The following position statement was developed by SASS Associates Holly Blankenship, Travis Camp, Jessica Scott, and Matthew Ward. This collaborative effort was born out of their experiences seeing patients for FEES studies and their desire to better understand GERD and its relationship to oropharyngeal dysphagia. We commend them for their efforts
Position Statement
Gastroesophageal reflux disorder (GERD) is a common condition—impacting up to 28% of adults in the United States (El-Serag et al., 2014). While the diagnosis and treatment of GERD fall outside the standard scope of practice for speech-language pathologists (SLPs), reflux can cause significant respiratory complications and often complicates the diagnosis of oropharyngeal dysphagia at the bedside. Treatment of known or suspected dysphagia by altering diet texture or liquid viscosity can significantly reduce quality of life and may exacerbate reflux. Hence, screening for dysphagia should include a thorough review of the patient’s history that includes common symptoms of reflux. Treatment for oropharyngeal dysphagia should not begin prior to completing an instrumental (VFSS or FEES) assessment of swallowing. Any signs concerning undiagnosed or poorly controlled reflux warrant a physician consultation.
Position Evidence and Support
Roughly, 40% of adults in the United States report weekly GERD symptoms, and 10% experience GERD weekly or daily (Bajwa et al., 2011). GERD can cause coughing during or after meals, and it is a common cause of chronic cough. In fact, GERD may present only with a cough—and no other GI symptoms—in up to 75% of cases (Irwin & Richter, 2000). Even further complicating the clinical picture for clinicians seeking to diagnose dysphagia at the bedside, there is a correlation between reflux and many chronic or recurrent respiratory conditions: pneumonia, bronchitis, COPD, asthma, and pulmonary fibrosis (Bajwa et al., 2011).
At the bedside, dysphagia screenings—whether completed by speech-language pathologists or other medical professionals—rely heavily on coughing during oral intake as an indicator of possible laryngeal penetration or aspiration. However, only 29% of SLPs report using a statistically valid tool to evaluate dysphagia (Carnaby & Harenberg, 2013). Therefore, any medical condition that can cause coughing is likely to confound bedside evaluations.
In medical settings, there is often a systemic urge to treat a cough—as the hallmark of aspiration—at the bedside without imaging. In short, SLPs are often tasked with eliminating or reducing frequent coughing with meals, when drinking, or when taking medications. However, attempting to ameliorate a symptom, without knowing its cause, is problematic at best. Moreover, when SLPs are consulted, a common intervention is diet texture modification or liquid viscosity alteration, and up to 30% of long-term care residents receive thickened liquids and mechanically altered diet textures (Castellanos et al., 2004). Thickened liquids are known to slow digestion (Cichero, 2013), which may exacerbate reflux. Thus, treating a cough, of unknown origin, with traditional swallowing intervention may prove futile and could ultimately cause harm.
The rate of pneumonia from prandial aspiration remains relatively low, and continuing to eat and drink orally, even when significant laryngotracheal aspiration is observed via FEES or VFSS, is poorly correlated with the development of pneumonia (Abdelhamid et al., 2016; Andersen et al., 2013; Beck et al., 2018; Bock et al., 2017; Feinberg et al., 1996; Hines et al., 2010; Loeb et al., 2003; Santos et al., 2021; Speyer et al., 2010). While trace aspiration of food and liquid may cause pneumonia or other complications, morbidity and mortality for gastric aspiration (due to reflux or emesis) are high—accounting for 30-40% of all acute respiratory distress-related mortality (Acosta-Herrera et al., 2014).
GERD Considerations after FEES
If patient history or changes in the soft tissue are concerning for unknown or poorly controlled reflux, physician consultation is warranted. Further, if aspiration of esophageal or gastric contents is witnessed during FEES, medical staff should be informed immediately.
While there is a poor correlation between prandial aspiration and pneumonia, aspiration of esophageal or gastric contents can have dire consequences. Thus, the reduction or elimination of prandial aspiration alone should not be the singular focus of recommendations based on FEES results. When making recommendations, clinicians should weigh the risks of any proposed intervention that could exacerbate GERD. Therefore, diet texture modifications and liquid viscosity alterations should be made with equal regard for their impact on quality of life, nutrition, hydration, and the possibility of exacerbating underlying medical conditions such as GERD.
References
Abdelhamid, A., Bunn, D., Copley, M., Cowap, V., Dickinson, A., Gray, L., Howe, A., Killett, A., Lee, J., & Li, F. (2016). Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis. BMC geriatrics, 16(1), 1-18.
Acosta-Herrera, M., Pino-Yanes, M., Perez-Mendez, L., Villar, J., & Flores, C. (2014). Assessing the quality of studies supporting genetic susceptibility and outcomes of ARDS. Frontiers in genetics, 5, 20.
Andersen, U. T., Beck, A. M., Kjaersgaard, A., Hansen, T., & Poulsen, I. (2013). Systematic review and evidence based recommendations on texture modified foods and thickened fluids for adults (≥ 18 years) with oropharyngeal dysphagia. e-SPEN Journal, 8(4), e127-e134.
Bajwa, A. A., Usman, F., Samuel, V., Cury, J. D., & Shujaat, A. (2011). Impact of GERD on common pulmonary diseases. Northeast Florida Medicine, 62(1), 31-34.
Beck, A. M., Kjaersgaard, A., Hansen, T., & Poulsen, I. (2018). Systematic review and evidence based recommendations on texture modified foods and thickened liquids for adults (above 17 years) with oropharyngeal dysphagia–An updated clinical guideline. Clinical nutrition, 37(6), 1980-1991.
Bock, J. M., Varadarajan, V., Brawley, M. C., & Blumin, J. H. (2017). Evaluation of the natural history of patients who aspirate. The Laryngoscope, 127, S1-S10.
Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567-574.
Castellanos, V. H., Butler, E., Gluch, L., & Burke, B. (2004). Use of thickened liquids in skilled nursing facilities. Journal of the American Dietetic Association, 104(8), 1222-1226.
Cichero, J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication, and feelings of satiety. Nutrition Journal, 12(1), 54. https://doi.org/10.1186/1475-2891-12-54
El-Serag, H. B., Sweet, S., Winchester, C. C., & Dent, J. (2014). Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut, 63(6), 871-880.
Feinberg, M. J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104-109.
Hines, S., McCrow, J., Abbey, J., & Gledhill, S. (2010). Thickened fluids for people with dementia in residential aged care facilities. International Journal of Evidence‐Based Healthcare, 8(4), 252-255.
Irwin, R. S., & Richter, J. E. (2000). Gastroesophageal reflux and chronic cough. The American journal of gastroenterology, 95(8), S9-S14.
Loeb, M. B., Becker, M., Eady, A., & Walker‐Dilks, C. (2003). Interventions to prevent aspiration pneumonia in older adults: a systematic review. Journal of the American Geriatrics Society, 51(7), 1018-1022.
Santos, J. M., Ribeiro, Ó., Jesus, L. M., & Matos, M. A. C. (2021). Interventions to Prevent Aspiration Pneumonia in Older Adults: An Updated Systematic Review. Journal of Speech, Language, and Hearing Research, 1-17.
Speyer, R., Baijens, L., Heijnen, M., & Zwijnenberg, I. (2010). Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review. Dysphagia, 25(1), 40-65.
May 2021