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

American Speech-Language-Hearing Association
Perspectives of the ASHA Special Interest Groups
Authors:

Abstract and Figures

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.
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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 lungs 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 hosts 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 hosts
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
patients 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 patients 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 useor
nonuseof the swallow.
Normal Use Reduced Use Nonuse
Normal frequency
(14 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 useoccurs 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 useas executing a swallow less than someone with regular
oral feeds, with only occasional engagement (such as limited tastes of food/liquid). We believe
reduced useexists on a spectrum from mild to severe. Finally, nonuseof 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 freezingas 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 patients
response to one ice chip in their mouth is very telling regarding the patients 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 patients 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 patients 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 patients 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 01.5 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
PenetrationAspiration Scale (PAS 18; Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996)
When did penetration or aspiration occur: before, during, or after the swallow; was the patients
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 patients 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 patients 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 patients 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: Its 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 facilitys 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: Its 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: Its 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 patients 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
1NPO 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
324icechipsatatime,
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
2NPO 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
2Small 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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3NPO (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
8trialsof35icechipswere
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)
3Nectar-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
4NPO since surgery
(824 days; 2.3 years)
Gtube dependent
Seen in outpatient
clinic
3•“Good impressionpathway
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
21 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
5NPO (for a long
time)
Gtube dependent
Seen in outpatient
clinic
4•“Good impressionpathway
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)
124 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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6NPO (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)
1Ground solids and
thin liquids
Return for continued
swallow therapy
Patient did not return
for follow-up
c
7NPO (8 days)
NGT dependent
Seen as inpatient
5•“Poor impressionpathway 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
3Strict 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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8NPO (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)
2Nectar-thick liquids
by spoon only (<5 ml)
and 24 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
9NPO (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)
21 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.
40
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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 studys 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 authorscombined
>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 714 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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... The Ice Chip Protocol described by Susan Langmore represents a classic hybrid of diagnostic and therapeutic procedures and was explicitly developed for the treatment of severely dysphagic, tracheotomized patients [92]. In these patients, ice-chips are particularly suitable since (i) the cold sensation acts as a strong sensory trigger that boosts swallowing activity, (ii) due to their solid consistency ice-chips can be better controlled in the mouth than liquid boluses, which more likely spill into the pharynx, (iii) they can be given in variable but defined amounts depending on the patient' s swallowing abilities (an ice chip has a volume of approximately 1 ml), and (iv) the patient is reasonably safe if aspiration occurs [93][94][95]. Ice-chips should first be used within FEES to assess the effects of the intervention on parameters such as swallowing frequency and secretion status and to determine the appropriate bolus size for the patient. Subsequently, ice chips can be regularly included into swallowing therapy, often serving as a transition between "nil-per-os" status and the introduction of regular food textures, such as semisolids or liquid boluses [94]. ...
... Ice-chips should first be used within FEES to assess the effects of the intervention on parameters such as swallowing frequency and secretion status and to determine the appropriate bolus size for the patient. Subsequently, ice chips can be regularly included into swallowing therapy, often serving as a transition between "nil-per-os" status and the introduction of regular food textures, such as semisolids or liquid boluses [94]. ...
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Background Decannulation in tracheotomized neurological patients is often complicated by severe dysphagia, which compromises airway safety and delays weaning. Additional challenges, including reduced cough strength, excessive bronchial secretions, and altered airway anatomy exacerbate weaning issues, thereby increasing morbidity and mortality. This review summarizes diagnostic procedures and therapeutic options crucial for the rehabilitation of tracheotomized patients. Main body Key diagnostic strategies for assessing decannulation readiness focus on airway protection, airway patency, bronchial secretion management, and cough function. These are collectively introduced as the A ² BC criteria in this review. Advanced tools such as flexible endoscopic evaluation of swallowing, endoscopic assessment of airway anatomy, measurement of cough strength, and intrathoracic pressure are essential components of a systematic evaluation. Therapeutic interventions encompass restoring physiological airflow, behavioral swallowing treatment, secretion management, and pharyngeal electrical stimulation. The proposed decannulation algorithm integrates two pathways: the “fast-track” pathway, which facilitates rapid decannulation based on relevant predictors of decannulation-success, and the “standard-track” pathway, which progressively increases cuff deflation intervals to build tolerance over time. Conclusion Successful decannulation in neurological patients demands a multidisciplinary, patient-centered approach that combines advanced diagnostics, targeted therapies, and structured management pathways. The proposed algorithm integrates fast-track and standard-track pathways, balancing rapid diagnostics with gradual weaning strategies. This framework promotes flexibility, enabling clinicians to tailor interventions to individual patient needs while maintaining safety and optimizing outcomes.
