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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
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, &
Perspectives of the ASHA Special Interest Groups
SIG 13, Vol. 3(Part 1), 2018, Copyright © 2018 American Speech-Language-Hearing Association
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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
, plus all nutrition
and hydration by mouth)
Swallowing is executed occasionally
The swallow is rarely
used, and when it is,
it is mostly reflexive
A patient with total oral
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
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
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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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),
Patient status Medical diagnosis
1 76, female Outpatient,
SCCa of the oral cavity, s/p resection of the floor of the mouth
with free flap, mandibulectomy, partial glossectomy
2 72, male Outpatient,
SCCa of supraglottis and lung s/p completion of chemoradiation
and radiation treatment
3 59, male Inpatient,
Sepsis and altered mental status
4 48, female Outpatient,
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,
Cerebral palsy, spastic quadriplegia
6 65, male Outpatient,
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,
SCCa of the floor of mouth s/p manibulectomy, bilateral neck
dissection, fibula free flap & tracheotomy (decanulated inpatient)
8 73, male Inpatient,
CABG x5 and left cerebellar, left precentral gyrus, and right
occipital lobe stroke
9 81, male Outpatient,
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).
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?
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
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
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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Table 3. Descriptive outcomes of Ice Chip Protocol case studies (all performed under endoscopy).
Case Baseline
Ice Chip
Recommendations Follow-up
1NPO since surgery
(27 days)
Gtube dependent
Seen in outpatient
3•“Fair/guarded impression ()
pathway to decision making
Thick secretions
Aspiration seen on multiple
Head turn to right effective
at reducing penetration/
Severely reduced clearance
20 times per day
Use water spritzer
throughout the day
to loosen oral secretions
Nutrition and
medications via Gtube
Return for continued
swallow therapy
Maintained good
health, no decline in
pulmonary status
At 2 months
phlegm was gone
(no longer needing
suction), thin liquids
in large volumes
PO, supplementing
nutrition via 2 cans
per day in Gtube
2NPO since surgery
(79 days)
Gtube dependent
Seen in outpatient
2•“Fair/guarded impression ()
pathway to decision making
Aspiration on first trial but
ejected with immediate, strong
A SSGM effective at
eliminating aspiration
2Small spoonfuls of ice
chips throughout the
day using SSGM
All other nutrition,
hydration, and
medications via Gtube
Return for continued
swallow therapy
Patient did not start
on ice chips until
2nd visit, then began
taking ice chips at
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
At 4 months, taking
100% oral diet, Gtube
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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
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
3Nectar-thick liquids
and pureed solids in
1/2 meal volumes
Supplement PO
intake with NGT
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
3•“Good impressionpathway
to decision making
Silent aspiration occurred
on first 2 trials of 2 ice chips,
but a cued strong cough was
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
Return for continued
swallow therapy
At 1 month
taking only ice chips
and on free water
protocol at nursing
At 4 months: taking
1/4 teaspoon of puree
No decline in
pulmonary status
5NPO (for a long
Gtube dependent
Seen in outpatient
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
improvement in
swallow initiation
and was upgraded
to puree solids and
thin liquids
No decline in
pulmonary status
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6NPO (14 days)
Gtube dependent
Seen in outpatient
2•“Fair/guarded impression (+)
pathway to decision making
First trial of 1 chip loosened
oral secretions, which were
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
1Ground solids and
thin liquids
Return for continued
swallow therapy
Patient did not return
for follow-up
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
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
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
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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
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
Supplement PO
intake with NGT
About 1 month later,
pt was reevaluated in
outpatient clinic
Rec nectar-thick
liquids and pureed
9NPO (20 days)
Gtube dependent
Seen in outpatient
5•“Fair/guarded impression ()
pathway to decision making
First trial of 1 chip loosened
oral secretions, which were
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
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
Nutrition and
medications via Gtube
Return for continued
swallow therapy
Patient did not return
for follow-up
Note. Gtube = gastronomy tube; NGT = nasogastric tube; NPO = nil per os; PO = per os; Pt = patient; rec = recommend; SSGM =
supersupraglottic maneuver.
