BackTable / ENT / Podcast / Transcript #59

Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Defining Key Terminology for Dysphagia

(2) Utility of Various Swallow Studies

(3) The Importance of History Taking and the Impact of Medications

(4) Aspiration Pneumonia Considerations

(5) Working With Different Dysphagia Patient Populations

(6) Considerations When Discharging Dysphagia Patients

(7) Best Practices for ENT Referrals to Speech Language Pathologists

(8) The Role of Stress and the Psychological Component of Dysphagia

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[Gopi Shah MD]
Hello everyone. And welcome to the back table ENT podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice.

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[Gopi Shah MD]
My name is Gopi Shah and I'm a pediatric ENT, and I'm here with my lovely, amazing colleague podcast, cohost, and my dearest friend, Dr. Ashley Agan.

[Ashley Agan MD]
Hello, Gopi. How are you this morning?

[Gopi Shah MD]
Excited. I'm happy. I'm always excited to be here on this podcast because we have amazing guests. And the last couple of days, it's our national COSM meeting. And so it's been nice to run into old friends, colleagues, mentors, and just more amazing people.

[Ashley Agan MD]
Absolutely. I know I felt the same way after getting to kind of run into some old friends and have a conference in person again, that was cool. Just to have that energy and be able to see people. It was a lot of fun. So, can I introduce our guest today.

[Gopi Shah MD]
Oh, yes, yes, yes.

[Ashley Agan MD]
Theresa Richard is a board certified specialist in swallowing and swallowing disorders and a medical speech and language pathologist in Jacksonville, Florida. She's founder and CEO of Medical SLP Collective and MedSLP Education and has her own podcast, “Swallow Your Pride” podcast. She is the author of the book, So You're Having Trouble Swallowing. She previously owned Mobile Dysphagia Diagnostics, which provided mobile FEES studies to thousands of patients in over a hundred skilled nursing facilities across four states. Welcome to the show, Theresa.

[Theresa Richard SLP]
Thank you for having me.

[Gopi Shah MD]
First, tell us a little bit about yourself and your background, your practice.

[Theresa Richard SLP]
Yeah. Yeah. So, went to grad school to be a speech pathologist. Always just wanted to get into a helping profession, really. I have a brother with cerebral palsy who used augmentative communication devices growing up. And I just was always frustrated with lack of access to the communication technologies and things like that. So that's really what sparked my interest in speech pathology to begin with. I went to graduate school, thought I was going to come out working with kids, did my fellowship with kids and realized that I did not want to work with kids. And decided to take another fellowship in the nursing homes. And oddly enough, I ended up just loving it. I did not think I would ever work with swallowing disorders, but I just found the work to be so impactful. I loved connecting with residents in the skilled nursing facility that have had these amazing long lives and have done these amazing things. And now all of a sudden find themselves not being able to swallow, it's something that's such a huge part of our quality of life and just means so much to so many people. And then to all of a sudden, not be able to do it. I just found the work to be really, really impactful. So I worked in skilled nursing for about five, six years. And at the time we had a company come in and do mobile FEES procedures, which is fiberoptic endoscopic evaluation of swallowing. It's within the speech pathologist scope of practice to do it to evaluate swallowing. I know you guys use the endoscope for a bajillion other things, but we just use it as a camera to view the swallow.

So I decided I really loved that diagnostic portion. I felt like a lot of what we did was really a puzzle and just being able to give these patients answers as to why they can't swallow or what they might be able to modify or what they might be able to have at Thanksgiving dinner. So I really just love that diagnostic portion. And so I ended up starting a mobile FEES company when I was living in Las Vegas, Nevada. So I had that for a few years and then I had a son who was born with a very rare chromosomal abnormality. And of course he had to have a baby FEES when he was a newborn. So things hit really close to home there. It was really interesting because we did not have a speech pathologist in the NICU. He was in the NICU for 15 days and was not eating. And they really just had no answers for us. They just said, “oh, we'll figure it out. We'll figure it out.” And I just knew, you don't just figure it out. So that really set my mama heart into overdrive and really inspired the book that I ended up writing as well, because I had all this experience with patients at the end of life. And now I'm working with my own son learning how to eat at the beginning of life. So hit me with anything, I've got experience across all ages.

[Gopi Shah MD]
I think you said it perfectly, it's a puzzle. The more I, obviously my practice is pediatric, but the more I see kids that have trouble swallowing, dysphagia, whether they're NPO to certain foods. It is so complicated. It's not just a little, okay, just do this. It's really hard to kind of understand why, and then, how do we use the tools that we have and what's going to benefit what not. And, like you said, it's a major quality of life as well as health with weight gain and things like that to how we connect with our families and our people around us. So it's such a hard [thing] and really requires a team approach.

[Ashley Agan MD]
Yeah. So what does your practice look like now?

[Theresa Richard SLP]
Yeah. So I've worked in mobile FEES. I, like I said, moved a few times, worked across a few states. I ended up selling my mobile FEES company last year. And the reason was because in the meantime I realized while I was out in the field that even so many people in our own profession, even so many other speech pathologists, didn't realize what we were capable of. Just didn't have the tool set. Didn't have the skillset. You'll learn very little about swallowing in graduate school. And I think selfishly I believe it's the most impactful. I just don't think, as you've mentioned, Gopi, there's nutrition, and there's quality of life. There's so many things that require eating. So I sort of went on this crusade of just education and I started blogging and the blog sort of took off. And from there, that's when I started podcasting and started the “Swallow Your Pride” podcast. And from there, speech pathologists kept reaching out, wanting more and more and more knowledge. So I started a continuing education membership site called the MedSLP Collective.

And once COVID hit, I actually, I had another baby, went on maternity leave and then COVID hit. When I went to go back to work after maternity leave, COVID was raring and there was more of a need for me to be involved with the continuing education, because speech pathologists were just wondering, what do we do? How do we help all these patients? How do we help these patients coming off the vent? Can we do swallow studies on COVID positive patients? What are the precautions look like? So I sort of found myself just on the back end of the education aspect of it. Which was not where I ever thought I would be, but I love it. I love being able to do the digging in the background and help deliver information to people that are on the front lines, people that are in the field like this is what the research says. This is what other facilities are doing. These are the procedures that other facilities have come up with. So it's been really, really rewarding to be on that end of it.

[Ashley Agan MD]
Yeah. And I don't want to skip over your podcast, her podcast is like number 10, number 11, like it's in the top of apple podcasts for medicine. So Theresa is a big deal. It's a pretty amazing podcast that is reaching a lot of people. So Bravo.