... Apenas um picolé de gelo mentolado reduz a intensidade da sede em 80,6%, e o desconforto em 75,9% (39) . Ressalta-se que o uso de gelo auxilia na recuperação da disfagia pela reativação da musculatura da deglutição (40) . ...
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Objetivo: elaborar, com base em evidências, dois protocolos distintos com critérios de segurança para pacientes pós-extubados e traqueostomizados a fim de sustentar a administração de métodos de alívio da sede. Método: estudo metodológico dividido em duas fases: definição do escopo e elaboração dos protocolos. Identificaram-se critérios de segurança que foram submetidos à avaliação de confiabilidade das evidências pelo sistema Grading of Recommendations, Assessment, Development and Evaluation (GRADEpro). Os critérios foram incorporados em fluxogramas com seus respectivos manuais operacionais. Os painelistas formularam recomendação e calculou-se o Índice de Validade de Conteúdo. Resultados: desenvolveram-se dois protocolos e respectivos manuais para avaliação de segurança na administração de métodos de alívio da sede: um para pacientes pós-extubados e outro para traqueostomizados. Critérios de segurança elencados: nível de consciência, sinais de insuficiência respiratória, náusea e/ou vômito, capacidade de deglutição, tosse/proteção das vias aéreas, alteração de voz e funcionamento adequado da cânula de traqueostomia. Obteve-se recomendação dos painelistas com Índice de Validade de Conteúdo de 87%. Conclusão: os protocolos clínicos, com seis critérios de segurança cada, com base em evidências para o manejo da sede em pacientes pós-extubados e traqueostomizados são inovadores, permitem avaliação da segurança para o manejo da sede e têm validade de conteúdo.
... Una sola paleta de hielo mentolada reduce la intensidad de la sed en un 80,6% y el malestar en un 75,9% (39) . Cabe destacar que el uso de hielo ayuda en la recuperación de la disfagia al activar los músculos de la deglución (40) . ...
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Objetivo: elaborar, con base en evidencias, dos protocolos distintos con criterios de seguridad para pacientes post-extubados y traqueostomizados con el fin de respaldar la administración de métodos de alivio de la sed. Método: estudio metodológico dividido en dos fases: definición del alcance y elaboración de los protocolos. Se identificaron criterios de seguridad que fueron sometidos a evaluación de confiabilidad de las evidencias mediante el sistema Grading of Recommendations, Assessment, Development and Evaluation (GRADEpro). Los criterios fueron incorporados en flujogramas con sus respectivos manuales operativos. Los panelistas formularon recomendaciones y se calculó el Índice de Validez de Contenido. Resultados: se desarrollaron dos protocolos y sus respectivos manuales para la evaluación de seguridad en la administración de métodos de alivio de la sed: uno para pacientes post-extubados y otro para traqueostomizados. Criterios de seguridad enumerados: nivel de consciencia, signos de insuficiencia respiratoria, náusea y/o vómito, capacidad de deglución, tos/protección de las vías aéreas, alteración de la voz y funcionamiento adecuado de la cánula de traqueostomía. Se obtuvo recomendación de los panelistas con un Índice de Validez de Contenido del 87%. Conclusión: los protocolos clínicos, con seis criterios de seguridad cada uno, basados en evidencias para el manejo de la sed en pacientes post-extubados y traqueostomizados, son innovadores, permiten la evaluación de seguridad para el manejo de la sed y tienen validez de contenido.
... It is worth noting that the use of ice helps in the recovery of dysphagia by reactivating the swallowing muscles (40) . ...
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Objective: to develop two distinct protocols, based on evidence, with safety criteria for post-extubated and tracheostomized patients in order to support the administration of thirst relief methods. Method: methodological study divided into two phases: definition of the scope and development of the protocols. Safety criteria were identified and submitted to the evaluation of reliability of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADEpro) system. The criteria were incorporated into flowcharts with their respective operational manuals. The Experts formulated recommendations and the Content Validity Index was calculated. Results: two protocols and its respective manuals were developed to assess the safety of the administration of thirst relief methods: one for post-extubated patients and the other for tracheostomized patients. Safety criteria listed: level of consciousness, signs of respiratory failure, nausea and/or vomiting, swallowing ability, coughing/airway protection, voice changes and adequate functioning of the tracheostomy tube. The Experts’ recommendations were obtained with a Content Validity Index of 87%. Conclusion: the clinical protocols, with six safety criteria each, based on evidence for the management of thirst in post-extubated and tracheostomized patients are innovative, allow safety assessment for thirst management and shows content validity.