Donzelli et al. (2003).
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).
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.
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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
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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.
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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... Regardless, use of such tubes does not consistently result in reductions in aspiration and associated adverse events (American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee, 2014; Blumenstein et al., 2014). In fact, feeding tubes can lead to oropharyngeal disuse atrophy, increased risk of extra-esophageal reflux, reduced ability to return to oral alimentation, increased oral bacterial load, and decreased quality of life (Kurien et al., 2017;Langmore et al., 1998;Leibovitz et al., 2003;Pisegna & Langmore, 2018). Furthermore, as duration of presence of the feeding tube increases, so do the number of associated complications (Pancorbo-Hidalgo et al., 2001). ...
... Based on limited data, there is no increase in extra-esophageal reflux in infants with a feeding tube (Murthy et al., 2018). In some cases, feeding tubes may lead to reduced swallow frequency, yielding increased oropharyngeal secretions and associated bacteria (Pisegna & Langmore, 2018). When aspiration occurs, greater levels of bacteria will be transported to the lungs essentially increasing the risk of an adverse event such as aspiration pneumonia. ...
Purpose The presence of oropharyngeal dysphagia increases the likelihood of prandial aspiration, and aspiration increases the likelihood of a dysphagia-related pulmonary sequelae such as aspiration pneumonia, acute respiratory distress syndrome, pulmonary fibrosis, and even death. Although these outcomes are unfortunate, it is important to point out that these consequences are not solely determined by the presence of aspiration. The purpose of this tutorial is to provide current information on pulmonary defenses and the variables that increase risk of an adverse outcome in individuals who aspirate. Method This tutorial reviews the basics of lung defenses and summarizes the literature to make the case that the host is a central theme in dysphagia management. Case studies are employed to highlight the key variables. Results Based on a literature review, a series of questions are proposed for consideration in dysphagia management. These questions, which take the focus away from the presence of aspiration and toward the associated risks within an individual, are then applied to two case studies. Conclusions A guiding framework is proposed to encourage clinicians to assess more than the presence of aspiration and consider the individual's ability to cope with the aspirated material. In the presence of aspiration, clinicians are urged to focus on the risk factors that can lead to a negative consequence, identify which factors are modifiable, and determine when a level of risk is acceptable.
... Although a formal ice chip protocol is not used with infants and young children, there are circumstances where use of ice chips is an appropriate option to facilitate swallowing activity (Miller et al., 2009). Descriptive efficacy data are available for adults (Pisegna & Langmore, 2018), but the premise of the use of ice chips should be similar for older children. Please see the guidelines in Part 1-Adult (Langmore et al., 2022, p. 170) for a full description of the adult ice chip protocol, modifying as needed for use with older children. ...
Full-text available
Purpose This is Part 2 of a two-part tutorial series establishing clinical guidelines pertaining to the administration of fiberoptic endoscopic evaluation of swallowing (FEES) developed by representatives of the American Board of Swallowing and Swallowing Disorders, all of whom are members of Special Interest Group 13. Whereas Part 1 focused on use of FEES with adults and included general information common to using FEES in any population, the purpose of this tutorial is to provide clinicians with updated best practice clinical guidelines for performing, interpreting, and documenting outcomes when using FEES with the pediatric population. This document has two main sections. The first section discusses the history of pediatric FEES, needed knowledge and skill pertaining to all elements of performing and interpreting the examination including detailed information related to indications and contraindications, developmental anatomical and physiological changes across childhood, preparing for and conducting the examination, medical collaboration, and patient safety. The second section provides detailed guidelines for clinicians who require training for use of FEES with the pediatric population. Conclusions This first of its kind tutorial offers guidelines for clinicians who perform, interpret, and/or want to train to perform FEES in the pediatric population. Important clinical distinctions exist when using FEES with the pediatric population versus with the adult population. Developmental changes, pediatric medical frailty, provider–parent/caregiver interaction, collaboration with physician colleagues, and patient safety are representative of key areas highlighted in this document.
