Aspiration is a concern in these patients, although it’s amazing that many of these patients can have this kind of finding and not have a history of pneumonia, said Dr. Dworkin. Near the top of his list is testing the cough reflex of patients.
Explore This IssueMarch 2007
Patients with a strong cough can clear the tracheal-bronchial tree, and are often good candidates for various methods of management, including behavioral management to try to facilitate swallowing, he said.
Weight loss is a major concern; therefore, getting a nutritionist involved is important, said Dr. Amin. Patients who can tolerate liquids can be put on a nutritional liquid diet, which can help patients regain strength. A speech pathologist may be able to help with the dysphagia too, showing the importance of a multidisciplinary team.
Panelists agreed that they would want to investigate what is happening further down in such a patient, though there are some tricks to getting a scope past the vocal folds. An endoscopic swallow evaluation (FEES), which lets the otolaryngologist watch the oral and pharyngeal phases of swallowing, is extremely useful for this, said Robert J. Stachler, MD, Associate Professor of Otolaryngology at Wayne State University.
When performing a swallow study, panelists concurred that starting with either a very thick liquid or a puree is the way to go. Water is the most difficult for most dysphagic patients to handle, and so this should not be the first thing tried. Other medical colleagues need to be educated about the problems with water and thin liquids in dysphagia patients, said Dr. Postma.
If you’re not sure where the patient’s going to be in terms of what he can swallow, I usually start with applesauce, then move to nectar-thick, Dr. Stachler said. Exams can be tailored depending on the type of dysphagia patients have.
When doing a swallow test in the ICU, Dr. Dworkin advised waiting several minutes before leaving the patient’s bedside. A patient might have delayed coughing and aspiration.
Case 3: Solid and Liquid Food Dysphagia, Aspiration
The third case presented was of a 60-year-old male with solid and liquid food dysphagia. Fluoroscopic swallow and manometry showed that the patient had difficulty transporting a bolus through the hypopharynx, with aspiration that penetrated up to the level of the vocal fold.
Manometry was key for helping diagnose this patient, and evaluating the strength of the pharynx was important. The patient proved to have a weak pharynx, although an initial diagnosis couldn’t determine this.