[Gopi Shah MD]
And, the title is amazing. I love it. “Swallow Your Pride.” It's amazing. It's a great title. And the, and the book title is great too.

[Ashley Agan MD]
I think another thing with speech therapists, or speech language pathologists, there's a bit of a branding issue when you're talking to patients about, I'm sending you to the speech therapist for swallowing. I find myself always having to kind of say like, well, but that is, they're also experts in that because they're like, I don't need a speech therapist, I can talk fine.

[Theresa Richard SLP]
Yup. Yup. Yup.

[Gopi Shah MD]
Yeah, and well, and I think it's, so it's one thing where you're kind of like, okay, this is what we're going to do. And then honestly, for my side of it, sometimes I don't always really know or understand, or maybe have the exposure to all the details and different things that the speech language pathologist does and offers. And really since I've been in my practice, I have to say coming out of training, I definitely didn't really get it. And the more and more I see patients, the more my poor speech pathologists here, Ashley Brown, she's like our swallow expert for our pediatric ENT patients. I send her stuff like messages all the time, questions all the time, because it's just such a hard patient population.

[Theresa Richard SLP]
Yeah. Yeah. Yeah. It's tough. And, and it's interesting. Because like I said, we don't get much training on it in grad school. There's a few graduate programs that have really intensive medical backgrounds, but on the other, most of us have just been out there working, learning by experience, learning, reading the research ourself, attending different conferences. So it's sort of the wild, wild west. It just was something I became so passionate about that I just dove head first into all the research and I just wanted to know more about this area because like I said, I just think it's so impactful and just, such a quality of life, but on the flip side and I don't want to talk about the negatives, cause I'm a half glass full person all the time, but we have a lot of speech pathologists in the field that mean well, and that think they're doing the right things with their patients and might be doing some exercises that we once thought were good, that we have no research or even effective. And same with swallow studies. People think it's pass/fail, and it's not, they can tell us a ton of information. So really just what I do is I just want people to be able to have this information at their fingertips so that they can help their patients the best that they can. Because what I don't want is a patient to go to a speech pathologist, say they have swallowing trouble and just not get the answers or not get guidance that they needed.

[Ashley Agan MD]
Yeah. I think it's so true that eating is such a core part of how we socialize and part of who we are, when patients can't eat anymore, it's a big deal.

[Gopi Shah MD]
Yeah. Whether it's your baby, your grandparent, your spouse, your friend.

(1) Defining Key Terminology for Dysphagia

[Ashley Agan MD]
Yeah. Having that anxiety or embarrassment about going out to eat with people, just all over the place. So let's get into talking about dysphagia and Gopi and I, when we were talking about it, we were thinking, well, first we probably need to just set the stage with some terminology because even Gopi and I use different terms when talking about, barium swallow, modified barium swallow, video fluoroscopy, FEES, there's all these different terms. That are technically swallow studies, different ways to look at the swallow, but if you can call them different things depending on who you are, where you are, or tell us about that.

[Theresa Richard SLP]
Interesting. The modified barium swallow study has been around a while. Gosh, I think maybe in the seventies I believe is when Dr. Jeri Logemann, basically, I don't want to say invented it, but pretty much is the one that came up with that procedure. And that sort of was the gold standard for the longest time. And that is an x-ray, it's done from the side. So you're able to see the swallow on an x-ray. Dr. Susan Langmore in the nineties, basically invented FEES, which is fiberoptic endoscopic evaluation of swallowing. It's a top-down view obviously with the endoscope. So each has their pros and cons. What I like to say is which test is best. And to me, it's the one you can actually get. And I think we all know limitations of working in hospitals, working in doctor's offices. Are you rural? Where are you located? Sometimes the logistics of getting the ideal test just do not happen, especially if you're in the NICU or working in skilled nursing. For me, ideally, I just always say the test you can get is the best. We can obviously get into the pros and cons of some.

What I do want to talk about also is the difference between the modified barium swallow study and a barium swallow that GI does, because so many times this is something that I just want to educate every intake coordinator and her schedule or at a hospital. I even went through it with my own son. We were trying to get one scheduled. And she's like, are you sure you don't want the barium swallow? And I was like, no, I know what test I need. And so that's just so frustrating and I hate that they're coined so similarly, but video fluoroscopy is sort of the new name now or a video swallow basically because it's done with fluoro. So, a lot of people still do call it the modified barium swallow study, but video fluoroscopy is now sort of the new term to use.

[Ashley Agan MD]
Okay. And, that's probably better because then it takes the barium name out of it. So you're less likely to confuse barium swallow and modified barium swallow. Okay. Good to know.

(2) Utility of Various Swallow Studies

[Gopi Shah MD]
And when you're thinking, let's say you, I think you make a great point. It's which one can you get? But let's say you have a patient that will tolerate both. Which one do you like for what problems or which one tells you what?

[Theresa Richard SLP]
So in my perfect world, I would always do a FEES first. And I say that because I think there's so much information that it can give us right off the bat. It's a real live picture. So you're viewing the larynx, you're viewing the vocal folds, you can see the esophageal inlet. So there's things that you can see right off the bat that we might be able to say, “Ooh, this is something that just needs to go right to ENT, or this just needs to go right to GI.” I think sometimes we get ahead of ourselves and try to intervene and try to fix things therapeutically that might need surgical or medical intervention. With the FEES specifically, a lot of times, I mean, we just see so much, effects of reflux or even allergies, things like that. So that's when we got to send them off to you guys to just get them medically or surgically stable first.

So that's why I'm such a big believer in FEES as sort of the primary tool, especially because it is so easy for us to use all the time and doesn't involve all the logistics of radiology, but things that you see on FEES, we assess, especially a lot of secretions, a lot of these patients that are trachs and vents, secretions are a huge thing. So we can sort of tell if they have secretion management or not. We are able to view different foods and liquids and textures that we can actually see them on the FEES. We assess for different laryngeal, pharyngeal anatomy, and sensory deficits. You can view if there's vocal fold paralysis or paresis, you can check out why there might be different voice changes. And especially, it can be really beneficial for things like pre or post head and neck cancer surgery as well. So those are sort of the top things that you would really want to go to FEES first. But like I said, I'm really biased. And I admit that, and I always say that FEES is the best tool to use first, but a lot of people that don't have experience with FEES and still believe that video fluoroscopy is the gold standard, I'll absolutely take the information we can get from that any day, but videofluoroscopy is superior when looking at esophageal issues, because we're able to see basically from the nose down to the stomach, if the radiologist allows us to scan down that far and get a view of the lower esophagus as well, you do get a much better image of the oral phase of the swallow on video fluoroscopy, because it's on the side. So you can tell if there's chewing, rotary chew, if they're able to, basically bolus transit. You're able to tell if the tongue is moving in the right direction, all that stuff. So, Yeah. Those are pretty much the biggest differences about when you would use one or the other, but a lot of it comes down to logistics if I'm being honest.