... Successivamente può essere effettuato un test di screening con la somministrazione di boli (23) (24) (25) (29) (30) . Data la frequente presenza di secchezza delle fauci e del deficit di sensibilità faringo-laringeo, può essere utile somministrare, previa igiene del cavo orale, piccoli pezzi di ghiaccio (ice chips) da far deglutire al paziente (32) . ...
Full-text available
Lo scopo di questo studio è quello di descrivere il ruolo del logopedista nelle terapie intensive in Italia. Ci sono sempre più evidenze a supporto dell'intervento precoce del logopedista nella valutazione e gestione delle difficoltà deglutitorie e comunicative con una ricaduta positiva sugli outcome in termini riabilitativi, nella riduzione della degenza ospedaliera, nella qualità di vita. Questo report è suddiviso in due sezioni. La prima definisce il ruolo del logopedista nella gestione della disfagia per pazienti con tracheostomia e disfagia post-estubazione. Sono descritte le procedure per la valutazione della funzione deglutitoria così come l'importanza del contributo del logopedista nel processo di svezzamento dalla cannula tracheostomica. La seconda parte descrive l'importanza del logopedista nell'implementare la comunicazione del paziente con il personale infermieristico e medico. Negli ultimi mesi c' è stato un incremento della richiesta dell'intervento del logopedista dovuta all' emergenza Covid 19 per il trattamento di pazienti positivi al virus nelle terapie intensive; questo report fornisce un contributo utile al logopedista nella gestione di questa popolazione. In conclusione questo documento vuole guidare i colleghi logopedisti nella gestione dei pazienti nelle terapie intensive. The purpose of this statement is to inform the role of speech and language therapist (SLT) in intensive care units in Italy. There is growing evidence to support the early intervention by SLTs in assessing and managing swallowing and communications impairments with positive outcomes for rehabilitation, reduction of hospital stay, nutrition and quality of life. This report is divided in two main subsections. The first one defines the role of SLTs in dysphagia managements for people with tracheostomy and post-extubation dysphagia. The procedures for swallowing assessment are described as well as the important contribution of SLTs in tracheostomy weaning process. The second subsections describes the value of SLTs in helping patient's communication with nurses and doctors. As in the last few months, there was an increased demand of SLTs to treat covid-19 patients in critical care settings; this report give also a contribution for the SLTs management with this population. In conclusion, this statement wants to guide SLTs colleges in the management of patients in intensive care unit. rIassunto aBstract 46 REVIEW
... Figure 2 provides a checklist for the items that should be included once the scope is in place. While this document does not cite all research that has established norms for different aspects of swallow function and physiology or evidence for differentiating normal from abnormal, citations referenced in the previous section on the FEES Protocol are relevant in this section and may be found at the end of Figure 2. Table 9. Summary of basic ice chip protocol (Pisegna & Langmore, 2018). ...
Full-text available
Purpose Representatives of the American Board of Swallowing and Swallowing Disorders (AB-SSD) and American Speech-Language-Hearing Association (ASHA) Special Interest Group (SIG) 13: Swallowing and Swallowing Disorders (Dysphagia) developed this tutorial to identify and recommend best practice guidelines for speech-language pathologists who conduct and interpret fiberoptic endoscopic evaluation of swallowing (FEES) procedures in adults. This document also includes proposed training needs and methods for achieving competency. Expert opinion is provided regarding indications for performing the FEES exam, potential contraindications, adverse effects and safety, equipment and personal protection, the exam protocol, interpretation and documentation of findings, and training requirements to perform and interpret the exam. Conclusions This tutorial by the AB-SSD and SIG 13 represents the first update about the FEES procedure since ASHA's position paper and technical report published in 2004. Creation of this document by members of the AB-SSD and SIG 13 is intended to guide professionals who are training for or practicing FEES in the adult population toward established best practices and the highest standards of care.
... Smith-Hammond and colleagues (2004) documented recommending dietary modifications for the majority of their participants with dysphagia. If a patient is not ready for an oral diet, an ice chip protocol with an emphasis on oral hygiene may be considered as a relatively safe way to stimulate the swallow mechanism and maintain or build strength until the patient is ready for other foods or liquids (Pisegna & Langmore, 2018). ...
