BackTable / ENT / Podcast / Episode #59
Feeding Difficulties in Adults
with Theresa Richard, SLP
Theresa Richard, SLP educates us on the best approach to evaluating the adult patient with swallowing difficulty, including the importance and challenges of obtaining high quality assessments, and recommendations for therapy.
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BackTable, LLC (Producer). (2022, May 10). Ep. 59 – Feeding Difficulties in Adults [Audio podcast]. Retrieved from https://www.backtable.com
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Theresa Richard, SLP
Theresa Richard is a speech language pathologist and the founder of Mobile Dysphagia Diagnostics in Florida.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
In this episode of BackTable ENT, Dr. Ashley Agan, Dr. Gopi Shah, and Theresa Richard, a board-certified speech language specialist (SLP) in swallowing and swallowing disorders, about diagnosing and managing adult dysphagia.
First, Richard speaks about starting Mobile Dysphagia Diagnostics, a company that provides mobile FEES studies, her experience with having a son with a swallowing disorder, and her recent career shift towards providing speech-language education for her colleagues. Then, she discusses the two primary swallowing imaging studies: the modified barium study (MBS) and fiberoptic endoscopic evaluation of swallowing (FEES). MBS, also known as video fluoroscopy, was traditionally the gold standard for swallowing imagery. It is the superior imaging technique for detecting esophageal issues and provides a better understanding of the oral phase of swallowing. Richard prefers to use FEES first because it provides a live picture of laryngeal and pharyngeal structures. It is useful in patients with secretion issues and post-head and neck cancer surgery patients. Mobile FEES is also an option, which involves an endoscope with recording capabilities and a laptop.
Next, Richard discusses how to work up a patient with dysphagia. She starts with taking a thorough history and asks the patient about their dietary routine, and their medical and surgical history. Common medications that may cause dysphagia are muscle relaxants, L-DOPA, and medications that can cause dry mouth, such as scopolamine patches. Next, she discusses eating habits, with special considerations for cultural practices, age, and disability status. She notes that functional swallowing can look different for individual patients. Patients who repetitively aspirate may have recurrent pneumonia and require further evaluation. The first basic test she performs is watching her patients swallow 3 ounces of water. If they cannot swallow the three ounces, she moves to imaging studies. If they can swallow the three ounces, she escalates the test and starts to give the patients thicker liquids and different food types.
Some patients with dysphagia may require special considerations, such as ICU patients, patients with nasogastric (NG) tubes, and head and neck cancer patients. Richard notes that the conventional rule of waiting 24 hours to give an ICU patient food is not supported by evidence. She performs swallowing studies in these patients, but is observant for issues. Richard also believes that NG tubes should only be placed and left in if absolutely necessary. She has taken care of elderly patients who have had malpositioned NG tubes or NG tubes that have been left in for too long, which has severely impacted their swallowing. For head and neck cancer patients, she emphasizes the importance of working with a specialized speech language pathologist before and after their surgeries. Additionally, they may face more problems with dysphagia due to radiation therapy and chemotherapy
Finally, Richard discusses how ENTs can help SLPs by providing a solid case history and being available for communication throughout the patient’s therapy. She also discusses a new type of therapy, adult neuromuscular stimulation, but notes that the parameters may be dangerous and not FDA approved.
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[Theresa Richard SLP]
Yeah. If the patient obviously can communicate, and if they can tell you, or if you have access to a family member too, I like to sort of hear what does a normal meal look like? What foods do they typically like to eat? What are some cultural considerations to think of too? Because sometimes we'll make recommendations to slow a patient down or things like that, but it's the way they've been eating for a million years. And a lot of patients with developmental disabilities, especially, kids with down syndrome, they eat in a very, for lack of a better term, it looks ugly under a swallow study. You would just say, this is a mess, but for them it's completely functional. And they may have never had an aspiration event. They may have never had a pneumonia. So it's really important to collect that data ahead of time, because what we've seen in our field is sort of just being too conservative by saying, oh my goodness, this is not functional. We need to alter the diet or we need to thicken the liquids. And then you can send the patient to all these behaviors because you've just modified things that they don't understand, or for what reason and decrease the quality of life. I like to take a lot of steps back and just see what is normal, what is considered functional for them? Because we're just learning now that the range of normal is much, much, much bigger than we once thought. So if we can get that information from the patient or a family member, that's something that's really so crucial because we don't want to be thickening a patient’s liquids without knowing for sure that that's absolutely what they need to be on.
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.