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Understanding the role of speech language pathologists in managing dysphagia

Clark, Sarah, MS, BA, CCC-SLP; Ebersole, Barbara, MA, BFA, CCC-SLP

doi: 10.1097/01.NURSE.0000547723.69610.20
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Abstract: Collaboration between nurses and speech language pathologists is vital to the screening and management of dysphagia in acute care settings. This article examines each discipline's role in caring for patients with dysphagia.

The authors discuss how nurses and speech language pathologists work together to care for patients with dysphagia.

Sarah Clark is a senior speech language pathologist at Jeanes Hospital in Philadelphia, Pa. Barbara Ebersole is director of speech pathology services at Jeanes Hospital, head and neck cancer program administrator at Temple University's Fox Chase Cancer Center, assistant director at the Temple Head and Neck Institute, and clinical instructor in the department of otolaryngology-head and neck surgery in the Lewis Katz School of Medicine at Temple University; all in Philadelphia, Pa.

The authors have disclosed no financial relationships related to this article.

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NURSES AND SPEECH language pathologists (SLPs) working in acute care settings are valuable members of interdisciplinary teams that treat a variety of patients. Collaboration between specialties is critical in healthcare environments because of the strong emphasis on following evidence-based practices, providing optimal patient care, decreasing lengths of stay, minimizing healthcare-acquired infections, and avoiding readmissions.

Optimal patient care incorporates the strengths, knowledge, and research of each discipline involved. This article discusses the roles of RNs and SLPs in medical-surgical units who have been tasked with caring for patients with dysphagia.

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Identifying dysphagia

One area of expertise for SLPs is evaluating and treating dysphagia (swallowing dysfunction). Left untreated, dysphagia can lead to dehydration and malnutrition.1,2 It is also a risk factor for respiratory infections such as aspiration pneumonia, which is associated with increased mortality and morbidity.3

The entire deglutition (swallowing) process normally takes only a few seconds, with no food or liquid left behind. It has three phases: oral, pharyngeal, and esophageal. A patient can experience swallowing difficulty in any phase (see The physiology of swallowing). Dysphagia can be classified as oropharyngeal, in which a patient has difficulty transferring food and liquid from the mouth into and through the pharynx, and esophageal, in which food or liquid does not pass through the esophagus normally.4

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Dysphagia risk

Several diseases and disorders can lead to dysphagia, including

  • stroke
  • neurodegenerative disorders, such as Parkinson disease, multiple sclerosis, amyotrophic lateral sclerosis, encephalopathy, and dementia
  • pulmonary disorders, such as chronic obstructive pulmonary disease or respiratory distress leading to endotracheal intubation or tracheostomy
  • gastroesophageal reflux disease
  • head and neck cancer.

Although these may not be the reason for an acute admission, patients may be experiencing chronic effects from one or more of these disorders during their stay at an acute care hospital.

Not all swallowing difficulties indicate dysphagia either. For example, an altered level of consciousness will likely cause decreased oral intake, but poor arousal is not dysphagia. Additionally, patients with poor dentition may have trouble chewing, but this does not necessarily lead to dysphagia. Dysgeusia and anorexia may also be present with dysphagia, but these disorders are not synonymous.

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How common is dysphagia?

Data on the incidence and prevalence of dysphagia are scarce, and the figures vary widely. Annually, it is estimated that over 9 million adults in the US report a swallowing problem.5

A systematic review of articles reporting on the prevalence of oropharyngeal dysphagia found evidence in up to 80% of patients who had experienced a stroke, up to 81% of patients with Parkinson disease, 27% to 30% of patients with traumatic brain injuries, and 92% of patients with community-acquired pneumonia.6 The estimated prevalence of dysphagia in acute care settings is 30% in patients age 65 and older and between 55% and 86% in older adults hospitalized with pneumonia.3,7

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Dysphagia screening

Nurses play a key role in dysphagia management by screening patients at high risk for aspiration before oral intake and determining if an SLP evaluation is required. Various nurse-initiated screening tools have been developed and validated as highly effective in detecting aspiration (see Validated aspiration screening tools).8-14

Most research on dysphagia screening has focused on neurologically impaired patients, primarily those who have experienced acute stroke.8-13 A systematic review and meta-analysis found that early dysphagia screening reduced the rate of pulmonary infections in patients with dysphagia, but the utility and effectiveness of bedside dysphagia screening outside of acute stroke populations remains less clear.15-18

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Dysphagia assessment

A clinical bedside swallowing evaluation conducted by an SLP includes a review of the patient's health history, reason for admission, any relevant test results (such as chest X-ray or brain imaging), and his or her baseline level of functioning. Additionally, the SLP notes the patient's level of independence. The presence of dysarthria, dysphonia, and/or drooling may signal abnormal motor function, elevating concerns regarding dysphagia.

