Anyone for Bubbles?
Speech and Language Therapists (SLTs) working with patients with severe dysphagia, will at some point face the dilemma of how to balance patient comfort and quality of life with aspiration and choking risk. This is a complex enough scenario, but when these patients are also considered end of life, the decision making is all the more intricate and often choices are limited.
When a patient’s dysphagia is so severe that they are at extreme risk of aspiration and/or choking with all diet or fluid textures there are two main courses of action. The first, to pursue non-oral feeding such as a PEG. The second, to continue with oral intake (be it modified in texture or not), with the accepted risks of aspiration/choking, in favour of comfort and quality
For some patients, often due to their medical status, disease progression or poor life expectancy, non-oral feeding is not appropriate and ‘risk’ or ‘comfort’ feeding is the sole option.
Of course, ‘comfort’ is an extremely subjective term and means very different things to different people. For some, coughing, spluttering, choking on oral intake is well tolerated due to the enjoyment received by eating and drinking. For others, the distress of these same dysphagia symptoms is simply too great for them to stomach (!) any oral intake.
So what do we do then?
Previously, these patients for whom neither oral or non-oral feeding is an option, would have been provided either with ice chips or lightly moistened oral hygiene sponges, neither of which was reported to offer much in the way of comfort or quality of life. Then in 2019, the Northumbria acute adult SLT team became aware of a product called Biozoon.
‘Biozoon Flavoured Air’ is a system which turns a liquid in to intensely flavoured foam bubbles that can be placed in a patient’s mouth via a spoon. The bubbles then disappear without the need for swallowing, leaving only the intense flavour of the original liquid. Following assessment by SLT, this would allow suitable patients who are Nil By Mouth (NBM) due to severe dysphagia, to have access to liquids of their choice in bubble form without the distress of coughing/choking.
A flurry of activity occurred over the next few months including:
• Research into the product
• Liaison with the wider MDT (pharmacy, palliative care, medical devises, infection control)
• Successful bidding for funding from the Northumbria Bright Charity Development Fund
• Procurement of the Biozoon equipment
• Development of a paperwork infrastructure
• Staff training
• Trust wide awareness raising, social media publications and live demonstrations
Then in January 2020 the Northumbria acute adult SLT team launched the new ‘Biozoon Flavoured Air’ service with the aims of:
• Maximising patient quality of life and comfort whilst nil by mouth
• Minimising distress from the symptoms of severe dysphagia.
• Offering an alternative to patients unable to tolerate risk feeding recommendations.
Throughout 2020 (and what a year that was!), we collected data about our use of Biozoon. There were no barriers to who we used Biozoon with. Our patient’s aetiologies included but were not limited to COVID, progressive neurological conditions, gastric and cardiac illness, drug misuse,stroke and attempted suicide via traumatic asphyxiation. Likewise, we found Biozoon was appropriate for use with patients at all stages of their medical journey including hyper acute presentation through to end of life. Our reasons for introducing Biozoon to individual patients centred largely around Nil By Mouth status, especially patients who were frustrated, depressed or agitated by being NBM, patients NBM whilst awaiting objective assessment of their swallow function and patients distressed by the symptoms of aspiration/choking but who were keen for a flavour in their mouth.
27.3% of those patients started on Biozoon went on to re-commence oral intake, 5.5% of which were deemed to be risk feeding. 25.5% of patients were able to use Biozoon until reaching the end of their lives, a percentage of the caseload which previously would have been limited to oral hygiene only.
Feedback from staff, patients and families/carers was overwhelmingly positive. Of the 83% of those providing feedback, 70% were positive about their experiences with Biozoon. Negative feedback centred wholly around lack of taste from the bubbles, an experience which we were able to link to the use of high flow oxygen and the loss of taste associated with COVID.
Over the year, Biozoon was provided to an average of 2.5% of the dysphagia caseload (range 2.2% – 3.4%). Whilst at first glance this number could appear to be quite low, to have positively affected the quality of life of more than 50 patients in a 12-month period with a brand-new service (as confirmed by the patient, family and staff feedback), we considered a fantastic achievement. As with all new innovations, it takes time for them to become imbedded into routine daily practice.
We predict that as awareness of Biozoon increases, so too will the demands for it as an integral part of the dysphagia management service. The referrals specifically for ‘bubbles’ have already started rolling in.
If ever there was a year we needed to be well armoured, 2020 and a global pandemic was it! Biozoon did exactly that for us. It has become another tool in our armoury in the fight against people dying nil by mouth or with reduced comfort and quality of life secondary to dysphagia.
What nicer way to celebrate increased patient well-being than with a glass of bubbles?!
Specialist Speech and Language Therapist / NSECH Locality Coordinator
Northumbria Healthcare NHS Trust
© Biozoon UK