What is the initial management and treatment for a patient with dysphagia?

Initial Management and Treatment for Dysphagia

The initial management of a patient with dysphagia should include a referral for a detailed swallowing evaluation by a speech-language pathologist (SLP) and instrumental assessment through videofluoroscopic swallow study (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) to identify appropriate treatment strategies. 1

Initial Assessment

• Patients with dysphagia should undergo screening as soon as they are alert and ready for oral intake using a valid screening tool by an expert in dysphagia, ideally a speech-language pathologist 1
• Alert patients at high risk for aspiration should be observed drinking small amounts of water (3 oz). If the patient coughs or shows clinical signs associated with aspiration, they should be referred for a detailed swallowing evaluation 1
• Patients with cough related to pneumonia and bronchitis who have conditions associated with aspiration should be referred to an SLP for an oral-pharyngeal swallow evaluation 1
• Patients with reduced level of consciousness should not be fed orally until their consciousness improves due to high risk of aspiration 1

Instrumental Evaluation

• Videofluoroscopic swallow study (VSE/VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) should be performed on all patients considered at risk for pharyngeal dysphagia or poor airway protection 1
• These instrumental evaluations provide direct visualization of swallowing anatomy and physiology, which is crucial for accurate diagnosis and treatment planning 1
• A biphasic esophagram is more accurate than single-contrast esophagram for detecting mucosal lesions, while prone single-contrast views best detect lower esophageal rings or strictures 1
• For immunocompromised patients with dysphagia, endoscopy is preferred because of the ability to obtain specimens for laboratory study 1

Management Approach

Multidisciplinary Team

• Patients with dysphagia should be managed by organized multidisciplinary teams that may include a physician, nurse, SLP, dietitian, and physical and occupational therapists 1
• This approach has been shown to significantly decrease rates of aspiration pneumonia from 6.4% to 0% in stroke patients 1

Compensatory Strategies

• Compensatory maneuvers can be used if the patient's cognitive status is appropriate for training 1
• Postural techniques such as chin-tuck posture have been shown to eliminate aspiration during VSE in 77% of patients 1
• In ALS patients with moderate dysphagia, postural maneuvers (such as chin-tuck posture) should be recommended to protect the airway during swallowing 1

Dietary Modifications

• Dietary counseling should focus on texture modification of food and liquids to facilitate swallowing and avoid aspiration 1
• Specific recommendations for liquid consistency should be made based on the results of VSE or FEES 1
• Thickened liquids have shown a dramatic reduction in aspiration compared to thin liquids in patients with acute stroke 1
• For patients with muscular fatigue (such as in ALS), fractioning meals and enriching them with energy or deficient nutrients is recommended 1

Rehabilitative Approaches

• Restorative swallowing therapy techniques may include:
  • Lingual resistance exercises
  • Breath holds
  • Effortful swallows 1
• The Shaker exercise (sustained and repetitive head lifts three times daily while in the supine position) has shown improvement in upper esophageal sphincter opening and resolution of aspiration in patients with pharyngeal dysphagia 1

Nutritional Support

• Enteral diet should be started within 7 days of admission after an acute stroke if oral intake is insufficient 1
• For patients with dysphagia, it is reasonable to initially use nasogastric tubes for feeding in the early phase and to place percutaneous gastrostomy tubes in patients with longer anticipated persistent inability to swallow safely (>2–3 weeks) 1
• Nutritional supplements should be considered for patients who are malnourished or at risk of malnourishment 1

Hydration Management

• Dehydration is a frequent and serious complication in patients with dysphagia that can lead to urinary tract infections, constipation, confusion, and worsening of chronic diseases 2
• Careful evaluation and monitoring of fluid intake is crucial in these patients 2

Special Considerations

• Implementing oral hygiene protocols may reduce the risk of aspiration pneumonia after stroke 1
• Patients should be permitted and encouraged to feed themselves whenever possible to reduce the risk of pneumonia 1
• Patients, families, and caregivers should receive education on swallowing and feeding recommendations 1

Potential Pitfalls

• Dysphagia is often underreported and underestimated by caregivers, leading to delayed diagnosis and treatment 3, 4
• Obstructive symptoms that seem to originate in the throat or neck may actually be caused by distal esophageal lesions 4
• Medication side effects, particularly from neuroleptics, can cause or worsen dysphagia through various mechanisms including extrapyramidal syndromes, tardive dyskinesia, and sedation 3
• For frail older adults with progressive neurologic disease, the diagnosis of dysphagia should prompt a discussion about goals of care before potentially harmful interventions are considered 4