... In this investigation, initiation of laryngeal closure of 2ml thin liquid was delayed 0.24 seconds more than that of 5ml . For example, using the ice chip is one of the strategies to stimulate the swallowing responses (Pisegna & Langmore, 2018). In addition, compensatory strategies such as chin down will help the pharyngeal swallow effectively by widening the vallecula (Macrae et al., 2014). ...
... Po zakończeniu badania endoskop musi być dokładnie umyty, zdezynfekowany zgodnie z wytycznymi zawartymi w instrukcji dezynfekcji sprzętu oraz zabezpieczony przed ewentualnym skażeniem do czasu ponownego użycia. W przypadku pacjentów z ciężkim przebiegiem COVID-19, z podejrzeniem ciężkiej dysfagii, badanie endoskopowe połykania można rozpocząć od The Ice Chip Protocol [Pisegna, Langmore, 2018]. ...
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Celem niniejszego artykułu jest przedstawienie procesu diagnostycznego w przypadku dysfagii ustno-gardłowej w przebiegu choroby COVID–19 na podstawie dostępnych publikacji naukowych oraz wytycznych opracowanych przez stowarzyszenia zrzeszające logopedów na całym świecie. COVID–19 to ostra choroba zakaźna układu oddechowego, wywołana zakażeniem wirusem SARS-CoV–2. Przebieg schorzenia może być różny – od bezobjawowego nosicielstwa aż po ciężką niewydolność oddechową prowadzącą do śmierci. Wśród pacjentów hospitalizowanych z powodu COVID–19 częstym objawem są zaburzenia połykania. Wykazano, że dysfagia jest niezależnym predyktorem śmiertelności wewnątrzszpitalnej, przedłużonego czasu hospitalizacji oraz wiąże się z niekorzystnym rokowaniem u tych chorych. W przypadku pacjentów z COVID–19 bardzo istotne jest właściwe rozpoznanie zaburzeń połykania, ustalenie mechanizmu prowadzącego do rozwoju tych zaburzeń oraz włączenie odpowiedniej terapii. Pozwoli to zapobiec poważnym powikłaniom dysfagii, stanowiącym zagrożenie dla zdrowia i życia pacjenta.
... The patient commenced a course of intensive dysphagia therapy focusing on improving pharyngeal drive and hyolaryngeal excursion (Masako manoeuvre, effortful swallow manoeuvre, Shaker manoeuvre) [17]. Ice chip therapy was also implemented with the aim of improving laryngeal sensation and secretion management [18]. ...
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We present an unusual case of a 62-year-old male presenting with contralateral hypoglossal and recurrent laryngeal nerve palsies following endotracheal intubation for emergency cardiac surgery. Postoperative, the patient was referred to Speech and Language Therapy due to concerns regarding the safety of his swallow. Oromotor assessment revealed left-sided tongue weakness and aphonia. Flexible endoscopic evaluation of swallowing (FEES) revealed a right vocal cord palsy and severe oropharyngeal dysphagia. There were no other focal neurological signs. An MRI head did not demonstrate a medial medullary stroke or other intracranial lesion. CT neck showed no abnormality identified in relation to the course of the right vagus nerve or recurrent laryngeal nerve at the skull base or through the neck respectively. The patient required a gastrostomy for nutrition and hydration. He continued to be assessed at several month intervals over the course of a year using FEES to obtain a range of voice, secretion and swallowing outcome measures. The patient commenced intensive dysphagia therapy targeting pharyngeal drive, hyolaryngeal excursion and laryngeal sensation. Swallow manoeuvres were trialled during FEES and a head-turn to the side of the vocal cord palsy during deglutition reduced aspiration risk which expedited return to oral intake. The patient had partial recovery over twelve months. Hypoglossal nerve palsy completely resolved. The right vocal cord remained paralysed however the left vocal cord compensated enabling the patient to produce a normal voice. The patient was able to take thin fluids and regular diet and the gastrostomy was removed.
... The precision of these commonly employed methods though, is highly questionable as to whether they assist in the accurate detection of PED as well as their contribution to prevent silent aspiration, which in turn is likely to predispose patients to pneumonia. The use of ice chips as a method to evaluate and rehabilitate impaired swallowing function is described as an alternative protocol outlined by Pisegna and Langmore (2018). However, to ascertain its safety, effectiveness, and related outcomes, this protocol needs to be systematically investigated. ...
