Dysphagia Management in Medically Stable Patients

Inpatients who exhibited a degree of pharyngeal dysphagia characterized by aspiration of thin liquids as observed by instrumental swallow studies (Modified Barium Swallow Study or Fiberoptic Endoscopic Evaluation of Swallowing) were referred to the study by their primary treating SLP. Patients referred were either on a NPO (nil-per-os; i.e. patients are not allowed to consume food or drinking orally) diet with alternate means of nutrition, or on a PO (per-os; i.e. patients are allowed food or drinking orally) diet with drink and food texture modifications as aligned with the National Dysphagia Diet (NDD)^{25 (link)}.
After referral, the principal investigator used the study criteria to further determine candidacy (Table 1). To be considered, patients needed to be 18 years of age or older, capable of ambulation with a physical or occupational therapist, have overall medical stability, and show no overt signs of discomfort (i.e. excessive coughing or gagging) when drinking thin liquids. The attending physician for each patient was consulted to determine medical stability, which was primarily constituted by the patient being afebrile, hemodynamically stable, having a stable respiratory status, and no known active infection. Excluded from the study were patients with a compromised pulmonary system, including both tracheostomy and ventilator needs, patients with poor oral hygiene status, patients with an absent pharyngeal swallow reflex, and patients with a Montreal Cognitive Assessment (MoCA) score less than 17; scores less than 17 indicate the presence of moderate to severe cognitive impairment^{26 (link)}. Conveniently, the Occupational Therapy department was already collecting MoCA scores for all patients at admission. We used these scores to ensure the cognitive capacity of candidates to adequately understand the rules of the protocol and give informed consent. If a patient was unable to complete the MoCA due to communication deficits, cognitive status was determined by consultation with the patient’s primary therapists, family, and analysis of etiology for hospitalization.Table 1

Enrollment criteria.

Inclusion criteria:
Aspirates thin liquids as evidenced via videofleuroscopy or fiberoptic endoscopy assessment methods
18 years of age or older
Capable of ambulating with physical or occupational therapy
Medically stable including: afebrile, hemodynamically stable, stable respiratory status, no active infections nor elevated white blood counts
Able to feed self or direct feeder
Without overt signs of discomfort (i.e. excessive coughing, gagging) when drinking thin liquids
Able to sign an informed consent form

Exclusion criteria:
Compromised pulmonary system, i.e. tracheostomy and/or mechanical ventilation requirements
Absent pharyngeal swallow reflex
Medically unstable including: febrile, active pneumonia, elevated white blood counts
Poor oral hygiene status
Fluid restrictions due to cardiopulmonary issues
A montreal cognitive assessment (MoCA) score of less than 17