What are the recommendations for a patient with a history of cardiovascular disease taking Metoprolol (beta blocker) who is experiencing dysphagia (difficulty swallowing) and is at risk of choking on foods?

Management of Metoprolol-Related Dysphagia and Choking Risk

Immediate Safety Assessment and Referral

Any patient on metoprolol experiencing choking with foods requires immediate referral to a speech-language pathologist for formal instrumental swallowing evaluation, as this symptom indicates oropharyngeal dysphagia with high aspiration risk. 1

• Implement NPO (nothing by mouth) status immediately if the patient shows lethargy, respiratory rate >35, or active choking episodes until formal assessment is completed 1
• Do not rely on bedside screening alone—instrumental assessment with videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) is mandatory, as bedside evaluation cannot predict aspiration presence or absence 2
• Silent aspiration occurs in up to 80% of cases, meaning absence of coughing does not indicate safe swallowing 2

Critical Medication Review

Beta-blockers like metoprolol do not directly cause dysphagia through pharmacologic mechanisms, but sedative properties and polypharmacy significantly increase aspiration pneumonia risk. 3

• Review all concurrent medications, particularly sedatives, which carry an 8.3-fold increased risk of aspiration pneumonia 1
• Assess for anticholinergic medications that reduce esophageal motility and pharyngeal reflexes 3
• Evaluate for CNS-depressing medications that worsen swallowing coordination 3
• Do not crush or modify metoprolol tablets without pharmacist consultation, as inappropriate crushing alters pharmacokinetics and may compromise cardiovascular control 4

Specific Red Flags Requiring Urgent Evaluation

Identify these high-risk features that mandate immediate instrumental assessment: 1, 2

• Coughing or choking specifically with liquids (88% sensitivity for aspiration on videofluoroscopy) 1
• Wet or gurgly voice quality after swallowing 2
• Unintentional weight loss or malnutrition 1
• Recurrent pneumonia or current chest infiltrates 1
• Weak voluntary cough or need for oral suctioning 1
• Dysarthria or dysphonia accompanying dysphagia 2

Diagnostic Workup Algorithm

Step 1: Immediate Clinical Screening

• Perform a 3-ounce water swallow test while observing for coughing, throat clearing, wet voice, or inability to complete the test 2
• Measure average volume per swallow—values <13-15 ml suggest significant dysphagia 2
• Obtain chest radiograph to evaluate for aspiration pneumonia (patchy opacity, lower lobe infiltrate) 1

Step 2: Instrumental Assessment (required before any treatment decisions)

• FEES is the preferred method for identifying aspiration and determining safe liquid/food consistencies 2
• VFSS is the alternative if FEES is unavailable 2
• These studies test compensatory strategies (chin tuck, multiple swallows per bolus) for safe swallowing 1

Step 3: Nutritional Assessment

• Dietitian evaluation to identify moderate or severe nutritional compromise 1
• Assess for dehydration, which increases DVT risk and slows stroke recovery 5

Treatment Protocol Based on Assessment Findings

Immediate Safety Measures:

• Keep patient NPO until instrumental assessment confirms safe swallowing strategies 2
• Implement oral hygiene protocols to reduce aspiration pneumonia risk 2
• Position patient upright during and for 30 minutes after any oral intake 5

Texture Modification (based on VFSS/FEES results):

• Prescribe standardized viscosity levels: thin liquids at 10 mPa·s, mildly thickened at 100 mPa·s, moderately thickened at 200 mPa·s 1
• Modify food consistency according to speech-language pathologist recommendations 5
• Avoid assuming thickened liquids are universally safer—they must be individualized based on instrumental findings 1

Medication Administration Strategy:

• Coordinate with pharmacist to identify which medications can be crushed or require liquid formulations 4
• For metoprolol specifically, consider switching to liquid formulation if available, or consult cardiology about alternative beta-blockers available in different forms 4
• Never crush extended-release formulations, as this alters cardiovascular control 4
• Administer medications with the safest consistency identified on instrumental testing 4

Multidisciplinary Team Coordination

Organize a team approach including: 1

• Physician (managing cardiovascular disease and overall care)
• Speech-language pathologist (swallowing assessment and therapy)
• Dietitian (nutritional optimization)
• Pharmacist (medication formulation guidance)
• Nursing staff (implementation of feeding protocols)

Common Pitfalls to Avoid

• Never assume absence of aspiration based on lack of coughing alone—silent aspiration is extremely common in older adults with cardiovascular disease 5, 2
• Do not delay instrumental assessment—bedside screening is insufficient for treatment planning and may miss up to 80% of aspiration cases 2
• Avoid relying on gag reflex testing—a preserved gag reflex does not indicate safe swallowing 5
• Do not automatically place feeding tubes—many patients can safely swallow with appropriate compensatory strategies identified on instrumental testing 5
• Never modify medications without pharmacist input—inappropriate crushing of metoprolol may cause cardiovascular instability 4

Prognosis and Goals of Care Discussion

• Aspiration pneumonia is a leading cause of death in patients with dysphagia and cardiovascular disease 2
• For frail older adults with progressive conditions, dysphagia diagnosis should prompt discussion about goals of care before considering potentially harmful interventions like feeding tubes 6
• Speech-language pathologists can provide structured assessments for safe swallowing, palliative care recommendations, or rehabilitation options 6