Talking Points in Response to a Recent Article in the Journal of the American Medical Directors Association
Campbell-Taylor, I. (2008). Oropharyngeal dysphagia in long-term care: Misperceptions of treatment efficacy. Journal of the American Medical Directors Association, 9, 523-531.
Letter to the editor from ASHA President Catherine Gottfred.
Oropharyngeal dysphagia assessment and treatment efficacy: setting the record straight (response to Campbell-Taylor)-full-text version
1. Is the use of videofluoroscopy warranted for evaluating dysphagia in the LTC population?
Campbell-Taylor criticizes the use of videofluoroscopy (also known as the modified barium swallow procedure) to evaluate swallowing, arguing that the procedure does not deserve to be considered a "gold standard" due to its potential to yield both false negative and false positive results with respect to identifying aspiration (the entry of material into the airway below the level of the vocal folds). Campbell-Taylor argues that the sensitivity and specificity of a full bedside examination to detecting aspiration is adequate and does not justify further examination using instrumentation.
- A videofluoroscopic swallowing study (VFSS) is not always required to confirm the presence of dysphagia. However, a bedside swallowing test is usually not adequate for defining the nature and severity of dysphagia, particularly for pharyngeal phase abnormalities or in cases of silent aspiration (aspiration without overt clinical signs such as cough). (1)
- In the case of pharyngeal phase abnormalities, a VFSS provides a direct opportunity to evaluate the effectiveness of compensatory maneuvers that may improve airway protection and facilitate the delivery of nutrients to the digestive system.
- Some dysphagia interventions may be unhelpful or even maladaptive for particular patients (2-5). Therefore, it is important to instrumentally observe the effect (and effectiveness) of specific interventions prior to recommending them for patients.
2. How effective are thickened liquids for preventing aspiration and pneumonia?
Campbell-Taylor argues that the results of two recent articles in the dysphagia literature show that thickened liquids are not effective as an intervention for dysphagia or aspiration.
- The studies to which Campbell-Taylor is referring report results from the largest randomized clinical trial of dysphagia interventions completed to date (6-7).
- The first article (6) confirms that one or more of 3 different interventions (swallowing thin liquids in a chin tuck position, the use of nectar-thick liquids and the use of honey-thick liquids) effectively eliminated aspiration in 51% of 711 individuals with dementia or Parkinson's disease who aspirated thin liquids. To dismiss this finding as showing that thickened liquids "do not work" is an inaccurate interpretation.
- Individuals who showed a preferential response (i.e. better aspiration reduction) on one, but not all three, of the interventions investigated in the first article were advised to implement the intervention that had proven most effective for them, but their health status outcomes were not monitored over the subsequent 3 months. They were not included in part II of the study. We do not know whether implementation of these interventions translated to favorable outcomes in these participants.
- The second article (7) reports health status outcomes over 3 months in the 515 participants who had truly equal chances of responding favorably (or unfavorably) to the experimental interventions. It must be recognized that 2/3 of these participants were previously confirmed to have continuing aspiration, despite any of the tested interventions. If such continuing aspiration constituted a direct risk for the development of pneumonia in the ensuing 3-month period, then one could have expected the pneumonia incidence in the study to approach 66%. The cumulative incidence of pneumonia experienced in part II of the study was, in fact, much lower: 8% for those on nectar-thick liquids; 12% for those employing the chin-tuck posture; and 15% for those on honey-thick liquids. Population estimates of pneumonia incidence are 10% for individuals aged 75 or older residing in nursing homes.
3. Can aspiration be prevented, and is it important to do so?
Campbell-Taylor argues that it is a misconception that aspiration can and must be prevented.
- Dysphagia intervention techniques are unlikely to address or limit occurrences of aspiration of saliva or gastroesophageal reflux. However, prandial aspiration (aspiration during the swallowing of food and liquid) can and should be prevented. Prandial aspiration serves as a direct vehicle for transporting pathogenic bacteria into the respiratory system (8-10). When aspiration of food and/or liquid is confirmed during swallowing assessment, it is incumbent upon clinicians to explore any interventions that successfully limit the aspiration of those items and to recommend such interventions in order to limit the opportunities by which bacteria travel to the lungs.
- The impact of a modest 10% reduction in either hospital admissions or in length of stay for aspiration pneumonia could save the health care system hundreds of millions of dollars each year and eliminate thousands of deaths annually (11).
4. Is there evidence to support the field of dysphagia intervention?
Campbell-Taylor lodges harsh criticism against the field of dysphagia intervention, citing a relative lack of evidence, a paucity of randomized controlled trials, and questionable applicability of results from research of better-studied population groups (i.e. stroke) to other groups (i.e. individuals in long-term care).
- Healthcare practices are constantly evolving as knowledge improves and changes. Many accepted medical practices have lacked robust evidence throughout history. While randomized controlled trials have become the accepted "gold standard", they are not always necessary to demonstrate effect (either positive or negative) (12). Dysphagia therapy is designed to reduce adverse sequelae, but complete elimination of sequelae is not possible in any disease/disorder treatment.
- While there may be some underqualified clinicians involved in dysphagia management, there are also underqualified physicians, dentists, pharmacists and lawyers practicing. Within the field of speech-language pathology, ASHA has an active Special Interest Division, professional development programs, and Specialty Recognition in Swallowing Disorders to support SLPs in continually advancing their knowledge and practice in dysphagia.
- McCullough, G. H., Wertz, R. T., & Rosenbek, J. C. (2001). Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke. Journal of Communication Disorders, 34, 55-72.
- Chaudhuri, G., Hildner, C. D., Brady, S., et al. (2002). Cardiovascular effects of the supraglottic and super-supraglottic swallowing maneuvers in stroke patients with dysphagia. Dysphagia, 17, 19-23.
- Ludlow, C. L., Humbert, I., Saxon, K., et al. (2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia, 22, 1-10.
- Garcia, J. M., Hakel, M., & Lazarus, C. (2004). Unexpected consequences of effortful swallowing: Case study report. Journal of Medical Speech-Language Pathology, 12, 59-66.
- Fujiu, M. & Logemann, J. A. (1996). Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5, 23-30.
- Logemann, J. A., Gensler, G., Robbins, J., et al. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's Disease. Journal of Speech-Language-Hearing Research, 51, 173-183.
- Robbins, J., Gensler, G., Hind, J., et al. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized trial. Annals of Internal Medicine, 148, 509-518.
- Langmore, S. E., Terpenning, M. S., Schork, A., et al. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13, 69-81.
- Loeb, M. B., Becker, M., Eady, A., & Walker-Dilks, C. (2003). Interventions to prevent aspiration pneumonia in older adults: a systematic review. Journal of the American Geriatric Society, 51, 1018-1022.
- Millns, B., Gosney, M., Jack, C. I., et al. (2003). Acute stroke predisposes to oral gram-negative bacilli-A cause of aspiration pneumonia? Gerontology, 49, 173-176.
- Centers for Disease Control and Prevention. (1999). Prevalence of disabilities and associated health conditions among adults-United States, 1999 (Rep. No. MMWR 50(7)). Atlanta, GA: U.S. Department of Health and Human Services.
- Smith, G. C. S & Pell, J. P. (2003). Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of randomised controlled trials. British Medical Journal, 327, 1459-1461.