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Adult Dysphagia

The scope of this page is swallowing disorders in adults (18+).


See the Dysphagia evidence map for summaries of the available research on this topic.

A swallowing disorder, known as dysphagia, may occur as a result of various medical conditions. Dysphagia is defined as problems involving the oral cavity, pharynx, esophagus, or gastroesophageal junction.

Models of swallowing function may represent the biomechanics of swallow function and bolus movement for liquids or may discuss physiological activity for liquid and solids (see, e.g., Logemann, 1998; Matsuo & Palmer, 2008). Clinicians consider each model relative to patient performance when assessing swallow function.

Malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death may be a consequence of dysphagia. Morbidity related to dysphagia is a major concern. Adults with dysphagia may also experience (a) disinterest and/or less enjoyment of eating or drinking and/or (b) embarrassment or isolation in social situations involving eating. Dysphagia may increase caregiver burden and may require significant lifestyle alterations for the patient and the patient's family.

Speech-language pathologists (SLPs) with appropriate training and competence are involved in the diagnosis and management of oral and pharyngeal dysphagia. SLPs also recognize causes and signs/symptoms of esophageal dysphagia and make appropriate referrals for its diagnosis and management. They are integral members of an interprofessional team. The SLP's specific role and level of involvement may vary for each clinician and across patients, work settings, and institutions.

Each year, approximately one in 25 adults will experience a swallowing problem in the United States (Bhattacharyya, 2014). Dysphagia cuts across so many diseases and age groups, its true prevalence in adult populations is not fully known and is often underestimated.

A number of epidemiologic reports indicate that the prevalence of dysphagia is more common among older individuals (Barczi, Sullivan, & Robbins, 2000; Bhattacharyya, 2014; Bloem et al., 1990; Cabré et al., 2014; Roden & Altman, 2013; Sura, Madhavan, Carnaby, & Crary, 2012). Conservative estimates suggest that dysphagia may be as high as 22% in adults over 50 years of age (Lindgren & Janzon, 1991; National Foundation of Swallowing Disorders, n.d.; Tibbling & Gustafsson, 1991); as high as 30% in elderly populations receiving inpatient medical treatment (Layne, Losinski, Zenner, & Ament, 1989); up to 68% for residents in long-term care settings (National Institute on Deafness and Other Communication Disorders [NIDCD], n.d.; Steele, Greenwood, Ens, Robertson, & Seidman-Carlson, 1997); and 13%–38% among elderly individuals who are living independently (Kawashima, Motohashi, & Fujishima, 2004; Serra-Prat et al., 2011). Additional studies suggest that elderly populations have an increased risk for the development of dysphagia-related complications such as pulmonary aspiration (Altman, Yu, & Schaefer, 2010; Marik, 2001; Schmidt, Holas, Halvorson, & Reding, 1994; Tracy et al., 1989). A report by the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality [AHRQ]) estimates that approximately one third of patients with dysphagia develop pneumonia and that 60,000 individuals die each year from such complications (AHCPR, 1999).

Various neurological diseases are known to be associated with dysphagia. The exact epidemiological numbers by condition or disease also remain poorly defined. This, in part, is due to the concomitant medical conditions being reported and the timing and type of diagnostic procedures being used to identify swallowing disorders across neurological populations. For example, a systematic review by Martino and colleagues (2005) found that the incidence of dysphagia in stroke populations was as low as 37% when identified using cursory screening procedures and as high as 78% when identified using instrumental assessments. A later study by Falsetti and colleagues (2009) found that dysphagia occurs in over one third of patients admitted to stroke rehabilitation units. Further studies suggest that dysphagia occurs in 29%–64% of stroke patients (Barer, 1989; Flowers, Silver, Fang, Rochon, & Martino, 2013; Gordon, Hewer, & Wade, 1987; Mann, Hankey, & Cameron, 1999).

Additional systematic reviews and studies have reported variable estimates of dysphagia in other acquired and progressive neurogenic populations as well as other medical conditions. Alagiakrishnan, Bhanji, and Kurian (2013) reported prevalence ranges of dysphagia in dementia patients from 13% to 57%, whereas Kalf, de Swart, Bloem, and Munneke (2011) reported prevalence ranges from 35% to 82% for individuals with Parkinson's disease. A study by Coates and Bakheit (1997) suggests that dysphagia is as high as 90% in individuals diagnosed with Parkinson's disease or amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease). Other neurogenic populations with dysphagia include individuals with multiple sclerosis (24%–34%; Calcagno, Ruoppolo, Grasso, De Vincentiis, & Paolucci, 2002; De Pauw, Dejaeger, D'Hooghe, & Carton, 2002; Roden & Altman, 2013) and traumatic brain injury (38%–65%; Terre & Mearin, 2009).

There are also other conditions known to have the consequence of dysphagia. A study by Garcia-Peris and colleagues (2007) found that 50% of patients with head and neck cancer experience oropharyngeal dysphagia, with these numbers increasing after chemoradiation treatment. The overall prevalence of dysphagia associated with gastroesophageal reflux disease (GERD) is approximately 14% (Mold et al., 1991; Spechler, 1999), and the frequency of dysphagia ranged from 3% to 64% following endotracheal intubation (Skoretz, Flowers, & Martino, 2010) and from 5% to 8% for adults with intellectual disabilities (Chadwick, Jolliffe, Goldbart, & Burton, 2006).

Signs of dysphagia may include

  • drooling and poor oral management;
  • food or liquid remaining in the oral cavity after the swallow;
  • inability to maintain lip closure, leading to food and/or liquids leaking from the oral cavity;
  • food and/or liquids leaking from the nasal cavity;
  • complaints of food "sticking";
  • globus sensation or complaints of a "fullness" in the neck;
  • complaints of pain when swallowing;
  • wet or gurgly sounding voice during or after eating or drinking;
  • coughing during or right after eating or drinking;
  • difficulty coordinating breathing and swallowing;
  • recurring aspiration pneumonia/respiratory infection and/or fever;
  • extra effort or time needed to chew or swallow;
  • changes in eating habits—specifically, avoidance of certain foods/drinks; and
  • weight loss or dehydration from not being able to eat enough.

It is important to consider signs and symptoms of dysphagia within a constellation of other clinical indicators, rather than relying on a single sign or symptom.

