The Ice Chip Protocol: A Description of the Protocol and Case Reports

Abstract

Purpose
There is limited information regarding the theoretical underpinnings of an Ice Chip Protocol. This article aims to discuss its use in assessment and rehabilitation of swallowing disorders.

Method
A brief outline of the Ice Chip Protocol has been published, but in the present commentary, we thoroughly describe the protocol. We explain the rationale, indications for use, steps, and expected outcomes. We also present 9 case reports of patients who presented as nil per os for a swallow evaluation and received the Ice Chip Protocol.

Result
We demonstrate that the Ice Chip Protocol led to positive outcomes in the majority of the case reports. In 77.8% of the cases (7/9), secretion amount and location improved. Our anecdotal experiences suggest that it is a safe and successful protocol for both the evaluation and rehabilitation dysphagia. However, there is no systematic evidence for support.

Conclusion
Clinicians and researchers are often asked to evaluate the swallows of patients who are severely dysphagic and sometimes critically ill. Our experience suggests that the Ice Chip Protocol is an effective and safe method, but it would greatly benefit from being formally studied. This commentary is meant to encourage more formal investigations of its outcomes.

Full text

The Ice Chip Protocol: A Description of the Protocol
and Case Reports
Jessica M. Pisegna
Department of Otolaryngology, Boston Medical Center
Boston, MA
Speech-Language Pathology Sciences, Boston University School of Medicine
Boston, MA
Susan E. Langmore
Department of Otolaryngology-Head & Neck Surgery, Boston University Medical Center
Boston, MA
Disclosures
Financial: Jessica M. Pisegna has no relevant financial interests to disclose. Susan E. Langmore
has no relevant financial interests to disclose.
Nonfinancial: Jessica M. Pisegna has no relevant nonfinancial interests to disclose. Susan E.
Langmore has no relevant nonfinancial interests to disclose.
Purpose: There is limited information regarding the theoretical underpinnings of an Ice
Chip Protocol. This article aims to discuss its use in assessment and rehabilitation
of swallowing disorders.
Method: AbriefoutlineoftheIceChipProtocolhasbeenpublished,butinthepresent
commentary, we thoroughly describe the protocol. We explain the rationale, indications for
use, steps, and expected outcomes. We also present 9 case reports of patients who presented
as nil per os for a swallow evaluation and received the Ice Chip Protocol.
Result: We demonstrate that the Ice Chip Protocol led to positive outcomes in the majority
of the case reports. In 77.8% of the cases (7/9), secretion amount and location improved.
Our anecdotal experiences suggest that it is a safe and successful protocol for both the
evaluation and rehabilitation dysphagia. However, there is no systematic evidence for support.
Conclusion: Clinicians and researchers are often asked to evaluate the swallows of
patients who are severely dysphagic and sometimes critically ill. Our experience suggests
that the Ice Chip Protocol is an effective and safe method, but it would greatly benefit from
being formally studied. This commentary is meant to encourage more formal investigations
of its outcomes.
For clinicians in the field of dysphagia, the use of ice chips for swallowing assessment and
rehabilitation is not a novel concept. However, despite the anecdotal use of ice chips, there is very
little empirical support in the literature.
The Effect of Water on the Lungs
The membranes of the human airway are made to facilitate transport of fluid in utero
while they are filled with fluid. Water-transporting proteins, called aquaporins, line the epithelia
and endothelia of the lungs and facilitate the passage of fluid across the lung’s lining. In adulthood,
high levels of aquaporins are still present, and the lungs remain highly permeable to water (Borok
& Verkman, 2002; Day et al., 2014; Verkman, Matthay, & Song, 2000).
Myriad literature endorses this premise, suggesting that trace aspiration of water does
not pose a serious risk for pneumonia (Feinberg, Knebl, & Tully, 1996; Feinberg, Knebl, Tully, &
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Segall, 1990; Langmore, 2001; Olson, 1970; Robbins et al., 2008; Simonelli et al., 2010; Splaingard,
Hutchins, Sulton, & Chaudhuri, 1988).
The Necessary but Insufficient Requirements for Aspiration Pneumonia
Three necessary conditions must co-occur to develop aspiration pneumonia, none of
which are sufficient in isolation. First, the material must be pathogenic, meaning a substance
that is harmful to the lungs: secretions with bacteria, food particles, stringent liquids, and
gastric contents. Second, aspiration must occur. It is impossible to get an aspiration pneumonia
without aspirating. In certain situations, this will be volume or location dependent. Similarly, a
trace amount of aspiration to the subglottic shelf in the superior trachea is not significant enough
to create an inflammatory response. In one study, only 38% of the patients who aspirated went
on to develop a pneumonia (Langmore et al., 1998). Third, the host’s defense must be unable
to process the aspirate. A history of lung disease, poor respiratory status, and a lowered immune
system are examples of a reduced defensive system. Thus, the necessary but individually insufficient
requirements for pneumonia are (a) a pathogenic aspirate must be (b) aspirated and (c) the host’s
defense system is unable to prevent colonization and subsequent infection (Langmore, 2011;
Langmore, Schatz, & Olsen, 1988; Rohmann, Tschernig, Pabst, Goldmann, & Dromann, 2011).