Chapter
Treatment is the natural continuation of the evaluation of swallowing in cases where difficulties are found. In terms of swallowing and oral feeding, two key concepts should be considered: safety and nutritional effectiveness. By safety, we refer to the neutralization of the risk that the bolus may enter the airways, increasing both the risk of choking, according to its size, and the risk of lung infection. Nutritional effectiveness, on the other hand, refers to the ability of the ingested bolus to meet the nutritional and hydration needs of the individual. The treatment of dysphagia is strongly bound by these two concepts, which determine the methods of execution and the limits of applicability. The goal of treatment is functional swallowing, that is, a para-physiological mode of swallowing with no aspiration, even if the transit times of the bolus in the oropharyngeal canal may be longer than normal and minimal residues may remain in the oral cavity (Schindler 1990) (Table 4.1). Historically, the treatment of dysphagia has been based on two different approaches: compensation and re-education. The compensatory approach includes all strategies that, while not modifying the physiology of the swallowing act, ensure the safety and functionality of swallowing. The rehabilitative approach, on the other hand, includes all strategies that affect the physiology of swallowing, achieving stable changes. In the first phase of its young history, speech therapy treatment was mainly based on the search for compensation, but today, there are techniques and tools, and above all theories, that have given a significant boost to the use of re-educational techniques. A preventive approach is also spreading, reserved for those individuals who must undergo treatments, for example, chemoradiotherapy, in which the onset of dysphagia is the expected consequence of the planned treatments. The choice of the type of approach is closely linked to the outcome of the evaluation, which is responsible for identifying the dysfunctional traits of swallowing. The use of one of the two approaches is almost never alternative, but most of the time, the rehabilitator uses both, with a different coefficient of use of the rehabilitative or compensatory approach on the basis of the phase of the rehabilitative path. In the early stages of taking charge of the dysphagic patient, the approach is predominantly compensatory, whereas during the course of therapy and with the progress of rehabilitative goals, the use of compensation is gradually reduced. Compensatory strategies, in fact, produce an immediate effect, thus quickly solving the patient’s swallowing problems. The rehabilitative approach, on the other hand, produces results that are spread over time, but are more stable. Furthermore, the functional improvement, obtained via a compensation technique, is strictly dependent on the use of the technique itself; the rehabilitative approach, on the other hand, produces improvements that, at a certain point, are independent of the exercise itself (Schindler et al. 2011).
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The Frazier Free Water Protocol was developed with the aim of providing patients with dysphagia an option to consume thin (i.e. unthickened) water in-between mealtimes. A systematic review was conducted of research published in peer-reviewed journals. An electronic search of the EMBASE, CINAHL and MEDLINE databases was completed up to July 2016. A total of 8 studies were identified for inclusion: 5 randomised controlled trials, 2 cohort studies with matched cases and 1 single group pre-post intervention prospective study. A total of 215 rehabilitation inpatients and 30 acute patients with oropharyngeal dysphagia who required thickened fluids or were to remain 'nil by mouth', as determined by bedside swallow assessment and/or videofluoroscopy/fiberoptic endoscopic evaluation of swallowing, were included. Meta-analyses of the data from the rehabilitation studies revealed (1) low-quality evidence that implementing the protocol did not result in increased odds of having lung complications and (2) low-quality evidence that fluid intake may increase. Patients' perceptions of swallow-related quality of life appeared to improve. This review has found that when the protocol is closely adhered to and patients are carefully selected using strict exclusion criteria, including an evaluation of their cognition and mobility, adult rehabilitation inpatients with dysphagia to thin fluids can be offered the choice of implementing the Free Water Protocol. Further research is required to determine if the Free Water Protocol can be implemented in settings other than inpatient rehabilitation.
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The aim of this study was to compare selected parameters of two swallow evaluations: fiberoptic endoscopic evaluation of swallowing (FEES) and the modified barium swallow (MBS) study. This was a cross-sectional, descriptive study. Fifty-five clinicians were asked to watch video recordings of swallow evaluations of 2 patients that were done using fluoroscopy and endoscopy simultaneously. In a randomized order, clinicians viewed 4 edited videos from simultaneous evaluations: the FEES and MBS videos of patient 1 and 2 each taking one swallow of 5 mL applesauce. Clinicians filled out a questionnaire that asked (1) which anatomical sites they could visualize on each video, (2) where they saw pharyngeal residue after a swallow, (3) their overall clinical impression of the pharyngeal residue, and (4) their opinions of the evaluation styles. Clinicians reported a significant difference in the visualization of anatomical sites, 11 of the 15 sites were reported as better-visualized on the FEES than on the MBS video (p < 0.05). Clinicians also rated residue to be present in more locations on the FEES than on the MBS. Clinicians' overall impressions of the severity of residue on the same exact swallow were significantly different depending on the evaluation type (FEES vs. MBS for patient 1 χ(2) = 20.05, p < 0.0001; patient 2 χ(2) = 7.52, p = 0.006), with FEES videos rated more severely. FEES advantages were: more visualization of pharyngeal and laryngeal swallowing anatomy and residue. However, as a result, clinicians provided more severe impressions of residue amount on FEES. On one hand, this suggests that FEES is a more sensitive tool than MBS studies, but on the other hand, clinicians might provide more severe interpretations on FEES.
