Managing Dysphagia in Pulmonary Patients: 5 Key Strategies
The intersection of pulmonary pathologies and dysphagia can present a significant challenge for clinicians, particularly when managing patients with chronic obstructive pulmonary disease (COPD), asthma, and other restrictive lung diseases. These conditions not only compromise respiratory function but also significantly impact swallowing mechanics, increasing the risk of aspiration.
As clinicians, particularly those working in acute and critical care settings, we must navigate the intricate interplay between these conditions to prevent complications and significantly improve patient outcomes.
Understanding Pulmonary Pathologies and Their Impact on Swallowing
Pulmonary pathologies, such as COPD, emphysema, chronic bronchitis, and asthma, significantly alter respiratory mechanics. These conditions often lead to difficulty in breathing, reduced lung elasticity, and increased mucus production. In turn, these effects can impact the coordination of breathing and swallowing. For example, in patients with COPD, the obstruction of airflow and the trapping of air in the lungs can disrupt the natural swallow-breathe cycle, which can interfere with normal swallowing.
Dysphagia is seen in patients with pulmonary conditions. The normal swallowing process involves a complex coordination of the respiratory and digestive systems, where breathing briefly pauses to allow safe passage of food and liquids through the pharynx without entering the airway. In patients with compromised lung function, this coordination may be disrupted. In some cases, patients with conditions like COPD may have trouble exhaling effectively or producing an effective cough, which can increase the risk of aspiration.
The Risks of Aspiration in Pulmonary Patients
As we manage pulmonary-compromised patients, it is crucial to be mindful of the risks associated with aspiration, which occurs when food or liquid enters the airway. Aspiration can be a major concern for these patients, as it can lead to aspiration pneumonia—a severe and often life-threatening condition, particularly in those with already weakened respiratory and immune systems. The risk is heightened by factors such as poor cough reflex, weakened respiratory muscles, decreased immune systems, and reduced mobility.
Studies have shown that the prevalence of aspiration is significantly higher in patients with pulmonary diseases. For example, Cvejic and Bardin (2018) found that individuals with COPD are at increased risk of aspiration due to factors such as impaired laryngeal closure, prolonged pharyngeal transit times, and the presence of pharyngeal residue following swallowing. Additionally, the chronic use of medications like bronchodilators and corticosteroids can further exacerbate swallowing difficulties by relaxing the lower esophageal sphincter, leading to gastroesophageal reflux, which may increase the likelihood of aspiration.
Strategies for Managing Dysphagia in Pulmonary-Compromised Patients
Effective management of dysphagia in patients with pulmonary pathologies requires a comprehensive, interdisciplinary approach that combines evidence-based strategies with practical, patient-centered care. The goal is not only to maintain adequate nutrition and hydration but also to minimize the risk of aspiration, improve overall quality of life, and promote long-term improvements in patient outcomes. This comprehensive approach includes not only the medical team, but also the rehab team, including physical, occupational, and speech therapists.
1. Comprehensive Swallowing Assessments
A thorough clinical swallowing evaluation is the first step in managing dysphagia. This includes a detailed assessment of the patient’s cranial nerves, respiratory status, cognitive function, and the coordination between breathing and swallowing. In many cases, instrumental assessments such as a modified barium swallow study (MBSS) or fiberoptic endoscopic evaluation of swallowing (FEES) are necessary to visualize the swallowing process and identify the presence and severity of aspiration.
The timing of these assessments is critical, especially in acutely ill patients. Evaluations should be performed when the patient can tolerate the evaluation process. You should avoid pushing the patient too hard, making it difficult for them to recruit. During the assessment, be mindful of the patient’s fatigue levels and overall endurance. Communicating with the registered nurse (RN), physical therapist (PT), and occupational therapist (OT) will help you understand the patient’s endurance levels.
2. Interdisciplinary Collaboration
Managing dysphagia in pulmonary patients requires close collaboration among speech-language pathologists, respiratory therapists, physical and occupational therapists, dietitians, nurses, and physicians.