When all three factors occur, an aspiration pneumonia may develop.
Ideal Candidates for the Ice Chip Protocol: Who and Why
The ideal patient for the Ice Chip Protocol is someone with a suspected severe dysphagia
or an unknown swallowing ability. Ice chips are ideal when the clinician is not confident in the
patient’s ability to safely swallow and/or has advanced pulmonary disease. These patients are
likely to aspirate anything given to them; hence, the exam should be conservative with a benign
bolus such as an ice chip. We view any patient who is currently tube fed as a good candidate
for the Ice Chip Protocol because these patients may have a severe dysphagia and may not have
swallowed any food or liquid for an extended time. In fact, it has been shown that tube-fed
patients have a lower frequency of swallowing than orally fed patients, to the point where
secretions are not managed (Crary & Groher, 2006).
We also regard candidacy for the Ice Chip Protocol by what the patient’s current swallow
status is in terms of how frequently the swallow is engaged: normal, reduced, or nonuse, which
are operationally defined below and in Table 1.
Table 1. A schema to consider swallowing condition prior to the Ice Chip Protocol. We have found
that ice chips are the best way to start an evaluation for patients presenting with “reduced use”or
“nonuse”of the swallow.
Normal Use Reduced Use Nonuse
Normal frequency
(1–4 times per minute
at rest
a
, plus all nutrition
and hydration by mouth)
Swallowing is executed occasionally
Mild————————————Severe
The swallow is rarely
used, and when it is,
it is mostly reflexive
Example:
A patient with total oral
feeding
Example:
Mild——————————————Severe
Example:
An intubated patient
A patient with a nasogastric
tube, supplementing with
some food or liquids boluses
by mouth
Nothing by mouth
with exclusive
feeding via
alternative means
Note.
a
Murray et al. (1996), Langmore (2001).
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“Normal use”occurs in a patient who can swallow at a normal frequency without great
hindrance (about one to four per minute at rest; Langmore, 2001; Murray, Langmore, Ginsberg,
& Dostie, 1996). We define “reduced use”as executing a swallow less than someone with regular
oral feeds, with only occasional engagement (such as limited tastes of food/liquid). We believe
“reduced use”exists on a spectrum from mild to severe. Finally, “nonuse”of the swallow is
defined as almost exclusive nonuse of the swallow, as in an intubated patient or a surgical
patient who cannot volitionally execute a swallow and requires suctioning. When the swallow
is engaged in this case, it is mostly reflexive. Some authors in the intubation literature have
mentioned swallowing dysfunction occurs postextubation in part due to “muscle freezing”as a
consequence of nonuse while intubated (Barquist, Brown, Cohn, Lundy, & Jackowski, 2001).
Ideal patients for the Ice Chip Protocol are those who are eligible for trials of oral feeding but have
recently shown reduced use or nonuse of the swallow (see Table 1).
The Advantage of Ice
Ice chips have unique and beneficial characteristics. First, they are a small controllable
volume, ranging from the size of a pea to the size of a pencil eraser (~5 ×7 mm). We have measured
each ice chip to be approximately 1 ml of melted water. The clinician can easily control the amount
of bolus on the spoon and the amount taken by the patient because they are small and contained
entities.
Second, ice chips are a cohesive bolus. Ice chips can be easily manipulated and held in
the mouth. They allow for engagement of the oral preparatory phase of swallowing, which stimulates
cortical structures and their role in facilitating the transit of the bolus and initiation of the swallow
(Hiiemae & Palmer, 1999; Palmer, Rudin, Lara, & Crompton, 1992). They are easier to control than
a small amount of water and can be propelled into the pharynx before they melt. The patient’s
response to one ice chip in their mouth is very telling regarding the patient’s oral control and ability
to execute a volitional swallow.
Third, ice chips are a cold, familiar-tasting bolus. Patients frequently report that the cold
ice “tastes good.”In fact, one study demonstrated that access to water and ice chips were
significantly associated with improved quality of life (Karagiannis & Karagiannis, 2014). Behind
the enjoyment is a much more complicated process. A cold solid bolus stimulates thermal,
chemoreceptor, and tactile receptors in the mouth. Afferent pathways to brainstem, subcortical,
and cortical centers are activated as the ice is held in the oral cavity.
Fourth, we suggest that small ice chips are beneficial because they are relatively benign
if aspirated. Because of the very small size of the ice chips, one of them cannot block the glottis
and is therefore not a choking hazard.
