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Article Excerpt
Consistent evaluation and management of patients with swallowing disorders requires that clinicians access a common clinical knowledge base with regard to normal and disordered swallowing physiology as well as principles of intervention. Recommendations for patients are made based in part on the clinician's level of familiarity with this knowledge base. This study surveyed 200 speech-language pathologists with regard to aspiration and clinical interventions; 78 surveys were returned and analyzed. Levels of agreement were determined for five questions regarding the nature of aspiration and five questions regarding interventions. There were no significant differences in response patterns based upon demographics of work setting, years of experience, or formal education in dysphagia. Agreement scores revealed variability in agreement with statements regardless of whether the statements were supported in the medical literature. Patterns of clinical decision making related to identified aspiration are discussed.
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Most speech-language pathologists (SLPs) working in hospitals and residential health care settings provide diagnostic and therapeutic services to patients with dysphagia (ASHA, 2001). SLPs generally possess education and clinical training in swallowing disorders, and they have therefore assumed much responsibility for providing recommendations for management of patients with dysphagia. Their responsibilities include completion of bedside and instrumental assessments, recommendations for diet consistencies, provision of dysphagia therapy, counseling for patients and families, education of other professionals about dysphagia, and advancing the knowledge base regarding swallowing and swallowing disorders (ASHA, 2001). An extensive list of knowledge and skills that clinicians should possess to provide services to individuals with dysphagia has been described (ASHA, 2002).
The field of dysphagia has grown with such rapidity that in 1985, 35% of clinicians in health care settings provided dysphagia services, and in 2000 these percentages exceeded 90% (ASHA, 2001). The Knowledge and Skills Assessment completed by graduate students includes education in dysphagia, and a curriculum has been suggested for graduate training (ASHA, 1997). There are, however, no data available at present to determine the degree to which graduate coursework meets either these recommendations or the knowledge and skills described (ASHA, 2002).
Many SLPs base clinical recommendations on information obtained from instrumental evaluations (Murry & Carrau, 2001); however, many other factors must be considered when managing patients with dysphagia. There is a vast literature available on swallowing and swallowing disorders from both the speech-language pathology and the medical perspectives. However, a thorough exploration of the literature may not have occurred during graduate school, when students might not have even had a course in dysphagia (PSHA Committee on Dysphagia, 2002), or if taken, the course may not have emphasized the medical literature. The rapid growth of the field, the expansion of the literature, and the lack of data regarding consistency of training across academic programs combine to create uncertainty regarding the knowledge base of clinicians making recommendations for patients in their care.
A literature review regarding dysphagia and aspiration reveals another dilemma. In any field, information published in peer-reviewed references may contradict information located in other references (West, King, & Carey et al., 2002); these types of inconsistencies are also noted when examining the pathophysiology of aspiration and pneumonia. Aspiration of food and fluids has traditionally been thought to cause aspiration pneumonia (Barczi, Sullivan, & Robbins, 2000; Logemann, 1997; Murry & Carrau, 2001), forming the rationale for the modified diets often recommended. However, this concept is not supported across the literature as a cause-effect relationship (Daly, 2000; Feinberg, Knebl, & Tully et al., 1990; Finestone, Greene-Finestone, Wilson, & Teasell, 1995; Martin-Harris, Logemann, & McMahon et al., 2000; Gillick, 2000). Respiratory infections often result from poor oral hygiene and aspiration of saliva (Gillick, 2000; Langmore, Terpenning, & Schork, et al., 1998), aspiration of oral bacteria (Finestone et al., 1995), aspiration of reflux (Barczi et al., 2000; Finestone et al., 1995; Martin-Harris et al., 2000), reduced immune system response (Daly, 2000; Feinberg et al., 1990; Feinberg, Knebl, & Tully, 1996), dependence on another for feeding (Langmore et al., 1998), and reduced mobility (Feinberg et al., 1996; Langmore et al., 1998). There are also different aspiration syndromes (i.e., aspiration pneumonitis versus aspiration pneumonia) that have different clinical causes and medical management strategies, but these are rarely differentiated by physicians referring to speech pathology (Marik, 2001; Marik & Kaplan, 2003; Mylotte, Goodnough, & Naughton, 2003; Mylotte, Goodnough, & Gould, 2005).
Inconsistencies are also noted in the literature with regard to assessment and treatment. The modified barium swallow (MBS) or videofluoroscopic swallow study (videofluoroscopy/VFSS) has a reputation as the "gold standard" for identifying patients at risk of developing pneumonia (Logemann, 1997; Murry & Carrau, 2001). However, use of the MBS to identify patients who will develop pneumonia has not been consistently validated (Agency for Health Care Policy and Research, 1999; Barczi et al., 2000; Leslie, Carding & Wilson, 2003; Levenson, 2003; Martin-Harris et al., 2000). Ostensibly the goal of dysphagia therapy is to prevent aspiration (Daniels, 2000), but this cannot reliably be accomplished since patients with dysphagia will continue to swallow and aspirate reflux, oral bacteria, and secretions (Daly, 2000; Finestone et al., 1995; Martin-Harris et al., 2000). Thickened liquids are often recommended for patients who aspirate thin liquids (Garcia, Chambers, & Molander, 2005), but use of thickened liquids often leads to dehydration in patients for whom they are prescribed, generally due to patient noncompliance and refusal (Feinberg et al., 1996; Finestone et al., 1995; Garon, Engle, & Ormiston, 1997; Sheiman & Pomerantz, 1998). Although patients receiving prethickened fluids drank more than patients receiving liquids thickened with powder, neither type of thickened fluids met patients' fluid needs in practice (Whelan, 2001) and leave patients with few choices of items to drink (Macqueen, Taubert, & Cotter et al., 2003). In one study, patients who received regular bedside water in addition to thickened liquids did not develop pneumonia (Garon et al., 1997), and the authors recommended the provision of water/ice chips for patients who refused thickened liquids. Some patients who aspirate thin liquids are permitted regular consistency bedside water and/or ice chips, but in over 90% of skilled nursing facilities, bedside water is not permitted for residents who aspirate thin liquids (Castellanos, Butler, Gluch et al., 2004). While a water swallowing test is often used as a bedside dysphagia screening by medical personnel (DePippo, Holas, & Reding 1992), at a time when patients are most medically fragile, water is often removed from the list of available fluids for patients who have demonstrated symptoms of thin liquid aspiration (Whelan, 2001). Families are often told that tube feeding will prevent aspiration, but elimination of oral intake does not reduce aspiration of bacteria and saliva and often increases the risk of reflux (Barczi et al., 2000; Feinberg et al., 1990; Finestone et al., 1995; Langmore et al., 1998).
Overall, the medical and speech pathology literature appears...
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