What is recommended for a patient who chronically chokes on foods and liquids?

Management of Chronic Choking on Foods and Liquids

Patients who chronically choke on foods and liquids should be promptly referred to a speech-language pathologist (SLP) for a comprehensive swallowing evaluation, as this is associated with improved outcomes and can reduce associated morbidity. 1, 2

Initial Assessment

• Document coughing during meals as a critical warning sign, even without obvious swallowing difficulties, as it may indicate silent aspiration with a sensitivity of 74% and specificity of 74% 2
• Identify risk factors that increase likelihood of dysphagia:
  • Neurological conditions (stroke, Parkinson's disease, dementia)
  • History of head/neck cancer or surgery
  • Respiratory conditions
  • Advanced age 2
• Screen for clinical signs that warrant immediate evaluation:
  • Coughing or throat clearing during/after eating
  • Wet or "gurgly" voice after swallowing
  • Need for frequent oral/pharyngeal suctioning
  • Unintentional weight loss or malnutrition 1

Diagnostic Evaluation

• Basic swallow screening should include observation of the patient drinking small amounts of water (3 oz) while noting any coughing, throat clearing, or voice changes 2
• Referral for instrumental assessment is crucial as aspiration can occur without obvious symptoms (silent aspiration) in up to 55% of cases 2
• Recommended diagnostic tests:
  1. Videofluoroscopic swallow evaluation (VSE) - the "gold standard"
  2. Fiberoptic endoscopic evaluation of swallowing (FEES)
  3. Chest radiograph to identify aspiration-related changes
  4. Nutritional assessment 1

Treatment Approach

1. Compensatory strategies based on instrumental swallowing studies:

   • Postural changes (chin tuck, head turn)
   • Altering food consistencies (thickened liquids, pureed foods)
   • Enhancing sensory input before swallowing 1

2. Swallowing exercises to strengthen muscles involved in swallowing:

   • These are currently under study for efficacy but are commonly recommended 1

3. Multidisciplinary team management including:

   • Speech-language pathologist
   • Dietitian
   • Physician
   • Nursing staff 1

Monitoring and Follow-up

• Regular reassessment of swallowing function by SLP
• Monitor for complications including:
  • Aspiration pneumonia
  • Malnutrition and dehydration
  • Weight loss
  • Reduced quality of life 2, 3

Important Considerations

• Silent aspiration is common and dangerous - patients may not show obvious signs of choking despite food/liquid entering the airway 2
• Patient and caregiver education is essential - reports from caregivers about coughing while eating are useful in identifying aspiration risk 1
• Surgical interventions may be considered in selected patients, but studies proving efficacy are generally lacking 1

Pitfalls to Avoid

• Don't delay evaluation - chronic choking can lead to serious complications including aspiration pneumonia, malnutrition, and dehydration
• Don't rely solely on patient reports - only 20-40% of patients with dysphagia are aware of their swallowing dysfunction, and less than 10% report it spontaneously 2
• Don't miss silent aspiration - the combination of reflexive cough AND wet voice after swallowing increases sensitivity to 86% for detecting aspiration 2