Thickened Liquids...It’s Complicated

Speaker0:
[0:15] Hi, everyone. I'm Emily.

Speaker1:
[0:17] And this is Eva.

Speaker0:
[0:18] And you're listening to Speech Talk.

Speaker1:
[0:21] We're your research book club so you can do evidence-based practice in practice.

Speaker0:
[0:25] So let's start talking. Eva, tell me the fun things this week.

Speaker1:
[0:33] I had one of those like, oh, I'm in the groove clinician moments this week. I have a patient who we are getting off MPO. So we're just doing like Frazier free water protocol, pleasure purees right now. But she had such bad cog initially and paresis on the opposite, you know, contralateral stroke side. And she was like dribbling food out of her mouth, is distracted, is trying to talk and food spraying. And that was kind of her about a week ago. And then this week I went in and I was just able to manage her distraction. I was like holding her hand because she kept fidgeting, like trying to grab the window. And with my other hand, I'm like administering like a spoonful of applesauce, hand immediately to the larynx, tactile verbal prompt, swallow. And she got through a whole applesauce and a whole thing of water and I was like, girl you go girl and I meant that both for her but also like kind of for me yeah

Speaker0:
[1:34] Oh that's so cool I've never put my hand on someone's throat to help them swallow and to give them that feedback.

Speaker1:
[1:41] You know what I get up all up in there in the Adam's apple and then I got off work one hour early and I was like I think I can pull off a manicure before I have to pick up the kids And I did.

Speaker0:
[1:53] There's nothing like self-care. All good for you. You know, and I was just like thinking back to all of our fun this week stories and how terrible they're so.

Speaker1:
[2:07] Sad a lot of the time.

Speaker0:
[2:09] A lot of the time, but that's actually like a fun story. Way to start off the episode, Eva.

Speaker1:
[2:15] All right, Emily, what is your fun story this week?

Speaker0:
[2:17] So my fun story this week hasn't officially happened yet i as of this monday am taking a student no.

Speaker1:
[2:29] You mentoring queen get on it

Speaker0:
[2:34] I know i'm so excited so like this weekend i went to the store and i bought a bunch of things for like my dementia program so we can do like really fun activities with my student so i'm just trying to get organized and oh.

Speaker1:
[2:53] My she is about to be mentored oh my god

Speaker0:
[2:57] I'm excited for the student to come in and learn from me and the site but also like i'm excited to have fresh eyes in the facility and learn from her so it'll be, yes it's gonna be good that's.

Speaker1:
[3:13] Gonna be awesome you can buddy cop that whole situation yes

Speaker0:
[3:17] It's like i don't know it's good all.

Speaker1:
[3:19] Right quick pause we'll be back right after this break

Speaker0:
[3:27] So, this week, what are we talking about this week?

Speaker1:
[3:30] We are talking about thickened liquids.

Speaker0:
[3:33] Da-da-da!

Speaker1:
[3:35] Yeah, not really sure how it took us so long to, like, talk about this because we are talking about thickened liquids all the time. So, I'm glad we're finally getting to it in the podcast.

Speaker0:
[3:46] Yeah, this is almost a daily thing where somebody is talking to me. Hey, have you seen so-and-so? They're coughing a lot. Hey you weren't here on saturday and he coughed on his water so we went ahead

Speaker0:
[4:00] and put him on nectar thick liquids are you gonna have time to see him today it's.

Speaker1:
[4:04] Like yeah jesus christ debbie i don't know if you remember this but fun even emily memory moment emily had been reading the back and forths on reddit about thickened liquids over a year ago when this was apparently a hot button issue and she was like we should really work on a project have we ever considered doing a podcast or something like we should be commenting on stuff like this and reading the research and uh so yeah think it's liquids is what got emily and i together on this yeah

Speaker0:
[4:38] Just the need for more research but um, To answer that question, is it still a hot-button topic? Forever. We are not done with this button. It's hot. It's lava. No one can decide.