[Ashley Agan MD]
And for your FEES, you're using dyed foods? You do thin liquids, thick liquids, puree, a cookie or something like that. And looking for residue and seeing how it passes.

[Theresa Richard SLP]
Yep. I just was trained to use green food coloring. So that's what I use. It colors the water easier. It's very easy to see on the contrast versus sort of the pinkish reddish features that we see. There's been a lot of research that's been done actually lately with white food coloring. So like white cake frosting dye and what they found is that actually the white is able to be visualized much better than any of the others when it is going down into the trachea. So it's been interesting to tell are patients aspirating more than we think they are with this white dye versus any other color. So that's been some interesting findings that have really come to light in the last few years that I know a lot of the researchers are looking into.

[Gopi Shah MD]
I wonder if when something goes through the cords, it's going to be shadowed and it's going to get, it's kind of dark down there and then wow. But I would have never thought about that.

[Theresa Richard SLP]
I think it's so fascinating. Like I said, I've been doing FEES for, I started in 2013, so almost 10 years now. And just to watch the technology improve as rapidly as it has I just think of the original endoscope that I had, sort of the grainy structures. And now it's this HD you can see just, it's crazy. You can see now. Yeah. It's beautiful.

[Gopi Shah MD]
So when you were just going to the mobile FEES practice, what were you taking with you? Did you also have a tower and a screen? Were you recording these? Is it mostly just what you see in your eye?

[Theresa Richard SLP]
Yeah. So, you guys are lucky enough that you get the big, huge, beautiful towers, but obviously that's not ideal for mobile. So a few companies make these mobile units, which is essentially just a laptop or like a tablet, and then the endoscope just plugs in via USB. So it does have recording capabilities, it's actual medical technology software on there. So I literally would just carry like a little briefcase with the laptop, with the endoscope, the USB cord in that. And then I also carried a bag that had the cleaning solution, alcohol swabs, everything that we need for the high level disinfectant to do that, as well as the green dyes. I would bring in, depending on which state, some states allow you to bring foods into the nursing home, some do not. So sometimes it had to use what they had there, but I like to make it really individual for the patient, to be honest. We do have protocols in that you should start with thin liquids up to thickened liquids, and then different food textures. But I really like to see what the patient likes and that's something that is my high horse. I will talk till the cows come home about patient preference and what's important to the patient and the family. And we can trial all these different textures, but if it's nothing that they even care to eat, then how do we transfer those results over into what they really want to do at home? So that's something I really would try to do too, especially in a skilled nursing setting, or if we know they're going home soon, what foods are you going to eat all the time? If I tell you to eat this, are you actually going to eat? So I like FEES in that I try to make it very individual. And I had this one woman, all she cared to eat was M and M's. And so we did the study with M and M's and she aspirated all the M and M's, but we at least had that information.

[Gopi Shah MD]
Oh man.

(3) The Importance of History Taking and the Impact of Medications

[Ashley Agan MD]
So in your evaluation, I guess we'll just kind of take it from the top, as a patient comes to see you or you're going to see them, if it's mobile, what's the history taking look like? What's important? What are important things to be asking? And I guess, another thing from our side of it, what important things that we need to be asking to, before we're sending patients your way?

[Theresa Richard SLP]
Yeah, yeah. It's sort of all the above, just a normal case history, what surgical interventions have they had? What does their medical history look like? Medications is a huge thing too, as I'm sure you guys know, medications can impact the swallow greatly. So sometimes it's just nothing that we can do therapeutically as much as just recommending, sending them back to the physician, getting a change in their medications.

[Ashley Agan MD]
Are there particular medications that are common ones that stand out that affect the swallow?

[Theresa Richard SLP]
There are, especially a lot of muscle relaxers. If you think of the swallow, it's about 40 different muscles that make the swallow happen. So sometimes if you have patients on Ativan or something like that, or another form of muscle relaxant, and they complain that they can't swallow, that's something to consider. So that's sort of when we work closely with the psychologists and the facility too, to see what can we do to sort of relax this patient or ease the behaviors that they're having, but also still allow them to be able to eat by mouth because it can be very dangerous. There's many cases of patients aspirating or choking while on a muscle relaxant.

The other thing is the Parkinson's medication. So Levodopa. The timing of those, we've seen, it's night and day. If you see a Parkinson's patient before or after they've had their medication, it can be just the most uncoordinated swallow ever, but you give them the medication and it's all of the sudden beautiful. So that's one thing as soon as you see a patient with Parkinson's and if you know that they're on Levodopa regimen, make sure that they're eating about a half an hour after they've been given that medication. So that's something that's very common in that to be an easy solution in nursing homes.

[Gopi Shah MD]
When you do your evaluation, do you have them time the medication so that you get the best possible test?

[Theresa Richard SLP]
Ideally. Yep. Yep. Cause sometimes you just can't get anything. And also just educate them too and just say, Hey, without this medication, you're going to be calling me in again, because it's going to be really ugly. The patient's going to be struggling. So do you want to do it before the medication or after? There's obviously pros and cons to both sides, but you want obviously the patient to be eating and swallowing as effectively and safely as possible.

[Ashley Agan MD]
Do you find that medications that have dry mouth as a side effect of those? Because I tend to blame that a lot because I'm like, well, you just don't have enough saliva. And your mouth is too dry. Do you see that?

[Theresa Richard SLP]
Absolutely. Yeah, Yeah, absolutely. And I think, one thing too, is those lemon swabs. A lot of people tend to in the nursing homes or in the hospitals tend to tell people to use those, to sort of do oral care, which no, we should just be using a toothbrush and toothpaste for oral care, but the lemon swabs too dry out the mucosa immensely. So then people don't have enough saliva to be able to produce a swallow. So usually I just tell everyone, please throw out all the lemon glycerin swabs. And yeah. So if you're a producer of those, please don't come after me, but figure out a way to keep the mouths wetter.

[Gopi Shah MD]
Yeah, that's a good question, Ash. And when I think about it in the peds world, Theresa, do you ever see, in terms of secretion right? Secretion management is a big thing. And every once in a while a patient might be on something like glycopyrrolate or a scopolamine patch to help dry it up a bit. Do you ever find that that can be that dysphasia or something can be a side effect from that medication as well?

