Medical Speech Pathology

Curiosity, Dialogue, and Knowledge

Quality vs. Quantity (or is it Safety?)


In medicine, if there is an acronym be warned… it’s probably Latin.  NPO stands for nil per os~ nothing by mouth.  If the acronym instead was NFD~ no food or drink, I don’t think it would improve things much for families or patients, but it might add transparency (a badly needed fix in our current medical environment).

Making a patient NPO is a tough thing to do, but a necessary evil.  There are actually some really great reasons to temporarily make a patient NPO:  recent stroke or neurological damage, severe delirium resulting in an inability to attend to feeding, upcoming surgery, and recent trauma to the larynx, mouth or esophagus (just to name a few reasons).  These decisions are made routinely and for good reason in hospitals all across the country.

Issues do tend to come up, however.

  1. How long do we keep a new stroke/TBI patient NPO?
  2. What happens when we identify aspiration during a MBSS or FEES procedure?
  3. If someone aspirates food or liquid into their lungs, do they automatically get aspiration pneumonia?
  4. When a patient has persistent dysphagia that prevents safe eating, do they never get food or drink again?
  5. How much rehab does a typical dysphagia patient need before they can eat and drink again?
  6. How realistic are harshly modified diets? (Puree food and Honey thick liquids anyone?)
  7. What about oral care and aspiration of secretions (saliva, mucous)?

My point with all these questions is to complicate things, because things are complicated.  I think I have good answers to many of these questions, but my answers have come from the last four years of practicing Speech Pathology with adults, digging through the research, and getting expert advice at conferences on dysphagia.  Sometimes my answers conflict with the Doctor’s answers, in which case I defer judgement to him or her.  Sometimes my answers conflict with the family’s answers, in which case I defer judgement to them after making sure I educate as best I can, as respectfully as I can.

If you are a new clinician and this seems like a tough recommendation to make to the Doctor, then realize that you are right.  If you are a family member of a patient that has been made NPO or a patient that has been made NPO, know that for the majority of us that take part in making this decision, it ain’t easy.  Even though the process for making my decisions is far more refined than when I started, I never take it lightly.

To deal with those questions I posed, I’d like to list a few articles as food for thought:

Paul E. Marik, M.B., B.Ch., Aspiration Pneumonitis and Aspiration Pneumonia,  N Engl J Med 2001; 344:665-671 March 1, 2001.

(I found this free online at http://jewishhospital-cincinnati.com/files/Aspiration_Pneumonitis_and_Pneumonia.pdf)

John R. Ashford, Oral Care Across Ages: A Review, Perspectives on Swallowing and Swallowing Disorders (Dysphagia) March 2012 vol. 21 no. 1 3-8.

Susan E. Langmore, Margaret S. Terpenning, Anthony Schork, Yinmiao Chen, Joseph T. Murray, Dennis Lopatin and Walter J. Loesche, Predictors of Aspiration Pneumonia: How Important Is Dysphagia?, Dysphagia,Volume 13, Number 2, 69-81.

Lori A. Davis Karol K. Rideout University of Tulsa, OK, A Survey of Speech-Language Pathologists’ Criteria To Determine Safety for Oral Intake, Contemporary Issues in Communication Science and Disorders • Volume 29 • 141–145 • Fall 2002.

If you would like to see what aspiration pneumonia looks like, there are some pictures here.

I will also gladly try to answer any specific questions via email.

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3 comments on “Quality vs. Quantity (or is it Safety?)

  1. Laurie DeLaurentis, SLP
    June 3, 2012

    As a clinician with primarily a pediatric background who is now working in a SNF setting, I would really like to hear your answers to the questions you listed above. I also would like to thank you for sharing your insights via this site. I have really enjoyed checking it out and have learned a lot in the process too. Thank you!!

  2. Admin
    June 3, 2012

    Thanks for commenting Laurie, and for taking a look around the site. I’ll do my best to list my answers to the above questions:

    Q:How long do we keep a new stroke/TBI patient NPO?