Speaker1:
[4:56] And we'll see if by the end of the day, we can make it less dramatic or less controversial. Less problematic? I don't know. One of those is the right adjective, though.

Speaker0:
[5:11] So the research.

Speaker1:
[5:13] What are we reading?

Speaker0:
[5:15] Today, we are starting off with the adverse effects and events of thickened liquid use in adults. A systematic review by Sophia Worden-Abrams et al.

Speaker1:
[5:27] Emily, if you were going to take a poll at your facility, what do you think nurses would say about thickened liquids and how they're used?

Speaker0:
[5:35] I think they think about thickened liquids as just thickened liquids. I don't think that their thought process about it, and not saying anything bad about nurses or the way that they think, but I don't think they think further about implications of thickened liquids than the act of coughing. And I honestly think that's where it stops. Coughing happens, you should thickened liquids and I don't know I that that's

Speaker0:
[6:04] where that's what I think.

Speaker1:
[6:05] Definitely okay and then what would you say your patients have to say about thickened liquids gag uh and like honestly we could probably end the episode there like that's A lot of what we're about to discuss. So in the study, they were showing how current literature suggests it's really common practice for SLPs to recommend thickened liquids for dysphagia management, and that clinicians tend to think of them as this conservative, safe option for patients with dysphagia. And I think just like you were saying, that's oftentimes how nursing or facilities tend to approach dysphagia and thickened liquids. They're like, that patient coughed on his water, got to downgrade him. Oh, so-and-so had a gurgly voice, we got to downgrade him. And they're not thinking through the clinical applications, and that's where we get to step in with some evidence.

Speaker0:
[7:02] And of course, there's conflicting evidence as to whether thickened liquids hurt or help patients. Surprise, surprise. But it's really a little bit of both. But there's a super fun discussion behind why, so let's get into it.

Speaker1:
[7:17] Let's talk about why. The research from our article started out with 3,438 studies that they scrubbed, and they actually decided that 33 texts were useful for their systematic review. So much research out there. 3,000 papers just for this alone. Amazing. And they made this incredible chart. You should really check out the article. We'll post it in the show notes. If you're looking for some research, you can very quickly look at their chart and you can see which articles might be most relevant to you because they also include things like the setting, the etiology of the dysphagia, the patient demographics, the swallow outcomes, you name it, they got it. And it gives you a quick take on a ton of research. But here were some highlights um there was a complete lack of standardization on what thickeners were so much of the research was like some of it had idsy but then some of them were just like thickeners used emily and i have talked a lot about this on the podcast that our field just has like such poor standardization like we don't know what everybody else is doing so when you're doing a research review it's like okay the person coughed was it on honey thick was it on mildly thick,

Speaker1:
[8:29] we don't know. Just as thickeners were used. And the participants ranged from 19 years old to 102. So those are some silly highlights.

Speaker0:
[8:38] So what did their research find, Eva?

Speaker1:
[8:42] Okay. So thickened liquids are still an important dysphagia management tool. They can reduce aspiration and pulmonary injury and can improve safety and comfort for patients who are appropriate for thickened liquids. Period. End of sentence. Full stop. I just wanted to say that because the next part of this episode is about to be so anti-thickened liquids that I think it's really important to remind people up front that they're still useful and diagnostically or, you know, they're appropriate in terms of how we are designing plan of care for our patients.

Speaker0:
[9:17] Yeah, so let's get to the cons. Thicker consistencies are associated with, Eva, do you want to do this?

Speaker1:
[9:26] Yeah, of course I do. Associated with aspiration, pneumonia, dehydration, reduced fluid intake, increased pharyngeal residue, UTI, hospitalization, reduced quality of life, and of course, death. That was a grain of salt for that one. Some of them were like terminal patients, so there was death involved. We can't really say it was caused from the thickened liquids, but it was listed.

