What are the treatment options for dysphagia?

Dysphagia Treatment

Dysphagia should be managed through instrumental swallowing evaluation (videofluoroscopy or fiberoptic endoscopic evaluation) followed by a multidisciplinary team approach that implements dietary modifications, compensatory maneuvers, and swallowing exercises based on the specific swallowing impairment identified. 1

Initial Assessment and Team-Based Care

• All patients with suspected dysphagia require instrumental evaluation (videofluoroscopic swallow evaluation [VSE] or fiberoptic endoscopic evaluation of swallowing [FEES]) to identify the specific swallowing impairment and guide treatment selection 1
• Multidisciplinary teams should manage dysphagia, including physicians, nurses, speech-language pathologists (SLPs), dietitians, and physical/occupational therapists 1
• Early evaluation by an SLP within 24 hours of hospital admission significantly reduces aspiration pneumonia rates from 6.4% to 0% (p=0.03) and decreases mortality from 11% to 4.6% 1

Dietary Modifications

Liquid Consistency Adjustments

• Thickened liquids are the primary intervention for reducing aspiration risk in patients who aspirate thin liquids 1, 2
• Aspiration occurs significantly more with thin liquids compared to nectar-thick liquids, and more with nectar-thick than honey-thick liquids (p<0.001) 1
• Water is particularly difficult to swallow because it flows quickly, requires precise coordination, and provides minimal sensory feedback, increasing aspiration risk 2
• In Parkinson's disease specifically, honey-thick liquids are most effective at preventing aspiration, while chin-down posture with thin liquids is least effective 1

Solid Food Modifications

• Modified consistency foods (soft, semisolid, or semiliquid) should be used to compensate for poor oral preparation and ease oral/pharyngeal transport 1
• The specific texture modifications must be determined by instrumental swallowing studies showing which consistencies can be swallowed without aspiration 1
• Foods with high water content (such as jellified water) are better alternatives than thin liquids for patients with delayed swallowing 1

Important Caveat on Thickened Liquids

• While thickened liquids reduce aspiration, exclusive use can lead to dehydration and decreased quality of life 2, 3
• Careful monitoring of fluid intake is essential, as dehydration is a frequent and serious complication that can cause urinary tract infections, constipation, confusion, and worsening of chronic diseases 3

Compensatory Postural Maneuvers

• Postural maneuvers eliminate aspiration in 77% of dysphagic patients when applied during instrumental evaluation 1
• Chin-down (chin-tuck) posture is the most universally applicable maneuver, offering airway protection by opening the valleculae and preventing laryngeal penetration 1
• In ALS patients specifically, chin-tuck posture should be recommended for moderate dysphagia to protect the airway during swallowing 1
• Head rotation is indicated for hypertonicity or incomplete upper esophageal sphincter release 1
• Hyperextended head posture is indicated only when lingual pump is absent and safe transit is ensured 1

Swallowing Exercises and Rehabilitation

Muscle Strengthening Programs

• Expiratory muscle strength training (EMST) for 4 weeks improves penetration/aspiration scores and hyolaryngeal complex function in Parkinson's disease patients 1
• The Shaker exercise (head lifts in supine position, three times daily for 6 weeks) significantly improves upper esophageal sphincter opening and anterior laryngeal excursion (p<0.01), with 93% of patients returning to regular or soft mechanical diet 1
• Muscle training with electromyographic biofeedback shows promise, with 9 of 10 patients showing dietary improvements after 1 week in brainstem stroke patients 1

Current Evidence Limitations

• Electrical stimulation and newer techniques (surface electrical stimulation, repetitive transcranial magnetic stimulation, video-assisted swallowing therapy) show promise but lack sufficient evidence for routine recommendation 1
• These techniques cannot be recommended until larger population studies are completed 1

Disease-Specific Considerations

Neurological Disorders (ALS, Parkinson's, Multiple Sclerosis)

• Rehabilitation treatment should be individualized after multidimensional swallowing assessment, adapting bolus characteristics, postural maneuvers, and exercise programs based on the specific neurological impairment 1
• In ALS, patients with fatigue should eat several small meals daily with meal enrichment using high-calorie foods 1
• Triggering of swallowing reflex can be enhanced by emphasizing taste or temperature 1
• Throat clearing every 3-4 swallows prevents post-swallowing inhalation in ALS patients with laryngeal penetration without aspiration 1

Multiple Sclerosis

• Modified consistency foods and fluids should be used according to individualized needs determined by instrumental evaluation 1
• Dysphagia affects approximately one-third of MS patients and becomes more frequent with moderate to severe disability 1

Enteral Nutrition

• Enteral nutrition via PEG tube is recommended for dysphagic patients unable to cover nutritional needs orally, particularly in chronic neurological disorders 1
• Alternative feeding methods should be instituted when patients cannot eat safely or take adequate oral amounts 4

Pharmacological Considerations

• ACE inhibitors may reduce pneumonia risk in elderly patients with dysphagia and stroke, decreasing pneumonia rates from 18% to 7% (relative risk 2.65, p=0.007) 1
• ACE inhibitors prevent breakdown of substance P, which plays a role in cough and swallow sensory pathways 1
• Anticholinergic medications and neuroleptics can worsen dysphagia through multiple mechanisms including reduced esophageal mobility, pharyngeal reflex impairment, and sedation 5

Critical Safety Points

• Silent aspiration (aspiration without cough) is common with thin liquids, particularly in neurological disorders, increasing respiratory complication risk 1, 2
• Patients with reduced consciousness should not receive oral liquids until their condition improves 2
• Cough while eating may indicate aspiration, but subjective reports alone are insufficient—instrumental evaluation is required 1
• Cup drinking causes more aspiration than spoon feeding (p<0.001), and straw drinking reduces airway protection in elderly patients 1