Systematic Weaning Process

Systematic Weaning Process

Reading: Wolter, N. E., Hernandez, K., Irace, A. L., Davidson, K., Perez, J. A., Larson, K., & Rahbar, R. (2018). A Systematic Process for Weaning Children With Aspiration From Thickened Fluids. JAMA otolaryngology-- head & neck surgery, 144(1), 51–56.

https://doi.org/10.1001/jamaoto.2017.1917


Level of Evidence: Retrospective case series study (IV) 

Purpose/ Importance: 

Thickening of fluids is a common strategy for feeding patients with oropharyngeal dysphagia but has known risks and should be stopped once it is safe to do so.

  • Using thickeners over a prolonged period can alter physiologic swallowing patterns, negatively affect quality of life, pose financial burden to families; may also increase amount of pharyngeal residue, increase risk of post-swallow aspiration.

Conventional approach of weaning off thickener: Step down approach (i.e. step down an IDDSI level at a time) àhowever, children might have difficulty adapting to the large, conventional changes in thickness.

Objective: Describe the use of a systematic weaning process (SWP) for children who received thickened liquids owing to oropharyngeal dysphagia and identified risk of aspiration.

Method:

Retrospective case review (2010-2015) of patients at a tertiary care center.

Participants: 50 children

  • Include: documented aspiration by clinical swallowing assessment, airway evaluation (endoscopy), and VFSS with at least 4 months of follow-up (lack of interval improvement from initial VFSS to repeated VFSS). All patients were initially receiving thickened liquid.
  • Exclude: Contraindications to the SWP, such as unstable respiratory status, severe aspiration requiring tube feeding, or unreliable follow-up

Systematic Weaning Protocol:

  • Method for transitioning from thickened liquids to a normal fluid diet
  • 10% reduction in thickness every 2 weeks based on clinical symptoms
    • Note on overt and subtle signs of aspiration
  • Progressed to the next incremental level if there were no signs or symptoms of aspiration
  • Successful: Transition to thin liquid while maintaining stable respiratory health without any clinical signs or symptoms of aspiration. 
  • Halt SWP: If any signs or symptoms of aspiration detected; resume previously tolerated consistency until further evaluation by SLP.
  • Fail: Could NOT tolerate any reduction in fluid thickness or had a significant respiratory event during the SWP.

Outcome measure: Number of patients weaned to a thin-fluid diet.

Results:

Under the SWP:

  • 39/50 (78%) successfully wean from thickened fluids to thin fluids
    • 14/39 (36%) experienced a temporary stall, at median of 0.51 (SD=0.12) years after the onset of the SWP, for a median duration of 9 weeks
      • Result of cough or concern by SLP on VFSS (7/14), parental choice (5/14), or pneumonia (2/14)
      • Unclear from medical record review whether pneumonia was directly related to swallowing, but aspiration was not documented and these patients were deemed safe to continue the SWP
  • 44/50 (88%) were able to reduce the amount of thickener used
  • 6/50 (12%) failed weaning, continue on thickened liquid
    • 2/6 developed pneumonia, neither required hospitalization
    • 4/6 have persistent aspiration on VFSS but did not develop pneumonia while undergoing the SWP
    • Patients whose wean failed had etiologies that were syndromic (n = 3 [50%]), anatomic (n = 1), cardiopulmonary (n = 1), or neuromuscular (n = 1 [17%]).

Overall: Only 2/50 (5%) developed pneumonia while all other successfully weaned patients (n = 37 [95%]) did not experience any substantial respiratory issues. 

Mean duration of a successful wean: 0.9 (0.6 sd) years. [~10-11 months] 

Implications:

Patients with oropharyngeal dysphagia and aspiration should be gradually weaned off of thickened fluids.

SWP uses small incremental steps to gradually reduce the amount of thickener based on the patient’s clinical response à most children tolerated a reduction in thickeners and a thin-fluid diet under this method.

  • (Hypothesis) slower and more subtle changes in viscosity over time may better allow the sensory-motor system to adapt to thinner consistencies, rather than attempting a large step-down process between broad viscosity categories.
  • The SWP presents a safe and effective way of gradually returning children to a more normal diet. 

Contraindications to SWP:

  • Unstable respiratory status, severe aspiration requiring tube feeding
+ New:
  • Severe cardiopulmonary issues
  • Severe aspiration
  • Unreliable caregiver follow-up
* Make careful consideration prior to attempting the SWP in children who are syndromic or have neuromuscular conditions + provide close monitoring to ensure safety.

Limitations:

  • Low number of subjects (patients)
  • No control group with the traditional step-down methods
  • Did not undergo routine instrumental (VFSS) assessment
  • Heterogenic patient population