    • Compromised Immune System
    • The Presence of Aspiration
    • Poor Oral Health
  • Susan Langmore (2002) listed the predictors of aspiration pneumonia to be:
    • Suctioning
    • Chronic Obstructive Pulmonary Disorder (COPD)
    • Congestive Heart Failure (CHF)
    • Presence of Feeding Tube
    • Bedridden
    • High Case Mix Index
    • Delirium
    • Weight Loss
    • Dysphagia
    • Urinary Tract Infection (UTI)
  • Research shows that 18% of healthy young adults silently aspirate regularly without
    pulmonary complications reported (Butler et al, 2018).
  • Only 12% of individuals who aspirate actually develop an aspiration-related pneumonia
    (Robbins et al., 2008).

Myth #7:
PEG Tubes Improve Outcomes

• FICTION:
  • PEG tubes are the end-all-be-all for prevention of aspiration and pneumonia, improving
    outcomes and reducing deleterious effects from dysphagia.
• FACT:
  • Patients with PEG tubes are often kept NPO, which prevents rehabilitation of the swallow
    mechanism with the use of bolus-drive exercise programs (Mittal et al, 2015).
  • Individuals with PEG tubes are likely to encounter negative outcomes such as aspiration
    of reflux which can lead to aspiration pneumonitis, pneumonia, malnutrition, site
    infections, or GI bleeds, (Komiya et al, 2018).
  • There is no current supportive evidence justifying the use of PEG tube feeding in
    improving outcomes for individuals with dementia or dysphagia (Komiya et al, 2018).
    In Conclusion:
  • Aspiration pneumonia doesn’t occur in isolation. There are multiple factors that
    contribute to the development of aspiration pneumonia (Ashford, n.d.).
  • Modifying diets or using compensatory strategies without instrumentals can lead to poor
    outcomes or even death (Langmore, 2002; Panther, 2016).
  • Swallow compensation techniques need to be tested during an instrumental test to
    determine whether they are effective (Logemann, 1993; Sheffler, 2015; Terre & Mearin,
    2012).
  • PEG tubes don’t necessarily lead to improved outcomes (Komiya et al, 2018).
  • Nothing beats a toothbrush! (Sheffler, 2018)

References

• Ashford, J. R. (n.d.). Three Pillars of Pneumonia. Retrieved from
  http://www.sasspllc.com/three-pillars-pneumonia/
• Butler, S. G., Stuart, A., Markley, L., Feng, X., & Kritchevsky, S. B. (2018). Aspiration
  as a Function of Age, Sex, Liquid Type, Bolus Volume, and Bolus Delivery Across the
  Healthy Adult Life Span. Annals of Otology, Rhinology, & Laryngology, 127(1), 21–32.
• Hollis, J. H. (2018). The effect of mastication on food intake, satiety, and body weight.
  Physiology & Behavior, 193(April), 242–245.
• Kaneoka, A., Pisegna, J. M., Saito, H., Lo, M., Felling, K., Haga, N., … Langmore, S. E.
  (2017). A systematic review and meta-analysis of pneumonia associated with thin liquid
  vs . thickened liquid intake in patients who aspirate. Clinical Rehabilitation, 31(8),
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• Komiya, K., Usagawa, Y., & Kadota, J. (2018). Decreasing Use of Percutaneous
  Endoscopic Gastrostomy Tube Feeding in Japan. Journal of the American Geriatrics
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• Langmore, S. E., Skarupski, K., Park, P., & Fries, B. (2002). Predictors of Aspiration
  Pneumonia in Nursing Home Residents. Dysphagia, 17(4), 298–307.
• Leder, S. B., Suiter, D. M., & Green, B. G. (2011). Silent Aspiration Risk is Volume-
  dependent. Dysphagia, 26, 304–309.
• Logemann, JA (1993). Manual for the Videoflourographic Study of Swallowing: Second
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• Maeda, K., Akagi, J. Oral care may reduce pneumonia in the tube-fed elderly: a
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• Mittal, R., Mishra, A., & Nilakantan, A. (2015). Therapeutic interventions by speech
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• Shaw, S. M., Flowers, H., Sullivan, B. O., Hope, A., Liu, L. W. C., & Martino, R. (2015).
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• Sheffler,K. The Toothbrush Defense. The ASHA Leader, May 2018.
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• Terre, R. & Mearin F. (2012). Effectiveness of chin-down posture to prevent tracheal
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• Robbins, J., Gensler, G., Hind, J., Logemann, J., Lindblad, A., Brandt, D., … Miller
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• Vilardell, N., Rofes, L., Arreola, V., Speyer, R., & Clave, P. (2016). A Comparative Study
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