Dysphagia Clinical Advise

Here are some clinical notes i've made while working with different supervisors around dysphagia assessment and treatment:

Dysphagia clinical advice

 Tea – hot bolus – patient likely to take more manageable sips.

·       Positioning – position in an upright position – keep the patient upright after the swallow trial incase they have residue and aspirate.

·       Ask the doctors before doing a trial on an acute/ medically unwell patient - + check charts, temperature (high?), Breathing rate (high?), blood pressure, white blood cell count (sign of infection), managing secretions?, pneumonia – don’t want to put the patient at risk. Crepitations in right lung? More likely to get pneumonia in right lung.

·       Previous swallow trial – use the same consistencies – can see if any change

·       Leave a break before switching consistencies – water may remove a residue and cause coughing.

·       Trial a few mouthfuls – patient may need time to get warmeds up if they have not swallowed for a long time. E.g. been nil by mouth for a while.

·       Right lung – Doctors report you are more likely to aspirate and therefore get pneumonia in your right lung – look for creps here

·       Pneumonia due to oral trials = often a few days after the trials.

·       Talk to a dementia patient after swallow – since may talk back + may be unable to vocalise on command.

·       Soft mashed diet = easier than a soft diet, Jelly= not soft

·       Respiratory rate – high= sign of infection

·       Sitting out – and good positioning may assist with clearing chest infections + getting to trial oral intake.

·       Continue swallow trials for a little while – patients often improve as warmed up – starting on water – may improve on yogurt as bolus is more stimulating.

·       Look at cranial nerves/ comprehension/ cognition when giving mouthcare.

·       Check patients at different times of day to see if their swallow changes or varies.

·       Oesophageal cancer/ stricture – difficulties with solids

·       Dropped/ low sodium can cause delirium and a worse swallow (holding of food etc.)

·       If not liking puree – try thickened fluid trials to strengthen swallow.

·       EPR – look for previous inpatient reports and VF/ chest x-ray results.

·       Gastro team – review patients with regurgitation and coughing – may be oesophageal stricture etc (due to UES problems) – therefore NG may help or could be hernia on stomach – so PEG or NG wouldn’t help etc.

·       Complete the Barthel assessment with the OT’s as part of the Therapy Outcome Measures TOM’s.

·       Try teaspoons of water initially to make sure the patient takes small amounts.

·       Ask physio’s to support with positioning patients + chest physio before feeding.

·       Neglect – make sure on the side a patient attends to when feeding a patient + ? joint with OT about attending to the neglected side.

·       Advice – go slowly, small mouthfuls, one sip at a time, hand over hand facilitation

·       Show the patient the thickener + explain why it is used and allow them to stir it to increase compliance. Repeatedly explain the rational for its use and gesture.

·       Puree diet – refer to dieticians as reduced nutritional value/ patients often have lower intake.

·       Tea – older people may not be used to drinking water and may prefer tea (also stimulates a stronger swallow reflex + smaller sips because hot).

·       Pulse Oximetry – use with chesty patients e.g. crackles/ COPD as another measure (change of two points -  may indicate aspiration.

·       Try a desensitisation program for patients who have significant impairments and who are not accepting/ refusing mouthcare. From here you may be able to transition onto oral trials.

·       Abnormal reflexes e.g. tongue thrusting/ rooting reflex – a poor diagnostic sign.

·       Brainstem stroke – poor diagnostic sign.

·       Monitor dysphagia patients for changes regularly esp. on the stroke unit.

·       Dysarthria/ CN deficits/ cognitive deficits increase the likelihood of having dysphagia

·       Small spoons – to make sure patients with cognitive difficulties take small mouthfuls.

·       Trial water as well as yogurt – with a few teaspoons of water you may be able to spot the patients overt signs of aspiration and can compare consistencies. – see what their clear indicators are.

·       Nil –by –mouth for just a few days can lead to loss of muscle function.

·       Watch and listen to a patients voice throughout the whole swallowing assessment – they may produce more secretions when eating and sound more wet after.

·       Look at a patients baseline before giving recommendations e.g. how do they normally eat/ drink.

·       Pace oral intake – when transitioning a patient back onto oral intake e.g. ½ yogurt – 1 yogurt – 3x a day – yogurt + syrup fluids, puree meal + fluids ….

·       Ask if a patient normally eats with their false teeth in ..

·       Patients on NG-feeding should be positioned at 45 degrees.

·       Asthmatic patients are at risk of chest infections

·       Have all therapists offer the patient a drink after their sessions with a dehydrated patient on thickened fluids.

·       Close the curtains when feeding a distractible patient

Assessment/ management

·       Try a small amount of water on a spoon – equivalent to amount of saliva in mouth – if not managing unlikely to manage full assessment – check for silent aspiration using pulse oximetry – if desaturating on such a small amount unlikely to manage assessment – may be unable to coordinate swallowing with breathing (swallow being so effortful).

·       Therapy – try using a spoon to stimulate a swallow if a mouthcare sponge is not working – try wetting the spoon and the using it to stimulate a swallow.

·       Changing fluids – (from syrup to normal) – try 5 teaspoons of water then try cup drinking (hand over hand) then try free cup drinking.

·       Try a nectar consistency – 1 spoon thicken up to 200mls of fluid.

·       Brainstem stroke – may have untrue hyoid movement without a swallow

·       Huckabee – recommends balancing exercises – so no floor of mouth exercises without laryngeal muscle exercises.