27 April 2018
One of the most prevalent
conditions we as Speech Therapists work with, is dysphagia. Well, that is adult
neuro-therapists. Coming out of varsity, I was ignorant to the astoundingly
high occurrence and demand for swallowing therapy in patients. We were taught
about dysphagia, and what it is, some of the techniques that can be used to
treat it, and how to assess for swallowing difficulties, but I doubt that we
spent more than 5 hours of class learning about it. This is shocking,
considering the high incidence of this condition in the real world.
Diagnosing dysphagia has many
components that need to be considered, and not all that can be clinically
assessed during a bedside evaluation. To give you an idea, I’ll start with the
anatomy. When you put food into your mouth, it enters the oral cavity, and is
masticated (chewed) and prepared for the swallow by the tongue. This bolus is
propelled backwards by the tongue, into the pharynx (throat). Now just below
the base of your tongue, you get what we call the valeculi, which is like a
little pouch, and the epiglottis, which is a “flap” that drops down to close
off your airway when you swallow. Your airway (trachea) sits in front – so when
you touch your throat, that bony part that you are touching is your airway.
Behind that, between your airway and your spine, sits your esophagus, which
carries the food down to your stomach.
Often when patients swallow, they
cough, which is an indication that some of the food goes into the lungs, which
is dangerous. An assessment that we often do to clinically assess whether this
aspiration occurs, is called a modified barium swallow study (videoswallow).
Doctors are not trained to assess for this, or interpret a swallow study for
that matter, so they refer to us to diagnose these patients. Now, you get two
types of swallow studies: a barium swallow, which is mainly focused on the
movement of the food down the esophagus and into the stomach, to test for reflux.
Then you get a videoswallow, which is what we do, and this focuses on the
throat and entrance to the lungs, so that we can test the functionality of a swallow,
and determine whether patients are able to swallow safely or not.
Here’s a quick swallowing 101
lesson: For a normal and safe swallow to occur, there should be good oral
control, tongue movement, bolus propulsion backwards, and there should be no
residue on the tongue or anywhere in the throat. Sometimes, some of the food
remains in the pharynx, and gets caught in the valleculi and pyriform sinuses,
which may eventually overflow into the airway and result in aspiration. This
can often be cleared using manoeuvres on how to position your head during
swallowing, and other techniques that may help clear the food from these
structures. If the food does not clear, it is considered a high risk for
aspiration, and the patient is not safe for oral feeding.
So I had a patient who was
referred to me following a rather large stroke. I assessed his swallowing, and
although he didn’t display any clinical signs of aspiration (such as coughing,
throat clearing, wet voice, watering eyes or delayed coughing), my gut instinct
told me that this patient is aspirating. So I took him for a videoswallow, and
I was right. My patient was aspirating severely on all three consistencies of
food (thin fluids, puree such as yoghurt, and solids – a cookie). Not only was
he aspirating severely, but the aspiration was silent, which means that the
coughing reflex – our airway’s protective mechanism - is not present and there
is no clinical sign of aspiration. My recommendation was to have a PEG tube
inserted, and that we would commence swallowing therapy in an attempt to
rehabilitate his swallow.
Once a month, for three months, I
took my patient to X-Rays to repeat the videoswallow to monitor for improvement
of his swallowing, and hopefully to slowly get him back onto an oral diet. The
risk for aspiration remained high, and I did not feel comfortable allowing my
patient any oral intake. So we continued religiously doing the swallowing exercises,
and feeding him via the PEG tube. So come month 3, my patient comes back to
X-Rays for his follow-up videoswallow. As I walk into radiology, my patient is
not there, so I set up and prepare the room, only to get a phone-call from his
wife. “Hello Lauren, I am sitting with the report in my hand, and it says that
he may eat. Does this mean that the feeding tube can come out?”. Imagine my
horror at hearing this result, when I have yet to lay eyes on my patient.
Considering his history, I highly doubted that he is able to swallow safely. So
I calmly asked them to please return so that I can confirm these results
myself.
In the mean time, I flew into the
radiologist’s offices, trying very hard to put a smile on my face, demanding to
know who performed my videoswallow and what EXACTLY they saw. One very friendly, very flirty and very young
doctor was very eager to tell me that he even gave my patient a marshmallow
(because yes this definitely replicates the consistency of your meat, hey?) and
he was able to swallow it safely. Red in the face, eyes blazing, heart racing,
and breathing very heavily, I slapped a smile on my face and asked him to
please assist me in repeating the study so that I can confirm the results
personally.
My patient arrives, and we
proceed into the screening room. I invite his wife in too, so that she can also
see the results of the swallow. I give my patient a sip of water… severe
pooling in the valleculi, with failure to clear using any of our manoeuvres.
This swallow has not started on a good note. Am I now supposed to break his
newly heightened spirits by telling him he may not really swallow? Perhaps the
other consistencies will get better.
I give him a spoon full of
yoghurt, and my heart drops a little more. The pooling in the valleculi hasn’t
improved at all, and in fact the yoghurt was completely lining the entrance to
the airway. Damn! I don’t even feel safe to give him a cookie - this result is
not good at all, but my patient has been told that he may eat, and he is so
happy about it, so I ignore the blaring red lights, I dip my cookie in the
yoghurt for the contrast to show up, and I ask my patient to chew it and swallow
when he is ready. I give him a sip of water hoping that it will wash the
residue out of the valleculi and clear the pharynx, maybe this will give me a
safe option to send him home with.
I think I stood starring at that
screen for at least a minute, trying to figure out how I can gently drag his
spirits through the mud. I turn around slowly to look at him, and watch as his
face turns from excitement and joy into disappointment and sadness. What did he
see on my face? Sadness? Disappointment? Horror? Fear? All the emotions I was
feeling. So I slowly start explaining the structures to them, and I replay the
video to show them what happened to the bolus, where it lodged in the pharynx,
and how I tried to clear it using every possible technique.
Here’s what I saw (please excuse
the quality, this was taken off a screen)… The first photo is a clear pharynx
before any boluses were presented. The second photo is following the cookie,
which you will see is the dark stuff in the throat. (1) tongue, (2) valleculi,
(3) epiglottis, (4) entrance to the airway, (5) esophagus.
My advice to this patient was to
only start taking in small bites of food with a puree consistency, and to take
a sip of water after each bite. I was not at all happy to send him home like
this, but to now take the new privilege of eating away – I just couldn’t.
A month later we repeated the
videoswallow, and it looked somewhat better, but still not great. I had learned
though, that my patient had decided to start eating normally again, against my
recommendation, and was “doing well”. His PEG tube had now become a nuisance
and was getting infected. So, against my recommendation that this was not safe,
they went to their doctor, who removed the PEG tube, and he has been eating
orally since.
Sometimes as Speech Therapists we
have to play the bad guy, and refuse to allow the small, pleasurable things in
life, such as eating and drinking. It sucks, but it is really in the best
interest of the patient. It is not easy to watch a patient’s hopes falter and
die down, and try and encourage them in therapy when they are so despondent
that they refuse to even look at you. These are the moments in your day that drain
you of emotional energy, and wipe that smile off your face. I often walk around
with just that, a face that I put on for the sake of my patients. But hey, if
it means that I know my patients will be safe, and I will not be the cause of
them developing a serious illness, I am happy to play the bad guy.
Until next time…
Xxx