    A:This really depends on more than one factor. First, how severe is the injury? All cases aren’t black and white here, so that doesn’t always answer the question, but often that defines what we do and when we do it. Second, where was the neurological damage done? A person with a brain stem injury has me more concerned than someone with a stroke of similar size in other areas. Third, how sick is the person from other comorbidities? Poor respiratory status or a widely variable ability to maintain alertness are also concerning factors. Finally, what was/is their reaction to the bedside evaluation? I will repeat it if the person’s alertness has improved or other medical factors are under better control (e.g.- medications, respiration, etc.). If a new neuro patient has concerning signs and symptoms of aspiration, I always feel more comfortable doing the MBSS or FEES rather than taking a chance. Also remember that we help come to these decisions by looking at the above information and collaborating with your fellow therapists, the M.D., R.T., and Nurses, to decide when and how to proceed. For me, when I realized that I was part of the medical team making this decision, and not the lone swallowing guru deciding this person’s fate, I was much better at communicating concerns and seeking advice from all the members of the team.

    Q:What happens when we identify aspiration during a MBSS or FEES procedure?

    A:First we get them to cough or clear the aspirated material as best we can. Then, we try compensations. Honestly if they are there for an instrumental evaluation, then there is a good chance they are going to have problems. Unless there are respiratory issues noted, we don’t stop the procedure. Compensations can include: changing the texture of the food or liquids, chin tuck, head turn, supraglottic swallow, bolus size, etc.

    Q:If someone aspirates food or liquid into their lungs, do they automatically get aspiration pneumonia?

    A:Apparently not. While I’m not sure about all the inner biology at play here, some patients don’t get sick even in the face of known aspiration. See the Langmore article for better details on risk factors. It’s a great piece.

    Q:When a patient has persistent dysphagia that prevents safe eating, do they never get food or drink again?

    A:This is a decision that should happen with the inclusion of the person and their family along with the Doctor. NG, PEG, and even some short term use of TPN can provide non-oral feeding. Many people eventually tire of this, and want to eat anyway. If you feel they are a palliative patient, pleasure feeds or all feeding by mouth can be a very reasonable choice when all the risks are explored and understood. If you think the patient needs more rehab before they can eat and drink again, then you may want to do some p.o. trials only in therapy and push them harder to work through it. This is a very patient specific problem, in my opinion.

    Q:How much rehab does a typical dysphagia patient need before they can eat and drink again?

    A:Hard question…who asked these? In all seriousness, there is such a wide array of differences out there between stroke patients, anoxic brain injuries, traumatic brain injuries, etc. that this becomes very patient specific. That caveat aside, I’d say 4-6 weeks should be enough time to see positive change in diet, given the fact that the person has been steadily working hard on therapy exercises for that period of time and has stayed medically stable.

    Q:How realistic are harshly modified diets? (Puree food and Honey thick liquids anyone?)

    A:Short term (2-6 weeks) I think they can be sold to the person with dysphagia as a necessary evil. Long term, I think motivation and compliance decline to the point that very few are actually sticking with these diets.

    Q:What about oral care and aspiration of secretions (saliva, mucous)?

    A:This is one of the most often missed areas (among the hospitals I’ve worked) in terms of the staff’s education level. It’s especially concerning with NPO patients. Prandial (mealtime) aspiration is on everyone’s minds, but often the liter to two liters worth of saliva that a patient is swallowing can be a potent bacterial cocktail without the proper oral care.

    Thanks for asking me to clarify those points Laurie. Good luck as you continue working with the adult population.

    Walt Greenslade, M.S., CCC-SLP

  3. Pingback: Dementia Vs Delirium Vs Tbi Background | The Brain Improvement

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This entry was posted on April 19, 2012 by in Dysphagia and tagged , , , , , , , , , , .
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