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Do you ever wonder why speech therapists get so “bossy” about swallowing recommendations? 

One patient can NOT have a straw… but another patient HAS to have a straw.  

One patient SHOULD do a chin tuck… but another patient should NEVER do a chin tuck. 

THERE ARE REASONS!!!!! 

Here are just a few reasons….

Chin Tucks CANNOT be a universal plan when we hear a patient cough at a meal. 

  • For some patients, the chin tuck HELPS to protect food or drink from entering the airway. But for other patients, the chin tuck pushes the food or drink into the airway! Staff should never decide how to guide the patient in the moment… at the dining room table… during the meal.
  • What staff can do… notify the SLP and nursing as soon as possible when they have a concern about swallowing during a meal.

No Straw!  or  Yes, Straw!

  • For some patients, straw sips shoot the liquid to the back of the throat so fast that impaired, swallow structures (e.g. base of the tongue or the epiglottis) don’t have time or coordination for getting ready to protect the airway.  
  • For other patients, a straw is helpful because the oral muscles are weak and can’t push the liquid backward to initiate the swallow (oral pocketing or spills out of mouth). 
  • Some patients a straw is helpful because they may not have the physical ability to hold and manipulate a glass of liquid (paraplegic or stroke patient). 
  • Straw use can help increase caloric intake if used with soups, shakes, etc.

Thickened Liquids are NOT always the safest solution.

  • Thickened liquids can make swallow safety worse. 
  • Thickened liquids often cause more residue in the throat than thin liquids do. This residue can build up in throat pockets and spill over into the airway. 
  • Thickened liquids create additional health risks such as dehydration.
  • Current research indicates that aspiration of thickened liquids has a higher rate of becoming pneumonia than aspiration of thin liquids. 
  • Placing a patient on thickened liquids significantly decreases quality of life for most patients. 
  • Thickening liquids should always be a last resort–not a first choice. 
  • Sometimes thicker liquids are safer than thin liquids– this should only be considered after swallow imaging indicates that it actually is safer than thin liquids.  

Oral Care — PLEASE! This is a big deal. 

  • The top predictor of a patient’s risk for getting aspiration pneumonia is… ORAL CARE. (see research list)
  • Bacteria build up in the mouth, if aspirated along with food or liquid, it poses a high risk for pneumonia.
  • This means it is better to use toothbrush with toothpaste, not a pink toothette. Bacteria hides and clings to tooth enamel, cheek cavities, the roof of the mouth, and the tongue. 
  • People at risk for aspiration MUST HAVE THOROUGH ORAL CARE BEFORE EACH MEAL/SNACK. Yep, it’s a lot to ask of staff, family, and the patient.
  • Oral care for people with swallowing disorders is not just hygiene– it is a medical need.

Behind every swallow recommendation are good reasons– based on current evidence and designed to improve the patient’s health. 

The speech therapists aren’t really bossy. They are advocates who care.  

Go team!

References:

  • Adult Dysphagia- https://www.asha.org/practice-portal/clinical-topics/adult-dysphagia/#collapse_6
  • Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia. 2002; Garcia J, Chambers E, Molander M.
  • Thickened liquids: practice patterns of speech-language pathologists. American Journal of Speech-Language Pathology, 2005; Kaneoka, A., Pisegna, J. M., Saito, H., Lo, M., Felling, K., Haga, N.,  Langmore, S. E. (2017).
  • Feeding and Swallowing Strategies for the Individual With Dementia
  • George A. Voyzey
  • https://doi.org/10.1044/gero15.2.48
  • https://pubs.asha.org/doi/epdf/10.1044/gero15.2.48
  •  A systematic review and meta-analysis of pneumonia associated with thin liquid vs. thickened liquid intake in patients who aspirate. Clinical rehabilitation, Kuhlemeier K, Palmer J, Rosenberg D.
  • Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagic patients. Dysphagia 2001; 1 Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998).
  • Sheffler, K. (2015). To chin tuck, or not to chin tuck? That is the question. Retrieved November 24, 2018 from https://www.swallowstudy.com/to-chin-tuck-or-not-to-chin-tuck-that-is-the-question/ Shin, H., Ahn, Y., & Lim, D. (2016). Association Between Chewing Difficulty and Symptoms of. Dental and Oral Health, 64(12) Terre, R. & Mearin F. (2012).
  • Terre, R. & Mearin F. (2012). Effectiveness of chin-down posture to prevent tracheal aspiration in dysphagia secondary to acquired brain injury: A videofluoroscopy study. Neurogastroenterology & Motility