Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial.

Importance: It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent. Objective: To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation. Design, Setting, and Participants: Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021. Interventions: Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 µg/kg; n = 575) immediately after injection of a hypnotic. Main Outcomes and Measures: The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%. Results: Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%). Conclusions and Relevance: Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference. Trial Registration: ClinicalTrials.gov Identifier: NCT03960801.

The Role of Aspiration Amount on Airway Protective Responses in People with Neurogenic Dysphagia.

The aim of this study was to examine relationships between the presence vs. absence of an aspiration-related airway protective response (i.e., coughing or throat clearing) with aspiration amount, trial volume, disease diagnosis, and disease duration in people with neurologic disease. A secondary analysis was completed of flexible endoscopic evaluations of swallowing (FEES) in people with neurologic disease. Thin liquid boluses with endoscopically confirmed aspiration were included. Aspiration amount was measured for each trial using the visual analysis of swallowing efficiency and safety (VASES). Statistical analyses were used to (1) compare aspiration amount between swallows with vs. without an airway protective response and (2) examine if trial volume, disease duration, and disease diagnosis were related to the presence of airway protective responses when controlling for aspiration amount. 422 aspirated swallows across 86 FEES were analyzed. Of the 59 people who aspirated more than once, 66.1% exhibited variability in the presence vs. absence of an airway protective response. Statistical analyses revealed airway protective responses were significantly related to aspiration amount (p < 0.001; Marginal R2 = 0.46) and disease duration (p = 0.036, L.R. = 4.35) but not trial volume (p = 0.428) or disease diagnosis (p = 0.103). The participants in this study were less likely to cough or throat clear when having smaller amounts of aspiration or longer disease durations. Future research is needed to examine if aspiration amount is related to airway protective responses in healthy adults and across other patient populations.

The current practice of aspiration prophylaxis in obstetric anesthesia: a survey among non-physician anesthetic providers working in hospitals in Ethiopia.

BACKGROUND: Pulmonary aspiration is one of the most important complications of obstetric anesthesia. Prevention of pulmonary aspiration is commonly performed by the application of different anesthetic maneuvers and administration of drugs. This study aimed to assess the non-physician anesthetic providers current practice of aspiration prophylaxis during anesthesia for cesarean section in Ethiopia. METHODS: This survey study was conducted from October 01 to November 05, 2020, on a total of 490 anesthetic providers working in hospitals in Ethiopia. A structured checklist was used to collect data from non-physician anesthetic providers. RESULTS: Four hundred and ninety (490) anesthetic providers participated in our study. The majority of the respondents (84%) were working in the public sector. Most of the cesarean delivery was done under regional anesthesia and more than half of anesthetic providers in Ethiopia administered aspiration prophylaxis routinely. Metoclopramide was the most frequently given as a prophylaxis for pulmonary aspiration. CONCLUSIONS: More than half of the anesthetic providers administered aspiration prophylaxis routinely. Metoclopramide was the commonest administered aspiration prophylaxis for parturients who underwent cesarean delivery to prevent aspiration.

Quality-improvement project to reduce actual fasting times for fluids and solids before induction of anaesthesia.

