Dysphagia Management:
From Evidence to Implementation
By Phyllis M. Palmer, PhD, CCC-SLP & Aaron H. Padilla, MS, CCC-SLP
Editor: Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com
Editor’s note: When I read: “Risk of an Adverse Event in Individuals Who Aspirate: A Review of Current Literature on Host Defenses and Individual Differences”, I urged Padilla and Palmer to write this blog to highlight this excellent summary and tutorial. Comprehensive and multi-phase dysphagia evaluations with a person-centered care approach are critical to “provide clinical guidelines for managing individuals with dysphagia,” as Palmer and Padilla note in this 2021 tutorial in the American Journal of Speech-Language Pathology (p 2).
Read on to discover what they consider to be their top five nuggets of this work. I urge you to also read the full text article, as it has excellent schematics, guiding questions, and case study algorithms to carry you through the holistic thinking and decision-making.
You have completed your comprehensive dysphagia evaluation, which included the finding of aspiration. Now what? Do not stop there, as there is a whole lot more to consider. The University of New Mexico Swallow Disorders Research Lab used evidence to propose a framework for weighing risk when working with individuals with prandial aspiration. (See our references and resources at the end of this article.) We have identified the top five nuggets or your consideration. NUGGET 1: There is compelling evidence dating back over (at least) the past three decades that provides guidance for clinical decisions regarding safe eating (NPO vs Oral Intake) of individuals with prandial aspiration. These data include factors beyond aspiration and emphasize that aspiration alone is insufficient to cause an adverse event. Despite the evidence, clinical recommendations are often linked to presence or absence of aspiration.
“Although not supported in the literature, there are still instances where NPO is recommended based on the presence of aspiration without strong consideration of one’s ability to tolerate aspiration.” (Palmer & Padilla, 2021a, p1)
NUGGET 2: The lungs’ response to aspiration plays an important role in the risk associated with aspiration. A healthy lung’s microbiome is maintained by having a balance between immigration (invasion of food, liquid, saliva, or gastric contents containing pathogens or chemical irritants) and elimination (individual’s response and host defenses to bacteria and other material). (See Figure 1 and supporting citations in Palmer & Padilla, 2021a). In healthy individuals, the elimination of bacteria occurs through a combination of phagocytosis and mucociliary clearance.
- Phagocytosis is a defense mechanism that engages macrophages to engulf and eliminate foreign material.
- Mucociliary clearance occurs when the mucus layer on the lung’s airway surface traps aspirate and transports it out of the airway through ciliary action.The cough aids the actions of the mucociliary escalator by supporting movement of trapped materials in an upward and outward direction.
Dysbiosis occurs when there is an imbalance between the immigration of bacteria or irritants into the lung and elimination out of the lung, and that may lead to an increased risk for opportunistic infection. NUGGET 3: The dysphagia clinician and medical team need to consider all the variables specific to an individual, as considering aspiration alone is not enough. All these variables guide clinical decision making for the person with prandial aspiration. These variables can be organized into Yes/No questions to aid the clinician and the team in:
- assessing the overall risk associated with oral intake for individuals with prandial aspiration, and
- identifying if these factors are modifiable.
NUGGET 4: The B-O-L-U-S framework proposed in our ASHA presentation (Palmer & Padilla, 2021b), organizes variables into an easy-to-remember framework to improve clinician recall and facilitate the implementation of evidence. The framework can also guide the education, conversations and the complex informed consent process with the person with dysphagia (and/or healthcare proxy) and the rest of the medical team. (See resources below for more on person-centered care, informed consent and documentation within a person-centered care approach). Questions in this framework that receive a response of YES show an increased risk of an adverse event.
Questions that receive a YES response show increased risks for an adverse event if the person has dysphagia and aspiration.
