From time to time, a patient comes to me for treatment of their dysphagia (swallowing problem), but they have undergone a video-swallow study elsewhere. The disadvantage to me in those circumstances, is that I do not have access to the actual video to review.

A video-flouroscopic swallow study (also referred to as a modified barium swallow study) is one of two diagnostic methods speech-language pathologists have available to assess the physiology of the swallow. This type of study should precede any treatment, because without this important information, I would only be treating a patient’s symptoms (e.g., coughing when eating or drinking) rather than the actual problem.

If I request a copy of the VFSS/MBSS study results from the hospital where it was completed, I may receive a radiology report with a brief statement as to whether the patient aspirated (food or liquid entering the airway). The problem with this, is that a finding of aspiration on its own is not meaningful, and does not provide me with enough information to guide treatment.

The patient may be told that they aspirated on the study and depending on where they reside (i.e., home or nursing home) that finding alone may lead to a diet consistency change, including thickened liquids which may not be in the patient’s best interest or consistent with their wishes.

A finding of aspiration on a swallow study is reason for concern, but, instead, it often creates an environment of fear, because, after all, what person with Parkinson’s hasn’t heard that if they aspirate, they will get pneumonia-or worse, die.

Patient-Centered Care Requires Critical Thinking

Clinical and diagnostic tools and research and education about management of dysphagia have grown tremendously over the last 40 years, giving many speech-language pathologists a solid bases of knowledge for managing a patient’s swallowing problems. There can still, however, at times, be errors in judgement and decision making. Examples might include over generalization of a finding on an instrumental assessment such as one episode of aspiration leading to a recommendation for thickened liquids that in the end, cause the patient to drink less or recommending a feeding tube be placed when the evidence is lacking that this will improve patient safety or quality of life. And even when different patients have similar findings on a video-swallow study including aspiration, those findings must be placed back into the context of all that is going on with the patient, since aspiration of liquids may have a very different consequence for an elderly nursing home patient who is bed-bound, or a patient recovery from surgery than it may have on an ambulatory adult, capable of brushing their own teeth and following through with recommendations that might include swallowing exercise.

 Mitigation of Aspiration Shoud Be the Goal

Anyone living in a hurricane prone state like I do, is aware of the steps homeowners take to mitigate damage to structures should a hurricane threaten the area where you live. Those steps will have little influence on the actual storm but may save you a costly repair.

Similarly, we cannot eliminate every risk factor for dysphagia or even aspiration, but we can mitigate the effects of swallowing problems especially on the lungs, no matter the underlying medical diagnosis.

Dysphagia is a frequent symptom associated with Parkinson’s and related disorders, and being proactive in reducing your risk is important, starting with a simple thing like diligent oral care. Your speech-language pathologist may recommend specific exercises or strategies that are based on your swallowing assessment and designed to yield improvement in motor control or timing of breathing and swallowing. As no two people are alike, even when it comes to aspiration, the risk for some will be greater or less than for others, and it’s important that patients and care providers understand those differences.

Educating Health Care Professional About Aspiration Risk

Speech-language pathologists, physicians, nurses, and other health care professionals involved in your care must also be aware of some of the treatment pitfalls to avoid. Some of these listed below, were contributed by James Coyle, PhD, CCC-SLP, BCS-S, Department of Communication Science and Disorders at the University of Pittsburgh School of Health and Rehabilitation Sciences. Dr. Coyle is Board Certified in Swallowing Disorders and has lectured frequently on issues related to aspiration and pneumonia risks.

DON’T:

• State a patient “passed” or “failed” a diagnostic evaluation, including an imaging study, rather, educate physicians and nurses that pass/fail is not the only option.
• Prescribe liquid texture modification for patients with only laryngeal penetration because the patient “might aspirate,” instead mitigate the laryngeal penetration and prescribe thin liquids.
• Tell a patient that if they aspirate, the will get pneumonia – or worse, die.

 DO:

• Incorporate patient goals into the treatment plan rather than prescribing treatments and expecting compliance.

Do you understand the reason for a specific strategy that has been recommended, such as “tuck you chin when you swallow” or an exercise you have been told to do? If not, ASK! 

How long will I have to do this exercise? How will I know if I am swallowing better? safer? Will I have to drink thickened liquids, eat pureed forever? If I get a feeding tube, does it mean I will never swallow food again?

What are YOUR questions about swallowing? Ask your physician or speech-language pathologist.

(Image attribution pexels-pedro-figueras)

My Mission: To enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate  and empower. Mary Spremulli, MA, CCC-SLP * FiTOUR® Group Exercise Instructor * Voice Aerobics® A Whole Body Approach to Voice Practice

Voice Aerobics the heART and Science of Voice Practice