The Ice Chip Protocol is based on the same tenants of any water protocol: Clean water, in
and of itself, is not harmful to the lungs (Holas, DePippo, & Reding, 1994; Robbins et al., 2008).
Water protocols have put forth that if a patient’s mouth is kept clean, then a small amount of
aspiration of water should not be harmful to the patient. We put forth that the same theory applies
to small and controlled volumes of ice chips and that ice chips hold additional advantages in
assessing and rehabilitating dysphagia.
The goal of this report is to describe the logistics of an Ice Chip Protocol and propose
guidelines to support clinical judgment. We postulate that the Ice Chip Protocol is a safe and
successful method to assess swallow ability and engage, or “wake up,”the swallowing system in
severely dysphagic patients who have been nil per os (NPO). It is hoped that future studies will
use the proposed standardized protocol to carry out the Ice Chip Protocol and formally investigate
its important clinical outcomes related to dysphagia.
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Method
Nine cases in an urban hospital were reviewed retrospectively to highlight a range of
patient types who received the Ice Chip Protocol. The cases included six men and three women
ranging in age from 22 to 81 years old with varying etiologies (see Table 2). For each patient, the
speech pathologist was consulted by the medical team to perform flexible endoscopic evaluation
of swallowing (FEES). All patients were strictly NPO prior to the evaluation. The Ice Chip Protocol
was administered to each patient as outlined below. A chart review was then performed to extract
recommendations and outcomes.
Preparatory Work
In order to perform the Ice Chip Protocol, we required the patients to be alert and able
to sit upright. Vitals were monitored during the evaluation, especially in the acute inpatient
setting, in case there was an acute change in status. Oral suctioning was available, if needed.
Immediately prior to the Ice Chip Protocol, the oral cavity of each patient was cleaned using
tooth and gum brushing (with a suction if needed), tongue swabbing, suctioning, hard palate
scraping, and rinsing and spitting. Oral care is arguably the most important step to remove
pathogenic material that could potentially be aspirated. Oral care protocols have been thoroughly
documented elsewhere that are beyond the scope of this article (Carlaw et al., 2012; Chalmers,
King, Spencer, Wright, & Carter, 2005; Cuccio et al., 2012; Dickinson, 2012).
Table 2. Patient demographics.
Case Age (years),
gender
Patient status Medical diagnosis
1 76, female Outpatient,
ambulatory
SCCa of the oral cavity, s/p resection of the floor of the mouth
with free flap, mandibulectomy, partial glossectomy
2 72, male Outpatient,
ambulatory
SCCa of supraglottis and lung s/p completion of chemoradiation
and radiation treatment
3 59, male Inpatient,
nonambulatory
Sepsis and altered mental status
4 48, female Outpatient,
ambulatory
Clival meningioma, cerebellar hemorrhage, and vestibular
schwannoma, multiple cranial neuropathies and neurologic
deficits s/p suboccipital resection, and craniotomy, and
tracheotomy (uncapped)
5 22, male Outpatient,
nonambulatory
Cerebral palsy, spastic quadriplegia
6 65, male Outpatient,
ambulatory
Follicular ameloblastoma of right mandible s/p segmental
mandibulectomy, right fibula osteocuteneous free flap, right
neck dissection, excision of right submandibular gland
7 82, female Inpatient,
nonambulatory
SCCa of the floor of mouth s/p manibulectomy, bilateral neck
dissection, fibula free flap & tracheotomy (decanulated inpatient)
8 73, male Inpatient,
ambulatory
CABG x5 and left cerebellar, left precentral gyrus, and right
occipital lobe stroke
9 81, male Outpatient,
nonambulatory
SCCa of the hard palate s/p mass excision (maxillectomy) with
bilateral neck dissection and tracheostomy
Note. CABG = coronary artery bypass grafting; SCCa = squamous cell carcinoma; s/p = status post.
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Each Ice Chip Protocol was performed under the guidance of endoscopy (FEES) because it
provides a direct view of the larynx, a direct view of secretions, a direct view of ice chips, and is more
sensitive to detecting aspiration (Kelly, Drinnan,&Leslie,2007;Pisegna&Langmore,2016a,2016b).
Procedure
The ice chips used in our protocols were sourced from the kitchen icemaker machine
on patient floors. Each ice chip was about 5 ×7 mm. We mixed a few spoonfuls of ice chips
with two drops of green food dye to enhance visualization of the ice chip bolus endoscopically.
1. Observation of Swallowing Anatomy and Secretions
Upon entry into the pharynx and before the Ice Chip Protocol, we noted the swallowing
anatomy, vocal fold mobility, and the patient’s ability to close the glottis with a cued cough or
phonation (Part 1 speech tasks of the FEES).
