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Letters to the Editor |
4303 New Waterford Highway, New Waterford, NS, Canada B1H 2E1, e-mail: irenecampbelltaylor{at}medscape.com
Letters to the Editor:
As an individual who has taught the procedure for videofluoroscopic swallow study (VFSS) to radiologists, I was most interested in the article by Gates et al (1) in the January 2006 of RadioGraphics. It is, indeed, unfortunate that there are fewer individuals now able to perform these studies.
In general, the authors’ description of the procedure is well done, especially their emphasis on the need for slow-motion review of every case. It has not been established, however (other than by means of anecdotal information), that intervention by speech language pathologists makes a difference in outcome. Some of the compensatory strategies that the authors describe are, in fact, harmful in many patients. The "chin tuck"—so-called although it is actually neck flexion—interferes with the anterior movement of the hyoid, thereby reducing the opening of the upper esophageal sphincter. The mixing of food with barium for VFSS has no benefit. The fact that the patient may swallow mashed potatoes mixed with barium does not mean that he or she can swallow mashed potatoes alone. The two mixtures bear no resemblance to one another, and the VFSS does not approach a real-life situation (2). In addition, it would seem that the often excessive concern with aspiration indicates that food should not be included in a swallowing examination (a context in which aspiration is likely). Barium alone is essentially innocuous to the lungs. Barium plus food is not necessarily so harmless. Finally, the widespread practice of thickening liquids in the belief that it will prevent or diminish aspiration is entirely without proof (3). There is increasing evidence that thickening fluids leads to dehydration and its negative sequelae, especially in the older patient (4–6). Until there is more than word-of-mouth evidence, it is suggested that intervention with respect to nutrition and hydration in the dysphagic patient be approached with more scientific rigor.
References
* Departments of Radiology and
Speech Pathology, Boston Veterans Administration Medical Center, West Roxbury, Mass
Department of Radiology, Baystate Medical Center, Tufts University School of Medicine, Springfield, Mass, 288 Park Drive, Springfield, MA 01106, e-mail: gandjhartnell{at}comcast.net
Thank you for giving us this opportunity to reply to the letter from Irene Campbell-Taylor, clinical neuroscientist. The collaborative efforts between speech pathologists and radiologists have been a long-standing tradition in most academic institutions in the northeastern United States. The speech pathologist is generally the first person to evaluate the dysphagic patient, usually at the bedside or in a clinic, and plays an active role during the VFSS. The speech pathologist is the same person who will then work with the patient long after the VFSS has been performed. This practice has less to do with study outcome and more to do with stepwise, comprehensive patient care.
The chin tuck maneuver has been validated in a number of studies. Welch et al (1) reviewed 30 patients and concluded that the posterior shift of anterior pharyngeal structures improves airway protection. Ertekin et al (2) studied 51 patients with neurogenic dysphagia and 24 healthy control subjects; the dysphagic patients with bilateral symptoms had a significant (P < .01) improvement in dysphagia limit in 50% of patients in the chin tuck position. Lewin et al (3) used the chin tuck maneuver in 21 esophagectomy patients who reported problems with aspiration of fluid or food; aspiration was eliminated in 81% of those patients when the chin tuck maneuver was used. Bulow et al (4) showed that use of the chin tuck position significantly (P = .008) reduced the depth of contrast material penetration into the larynx and trachea; however, in a separate report (5), they found that the chin tuck maneuver did not alter peak amplitude or duration of the intrabolus pressure. In a similar study that involved only eight healthy volunteers, Bulow et al (6) concluded with a leap of faith that a chin tuck maneuver could impair protection of the airways in dysphagic patients with weak pharyngeal constrictor muscles. The usefulness of the chin tuck maneuver has also been studied in patients after partial tongue resections; "compensatory procedures, such as a chin tuck, and therapy techniques were found to be effective in 50% of patients who aspirated," and such techniques tended to be more effective between the 1-month and 6-month follow-up in patients with smaller resections (7). We were unable to identify any reports in the peer-reviewed literature that supported the assertion that a chin tuck maneuver is harmful to patients. This has not been our experience with many thousands of such studies over many years.
The opacification of different consistencies of liquids and foods with barium is done for imaging purposes and has no reflection on the anticipated materials to actually be ingested. The degree to which food consistency is altered by the addition of barium sulfate is negligible in most instances. Furthermore, we know of no single definable consistency for mashed potatoes. Because these opacified materials are administered by spoon in 3-mL and 5-mL aliquots, the volume of potentially aspirated material is controlled and the risk of pneumonitis is negligible. Straw sipping and cup drinking are not attempted if the patient is an obvious aspiration risk; these activities are performed later in the study.
The objective of a VFSS is not only to provide information for making informed decisions on nutritional management. Eating and drinking are pleasurable, social activities that enhance a patient’s quality of life. Once the food and beverage consistencies appropriate for a specific dysphagic patient have been identified, it is hoped that he or she can safely benefit from these studies and lead as normal a life as is possible. Average daily fluid intake is a separate issue; beverages that have been thickened have been altered to prevent aspiration.
Dehydration is a medical condition that results not from food additives but from inadequate fluid intake. In a study on fluid viscosity and perceived aspiration, Goulding and Bakheit (8) did not investigate dehydration but merely mentioned that some patients failed to finish proffered beverages that had been thickened. This reference has been misrepresented. Finestone et al (9) used extremely small sample sizes—six and seven—in their report; we find this worrisome. Finally, Whelan (10) suggested that volume depletion is a cause of concern but also failed to demonstrate frank dehydration; in fact, none of these three groups of authors measured serum creatinine and blood-urea-nitrogen levels as measures of clinical dehydration. Although we agree that it is important to maintain patients’ hydration status, it is just as important to safely maintain enteral feeding and beverage consumption, whenever possible, for nutritional, physiologic, and psychologic benefit.
References
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