[Theresa Richard SLP]
Absolutely. I know the scopolamine patches are such a necessary evil sometimes. I know we see patients, almost for lack of a better term, drowning in their own secretion. So they'll be recommended one of those patches, but then on the flip side, it dries them out so much that they can barely swallow. So that's something that I think is so important for the speech pathologist and the doctors to work so closely together to weigh the pros and cons of that. Because I've seen the scopolamine patches help tremendously, but then I've also seen them tip back the other way and cause all these unwanted side effects. So when I do see that patch, I usually will bring it up and just probe a little bit more. Why did you start using this patch? Have you noticed anything different since? And sometimes patients are like, it's been a lifesaver and other times they’re like I'm so dry. So that's when we'll go back to the doctor and just try to brainstorm it. Is there something else we can do?

[Gopi Shah MD]
It's such a hard balance. Because of secretion management, aspiration, are they eating and drinking that little bit, how much benefit? It's such a tough balance with so many different factors.

[Theresa Richard SLP]
Right, right. Because obviously we don't want them aspirating all their own secretions too. So if it's helping in that aspect, then that’s wonderful.

[Gopi Shah MD]
Yeah, but like, if there's amazing pleasure and that 15 CCS of whatever, four times a day, like that's a little bit of joy that I can bring my kid or my relative. That's still huge too.

(4) Aspiration Pneumonia Considerations

[Ashley Agan MD]
Moving on kind of through your visit and you've asked your questions and kind of gathered your history. What's next, I guess, it might depend on where you are, right? If you're at bedside or from your office.

[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.

[Ashley Agan MD]
I'm glad you brought up pneumonia. Because I think, when I was a junior resident, I kind of thought if a patient coughs, when they eat, then they should be NPO. Like aspiration equals don't eat. Right. But, now it's like, well, if you're not getting pneumonia, then maybe you have a strong cough and if you aspirate a little bit, you can get it out and we don't have to just keep you from eating. Right. Which is probably the worst thing you can do for a patient that's maybe having some issues. Because maybe, I don't know, you don't use it, you lose it and maybe things get worse. I don't know.

[Gopi Shah MD]
I was going to say those little minor modifications might be 20,000 steps back. I feel like, tell us about your experience.

[Theresa Richard SLP]
Yeah. So we know a lot more about sort of the pillars of pneumonia at this point. Now we know that you have to have a lesser functioning immune system. So if you have a well-functioning immune system, your chances of getting pneumonia are a lot less. Another thing to consider is the oral microbiome. What does that look like? If you have healthy oral care, you're brushing your teeth, toothpaste, mouthwash, you're killing all that oral bacteria. So the chances of it, even if it does go into the lungs and you aspirate, the chances of it turning into pneumonia are really slim. And part of the healthy immune system, we say, are they a walkie-talkie? Are they walking and talking? Because if they're up and functional and moving, then obviously they're going to have a stronger immune system. So those are things to consider too, before we even look at, okay, so is this patient aspirating? Okay. Yes they are. But how was their immune system? How is their oral care? These are the things to consider. If those things are poor, then we know that they're at a much higher chance of aspirating.

My son for one, is what we call a functional aspirator. So he does aspirate. We've seen it on a swallow study. He's never had pneumonia. Obviously, he's got severe special needs. So we are religious about brushing his teeth constantly. He doesn't walk on his own. He uses a gait trainer, but we make sure to get him up in it a few times a day, things like that to keep walking, keep his immune system functioning. So there's a lot to consider with that. And then on the flip side, if we do see that patients have recurrent pneumonia or they are in for aspiration pneumonia, what causes it? So then we try to go backwards and figure out that puzzle piece, is it because of a poor immune system or do they have a true dysphasia? That they are aspirating all the time. So we've talked about, this is just a really complex mechanism.

But, Dr. Susan Langmore, who's one of the researchers that created the FEES procedure that I do, actually wrote a seminal paper. I think she wrote two iterations of it, 1998 and 2002, on the predictors of aspiration pneumonia and dysphagia actually was number seven. So, things like dependent for oral care, dependent for feeding, the number of medications, smoking, multiple medical diagnoses, number of decayed teeth and suctioning are all before dysphasia. So these things are all really important to consider as well. And like I said, we for just lack of knowing better, just assume when you aspirate it turns into pneumonia. Right. But there's so many other factors that we have to consider before we just say, oh, you're going to get pneumonia if you aspirate, here's some thickened liquids, good luck.

(5) Working With Different Dysphagia Patient Populations

[Gopi Shah MD]
Can you tell us a little bit about the different patient populations that you see and those nuances, whether it's the stroke patient, the head neck cancer patient, and I think you'd mentioned some of your prolonged intubation patients. how does that affect?

[Theresa Richard SLP]
Very much so. And I think that's what's interesting because it causes a lot of conflict in our field because we do have SLPs that work with, like I said, these walkie talkies, these patients that may have had a stroke, so they may have some impaired muscle functioning. They may have a paralyzed vocal fold, but other than that we're able to rehab the swallow back to it being functional. On the flip side, you might have a patient that's in the ICU or a patient that has had neck cancer. We're going to be much more conservative with those patients, especially the transplant population, the lung transplant population. Those you have to be extremely conservative with. So, a lot of times within our own field, you'll say, oh, I never use thickened liquids or I use thickened liquids all the time. And, we sort of have to back up and say, okay, what setting are you working with? What patient population are you working with? Because that makes a world of difference. Working in home health is going to be a lot less conservative because the patient is home. They are stable. Whereas obviously seeing patients in the ICU that may just be post-COVID coming off the vent, we're going to be a little more conservative with those. We work with a lot of different patient populations, in the NICU, with developmental disability. So there's a lot of populations that we work with and it's just something that I do in my continuing education is just make sure that what we're doing and the patient populations that we're serving, we're really knowledgeable in those conditions and how those specifically impact the swallow. And we're not just treating with this blanket approach to everything.

[Gopi Shah MD]
Yeah. That's a great point. Even in our own practices. I mean, how many times Ash, have you changed up either your workup or your management options, whether it's something, ear fluid is ear fluid or whatever it is, but because of the actual, when you tease out the clinical history, it's a whole different thing, right?

[Ashley Agan MD]
There's always nuances depending on the patient and what you’re trying to treat, what are your expected outcomes and that sort of thing, for sure. Can you walk us through some of the different assessments? So for example, what does a bedside swallow evaluation look like in the ICU, versus the kind of workup you would do when you're in a clinic or seeing patients outpatient.