We rated secretions before the swallow because they have the potential to block the
bolus path; lead to penetration, aspiration, or both; and may accumulate with added boluses (see
Figure 1a). We rated them after the ice chip trials to indicate the success, or lack thereof, of the ice
chip trials in engaging the swallow and loosening (see Figure 1b), moving, and clearing secretions
(see Figure 1c) using a standardized rating tool (Marianjoy 5-point ordinal scale; Donzelli, Brady,
Wesling, & Craney, 2003).
Figure 1. Secretions (a) before, (b) during, and (c) after the Ice Chip Protocol in NPO patients in need
of a swallow evaluation.
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2. Administration of Ice Chips: Three Trials
Trial 1: We put one-half to two ice chips (<2 ml fluid volume) on a clean spoon and
administered them with the following directions to the patient: “Take these ice chips, move
them around your mouth, and swallow all at once when you are ready.”The amount of ice to
start with required clinical judgment regarding the patient’s condition and ability within the
flexible structure of this protocol. During and after the first trial of ice chips, we observed the
following outcomes to build a clinical impression:
•Oral control
○Bilateral lip closure; manipulation of the ice chips with the tongue; jaw movement.
○Spillage: anterior spillage, laterality and amount; posterior spillage, laterality and amount; length of
spillage in seconds (some spillage is normal on liquids from 0 to 3 s to the valleculae and 0–1.5 s to
the piriform sinuses (Butler et al., 2011; Dua, Ren, Bardan, Xie, & Shaker, 1997; Saitoh et al., 2007;
Stephen, Taves, Smith, & Martin, 2005).
•Initiation of the swallow
○Where was the head of the bolus when the swallow was triggered; was the swallow initiation delayed;
was it spontaneous or cued; brisk or effortful (i.e., pumping or slowed movements)?
•Airway closure
○Did the epiglottis retroflex; did the laryngeal complex elevate?
•Penetration or aspiration
○Penetration–Aspiration Scale (PAS 1–8; Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996)
○When did penetration or aspiration occur: before, during, or after the swallow; was the patient’s
reaction to penetration/aspiration (cough, throat clear, repeated swallowing) necessary, spontaneous,
or strong?
•Secretions
○If secretions were present, were they mostly cleared, partly cleared, or not at all by the swallow; did
the ice chips thin the secretions; did they loosen and move; did the patient sense the secretions; was
suctioning required?
○We wait to rerate the secretion scale formally (Donzelli et al., 2003) until after the end of the protocol,
not in between trials, because the loosening of secretions typically makes them worse before they can
be cleared.
•Pharyngeal clearance/residue
○Was there compete and adequate white out?
○How much of the melted ice chips remained; if there was some residue, where did it pool; how did
the patient manage them; were any strategies necessary and effective in clearing the pooling (e.g.,
double swallow, head turn)?
•The patient’s response
○Ice chip trials usually make the patient more alert due to the coldness, wetness, and required engagement.
Was the patient more awake; did he or she express enjoyment over the ice chips or was his or her response
muted; what was the vocal quality like?
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A critical aspect of the Ice Chip Protocol was that even if the outcomes of the first trial
are poor (i.e., the swallow is delayed or aspiration occurred), the trials continue. Reengaging the
swallowing mechanism often required more than one attempt, especially after prolonged NPO
status. Engaging the sensory and motor neural pathways may take multiple attempts, even over
several days, to recover the swallow. We must emphasize that clinicians may see aspiration.
Trial 2: We performed a second trial of one-half to two ice chips in the very same manner
regardless of the outcome of the first trial (an exception would be an emergency change in status/
alertness/vital signs). Again, we made note of the aspects described above, including oral control,
initiation, airway closure, and so forth.
Trial 3: We repeated one-half to two ice chips for a third time, regardless of the outcomes
of the first and second trial (exception: an emergency change in status/alertness/vital signs).
In other words, even if it did not go well on the first two trials, we continued with a third trial. We
made note of the events of the third trial for each of the outcome areas listed above, in addition
to any new clinical information.
3. Clinical Decision Making: A Decision Tree
After three trials of ice chips, we formed a clinical judgment about the patient’s ability
to swallow. Figure 2 depicts a decision tree based on our decision-making process. It is worth
repeating that each patient was taken on a case-by-case basis and the patient’s response was
closely monitored for acute changes. Other nonswallowing factors too abundant to list were
considered while building a clinical judgment (i.e., cognitive status, dependence for feeding,
medical conditions).
Figure 2. Decision making after the first three trials of ice chips.
Note. *Unless the patient is a candidate for a free water protocol, comfort measures only, or other
extenuating circumstances. NPO = nil per os; PO = per os; Rec = recommend.
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From our experience, there are three overall impressions that could be made after three
trials of ice chips: (a) a good impression, (b) a fair/guarded impression, or (c) a poor impression.