Speech-language pathologists working with adults in medical settings are likely to encounter patients with a diagnosis of diabetes mellitus on a regular basis (NCD Risk Factor Collaboration, 2016). The current literature supports an association between diabetes and mild cognitive impairment (Moreira, Soldera, Cury, Meireles, & Kupfer, 2015; Vincent & Hall, 2015). Mild impairments in executive functioning are of particular relevance in this population. Even within the range of normal cognitive abilities, reduced executive functioning can negatively impact patients’ self-management of their diabetes (and potentially adherence to therapy programs and strategies) and therefore their overall health. Mild cognitive deficits in this population are therefore clinically relevant and may warrant intervention (Vincent & Hall, 2015). Diabetic complications may also impact digestion, indirectly impacting patients’ intake and tolerance of food and drink (Borgnakke, Anderson, Shannon, & Jivanescu, 2015; Gatopoulou, Papanas, & Maltezos, 2012; Hüppe et al., 1992; Sandberg, Sundberg, Fjellstrom, & Wikblad, 2000).
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Purpose Fiberoptic endoscopic evaluation of swallowing (FEES) is a well-respected swallowing assessment, harking back to 1988 when it was first published by Susan Langmore as a procedure. Since then, its methodology has evolved to afford clinicians, researchers, and patients a sensitive, specific, and predictive exam. A myriad research has investigated FEES technique and its outcomes, rendering it an effective and efficient procedure for swallowing assessment and therapy. This commentary will outline evidence for FEES to support evidence-based practice. What is the evidence for speech tasks? Secretion scales? What is the predictive nature of aspiration as seen on FEES? This comprehensive review will outline the science bolstering the use and confidence in FEES. Conclusions This commentary reviews studies that have proposed normative data collected via FEES for decision making, specifically when assessing pharyngeal and laryngeal anatomy, bolus spillage, and the white out period. Evidence for FEES sensitivity and predictive aspects are reviewed in relationship to speech tasks, secretions, aspiration and penetration–aspiration scale scores, and pharyngeal residue scales. The acute care advantage of FEES is defined in its use on postextubation populations, assessment of dysphagia in COVID-19 positive patients, and safe evaluation during ice chip administration with acutely ill patients. Finally, inference making on FEES is discussed in regard to epiglottic retroflexion and depth of aspiration. When it comes to assessing pharyngeal dysphagia, the true strengths of FEES are rooted in evidence. It has been shown to be sensitive, predictive, and practical and will likely continue to have stronger support as research continues to enrich its potential. Supplemental Material
Purpose The speech-language pathologist (SLP) plays an integral role when working with patients who have tracheostomy tubes and are on mechanical ventilation. The patients and the clinical team depend on our expertise to make critical decisions on speaking valve use, introduction of food by mouth (per os), weaning off of the ventilator, weaning from the feeding tube, and tracheostomy tube decannulation. Conclusions While not expected to be experts on the cardiopulmonary function of patients, SLPs must have a solid foundation of knowledge when it comes to patients with highly complex disease processes and care plans. This clinical focus article is meant to serve as an overview for the SLP working with tracheostomy tubes and ventilators and for those SLPs interested in entering this area of practice.
The topic of this chapter is the general use and basic principles of FEES as a therapeutic examination in patients with neurogenic dysphagia and to compare it’s findings with those of VFSS. When used for this purpose, usually by speech-language pathologists (SLPs) or by SLPs and neurologists working together as a team, endoscopy is applied as a tool to identify the presence and severity of dysphagia, to uncover the nature of the problem, and, finally, to guide dietary and behavioral treatment of the patient. FEES can also be used to guide surgical and medical treatment. This will be further addressed in Chap. 7 of this book.