[Theresa Richard SLP]
Yeah. Yeah. So pretty much going to do the case history, do a clinical swallow examination, do a cranial nerve exam. Those are obviously pretty important for us to figure out is what we're working with. Neurological, what are the impairments there? The clinical swallowing exam, you're going to probably start with the Yale swallow protocol or just a three ounce water challenge. These are actually nurses can even do these, can be a nursing screen. So you take three ounces of water. And if the patient is able to chug the entire thing without stopping, without taking a breath, they are considered passed. So it means they don't have to go on for further swallowing evaluations. I will say the caveat with that is we are finding that for some different patient populations that the test isn't as reliable as we thought. So sort of back to the drawing board with that, but that at least gives us a good foundation because if, like I said, if they had to stop, if they had to cough, if they had to do anything, it should go to an automatic instrumental assessment. So FEES or video fluoroscopy. Yeah, depending on what the patient looks like, we might trial some foods and some liquids with them, obviously if they’re in the ICU, we're not going to go there right away. But if they are coming to the clinic, we'll try some different textures, see how they do. Things that are also important is different coughing. It's a huge thing. If they're able to cough, then that's a good thing. Right. They're able to protect their airway. So, those are things that we assess as well.

[Ashley Agan MD]
And I would think that drinking a cup of water, that challenge is going to be more sensitive for picking up someone who might be at risk for aspiration. Because when you drink water, it's going to go down faster, but you may not catch people who are going to have issues with solids or thicker foods. We have patients who are like, oh, I have trouble swallowing bread or things like that.

[Theresa Richard SLP]
Yup. Yup, Yup, yup. So that's obviously the nuance of the test, right? So, that's part of teasing that out a little bit more and trialing the different food textures. There's a lot that we do and there's sort of a movement away from doing just that from just watching your patients eat as an assessment, to doing a lot of these other tools, we have a lot more rating scales and things like that now that help us get a lot more information about our patients than just sort of like you said, sitting and watching them eat bread and seeing if they can do it or not.

[Gopi Shah MD]
Yeah. Well, and I would imagine, I mean, do you ever have to, like, if you're in the ICU or even maybe routinely, do you ever have to have a section available? Do you have to tell RT or the nurse, like, “Hey, I might need an extra hand.” Because things, most of the time before speech is involved you think that the patient's ready for that, right?

[Theresa Richard SLP]
Yes. Yes. That's very hospital specific and the ICUs all sort of have their own practice patterns of how they do that. A big thing that we're sort of starting to overturn is this 24 hour rule. It used to be that when a patient came off the vent, they had to wait 24 hours to eat or drink. There wasn't really research to support that. It just was sort of like this guideline that was put into place and nobody really knew why. So, depending on the patient's status and respiratory status, all that stuff, it's getting to be a lot sooner. That being said, sectioning is something that speech pathologists can do if they're deemed competent by a respiratory therapist or whatever the competencies in that hospital are. So, I worked in one long-term acute care hospital that I was competent to do the suctioning. I worked in another one that they didn't allow us to do them, RT had to do it. I worked with some wonderful respiratory therapists and I'm like, can you please come help me? So luckily I've worked with some phenomenal RTS and it is what it is, but, yeah, I know there's definitely been a big push to get speech pathologists, to have this competency to be able to manage the patients on their own. We do, speaking valve trials and actually they're called speaking valves, but they're actually also called speaking and swallowing valves. So doing those trials are important for us to be able to suction if we need to inflate, deflate the cuff, all that stuff, as long as we've been deemed competent by the facility, is something that we're able to do.

[Ashley Agan MD]
Yeah. Speaking of, for example, patients who have a trach or maybe patients who have an NG tube or a Dobhoff tube, there's other things that are in the upper air to just track that are usually not there. And, just thinking intuitively, it seems like those are going to affect your swallow.

[Theresa Richard SLP]
Yes.

[Ashley Agan MD]
How do you take that into account when you're assessing someone? Because you assume, okay maybe some of this dysfunction is because that's there. But we're also trying to kind of move you along and pass the patient to be able to start eating more. How does that play into your evaluation?

[Theresa Richard SLP]
Yeah. And I think that's the necessary evil of the NG tubes, right? I mean, I used to love FEESing patients with an NG tube because you would just pass the scope right along next to the NG tube. And you had very clear entry there. But on the flip side, how many NG tubes have you've seen that have been twisted and wrapped around and in horrible positioning? And that gives your answer right there. A lot of it depends on how long they've had the NG tube as well. We all know they should not be in there long. It's a temporary fix, but sometimes these patients get sent from the nursing homes with them, or they get just lost in the shuffle and they have them for an extended period of time. And swallowing, as you mentioned, is a use it or lose it type thing, and the best cure for a swallowing problem is swallowing. So if this is in there and it is impeding, what we try to do is can we pull it to get some exercises done? Are there alternate means of nutrition? Do they really, truly need the NG tube? So there's a lot to evaluate here because we absolutely have seen a lot of patients that their swallowing is impaired because of the NG tube. And once that's pulled, they're able to regain functioning pretty rapidly.

[Ashley Agan MD]
What are your thoughts on a G-tube tube, do you feel like it's better to move forward and maybe do that earlier just to get the NG out of the way and get them able to practice more eating normally and then just supplement nutrition with the G-tube or do you feel like, I mean, it's probably patient-specific…

[Theresa Richard SLP]
Definitely patient specific. And I would say sort of the camp that I'm in is we want to avoid a G-tube at all costs. So we usually are begging to allow the doctors to give us a few days to rehab the swallow. Usually, a lot of times it comes head to head on like a Friday night, right. And they just want to stick a PEG in the patient. It's like, please just give me till Monday to try to get some swallowing going to see if we can really get this patient going because what's so hard is it's tough to rehab the patient that has a G-tube. Because if you think about it, the G-tube is in the stomach, it's telling the patient that they're fed, that they're getting nutrition, it signals to the brain, “you don't need food, you're not hungry.” So going in to do swallowing therapy on a patient with a PEG, they're usually like, oh, I'm not hungry. I don't want to eat. I feel really full. I have this tube in. And it's sort of this mental gymnastics that you have to tell them, like, I know your brain's telling you that, but I'm telling you that we need to try to swallow because that's the only way that we're going to get rid of that tube. So, it's a big school of thought that we want to try to prolong the G-tube as long as humanly possible. Obviously we don't want to starve our patients or have them lose nutrition status or anything like that. But if there's something that can be done in the meantime that's really what we try to fight for.