Dysphagia may result from numerous etiologies secondary to damage to the central nervous system (CNS) and/or cranial nerves, and unilateral cortical and subcortical lesions, due to

  • stroke;
  • traumatic brain injury;
  • spinal cord injury;
  • dementia;
  • Parkinson's disease;
  • multiple sclerosis;
  • ALS (or Lou Gehrig's disease);
  • muscular dystrophy;
  • developmental disabilities in an adult population (i.e., cerebral palsy);
  • post-polio syndrome; and/or
  • myasthenia gravis.

Dysphagia may also occur from problems affecting the head and neck, including

  • cancer in the oral cavity, pharynx, nasopharynx, or esophagus;
  • chemoradiation for head and neck cancer treatment;
  • trauma or surgery involving the head and neck;
  • decayed or missing teeth;
  • critical care that may have included oral intubation and/or tracheostomy;
  • certain medications;
  • in patients with certain metabolic disturbances;
  • in patients with infectious diseases (e.g., sepsis, acquired immune deficiency syndrome [AIDS]);
  • in patients with a variety of pulmonary diseases (e.g., cardiac obstructive pulmonary disease [COPD]);
  • in patients with GERD;
  • in patients following cardiothoracic surgery; and/or
  • in decompensated elderly patients.

Specialized knowledge, skills, and clinical experience related to the evaluation and management of individuals with swallowing and swallowing problems may be acquired on the graduate or postgraduate level, in formal coursework, and/or in a continuing education framework. The standards for ASHA certification effective in 2014 require competence in dysphagia. The American Board of Swallowing and Swallowing Disorders, under the auspices of ASHA's specialty certification program, offers clinical specialty certification in swallowing and swallowing disorders. Board Certified Specialists in Swallowing are individuals who hold ASHA certification and have demonstrated advanced knowledge and clinical expertise in diagnosing and treating individuals with swallowing disorders.

SLPs have extensive knowledge of anatomy, physiology, and functional aspects of the upper aerodigestive tract—including oral, pharyngeal, and cervical esophageal anatomic regions—for swallowing and speech. In addition, SLPs have expertise in all aspects of communication disorders that include cognition, language, and behavioral interactions, many of which may affect the diagnosis and management of swallowing disorders. Because of the complexities of assessment and treatment in most persons with swallowing disorders, SLPs work collaboratively with other professionals, individuals, families and caregivers. Interprofessional practice (IPP) is critical to successfully achieving the desired improvements and outcomes.

SLPs play a central role in the assessment and management of individuals with swallowing disorders. An SLP's roles include

  • Identifying the signs and symptoms of dysphagia
  • Identifying normal and abnormal swallowing anatomy and physiology
  • Identifying indications and contraindications specific to each patient for various non-instrumental and instrumental assessment procedures
  • Identifying signs of potential disorders in the upper aerodigestive tract and making referrals to appropriate medical personnel
  • Performing, analyzing, and integrating information from non-instrumental and instrumental assessments of swallow function collaboratively with medical professionals, as appropriate
  • Providing safe and effective treatment for swallowing disorders, documenting progress, and determining appropriate dismissal criteria
  • Identifying and using appropriate functional outcome measures
  • Understanding a variety of medical diagnoses and their potential impact(s) on swallowing
  • Awareness of typical age-related changes in swallow function
  • Providing education and counseling to individuals and caregivers
  • Incorporating the client's/patient's dietary preferences and cultural practices as they relate to food choices during evaluation and treatment services
  • Respecting issues related to quality of life for individuals and/or caregivers
  • Practicing interprofessional collaboration as an integral part of the patient's medical care team
  • Educating other professionals on the needs of individuals with swallowing and feeding disorders and the SLP's role in the diagnosis and management of swallowing and feeding disorders
  • Advocating for services for individuals with swallowing and feeding disorders
  • Advancing the knowledge base through research activities
  • Maintaining competency of skills through reading current research and engaging in continuing education activities
  • Determining the safety and effectiveness of current nutritional intake (e.g., positioning, feeding dependency, environment, diet modification, compensations).

As indicated in the Code of Ethics (ASHA, 2016), SLPs who serve this population should be specifically educated and appropriately trained to do so. Assessment and management of dysphagia requires training and competence.

See the Assessment section of the Dysphagia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

Screening

Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services (ASHA, 2004b). Screening for dysphagia may be conducted by a speech-language pathologist or other member of the patient's care team. Screening does not provide a detailed description of the patient's swallow function but, rather, identifies individuals who are likely to have swallowing impairments related to function, activity, and/or participation as defined by the World Health Organization (WHO, 2001).

Individuals of all ages are screened as needed, requested, or mandated, or when other evidence (e.g., neurological or structural deficits) suggests that they are at risk for a swallowing disorder involving body structure/function and/or activities/participation.

The purpose of the screening is to determine

  • the likelihood that dysphagia exists and
  • the need for further swallowing assessment

(ASHA, 2009).

Screening protocols may include

  • the administration of an interview or a questionnaire that addresses the patient's perception of and/or concern with swallowing function;
  • observation of the presence of the signs and symptoms of oropharyngeal and/or esophageal swallowing dysfunction;
  • observation of routine or planned mealtime situations, if indicated;
  • administration of the 3-oz Water Swallow Test (DePippo, Holas, & Reding, 1992);
  • recommendation for additional assessment; and
  • communication of results and recommendations to the team responsible for the individual's care and to the patient and caregivers.

The Modified Evans Blue Dye Test (more informally referred to as "blue dye test") is completed in patients with a tracheotomy by tinting oral feedings blue/green with the intent to identify aspiration in these patients.

Screening may result in

  • recommendations for rescreening;
  • recommendations for additional assessment—including clinical and/or instrumental examinations—to determine whether, and the degree to which, swallowing physiology may be impaired; and/or
  • referral for other examinations or services (ASHA, 2004b).

It is common for precautions (e.g., no oral intake, stipulation of specific dietary precautions) to be put in place while the patient is waiting for further assessment (ASHA, 2009).

Assessment

Assessment and treatment of swallowing and swallowing disorders may require use of appropriate personal protective equipment.

Consistent with the WHO (2001) framework, the purpose of assessment is to identify and describe

  • typical and atypical parameters of structures and functions affecting swallowing;
  • effects of swallowing impairments on the individual's activities (capacity and performance in everyday contexts) and participation; and
  • contextual factors that serve as barriers to or facilitators of successful swallowing and participation for individuals with swallowing impairments.

Swallowing assessment allows the SLP to integrate information from (a) the interview/case history, (b) medical/clinical records including the potential impact of medications, (c) the physical examination, (d) previous screening and assessments, and (e) collaboration with physicians and other caregivers. During assessment, SLPs determine whether the patient is an appropriate candidate for treatment and/or management; this determination is based on findings that include medical stability, cognitive status, nutritional status, and psychosocial, environmental, and behavioral factors.

