First, Do No Harm: A comprehensive approach to dysphagia management

First, do no harm. It’s the healthcare mantra. It rings loudly in our ears when we make any and every clinical decision. It might in fact be the reason we are so apt to prevent aspiration at all costs. Even with all of the training and education we’ve had on the complex relationship between aspiration and pneumonia, our primitive emotional minds simplify this complexity into a basic formula: Cough with liquid = dysphagia. Dysphagia = aspiration. Aspiration = pneumonia. Pneumonia = death. And of course then the transitive law tells us that cough with liquid = death. Eek, somebody save that poor coughing man immediately!

Intervening

When we are providing any type of intervention we are, by definition, intervening. The definition of intervening is to approach a situation with the intention to alter its events. You may have noticed that it doesn’t specify whether that alteration is good or bad. And when you intervene, you can very quickly change the entire dynamic of a situation. When that situation involves the human body, we are intervening with a complex interplay between many bodily processes that can lead to a domino effect (timber!). 

Connecting the Dots

What and how we swallow is connected to everything. Ever play 6 degrees of Kevin Bacon? The same principle applies to the swallow. Let’s use my favorite example of thickening liquids to clarify (because it just so happens to be our favorite intervention, for better or for worse). 

The patient coughs on drink. We thicken drink. No more coughing. No more problem! Right? Wrong. Instead, when we thicken liquids we are intervening in a way that changes the most basic bodily function: the process of hydration. We need to drink to stay alive. For most of the history of mankind, humans only drank water. Unadulterated, pure, crisp water. That is what our body is meant to process. By thickening our water we increase the risk of dehydration, altered processing of medication, and even silent aspiration (didn’t see that last one coming did you?). It doesn’t stop there… Let’s touch on each of these to see how they can evolve into more complications.

Dehydration can cause a downhill trajectory for your patient leading to conditions as severe as kidney issues, seizures, and a drop in blood pressure. Any or all of these outcomes can precipitate into many other clinical outcomes, most of which will not get a warm-embrace from the patient.

The delay in processing medication can be devastating for the patient. When the body takes longer to process medication, the reactions needed for the body to function in the intended way could be delayed, interrupted, or may even unintentionally interfere with other medications, creating a snowball of unintended consequences.

And as for silent aspiration? Being an SLP, you’re probably already scared of this enough so I won’t go there.

Remember Homeostasis? 

Thickened liquids may have significant benefits for our patients, but the costs need to be considered. Healthcare is sort of like wack-a-mole (terribly violent example, I know). You knock down one problem and three others pop up. A healthy body relies on a well-balanced foundation (remember, homeostasis from your high school text book?) Even, small changes can mess with that stability. 

First, do no harm. When we see a patient coughing, we have to fight our primitive brains and come up with a comprehensive approach so that we can see the full picture without scaring ourselves into preventing aspiration at all costs. Ready for that approach? Ok, here we go…

Comprehensive Dysphagia Management Approach

First ask why: Why is the dysphagia happening. Underlying conditions? Medical complexity or is there one direct link? Chronic or acute? Temporary or permanent? There can be more than one possibility. List them all out in order of likeliness so you can slowly rule out those that seem less likely.

Then ask what: Identify the signs and symptoms as well as any other issues that may be occurring from the dysphagia (e.g. cardiopulmonary issues, dehydration, malnutrition, chronic coughing, depression, pain, etc.). List the possibilities for intervention that aim to manage these signs and symptoms.

Discuss: What does the patient want? What do they expect to happen next and what would they like you to do for them? How do they feel about the situation (sounds kumbaya, but remember you’re treating the patient, not the symptom)?

Hypothesize and test: The scientific method shouldn’t have been left back in grade school. Hypothesize the cause and affect of the dysphagia and potential interventions to manage those causes. Then use a systematic approach to test it (preferably in the form of initial and follow-up instrumental studies).

Results: What did the initial results tell us about the dysphagia? How about after our intervention? Was our hypothesis correct? Why or why not? Most importantly, what can we do with the results to create a plan of care and to improve the life of the patient based on the causes and effects of the dysphagia, as well as the patient’s goals and expectations?

Troubleshoot

Follow the effects of your intervention closely over time. Is the intervention having unintended consequences? Then start from the beginning again. Sounds grueling? It is. Human disease is a fierce competitor so we have to be fiercer (It’s a word, I checked). Be persistent and go through this cycle as may times as we need to in order to get the full picture so we can address all the issues. This will ensure nothing is missed and will also account for any acute changes that may have occurred since your initial evaluation. You might not need to repeat every step in the same way or even repeat every step at all based on what you find and based on what the patient wants. But this basic outline will be helpful in making sure everything is being covered.

Conclusion

I don’t claim this comprehensive approach to be a panacea. Few things in healthcare are. But it forces us to be more thoughtful. It gives some room for error. And it allows us to rise above our primitive brains and take a helicopter view at all the confusing traffic below. It won’t solve all of our problems or even most of them. But, if it finds one extra thing for one extra patient that ultimately benefits them in some way? It would be worth it.

Thanks for reading.

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