A Randomized Control Study to Determine the Effects of Unlimited Oral Intake of Water in Patients with Identified Aspiration

Abstract

Boulevard, St. Paul, MN 55103, phone (612) 232-2358, fax (612) 23 2-2268. St~mmcnt yth~ Problem: In the past J;c;iLl;, thc literature on swallow dysfunction has expanded to include research regarding aspiration, silent aspiration, and varying compensatory techniques and dietary changes to avoid aspiration. There is presently a dearth of research regarding aspiration of roods and liquids and the relationship to aspiration pneumonia. The issue uf causality of aspiration pneumonia and medical complicatic,ns therein is of major concern to physicians and swaHow professionals working with swal!nw dysfunction.MechoJ oJ Smoh':Using a randomizeJ-o JI1[fol prospective design, this one year study examined two groups of stroke patients with previously identified thin liquid aspiration. The m)ntrt)1 group ( 10 patients) rccciBml thickened liquids onty. The study group (10 patients) had aH tiquids thickened in the same manner, hut were ,ill<i,,,cLl free access to water in addition ro the thickened liquids.Results: No patient in either group devetoped pneumonia, dehydration, or c()mpjications during the course ot the study, <ir during a 30-Jay )o!!ow-up period. Controt group subjects (thickened liquids onty) averaged a mean uf 27.2 days in the study (range 8 to 64 days) prior to reaching the end point of no thin liquid aspiration as documented hy tWIIOB1'-ll(, videofjuoroscopic evaluation. Contro) group subjects had a mean intake elf 1,210 cc/Jay (range 400 to 1,800 cc/day) of thickened liquids. Control group subjects averaged 39 days from onset of stroke to end point of no thin liquid aspiration.Study group subjects (thickened liquids with addifionat water intake) averaged a mean of 19.1 days in the study (range 7 to 35 days) prior to reaching the end point of no thin liquiJ aspiration as documented by ft)llt)w-up videonuoroscopic evaluation. Study group subjects had a mean nf 461 cc (range 200 tn 800 cc) of water intake/day; and 855 cc (range 640 to I , 1 7 cc) of thickened liquid/day, Combined fluid intake for the study group was a mean of 1,3 18 cc/day (range 800 to ),900 cc/~lay). The mean from onset of stroke to end point of no thin liquid aspiration was 33 days for the study groupSL~bjects. ( CCJ1lci1ll1t'd) at OAKLAND UNIV on June 3, 2015 nnr.sagepub.com Downloaded from 140No statistical differences were found in the moderator variables of age, gender, ethnicity, stroke location, amount of initial aspiration, or presence/absence of a cough reflex. Using a t-test for independent means, a significant difference (p = 0.03) occurred between groups on average intake of thickened liquids.Conclusion : Until further larger scale research utilizing water intake with known aspirators is conducted, it is recommended that water (and ice chips) be given presently only in instances of patient refusal to drink thickened liquids or when hydration issues cause medical concern.Over the past decade, active research has been conducted regarding swallow dysfunction, aspiration, silent aspiration, and treatment for swallow disorders. The...

Does a Water Protocol Improve the Hydration and Health Status of Individuals with Thin Liquid Aspiration Following Stroke? A Randomized Controlled Trial

“…In this study, 21% of participants across both groups were medically diagnosed to be dehydrated. This is in contrast to the findings of other studies of water protocols, which found no adverse events for any of their participants [31,33]. This discrepancy may be attributable to the differing definitions for dehydration and follow-up periods.…”

“…Given there was no other influence on fluid intake from demographic or stroke related clinical factors such as age, sex, mobility/ambulation or level of dependency, it is likely that the dysphagia itself limited their intake. Even when given the choice to drink water, participants in the water protocol group drank more thickened liquids (807mls) than water (299mls), a finding that is consistent with the other published water protocol studies [31][32][33].…”

“…Consequently, there were mixed findings about effectiveness and safety. Total fluid intake increased significantly in two of the three studies [31,32]; and there were no adverse events of pneumonia or dehydration for participants in two of the studies [31,33]. Karagiannis et al (2011) reported adverse outcomes of pneumonia for 14% of participants in the water protocol condition, particularly for patients with progressive neurological disease and poor mobility.…”

“…A retrospective chart review of 234 rehabilitation inpatients by the original authors revealed only two patients developed aspiration pneumonia after receiving the water protocol [30]. Since then, three randomized control trials have investigated the effectiveness and safety of water protocols [31][32][33]. These studies differed in terms of the clinical populations included, average age of participants, assessment of aspiration for participant inclusion, research design, control conditions, numbers recruited and methods of outcome measurement.…”

Dysphagia Management in Stroke Rehabilitation

“…Research on the use of ''free'' water protocols is limited with contradictory findings [43][44][45]. Some studies reported no adverse events in patients randomized to either the free water group or the thickened liquid only control group [43,44], whereas another study identified significantly increased risk of respiratory infection in patients randomized to free water [45]. Rather than instituting a single protocol for all patients in a single facility or hospital ward, it seems more intuitive to evaluate the appropriateness of allowing water for patients with thin liquid aspiration on a case-by-case basis.…”