Assessment may result in one or more of the following outcomes:

  • Description of the characteristics of swallowing function, including any breakdowns in swallow physiology
  • Diagnosis of a swallowing disorder
  • Determination of the safest and most efficient route (oral vs. non-oral) of nutrition and hydration intake
  • Identification of the effectiveness of intervention and support
  • Recommendations for intervention and support for oral, pharyngeal, and/or laryngeal disorders
  • Prognosis for improvement and identification of relevant factors
  • Referral for other services or professionals
  • Counseling, education, and training to the patient, health care providers, and caregivers

Change in a patient's functional or medical status may indicate the need for additional assessment. An SLP may additionally monitor a patient's swallow function at appropriate intervals to determine whether the patient remains safe on the current diet (including adequate intake) and to assess the progress of current intervention strategies. Ongoing assessment may include additional instrumental assessments or may be completed through observation of performance throughout therapy sessions.

SLPs conduct assessments in a manner that is sensitive to the individual's cultural background, religious beliefs, and preferences for medical treatment (See Cultural Competence for additional information). Consider how culture influences activities of daily living (Riquelme, 2004). Discuss dietary changes with the patient and with the family member who prepares the food. In some cases, caregivers may be encouraged to bring familiar food and drink that maintain compatibility with SLP recommendations. Recommendations may affect spiritual practices that involve food and drink. Using ethnographic interviewing strategies during the assessment process is an excellent way to gather information about an individual's specific needs (Westby, Burda, & Mehta, 2003).

There are specific indications for both non-instrumental and instrumental examinations. For patients with signs and symptoms of pharyngeal dysphagia, instrumental procedures can provide more sensitive and objective findings than the clinical examination.

Non-Instrumental Swallowing Assessment

The purpose of a non-instrumental swallowing assessment is to observe patient behaviors associated with swallow function—that is, to observe the presence (or absence) of signs and symptoms of dysphagia, with consideration for factors such as fatigue during a meal, posture, positioning, and environmental conditions. A non-instrumental assessment may provide sufficient information for a clinician to diagnose oral dysphagia; however, aspiration and other physiologic problems in the pharyngeal phase can be directly observed only via instrumental assessments.

A non-instrumental swallowing assessment may include the following procedures:

  • A case history, based on a comprehensive review of medical/clinical records, as well as interviews with caregivers and other health care professionals
  • An oral mechanism exam, including one or more of the following:
    • Cranial nerve assessment
    • Structural assessment of face, jaw, lips, tongue, hard and soft palate, oral pharynx, and oral mucosa
    • Functional assessment of muscles and structures used in swallowing, including symmetry, sensation, strength, tone, range and rate of motion, and coordination of movement
    • Observation of head–neck control, posture, oral reflexes, and involuntary movements
  • Assessment of overall physical, social, behavioral, and cognitive/communicative status
  • Assessment of the patient's perception of function, severity, change in functional status, and quality of life
  • Assessment of speech and vocal quality at baseline and any changes following bolus presentations
  • Monitoring of physiological status, including heart rate and oxygen saturation
  • Assessment of alterations in bolus delivery and/or use of rehabilitative or compensatory techniques, as indicated
  • Evaluation of the method (spoon, cup, self-fed, examiner-fed) and rate of bolus presentation to assess the effects on swallow function
  • Assessment of secretion management skills, which might include frequency and adequacy of spontaneous saliva swallowing and ability to swallow voluntarily
  • Observation of the patient eating or being fed food items with consistencies typically eaten by the patient in a natural/typical environment for the patient's situation
  • Assessment of labial seal and anterior spillage, and evidence of oral control, including mastication and transit, manipulation of the bolus, presence of hyolaryngeal excursion as observed externally or to palpation, and time required to complete the swallow sequence
  • Identification of signs and symptoms of penetration and/or aspiration, such as throat clearing or coughing before/during/after the swallow
  • Assessment of consistency of skills across the feeding opportunity to rule out any negative impact of fatigue on feeding/swallowing safety
  • Assessment of the ability to clear the airway, and assessment of cough strength
  • Consideration of the respiratory rate and respiratory/swallowing pattern, which may vary across individuals and across the lifespan (Martin-Harris et al., 2005)

The effectiveness of various compensatory and rehabilitative techniques may also be assessed. Assessment may also include monitoring vital signs.

The clinical examination alone may form the basis for recommendations for the management of dysphagia—or it may serve as a tool for (a) identifying clinical presentations of dysphagia, (b) determining the potential need for additional instrumental evaluation, and (c) specifying diagnostic questions to be answered by any instrumental evaluations.

Instrumental Swallowing Assessment

SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. In addition, instrumental procedures are used to determine the appropriateness and the effectiveness of a variety of treatment strategies.

Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist). Competence in videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) requires appropriate training and education. SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient's swallowing deficits. SLPs interpret and apply the results of objective testing to the formulation of dysphagia treatment plans, and they also determine patient capacity and safety for oral feeding.

Indications for an instrumental exam include the following:

  • Concerns regarding the safety and efficiency of swallow function
    • Contribution of dysphagia to nutritional compromise
    • Contribution of dysphagia to pulmonary compromise
    • Contribution of dysphagia to concerns for airway safety (e.g., choking)
  • The need to identify disordered swallowing physiology to guide management and treatment
  • Inconsistent signs and symptoms in the findings of a non-instrumental examination
  • The need to assist in the determination of a differential medical diagnosis related to the presence of pathological swallowing
  • Presence of a medical condition or diagnosis associated with a high risk of dysphagia
  • Previously identified dysphagia with a suspected change in swallow function that may change recommendations
  • Presence of a chronic degenerative condition with a known progression or the recovery from a condition that may require further information for the management of oropharyngeal function

Contraindications for an instrumental exam include the following:

  • The patient is not medically stable enough to tolerate the procedure.
  • The patient is not able to participate in an instrumental examination (e.g., cognitive difficulties, inability to maintain an appropriate level of alertness).
  • The SLP's clinical judgment indicates that the instrumental assessment would not change the clinical management of the patient.