The SLP plays a central role in assessing swallowing function and developing a treatment plan, while the respiratory therapist monitors the patient’s oxygen needs and adjusts oxygen delivery methods accordingly. Dietitians ensure that the patient receives adequate nutrition and hydration. Nurses provide ongoing care, monitoring the patient’s condition and ensuring adherence to the prescribed swallowing strategies. PTs and OTs are crucial in getting that patient mobile and working on their activities of daily living (ADL).
Regular interdisciplinary team meetings are essential to review the patient’s progress, adjust treatment plans, and address any emerging issues. This collaborative approach ensures that all aspects of the patient’s care are considered, leading to more effective management of both dysphagia and the underlying pulmonary condition.
3. Adjustments to Oxygen Delivery Systems
Oxygen therapy, commonly used in patients with pulmonary diseases, may impact swallowing function. High-flow oxygen delivery systems, for example, may affect the patient’s ability to coordinate swallowing and breathing. In such cases, it is crucial to adjust the oxygen flow to a level that supports both respiration and safe swallowing.
The key concept with oxygen delivery is the “why” they need it and whether the patient can accommodate those needs to mobilize and swallow safely. Additionally, using nasal cannulas, which allow for more natural breathing patterns compared to masks, may help during eating and drinking.
4. Swallowing Therapy and Exercises
Targeted swallowing therapy can help strengthen the muscles involved in swallowing and improve coordination between breathing and swallowing. Techniques such as the Mendelsohn maneuver, effortful swallow, and supraglottic swallow can be particularly effective in improving airway protection and reducing the risk of aspiration.
Breathing exercises, such as diaphragmatic breathing and pursed-lip breathing, can also help improve respiratory control and support better coordination during swallowing. These exercises not only enhance the patient’s ability to manage their secretions but also contribute to overall respiratory health.
Expiratory Muscle Strength Training (EMST) and Inspiratory Muscle Strength Training (IMST) can help patients improve their pulmonary effort, airway clearance, and overall respiratory compliance. These training techniques have also been shown to enhance swallowing, increase cough effort, and improve vocal strength and quality.
For SLPs looking to provide their patients with targeted home exercise programs, MedBridge offers comprehensive HEP resources specifically designed for speech-language pathologists to reinforce these techniques and promote effective dysphagia management.
5. Patient and Caregiver Education
Patient education is a critical component of dysphagia management in pulmonary patients. As a speech-language pathologist, you play a key role in ensuring that your patients understand the importance of following prescribed swallowing strategies, maintaining good oral hygiene, and recognizing the early signs of aspiration. Equally important is educating caregivers on safe feeding techniques, such as pacing intake and ensuring proper positioning during meals, to help reduce the risk of aspiration.
To support you in this effort, MedBridge offers patient education resources that can help you engage both patients and caregivers more effectively, fostering a deeper understanding and better adherence to care plans. These tools are tailored specifically for SLPs to enhance patient education and engagement, equipping you to make a meaningful impact in your patients’ lives.
Enhancing Pulmonary Patient Outcomes Through Dysphagia Management
As clinicians dedicated to improving patient outcomes in acute and critical care, it’s imperative that we continuously refine our approaches to managing the intersection of pulmonary pathologies and dysphagia. By staying informed and embracing interdisciplinary collaboration, we can provide the highest standard of care.
If you’re looking to enhance your expertise in managing dysphagia in pulmonary-compromised patients, my MedBridge course, Pulmonary-Compromised Patients: Oxygen Delivery and Dysphagia Issues, offers practical insights and advanced strategies that I’ve found invaluable in my own practice. You’ll gain a clear understanding of how pulmonary pathologies impact swallowing, learn to navigate complex oxygen delivery systems, and make informed decisions during clinical and instrumental evaluations to improve care and outcomes for these patients.
References
- Cvejic, L., & Bardin, P. G. (2018). Swallow and aspiration in chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 198(7), 833-841. https://doi.org/10.1164/rccm.201804-0704PP