Speaker0:
[9:50] And then some of the big adverse effects, not that death isn't a big adverse effect. This is a huge list of cons we have. Aspiration, pneumonia, dehydration. These are terrible. You think about trying to drink thickened liquids. It's not fun to drink. So you're already getting reduced fluids. And then you're drinking something

Speaker0:
[10:15] that doesn't feel like it's quenching your thirst. So you just don't want to. So then you're getting dehydrated. There can be increased residue if your structures aren't moving quickly. They're probably not moving together fully, hence the residue. And then you're just breathing all that stuff in. And again, aspiration.

Speaker1:
[10:38] Well, and this is like what gets back to our point initially in terms of it being a hot button topic and how buildings perceive it and how clinicians perceive thickened liquids because it's like, yeah, someone so coughed on water, but. Just because you switch them over to thickened liquids doesn't mean it's going to be issue-free. Like, there are all these potential consequences of thickened liquids. Yes, they can also be present within liquids, but they're not just going to go away because you made someone's diet nectar or honey thick. Like, they can still aspirate on it. They can still get dehydrated with it. They can still get UTIs. Like, you didn't solve everything.

Speaker0:
[11:18] Yeah. Just because you got rid of that overt thing doesn't mean that it's not still happening. Now we just don't know. Like, it's just happening. Aspirating on thickened liquids is more likely to be silent than on thin. So now they're very comfortably aspirating on these thickened liquids and not clearing them. So now we're building up. So what is worse?

Speaker1:
[11:50] I was explaining that to somebody this week. The patient is NPO. Family wants them to go back to oral intake. And I'm like, look, I really want an MBS done. But she's not coughing. And I was like, she's got like full paralysis on one side. That could be happening internally. We don't know if she's aspirating. She's got poor sensory feelings. Overall, sensory feelings, sensory senses whatever um and i'm like you don't know what's gonna happen reintroducing solids so i'm not saying we can't do it of course we'll we'll do conservative trials but you don't know what's going on in there so we we really need the evidence and we can't assume that just because we're getting somebody on thickened liquids that they they aren't silently aspirating Yeah,

Speaker0:
[12:41] And we don't know either, Like we don't know what's going on until we have some kind of instrumental. And if there's not an instrumental and we're just making guesses or changing things, you could be doing more harm than good.

Speaker1:
[12:57] Yeah. Preach. Okay. So let's talk about some of those main adverse effects. One of the big ones is just aspiration pneumonia. And dysphagia alone is not like the primary driver of aspiration pneumonia. Emily, I found a really nice quote that I think kind of encapsulates that idea. Would you mind giving it to us?

Speaker0:
[13:24] Dysphagia alone is not the most significant risk factor for developing aspiration pneumonia, as it typically occurs in combination with factors such as dependence with feeding, poor oral care, and reduced mobility. Eva, you wrote something called the proxy issue from the article. What is that?

Speaker1:
[13:43] The proxy issue. So this was another kind of logic problem in recommending thickened liquids. The proxy issue is that in a lot of research, aspiration or material just like getting into the airway is used to represent potential negative consequences, such as pneumonia. We talk about all the time, aspiration pneumonia, but then they don't actually have any evidence of pneumonia. So what is all the literature that talks about aspiration building towards if it's not also showing that the like secondary sequelae of pneumonia is also occurring?

Speaker0:
[14:19] Everybody aspirates. You aspirate in your sleep. You aspirate your saliva all the time. And And I'm not waking up with pneumonia all the time, right? You don't have pneumonia all the time. It happens, but we also are generally healthy people. I brush my teeth. I move around a bit during the day.

Speaker0:
[14:41] So I'm doing those like healthy combative things that a lot of our patients aren't getting to do.

Speaker1:
[14:49] I totally agree. I think we had a professor who said we are not the coughing police. And just because people are having penetration and potentially minimal aspiration does not necessarily mean that transferring to a thickened liquid is the right answer.

