Medically Fragile Patients
Fitting Dysphagia Into the Bigger Clinical Picture
There have been dramatic changes in the health care community during the last 20 years. Due to advanced medical technology, critically ill patients are surviving health conditions that would have proven fatal years ago. Consequently, speech-language pathologists are experiencing increased caseloads of medically fragile patients.
To complicate matters, there seems to be no clear definition in the medical community as to what constitutes a "fragile" patient. My interpretation of a fragile patient is an individual who has any problem that interferes with the airway, breathing, and/or circulatory system. Treating the medically fragile patient requires a multidisci plinary team approach. It is my belief that the SLP, as a member of the team, needs a clear understanding of anatomy/physiology and common disorders pertaining to pulmonary, GI, neurological, and nutrition/hydration parameters.
The SLP's Role
The role of the SLP dysphagia clinician in treating medically fragile patients is multifaceted. SLPs need to consistently assess when the patient can eat safely and if they are able to maintain quality nutrition/hydration orally. Fragile patients can change from day to day; the timing of when or if to feed the patient is critical. When asked to evaluate a patient, one needs to complete an extensive bedside evaluation and an instrumental evaluation, as appropriate. A chart review should include all radiology procedures , clinical labs, nursing notes, MD notes, medications (including medication schedule), dietitian's notes, and advanced directives. Positioning the patient properly for the evaluation is essential. An extensive oral-physical evaluation, including motor and sensory function, should be completed. Knowledge of the patient's pulmonary status is paramount to knowing when to stress the patient for feeding and diet changes. Knowledge of the time between when the bolus leaves the pharynx and enters the stomach is critical and gives the clinician an idea of when, how much, and how quickly to feed the patient via cervical/esophageal auscultation).
Therapy for the fragile patient depends on the patient's tolerance. Various techniques, including oral/pharyngeal/laryngeal exercises, are utilized, depending on the cause of the dysphagia. Patients may benefit from shorter therapy sessions more frequently throughout the day. Educating the patient and family regarding all aspects of the swallowing disorder is a crucial part of intervention. The SLP also must have knowledge of the patient's advanced directives and abide by his/her ethical standards of practice to do what is best for the patient.
Patients need adequate hydration and nutrition in order to survive and fight disease or infections. Patients may receive nutrition orally, through feeding tubes, hyper-alimentation, or from a combination of these methods. When patients have infections, wounds, fevers, and respiratory compromise, their daily caloric needs will be higher than normal. The responsibility of the clinician is to determine whether or not the medically fragile patient can orally tolerate increased calories safely.
Sometimes patients become frail and have difficulty fighting disease and infection because of their "dependency for care." It is important to know whether patients feed themselves safely or if they depend on staff to feed them. The patient's level of alertness, mentation, and orientation also must be taken into consideration, as well as their ability to attend to task and safely tolerate an entire meal. There is widespread research that indicates the necessity of maintaining good oral hygiene to prevent nosocomial pneumonia, so educating staff to provide good oral care is necessary, as is the need for individualized feeding schedules to maintain hydration and nutrition.
Working with the pulmonary patient who is fragile can be challenging. It is important to understand functional chest anatomy/physiology and common pulmonary disorders. I have found it valuable to my practice to perform cervical and chest auscultation with every patient, using a good-quality stethoscope.
Listening to breath sounds is an essential tool for monitoring the patient's pulmonary status on a daily basis. Common questions when evaluating or treating pulmonary patients are: Is their problem chronic or acute? Do they have an effective cough to clear secretions? Do they tolerate their secretions? How copious are their secretions and what do the secretions look like? Patients who have weak coughs may not be able to protect their airways effectively, especially during feeding. If patients are being suctioned frequently secondary to copious secretions, their ability to swallow and clear the pharynx is obviously impaired.
