For a patient with dysphagia, should I refer them to a Speech-Language Pathologist (SLP) or a Gastroenterologist (GI) first?

Refer to Speech-Language Pathologist (SLP) First for Oropharyngeal Dysphagia

For patients presenting with dysphagia, initial referral should be to a Speech-Language Pathologist (SLP) for oropharyngeal swallow evaluation, as this represents the most common type of dysphagia and carries significant risks of aspiration, pneumonia, and mortality if not promptly addressed. 1

Clinical Decision Algorithm

Step 1: Identify the Type of Dysphagia

Oropharyngeal dysphagia indicators (refer to SLP):

• Coughing or choking while eating or drinking 1
• Wet or gurgling vocal quality after swallowing 1
• Nasal regurgitation of food 1
• Difficulty initiating swallows 1
• Drooling or poor secretion management 1
• Dysarthria or dysphonia 1
• Weak voluntary cough 1
• Fear of choking while eating 1

Esophageal dysphagia indicators (refer to GI):

• Food "sticking" sensation in the chest after successful swallow initiation 1
• Progressive difficulty with solids more than liquids 1
• No coughing or choking during the swallow itself 1

Step 2: Assess High-Risk Conditions Requiring SLP Referral

The ACCP guidelines specifically recommend SLP referral for patients with conditions associated with aspiration risk 1:

• Stroke or other neurological conditions 1
• Parkinson's disease or dementia 1
• Head and neck cancer treated with chemoradiation 1
• Recurrent pneumonia or bronchitis 1
• Unexplained cough with eating 1
• Reduced level of consciousness 1

Step 3: Perform Bedside Water Swallow Test

Alert patients should be observed drinking 3 ounces of water 1:

• If the patient coughs, develops wet voice, throat clearing, or hoarseness after swallowing, refer immediately to SLP 1
• This simple test helps identify aspiration risk at the bedside 1

Why SLP First?

Mortality and Morbidity Considerations

Oropharyngeal dysphagia poses immediate life-threatening risks:

• Aspiration pneumonia is a leading cause of death in dysphagic patients 1
• Implementation of SLP screening programs for dysphagia has resulted in dramatic reductions in aspiration pneumonia rates 1
• Silent aspiration (aspiration without coughing) occurs frequently and requires instrumental assessment by SLP to detect 1
• Asphyxiation from choking is an acute mortality risk 1

SLP Scope of Practice

The American Speech Language and Hearing Association formally includes oropharyngeal dysphagia evaluation and treatment within the SLP scope of practice 1:

• SLPs perform clinical bedside swallow evaluations 1
• SLPs conduct instrumental assessments (videofluoroscopic swallow studies [VFSS] and fiberoptic endoscopic evaluation of swallowing [FEES]) 1
• SLPs determine therapeutic interventions and compensatory strategies 1
• SLPs provide swallowing rehabilitation and muscle strengthening exercises 1, 2

When to Consider GI Referral

Refer to gastroenterology when:

• Esophageal dysphagia is suspected based on symptom pattern (food sticking in chest, progressive solid dysphagia) 1
• Both oropharyngeal and esophageal dysphagia are present—consider combined VFSS with barium swallow 1
• Esophageal abnormalities are identified during SLP evaluation 3, 4

Important Caveat About Esophageal Screening

One-third of patients referred for oropharyngeal dysphagia evaluation actually have esophageal abnormalities 3:

• When esophageal visualization is added to standard VFSS, 26-68% of patients show esophageal dysfunction 3, 4
• Many patients have mixed oropharyngeal and esophageal dysphagia requiring both SLP and GI involvement 3, 4
• SLP-performed VFSS can include esophageal screening to identify patients needing GI referral 3, 4

Contraindications to Immediate Swallow Evaluation

Do not proceed with swallow evaluation if the patient has 1:

• Lethargy or reduced level of consciousness 1
• Absent swallow response on command 1
• Respiratory rate >35 breaths/minute 1
• Inability to manage oral secretions requiring frequent suctioning 1
• Delirium preventing participation in assessment 1

These patients should not be fed orally until their condition improves 1.

Multidisciplinary Management

After initial SLP evaluation, dysphagia management should involve organized multidisciplinary teams 1:

• Physician oversight 1
• SLP for swallow therapy 1
• Dietitian for nutritional assessment 1
• Nursing for feeding assistance 1
• Physical and occupational therapists as needed 1
• Gastroenterologist if esophageal pathology identified 1, 3