How to manage dysphagia?

Management of Dysphagia

All patients with suspected dysphagia should undergo immediate screening by a speech-language pathologist, followed by instrumental assessment with videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES), and then be managed by a multidisciplinary team using compensatory strategies and dietary modifications tailored to their specific swallowing deficits. 1, 2

Initial Screening and Assessment

• Screen patients as soon as they are alert and ready for oral intake using a validated screening tool, ideally performed by a speech-language pathologist (SLP); if unavailable, use another appropriately trained professional 1
• Abnormal screening results require immediate referral to an SLP, occupational therapist, dietitian, or trained dysphagia clinician for detailed bedside assessment 1
• Critical warning: Clinical bedside evaluation alone is dangerously inadequate because silent aspiration occurs in over 70% of patients whose aspiration is detected on videofluoroscopy 2, 3

Instrumental Evaluation (Mandatory)

All patients considered at risk for pharyngeal dysphagia or poor airway protection must undergo VSE or FEES 1, 2, 3

• VSE provides motion picture radiography showing barium-mixed food passing through all swallow stages in lateral and anterior-posterior positions, and is cost-effective for detecting silent aspiration 3
• FEES can be performed at bedside using transnasal flexible nasopharyngoscopy to directly observe the pharynx and larynx before and after swallowing 3
• These instrumental studies serve dual purposes: diagnosis and treatment planning, providing critical information unavailable from bedside evaluation 2

Multidisciplinary Team Management (Essential)

Assemble a team including physician, SLP, nurse, dietitian, physical therapist, occupational therapist, and pharmacist 1, 2

• This approach has demonstrated substantial clinical benefit, reducing aspiration pneumonia from 6.4% to 0% and showing trends toward decreased mortality from 11% to 4.6% 1, 2
• The team should develop an individualized management plan addressing therapy for dysphagia, dietary needs, and specialized nutrition plans 1

Compensatory Strategies

Test postural maneuvers during VSE or FEES to identify which eliminate aspiration 1, 2, 3

• Chin-down (chin-tuck) posture is the most universally useful maneuver, offering valuable airway protection by opening the valleculae and preventing laryngeal penetration 1, 2
• Head rotation is indicated for hypertonicity, incomplete release, or premature upper esophageal sphincter closure 1
• Head tilt and lying down positions may be appropriate for specific swallowing deficits 1
• Postural maneuvers eliminated aspiration in 77% of patients during videofluoroscopic evaluation 1, 2
• Critical pitfall: Never implement compensatory strategies without instrumental confirmation of their effectiveness 2, 3

Dietary Modifications

Prescribe thickened liquids and texture-modified foods using the International Dysphagia Diet Standardisation Initiative (IDDSI) framework 2, 3

• Aspiration is more common with thin liquids than nectar-thick liquids, and more frequent with nectar-thick than ultra-honey-thick liquids 1
• Cup drinking causes more aspiration than spoon feeding 1
• Test foods and liquids simulating the patient's normal diet during VSE or FEES to refine dietary recommendations 1, 2, 3
• For patients with moderate dysphagia, adapt texture of solids and liquids to facilitate swallowing and avoid aspiration 1

Restorative Therapy

Implement active swallowing therapy when a treatable disorder in swallow anatomy or physiology is identified 1

• Restorative therapy may include lingual resistance exercises, breath holds, and effortful swallows 1
• Chin tuck against resistance in addition to conventional dysphagia therapy improves oropharyngeal swallow function and reduces aspiration by targeting suprahyoid musculature 2
• Respiratory muscle strength training decreases aspiration in patients without tracheostomy 2
• Reassess regularly as swallowing function changes 1

Nutritional Support

Consider enteral feeding for patients unable to orally maintain adequate nutrition or hydration 1

• While tube feeding is recommended when oral intake is insufficient, there is no evidence favoring one feeding route over another 1
• Early gastrostomy placement should be considered in patients with progressive weight decline or uncontrolled aspiration risk 2, 3

Patient and Caregiver Education

• Provide education on swallowing and feeding recommendations in interactive and written formats 1
• Train patients and caregivers on safe feeding techniques 1
• Permit and encourage patients to feed themselves whenever possible to reduce pneumonia risk 1
• Provide meticulous mouth and dental care 1

Critical Safety Monitoring

Monitor for signs requiring urgent re-evaluation: 2, 3

• Recurrent pneumonia
• Progressive weight loss
• Worsening respiratory symptoms
• Development of silent aspiration
• Patients with reduced level of consciousness should remain NPO (nothing by mouth) until consciousness improves due to high aspiration risk 2

Common Pitfalls to Avoid

• Never assume absence of cough means safe swallowing—silent aspiration is extremely common 2, 3
• Never delay instrumental assessment in favor of prolonged bedside evaluation alone—this leads to inadequate management 2, 3
• Never manage patients in isolation—multidisciplinary team approach significantly improves outcomes 1, 2
• Never implement dietary modifications without instrumental confirmation of effectiveness 2, 3