return to: Swallowing Disorders Management Protocols or Clinical Bedside Swallowing Assessment

see also: Speech Pathologists

Note: last updated before 2019

INDICATIONS

1. Swallowing dysfunction (dysphagia) is often associated with patients who have head and neck cancer, as well as patients who are elderly or who have neurological involvement. These instructions are generally for those patients who have had cancer of the head and neck. They may include patients with the following:
   1. Head and neck radiation or chemo-radiation
      1. Loss of sensation
      2. Fibrosis of musculature and mucosa
      3. Reduced moisture (saliva)
   2. Anterior floor of mouth composite resection
      1. Reduced labial closure, abnormal hold position
      2. Reduced lingual control (aspiration before swallow)
   3. Lateral floor of mouth, tonsil/base of tongue composite resection
      1. Reduced lingual control (aspiration before swallow)
      2. Delayed reflex (aspiration before swallow)
      3. Reduced pharyngeal peristalsis (aspiration after swallow)
      4. If extended into soft palate, nasal regurgitation that also may occur if nasogastric tube in place.
   4. Partial tongue resection
      1. Difficulty triggering the swallow reflex (temporary).
      2. Poorly coordinated tongue movements for speech and swallowing.
      3. Difficulty with control of material and lingual peristalsis.
   5. Hemilaryngectomy
      1. Usually no problems; however, may experience reduced airway closure (aspiration during swallow)
   6. Supraglottic laryngectomy
      1. Reduced laryngeal closure (aspiration during swallow)
   7. Total laryngectomy
      1. Scar tissue "pseudoepiglottis" at base of tongue
      2. Stricture in pharyngoesophagus
      3. Diverticulum
2. If a patient has any of the above conditions, some assessment of swallowing (clinical/bedside, OPMS, FEES) should be done before the patient is fed intraorally.
3. From the above assessment, treatment by an appropriately-trained speech-language pathologist follows with observation, especially during initial oral intake. It may be necessary to do exercises to increase strength and mobility of the oral musculature before intake is considered. Likewise, exercises to improve glottal closure and techniques to stimulate the swallow reflex, such as thermal stimulation, may be appropriate. In some cases, a prosthesis and/or surgery may be needed before oral intake is considered as a viable option.

ENTERAL FEEDING TUBES AND NUTRITIONAL MAINTENANCE

1. Prior to reintroduction of oral feedings, nutrition may be maintained via an enteral feeding tube, usually nasogastric. Some patients may find swallowing easier after removal of the feeding tube, as its presence in the posterior pharynx and cervical esophagus may contribute to a feeling of obstruction or a "lump in the throat," particularly if the tube tends to coil and reduplicate in the pharynx and oral cavity. If the feeding tube is to remain in place until the supraglottic swallow technique has been mastered, its position in the pharynx should be ascertained and any coiling eliminated prior to each oral feeding. Most patients are able to swallow while the feeding tube remains in place, particularly if a soft feeding tube small in diameter is used. If the feeding tube is removed and oral intake is insufficient to maintain nutrition and body weight, the feeding tube must be temporarily replaced while the patient continues to practice the supraglottic swallow. This may foster patient feelings of discouragement, failure, and guilt.
2. Tracheostomy Tube
   1. A cuffed tracheostomy tube may temporarily diminish aspiration while the cuff is inflated. Food/fluids may pool above the inflated cuff and may be aspirated when the cuff is deflated unless tracheal suctioning is done immediately after cuff deflation. If the tracheostomy decannulation process has begun and the patient tolerates a fully corked cuffless tracheostomy tube, it should be corked during feedings. A fully corked tube or decannulated healed stoma facilitates glottic closure to prevent aspiration. Never place a full cork into the tracheostomy tube with an inflated cuff, as this would occlude the airway.

THE SUPRAGLOTTIC SWALLOW

1. The supraglottic swallow has often been used with patients who have swallowing difficulties. It includes the following:
   1. Clear throat
   2. Inhale and exhale deeply
   3. Inhale normally and hold breath, tighten stomach muscles and bear down (Valsalva maneuver)
   4. Place small amount of food in mouth (approximately 1/3 tsp)
   5. Without exhaling, swallow one to three times
   6. Without inhaling, cough and clear throat to clear away any food that has pooled in the pharynx.
   7. Without inhaling, swallow again (dry swallow without any food in mouth)
   8. Breathe and then rest
2. The speech-language pathologist should note if the patient has a coughing spell in any specific head position or with any particular food. The patient should be encouraged to cough as needed.
3. The nurse should evaluate the patient 20 to 30 minutes after the meal to assess for coughing, which may indicate delayed aspiration.
4. Suction equipment should be readily available. When aspiration occurs, encourage the patient to cough and expectorate aspirated materials. Suction if the cough seems ineffective.
5. Feedings may be lengthy, anxiety provoking, fatiguing and frustrating.
6. Position the patient for comfort, conservation of energy, and facilitation of swallow. Encourage the patient to persevere and reassure that the supraglottic swallow may take several days to master completely. Document the following:
   1. Patient success
      1. Identify foods, swallowing techniques, head and body positions that are most helpful.
      2. Total dietary intake (PO and feeding tube supplementation)
      3. Calorie counts
      4. Successful teaching aids
   2. Aspiration and remedial action taken by patient or nurse
   3. Patient fatigue after feedings
   4. Daily weight
   5. Fever, chest pain, shortness of breath, and purulent tracheal secretions (may indicate aspiration pneumonia)

ELECTRICAL STIMULATION OF SWALLOWING

1. Although there are proponents to use of ESS (electrical stimulation of swallowing) - other have identified (as per Krisciunas 2016): in a large randomized controlled study: "The addition of estim to swallowing exercises resulted in worse swallowing outcomes than exercises alone"

ROLE FOR NPO WITH ENTERAL FEEDINGS

MANAGEMENT OF INTRACTABLE ASPIRATION

(see: Laryngotracheal Separation) - Despite NPO status some patients may continue to aspirate secretions to the point that separation of the lungs from the digestive tract is necessary. Options include: "tracheotomy with obturation of the larynx", "laryngeal diversion procedure" and 'near field 'laryngectomy"

1. Tracheotomy with obturation of larynx

2. Laryngeal diversion procedure (modification: Laryngotracheal Separation)

3. Near-field laryngectomy for aspiration case example

References

Krisciunas GP, Castellano K, McCulloch TM, Lazarus CL, Pauloski BR, Meyer TK, Graner D Van Daele DJ, Silbergleit AK, Crujido LR Rybin D, Doros G, Kotz T, Langmore SE.: Impact of Compliance on Dysphagia Rehabilitation in Head and Neck Cancer Patients: Results from a Multi-center Clinical Trial.    Dysphagia. 2017 Apr;32(2):327-336. doi: 10.1007/s00455-016-9760-4. Epub 2016 Nov 16.