Swallowing Techniques For Stroke Patients: A Guide

Stroke patients often experience swallowing difficulties, known as dysphagia, which can cause serious complications such as malnutrition, dehydration, and aspiration pneumonia. Dysphagia is caused by impaired control of the muscles in the throat responsible for swallowing, and it can range from minor difficulties to a complete inability to swallow. Treatment options include rehabilitative exercises, compensation techniques, and complementary treatments, with most patients recovering within weeks or months. Speech-language pathologists play a crucial role in diagnosing and treating dysphagia, working closely with patients to improve their swallowing function and ensure safe eating and drinking practices.

Recognising signs of dysphagia

Recognising the signs of dysphagia is important to prevent serious complications such as malnutrition, dehydration, and aspiration pneumonia. Here are some key signs to look out for:

• Coughing or choking when eating or drinking: This is one of the most common signs of dysphagia. If a person coughs or chokes while swallowing, it could indicate that food or liquid is entering their airway instead of their oesophagus.
• Gagging or coughing when swallowing: Similar to coughing or choking, gagging can be a sign that the swallowing process is impaired, and food or liquid is going down the wrong way.
• Food or drink going down the "wrong way": If food or drink enters the airway instead of the oesophagus, it can cause a person to cough or choke. This is a sign that swallowing reflexes are not functioning properly.
• Feeling that food is stuck in the throat or chest: This sensation can indicate that food is not passing through the oesophagus normally, and may be stuck in the throat or upper chest area.
• Inability to control saliva in the mouth: Dysphagia can sometimes cause a person to drool or have difficulty managing their saliva, which is often a sign of impaired oral muscle control.
• Recurrent pneumonia: Aspiration pneumonia can occur when food or liquid enters the lungs, leading to bacterial infections. Stroke survivors with dysphagia are at a significantly higher risk of developing aspiration pneumonia.
• Weight loss: Over time, swallowing problems can lead to weight loss, as the person may not be able to consume enough nutrients. This can also indicate other health issues.
• Difficulty controlling food in the mouth: Dysphagia can make it difficult for a person to manage food in their mouth, chew effectively, or move food to the back of the mouth for swallowing.
• Difficulty starting the swallowing process: In some cases, a person with dysphagia may have trouble initiating the swallowing reflex, which can lead to food or liquid aspiration.

It is important to note that dysphagia can vary in severity and may present with different symptoms in different individuals. If you or someone you know is experiencing any of these signs, it is important to seek medical advice, especially if the symptoms persist or affect the person's ability to eat, drink, or breathe normally.

Swallowing assessments

Initial Assessment:

When a stroke patient presents with swallowing difficulties, an initial assessment should be conducted within four hours of their arrival at the hospital. During this assessment, the patient should not be given any food, drink, or medication by mouth until their swallowing function has been evaluated. The assessment typically begins with the patient attempting to swallow a small amount of water, followed by food and drinks of varying consistencies, to determine their ability to swallow safely.

Videofluoroscopy:

Videofluoroscopy, also known as a video fluoroscopic swallowing study (VFSS), is a diagnostic tool that involves taking a video X-ray of the patient's mouth and throat while they swallow. The patient is positioned beside an X-ray machine and given different foods and drinks mixed with barium, a contrast agent that shows up on the X-rays. This allows physicians to observe, record, and analyse the swallowing process, including the passage of food and liquid through the throat and oesophagus, as well as the presence of aspiration (food or liquid entering the airway).

Fibreoptic Endoscopic Evaluation of Swallowing (FEES):

FEES is another diagnostic technique that uses an endoscope, a long, thin, flexible tube with a light and a tiny camera at the end, inserted through one of the nostrils and down the throat. This allows the therapist to visualise the pharynx and larynx, providing valuable information on the condition of these structures and the associated muscles during swallowing. FEES can be performed at the bedside and does not expose the patient to radiation, but it is less effective at evaluating the oral phase of swallowing and is not as quantitative as videofluoroscopy.

Additional Assessments:

If a patient's swallowing function changes during their recovery, they can request additional swallowing assessments to re-evaluate their condition. These assessments are important to ensure the patient's safety and adjust their treatment plan accordingly. If a patient is unable to swallow, they will be given fluids through a drip to prevent dehydration, and their medical team may also consider tube feeding to ensure adequate nutrition.

In summary, swallowing assessments are a critical component of managing dysphagia in stroke patients. They help identify the presence of aspiration, determine the patient's ability to swallow safely, and guide the development of a treatment plan that may include dietary modifications, swallowing exercises, and tube feeding if necessary.

