Things We Do for No Reason: The Use of Thickened Liquids in Treating Hospitalized Adult Patients with Dysphagia

In patients who have extreme choking with water intake, restricting access to oral water may be reasonable to avoid the physical stress of coughing. Similarly, in end-of-life situations, if coughing is so bothersome to patients or families as to be inconsistent with goals of care, then thickened liquids for comfort measures may be reasonable. Finally, Foley et al. found that combining thickened liquids with texture-modified diets and intensive training sessions with speech-language pathologists focused on swallowing techniques led to a reduced risk for aspiration pneumonia during the first seven days following an acute stroke. Since risk reduction did not persist after seven days, prolonged modification is likely not helpful.⁴

Access to free water is important for hydration, quality of life, and delirium prevention. A collaborative approach with nurses, speech therapists, and caretakers should be employed to focus on strategies to prevent aspiration pneumonia via positioning, oral hygiene, and patient and family education. Postural adjustment with the chin-down posture alters the flow of the bolus during the pharyngeal phase of the swallow.^14,17 This technique has shown superior safety when directly compared with thickened liquids without any difference in aspiration pneumonia rates.¹⁴ In addition, oral hygiene for patients who cannot perform oral care themselves should be implemented to decrease the amount of pathogenic bacteria in secretions.^1,15 Finally, ensuring that patients and families understand the risks and benefits of access to free water is paramount.

Tube feeding (eg, nasogastric and gastric tubes) allows for reliable delivery of enteral nutrition and medications. Tube feeding does not decrease aspiration events compared with oral diets. Moreover, the risk of developing aspiration pneumonia appears to be similar among gastrostomy, nasogastric, and postpyloric feeding tubes.⁵ This approach may be preferable, though, when the dysphagia is the result of a structural abnormality such as stroke deficit, neoplastic changes, or surgical alteration of the larynx.

Free water protocols use an interdisciplinary approach to safely improve access to water for patients with dysphagia. Free water protocols involve screening high-risk populations such as the elderly, confused, or stroke patients with a bedside swallow evaluation. Those with difficulty following directions, who are unable to limit their drinking to manageable-sized sips, or with excessive cough are restricted to supervised water drinking with access to water only between meals (30 minutes after a meal) and with aggressive oral hygiene. Posturing techniques with the chin-down position may be employed. Patients and their families must be educated on protocol implementation and rationale.^1,9,12

Overall, free water protocols have demonstrated an improvement in quality of life, no change in adverse events, and improved water intake. SWAL-QOL scores were significantly improved by nearly three points (P < .05).¹⁵ There was no significant difference in the odds of developing aspiration pneumonia when comparing those on thickened liquids to those with access to free water.^1,9,12 Furthermore, one study by Loeb et al. even found that those allocated to a thickened liquid group were more likely to develop aspiration pneumonia, although this difference was not statistically significant.⁹ Finally, those given access to free water had higher amounts of fluid intake by a mean of 180 ml.¹