Speaker0:
[15:07] Like we are not the coughing police. we are also not the defenders of aspiration. It is not your job to be the defender of aspiration. If somebody is getting aspiration pneumonia in your facility, you are not, do not take that mental load and responsibility onto yourself. There are so many factors that go into aspiration pneumonia and it's not just dysphagia that's causing it. Obviously, there's more that's going on. So if somebody has chronic aspiration pneumonia, what are the other factors that we are addressing? Is this person getting adequate oral hygiene? Is this person getting up out of bed? How does eating look? How does regular hygiene look? Like, are they, you know, washing hands and doing those things? Are they getting their frequent showers or baths? And looking at that whole picture, because just because aspiration pneumonia happens and just because that is something that is at times tackled with modified diets does not mean that you are the sole guarantor that no one is ever going to get aspiration pneumonia in your facility.

Speaker1:
[16:29] I really like that you said that because I used to feel so guilty when someone would be like, well, you know, Mr. Jones— aspirated and i was like oh like i didn't do my job you know and those things were like okay well mr jones is 92 and keeps shoving graham crackers under his pillow so like we just have to accept that he like was going to aspirate and we need to now be focusing on potentially behavioral management, safety, comfort, you know, if he has severe enough dimension, he can't be adherent with our recommendations, then maybe we need new plans, you know, like, just because someone got aspiration pneumonia does not mean that it was my fault. But I used to think it was. And so I would get so stressed. It's not, it's just like Good Will Hunting. I don't think that's the first Good Will Hunting reference I've made either.

Speaker0:
[17:28] I don't think it is either. I might have to rewatch that movie. It's not your fault. It's not your fault. It's not your fault.

Speaker1:
[17:34] I hope everyone really feels that. It's not your fault. Okay. What were some other risk factors?

Speaker0:
[17:43] Other risk factors are abnormal physiology. So that is an increased risk factor for aspiration pneumonia, which we know we can't know without a swallow study. How are you going to know what something looks like on the inside if you don't see the inside?

Speaker1:
[17:57] Dude, I used to get so worked up. I used to get so mad when I would take these CEUs or listen to people who work in hospital settings say, well, you know, we just need a swallow study. And I just want to be like, you try and get one where I work, you know. And so I think I really resisted that advice because of the access issue. But I've really come to appreciate that ultimately we can't know a lot of things without swallow studies. And so I can make best recommendations without that information. But now I also make it super clear when I'm talking to my colleagues or to the doctor or to family or even to patients, like, I'm like, I do not feel comfortable making X, Y, or Z recommendation because I do not know what's happening inside your body. I do not have x-ray vision.

Speaker0:
[18:46] Yeah.

Speaker1:
[18:46] I can't know. And Emily and I have certainly talked about advocating as early as possible for swallow studies. Like, the moment you have any concerns and want one, like, start the documentation. Start it now.

Speaker0:
[19:00] Yeah. And I feel like this is still such a, it's unfortunately still such a hot button topic in our field that.

Speaker0:
[19:12] Swallowing studies are just not as appreciated as x-rays like if someone falls or something like that we're not getting that information but that is information that we need to help people make an informed decision about their plan of care how is someone going to make an informed decision on whether thickened liquids or a modified diet is actually safe for them an actual good recommendation, an educated recommendation, if we don't have that education. During my student study rotation, my supervisor would go to her DOR and say, so-and-so needs a swallow study is an automatic no. It didn't matter who it was, what the concern was. The answer was always just downgrade. There was no care in that situation whatsoever. And I remember when I first started this podcast, I reached out to my supervisor, Michaela, and she was like, I hope you're going to be honest about how difficult it is to get swallowing studies. And it is. It's super hard. And watching her DOR shut her down like that honestly scarred me for my CFY. And I was scared to ask. I was like, oh, they're going to say no. They're going to get mad at me that I'm costing the facility money. But like, F that. It doesn't matter.