NUGGET 5: Across the continuum of care, the framework can be applied to dysphagia management and clinical decision making. See Figure 3 on page 10 of Palmer & Padilla (2021a), which provides a visual comparison of two people with dysphagia who both aspirated per their videofluoroscopic swallow studies. See how their underlying cases, issues and support systems were very different. (Case Study 1 & 2 start on page 8). The first person was 36-year-old with acute dysphagia from a traumatic brain injury who had significant safety and efficiency issues (significant silent aspiration with a Penetration Aspiration Scale/PAS score of 8), and compensatory strategies were unsuccessful. However, this individual was not bedridden and had supportive care (i.e., strong family support and assistance with feeding). The second person had trace aspiration across all liquid consistencies (with a PAS of 7). However, that person was bedridden and living in long-term care facility. Her underlying medical status included: oxygen-dependent COPD, diminished cognition, a weak cough, poor oral condition, and dependence on facility staff for her oral care (aka, oral infection control). Using the guiding questions proposed, you will note that despite similar aspiration scores, these two patients require very different considerations.
Editor’s Note & Summary:
The authors noted in their 2021 tutorial that these guidelines do not specifically include the factors of quality of life, goals of care of the individual, and the influences of the person’s culture.
“Non-physiological variables important in dysphagia management, such as quality of life and cultural experiences, should be evaluated for their role” in decision-making (page 9). These are all critical factors the team must consider when holistically weighing the risks versus benefits of any healthcare decision.
Ask questions, listen, and discuss in adequate sit-down conversions with the person who has dysphagia (and/or healthcare proxy), along with the rest of the team.
The individual is the driver of this team, and they/she/he are a whole person long before being a patient.
REFERENCES
Palmer, P. M., & Padilla, A. H. (2021a, online). Risk of an Adverse Event in Individuals Who Aspirate: A Review of Current Literature on Host Defenses and Individual Differences. American Journal of Speech-Language Pathology, 1-15. https://doi.org/10.1044/2021_AJSLP-20-00375
Palmer, P.M., Padilla, A. H., (2021b, November). Aspiration and the Pulmonary Biome: A Clinical Framework. Online presentation at the annual convention of the American Speech-Language-Hearing Association, Washington, D.C.
RESOURCES (from authors & editor)
- Link to YouTube video of the oral presentation from ASHA 2021 at https://www.youtube.com/watch?v=JVq0iQJrbp4
- Reframing Documentation within a Person-Centered Care Approach, by Yvette McCoy & Karen Sheffler: Please see more about person-centered care and informed consent in this webinar, which will also help ensure good documentation with a person-centered care approach.
- In addition to the blogs from SwallowStudy.com linked throughout, here is another blog that has a decision-making framework at the end of the article to guide clinician decision-making for people on high flow nasal cannula.
REFERENCES to support the BOLUS Framework (listed within each letter):
B
Bock, J. M., Varadarajan, V., Brawley, M. C., & Blumin, J. H. (2017). Evaluation of the natural history of patients who aspirate. The Laryngoscope, 127, S1-S10. https://doi.org/10.1002/lary.26854
Logeman, J. A., Gensler, G., Robbins, J., Lindblad, A. S., Brandt, D., Hind, J. A., Kosek, S., Dikeman, K., Kazandjian, M., Gramigna, G. D., Lundy, D., McGarvey-Toler, S., & Miller Gardner, P. J. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or parkinson’s disease. Journal of Speech, Language, and Hearing Research, 51(1), 173-183. https://doi.org/10.1044/1092-4388(2008/013).