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The benefit of water protocols for individuals with thin liquid aspiration remains controversial, with mixed findings from a small number of randomized controlled trials (RCTs). This study aimed to contribute to the evidence of the effectiveness of water protocols with a particular emphasis on health outcomes, especially hydration. An RCT was conducted with patients with known thin liquid aspiration post stroke randomized to receiving thickened liquids only or a water protocol. For the 14 participants in rehabilitation facilities whose data proceeded to analysis, there was no difference in the total amount of beverages consumed between the water protocol group (mean = 1103 ml per day, SD = 215 ml) and the thickened liquids only group (mean = 1103 ml, SD = 247 ml). Participants in the water protocol group drank on average 299 ml (SD 274) of water but offset this by drinking less of the thickened liquids. Their hydration improved over time compared with participants in the thickened liquids only group, but differences between groups were not significant. Twenty-one percent of the total sample was diagnosed with dehydration, and no participants in either group were diagnosed with pneumonia. There were significantly more diagnoses of urinary tract infection in the thickened liquids only group compared to the water protocol group (χ 2 = 5.091, p = 0.024), but no differences between groups with regard to diagnoses of dehydration (χ 2 = 0.884, p = 0.347) or constipation (χ 2 = 0.117, p = 0.733). The findings reinforce evidence about the relative safety of water protocols for patients in rehabilitation post stroke and provide impetus for future research into the potential benefits for hydration status and minimizing adverse health outcomes.
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Texture modification has become one of the most common forms of intervention for dysphagia, and is widely considered important for promoting safe and efficient swallowing. However, to date, there is no single convention with respect to the terminology used to describe levels of liquid thickening or food texture modification for clinical use. As a first step toward building a common taxonomy, a systematic review was undertaken to identify empirical evidence describing the impact of liquid consistency and food texture on swallowing behavior. A multi-engine search yielded 10,147 non-duplicate articles, which were screened for relevance. A team of ten international researchers collaborated to conduct full-text reviews for 488 of these articles, which met the study inclusion criteria. Of these, 36 articles were found to contain specific information comparing oral processing or swallowing behaviors for at least two liquid consistencies or food textures. Qualitative synthesis revealed two key trends with respect to the impact of thickening liquids on swallowing: thicker liquids reduce the risk of penetration–aspiration, but also increase the risk of post-swallow residue in the pharynx. The literature was insufficient to support the delineation of specific viscosity boundaries or other quantifiable material properties related to these clinical outcomes. With respect to food texture, the literature pointed to properties of hardness, cohesiveness, and slipperiness as being relevant both for physiological behaviors and bolus flow patterns. The literature suggests a need to classify food and fluid behavior in the context of the physiological processes involved in oral transport and flow initiation.
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Limited information is available regarding use of the Frazier free water protocol (FWP) with hospitalized patients who have dysphagia and have survived a critical illness with compromised pulmonary status. This pilot study used a two-group nonequivalent comparison group design to evaluate the FWP in 15 adults admitted to a respiratory care unit (RCU) with dysphagia concerns. Inclusion criteria included recommendation for a modified diet with thickened liquids by a dysphagia therapist and ability to follow the specific free water guidelines. The 15 control participants were chosen from a retrospective chart review of consecutive RCU admissions that met the same inclusion criteria. The intervention group for whom the free water guidelines were implemented did not differ significantly from the control group in rate of development of aspiration pneumonia, χ²(30) = .01, p = 1.00.
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In this opinion piece, I present my major reasons for advocating for the free water protocol (FWP). Although there is a lack of strong direct evidence in support of the FWP, there are multiple bits of indirect evidence supporting it: patients do not like thick liquids and avoid them; thick liquids are more harmful to the lungs than are thin liquids; feeding tubes are associated with high rates of pneumonia; and thin liquids, especially water, are relatively benign to the lungs. We need solid evidence in the form of a randomized clinical trial, but, in the meantime, decisions regarding allowing free water to patients who aspirate this consistency should be made on a case-by-case basis.
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