Similar to non-instrumental assessment, instrumental assessment also includes a thorough case history; an oral mechanism exam; and assessment of overall physical, social, behavioral, and cognitive/communicative status (see previous section on Non-Instrumental Swallowing Assessment for details on these components of an evaluation). The purpose of the instrumental examination is to enable the SLP to

  • visualize the structures of the upper aerodigestive tract;
  • assess the physiology of the structures involved in swallowing and to make observations, measures, and inferences of symmetry, sensation, strength, pressures, tone, range of motion, and coordination or timing of movement to determine the diagnosis of dysphagia;
  • determine presence, cause, and severity of dysphagia by visualizing bolus control, flow and timing of the bolus, and the individual's response to bolus misdirection and residue;
  • visualize the presence, location, and amount of secretions in the hypopharynx and larynx, the patient's sensitivity to the secretions; and the ability of spontaneous or facilitated efforts to clear the secretions;
  • determine the cause(s) for laryngeal penetration and/or aspiration; and
  • determine with specificity the relative safety and efficiency of various bolus consistencies and volumes.

In clinical settings, SLPs typically use one of two types of instrumental evaluations: the videofluroscopic swallowing study (VFSS) or the fiberoptic endoscopic evaluation of swallowing (FEES). The implementation of the VFSS and FEES requires the SLP to have advanced knowledge and specific skills in order to determine an appropriate test protocol; make decisions regarding management options during the examination; assess oral, pharyngeal, and cervical esophageal swallowing physiology; make specific functional diagnoses and diet consistency recommendations; and understand issues relative to radiation equipment, equipment maintenance, and safety.

At some facilities, qualified SLPs may also screen for esophageal motility and GERD to identify the need for appropriate referral. Oropharyngeal function may be altered in some patients with esophageal motility issues.

Videofluoroscopic Swallowing Study (VFSS)

The videofluroscopic swallowing study (VFSS), also known as the modified barium swallow study (MBSS), is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function (Logemann, 1986). An SLP completes the VFSS by providing the patient with various consistencies of food and liquid mixed with barium, which allows the bolus to be visualized in real time on an x-ray during the swallow. The VFSS is beneficial not only in identifying whether aspiration has occurred but also in allowing assessment of amount and timing of aspiration as well as assessment of anatomy and pathophysiology of swallow function in the oral and pharyngeal phases. It provides clinically useful information on the influence of compensatory strategies and diet changes (Martin-Harris, Logemann, McMahon, Schleicher, & Sandidge, 2000).

VFSSs are typically performed with both a speech-language pathologist and radiologist present, allowing for professional collaboration. The speech-language pathologist focuses on swallowing physiology and functioning and the radiologist makes medical diagnoses. The VFSS assessment and report do not include medical diagnoses. The SLP should be aware of state legal and regulatory issues regarding the presence of a radiologist or other physician, as well as third party payer requirements.

The contraindications specific to VFSS may include the following:

  • SLP cannot adequately position the patient.
  • Patient's size and/or posture prevents adequate imaging or exceeds limit of positioning devices.
  • Patient has an allergy to barium and/or other contrast media (e.g., iohexol).
  • Absence of swallow response in patient.

At minimum, a VFSS includes the following protocols:

  • Educating the patient and/or caregiver regarding VFSS procedure, radiation safety, and rationale for the exam
  • Positioning the patient upright, or in the typical eating position if possible, to simulate normal ingestion
  • Using postural supports (e.g., head, trunk) as necessary
  • Identifying the relevant anatomical structures visible on fluoroscopy
  • Obtaining lateral and anterior–posterior views of oral cavity, pharynx, and upper esophagus, as needed, for each of the bolus types
  • Evaluating the oral phase of swallowing
  • Assessing the pharyngeal components of swallowing and related physiological events
  • Assessing the influence and effectiveness in altering bolus delivery and/or the use of rehabilitative or compensatory techniques on the swallow
  • Visually identifying the presence and effectiveness of swallow function and sensory awareness
  • Assessing the presence and effectiveness of the patient's response to laryngeal penetration, aspiration, and/or residue as part of an assessment of the airway integrity

Clinicians select bolus type (e.g., consistency, volume) for each trial carefully, as some consistencies and/or volumes may influence the clinician's overall impression of the swallow function more than others (Martin-Harris et al., 2008; Sandidge, 2009). Clinicians also evaluate influence of the method and rate of presentations, such as when the patient is a) fed by the examiner, b) self-fed, or c) fed by a caregiver and d) when solids and liquids are alternated. Clinicians also note any differences in swallow function when the patient is instructed to swallow versus spontaneous swallows.

A complete VFSS requires a sufficient number of swallowing attempts to (a) make a clinically informed decision about route of intake, consistency of oral diet (if appropriate), exercises to improve swallowing function, and compensatory techniques to maintain patient safety while consuming an oral diet and (b) determine the need for additional assessments/interventions through interprofessional team referral(s). Clinicians additionally note the individual's tolerance of and response to the examination (e.g., following directions, fatigue, signs of stress related to medically complex patients, ability to repeat therapeutic interventions). Indications of an adverse reaction to the examination may include, but are not limited to, agitation, changes in breathing pattern, changes in alertness, changes in coloring, nausea and vomiting, changes in overall medical status which may be assessed via the pulse oximeter, heart rate monitor, etc.

Given the speed and dynamic nature of swallow function, it is highly beneficial that the SLP record these studies and their results so that review and confirmation of findings can be observed in real time.

Anatomical Structures

During VFSS or review of the recording, clinicians identify the anatomical structures, as illustrated in Table 1, including any anatomical and/or physiological abnormalities.

Anatomical Structures

Table 1. Clinical Observations of Physiologic Swallowing Components During MBS

Aspect of Swallowing Observation
Lip closure Patient's ability to approximate top and bottom lip
Tongue control Volitional and controlled lingual movement
Bolus preparation Patient's ability to create a well-contained bolus
Bolus transport Patient's ability to move the bolus from the oral cavity to the pharyngeal cavity
Oral residue Remaining residue in the oral cavity following oral transport
Initiation of the pharyngeal swallow response Position of the bolus at the initiation of the pharyngeal swallow response
Soft palate elevation Upward movement of the soft palate to create velopharyngeal closure
Laryngeal elevation Extent and timeliness of upward movement of the larynx during the swallow
Anterior hyoid motion Extent and timeliness of forward movement of the hyoid
Epiloglottic movement Extent and timeliness of passive epiglottic inversion to meet with the arytenoids (moving anteriorly and superiorly)
Laryngeal closure Medial movement of the larynx observed at the vocal folds; may only be able to observe from anterior–posterior view
Pharyngeal stripping wave Contraction of the posterior pharyngeal wall from top moving downward
Pharyngeal contraction Approximation of the pharyngeal walls
Pharyngeal esophageal sphincter opening Opening of the pharyngeal esophageal sphincter, including the upper esophageal sphincter, to allow the bolus to move from the pharynx to the esophagus
Tongue base retraction Posterior movement of the tongue base to make contact with the posterior pharyngeal wall
Pharyngeal residue Remaining residue in the pharynx sfollowing the pharyngeal swallow
Esophageal clearance in upright position Residue that is not cleared following swallow

