Pulmonary Disease and Dysphagia: What SLPs need to know
Lung disease and dysphagia often go hand in hand. But I don't need to tell you that. You wouldn't be reading this unless you understood that dysphagia is widely seen in this complex, often high-risk population. Let's explore the world of pulmonary pathologies and swallowing impairments together. I was motivated to write this article after watching Jo Puntil's MS, CCC-SLP, BCS-S, F-ASHA incredibly detailed course, "Pulmonary-Compromised Patients: Oxygen Delivery and Dysphagia Issues," which is jam-packed with practical insights and valuable takeaways. We will break down this complex topic into the essentials so you can use this as a user-friendly guide, like a map that will help you find your way in an area of practice that can be very easy to get lost in.
Dysphagia and Pulmonary Disease
Swallowing impairment can happen with an exacerbation of pulmonary diseases. Some swallowing impairments seen in patients with pulmonary issues include:
Food channeled to the valleculae before initiation of the swallow
Delayed laryngeal closure
Inconsistent laryngeal penetration with large volumes
Premature reopening of the larynx
Post swallow residue
Decreased pharyngeal contractive wave
Unusual swallow-to-swallow variability
Slow esophageal motility
Jo Puntil has some wonderful insights and takeaways she has acquired after spending decades caring for patients with respiratory disease in the ICU. Here are a few:
Breath Sounds
Understanding normal and disordered breath sounds and possible sequelae can help clinicians make better clinical decisions about disorders and how they affect independent living and health management. Normal and abnormal respiratory patterns provide an understanding of the patient's medical issues. Understanding normal swallowing patterns and how they are superimposed on breathing can also help clinicians learn about a patient's trends and possible risk of aspiration. It’s not x-ray vision, but it’s about as close to it as we can get without follow-up imaging, and it can give us a tremendous amount of information regarding the trajectory of the patient’s status.
Goal and Timing of the Evaluation
Understanding the goal and timing of the swallowing evaluation will help us determine the best approach. For example, a patient complaining of fatigue and a sore throat who was just extubated after a week and a half with an endotracheal tube down their throat may not be ready for three meals daily. What's the goal then? Maybe the goal is to take meds and maintain comfort via sips of liquid and small ice chips (aka sips and chips). Being OK with taking a step back and moving forward slowly and deliberately allows you to use time to your advantage. Never feel like you should be rushed into a decision with this sensitive population, no matter who is begging you to move faster or breathing down your neck as you make a decision.
Even healthy people aspirate
It's true. Healthy people occasionally penetrate and aspirate during their meals, especially while sleeping. So then, setting a goal to tolerate a consistency with "no" signs or symptoms of aspiration would be a fool's errand and only set the patient up for failure. Remember SMART goals: We need to make our goals achievable for the patient, or they'll end up like Sisyphus, but instead of endlessly lugging a huge boulder up a hill, they'll be trying to swallow dried-up secretions or thickened liquids. Instead, set achievable goals that allow the patient to start swallowing safely, with small amounts of water, for example, to lower the stakes of aspiration while preventing disuse atrophy.
Should You Feed Your Patient on High-Flow?
Say your patient is on a high-flow nasal cannula (HFNC) and is on 60 liters per minute and 70% FiO2. That's a lot of respiratory support, and high pressure may be like trying to eat with your head sticking out of a 747. Right? Maybe not. The use of HFNC should not automatically disqualify patients from PO trials. We should instead look at the whole picture. What are some of the other risk factors for aspiration and pneumonia that we should be mindful of?
Reduced pitch elevation
Dysarthria
Cough strength
Dependence for feeding
Dependence on oral care
Number of decayed teeth
Tube feeding/NPO
Immobility/reduced activity
Key Takeaways
Clinical experience counts. So let's take some of the key takeaways Jo Puntil has acquired in her decades of experience in the ICU:
Sips and chips are important for maintaining basic swallowing function and comfort.
Don't fear aspiration. Even healthy people aspirate.
Awake, alert, and mobile patients are less likely to aspirate and less likely to decline due to that aspiration.
Monitor patients throughout the day. You’d be surprised how the status could change from morning until afternoon.
Talk to the RN/RT about the patient's condition. They typically know more about the patient than you do.
Don't push a patient who is in decline. Instead, take your time and wait until tomorrow to advance if needed.
That concludes our exploration of pulmonary pathologies and swallowing impairments! I hope you found this journey informative and insightful. Remember, as SLPs, we are critical in caring for patients with pulmonary conditions. By understanding the complexities of these conditions and their impact on swallowing, we can provide the best possible care to our patients and help them achieve their goals.
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Want to learn more about this topic? Jo Puntil's course, “Pulmonary-Compromised Patients: Oxygen Delivery and Dysphagia Issues,” goes WAY deeper into pulmonary pathologies, a much-needed review for clinicians (it includes education credits for SLP, PT, and OT). Use this code to save over $100 and access it via Medbridge.
