Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence

A Randomized Trial

1 April 2008 | Volume 148 Issue 7 | Pages 509-518

Background: Aspiration pneumonia is common among frail elderly persons with dysphagia. Although interventions to prevent aspiration are routinely used in these patients, little is known about the effectiveness of those interventions.

Objective: To compare the effectiveness of chin-down posture and 2 consistencies (nectar or honey) of thickened liquids on the 3-month cumulative incidence of pneumonia in patients with dementia or Parkinson disease.

Design: Randomized, controlled, parallel-design trial in which patients were enrolled for 3-month periods from 9 June 1998 to 19 September 2005.

Setting: 47 hospitals and 79 subacute care facilities.

Patients: 515 patients age 50 years or older with dementia or Parkinson disease who aspirated thin liquids (demonstrated videofluoroscopically). Of these, 504 were followed until death or for 3 months.

Intervention: Participants were randomly assigned to drink all liquids in a chin-down posture (n = 259) or to drink nectar-thick (n = 133) or honey-thick (n = 123) liquids in a head-neutral position.

Measurements: The primary outcome was pneumonia diagnosed by chest radiography or by the presence of 3 respiratory indicators.

Results: 52 participants had pneumonia, yielding an overall estimated 3-month cumulative incidence of 11%. The 3-month cumulative incidence of pneumonia was 0.098 and 0.116 in the chin-down posture and thickened-liquid groups, respectively (hazard ratio, 0.84 [95% CI, 0.49 to 1.45]; P = 0.53). The 3-month cumulative incidence of pneumonia was 0.084 in the nectar-thick liquid group compared with 0.150 in the honey-thick liquid group (hazard ratio, 0.50 [CI, 0.23 to 1.09]; P = 0.083). More patients assigned to thickened liquids than those assigned to the chin-down posture intervention had dehydration (6% vs. 2%), urinary tract infection (6% vs. 3%), and fever (4% vs. 2%).

Limitations: A no-treatment control group was not included. Follow-up was limited to 3 months. Care providers were not blinded, and differences in cumulative pneumonia incidence between interventions had wide CIs.

Conclusion: No definitive conclusions about the superiority of any of the tested interventions can be made. The 3-month cumulative incidence of pneumonia was much lower than expected in this frail elderly population. Future investigation of chin-down posture combined with nectar-thick liquid may be warranted to determine whether this combination better prevents pneumonia than either intervention independently.

Editors' Notes Context Patients with dysphagia are at increased risk for aspiration pneumonia. Contribution This trial involved 515 adults with dementia or Parkinson disease and videofluoroscopically demonstrated aspiration. Participants were randomly assigned to drink thin liquids with a chin-down posture or to drink nectar- or honey-thick liquids in a head-neutral position. At 3 months, the cumulative incidence of pneumonia was about 10%, 8%, and 15% in the thin, nectar-thick, and honey-thick liquid groups. Dehydration was more common with thick than thin liquids. Caution Findings were inconclusive. The incidence of pneumonia was lower than expected, and confidence bounds around differences between groups were wide. —The Editors

 

Author and Article Information

From William S. Middleton Memorial Veterans Hospital, Geriatric Research Education and Clinical Center, and University of Wisconsin, Madison, Wisconsin; EMMES Corporation and American Speech-Language-Hearing Association, Rockville, Maryland; Northwestern University, Evanston, Illinois; ORC Macro, Calverton, Maryland; Stanford University School of Medicine, Palo Alto, California; Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota; University of Miami Hospital and Clinics, Miami, Florida; New York Hospital Medical Center–Queens, Flushing, New York; Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts; and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana.

ClinicalTrials.gov registration number: NCT00000362.

Acknowledgment: The authors thank Susi Nehls, BS, for editing expertise; Abby Duane, BS, for preparing the manuscript; E. Kenneth Sullivan, PhD, for study design and statistical analysis; Carol Caperton Wenck, MS, CCRA, for coordination of the project; and Jeffrey Glassroth, MD, and Jeffrey Grossman, MD, for sharing their perspectives on critical care of patients with pneumonia.

Grant Support: By the National Institute on Deafness and Other Communication Disorders, National Institutes of Health (DC03206). Additional support for the grant was provided by Novartis and E-Z-EM to the American Speech-Language-Hearing Association, Communication Sciences and Disorders Clinical Trials Research Group.