Physiological components of swallowing identified and further discussed by Martin-Harris et al, 2008

Observation of Penetration and Aspiration During VFSS

In addition to observing the physiological components of swallow function, accurate assessment and diagnosis also requires clinicians to note episodes of penetration and aspiration during VFSS in order to appropriately plan for safe and effective treatment. Episodes of both penetration and aspiration can occur before, during, or after the swallow event occurs. The Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) is an eight-point scale used to describe penetration and aspiration events. The clinician observes the bolus and the patient's response to the bolus, including the following scenarios:

  • If the bolus enters the airway, at what level, and how much bolus enters the airway
  • If the patient attempts to clear the bolus (if it does enter) from the airway
  • If the patient is successful in ejecting the bolus from the airway (if clearing is attempted; Rosenbek et al., 1996).
Limitations of the VFSS

Limitations of the VFSS include

  • time constraints due to radiation exposure;
  • a limited sample of swallow function that may not be a representation of mealtime function;
  • challenges in visualizing the swallow due to poor contrast;
  • challenges in viscosity to represent real-life foods;
  • limited evaluation of the effect of fatigue on swallowing unless specifically evaluated; and
  • refusal of the bolus, as barium is an unnatural food source and is not tolerated by some patients (Logemann, 1998).
Considerations Related to Radiation Exposure

The speech-language pathologist should be aware of the principles of ionizing radiation and dosage when performing VFSS. Considerations are detailed in the list below.

  • Acceptable radiation exposure levels are set by the radiology department and controlled by the radiologist.
  • The SLP and radiologist work together to ensure that the observations are completed within the dosage limits for the patient; dosage amount is As Low as Reasonably Achievable (ALARA) as recommended by the International Commission on Radiological Protection (ICRP) without affecting the accuracy of the swallowing assessment (ASHA, 2004a). Frame rates should also be discussed. Consider the patient's cumulative need for radiological procedures given his or her diagnosis, and proceed as clinically reasonable.
  • Individuals in the fluoroscopy suite wear protective equipment to minimize their exposure to scattered radiation.
  • Decreased fluoroscopic pulse rate reduces radiation exposure but may also influence clinician judgments and findings during the assessment (Bonilha et al., 2013a).

Significant swallowing deficits or decreased clinician experience may lead to an increase in fluoroscopy times (Bonilha et al., 2013b).

Federal regulations mandate that all fluoroscopic equipment contain a timer that has a maximum of 5 minutes (U.S. Food and Drug Administration, n.d.). Although the timer may sound during a VFSS, it is not an indication that the VFSS must stop. It is only a reminder to the clinician(s) that 5 minutes of radiation have elapsed. The clinician takes care to reduce radiation beyond this time point, and additional swallow attempts beyond this point are well-justified, allowing for additional information for recommendations.

For additional more information, see ASHA's Radiation Safety Resource Page. Additional information regarding equipment and radiologic care is also available from the American College of Radiology's Practice Parameter for the Performance of Modified Barium Swallow.

Fiberoptic Endoscopic Evaluation Of Swallowing (FEES)

Fiberoptic endoscopic assessment of swallowing function (FEES) is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally (Langmore, Kenneth, & Olsen, 1988). FEES additionally provides the opportunity for frequent use without concerns of radiation exposure and can be used within therapeutic contexts and for diagnostic therapy to assess current progress and effectiveness of therapy. Unlike assessment via the VFSS, FEES does not permit visualization of either the oral or the esophageal phase of swallowing.

Passage of the bolus and movement of the pharyngeal structures cannot be observed during the swallow because of reflected light from pharyngeal and laryngeal tissues into the endoscope, causing a brief condition referred to as "white-out."

In addition to the general indications for instrumental evaluation, the following indications are specific for FEES:

  • Sensitivity to increased difficulty with swallowing over the course of a meal, secondary to fatigue
  • Sensitivity to velum function for hypernasality and/or suspected nasal regurgitation
  • Need for visualization of the hypopharynx/larynx for biofeedback and/or rehabilitation
  • Documented pharyngeal dysphagia on VFSS that can be retested with endoscopy to
    • monitor progress
    • directly assess pharyngeal and laryngeal anatomy
    • limit radiation exposure
  • Suspected or observed difficulty with swallowing saliva/oral secretions
  • Inability to tolerate contrast media (e.g., barium, iohexol) as a result of allergy or aversion
  • Concerns or safety issues associated with radiation exposure (e.g., pregnancy)
  • Inability by patients (including individuals on a ventilator) to leave the bedside because of mobility and postural deficits
  • Difficulties with obstructed fluoroscopic viewing (e.g., patients wearing a halo, patients wearing a cervical collar)
  • Limited access to radiologic equipment

In addition to the contraindications for all instrumental evaluation, the following are specific to FEES:

  • Severe agitation and possible inability to cooperate with the examination
  • Severe movement disorders (dyskinesia)
  • Severe bleeding disorders and/or recent severe epistaxis (nosebleed)
  • History of recent trauma to the nasal cavity or surrounding tissue and structures secondary to surgery or injury
  • Bilateral obstruction of the nasal passages

The protocol for FEES minimally includes the following:

  • Educating the patient and/or caregiver regarding FEES procedure and rationale for the exam
  • Positioning the patient consistent with typical eating (e.g., upright, supine)
  • Identifying anatomical landmarks and any abnormalities
  • Assessing basic movement abilities of anatomical structures through specific maneuvers (e.g., valsalva to evaluate vocal fold closure, words with no nasal phoneme stimuli to assess velopharyngeal closure)
  • Assessing the influence of fatigue on pharyngeal swallow function over multiple trials
  • Identifying any residue remaining in the pharyngeal or laryngeal cavities after the swallow
  • Introducing strategies to minimize and/or eliminate aspiration
  • Identifying abnormal swallow function and the subsequent effect on laryngeal penetration, residue, sensory awareness, and effectiveness of the patient's response to laryngeal penetration and/or residue—aspiration is inferred based on patient response and/or observation of material below the vocal folds after the swallow
  • Assessing timing of movement of structures for swallow
  • Monitoring for adverse reactions to the examination and responding appropriately

At times, food is minimally colored to assist in assessing secretions and residue in the pharynx after the swallow is completed.

