it's not just about the swallow

When I was in graduate school, I thought that swallowing was fairly formulaic--3 phases, right? Oral, pharyngeal, and esophageal. Assess and improve each phase of swallowing and then the patient is on their way! 

Well, after a few days working in a hospital, I quickly learned that there was a lot more involved with swallowing than the 3 phases that I as an SLP is involved with. In fact, there are a lot of factors and disciplines that contribute to safe and functional swallowing/oral intake. 

Here are a few of the factors to be aware of:

-Physical/medical status: Patients that are in the hospital that have dysphagia have complicated medical statuses. You have to take into account their diagnosis and how that can impact your treatment. We as SLPs know some of the big diagnoses that can impact swallowing--stroke, TBI, respiratory failure, etc. However, there are other diagnoses that will impact treatment. What if a patient is recovering from a surgery or has a pressure wound that would preclude them from sitting upright at 90 degrees until further clearance from the doctor/nurses? What if a patient has consistently low blood pressure and if you sit them upright at 90 degrees, they may pass out. Furthermore, what if a patient has a GI issue such as an ileus that makes the patient inappropriate for PO trials until further clearance? There are a lot of things you have to consider related to medical status to see if the patient is appropriate for PO trials. 

-Cognitive/mental status: A lot of people don't understand that there is a large cognitive component to swallowing. If a patient is unable to stay awake during a therapy session or follow basic commands, will they be able to safely have PO intake, especially when unsupervised? What about a patient that is highly sedated? All these patients are at a high risk of choking and aspiration if they are unable to be alert/awake enough to participate in PO trials? Patients must be awake and alert enough to be safe. 

-Respiratory status: A patient's respiratory status is related to swallowing function. When a patient is at high risk of aspiration, their respiratory status can be indicative of their swallowing function. If a patient's lungs sound "crackly" or patient has an increase in O2 needs/change in respiratory status, that can be indicative of aspiration. When patients are on ventilators, it is especially important to check in with the respiratory therapy staff to see how a patient's respiratory status is. Any PO trials you as an SLP are performing can be harmful to respiratory status. If problems in breathing arise, this will impact your ability to safely treat. 

These are just a few things to be mindful of in a medical setting. A patient's diagnosis gives you important information that relates to your plan of care. When in doubt, check in with nursing staff or the doctor and respiratory therapy team before having the patient participate in PO trials. 

There is a lot more at bay than just swallowing function and you as an SLP need to be aware that what you do can be potentially harmful if you are not being mindful of the patient's whole medical status. 

Happy treating! 

Mallory