Potential Financial Conflicts of Interest: Honoraria: J. Robbins (E-Z-EM). Grants received: G. Gensler (National Institute on Deafness and Other Communication Disorders, National Institutes of Health), A.S. Lindblad (National Institute on Deafness and Other Communication Disorders, National Institutes of Health), D. Brandt (National Institute on Deafness and Other Communication Disorders, National Institutes of Health). Patents received: J. Robbins (Wisconsin Alumni Research Association). Receipt of payment for manuscript preparation: G. Gensler (National Institute on Deafness and Other Communication Disorders, National Institutes of Health), A.S. Lindblad (National Institute on Deafness and Other Communication Disorders, National Institutes of Health), D. Brandt (National Institute on Deafness and Other Communication Disorders, National Institutes of Health). Royalties: J. Robbins (Wisconsin Alumni Research Association).

Reproducible Research Statement: Study protocol: Available from the Communication Sciences and Disorders Research Group Executive Policy Board (CSDRG-EPB). Statistical code: Not available. Data set: Available from Dr. Jeri Logemann (e-mail, j-logemann{at}northwestern.edu).

Requests for Single Reprints: JoAnne Robbins, PhD, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Geriatric Research Education and Clinical Center 11G, Madison, WI 53705; e-mail, jrobbin2{at}wisc.edu.

Current Author Addresses: Dr. Robbins and Ms. Hind: William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Geriatric Research Education and Clinical Center 11G, Madison, WI 53705.

Mr. Gensler, Dr. Lindblad, and Ms. Brandt: The EMMES Corporation, 401 North Washington Street, Suite 700, Rockville, MD 20850.

Dr. Logemann: Northwestern University, Communicative Sciences and Disorders, 2240 Campus Drive, Evanston, IL 60208.

Dr. Baum: ORC Macro, 11785 Beltsville Drive, Calverton, MD 20705.

Dr. Lilienfeld: FibroGen, Inc., 225 Gateway Boulevard, South San Francisco, CA 94080.

Mr. Kosek: Minneapolis Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, MN 55417.

Dr. Lundy: University of Miami Miller School of Medicine, UMHC-4035, 1475 Northwest 12th Avenue, Miami, FL 33136.

Ms. Dikeman and Ms. Kazandjian: Silvercrest Center for Nursing and Rehabilitation, 144-45 87th Avenue, Briarwood, NY 11435.

Mr. Gramigna: Veterans Affairs Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132.

Ms. McGarvey-Toler: Richard L. Roudebush Veterans Affairs Medical Center, 1481 West 10th Street, Indianapolis, IN 46202.

Ms. Miller Gardner: American Speech-Language-Hearing Association, 2200 Research Boulevard, #245, Rockville, MD 20850.

Author Contributions: Conception and design: J. Robbins, J.A. Logemann, A.S. Lindblad, H. Baum, D. Lilienfeld.

Analysis and interpretation of the data: J. Robbins, G. Gensler, J.A. Logemann, A.S. Lindblad, D. Brandt, D. Lilienfeld.

Drafting of the article: J. Robbins, G. Gensler, J. Hind, J.A. Logemann, A.S. Lindblad, D. Brandt, P.J. Miller Gardner.

Critical revision of the article for important intellectual content: J. Robbins, G. Gensler, J. Hind, J.A. Logemann, A.S. Lindblad, D. Brandt, H. Baum, D. Lilienfeld, S. Kosek, D. Lundy, K. Dikeman, M. Kazandjian, G.D. Gramigna, S. McGarvey-Toler.

Final approval of the article: J. Robbins, G. Gensler, J.A. Logemann, A.S. Lindblad, P.J. Miller Gardner.

Provision of study materials or patients: J. Robbins, J. Hind, J.A. Logemann, S. Kosek, D. Lundy, K. Dikeman, M. Kazandjian, G.D. Gramigna, S. McGarvey-Toler.

Statistical expertise: G. Gensler, A.S. Lindblad.

Obtaining of funding: J. Robbins, J.A. Logemann, A.S. Lindblad, H. Baum, D. Lilienfeld.

Administrative, technical, or logistic support: J. Robbins, J. Hind, J.A. Logemann, D. Brandt, H. Baum, P.J. Miller Gardner.

Collection and assembly of data: J. Robbins, J. Hind, J.A. Logemann, D. Brandt, S. Kosek, D. Lundy, K. Dikeman, M. Kazandjian, G.D. Gramigna, S. McGarvey-Toler.

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