An oral-mechanism exam analyzes the structure and function of the physical components used in mastication and swallowing. Typically, patients are given food of different textures to eat and liquid of various viscosities to drink, then the SLP assesses for any signs and symptoms of reduced efficiency in chewing or swallowing. These include:

  • poor mastication
  • oral pocketing or holding of food/liquid
  • reduced laryngeal elevation during deglutition
  • multiple swallows per bolus
  • bolus regurgitation or expectoration
  • patient complaints of bolus holdup (for example, “It feels like I've got something stuck in my throat”).

The SLP also assesses for any overt signs of aspiration such as throat clearing, coughing, choking, or a wet vocal quality.

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Due to lack of visibility in the pharyngeal and esophageal phases, bedside swallowing evaluations are limited. When dysphagia is suspected based on a bedside exam, instrumental evaluations are usually recommended to detect the presence of aspiration. These tests definitively identify the presence and potential causes of aspiration. For example, there may be a weakness in musculature, a tumor, a diverticulum, and/or a delay in the swallow reflex. This information helps the SLP determine the most effective interventions and the overall prognosis.

An example of an instrumental study is the modified barium swallow (MBS), also called the videofluoroscopic swallowing study. For this noninvasive radiographic study, the patient is asked to swallow food with varying textures and liquid mixed with barium. Fluoroscopy allows visualization of all three phases of swallowing, as well as any penetration into the larynx (contrast in the laryngeal vestibule), aspiration (contrast below the vocal folds), and pharyngeal retention postswallow.

Another instrumental evaluation study is the fiberoptic endoscopic examination of swallowing (FEES), during which the oropharynx and larynx are visualized transnasally with a laryngoscope while the patient swallows food and liquid dyed with food coloring for contrast.19 Laryngeal and pharyngeal structures are visually examined, and, if present, penetration, aspiration, and residue can be seen postswallow. This study can be performed at the patient's bedside or in an SLP's office.

The MBS and FEES are equally sensitive in detecting aspiration and complementary to the other, but each has slightly different benefits and limitations in the evaluation of swallowing function.20,21

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Therapeutic interventions

Using these clinical and instrumental evaluations, SLPs make recommendations for oral intake, the need for alternative nutritional routes, diet modifications, appropriate positioning, safe swallow strategies, and oral or pharyngeal exercises. They may also recommend potential referrals for gastrointestinal evaluation of esophageal dysphagia; occupational therapy assessment for self-feeding strategies; nutrition assessment for supplement recommendations; and ear, nose, and throat evaluation for laryngeal pathology (see An SLP's many roles).

In acute care, an SLP's primary goal is establishing a safe diet. SLPs will typically see a patient only once or twice during his or her admission, so they rely on the nursing staff to reinforce safe swallowing techniques and diet recommendations (see Roles of RNs and SLPs in treating acute care patients). These may include:

  • therapeutic swallowing strategies, such as swallowing twice for each bite or sip and alternating between solids and liquids.
  • postural modifications, such as turning the head to the weak side and keeping the chin tucked, getting out of bed for meals, and remaining upright afterward.
  • any meal assistance needs, such as maintaining a slow rate of feeding, small bites and sips, or one-on-one assistance.
  • making sure oral medications are taken in the recommended form (crushed in puree, whole in puree, with thick liquids, and so on).
  • encouraging patients to perform swallowing exercises as prescribed by the SLP.

Nurses and SLPs can educate caregivers on safe feeding practices, including slow feeding rates, small sip and bite volumes, and the importance of observation in taking cues from the patient to stop or continue.

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A collaborative relationship

In the acute care setting, SLPs diagnose and manage dysphagia primarily with safe diet recommendations. RNs play a critical role in identifying those at risk for dysphagia and making sure SLP recommendations are being followed. The collaboration between RNs and SLPs facilitates timely diagnosis and ensures safe, efficient, and optimal patient care.

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Validated aspiration screening tools

  • The Gugging swallowing screen (GUSS)9
  • The Toronto bedside swallowing screening test (TOR-BSST)8
  • The Barnes–Jewish Hospital stroke dysphagia screen (BJH-SDS)13
  • Yale swallow protocol14
  • Rapid aspiration screening for suspected stroke12
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An SLP's many roles22

SLPs evaluate and treat disorders of swallowing and communication in a wide range of patient populations, including disorders of:

  • swallowing: also called dysphagia; puts patients at risk for poor nutrition, weight loss, and pneumonia
  • language: disorders affecting how a patient verbally communicates and/or understands language; also known as aphasia
  • speech sounds: including dysarthria, a motor-speech disorder affecting articulation
  • cognitive-communication: affecting memory, problem solving, visual-perceptual skills, and reasoning
  • voice and airway disorders: such as hoarseness (also called dysphonia) and laryngeal disorders that affect breathing, such as vocal fold dysfunction and laryngospasm.
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            Keywords:

            dysphagia; esophageal dysphagia; oropharyngeal dysphagia; speech language pathologist

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