BACKGROUND: Despite well-defined recommendations, prolonged fasting times for clear fluids and solids are still common before elective surgery in adults. Extended fasting times may lead to discomfort, thirst, hunger and physiological dysfunctions. Previous studies have shown that prolonged fasting times are frequently caused by patients being misinformed as well as inadequate implementation of the current guidelines by medical staff. This study aimed to explore how long elective surgery patients fast in a German secondary care hospital before and after the introduction of an educational note for patients and re-training for the medical staff. METHODS: A total of 1002 patients were enrolled in this prospective, non-randomised interventional study. According to the power calculation, in the first part of the study actual fasting times for clear fluids and solids were documented in 502 consecutive patients, verbally instructed as usual regarding the recommended fasting times for clear fluids (2 h) and solids (6 h). Subsequently, we implemented additionally to the verbal instruction a written educational note for the patients, including the recommended fasting times. Furthermore, the medical staff was re-trained regarding the fasting times using emails, newsletters and employee meetings. Thereafter, another 500 patients were included in the study. We hypothesised, that after these quality improvement procedures, actual fasting times for clear fluids and solids would be more accurate on time. RESULTS: Actual fasting times for clear fluids were in the median 11.3 (interquartile range 6.8-14.3; range 1.5-25.5) h pre-intervention, and were significantly reduced to 5.0 (3.0-7.2; 1.5-19.8) h after the intervention (median difference (95%CI) - 5.5 (- 6.0 to - 5.0) h). The actual fasting times for solids also decreased significantly, but only from 14.5 (12.1-17.2; 5.4-48.0) h to 14.0 (12.0-16.3; 5.4-32.0) h after the interventions (median difference (95%CI) - 0.52 (- 1.0 to - 0.07) h). CONCLUSIONS: The study showed considerably extended actual fasting times in elective adult surgical patients, which were significantly reduced by simple educational/training interventions. However, the actual fasting times still remained considerably longer than defined in recommended guidelines, meaning further process optimisations like obligatory fluid intake in the early morning are necessary to improve patient comfort and safety in future. TRIAL REGISTRATION: German registry of clinical studies (DRKS-ID: DRKS 00020530 , retrospectively registered).

Surgical treatment of T2-3 posterior hypopharyngeal carcinoma with preservation of laryngeal function.

BACKGROUND: Posterior hypopharyngeal carcinoma indicates a poor prognosis. Previous treatments predicted negative influence to the pronunciation and swallowing function. The present study focuses on improving survival rate while improving quality of life. AIM: To investigate on the surgical techniques of the preservation of laryngeal function of posterior hypopharyngeal carcinoma. METHODS: Eighteen patients with posterior hypopharyngeal carcinoma of T2-T3 were studied. All primary lesions were removed and the defects were repaired with the radial forearm free flap (RFFF). RESULTS: The 3-year overall survival rate was 51.9%. All patients could maintain daily caloric intake by feeding orally, and remove the gastric tube 28-61 days after operation. Assessed swallowing function by Fiberoptic endoscopic evaluations of swallowing. When eating solid food, 66.67% patients had food residue; no food entered airway, and all patients had Penetration-Aspiration Scale of level 1. As for liquid, 11.11% patients had level 5, 16.67% level 4, 27.78% level 2 and 44.44% level 1. CONCLUSIONS: By preserving the integrity of larynx and superior laryngeal nerve with repairing the defects of posterior wall of hypopharynx with RFFF, patients with T2 and T3 stage posterior hypopharyngeal carcinoma could live a better quality of life.

Decrease in Respiratory Related Hospitalizations in Tracheostomy-Dependent Children Who Tolerate Passy-Muir Valve Use.

OBJECTIVE: To assess the effect of Passy-Muir® Valve (PMV) tolerance on respiratory illness and respiratory related hospital admissions in tracheostomy-dependent children. METHODS: Retrospective cohort study of 262 patients who underwent tracheostomy placement between 2012 and 2018 at a tertiary free-standing children's hospital. Outcome measures studied were number of reported upper respiratory infections and respiratory related hospitalizations per year (RRH/year). RESULTS: About 135 (51.5%) tracheostomy-dependent children underwent PMV trials, and 106 (78.5%) of these children were able to tolerate PMV for at least 1 hour daily. When comparing children who tolerated PMV versus those who did not, the latter group had significantly higher rates of subglottic stenosis but no significant differences in RRH/year or average age. In those children who tolerated PMV and achieved routine use of PMV > 1 hour/day, an average of 1.14 RRH/year occurred prior to PMV tolerance, as compared with 0.57 RRH/year after PMV tolerance (P = .003). Multivariate analysis shows that in patients <2 years, there is a significant decrease in RRH/year after PMV tolerance is attained (1.53 vs 0.76, P = .001), independent of indication for tracheostomy. CONCLUSION: In tracheostomy-dependent children who tolerate PMV use routinely >1 hour/day there are decreased rates of respiratory related hospitalizations (RRH). Children <2 years of age have the most impact of RRH, with rates that are significantly lower with routine use of the PMV.