Sensation in the hypopharynx and larynx can be tested directly with a modification of the FEES procedure. The flexible endoscopic evaluation of swallowing with sensory testing (FEESST) requires a two-channel scope and uses pulses of air to assess sensory perception of the larynx and to monitor the laryngeal adductor reflex, characterized by a brief closure of the true vocal folds. FEEST is rarely used.

SLPs with appropriate training and competence in performing FEES are qualified to use this procedure independently for the purpose of assessing swallow function and related functions of structures within the aerodigestive tract. Physicians may also be involved in the functional evaluation of swallowing and/or may be present to assess the integrity of the laryngeal and pharyngeal structures in order to provide a medical diagnosis. SLPs should be aware of state laws, facility policy, and third-party payer requirements related to the presence of a physician during FEES. See ASHA's page on States with Specific Endoscopy Requirements.

Precautions and Safety Considerations

The patient may, on rare occasions, experience adverse effects when undergoing a FEES. These may include, but are not limited to, discomfort, vomiting, nosebleed, mucosal perforation, allergic reaction/hypersensitivity to topical anesthesia or nasal spray, and laryngospasm.

The overall risk is minimal, but it is recommended that clinicians be well trained in the signs and symptoms of adverse reactions and be ready to take appropriate action if they occur. In developing a FEES program, clinicians should know their facility's proper response to adverse reactions and should develop a plan for reaction and intervention should an adverse reaction occur.

If an SLP performs the examination independently and administers topical anesthesia and/or decongestants in an effort to maximize comfort, it must be approved in writing by the institution. SLPs follow institutional and pharmacy guidelines for administration of topical anesthesia, decongestants, and barium. Because of the risk of anesthetizing the pharyngeal and laryngeal mucosa and compromising the swallow, many clinicians perform FEES with either no anesthesia or only a small amount of a well-placed topical anesthetic in the nares. Use of anesthesia has not been shown to reduce patient discomfort during FEES (Leder, Ross, Briskin, & Sasaki, 1997).

The other area of concern with regard to safety is the possibility that a serious medical condition may be missed if an SLP were to complete the procedure independently; however, FEES is a procedure used to address swallow function and to screen for anatomical and physiological abnormalities in the nasal cavity, pharynx, and larynx. If there are clinical indications for a laryngoscopy evaluation (e.g., hoarse voice, pain on swallowing, etc.), the physician should make a referral to an otolaryngologist to rule out the possibility of disease in the nasal, pharyngeal, or laryngeal region.

SLPs follow universal precautions and facility procedures for infection control (e.g., adequate disinfection of equipment, etc.). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturer's instructions. All equipment is used and maintained in accordance with the manufacturer's specifications.

Other Instrumental Procedures

Other instrumental procedures are used primarily in research at this time but may develop into clinical diagnostic tools. Ultrasonography involves the use of a transducer to observe movement of structures used for swallowing, including the tongue and hyoid (Hsiao, Wahyuni, & Wang, 2013). Surface electromyography records electrical activity of the muscles involved in swallowing (O'Kane, Groher, Silva, & Osborn, 2010).

SLPs should also be familiar with other diagnostic procedures performed by different medical specialists that yield information about swallowing function. These include procedures such as the esophagram/barium swallow, manofluorography, scintigraphy, pharyngeal manometry, 24-hour pH monitoring, and esophagoscopy.

See the Treatment section of Dysphagia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

The primary goals of dysphagia intervention are to

  • safely support adequate nutrition and hydration and return to safe and efficient oral intake (including incorporating the patient's dietary preferences and consulting with family members/caregivers to ensure that the patient's daily living activities are being considered);
  • determine the optimum feeding methods/technique to maximize swallowing safety and feeding efficiency;
  • minimize the risk of pulmonary complications;
  • reduce patient and caregiver burden while maximizing the patient's quality of life; and
  • develop treatment plans to improve safety and efficiency of the swallow.

Management of individuals with dysphagia should be based on results of the comprehensive assessment. Decision making must take into account many factors about the individual's overall status and prognosis. This might include information concerning the individual's health and diagnosis, cognition, social situation, cultural values, economic status, motivation, and personal choice. Of primary concern is how the individual's health status can be maintained or maximized. The SLP should consider and integrate the patient's wishes and advocate on behalf of the patient to the health care team, the family, and other relevant individuals.

Treatment Approaches and Principles

Consideration for the underlying neurophysiological impairment is necessary for understanding swallow function and deficits. Different management approaches may be necessary for individuals with dysphagia that has resulted from an acute event, chronic/stable condition, or progressive neurological disorder. Treatment targeting a specific function or structure may also affect function in other structures.

Treatment of dysphagia may include restoration of normal swallow function (rehabilitative), modifications to diet consistency and patient behavior (compensatory), or some combination of these two approaches.

Compensatory techniques alter the swallow when used but do not create lasting functional change. An example of a compensatory technique includes a head rotation, which is used during the swallow to direct the bolus toward one of the lateral channels of the pharyngeal cavity. Although this technique may increase swallow safety during the swallow, there is no lasting benefit or improvement in physiology when the technique is not used. The purpose of the technique is to compensate for deficits that cannot be or are not yet rehabilitated sufficiently.

Rehabilitative techniques, such as exercises, are designed to create lasting change in an individual's swallowing over time by improving underlying physiological function. The intent of many exercises is to improve function in the future rather than compensate for a deficit in the moment.

In some circumstances, certain techniques may be used for both compensation and rehabilitative purposes. For example, the super-supraglottic swallow is a rehabilitative technique that increases closure at the entrance to the airway. If used during a meal, it can serve as a compensation to protect the airway.

Treatment Options and Techniques

Upon completion of the clinical and/or instrumental evaluation, the clinician should be able to use the acquired data to identify which treatment options would be most beneficial. Treatment options for patients with dysphagia should be selected on the basis of evidence-based practice, which includes a combination of the best available evidence from published literature, the patient's and family's wishes, and the clinician's experience. Options for dysphagia intervention include medical, surgical, and behavioral treatment.

Biofeedback

Biofeedback incorporates the patient's ability to sense changes and aids in the treatment of feeding or swallowing disorders. For example, patients with sufficient cognitive skills can be taught to interpret the visual information provided by these assessments (e.g., surface electromyography, ultrasound, FEES) and to make physiological changes during the swallowing process.