Speaker0:
[20:40] It's a cost. These facilities signed on to provide services and they get reimbursement through these services from their insurance. So if these facilities are not doing things that you need them to do to do your due diligence, dip get out because it's not worth it and i i now work for a facility with a dor that supports my clinical judgment and will advocate for swallow studies when i need them when i you know feel that they are warranted um, And it's not an issue. But I had to overcome this whole big hurdle that I'm like, you know, I'm being needy as a therapist or I'm doing too much as a therapist asking for these so expensive. I know. I just want it just to see. And then if they came out, the imaging I did get, if they came out that there was no problem, I felt like a... I'm trying like not to cuss in this one because I'm like riffing too hard. But I felt like such a, you know, a butthead because I'm like, oh, my God, I pushed so hard for this follow study and nothing was wrong all along. But I mean, in the end, that is still valuable information.

Speaker1:
[21:59] 100%. And if you look at hospital documentation, they run a whole bunch of labs to support differential diagnosis. You know, they're like, we're not sure if it's A or if it's B. So we're going to run all these tests to give us more information to help understand whether or not it's condition A or condition B. Yes. We're allowed to do that, too. We're allowed to say, hey, I need some imaging because I have a concern for this. And if my concern is correct, then we have a whole series of issues we need to address. If I'm wrong, then we learn that about the patient, you know, that's okay. Yeah.

Speaker0:
[22:32] Can you imagine walking into an ER with, you know, single-sided paralysis, facial droops, slurred speech, and the doctor was just like, stroke, here's a TBI. The doctor was just like, stroke, here's some medicine, go sleep it off. Here's some thickened liquids. I'm sure you'll get better eventually. It's like, no, they're going to do imaging. You'll probably do an MRI or a CT scan. Like, they want to see your brain. Like, they will not say, yes, you in fact had a stroke unless they see the stroke. Like, it's the same thing.

Speaker1:
[23:08] Yeah. And sometimes the stroke work comes back negative.

Speaker0:
[23:11] Yeah. Yeah. Sometimes it really does. Like, I don't know what's wrong with you. You're just limpid now.

Speaker1:
[23:18] I'm going to make that complaint next time. I'm going to be like, you got to see their brain. I want to see their throat.

Speaker0:
[23:25] It's not fair. It's not fair.

Speaker1:
[23:30] Anyways, let's move on to the next adverse effect from Thickened Liquids.

Speaker0:
[23:36] Dehydration, reduce fluid intake. So we definitely touched on this a little bit, but Eva, tell us what freezer-free water protocol is.

Speaker1:
[23:49] Yeah. So the freezer-free water protocol, let people have water. Let the people have water.

Speaker1:
[23:54] A lot of the free water protocol research already supports this. There's a ton of clinical evidence now that shows that people getting access to water improves outcomes regarding hydration, overall quality of life, because people don't feel like they're dehydrated. And two, the aspiration risk on water as a thin liquid has such a low relationship to pneumonia. So let the people have water.

Speaker0:
[24:26] Yeah. And they'll drink water if you're dehydrated and you're thirsty, you should drink water. And dehydration, it can be serious, right? It can lead to UTI, which in our very juries can be detrimental. They can be just confused. And, you know, that is just the beginning of the domino effect for like falls, sepsis, delirium, hospitalizations, And da-da-da-da-da-da-da, it just keeps going down.

Speaker1:
[24:59] That well-known path, it's like, oh, so-and-so seems kind of off. Oh, they have a UTI. Oh, now they're septic. Now they're in the hospital. Gross. All comes back to water, I promise you. Anyways, we also have patients with water-related conditions like electrolyte imbalances, kidney conditions, fall risks. I mean, we can't just write dehydration off as this kind of smaller secondary thing. It can have larger medical complications. You do not need to say much to get me started on the importance of hydration. Like, I call my sink in my house the hydration station.

Speaker0:
[25:38] Oh, that's good for you. You must have good city water.

