Title: Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence: A Randomized Trial

Background: Progressively thicker liquid consistencies are routinely recommended to patients with evidence of dysphagia without robust evidence that this intervention prevents pneumonia. Elderly patients may already have difficulty remaining hydrated and changing the consistency of liquids may contribute to decreased liquid intake for some patients. In my hospice organization, nurses recommend increasingly thickened consistencies for patients who continue to cough with meals. 

Design and Participants: . Randomized, controlled trial. 515 patients > or = 50-year-old with dementia or Parkinson’s and objective evidence of aspiration of thin liquids were enrolled from June 1998 to Sept 2005 across multiple hospitals and facilities. Three intervention arms: chin-down posture only (259), nectar-thick (133), honey-thick (123). The primary outcome was pneumonia. Patients were followed for 3 months or death whichever came first. Of note, only patients who did equally well (1/3) or equally poorly (2/3) on all interventions by videoflouroscopy were randomized. 

Results: 52 patients had pneumonia over 3 months. There was no statistical difference between the 3 arms in incidence of pneumonia, though the results trended towards more pneumonia in the thickened-liquid groups overall and in the subgroup of patients who aspirated during all 3 interventions. More pneumonia events occurred in the honey-thick than the nectar-thick groups. Patients in the thickened liquids groups were more likely to have dehydration, UTI, and fever. Withdrawal from the study due to hospitalization or complications was more common in the thickened liquid group. Of note, the overall rate of pneumonia in this cohort was lower than expected which might reflect benefit from all three interventions. The authors note that nectar-thick liquids may be easier to clear from the airway than more viscous liquids. 

Commentary: No comment on which intervention was more acceptable to patients or caregivers. Chin-down posture is difficult to achieve in patients who cannot follow commands. The fact that only patients who did equally well or equally poorly by videofluoroscopy were randomized may render results less useful. We have selected the patients for whom no difference is what would have been predicted by objective testing. This does bely the mantra that the thicker the liquids the less the aspiration and thus the less the pneumonia.