The subjective labels of these results are intentional, as clinical impression is difficult to
specifically outline. The following text aims to describe each pathway in Figure 2 to combine
clinical impression with outcomes of the three administrations of ice chips.
“A Good Impression”: It’s going well.
Possible next steps include additional trials of ice chips, larger volumes of ice chips,
thin or nectar-thick liquid, or foods such as pureed solids. Each facility’s protocol for
other bolus trials may differ; a standardized protocol for FEES is described elsewhere
(Langmore, 2001).
•Complete or adequate oral control and manipulation
•No lengthy spillage anteriorly/posteriorly
•Quick and timely initiation of the swallow
•If aspiration occurred, a spontaneous cough/throat clear was successful at clearing
the aspirate
•Secretions reduced, if they were present
•The patient became more awake and alert
“A Fair/Guarded Impression”: It’s going ok.
If the clinical impression is more favorable (+), then other boluses could be trialed. If the
clinical impression is less favorable (–), then perhaps the patient requires more attempts
on ice to fully engage the swallow. In the case studies, it was not unusual for many trials
of ice to be carried out to clear oral and pharyngeal secretions.
•Reduced oral control
•Mild to moderate spillage anteriorly/posteriorly
•Delayed initiation of the swallow
•If aspiration occurs, a spontaneous or cued cough/throat clear is inconsistently
successful
•Same or reduced secretions and/or secretions are mobilized to be suctioned, coughed
up, or swallowed
•Each trial of ice chips seemed slightly better than the prior
“A Poor Impression”: It’s not going well.
After three trials of small ice chips, the clearest stopping guideline is if the patient cannot
execute initiation of the swallow, or if they become less alert. We may also stop if we see
three or more events of silent aspiration with no attempt to eject or unsuccessful ejection
of the bolus upon cueing. We recommend retrying the Ice Chip Protocol at a later time
(once the patient’s status improves).
•No initiation of the swallow (two to three times)
•Consistent spillage of whole ice chips into the larynx
•Aspiration with no spontaneous response for more than three times OR cued cough/
throat clear was unsuccessful OR silent aspiration occurred more than three times
•Excessive coughing resulting in shortness of breath
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•Significant change in vitals to outside of normal limits
•Increase in amount of secretions, which are not cleared despite cueing
•An excessively gurgly voice with no success at spontaneous or cued clearing
Results
Table 3 describes each of the nine patients who began with NPO status and received the
Ice Chip Protocol. The length of NPO ranged from 7 days to 2.3 years, and all patients were
receiving nutrition, hydration, and medication via a feeding tube at the time of the evaluation.
Two experienced speech language pathologists reviewed the videos and determined clinical
recommendations. Aspiration was seen in five of nine cases. In six of the cases, clinical impression
of swallowing ability was determined to be fair/guarded, which is expected given the extended
length of NPO presented by all of the patients. However, the flow chart proposed for the Ice Chip
Protocol enabled the clinicians to follow a favorable (+) or unfavorable (−)impressionoftheswallowing
presentation, which assisted with the often borderline and difficult clinical decision making. In two
cases, the impression was “good,”and in one case, the impression was “poor.”In all but one case,
it was recommended to start taking at least ice chips or other boluses, and the one case (Case 7)
was complicated by many other factors during the inpatient course.
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(continued)
Table 3. Descriptive outcomes of Ice Chip Protocol case studies (all performed under endoscopy).
Case Baseline
diet
Baseline
secretions
a
Ice Chip
Protocol
Secretions
after
protocol
a
Recommendations Follow-up
1•NPO since surgery
(27 days)
•Gtube dependent
•Seen in outpatient
clinic
•3•“Fair/guarded impression (−)”
pathway to decision making
•Thick secretions
•Aspiration seen on multiple
trials
•Head turn to right effective
at reducing penetration/
aspiration
•Severely reduced clearance
•3•2–4icechipsatatime,
20 times per day
•Use water spritzer
throughout the day
to loosen oral secretions
•Nutrition and
medications via Gtube
b
•Return for continued
swallow therapy
•Maintained good
health, no decline in
pulmonary status
•At 2 months
c
,thick
phlegm was gone
(no longer needing
suction), thin liquids
in large volumes
PO, supplementing
nutrition via 2 cans
per day in Gtube
b
2•NPO since surgery
(79 days)
•Gtube dependent
•Seen in outpatient
clinic
•2•“Fair/guarded impression (−)”
pathway to decision making
•Aspiration on first trial but
ejected with immediate, strong
cough
•A SSGM effective at
eliminating aspiration
•2•Small spoonfuls of ice
chips throughout the
day using SSGM
•All other nutrition,
hydration, and
medications via Gtube
b
•Return for continued
swallow therapy
•Patient did not start
on ice chips until
2nd visit, then began
taking ice chips at
home
•Maintained good
health, no decline in
pulmonary status
•At 3rd visit, thin
liquids mastered
with SSGM
•At 4th visit, upgraded
to soft solids, thin
liquids liquid wash
with supersupraglottic
swallow