The Clinical Use of Cricoid Pressure: First, Do No Harm.

Application of cricoid pressure (CP) during rapid sequence induction and intubation sequence has been a "standard" of care for many decades, despite limited scientific proof of its efficacy in preventing pulmonary aspiration of gastric contents. While some of the current rapid sequence induction and intubation guidelines recommend its use, other international guidelines do not, and many clinicians argue that there is insufficient evidence to either continue or abandon its use. Recently published articles and accompanying editorials have reignited the debate on the efficacy and safety of CP application and have generated multiple responses that pointed out the various (and significant) limitations of the available evidence. Thus, a critical discussion of available data must be undertaken before making a final clinical decision on such an important patient safety issue. In this review, the authors will take an objective look at the available scientific evidence about the effectiveness and safety of CP in patients at risk of pulmonary aspiration of gastric contents. We suggest that current data are inadequate to impose clinical guidelines on the use of CP because we acknowledge that currently there is not, and there may never be, a method to prevent aspiration in all patients. In addition, we reiterate that a universally accepted medical-legal standard for approaching the high-risk aspiration patient does not exist, discuss the differences in practice between the US and international practitioners regarding use of CP, and propose 5 recommendations on how future studies might be designed to obtain optimal scientific evidence about the effectiveness and safety of CP in patients at risk for pulmonary aspiration.

A prospective study of paediatric preoperative fasting times at Red Cross War Memorial Children's Hospital, Cape Town, South Africa.

BACKGROUND: Fasting for liquids and solids is recommended prior to procedures requiring anaesthesia, to reduce the risk of pulmonary aspiration. Children often experience excessive fasting, which is associated with negative physiological and behavioural consequences, and patient discomfort. The duration of preoperative fasting in children in South Africa (SA) is unknown. OBJECTIVES: To determine compliance with fasting guidelines and fasting times of children prior to elective procedures performed under anaesthesia at a paediatric hospital in Cape Town, SA. The primary focus was fasting for clear liquid. We also intended to identify the most common reasons for prolonged clear liquid fasting. METHODS: Over a 7-week period, we prospectively captured fasting times of consecutive patients undergoing elective surgical, medical and radiological procedures at Red Cross War Memorial Children's Hospital. Measurement outcomes were defined as the period from the last clear liquid, milk or solid feed to the start of anaesthesia. For analysis of compliance with preoperative fasting guidelines, institutional preoperative fasting target limits were established based on the standard 6-4-2-hour guideline. RESULTS: The study included 721 elective paediatric cases. The mean (standard deviation (SD)) fasting time for clear liquids (n=585) was 8.0 (4.8) hours, with an adherence rate of 25.5% (95% confidence interval 22 - 29) to the institutional target of 2 - 4 hours. The mean (SD) fasting times for breastmilk (n=92), formula milk (n=116) and solid feeds (n=560) were 7.1 (2.8), 8.8 (2.8) and 13.9 (3.6) hours, respectively. The factors associated with clear liquid fasting >4 hours were inadequate fasting instructions, poor adherence to fasting orders, procedural delays and fasting to promote theatre flexibility. CONCLUSIONS: This study demonstrates that children in an SA hospital experience excessive fasting times prior to elective procedures. To reduce fasting durations and improve the quality of perioperative care, quality improvement interventions are required to create an adaptable fasting system that allows individualised fasting. Improving preoperative fasting times in children is the responsibility of all healthcare professionals in the multidisciplinary management team.