Changing how you eat and drink

Swallowing is a complex task that requires the brain to coordinate many different muscles. If a stroke patient has dysphagia, or swallowing difficulties, they may need to make changes to how they eat and drink. Here are some tips to help with this transition:

• Drink thickened liquids: Thickened drinks move slower than thin liquids, reducing the risk of choking or aspirating. These can be made using special powders to achieve the right consistency. Chilled or flavoured drinks can also make thicker liquids more enjoyable.
• Eat soft or pureed foods: Soft foods are easier to chew and swallow, ensuring adequate nutrition and preventing malnutrition. A speech-language pathologist or therapist can advise on the right texture.
• Change the temperature: Hot foods and drinks can be difficult to swallow as they cannot be held in the mouth for long. Opting for cold foods or allowing hot foods to cool down can make swallowing easier.
• Eat small meals throughout the day: Eating smaller amounts more frequently can be beneficial if concentration or energy levels are low. Smaller portions are generally easier to manage and eating earlier in the day when energy levels are higher may be preferable.
• Sit up straight: Eating or drinking in a position that isn't upright increases the chances of choking or aspirating. Maintaining a straight back and keeping the feet flat on the floor while seated can aid in safer swallowing.
• Take small bites and sips: This reduces the risk of choking and ensures that food is sufficiently chewed before swallowing.
• Avoid distractions: It is important to focus on eating without distractions. Turn off the TV or create a quiet, private space to facilitate better concentration during mealtimes.
• Use positioning techniques: Your medical team or speech-language pathologist can advise on specific positions or movements that make swallowing safer and easier.
• Practice swallowing exercises: Working with a speech-language pathologist to practice swallowing exercises can help improve oral motor control and strengthen the muscles involved in swallowing.

It is important to work closely with a speech-language pathologist or therapist to determine the best diet and swallowing techniques for your specific needs. They will guide you through the process and make recommendations to ensure safe and effective swallowing.

Tube feeding

NGT feeding is typically preferred for short-term feeding during the acute phase of a stroke. It is easily placed at the bedside and is less invasive than other methods. However, it can be challenging to insert and may be dislodged by agitated or confused patients, leading to potentially fatal complications.

On the other hand, a PEG tube is considered a more secure method for long-term nutritional support. It is inserted directly into the stomach through a small hole in the skin. While PEG tube feeding is generally safe and comfortable for the patient, it is an invasive procedure that carries a higher risk of morbidity and mortality.

The decision to use tube feeding, especially long-term PEG tube feeding, can be distressing for patients, their families, and physicians due to cultural, ethical, and religious beliefs. Additionally, there is a lack of clinical data on the outcomes of PEG tube feeding, making it a challenging decision.

To ensure the best outcome for the patient, it is crucial to evaluate the clinical benefits, risks, and burdens of long-term nutrition. It is also essential to involve the patient and their family in the decision-making process, taking into account their life goals and end-of-life goals. While tube feeding can be life-saving, it is important to consider the potential risks and burdens associated with this intervention.

Exercises to strengthen swallowing muscles

Swallowing is a complex motor skill that requires the coordination of many different muscles. If a stroke patient has dysphagia, or difficulty swallowing, they may benefit from doing different swallowing exercises to improve their swallowing muscle strength and coordination. These exercises can be done at home but should be learned first under the care of a medical professional, such as a speech-language pathologist, who can guide the person through the exercises and advise on how to perform them correctly.

• Effortful Swallow: Gather saliva in the middle of your tongue, keep your lips pressed together, and swallow all the saliva at once as if swallowing a grape or a pill.
• Head Lift: Lie on your back on a flat surface with your shoulders against the surface and no pillow or headrest. Keeping your shoulders on the surface, lift your chin as if trying to look at your feet, then lower your head back down. Repeat this 30 times, rest for 2 minutes, then repeat as many times as indicated by a medical professional.
• Jaw Push: Push your lower jaw as far forward as possible, placing your lower teeth in front of your upper teeth. Hold this position for as long as determined by your doctor or physical therapist, and repeat as many times as indicated.
• Tongue Hold: Stick your tongue out of your mouth and bite down on it gently to keep it in place. Swallow while holding your tongue between your teeth, then release. Repeat as many times as indicated by a medical professional.
• Mendelsohn Maneuver: Locate your Adam's apple by pressing your fingers on your neck. Swallow and notice how your Adam's apple moves up and down. Swallow again, but this time squeeze your throat muscles to hold your Adam's apple at its highest point. Hold for as long as indicated by your doctor or as long as you can.
• Supraglottic Maneuver: Take a deep breath and hold it. Swallow while holding your breath, then immediately cough. Once you have practised this with saliva, try with food or drink, as directed by a medical professional.
• Hyoid Lift Maneuver: Place a drinking straw in your mouth and suck on it to pick up pieces of paper. Keep the suction strong enough to carry each piece of paper over to a cup and let it fall. Repeat until all pieces of paper are in the cup. Start with 3-5 pieces of paper and work up to 10.

These exercises can help stroke patients strengthen their swallowing muscles and improve their swallowing function over time.

Frequently asked questions