In today’s blog post we’re taking a look at the new position paper from RCSLT around thickened fluids. We will mainly be providing an overview of the content. Check out the position paper here.
Aim
The aim of this position paper is to support clinicians’ awareness of and reflection on the best available evidence on the use of thickened fluids in the assessment, treatment and management of dysphagia, to enable informed decision-making and support the application of evidence-based practice (EBP) principles
Why was it developed?
Developed in response to RCSLT members requesting guidance on the use of thickened fluids in the management of dysphagia. The paper states that it is not within the remit of the paper to advise SLTs about when or whether they should or should not use thickened fluids in specific clinical populations, or about alternative dysphagia management methods.
Benefits of thickened fluids
Benefits of thickened fluids may include:
● Reduced aspiration and negative aspiration-related health consequences
● Improved oral motor control
● Taste preference over water
● Improved hydration
● Opportunity to continue drinking fluids and/ or engage in dysphagia rehabilitation in the short term, where drinking thin fluids is unmanageable
● Reduced symptoms such as coughing, wheezing, and apnoeas
Potential adverse effects of thickened fluids
● Reduced fluid intake, dehydration and urinary tract infections
● Feeling of fullness leading to reduced appetite
● Unpleasant or altered taste and texture
● Increased thirst
● Altered bowel habits
● Delayed or reduced absorption of certain medications
● Increased swallowing effort (Shim et al, 2013).
● Increase in post-swallow residue
● Increased risk of adverse pulmonary events from aspirating thickened fluids
● Worsening emotional well-being, health-related and social-related quality of life
It is specifically noted that recommending thickened fluids whilst awaiting SLT assessment or for long periods without ongoing monitoring or planned follow up has the potential for increasing the likelihood of unwarranted adverse effects (O’Keeffe et al, 2023, O’Keeffe, 2018).
Discussion around cough
‘Although coughing may be a symptom of potential penetration or aspiration, it is also an essential defence mechanism that is not always a sign of dysphagia’.
● Does the patient have a baseline cough outside of eating and drinking due to another condition, unrelated to dysphagia?
● Does the coughing cause the patient to drink less?
● Does the patient who coughs while drinking communicate distress?
● What is the evidence supporting the level of the distress? Is the distress that of the patient, or that of the healthcare professional and/or caregiver (Bogaardt et al, 2015)?
● What is the patient’s experience of their swallowing-related cough symptoms? A range of complex, individual factors might exist around coughing, including social and cultural impacts related to cough etiquette (Brown et al, 2021).
● What is the ‘acceptable’ level of coughing for the person and are they willing to accept some coughing in order to continue with thin or less thick fluids? Is it a primary aim to alleviate this symptom for them?
Conclusion
Thickened fluids remains one of a number of existing tools in the dysphagia practitioner’s toolkit. The uncertainty of the evidence surrounding thickened fluids does not preclude their use; however, it is important to communicate this uncertainty to patients and their representatives. Additional resources, suggested reading and an easy-read document will be provided as an adjunct to this position paper.
It has highlighted the importance of informed consent and patient choice in decision-making and that ultimately, holistic assessment should balance the individual needs of the patient with the best available evidence of risks and benefits of thickened fluids.
The literature suggests that over-relying on common sense reasoning may influence how treatments like thickened fluids are perceived and presented to patients, with the potential for overstating treatment benefits and understating potential risks
Thoughts…
So, what are your thoughts on the position paper? Where do you think we go from here? What could we change within our clinical practice right now? What might we want to do in the long-term?