Ayuno preoperatorio / Preoperative fasting

La broncoaspiración es una de las complicaciones más temidas por parte de los anestesiólogos durante todo el periodo perioperatorio. Desde hace más de un siglo, con el propósito de evitar esta complicación, se ha implementado el ayuno preoperatorio, periodo en el cual el paciente no ingiere alimentos para disminuir el contenido gástrico. El objetivo de este artículo es realizar una revisión de los aspectos más destacados y actuales sobre el ayuno preoperatorio. Para lo cual se realizó una búsqueda manual y digital en diferentes bases de datos como MEDLINE, Scielo, IBECS y Cochrane, con los descriptores siguientes: ayuno preoperatorio, efectos del ayuno. Cuando surge el concepto de ayuno preoperatorio el paciente debía estar más de 8 horas sin alimentarse, provocando esto no solo sensación de hambre, sed, irritabilidad, sino que también provocaba serias alteraciones endocrinometabólicas. Según las últimas recomendaciones, basadas en la evidencia científica, se aconseja seguir los siguientes tiempos de ayuno quirúrgico: 2 h para líquidos claros, 4 h para leche materna, 6 h para la leche de vaca, 8 h para sólidos. En conclusión, se considera que un periodo prolongado sin ingerir alimentos antes de la intervención quirúrgica lejos de ser beneficioso es deletéreo para el buen pronóstico del paciente(AU)

Bronchoa aspiration is one of the most feared complications by anesthesiologists throughout the perioperative period. For more than a century, in order to avoid this complication, preoperative fasting has been implemented, a period in which the patient does not eat food to decrease the gastric content. The purpose of this article is to review the highlights and current aspects of preoperative fasting. For which a manual and digital search was carried out in different databases such as MEDLINE, Scielo, IBECS and Cochrane, with the following descriptors: preoperative fasting, fasting effects. When the concept of preoperative fasting arises the patient had to spend more than 8 hours without feeding, causing this not only feeling hungry, thirsty, irritating, but also causing serious endocrine-metabolic alterations. According to the latest recommendations, based on scientific evidence, it is advised to follow the following times of surgical fasting: 2 h for clear liquids, 4 h for breast milk, 6 h for cow's milk, 8 h for solids. In conclusion, it is considered that an extended period without ingesting food before surgery far from being beneficial is deterreal for the patient's good prognosis(EU)

Clinical trial readiness study of distal myopathy and dysphagia in nephropathic cystinosis.

BACKGROUND: Nephropathic cystinosis is a lysosomal storage disorder with late-onset systemic complications, such as myopathy and dysphagia. Currently employed outcome measures lack sensitivity and responsiveness for dysphagia and myopathy, a limitation to clinical trial readiness. METHODS: We evaluated 20 patients with nephropathic cystinosis in two visits over the course of a year to identify outcomes sensitive to detect changes over time. Patients also underwent an expiratory muscle strength training program to assess any effects on aspiration and dysphagia. RESULTS: There were significant differences in the Timed Up and Go Test (TUG) and Timed 25-Foot Walk (25-FW) between baseline and 1-y follow-up (P < .05). Maximum expiratory pressure (MEP) and peak cough flow (PCF) significantly improved following respiratory training (P < .05). CONCLUSIONS: Improved respiratory outcomes may enhance patients ability to expel aspirated material from the airway, stave off pulmonary sequelae associated with chronic aspiration, and yield an overall improvement in physical health and well-being.

Development of an Accurate Bedside Swallowing Evaluation Decision Tree Algorithm for Detecting Aspiration in Acute Respiratory Failure Survivors.