•At 4 months, taking
100% oral diet, Gtube
removed
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3•NPO (8 days)
•NGT dependent
•Seen as inpatient
•5•“Fair/guarded impression (+)”
pathway to decision making
•First 2 trials of 1 chip were
absorbed by dry mouth, adequate
oral stage
•8trialsof3–5icechipswere
administered, loosening oral/
pharyngeal secretions
•Patient tried to clear secretions
with swallows, some suctioning
required with cueing to cough,
ultimately removed from larynx
•Secretions were penetrated
but not aspirated
•Further PO trials were carried
out after Ice Chip Protocol
(nectar-thick liquids and pureed
solids)
•3•Nectar-thick liquids
and pureed solids in
1/2 meal volumes
•Supplement PO
intake with NGT
b
•By discharge 2 weeks
later, NGT had been
removed and patient
was on grounds and
thin liquids
•No decline in
pulmonary status
4•NPO since surgery
(824 days; 2.3 years)
•Gtube dependent
•Seen in outpatient
clinic
•3•“Good impression”pathway
to decision making
•Silent aspiration occurred
on first 2 trials of 2 ice chips,
but a cued strong cough was
effective
•No aspiration on subsequent
trials but poor management
of secretions and reduced
pharyngeal clearance
•2•1 ice chip, 5 times
per sitting, 3 times
per day, under close
supervision with a
cue to cough after
every trial
•Nutrition and
medications via Gtube
b
•Return for continued
swallow therapy
•At 1 month
c
,patient
taking only ice chips
and on free water
protocol at nursing
home
•At 4 months: taking
1/4 teaspoon of puree
•No decline in
pulmonary status
5•NPO (for “a long
time”)
•Gtube dependent
•Seen in outpatient
clinic
•4•“Good impression”pathway
to decision making
•Spillage to piriform sinuses,
but no aspiration seen on
multiple trials of ice chips
•Further PO trials were carried
out after Ice Chip Protocol (thin
liquid, nectar-thick liquid, and
puree boluses)
•1•2–4 ice chips at a
time, 30 times per day
•Return for continued
swallow therapy
•By 4th visit, patient
demonstrated
improvement in
swallow initiation
and was upgraded
to puree solids and
thin liquids
•No decline in
pulmonary status
(continued)
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6•NPO (14 days)
•Gtube dependent
•Seen in outpatient
clinic
•2•“Fair/guarded impression (+)”
pathway to decision making
•First trial of 1 chip loosened
oral secretions, which were
swallowed
•On the second trial, penetration
to the vocal folds occurred
before the swallow, an immediate
strong, spontaneous cough
cleared it
•The third trial of ice was
swallowed briskly without
penetration/aspiration, or
any residue
•Further PO trials were carried
out after Ice Chip Protocol (thin
liquids and pureed, ground
solids)
•1•Ground solids and
thin liquids
•Return for continued
swallow therapy
•Patient did not return
for follow-up
c
7•NPO (8 days)
•NGT dependent
•Seen as inpatient
•5•“Poor impression”pathway to
decision making
•On first trial, pt aspirated
spillage of melted ice before
swallow initiation, which had
to be cued
•No patient reaction, cued
cough not successful at clearing
aspiration and pooled ice chip
in piriform sinus
•On second trial, swallow
initiation was brisker, but silent
aspiration occurred on residue
after the swallow, a delayed
cough was weak an ineffective
•Third trial same as the second
•Severe residue of ice chips
remained, although initial
secretions were reduced
•Suctioning was required
•No further trials carried out
•3•Strict NPO
•All other nutrition,
hydration, and
medications via NGT
b
•Percutaneous
endoscopic gastronomy
tube was placed due
to poor swallowing
ability and complicated
hospital course
•One month later,
patient was reevaluated
in outpatient setting,
had remained NPO
c
•Swallow ability
improved, speech-
language pathologist
rec transition to oral
feeding with pureed
solids and thin liquids
•Continue to use
Gtube as indicated by
other team members
(continued)
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8•NPO (7 days)
•NGT dependent
•Seen as inpatient
•4•“Fair/guarded impression (+)”
pathway to decision making
•First ice chip was absorbed by
mouth, pt was extremely dry
•Second and third ice chip
were swallowed but copious
dry secretions loosened, cough
was spontaneous and strong,
suctioning required but
successful
•Further PO trials were carried
out after Ice Chip Protocol (thin
liquids, nectar-thick liquids,
and pureed)
•2•Nectar-thick liquids
by spoon only (<5 ml)
and 2–4 ice chips at a
time, throughout the
day
•Supplement PO
intake with NGT
b
•About 1 month later,
pt was reevaluated in
outpatient clinic
c
•Rec nectar-thick
liquids and pureed
solids
9•NPO (20 days)
•Gtube dependent
•Seen in outpatient
clinic
•5•“Fair/guarded impression (−)”
pathway to decision making
•First trial of 1 chip loosened
oral secretions, which were
swallowed
•On the second trial, brisk
swallow, immediate strong,
spontaneous cough on
penetrating residue
•The third trial of ice same
as second
•Further ice chip trials were
carried out, pt successfully
coughed up thick yellow
secretions
•Other PO trials were carried
out after Ice Chip Protocol (thin
liquids and pureed)
•2•1 ice chip, 5 times
per sitting, 3 times
per day, under close
supervision with a cue
to cough after every
trial
•Nutrition and
medications via Gtube
b
•Return for continued
swallow therapy
•Patient did not return
for follow-up
c
Note. Gtube = gastronomy tube; NGT = nasogastric tube; NPO = nil per os; PO = per os; Pt = patient; rec = recommend; SSGM =
supersupraglottic maneuver.