Swallowing disorders play a special role in both the stroke unit and the neurological intensive care unit due to their extraordinary incidence, the acuteness of their occurrence, their related complications, and the different therapeutic options for treating them. When planning the diagnostic algorithm, it is important to keep in mind that the VFSS is applicable only in a limited number of often seriously ill patients (Langmore 1996) as these patients not only have to be transported to the radiological unit but must also remain in an upright position and be able to cooperate. In contrast, in this clinical context, FEES has the advantage that it can be performed at the bedside as well as on uncooperative and not fully mobilized patients (Langmore 1996). In this chapter, specific applications of the FEES in the stroke unit and the neurological intensive care unit are explained, typical problems are addressed, and the possibilities and limitations of a standardized diagnostic and therapeutic procedure are described.
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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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Maintenance of skeletal muscle is essential for health and survival. There are marked losses of skeletal muscle mass as well as strength and physiological function under conditions of low mechanical load, such as space flight, as well as ground based models such as bed rest, immobilization, disuse, and various animal models. Disuse atrophy is caused by mechanical unloading of muscle and this leads to reduced muscle mass without fiber attrition. Skeletal muscle stem cells (satellite cells) and myonuclei are integrally involved in skeletal muscle responses to environmental changes that induce atrophy. Myonuclear domain size is influenced differently in fast and slow twitch muscle, but also by different models of muscle wasting, a factor that is not yet understood. Although the myonuclear domain is 3-dimensional this is rarely considered. Apoptosis as a mechanism for myonuclear loss with atrophy is controversial, whereas cell death of satellite cells has not been considered. Molecular signals such as myostatin/SMAD pathway, MAFbx, and MuRF1 E3 ligases of the ubiquitin proteasome pathway and IGF1-AKT-mTOR pathway are 3 distinctly different contributors to skeletal muscle protein adaptation to disuse. Molecular signaling pathways activated in muscle fibers by disuse are rarely considered within satellite cells themselves despite similar exposure to unloading or low mechanical load. These molecular pathways interact with each other during atrophy and also when various interventions are applied that could alleviate atrophy. Re-applying mechanical load is an obvious method to restore muscle mass, however how nutrient supplementation (e.g., amino acids) may further enhance recovery (or reduce atrophy despite unloading or ageing) is currently of great interest. Satellite cells are particularly responsive to myostatin and to growth factors. Recently, the hibernating squirrel has been identified as an innovative model to study resistance to atrophy.
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.
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.
Swallowing disorders are associated with increased morbidity and mortality. An estimated 18 million adults will require care for dysphagia-related malnutrition, dehydration, pneumonia, and reductions in quality of life by 2010 (1-3). Patients with dysphasia have an increased incidence of aspiration pneumonia because the aspirated material is heavily colonized with bacteria. Pneumonia is the most common cause of infectious death in the United States among persons age 65 years or older and the third leading cause of death for persons age 85 years or older (4). One hospital admission for pneumonia is estimated to cost $7166 (5). Rates of hospital discharge for Medicare beneficiaries with pneumonia as a primary diagnosis have increased by 93.5% in the past decade (6), along with length of stay and death rates (4). Liquid aspiration is the most common type of aspiration in elderly persons (1). Relative risk for pneumonia is highest in patients with dementia, followed by those who are institutionalized (7). As many as 50% of patients with parkinsonism are estimated to have dysphagia (8), and one third aspirate silently---that is, with no external sign (such as coughing) to eject material or alert caregivers (9). Many short- and long-term care facilities use thickened liquid diets to treat of aspiration (10). In these diets, thin liquids (for example, water, tea, coffee) are eliminated, even in the absence of efficacy data, at a substantial cost in financial and quality-of-life terms. It costs approximately $200 per month for an individual to drink thickened liquids (11,12). A common alternative to thickened liquids is use of a chin-down posture (13-17). Welch and coworkers (13) noted that posterior shift of anterior pharyngeal structures with the chin-down posture improved airway protection. Whereas previous studies have provided a basis for the widespread clinical use of chin-down posture, none has provided long-term health outcome data. Results from a previously reported portion of this study demonstrated short-term elimination of aspiration during the videofluorographic swallowing evaluation most often with honey-thick liquids, followed by nectar-thick liquids, and finally chin-down position (18). We sought to compare the effectiveness of chin-down posture and thickened liquids (nectar thick and honey thick) on the incidence of pneumonia in participants with dementia or Parkinson disease during 3 months of treatment.