Diet Modifications

Modifications to the texture of the food may be implemented to allow for safe oral intake. This may include changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods. Modifications of the taste or temperature may also be employed to change the sensory input of the bolus. Clinicians consult with the patients and caregivers to identify patient preference and values for food when discussing modifications to oral intake. Consulting with the team, including a dietician, is also a relevant consideration when altering a diet to ensure that the patient's nutritional needs continue to be met.

Electrical Stimulation

The body of literature about electrical stimulation for swallowing is growing, and additional studies are underway to further the knowledge about this technique and its implications for dysphagia treatment. Electrical stimulation is promoted as a treatment technique for speech and/or swallowing disorders that uses an electrical current to stimulate the nerves either superficially via the skin or directly into the muscle in order to stimulate the peripheral nerve. Electrical stimulation for swallowing is intended to strengthen the muscles that move the larynx up and forward during swallow function.

Equipment/Utensils

Patients may benefit from the use of specific equipment/utensils to facilitate swallow function. A patient can use utensils to bypass specific phases of the swallow, to control for bolus size, or to facilitate oral control of the bolus. SLPs collaborate with other team members in identifying and implementing use of adaptive equipment.

Maneuvers

Maneuvers are specific strategies that clinicians use to change the timing or strength of particular movements of swallowing. Some maneuvers require following multistep directions and may not be appropriate for patients with cognitive impairments. Examples of maneuvers include the following:

  • Effortful swallow —increases posterior tongue base movement to facilitate bolus clearance. The patient is instructed to swallow and push hard with the tongue against the hard palate (Huckabee & Steele, 2006).
  • Mendelsohn maneuver —designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway. The patient holds the larynx in an elevated position at the peak of hyolaryngeal elevation.
  • Supraglottic swallow —designed to close the vocal folds by voluntarily holding one's breath before and during swallow in order to protect the airway. The patient is instructed to hold his or her breath just before swallowing to close the vocal folds. The swallow is followed immediately by a volitional cough.
  • Super-supraglottic swallow —designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow. The super-supraglottic swallow is similar to the supraglottic swallow; however, it involves increased effort during the breath hold before the swallow, which facilitates glottal closure (Donzelli & Brady, 2004).

Oral-Motor Therapy/Exercises

Oral-motor treatments include stimulation to or actions of the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles that are intended to influence the physiologic underpinnings of the oropharyngeal mechanism in order to improve its functions. Some of these interventions can also incorporate sensory stimulation. Oral-motor treatments range from passive to the more active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). Examples of exercises include the following:

  • Laryngeal elevation —similar to the Mendelsohn maneuver (discussed in "Maneuvers" section above), the patient uses laryngeal elevation exercises to lift and maintain the larynx in an elevated position. The patient is asked to slide up a pitch scale and hold a high note for several seconds. This maintains the larynx in an elevated position.
  • Masako or tongue hold —the patient holds the tongue forward between the teeth while swallowing; this is performed without food or liquid in the mouth, to prevent coughing or choking. Although sometimes referred to as the Masako "maneuver," the Masako (tongue hold) is considered an exercise (not a maneuver), and its intent is to improve movement and strength of the posterior pharyngeal wall during the swallow.
  • Shaker exercise, head-lifting exercises —the patient rests in a supine position and lifts his or her head to look at the toes to facilitate an increased opening of the upper esophageal sphincter through increased hyoid and laryngeal anterior and superior excursion.
  • Lingual isometric exercises —the patient is provided lingual resistance across exercises to increase strength.

Pacing and Feeding Strategies

Specific volumes of food per swallow may result in faster pharyngeal swallow responses. Clinicians modify the bolus size (i.e., bigger/smaller bolus amounts), particularly for patients that require a greater volume to adequately stimulate a swallow response or for patients that require multiple swallows per bolus. Patients may also require cuing and assistance to maintain an appropriate rate during meals. Impulsivity and/or decreased initiation are examples of cognitive deficits evident across a number of disorders that may affect a patient's pace during meals.

Postural/Position Techniques

Postural techniques redirect the movement of the bolus in the oral cavity and pharynx and modify pharyngeal dimensions in a systematic way. Postural techniques may be appropriate to use with patients with neurological impairments, head and neck cancer resections, and other structure damage. Postural techniques may be used in patients of all ages. Examples of postural techniques include the following:

  • Chin-down posture —the chin is tucked down toward the neck during the swallow, which may bring the tongue base closer to the posterior pharyngeal wall, narrow the opening to the airway, and widen the vallecular space.
  • Chin-up posture —the chin is tilted up, which may facilitate movement of the bolus from the oral cavity.
  • Head rotation (turn to the side) —the head is turned to either the left or the right side, typically toward the damaged or weak side (although the opposite side may be attempted if there is limited success with the first side) to direct the bolus to the stronger of the lateral channels of the pharynx.
  • Head tilt —the head is tilted toward the strong side to keep the food on the chewing surface.

Postures and maneuvers may be combined in an appropriate manner, taking care to minimize patient effort/burden, where possible.

Prosthetics/Appliances

Prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize pressures and movements in the intraoral cavity by providing compensation or physical support for patients with structural deficits/damage to the oropharyngeal mechanism. With this support, swallowing efficiency and function may be improved. Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved swallow function. This treatment option is most often used with patients following treatment for head and neck cancer; however, it may be implemented with other patients suffering from similar challenges.

Note: Future Practice Portal pages on head and neck cancer and on craniofacial anomalies will further discuss prosthetics and appliances. Check back regularly with the Practice Portal website for updates.

Sensory Stimulation

Sensory stimulation techniques vary and may include thermal-tactile stimulation (e.g., using iced lemon glycerin swab, cold laryngeal mirror) or tactile stimulation applied to the tongue, around the mouth, and/or in the oropharynx. Patients who are tactically defensive may need approaches that reduce the level of sensory input initially, with incremental increases as tolerance improves. The opportunity for sensory stimulation may be needed for those with reduced responses, overactive responses, or limited opportunities for sensory experiences. Sensory stimulation may prime the swallow system for the subsequently presented bolus to lower the threshold needed to initiate a swallow response and improve the timeliness of the swallow.

Medical Management Of Swallowing Disorders

Due to the interprofessional management of dysphagia, clinicians should be aware of multiple options for dysphagia intervention, including medical, surgical, and behavioral treatment. Such knowledge increases pertinent communication with other health care providers and facilitates selection of the best treatment options for individual patients (Groher & Crary, 2010).