BACKGROUND: The bedside swallowing evaluation (BSE) is an assessment of swallowing function and airway safety during swallowing. After extubation, the BSE often is used to identify the risk of aspiration in acute respiratory failure (ARF) survivors. RESEARCH QUESTION: We conducted a multicenter prospective study of ARF survivors to determine the accuracy of the BSE and to develop a decision tree algorithm to identify aspiration risk. STUDY DESIGN AND METHODS: Patients extubated after ≥ 48 hours of mechanical ventilation were eligible. Study procedures included the BSE followed by a gold standard evaluation, the flexible endoscopic evaluation of swallowing (FEES). RESULTS: Overall, 213 patients were included in the final analysis. Median time from extubation to BSE was 25 hours (interquartile range, 21-45 hours). The FEES was completed 1 hour after the BSE (interquartile range, 0.5-2 hours). A total of 33% (70/213; 95% CI, 26.6%-39.2%) of patients aspirated on at least one FEES bolus consistency test. Thin liquids were the most commonly aspirated consistency: 27% (54/197; 95% CI, 21%-34%). The BSE detected any aspiration with an accuracy of 52% (95% CI, 45%-58%), a sensitivity of 83% (95% CI, 74%-92%), and negative predictive value (NPV) of 81% (95% CI, 72%-91%). Using recursive partitioning analyses, a five-variable BSE-based decision tree algorithm was developed that improved the detection of aspiration with an accuracy of 81% (95% CI, 75%-87%), sensitivity of 95% (95% CI, 90%-98%), and NPV of 97% (95% CI, 95%-99%). INTERPRETATION: The BSE demonstrates variable accuracy to identify patients at high risk for aspiration. Our decision tree algorithm may enhance the BSE and may be used to identify patients at high risk for aspiration, yet requires further validation. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02363686; URL: www.clinicaltrials.gov.

Aspiración intrabronquial de cuerpo extraño en el niño / Intrabronchial foreign body aspiration in children

La aspiración de cuerpos extraños por vías respiratorias no es una rareza y constituye un problema urgente y grave en la población pediátrica. Se realizó esta investigación con el objetivo de conocer el comportamiento clínico epidemiológico de la aspiración intrabronquial de cuerpos extraños en niños menores de 5 años en el Hospital Hermanos Cordové y elaborar un procedimiento que favorezca la calidad atencional a este grupo de pacientes. Se realizó un estudio descriptivo, retrospectivo y transversal, con una línea analítica, en menores de 5 años de edad egresados del Hospital Pediátrico Provincial Docente Hermanos Cordové, de Manzanillo, con diagnóstico de aspiración intrabronquial de cuerpos extraños en el periodo de enero de 2017 a diciembre de 2018. Los factores de riesgos que condicionan la aparición de la aspiración de cuerpos extraños incluyen la edad menor de tres años, del sexo masculino y de procedencia rural. Los cuerpos extraños orgánicos necesitaron de menor tiempo para su diagnóstico y no fue posible establecer una secuencia típica del comportamiento clínico. Se elaboró un procedimiento de actuación ante el accidente para los diagnósticos y conducta a seguir ante la aspiración intrabronquial de cuerpos extraños en niños(AU)

Aspiration of foreign bodies through the respiratory tract is not a rarity and constitutes an urgent and serious problem in the pediatric population. This research was carried out with the aim of knowing the epidemiological clinical behavior of intrabronchial aspiration of foreign bodies in children under 5 years of age at Hospital Hermanos Cordové and to develop a procedure that favors the quality of care for this group of patients. A descriptive, retrospective and cross-sectional study was carried out, with an analytical line, in children under 5 years of age graduated from the Hermanos Cordové Provincial Pediatric Teaching Hospital, in Manzanillo, with a diagnosis of intrabronchial aspiration of foreign bodies in the period from January 2017 to December 2018. The risk factors that determine the appearance of foreign body aspiration include the age of less than three years old, male and of rural origin. Organic foreign bodies needed less time to diagnose and it was not possible to establish atypical sequence of clinical behavior. An accident response procedure was prepared for diagnoses and behavior to be followed when faced with intrabronchial aspiration of foreign bodies in children(EU)

Methods of Estimating Nasogastric Tube Length: All, Including "NEX," Are Unsafe.

