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Stressful Swallowing: Presentation and Management


06 Jan 2016

All this week David G Smithard MD FRCP, consultant in elderly and stroke medicine, chair of the UK Swallowing Research Group, Hon Reader University of Kent, is dispensing advice about dysphagia.

Read today’s episode to learn more about the presentation and management of this often-unrecognised condition.

Presentation

The presentation of dysphagia will often depend on the context in which it occurs.

The most common complaints will be that food/liquid goes down the wrong way, may regurgitate through the nose, may cause coughing or a change of diet.

In others where they cannot recognise or communicate their problem, food refusal, regurgitation, and spitting may be the presenting complaint by carers.

In those people who are frail, the swallowing only becomes a problem when another stressor such as infection or prescribed (or non prescribed) medication wipes out their physiological reserve resulting in dysphagia and the risk of aspiration.

Signs of dysphagia will be a changed/wet voice, recurrent chest infection, hypoxia, a grumbling pyrexia or weight loss.

Coughing is frequently a sign of airway penetration (food/liquid not going below the vocal cords), then the airway is cleared with a cough and aspiration does not occur.

Management

The management of dysphagia is a multidisciplinary problem.

First the problem has to be identified by a clinical history and a swallow screen (such as the water-based Bedside Swallowing Assessment).

Any member of the clinical team can do this.

Once the problem has been identified, referral to the local expert should occur – in the UK this will be the speech and language therapist.

The speech and language therapist will then fully assess the patient looking at the anatomy of the swallow as well as the functional aspects.

Following the clinical assessment, recommendations will be made to ensure nutrition can be provided safely, and, in some situations, further assessment is required.

Various guidelines suggest instrumental assessment of the swallow should occur where indicated, and different countries have different approaches.

In the UK, the speech and language therapist will recommend videofluoroscopy and/or Flexible Endoscopic Evaluation of Swallowing (FEES), the approach is often dictated by local availability.

Other investigations that may be required include manometry and pH monitoring where reflux is considered to be the aetiology of oro-pharyngeal dysphagia.

The management of swallowing is to encourage a safe swallow and ensure the patient receives adequate nutrition and is able to take their medication.

From a nutrition point of view, there are two basic approaches – one is to modify the diet (ie consistency of food taken) and the other is to modify the swallowing physiology (swallowing manoeuvres).

Where it is not possible to swallow safely, or it is not possible to ensure someone’s nutritional needs are met, enteral feeding needs to be considered.

In the acute phase nasogastric feeding is the route of choice, and where necessary a nasal loop or bridle is used to keep the tube in place.

Longer term, depending on patient choice and acceptability, a gastrostomy may be placed either endoscopically or radiologically.

Some, usually younger patients, may prefer to repeatedly pass a nasogastric tube.

There is at the present time a lot of hope and expectation around the management of swallowing disorders, particularly in those due to neurological disease and presbyphagia (swallowing difficulties in older people with no other health problems).

In the case of brain injury (including stroke), there are opportunities with transcranial stimulation, pharyngeal stimulation and neuromuscular stimulation.

Where there is reduced tongue strength, either due to brain injury, post surgery or sarcopenia, muscle resistance training may be beneficial, not only in strengthening the tongue but also improving the swallow.

Where laryngeal elevation is a problem, neuromuscular stimulation or muscle strengthening of the hyoid musculature (shaker exercise and chin tuck against resistance) offers hope.

Come back tomorrow for the next episode of our weekly feature as we examine the damaging effects dysphagia has for patients with the condition and the role of the pharmacist.


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