(6) Considerations When Discharging Dysphagia Patients

[Gopi Shah MD]
Yeah. I find that we have a lot of infants that are home with a Dobhoff tube for months depending on their overall clinical history, prognosis, our pediatric GI and SLPs are amazing when it comes to outpatient management of that. And, again, I don't do adults anymore, but I did find that dispo-ing, right. You had to figure out how to get the patient out of the hospital and having an NG or a Dobhoff as internal access, always limited that as well. And is it more common to dispo adults now with NG and Dobhoff, whether it's skilled nursing, LTAC home, or do you find that that's not as much of an issue anymore?

[Theresa Richard SLP]
I would say it really depends. I've worked in some facilities that absolutely. And I've worked in others that really try to avoid that as much as possible. So I think it really just depends on the interdisciplinary team there, because I think we all want them to be as stable nutrition-wise as possible, but we also don't want to make it an even harder rehab road to begin with. So, it stinks because obviously now there's the big push for decreasing length of stay in the hospital. So we want to get patients out as quick as possible, but then the people on the rehab end are please, keep them one more day or stabilize them a little bit more. So it's really tough to balance. And I think that's just where it comes down to the interdisciplinary team, getting together and setting sort of these guidelines and these competencies in place like, okay, this is what we're going to do with this patient. Or this is what this really looks like. And the SLP fighting for one more day to, maybe get that NG tube pulled and get some swallowing started, or, working with RT to see is respiratory stable, things like that. So I just think it really comes down to obviously patient specific, but really the interdisciplinary team working together to figure out what's the best long-term plan for this patient.

[Gopi Shah MD]
Yeah. And I feel like rehab criteria is so stringent. I mean, they really are strong, or kind of firm maybe is a better word about when they feel like the patient's ready. And I think that's a great thing because they want it to be successful. Right. You don't want a bunch of back and forth and you want the goals of the rehab to be met as the patient's ready. So have to appreciate that.

[Ashley Agan MD]
But it's also frustrating to think that you're making clinical decisions based on the ability to go to rehab, right. That you're making a decision to put in a PEG just for a dispo. So it's tough. But it's the healthcare environment that we live in. So we make it work. Right.

[Theresa Richard SLP]
I know. I know.

[Ashley Agan MD]
We take care of a lot of head-neck cancer patients, which is a unique patient population itself when it comes to swallowing. Because a lot of times there's been an alteration in the oral cavity, pharynx, larynx, there's been surgery or radiation, all these types of changes. And so I think, those patients in particular are a unique group, and probably need to start working with an SLP, from the beginning. I don't know, what's your experience with that?

[Theresa Richard SLP]
Yeah. Yeah. So a lot of my really close colleagues, that's really all they do. They work in these head and neck cancer centers and that's really all that they see is they see patients prophylactically and get them started on swallowing exercises before the surgery. So, there's a lot of research, obviously, that getting started with exercises, prophylactically, is so important. I've worked with a few laryngectomy patients. There was one place that I worked, that we got a lot of laryngectomy patients and I haven't seen any since, but really, really fascinating to see patients swallow that have a laryngectomy. It's pretty amazing what the body can actually do, but I think one thing about our field that is so cool is that if you can specialize, it's really super rewarding to learn everything about that specific patient population. And I just, yes, like I said, some of my best friends work in these really specialized cancer centers and that's all that they see and, they know about the different chemo and radiation and the impact that that can have and the fibrosis and all the side effects that it can create. And so, I feel so passionately for them in the work that they do.

[Ashley Agan MD]
Yeah, and I think there's a misunderstanding that a patient with a laryngectomy, should be able to swallow no problem, cause they can't aspirate anymore. Right. They've had complete separation of their upper digestive tract. But, I remember attendings in residency being like there's nowhere else for it to go, they'll eat fine. Just put it in the mouth, it's got to go down, but it's a big surgery that changes all of that anatomy and it can take time to get to where you can get–

[Theresa Richard SLP]
Yeah, yeah. There can be fistulas. There can be all sorts of complications. Yeah, And I think that is a tough part. Obviously we want the surgery to go so smoothly. It's great when you have a laryngectomy patients that can eat without any troubles, but the reality is there's different pressures that are now changed and the swallowing mechanism really is just based on pressures. So there's a lot to consider and why they should have swallow studies pre and post surgery, and really pretty often actually throughout the whole head and neck cancer process.

[Gopi Shah MD]
I was going to say it's probably something that's almost lifetime. I mean, if you think about the head and neck cancer patient, if they've had primary surgery, whether it's a laryngectomy to whatever free flap to having a trach, then maybe getting decannulated, then having had potentially chemo, radiation, those long-term effects. I mean, the way everything changes whether it's anatomy and side effects are going to affect over time. And so I can only imagine your SLP is going to be your right-hand person to kind of help you gain all that back, whether it's speaking or swallowing in those patients.

(7) Best Practices for ENT Referrals to Speech Language Pathologists

[Ashley Agan MD]
As far as when we're sending patients to our SLP colleagues, what can I be doing, to kind of help tee up that visit? Are there things that we can have patients start working on or is it good to get some sort of swallow study before they see you? Do you like to have that video fluoroscopy swallow eval during that first visit when you're evaluating a patient or is it better to just, I guess it depends on if the SLP has FEES available to them. Right? But what can we be doing just to help set patients up other than reiterating that speech language pathologists do treat dysphasia.

[Theresa Richard SLP]
I love this question, Ashley. Thank you. I think the fact that you're even asking this just means so much to a lot of SLPs, but I think really the most important thing, a lot of times we get a lot of patients without any sort of paper trail whatsoever. And we have no idea where they came from, what they've been through, what medical intervention they've had, waht surgical intervention they've had, what pharmacological intervention they've had. So really just a solid thorough case history is worth its weight in gold to us. If we can get a swallow study ahead of time also, that means so much because that at least gives us a starting point to say, oh wow, it looks like they functionally improved, or it looks like they're going downhill, it gives us a good baseline. So in a perfect world, that would be wonderful, but really, truly just a solid case history. And I think just being accessible. We work as part of a big interdisciplinary team, and sometimes there's just a lot of holes in the story and, oh, could we just call the ENT and get some more information or could we call the pulmonologist and get some more information? I think that's usually, I, for lack of a better term, hate our healthcare system right now in that it's so hard to get ahold of each other. You have to call like the zero line at the hospital and track down everybody. And I just wish there was a way for medical professionals to like, have backdoor communication to, Hey, I've got a question about this patient, what can you tell me? So I think just being accessible or, letting the SLP know, Hey, my name's Ashley, here's the number of my office, let me know how I can help. That's really just so helpful because a lot of times we're just piecing together what we have with a patient that's been dropped in our doorstep for lack of a better term. And we're left to do the solo study with the information that we have in front of us with a very limited amount of time. And then you sort of send them back off into the world, like, did I answer all their questions? Was that the right answer? So, a really solid case history is everything.

