What is the approach to managing dysphagia (difficulty swallowing)?

Approach to Dysphagia Management

A comprehensive, interprofessional team approach is essential for effective dysphagia management to reduce mortality, morbidity, and improve quality of life. 1

Initial Assessment

Screening and Evaluation

• Use validated screening tools:
  • EAT-10 questionnaire (sensitivity 86%, specificity 76%) 1
  • Water swallowing tests and Volume-Viscosity Test (V-VST) (sensitivity 92%, specificity 80%) 1
• Determine functional degree of swallowing impairment:
  • Unable to swallow saliva
  • Able to swallow liquids only
  • Able to swallow semisolid food
  • Able to swallow solid food cut into pieces
  • Able to eat solid food without special attention 2

Diagnostic Testing

1. First-line test: Biphasic esophagram (95% sensitivity for detecting lower esophageal rings and peptic strictures) 1
2. Advanced testing based on initial findings:
   • Videofluoroscopic Swallowing Study (VFSS) - gold standard for evaluating swallowing dynamics 2, 1
   • Fiberoptic Endoscopic Evaluation of Swallowing (FEES) - visualizes pharyngeal and laryngeal anatomy during swallowing 2
   • Esophageal manometry - for suspected motility disorders 1

Management Algorithm

1. For Complete Esophageal Obstruction

• Endoscopic lumen restoration
• Establish enteral access (jejunal or gastrostomy tube) if endoscopic restoration unsuccessful
• External beam radiation therapy or brachytherapy if appropriate
• Consider chemotherapy or surgery in selected cases 2

2. For Severe Obstruction (liquids only)

• Endoscopic lumen enhancement:
  • Wire-guided or balloon dilation
  • Placement of covered expandable metal stents 2

3. For Moderate Obstruction (semisolid food)

• Endoscopic lumen enhancement as necessary 2

4. For Neurological Dysphagia (e.g., post-stroke)

Compensatory Approaches

• Postural changes:

  • Chin down (positioning chin to chest) - improves airway protection 2, 1
  • Head turn (over right or left shoulder) - changes swallowing biomechanics 2
  • Head hyperextension - for absence of lingual pumping (only if safe passage guaranteed) 1

• Dietary modifications:

  • Use International Dysphagia Diet Standardisation Initiative (IDDSI) framework 2
  • Consider thickened liquids for patients with aspiration risk 2, 1
  • Caution: Thickened liquids may increase dehydration risk and reduce quality of life 2, 3

• Oral care:

  • Implement rigorous oral hygiene to reduce pneumonia risk 2

Rehabilitative Interventions

• Swallowing exercises:

  • Effortful swallow
  • Mendelsohn maneuver (holding larynx in uppermost position for 2-3 seconds)
  • Progressive lingual strengthening exercises
  • Expiratory muscle strength training 2

• Structured programs:

  • McNeill Dysphagia Therapy Program (MDTP) - progressive strengthening across increasingly challenging feeding tasks 2

Special Considerations

Preventing Complications

• Aspiration pneumonia:

  • Up to 55% of patients who aspirate may not exhibit protective cough reflexes 1
  • Silent aspiration occurs in up to 22% of patients 1

• Dehydration:

  • Common complication leading to UTIs, constipation, confusion 3
  • Monitor fluid intake carefully
  • Consider alternative hydration strategies 3

• Malnutrition:

  • If estimated caloric intake is <1500 kcal/day, consider oral/enteral nutrition
  • Feeding jejunostomies or nasogastric tubes may be necessary 2

Post-Stroke Dysphagia

• Maintain nil per os status until dysphagia assessment is complete
• Ensure adequate hydration with maintenance fluids
• Consider nasogastric or small-bore feeding tube if unable to swallow safely
• Obtain dietician consult for specific nutritional needs
• Reassess after extubation (if applicable) 2

Interprofessional Team Approach

• Speech-Language Pathologist (SLP) - for assessment and therapy
• Dietician - for nutritional management
• Physician - for medical management and procedures
• Nursing - for monitoring, education, and care coordination 2

Pitfalls to Avoid

• Relying solely on bedside evaluations without instrumental assessment 2
• Assuming dysphagia symptoms always correlate with location (abnormalities in distal esophagus can cause referred sensation to pharynx) 1
• Overlooking silent aspiration in patients without obvious symptoms 1
• Neglecting hydration status when using thickened liquids 2, 3
• Delaying SLP involvement, especially for patients requiring neural recovery (stroke) or maintenance of function (dementia) 2

By following this structured approach to dysphagia management, clinicians can effectively reduce morbidity, mortality, and improve quality of life for patients with swallowing disorders.