a
Donzelli et al. (2003).
b
For any decision making regarding calorie counting, means of alternative nutrition, and amount via NGT
of Gtube, we always defer to the other medical professionals to make those determinations (nutrition/dietary).
c
In the outpatient
clinic, follow-up visits did not happen as frequently as requested.
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The amount of secretions was greatly reduced by the Ice Chip Protocol, as demonstrated
in Figure 3, highlighting the baseline secretion score and the secretion score after the Ice Chip
Protocol. In no instances did the secretions get worse, but that was likely due to suctioning,
which was a goal of the protocol and an advantage to clear the pharynx for other trials. In 77.8%
of the cases (7/9), secretion amount and location improved.
Long term follow-up data (diet maintenance, pulmonary status, quality of life) was limited
due to access to what was documented in the electronic medical records alone, and therefore, no
long-term outcomes could be investigated. However, it can be stated that none of the patients
who returned to clinic became significantly worse from the Ice Chip Protocol and none reported
recurrent aspiration pneumonias, hospitalization, or a worsening health status.
We highlight two of the case studies below:
Case 1: Aspiration was seen during and after the first three swallows as the ice chips
mixed with the secretions, but a cued throat clear ejected all secretions and water out of the
airway. Multiple trials of ice in larger volumes (up to five ice chips) were effective at clearing all
secretions, although there was moderate residue of the melted ice chips pooling in the piriform
sinuses. It was recommend that she take two to four ice chips at a time, 20 times per day, and
use water spritzer into her mouth throughout the day to loosen oral and pharyngeal secretions.
Within 2 months, her secretions were gone, and she was taking thin liquids without any problems.
Over 4 months, the patient began taking puree and thin liquids with onset of therapeutic trials.
She was started on semisolids foods, but because of a prolonged oral stage, she still required a
Gtube, which stayed in place until 8 months postsurgery when she was able to take enough PO.
Case 4: Silent aspiration was seen on the first two trials of ice chips, but a cued cough
was strong. No aspiration occurred on subsequent trials, but clearance of the ice chips was
reduced and required multiple swallows to clear the melted ice and secretions. It was recommended
that she receive aggressive oral care and be given single ice chips, five times per sitting, three times
per day under close supervision. A family member was taught how to cue the patient to take ice,
look for signs of a swallow, and then cue to cough. Upon follow-up, the patient remained pneumonia
free despite reports of frank aspiration out of the tracheostomy tube. At the 2-month follow-up, the
patient was receiving ice chips and was put on a free water protocol by the nursing home, remaining
pneumonia free. At the 4-month follow-up, the patient demonstrated the ability to take very small
volumes of puree for pleasure feeding. At 8 months, no pulmonary complications were reported.
Figure 3. Secretion ratings with the 5-point Marianjoy secretions rating scale at baseline before any
trials were carried out and after three administrations of ice chips, per the Ice Chip Protocol.
41
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Discussion
The goal of this commentary was to describe the theoretical framework of a proposed Ice
Chip Protocol. Our clinical experience suggests that the Ice Chip Protocol is a safe and successful
protocol to both evaluate and rehabilitate dysphagia where other boluses would not have been
as successful. Our case studies demonstrated that the Ice Chip Protocol is effective in reducing
secretions and assessing the oral and pharyngeal stage of swallowing in a safe and functional
way. Furthermore, we demonstrated several anecdotal cases where ice chips were used in a
rehabilitative fashion and moved patients to recover the swallow. Other countries appear to
be using a similar technique involving an ice chip exercise, which is also used for swallowing
rehabilitation in severely dysphagic patients (A. Kaneoka, personal communication, April 10, 2015).
Outcomes of the Ice Chip Protocol are largely unstudied. Only one published study could be found:
a poster from 2011 describing two small cohorts of patients who took ice chips during a FEES
protocol. The authors found that aspiration on ice chips was predictive of aspiration on thin liquids
and also predictive of a diet recommendation (Kaszuba, Brady, Wesling, Donzelli, & Stewart, 2011).