[Gopi Shah MD]
Without that communication, it's so interesting that you could be like, as the ENT, I have one idea of what I think is going on, then they have an assessment or an evaluation it's completely different. And then I'm like, I'm obviously missing something. And so that dialogue is so beneficial for the patient. And it's easy when you're on the same Epic system or whatnot, but having to reach out and it can definitely make it real painful for everybody, for the patients too because they're just like, “Can y’all just talk to each other?”

[Theresa Richard SLP]
Yeah, yeah. I even went through that with my own son. He was sent to a rehab center and a speech pathologist evaluated him. And, she called, didn't know I was a speech pathologist and just gave me this whole report of like, he can't do this, we're going to modify his diet to this. He can't do this. And I was like, “Yeah, no crap lady.” And I was so angry because I was like, had they just reached out to me to begin with, I could have given them all this information, But instead, it seemed just like a whole waste of her time and medical resources to go through and do this whole thing and had really nothing to do with how he presents on a daily basis. So, obviously that could be a whole nother episode– interdisciplinary communication.

[Ashley Agan MD]
Absolutely.

[Gopi Shah MD]
Yeah.

[Ashley Agan MD]
Yeah. It's eyeopening when you're a patient, when you are on the other side of healthcare, it really changes the way you think about your interactions with patients when you kind of have to walk in those steps.

[Theresa Richard SLP]
Sounds horrible and inhumane. It's like a dog chip. You want to like put a chip in them with like all of their information, like so that anybody can read it.

[Ashley Agan MD]
Especially patients that have a complex medical history.

[Gopi Shah MD]
Do you all do a lot of adult neuromuscular electrical stimulation? The NMES or VitalStim is what I think people like to call it.

[Theresa Richard SLP]
It's controversial.

[Gopi Shah MD]
Is it in Vogue, out of Vogue?

[Theresa Richard SLP]
It depends on the patient population. It depends on the device that you're looking for. So, neuromuscular electrical stimulation is a wonderful tool. What depends is the device that you use and the parameters that you use, because there are some that are approved by the FDA and there are some that are not, and the answer is no, you can not just pick up any device, slap electrodes on someone's swallow and start zapping them and hope that they can swallow because you can send them into laryngeal spasms and all that. And we don't want to be on the end of that.

So, short answer, there's absolutely a place for it. It's just very device specific and I don't want to get into the nitty gritty of that right now, but there are some devices that I don't ever want to use because their parameters can be dangerous and are not FDA approved. And then there's others that are, so the big thing is that some of the devices really only are for sensory stim and there's others that actually have been shown on FEES and videofluoroscopy that they get actual motor movement of the swallowing muscles as well. So, really ideal for sort of those post stroke patients, really helping to sort of bring those muscles and nerves back to life after having a stroke. And, I’ve seen some really, really cool data with it. So it's a wonderful tool. It's definitely something we should have in our toolbox, but I just have to put that caveat and disclaimer out there that you can't just pick up any device and slap electrodes on a patient's neck.

[Ashley Agan MD]
Yeah. Yeah. Is it like a TENS unit?

[Theresa Richard SLP]
It is. But what I believe TENS is just sensory, right? Whereas I believe neuromuscular electrical stimulation is actually supposed to cause a motor movement as well.

[Ashley Agan MD]
Interesting. Well, and when we're sending patients to you, what can we do as far as setting expectations? Because sometimes I'll talk to patients, and say, maybe you may only have to see them one time and maybe they'll give you some exercises you can do on your own. They may want you to come back and see them a few times. It depends on the evaluation. That's kind of generally what I tend to tell patients, but, what other things should we say?

[Theresa Richard SLP]
It's really patient specific, to be honest, like a lot of patients want to improve rapidly. They want to be able to chew the finest chewiest steak ever, or some really just don't care. So, the prognosis and the length of treatment and the intensity of treatment really depends on their goals of care. And I think that's somewhere that we sort of get ourselves in trouble because we just assume, oh, well, let me just put you on a puree diet, you'll be on your way. And the patient gets home and they're like, what the heck? Like, no, I want a burger. I want a steak. Or on the flip side, you have somebody that maybe doesn't have dentures or just wants to eat ice cream for the rest of their life. They don't care about eating a steak. So it really, truly depends. So I think getting that information out in the case history. And when you're doing the swallow study, we have a lot of wonderful tools available to us. Technology is beautiful in what we're able to do. Now, we have a lot of different biofeedback tools that we can use. We do have some really intense dysphasia exercise programs too. So, there's a few different programs that, I mean, it's hours of swallowing therapy for three to four weeks on end. And we've seen some patients go from NPO back to eating again in a month on these protocols. So it really just depends on how much the patient wants to put into it and really what they want their quality of life to be. And if they want to eat ice cream for the rest of their lives, and they're fine with that, then we'll just do one or two sessions and tell them, do this, don't do this, do this, come back and see me if you change your mind or we will do some really intense rehab.

[Gopi Shah MD]
Can you do some of it virtually? Are y'all able to?

[Theresa Richard SLP]
Yeah, yeah. And the beauty of COVID, if there is such a thing, is that was one thing that right when COVID first hit I believe Medicare allowed us to do teletherapy for dysphasia, which they didn't used to allow. And then I believe they were going to overturn it, but they actually kept it that we still can do it. So I think that's been a game changer, especially for a lot of these rural, if you live three hours away from a major medical center, come in for your swallow study, but then if we can just do treatment, over Zoom or something, it's a huge, huge benefit to the patient. So, short answer, yeah. There's still obviously a lot of nuances with the different insurance companies and what they'll pay for and dealing with technology with patients. But I believe for the most part, it's a huge, huge, huge blessing. I actually have a friend in Texas and she just got some teletherapy regs overturned for working with babies. So she's actually, she's doing a whole seminar called “Fed with Telemed.” Just really helping the parents.

[Gopi Shah MD]
That's awesome.

[Ashley Agan MD]
Yeah. I think for virtual is here to stay in some form or another.

[Theresa Richard SLP]
Yeah. Yeah. And I think it's beautiful in this aspect, we can just do a lot of consulting and things like that and have them only come in when they really truly need to.

[Gopi Shah MD]
Well, and they're eating at home. So to be able to do therapy at home in their natural setting and where they're going to be, also those adjustments, modifications, questions,[Gopi Shah MD] hopefully only maximizes [success].

