Treat the Patient, Not the Illness: An SLP's Stance on Temporary Dysphagia

The chart for Nick was a mystery. Imagine a 70-year-old, previously independent and working, now on the general medical floor. Admitted for altered mentation, his chest CT raised concerns for aspiration pneumonia and sepsis. He was confused, disoriented, and his speech was non-fluent, yet he was wide awake with normal brain imaging results.

During the evaluation, the story only got worse: Nick coughed on 3 of 3 water sips and had significant oral residue during puree trials. His work of breathing increased so much afterward that he became dependent on oxygen. What should I recommend? 

My hesitation lingered. Was this a genuine, long-term dysphagia, or an acute condition? Did fear of his decline paralyze me and prevent me from seeing the picture clearly? How could a healthy man suddenly have such severe dysphagia when his head imaging was normal, and he had no history of impairment?

I stood at the foot of Nick's bed that evening, watching the shallow rise and fall of his chest. The tension wasn't just in the room; it was inside me. My primary role as an SLP is patient safety, and every fiber of my professional instinct screamed: He is aspirating, and he needs a feeding tube—now. Yet, the thought of this intervention for a man who had no history of swallowing problems felt like a violation. 

I felt the pressure of the medical team, who often default to tubes when dysphagia is identified in a confused patient, but I kept picturing Nick's proud, alert eyes trying to focus through the haze of delirium. Was I protecting him, or was I giving up on the man he was just a week ago? I knew the diagnosis of sepsis and resulting delirium was likely the theoretical "explosion" that caused the dysphagia, not a permanent neurological deficit. The dilemma was still palpable: Should I recommend a drastic, potentially life-altering measure driven by acute fear, or advocate for patience and recovery, knowing the immediate risk was high?

The Cause: Acute Illness Creates Acute Risk (Of All Kinds)

The issue, as is often the case in medical speech-language pathology, lies in the acute medical condition, rather than a fundamental baseline dysfunction or neurological condition. Swallowing is a highly complex, fine motor activity. It’s highly susceptible to anything that disrupts cognition and muscle control. Imagine trying to knit sweaters at the end of a bachelor or bachelorette party. Not so easy, right?

In Nick’s case, his dysphagia doesn’t have a long-term anatomical or physiological manifestation. Instead, it’s his sepsis and subsequent delirium—a common complication in acute care—as the likely cause of his sudden, seemingly severe dysphagia. We see this scenario daily: an independent patient suddenly develops confusion and is now at extreme risk for aspiration. Impaired cognition disrupts the complex muscular coordination and precise timing required for a safe swallow. This manifests as weakness, sensory impairment, or a delayed pharyngeal trigger, increasing the risk of aspiration and residue.

The Chicken or the Egg?

The Chicken-or-the-Egg Dilemma was introduced by Dr. James L. Coyle, PhD, CCC-SLP, and Christine Matthews, CScD, CCC-SLP, in their 2010 article on the topic. They report that when we see a patient diagnosed with pneumonia and observe dysphagia, our mind often jumps to the conclusion that dysphagia caused the pneumonia. But before we jump to any conclusions or make any recommendations, we must ask: Are we seeing the chicken (dysphagia caused by aspiration pneumonia) or the often-missed egg (pneumonia causing acute, reversible dysphagia)? 

The answer is usually the latter, where the disease causes dysphagia and not the other way around. This reality demands that we avoid assuming there is a baseline dysphagia from underlying long-term physiological deficits and instead use the likely good prognosis and short recovery period of the acute illness to guide our decision-making.

Dysphagia Isn’t the Only Way to Aspirate

Don’t get me wrong. Nick is a high-risk patient who needs immediate safety measures, but we must avoid making permanent, drastic recommendations for a potentially temporary problem. That would be like amputating a finger for a paper cut.

And remember, anterograde aspiration (from the mouth to the lungs) is not the only, nor even the most likely, path of aspiration in some cases. There’s another possibility we need to consider when assessing patients and recommending interventions…

Retrograde aspiration is the aspiration of gastric contents into the lungs during a reflux or vomiting event. Often, our knee-jerk reaction is to recommend NPO status with a feeding tube for a patient like Nick without considering the retrograde risk. This is a consideration worth making because feeding tubes may dramatically increase the risk of aspiration from the stomach beyond the patient’s aspiration risk related to a temporary oropharyngeal dysphagia.

What Can We Do to Help?

First, find the cause. To manage a case accurately, the SLP must use knowledge of pulmonary physiology to differentiate between dysphagia-related aspiration pneumonia, non-dysphagia-related aspiration pneumonia (such as Nick's), and aspiration pneumonitis (from reflux or vomiting). Don’t hesitate to go out of your comfort zone. Have those tough conversations with the medical team, including the pulmonologist and gastroenterologist, to figure out what might be going on. You have value to contribute to this conversation too, as the presence or absence of dysphagia and knowledge regarding the clinical trajectory help the team navigate clinical questions and treatment plans.

So what is one critical action we can take to help in a case like Nick’s? 

Set a time limit. 

Seriously. Being an effective SLP means practicing patience and persistence. Advocate for holding off on a feeding tube placement for as long as possible to allow time for the patient to recover and for reassessments and instrumental swallowing evaluations, if indicated. 

We only move to more invasive alternative methods if the delirium persists and Nick fails to show improvement. Avoid making fear-based decisions that prioritize long-term solutions for short-term problems. We must not let a fear-based decision, driven by poor function in an acute state, lead to unnecessary interventions, especially if they’re irreversible, invasive, or have risks that outweigh the potential benefits.

What happened to Nick?

I stood firm on my recommendation to hold off on the feeding tube. We initiated aggressive delirium management and kept him NPO for 72 hours, promising the team a reassessment as soon as his sepsis markers dropped. Three days later, the delirium lifted almost as quickly as it had begun, and we saw signs of recovery. My second evaluation confirmed it: Nick was safe with thin liquids and a regular diet—a true return to baseline. He was discharged a week later, back to his prior, independent life, grateful and clear-minded. The initial, terrifying cough was just a temporary symptom of an acute storm. The clouds eventually lifted.

We must treat our patients not only as they are, but also for who they’ve been and for their potential to be. Nobody wants to be defined by their worst day. So let’s not define our patients by their acute dysphagia. Instead, consider the expected clinical trajectory based on their baseline and potential for recovery from their acute condition. Resist the temptation to think only about the here and now; instead, focus on what’s needed to support the patient, how we can manage acute cognitive deficits, reduce the risk of disuse atrophy, and maximize the chance of a full recovery.

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