Common Medical Options for Dysphagia Treatment

Pharmacologic Management

  • Anti-reflux medications
  • Prokinetic agents
  • Salivary management

Common Surgical Options for Dysphagia Treatment

Improved Glottal Closure

  • Medialization thyroplasty
  • Injection of biomaterials

Protection of the Airway

  • Stents
  • Laryngotracheal separation
  • Laryngectomy
  • Tracheostomy tubes
  • Feeding tubes

Improved Pharyngoesophageal Segment Opening

  • Dilation
  • Myotomy
  • Botulinum toxin injection

Tube Feeding for Dysphagia Treatment

If the individual's swallowing safety and efficiency cannot reach a level of adequate function, or if swallow function does not support nutrition and hydration adequately, the swallowing and feeding team may recommend alternative avenues of intake (e.g., nasogastric [NG] tube, gastrostomy). In these instances, team members consider whether the individual will need the alternative source for a short or extended period of time. Education and counseling may be provided concerning issues related to tube feeding, such as appropriate positioning and duration of feeding times. Alternative feeding does not preclude the need for rehabilitative techniques to facilitate sensory and motor capabilities necessary for oral feeding. Percutaneous endoscopic gastrostomy (PEG) tubes may not be appropriate in all populations and may not necessarily improve outcomes or quality of life (Plonk, 2005).

The decision to recommend use of a feeding tube is made in collaboration with the medical team. The physician is ultimately responsible for selecting which type of tube is used, but a brief description of several options is provided below, for the benefit of clinicians.

  • Gastrostomy tube (PEG, G-tube) inserted through the abdomen to provide non-oral nutrition. A percutaneous endoscopic gastrostomy tube, or PEG tube, is a common type of G-tube.
  • Jejunostomy tube (PEJ, J-tube) inserted through the abdomen and into the jejunum, the second part of the small intestine, to provide non-oral nutrition.
  • Nasogastric tube (NG-tube) inserted through the patient's nose and passed through the esophagus to the stomach to provide non-oral nutrition. NG-tubes are often the preferred option for short-term use (over G-tubes or J-tubes). Tube size may vary and may influence swallow function.

The patient, with his or her proxy, then chooses to accept or reject use of alternative nutrition and hydration following a shared decision making, informed consent discussion.

Treatment Considerations Related to Progressive Disorders and End-of-Life Issues

The role of the SLP in treating individuals with progressive neurological disorders is designed to maximize current function, compensate for irreversible loss of function, assess and reassess changes in status, and educate and counsel patients regarding the progression of the disorder and potential options, including non-oral means of nutrition.

SLPs may encounter patients approaching the end of life. These patients may have complex medical conditions related to feeding and swallowing. SLPs may work with these patients and caregivers to develop compensatory strategies that will allow the patients to eat an oral diet for as long as possible. As a member of the interprofessional team, the SLP may contribute to decision making regarding the use of alternative nutrition and hydration.

Understanding emotional and psychological issues related to death are essential to treating patients with swallowing problems at the end of life. When considering end-of-life issues, it is important for clinicians to respect the patient's wishes, including social and cultural considerations. Patients and caregivers may not agree with clinical recommendations and may feel that these recommendations do not provide the best quality of life for their loved one.

Ethical Concerns

One model for ethical decision making includes consideration of (Jonsen, Siegler, & Winslade, 1992):

  • Medical indications Consider the patient's medical history, prognosis, and available viable treatment options.
  • Patient preferences Consider the patient's cultural and personal background influence, his or her preference to pursue or reject treatment, the patient's ability to make and communicate these decisions, and the presence of an advance directive.
  • Quality of life Consider if the treatment creates a burden that outweighs the potential benefit
  • Contextual features Consider the implications for caregiver burden if the patient chooses to pursue or reject treatment and if there are relevant legal ramifications to consider

Clinicians provide information regarding these considerations without factoring in their own personal beliefs. Conflict may occur when medical recommendations do not match patient preferences. After being educated about the risks and benefits of a particular recommendation (e.g., oral vs. non-oral means of nutrition, diet level, rehabilitative technique), if a patient (or his or her decision maker) chooses an alternate course of action, then the SLP makes any appropriate recommendations and offers treatment as appropriate. The SLP educates involved parties on the possible health consequences and documents all communication with the patient and caretakers. If no treatment is warranted, then the SLP may make recommendations about the safest course (and still document the risks of such action) and may provide training to caregivers and family, as appropriate. The SLP may then decide to discharge the patient but should avail him/herself to additional consultation or communication with the parties involved, as appropriate. Many facilities have an ethics consultation service that can help clinicians, patients, and families address challenges when an ethical issue arises.

Service Delivery

See the Service Delivery section of the Dysphagia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.

In addition to determining the type of assessment and treatment that is optimal for adults with dysphagia, SLPs consider other service delivery variables that may affect swallowing outcomes—variables such as format, provider, dosage, and timing.

Format

Format refers to the structure of the assessment or treatment session, such as whether a person is seen for treatment one on one (i.e., individual), as part of a group during meal time, or via telepractice.

Provider

Provider refers to the person providing the assessment or treatment (e.g., SLP, trained volunteer, caregiver).

Dosage

Dosage primarily refers to the amount of treatment provided (e.g., the frequency, intensity, and duration of service).

Timing

Timing refers to the timing of rehabilitation relative to the onset of dysphagia.

Setting

Setting refers to the location of treatment (e.g., home-based, community-based).

Resources Related to Dysphagia/Swallowing

Resources Related to Radiation Awareness and Practices Among SLPs

Additional Articles Related to Radiation

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Acknowledgments

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Adult Dysphagia page:

  • Tara Adducci, MA, CCC-SLP
  • Martin Brodsky, Ph.D., ScM, CCC-SLP
  • James Coyle, Ph.D., CCC-SLP, BCS-S
  • Karen Wheeler Hegland, Ph.D., CCC-SLP
  • Alice Inman, MS, CCC-SLP, BCS-S
  • Bonnie Martin-Harris, Ph.D., CCC-SLP, BCS-S
  • Luis Riquelme, Ph.D., CCC-SLP, BCS-S
  • Cesar Ruiz, SLP.D., CCC-SLP, BCS-S
  • Helen Sharp, Ph.D., CCC-SLP
  • Debra Suiter, Ph.D., CCC-SLP, BCS-S
  • Nancy Swigert, MA, CCC-SLP, BCS-S
  • Lynne Brady Wagner, MA, CCC-SLP

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Adult-Dysphagia/.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.

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