Speaker1:
[25:41] Oh, I got that good city water.

Speaker0:
[25:44] Okay. And finally, our reduced quality of life.

Speaker1:
[25:48] Yeah. So if you remember that ICF framework, I could not remember what ICF stood for when I read this. So in case you don't know or have forgotten, it's International Classification of Function, Disability, and Health. And it's basically how we can analyze quality of life. Thicken liquids have negative impacts on a large number of the factors in the ICF framework.

Speaker0:
[26:10] So when we're thinking about quality of life, if someone feels like they have a poor quality of life, they are less likely to adhere to recommendations. These people, thicken liquids, are going to have negative perceptions of their mouth cleanliness and feel more thirsty. So you think about how thick that is. Like you want to clear that. It's not, it's not, your brain is not used to that. So it feels thick and gummy in your mouth.

Speaker1:
[26:42] Yeah. And it is gross. Like really go ahead and try a thickened liquid. See if you feel good afterwards.

Speaker0:
[26:49] And not just once, like for a day. Don't do it just once. Like really go for the gold and go a full day thickened and just see how you feel. How many times your tongue is just swiping those teeth?

Speaker1:
[27:06] And like, there was a section in the research article where they were including quotes from some of the research that they had reviewed. And I really liked this one because it just shows how intense it can be for people. It said, patient notes that following modified diets makes them feel like, quote, life is falling apart. It's like one of your most basic functions, eating and drinking, and your drinks are just gross. And I think that kind of gets us to the idea of how empathy for our patients makes us understand whether or not they want to do what we're asking them to. So one of the things they talk about is like non-compliance versus non-adherence is a little bit of a tangent. They don't discuss it in this article, but it's a big topic in, I think, the speech world right now, which is that the wording non-compliance makes people sound combative or argumentative versus non-adherence, like they just didn't follow what you said and people yes are technically non-compliant they're not adhering to what you recommended but just remember they're not doing it to like hate on your recommendations they're doing it because they feel disgusting like their mouths are yucky they're constantly feeling thirsty they don't want to follow it and we kind of have to respect that at some point yeah

Speaker0:
[28:27] At every point that that is that is the point that is like the biggest point that we need to take home that to have adherence, there has to be a buy-in and your patient making an informed decision about their care. If they're not adhering to what you're telling them is, you know, least restrictive, what is safest, then, you know, you have to respect their informed consent. Like that is their choice to treat their medical ailments however they want to. And if they don't want to do it, that is their choice to not do it. And we have to respect it. Like it's not, it's not a choice. It's not our choice to make for our patients what they can and cannot have or what they can and cannot do with their medical decisions.

Speaker1:
[29:28] And to that end, I had a patient today who has an esophageal stricture, has routine vomiting, has been placed on a full liquid diet by the GI at the hospital with no end date in sight. And I get into his room and there's of course like a box of donuts he bought himself and i was like hey do you know what your esophageal structure is and he was like yeah my my throat is really tight and i was like yeah close enough how are you getting the donuts down he was like i can't get anything down i throw everything up he was like before it's even like 30 seconds are up he's vomiting things so he was really just eating them for like the sensation of chewing on things. I was like, oh man, we got to talk to your GI because this whole full liquid diet is driving you crazy to the point where you're just like trying to cram donuts into your face.

Speaker0:
[30:25] No. And that's so like, that's so hard too, because like, Think about how unpleasant that is to throw up. Like, that's my least. I will have COVID eight times in a row before I'll have the stomach flu. Like, that's how much I hate throwing up. And this patient chooses to throw up because he wants to have donuts.

Speaker0:
[30:47] And I can be like, that's not my choice, man. Like, that, I don't know. I can't put myself in that position. But I respect your choice to do it. Like, I might make a face. I might have to leave at the smell.

