Taking a Deep Breath with Dysphagia: What the level of respiratory support tells you about your patient

By George Barnes MS CCC-SLP

Breathing and swallowing are two wings of the same bird. When well-coordinated, they fly together without a hitch. When out of tune, they can have a deleterious effect on one another and lead to a downward spiral.

One of the quickest indicators of the patient’s respiratory status is their support. But there are enough forms to take your breath away. There’s supplemental oxygen via nasal cannula, venti-mask, non-rebreather mask, high flow nasal cannula, CPAP, biPAP, and several levels of invasive mechanical ventilation (insert deep breath). These levels of support can be intimidating. What do they all mean? Should I hold off on seeing my patient if they are on one? I never studied to be a respiratory expert!

First, take a deep breath before you are the one that needs the high flow. The number one thing to remember is that the level of support actually only tells a small part of the story. You have to first put it into context in order to fully understand what’s going on…

1. WHY are they on x level of support? The cause is always more important than the effect. Is it an infection that is on its way out or end-stage COPD? Acute neurological damage with otherwise healthy lungs or late-stage lung cancer? This information will give us a better sense of the patient’s cardiopulmonary status, as well as their ability to expel aspiration and fight off an infection.

2. Talk to the respiratory team: What is the plan? Are they weaning or are we anticipating further decline? Someone smart said that timing is everything. They were wrong. But it IS still very important. If a patient is on the verge of intubation it probably isn’t the best time to start PO trials. Doing great on non-rebreather? Give them a chance on a venti-mask or a nasal cannula (with MD approval of course) and see how they tolerate PO.

3. Look at the device itself: Is this level of support likely to impact oral intake? General rule of thumb: the more pressure, the more likely it is to disrupt airway protection. Not much is black and white in this field, but if you see your patient on BiPAP or CPAP... Turn around and walk out. These devices are meant to seal off the nose and mouth to create enough pressure in the throat in order to open up the alveoli in the lower airway. Put food and liquid in there and it could have the same destination (The products even come with warning labels). Also- anything with a mask is tricky. Remember, every time the patient takes PO that mask has to be removed. Over a full meal, that’s a lot of time without the support they need.

4. Use those clinical skills you’ve been sharpening up. Is the patient awake and alert? Is the respiratory rate too high (anything over 30 means the patient has a VERY high chance of needing to inhale while they’re swallowing¹)? Do they appear strong enough to overcome the respiratory insufficiency and changes in pressure the respiratory support creates (check posture and oral motor function)? And if the risk is there- ALWAYS seek a FEES/MBSS to be absolutely sure of what’s going on.

There’s not going to be an “if this then that” algorithm that will tell us exactly who and who not to see. Take in the whole picture, know the patient as well as you can, ask lots of questions, and make the best clinical judgment you can in the moment. Take a deep breath and don’t worry- you got this.

Reference:
¹Steele, C. M., & Cichero, J. A. Y. (2014). Physiological Factors Related to Aspiration Risk: A Systematic Review. Dysphagia, 29(3), 295–304. https://doi.org/10.1007/s00455-014-9516-y

Questions, thoughts, suggestions? Please comment below!

About George:

George Barnes MS CCC-SLP has clinical experience in a variety of settings including acute care, acute rehab, skilled nursing, and long-term acute care. This variety has developed his specialization in dysphagia management with a focus on diagnostics through instrumental swallow evaluations. His concentration is on geriatric patients with complex medical status. He is the co-founder of FEESible Swallow Solutions, a mobile speech pathology company dedicated to improving access to high-quality dysphagia services for patients in the skilled nursing setting.

George has a track record of supporting the field of speech pathology by paying his knowledge forward to other professionals via graduate-level education, clinical fellowship and student supervision, the Student to Empowered Professional (STEP) mentorship program, The Medical SLP Collective mentorship service, ASHA special interest groups, peer review for ASHA course material, the SIG13 dysphagia editorial committee, and participation in various interdisciplinary teams and committees in the hospital setting. He is a multiple ASHA ACE Award recipient for his dedication to continuing education. George actively conducts and supports new research aimed to improve efficiency and accuracy in dysphagia diagnostics, management, and care.