BACKGROUND: Predominance of blind feeding tube placement makes esophageal tube misplacement and aspiration risk commonplace. Accurate estimation of nose-to-stomach length could reduce this risk. Standards for estimating this length were audited against the length measured from guided tube placement. METHODS: This prospective, single-center observational study used electromagnet-guided tube placement to measure the length from nose to gastric body flexure as part of routine care. This measurement was used to audit standard equations used to estimate this length from external measures: xiphisternum-ear-nose + 10 cm (XEN+10), nose-ear-xiphisternum (NEX), and Hanson_A and Hanson_B. RESULTS: From April 23, 2015, to March 2, 2020, measurements were obtained from 200 primary tube placements. Median length to the gastric body flexure (61 cm) was significantly different from that to the pre-gastroesophageal junction flexure (48 cm) or lengths predicted by NEX (51 cm) or Hanson_A (50.5 cm) and Hanson_B (56.1 cm) (all P < .00001) but similar to XEN+10 (61 cm). Esophageal placement was a potential risk for all methods (NEX: 96.3%, Hanson_A: 99.5%, Hanson_B: 86.9%, XEN+10: 43.2%) and a definite risk for most (NEX and Hanson_A: 14.9%, Hanson_B: 1%, XEN+10: 0%). CONCLUSIONS: NEX and Hanson methods of predicting the length from nose to gastric body flexure are too short and risk esophageal misplacement. XEN+10 reduces but does not eliminate this risk. External measurement predictions are clinically unsafe as a guide blind tube placement. Guided placement is recommended.

Point-of-care ultrasound in pregnancy: gastric, airway, neuraxial, cardiorespiratory.

PURPOSE OF REVIEW: This review focuses on the use of point-of-care ultrasound (PoCUS) in the obstetric context for airway management and assessment of aspiration risk, the placement of neuraxial blocks and the diagnosis and follow-up of cardiorespiratory dysfunction. RECENT FINDINGS: Gastric ultrasound is a useful aspiration risk assessment tool in pregnant patients. Total gastric fluid assessment models and specific cut-offs between high-risk and low-risk stomachs are presented. Airway assessment is useful to detect specific changes in pregnancy and to guide airway management. Handheld ultrasound devices with automated neuraxial landmark detection capabilities could facilitate needle placement in the future. Lung and cardiac ultrasonography is useful in the management of preeclampsia, pulmonary arterial hypertension and peripartum cardiomyopathy. SUMMARY: Owing to its noninvasiveness, ease of accessibility and lack of exposure to radiation, PoCUS plays an increasing and essential role in aspiration risk assessment, airway management, neuraxial anaesthesia and cardiorespiratory diagnosis and decision-making during pregnancy.

Thickened liquids: do they still have a place in the dysphagia toolkit?

PURPOSE OF REVIEW: The use of commercially or naturally thickened liquids is a well-established treatment for patients with dysphagia to fluids, the aim of which is to improve swallow safety by minimizing risk of aspiration. Although the most recent systematic reviews conclude that this treatment lacks evidential support and leads to patient-reported worsening health and quality of life, thickened liquids continue to be used with patients with dysphagia across clinical settings. This review briefly summarizes the evidence and considers potential reasons for the apparent mismatch between the evidence and clinical practice. RECENT FINDINGS: Continuing practice with thickened liquids is influenced by a range of factors, including gaps in clinical knowledge, inadequate patient involvement, a culture of common practice and a reliance on invalid surrogate studies or research lacking a credible association between thickened liquids and clinically meaningful endpoints. SUMMARY: While awaiting further research, clinical decision-making about thickened liquids can be improved by considering the evidence of clinically meaningful endpoints, promoting shared decision-making with patients and underpinning practice with knowledge about the complex relationship between dysphagia, aspiration and pneumonia.