That study’s findings demonstrate the advantage of using ice to assess for aspiration risk prior to
more difficult boluses. What remain unknown are other outcomes involving safety in using ice
chips for evaluation purposes and efficacy for rehabilitation.
Frequently asked questions from a wide range of clinicians have been collected to assist
in the dissemination and implementation of the Ice Chip Protocol. The answers, compiled in
the Supplementary Material, are based on the clinical experience from the authors’combined
>40 years of experience using the Ice Chip Protocol. It is important to note that, in most cases,
taking ice chips was not the treatment goal but was viewed as a means of transitioning from an
NPO status to oral intake of liquids and food. In most cases, ice chips were viewed as a practice
bolus to stimulate the swallow mechanism and to build strength until other foods and liquids
could be taken safety.
The case studies we have documented here exemplify ideal candidates for the Ice Chip
Protocol: patients on NPO status who have reduced use or nonuse of the swallow. After prolonged
NPO, it is likely that the swallowing musculature will demonstrate atrophy and weakness. One
may wonder what length of time contributes to significant deconditioning. There is no clear
evidence to answer this question, but literature discussing skeletal muscle of the limbs suggests
that after 7–14 days of disuse, atrophy and weakness will set in (Baldwin, Paratz, & Bersten, 2013;
Bloomfield, 1997; Brooks & Myburgh, 2014; Clark, Fernhall, & Ploutz-Snyder, 2006; Narici &
de Boer, 2011). The neurological input to the muscular system will also become disengaged with
extended disuse. In a seminal study, Clark and colleagues (2006) found significant interplay
between the muscular system and the neurological system: Neural factors explained 48% of the
variation in strength loss over 4 weeks.
The theory supporting the Ice Chip Protocol is the same as that of water protocols. Taken
collectively, the outcomes of 12 clinical trials documenting water protocols do not support an
increased rate of pneumonia in dysphagic patients who take water orally with a structured
protocol in place. The trials included patients across the acute, subacute, and long-term
rehabilitation settings (Becker, Tews, & Lemke, 2008; Bernard, Loeslie, & Rabatin, 2012, 2015;
Bronson-Lowe et al., 2008; Carlaw et al., 2012; Frey & Ramsberger, 2011; Garon, Engle, & Orminston,
1997; Karagiannis, Chivers, & Karagiannis, 2011; Murray, Doeltgen, Miller, & Scholten, 2016;
Panther, 2005; Robbins et al., 2008; Scibilia, Hreha, Piscopo, Adler, & Barrett, 2016). Some of
the water protocol authors did discuss the use of unrestricted water and ice chips (Bernard et al.,
2012; Panther, 2005). In fact, one author noted, “In our practice, ice chips are more likely to be
the first step toward allowing waterintheacutecareenvironment”(Panther, 2005). In further
support, there are three systematic reviews that concluded that pneumonia is not significantly
different in those who take thin liquids with compensation versus those who take thickened
liquids (Gillman, Winkler, & Taylor, 2017; Kaneoka, Pisegna, Saito, & Langmore, 2016; Steele
42
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et al., 2015). Despite these claims, no conclusions can be made about the use of ice chips themselves
because they are unstudied. We propose the use of ice chips as a protocol for clinicians to use
before, in supplementation to, or in replace of a water protocol to both assess and rehabilitate a
dysfunctional swallow.
Limitations
The reports here are anecdotal and are, as such, limited by a lack of a large controlled
sample size. They should be taken as anecdotal experiences alone and hopefully indicate the
need for greater study. Similarly, given the restrictions that accompany retrospective studies,
it could not be empirically determined if the Ice Chip Protocol resulted in shorter feeding tube
durations, reduced pneumonia incidence rates, earlier discharge from the hospital, or quality of
life improvements. Other factors could be influential, such as history of intubation, ambulatory
status, breathing abilities and reserve, disease course, and age. These variables would be
invaluable for future studies.
Conclusion and Future Directions
The Ice Chip Protocol is intended to assist clinicians in evaluating a swallow, especially
in patients with severe dysphagia or extended NPO status. In the majority of the case reports,
patients were given ice chips and demonstrated an overall decrease in pharyngeal secretions
and subsequent success in transitioning to food and liquids by mouth. Our experience suggests
that the Ice Chip Protocol is an effective and safe method, but it would greatly benefit from being
formally studied to determine the safety, utility, and outcomes. This commentary is meant
to encourage more formal investigations of the use of ice chips in swallowing evaluation and
rehabilitation using the proposed protocol.
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History:
Received July 30, 2017
Revised October 08, 2017
Accepted November 15, 2017
https://doi.org/10.1044/persp3.SIG13.28
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