[Theresa Richard SLP]
Yeah. Yeah. And we do have, like I said, the technology is just wild, what we're able to do now. And there's a lot of different biofeedback tools that the patients are able to place on themselves and then we're able to read the muscle activation and things like that on our end. So that's really cool.

(8) The Role of Stress and the Psychological Component of Dysphagia

[Ashley Agan MD]
One more thing before, before we let you go. There's a patient group that I always struggle with. The patient comes in and their chief complaint is dysphasia. They're having some trouble swallowing. They have a normal, flexible scope exam. They are not losing weight, seem perfectly healthy and normal otherwise. Get a modified barium swallow, it's also normal. And they're like, well, doc, why can't I swallow? I really am having trouble swallowing. I'm really not gonna let this go. Because you tell them, okay, the good thing is everything looks normal, normal, normal, but they're like, no, I'm not normal. What's going on? How do you take care of those patients or what do you usually find?

[Theresa Richard SLP]
A majority of the time is it's muscle tension dysphasia, I'm not sure if you guys are familiar with that.

[Ashley Agan MD]
Yeah. Yeah. Let's talk about that. As I feel like I learned that term in the last, maybe couple of years from our speech therapists.

[Theresa Richard SLP]
Yup. Yup. And that's really sort of what we're finding. And, I believe there's even more work that came out this year. Even spelling it out even more. And a lot of it is just stress. They're seeing it a lot more now after COVID. It's really interesting because it's a lot of just where people are holding their stress and their tension, but it's so bad that the muscles are so inflamed that it's really impairing the swallow. So a lot of it is these vocal exercises, these vocal relaxation techniques. So, speech pathologists work with swallowing and voice. I only do swallowing, but a lot do both or some just do voice, but that's sort of where I rely on my SLP colleagues that specialize in voice to do these vocal relaxation techniques, which can help to relax the swallow. Something else that I don't know that it's controversial now, but I did write about it in my book because it comes up enough is sort of the psychological component too. And patients going for hypnotherapy or therapy, or they may have been through trauma subconsciously long, long, long ago. And so there actually is research and there are studies that have shown that, sometimes these patients need this subconscious change in order to be able to swallow if there is nothing that we can see on an actual swallow study.

[Gopi Shah MD]
I mean it makes sense when you think about, in our GI clinic, there's a GI psychologist, you know what I mean? So your swallow, it's all together. It's part of that theme. So it makes sense for sure.

[Theresa Richard SLP]
Yeah, I think as a medical professional, you want to just be able to see the problem and diagnose it and fix it. And it's not that easy sometimes. And I know some people think that's woo woo and isn't the truth, but there is some truth to it. And so I do want patients to know that is something. If they're desperate and want to research that a little bit further.

[Gopi Shah MD]
I think in ENT, especially because so much of it is quality of life, right? Some of the problems that we have, or see in our patients, whether it's vertigo, feeling dizzy, the migraine, the sinus headache patient, or, dysphasia. Any little bit that can help the patient move forward, whether you've identified something or not. And many times there's not necessarily a pathologic reason, or a surgery or medicine, but if there's some things, some tool, that's always helpful.

[Ashley Agan MD]
Yeah. And I've had patients who bring up stress to me. So, I may be talking to him and say, well, good thing is everything looks normal. We're not finding anything. And like, sometimes they'll say, do you think it could be stress? You know? And I'll be like, well, yes. Tell them are you stressed? Like, yeah, actually let's talk about that. So I think, patients are, kind of, cluing in, on how that mind-body connection works and how if you are stressed out, sometimes your body doesn't work right.

[Gopi Shah MD]
Sometimes as physicians, especially, I don't think we're always clued into that.

[Ashley Agan MD]
Right. That's not part of our training. Yeah.

[Gopi Shah MD]
We’re supposed to find that pathologic problem.

[Ashley Agan MD]
See the problem. Yeah. And fix the problem. [Gopi Shah MD]

[Theresa Richard SLP]
I've definitely gotten into some arguments with other professionals just in our field about it, because I'm just like, there's nothing else to explain. Like you said, and then you send a patient off to a psychologist or to further explore it and they come back and they're like, that worked. I had to do these exercises or do these different guided meditation exercises and it helped. So, I think it's one thing I know from being a mother and dealing with my son's issues, you have to listen to the patient, we know what we know, but we only know what we learned.

[Ashley Agan MD]
Yeah.

[Gopi Shah MD]
I remember this was probably January when Omicron was surging? And I had like a sore throat and a headache. I swear. I had thought I had COVID. Got the test three days later, and I was fine. And I was like, Nope, that's just me. Middle-aged, reflux, two kids and a headache. You know what I mean? There is nothing wrong. Okay.

[Theresa Richard SLP]
Yup.

[Gopi Shah MD]
Take a look in the mirror, figure your stuff out. It's not COVID, go back to work.

[Ashley Agan MD]
Well, I think we could probably go on and on about this. But, as we round it out, is there anything that we have left out as far as the workup and management of the adult dysphasia patients, anything you want to leave our listeners with?

[Theresa Richard SLP]
I think we pretty much covered it all. I think it's just so important to really, figure out what the patient wants and what sort of their swallowing and eating rituals look like before this impairment or sickness or illness happened. Because sometimes we try to fix things that weren't broken to begin with. Or we have these ideas what is important in our culture and may be totally different to a different family. So, really, I think that's paramount. And first and foremost, obviously getting the swallow studies is so important as well. You guys are doctors, you know the importance of instrumentation and it's just so tough when we hear administrators saying, well, we don't want to pay for those tests or, can't you just tell if they're aspirating? No, you can't like, there's no explanation other than no, you don't have x-ray vision. So, as much as you can help us and advocate to get those tests done, it is really what's best for the patient.

[Ashley Agan MD]
Yeah. Awesome. Well, thank you so much for taking the time and listeners, please check out Theresa on her podcast, “Swallow Your Pride,” her book, So You're Having Trouble Swallowing. Are you on any social media?

[Theresa Richard SLP]
I am. I'm mostly on Instagram. Theresa Richard SLP is my name on there. I think I'm on Twitter. Sometimes I'm on Facebook, but Instagram is usually where I am.

[Ashley Agan MD]
Awesome. Check out Theresa y'all.

[Gopi Shah MD]
Thank you, Theresa.

Podcast Contributors

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.

Cite This Podcast

BackTable, LLC (Producer). (2022, May 10). Ep. 59 – Feeding Difficulties in Adults [Audio podcast]. Retrieved from https://www.backtable.com

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.