The most common risk factor for pulmonary patients is fatigue, especially upper-body fatigue. Feeding seems simple, yet for a compromised pulmonary patient, the act of bringing food to the mouth can be exhausting. When these patients tire, eating, sitting, and walking become secondary in importance to simply breathing. These patients require higher nutritional intake due to their high metabolic rate and smaller, more frequent meals are often more manageable. The intricate complexity of the respiratory and swallowing systems increases the risk of the patient experiencing shortness of breath. These patients also have a higher incidence of laryngeal penetration and eventual inconsistent aspiration with the exacerbation of pulmonary issues, especially when fatigued.
A critical factor to consider in the management of patients with pulmonary issues is their medication, including their medication schedule (see box, below left). Many of the inhalers and breathing treatments used by pulmonary patients may affect the GI system by relaxing smooth muscle, including the lower esophageal sphincter, and increasing the incidence of gastroesophageal reflux. Keeping patients upright during and after meals is highly recommended. Becoming familiar with what to expect from common pulmonary issues better prepares the clinician to evaluate and treat the medically fragile patient.
Clinicians also should become familiar with the gastroesophageal system, esophageal motility, and common disorders to better serve the patient. The system from the lips to the duodenum forms a single, complex functional unit, with each segment exercising influence on the others [Triadafilopoulos, G., Hallstone A., Nelson-Abbott, H., Bedinger, K. (1992). Dig Dis Sci, 37: 551–557]. Through radiological procedures and techniques such as cervical/esophageal auscultation, we can time when the patient swallows and then watch/listen for the head of the bolus to enter the stomach. It is common for a liquid bolus to take 6–10 seconds to reach the stomach and up to 20 seconds for solid foods. It is also prudent to know how long it takes for food or fluid to digest. It normally takes about an hour for liquids to pass through the entire stomach and up to three hours for solid foods. Peak acid time after a meal is between 2–3 hours. In patients with diabetes or other disorders causing gastroparesis, the stomach can take up to 12 hours to empty.
Understanding common GI motility and its disorders can assist the clinician in determining what consistencies of food/fluid patients can tolerate. An esophageal disorder contributes to decreased ability for solid foods to pass to the stomach in normal rates of time. These patients typically demonstrate early satiety and have poor intake. Common esophageal disorders and diseases include achalasia, esophageal trauma, esophageal web, strictures, diverticulas, hiatal hernia, and cancer. Esophageal dysmotility is a condition with a number of causes, including gastroesophageal reflux disease (GERD), and is commonly seen in both infants and the elderly. Common treatments for GERD are anti-reflux therapy such as dietary modification, antacids, lifestyle modifications (positioning, quit smoking etc), and medication. People with GERD also may benefit from smaller meals periodically throughout the day to achieve nutritional goals.
The medically fragile patient is a difficult one to manage due to all the complexities of the illness process. Understanding the impact of disease, as well as the various systems within the body, on swallowing and feeding allows the SLP to make better management decisions for each patient. Take time to learn from your associates and ask questions. Strive to increase your knowledge and expertise beyond the basics to better serve your patients.
Respiratory IssuesThe average respiratory rate for infants is 30–40 breaths per minute (bpm). A sharp decline to 24–30 bpm occurs at age 2. There is a slow, steady decline to 20–25 bpm for children, a further decline of 15–20 bpm for adolescents and adults, and continued decline for the elderly [Irwin & Techlin. (1985). Cardiopulmonary Physical Therapy, 345]. Therefore, a respiratory rate of 35, for example, in an elderly patient needs to be treated with concern.
Medication and Swallowing
Polypharmacy may interfere with eating or the amount that the patient takes in safely. The following lists include common symptoms and examples of medications that may exacerbate them. Knowing what medications the patient takes and when is helpful in implementing a treatment plan or changing diet levels.
Decreased saliva (dry mouth)
- Oxybutynin (Ditropan)
- Diphenhydramine (Benadryl)
- Nifedipine (Procardia)
Impaired chewing and swallowing
Impaired cognition and attention
- Diazepam (Valium)
- Lorazepam (Ativan)
Note: Certain drugs such as Ritilan and Provigil increase a patient' s ability to focus on tasks such as eating
- Chemotherapeutic drugs