Marik, P. E. (2001). Aspiration pneumonitis and aspiration pneumonia. The New England Journal of Medicine, 344(9), 665-671.https://doi.org/10.3810/hp.2010.02.276
Nativ‐Zeltzer, N., Kuhn, M. A., Imai, D. M., Traslavina, R. P., Domer, A. S., Litts, J. K., Adams, B., & Belafsky, P. C. (2018). The effects of aspirated thickened water on survival and pulmonary injury in a rabbit model. The Laryngoscope, 128(2), 327-331. https://doi.org/10.1002/lary.26698
Nativ‐Zeltzer, N., Ueha, R., Nachalon, Y., Ma, B., Pastenkos, G., Swackhamer, C., Bornhorst, G. M., Lefton-Greif, M. A., Anderson, J. D., & Belafsky, P. C. (2020). Inflammatory effects of thickened water on the lungs in a murine model of recurrent aspiration. The Laryngoscope. https://doi.org/10.1002/lary.28948
Robbins, J., Gensler, G., Hind, J., Logemann, J. A., Lindblad, A. S., Brandt, D., Baum, H., Lilienfeld, D., Kosek, S., Lundy, D., Dikeman, K., Kazandjian, M., Gramigna, G. D., McGarvey-Toler, S., & Miller Gardner, P. J. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized trial. Annals of Internal Medicine, 148(7), 509-518. https://doi.org/10.7326/0003-4819-148-7-200804010-00007
Bock, J. M., Varadarajan, V., Brawley, M. C., & Blumin, J. H. (2017). Evaluation of the natural history of patients who aspirate. The Laryngoscope, 127, S1-S10. https://doi.org/10.1002/lary.26854
O
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Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13(2), 69-81. https://doi.org/10.1007/PL00009559
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307. https://doi.org/10.1007/s00455-002-0072-5
L
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Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307. https://doi.org/10.1007/s00455-002-0072-5
Wang, T. H., Wu, C. P., & Wang, L. Y. (2018). Chest physiotherapy with early mobilization may improve extubation outcome in critically ill patients in the intensive care units. The clinical respiratory journal, 12(11), 2613-2621.https://doi.org/10.1111/crj.12965
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Nativ‐Zeltzer, N., Nachalon, Y., Kaufman, M. W., Seeni, I. C., Bastea, S., Aulakh, S. S., … & Belafsky, P. C. (2021). Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia. The Laryngoscope.
Kurien, M., Andrews, R. E., Andrews, R. E., Tattersall, R., McAlindon, M. E., Wong, E. F., Johnston, A. J., Hoeroldt, B., Dear, K. L., & Sanders, D. S. (2017). Gastrostomies preserve but do not increase quality of life for patients and caregivers. Clinical Gastroenterology and Hepatology, 15(7), 1047- 1054. https://doi.org/10.1016/j.cgh.2016.10.032
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Pisegna, J. M., & Langmore, S. E. (2018). The ice chip protocol: A description of the protocol and case reports. Perspectives of the ASHA Special Interest Groups, 3(13), 28-46. doi: 10.1044/persp3.SIG13.28
Takayama, K., Hirayama, K., Hirao, A., Kondo, K., Hayashi, H., Kadota, K., Asaba, H., Ishizu, H., Nakata, K., Kurisu, K., Oshima, E., Yokota, O., Yamada, N., & Terada, S. (2017). Survival times with and without tube feeding in patients with dementia or psychiatric diseases in Japan. Psychogeriatrics, 17(6), 453-459. https://doi-org.libproxy.unm.edu/10.1111/psyg.12274
S
Bock, J. M., Varadarajan, V., Brawley, M. C., & Blumin, J. H. (2017). Evaluation of the natural history of patients who aspirate. The Laryngoscope, 127, S1-S10. https://doi.org/10.1002/lary.26854
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Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13(2), 69-81. https://doi.org/10.1007/PL00009559
Langmore, S. E., Skarupski, K. A., Park, P. S., & Fries, B. E. (2002). Predictors of aspiration pneumonia in nursing home residents. Dysphagia, 17(4), 298-307. https://doi.org/10.1007/s00455-002-0072-5
Nativ‐Zeltzer, N., Nachalon, Y., Kaufman, M. W., Seeni, I. C., Bastea, S., Aulakh, S. S., … & Belafsky, P. C. (2021). Predictors of Aspiration Pneumonia and Mortality in Patients with Dysphagia. The Laryngoscope.
Thank you to my guest contributors:
Phyllis M. Palmer, PhD, CCC-SLP, from the University of New Mexico, Swallowing and Voice Lab, worked as a clinician in various medical settings for 10 years before completing her Ph.D. from University of Iowa. Her teaching has focused on the evaluation and treatment of swallowing function. Dr. Palmer’s research has focused primarily on oral, pharyngeal, and laryngeal motor function as it relates to swallowing in healthy individuals and individuals with various disorders.
Aaron Padilla, MS, CCC-SLP is an acute care speech pathologist at Presbyterian Healthcare Services, who completed his master’s degree at the University of New Mexico. His research interests include dysphagia management and cultural considerations.