Dysphagia

What is Dysphagia? Difficulty or inefficient swallowing that can cause coughing, choking, or aspiration (inhalation) of food, liquid, and saliva.

• Can occur after direct physical injury to the head, neck, brain, or in relation to neurodegenerative disease (Parkinson’s, Alzheimer’s, etc.)
• Inability to swallow efficiently can lead to weight loss, malnutrition, dehydration, and in some cases when material is aspirated, aspiration pneumonia. It also degrades quality of life.
• Assessment of dysphagia should both determine what a safe diet should consist of for the patient as well as make a plan for treatment and compensatory strategies.

How to assess for Dysphagia and difficulty swallowing

• Bedside evaluation: materials needed are a cup of water/ice chips and a small quantity of something to eat such as crackers, yogurt, bread, etc. 
  • Always start patient off with “easiest” consistency. They might only be able to swallow drops of water from ice chips, or they might feel more confident having a cracker or even a full meal.
  • Hierarchy is roughly as follows: Ice chips > sip of water > drinking from straw/cup > puree consistency > soft solid > hard/dry solid (remember that liquids are not always easier to manage as they move quickly down the throat). 
  • You will be visually observing their ability to chew, manage the food/liquid, the timeliness of their swallow, whether there are any emissions from the nose, side of the mouth, etc. and most importantly if they cough/gag/choke at any point during the assessment. 
  • You can also use your hand to palpate or touch their larynx while they swallow to determine if you feel strong and efficient muscle movement (hyolaryngeal elevation). 
  • If the patient is coughing/gagging/choking, you do not need to continue with that consistency, you should try something one step lower from the hierarchy listed above. (Ex: if they have difficulty with crackers, try yogurt or another smooth puree. If there is difficulty with cup sips, try ice chips). 
  • If the patient appears to be managing all items without any perceived difficulty, ask about what is concerning them to find out more. They might describe an intermittent problem that you didn’t see.
  • Identify what they are able to tolerate currently. Make notes on observations. Make a determination in what their current diet should safely consist of (Ex: liquid diet only, soft solids accompanied by liquid, etc.) 
    • Remember that food can be modified. They don’t have to eat an entire meal of rice and meat if they are not able to. Vegetables can be cooked until soft and mashed/pureed for a smooth consistency. Smoothies, juices, etc. can provide valuable nutrition for someone who can manage drinking. Tough and dry food items can be improved by adding sauces, dips, oil, etc. to increase their slip and ability to slide down the throat. Be creative with your recommendations and suggestions as long as they are appropriate for the patient. 
  • If they are having significant difficulties, consider the below treatment approaches. Speak to their doctor about the use of a feeding tube if there is a severe impairment in their ability to swallow (i.e., they will not maintain appropriate nutrition or have difficulty eating anything without choking/aspirating their food). 

• Video Fluoroscopic Swallow Study: If available, use video fluoroscopy (camera inserted into the nose to view the throat) to assess their ability to swallow and clear the food/liquid. Resources available can provide you with further information on what to look for, however you will be better able to visualize whether the swallow is inefficient, or whether there is any penetration/aspiration to or below the level of the vocal folds (i.e., into the lungs). 
• Modified Barium Swallow Study: If available, use barium coated food and liquid to observe the swallow through x-ray imagery. Resources available can provide you with further information on what to look for, however you will be better able to visualize whether the swallow is inefficient, or whether there is any penetration/aspiration to or below the level of the vocal folds (i.e., into the lungs).

Treatment of Dysphagia

• Compensatory strategies: These are techniques that the patient can use to alter their anatomy while swallowing to make it safer. These strategies are intended to be used while eating/swallowing. Examples include tucking the chin down, turning the head right or left, the Mendelsohn Maneuver, etc. Resources available can provide a better understanding of when to use each strategy. These should generally not be used on patients with cognitive impairment. 
• Exercises: Exercises specific to swallowing can be assigned to almost any patient to increase their muscle strength and ability to safely clear food. They are not intended to be used while eating. Exercises will target tongue, jaw, and laryngeal muscles to build strength over time. They can be done while hospitalized, in rehab, and at home for continued practice. Detailed instructions can be found in resources. 
• McNeil Dysphagia Therapy Program: An exercise based treatment approach that is done in the context of eating/drinking to improve functional abilities. This should be a systematic approach to improving swallow abilities beginning with the easiest item the patient can master and gradually increasing their diet. Patients are prompted to use a “strong, hard swallow” and repeat sips/bites of liquid/food for multiple repeated trials. 
  • For example: A patient who can swallow purees but coughs and chokes on water is asked to consume an entire cup of regular yogurt using a strong hard swallow (swallowing with intention and effort). Later/in another session, the yogurt is thinned down with water or milk to make it more runny, essentially more challenging for them to manage. They must again consume the cup of yogurt with strong, hard swallows attempting to manage the food as best as possible. They are expected to have some difficulty or coughing, but the patient should not be having significant choking or inability to breathe. After several days at the thinned yogurt consistency, they should be given something between water and puree, like a thick juice. The protocol follows the same steps until they are able to manage this consistency, and then eventually regular water. This trains the muscles in a systematic and repetitive approach to manage a variety of consistencies. This will take time! Patients get frustrated, but each consistency should be “mastered” before moving to the next one. 

References:

American Speech-Language-Hearing Association. (n.d)  Adult Dysphagia: Treatment. Retrieved February 20, 2021, from http://www.asha.org/