Speaker1:
[31:05] And realistically, this is kind of something they mentioned in a very small comment in the article, that thickened liquids are hard for people to follow. In the outside world, you're thirsty. What are you going to do? Go home, get your Hormel's thickened liquid? No, like you're going to go fill up your water bottle at a water fountain, you know, or at a sink bathroom. And putting people on these restricted diets is not just a recommendation about their swallow it's a recommendation for their entire way of life yeah and so just saying like hey man you put somebody on thickened liquids for a long time or in this case you put somebody on full liquids all the time what is their life like when they leave a sniff when their food isn't prepared for them. You know, when everyday nursing doesn't bring by three little cartons of Ensure, so thickened Ensure, so that they are both nutritionally balanced and are having a thickened liquids. No, man, they're going to go out to restaurants with their friends. They're going to be at home and they're not going to be able to do this full time without some seriously hard work. So just also recognizing that these recommendations are effort.

Speaker0:
[32:19] Mm-hmm. And costly. That's one of the big things I talk to patients about and facilities about. Because the cost of having to have someone on a thickened liquid is tremendous. So now we're not just telling people that, yeah, it's going to suck. You're going to be thirsty. You could possibly get dehydrated and have UTIs. But now you have to spend $60 a week on Thickener to make sure that you're adhering to these recommendations. Like, ugh. I don't—no one wants to do that. And I don't blame the people who don't want to.

Speaker1:
[33:02] Yeah. You know, we really started on, like, a giggly note. And I think we really delved into the fire. I think we can concretely say this is still a hot-button issue. Like, we're getting very hot and fired up about it.

Speaker1:
[33:17] And if those rants that we just went through aren't enough, buckle up, y'all, because I'm really about to get into it.

Speaker1:
[33:24] There's some really weird things we have to consider in this article, and I think the next segment really highlights it. Okay, here's a takeaway. One of the studies that they reviewed is that for dementia and Parkinson's patients, there was no difference in signs or symptoms indicating pneumonia for groups of people who had thin liquids with a chin tuck versus thickened liquids. So you might be asking, why are we making so much ado about nothing? Like, there's no difference between the thin liquids plus chin tuck and having just thickened liquids. But think about that context. A Parkinson's patient who can do a chin tuck and drink thin liquids is going to have comparable outcomes if they're drinking thickened liquids.

Speaker1:
[34:12] Fine. But what if they can't do a chin tuck? It's cognitive or maybe it's motoric. What if their caregiver can't ensure thickened liquids are available to them? What if they can provide thickened liquids, but they can't do consistent supervision to ensure that the patient would be doing chin tucks on thin liquids? What if, getting to do a lot of what ifs, what if the person is on hospice and they say, I have all of these recommendations. I love cherry cola. Like all of these are possible outcomes. So just because we know that thickened liquids can have poor outcomes and thin liquids can have poor outcomes, they both can also have great outcomes. And it is up to you to decide. That's my rant.

Speaker0:
[34:58] So ultimately, we're boiled down to clinical judgment is still our best answer.

Speaker1:
[35:07] Yeah, pretty much. It's not that people don't aspirate on thin liquids. It's just that people also aspirate on thickened liquids. So we have to be making sure that our buildings, the caregivers, the doctor, whoever we are collaborating with for patient care is aware that thickeners are not just a default. They're not just a one and done fix it.

Speaker0:
[35:29] Yeah. And... This whole discussion is not to throw the baby out with the bathwater. No babies, no bathwater. I know. Why are we always leaving babies in bathwater?

Speaker1:
[35:42] You're specifically not supposed to leave your baby in the bathwater. We've talked about this.

Speaker0:
[35:50] There is a time and a place for thickened liquids. If people are more comfortable on thickened liquids, if they are coughing less on thickened liquids, and that is their goal, to just feel more comfortable, maybe thickened liquids are for them. If you've done your due diligence and had a modified or a fees and it showed that thickened liquids are safer and you've discussed this with your patient and they agree that thickened liquids are for them, then go for it.

