Thickened Liquids With Dysphagia (Part I)
Patients who have difficulty swallowing (dysphagia) are sometimes prescribed thickened liquids to reduce the risk of aspirating fluid into the lungs. The purpose of this two-part essay is to discuss the topic of thickened liquids for dysphagic patients.
Dysphagia is a medical term that refers to difficulty with swallowing. Dysphagic patients are at an increased risk for developing aspiration pneumonia because the foods and fluids that they consume may inadvertently enter their lungs.
According to Mosby's Medical Dictionary (2009), oropharyngeal dysphagia refers to difficulty in either the oral or pharyngeal phases of swallowing, such as in chewing, initiating the swallow, or propelling the bolus through the pharynx to the esophagus. This type of dysphagia is very common since it strikes nearly one-third of patients who have had cerebrovascular accidents (strokes), more than one-half of patients with Parkinson's disease, and more than three-fourths of patients who have been diagnosed with Alzheimer's disease. Also, more than one-half of all elderly institutionalized patients have some degree of oropharyngeal dysphagia.
Patients who struggle to swallow thin liquids are usually prescribed thickened liquids. The consumption of thickened liquids may help dysphagic patients by reducing the incidence of choking and preventing fluid from getting into the lungs. Thickened liquids tend to be easier for dysphagic patients to consume than thin liquids because they are more viscous, and therefore, have a much slower transit time during the process of swallowing. Furthermore, the thickness of these liquids reduces the likelihood of fluids silently seeping into the lungs, which greatly lessens the chance of the development of aspiration pneumonia.
Here is another way of mentally picturing the situation.
If a person pours a glass of water or coffee onto the floor, it will make contact with the floor rather rapidly.
On the other hand, if the person attempts the same task with a thicker fluid such as molasses or honey, the transit time that elapses until it reaches the floor will be slightly longer. This increased transit time may help to minimize the likelihood of any fluids entering the patient's lungs. Thus, thickened liquids contribute to safe oral intake and hydration for the dysphagic patient.
The three most common consistencies of thickened fluids include nectar thick, honey thick, and pudding thick. Nectar thick liquids share the same consistency and thickness as eggnog, fruit nectar, milkshakes, and buttermilk.
Honey thick liquids are similar in consistency to honey, molasses, and maple syrup, and pudding thick liquids have the same thickness as puddings, yogurts, and custards.
Thickening powders can be added to thin liquids to get them to the correct thickness. Also, commercially-thickened liquids may be purchased at medical supply stores, drugstores, pharmacies, and over the internet.
Since oropharyngeal dysphagia is so prevalent in healthcare settings, it is imperative that nurses and other healthcare workers are knowledgeable about thickened liquids. Knowledge is power, and together we can bestow our nuggets of expertise upon our patients and their families to assist in keeping people safe.Last edit by Joe V on Jan 12, '15
About TheCommuter, BSN, RN Senior Moderator
TheCommuter is a moderator of allnurses.com and has varied workplace experiences upon which to draw for her articles. She was an LPN/LVN for four years prior to earning RN licensure.
TheCommuter has '10' year(s) of experience and specializes in 'Case mgmt., rehab, (CRRN), LTC & psych'. From 'Fort Worth, Texas, USA'; 35 Years Old; Joined Feb '05; Posts: 36,736; Likes: 65,991.Jul 23, '12 by nurseprnRNgreat topic, many thanks.
it's so important to remember that although the usual oral progression for impaired swallowing is water-nectars-puddings-pureed-ground, it's not usually a good idea. many, many people cannot successfully get nectars down without some leakage into the airway-- which can be silent, without the choking and coughing you might expect. they certainly shouldn't be getting water or juices, but they shouldn't be getting nectars either. there are far more people who can succeed with pureed things that can't drink liquids.
positioning helps. sitting the person bold upright (not holding the cup or spoon to the lips of a person lying down) and teaching him to tuck the chin under will help oral intake avoid the airway. if you think of how you open an airway for cpr-- laid flat, head back, chin up to open the airway-- you'll remember to avoid those maneuvers when feeding.
other stimuli that help with the swallow reflex are temp and taste. you can see why room-temperature water would be a bad choice, lacking both. alas, the traditional vehicle for crushed pills, applesauce, comes in a close second, because it is usually room-temp and completely falls apart in the mouth. icy jello holds together well in the mouth and throat; chocolate pudding works for some folks.
really, though, the best thing to do is to get a swallow eval, including a barium fluoroscopy, done by qualified speech-language pathology (slp). this will show how intact the swallow reflex is, where the leakage is, and what foods are safest. their notes tend to be very detailed and give you exactly the rationales for their determination. if your facility doesn't have one on staff, there is likely one in the community.Jul 23, '12 by tewdlesThanks for the article.
As one might imagine, dysphagia is a recurring issue in hospice and we provide thickeners for patient use in the home.
Of course, our goals for care are a bit different than they are in the "curative" arena of health care, but we still don't want our patients to suffer through choking, paroxysmal coughing, and aspiration pneumonitis.Jul 23, '12 by cherryames1949Thanks commuter and green tea for shedding light on an important topic. It isn't only a matter of patient safety but also a quality of life issue.Jul 24, '12 by StaragateAs long as it's mixed right. Thickener gets thicker over 5 minutes. What may be perfect at the time of mixing, may be a solid paste by the time they start drinking it.Jul 24, '12 by animal1953Teh Commuter you must be reading my mind!! Get out of there, it could be hazardous to your health and sanity!!! One of the reasons I became a CNA was my wife. She has have numerous strokes and is relatively stable now. One of the by-products of her strokes is Dysphagia. Over the last 5 years, I have been setting her fluids up with thickener. It is a trial and error process in getting the right thickness. Stargate is right in the fact that it continues to thicken over a 5 minute timeframe. I use a fork to beat it like making scrambled eggs and check the thickness as it goes. I have also found that hot and cold beverages thicken differentlyAfter time you get to know the proper mixture but you still have to watch it to make sure that instead of them drinking it, you have to spoon feed it. We have also found out and verified with the speech pathologist that milkshake are not the best way to go because the milkshake thins a bit and there is a good chance of leakage.
The Commuter, you and VickyRn rock with your timely and informative articles. :bowingpur