Speaker1:
[36:23] They also may be like, I'm not safe on it, but it's comfortable because when I'm drinking water, I start just like coughing and gagging, and that's painful. They may be silently aspirating, as Emily said, on the thickened liquids and be like, hey man, I'm aspirating on both, but one of them is easier.

Speaker0:
[36:40] Yeah. Yeah. And that's, it's definitely their choice. All in all, if there's any big, big takeaways from this article, thick and liquids have their time in place, but you have to have a modified to really recommend them. And you should be advocating for that because you could be doing more harm than good for the patient, for your facility, and you can't make an informed decision without one. So demand them when you need them.

Speaker1:
[37:16] Yeah. And if people are saying no, put it everywhere that you recommended it. Put it on the PCC orders. Put it in your eval. Put it in your daily notes. So that if anybody's going through this patient's documentation, they know that there was supposed to be a modified order.

Speaker0:
[37:36] And educate your nurses on the downsides of these thickened liquids like we should not be thickening liquids at bedside I don't when I was in my CFY my supervisor was like well did you trial them on thickened liquids at bedside no ma'am I did not and I will not because there is no good reason for me to trial thickened liquids at bedside unless I'm looking for quality of life reassurance. Like anything else, I can't tell if they can liquids are better because there's less coughing at bedside. So what's the point? We just need a modified. If they cannot do the yellow on thins or every time they do a thin sip and they're just hacking away, swallow study. Swallow study. If there's no comfort, swallow study. If they say no, quit. Get out. Because It's not worth your time or a headache. You are valuable and your clinical judgment is valid. And if you aren't being taken serious, there's another building, a stone to throw away, who will take you serious.

Speaker1:
[38:44] I think this is also like... Kind of an issue of this being a new field. People aren't used to these studies being requested. I've talked a hundred times about how hard it is to get fees. Fees is also a good alternative. Getting really any kind of swallow study is the answer. And people are just still not used to speech therapy wanting stuff. They're like, don't you guys just like listen and touch throats and check teeth and it's like no actually we are have methods to have standardized information but we we need these studies to do it and you not letting me get it is inhibiting my best recommendation so you'd go like i think you said it really well like you'd send them for an x-ray you'd send them for a ct like on what to tell you we got to get a camera up their nose and in their throat. That's just how it's got to be. Okay. Is there a way we can end on a light note?

Speaker0:
[39:49] No. No. No. No. I'm fiery and that's it.

Speaker1:
[39:54] Yeah. Light note. Hey man, y'all's work just got easier. Keep everyone on thin liquids.

Speaker0:
[39:59] Yeah. So true. Your work is so much easier. You have relieved yourself from the pressures of avoiding aspiration pneumonia in your facility. That is not you. You are a therapist. You are not a savior. We are not out here, you know, bringing God's light to people. We are just people.

Speaker1:
[40:19] We are not out here taking donuts from old folks.

Speaker0:
[40:22] We're not taking donuts away. We just provide the education. We are a messenger. And that's it.

Speaker1:
[40:30] It's so much easier to just tell nursing downgrading to thickened liquids isn't appropriate at this time than it is to write the order to downgrade the thickened liquids. You're welcome. Yeah, that's all for today, y'all. Now get all EBP about QOL and your in-services.

Speaker0:
[40:52] You've been listening to Speech Talk.

Speaker1:
[40:54] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker0:
[41:00] If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, because as podcasters, our love language is in positive affirmations.

Speaker1:
[41:11] If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Speaker0:
[41:25] If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker1:
[41:38] We're your hosts, Eva Johnson and Emily Brady.

Speaker0:
[41:40] Our editor and engineer is Andrew Sims.

Speaker1:
[41:43] Our music is by Omar Benzvi.

Speaker0:
[41:45] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker1:
[41:50] To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers.

Speaker0:
[42:02] Speech Talk is a proud member of the Human Content Podcast Network.