The Pulse

Part 1: Ethics and Considerations in Patient and Caregiver Perspectives

Speech-language pathologists (SLPs) are commonly involved in the rehabilitation of patients with cardiopulmonary disorders. Patients hospitalized with respiratory diseases such as COPD and heart failure (HF) are identified as at risk for development of oropharyngeal dysphagia. Additionally, patients who experience prolonged endotracheal intubation have an increased risk of developing dysphagia. (Malandraki et al., 2016) This is often seen in patients hospitalized for COVID-19.

Patient Information: Male, Age 65

Diagnosis: Stroke / Oropharyngeal Dysphagia

History: This gentleman was admitted to a skilled nursing facility for rehabilitation services following hospitalization due to a stroke. He was diagnosed with oropharyngeal dysphagia (difficulty swallowing). His swallow initiation was inconsistent and he had difficulty managing his own secretions. He could not take any food or liquid by mouth and a feeding tube was placed. Prior to his stroke, he ate a regular diet.

Patient Information: Female, Age 69

Diagnosis: Heart Failure / Dysphagia

History: This woman, a long-term rehab center resident, was admitted to the hospital due to heart failure which resulted in dysphagia (difficulty swallowing). A feeding tube was placed and she was not allowed to eat or drink by mouth. Following hospitalization, she was referred to speech therapy with a goal to return to eating a regular diet and drinking thin liquids independently in the dining room.

As speech-language pathologists (SLPs) we often make diet recommendations. The unfortunate reality is we have scant information to direct these decisions. There is some evidence concerning the impact of volume and viscosity on swallowing kinematics (Barikroo, 2015; Chi-Fishman, 2002; Miller, 1996; Nagy, 2015; Watts, 2015). However, a systematic review (Steele, 2015) revealed little evidence to guide practice with respect to different degrees of modifying solid foods for patients with dysphagia. This means SLPs must rely on the sound understanding of the mastication process to make these decisions. Unfortunately, the system is quite complex and difficult to evaluate. This article represents the first of a series related to mastication that will address how mastication works and some possible assessment methods. Armed with this knowledge, SLPs may formulate more informed recommendations as part of a comprehensive patient care plan.

In the previous two articles in this series we examined the evidence concerning the clinical indictors of coughing and a runny nose. The conclusion was, both indicators provide us with weak information concerning swallowing function. In this edition, the evidence for wet vocal quality as a meaningful clinical finding will be discussed.

Patient Information: Male, Age 77

Diagnosis: Oropharyngeal Dysphagia / Hypoxic Respiratory Failure / Childhood bulbar polio
with paralyzed vocal cord

Therapist have often relied upon “clinical signs” to assist in determining if a patient is experiencing aspiration. Those signs have included coughing (see "Cough Up The Facts"
previous blog post), throat clearing, wet vocal quality, runny nose, and many others. There is very little empirical evidence to support the correlation of “clinical signs” to an episode of aspiration. A runny nose is often considered to be a salient sign of aspiration; perhaps this is an over generalization.

Speech Pathologists who treat dysphagia often rely on a patient’s cough as a marker of aspiration. Other healthcare professionals have been educated that coughing is a sign of swallowing difficulty. How accurate is this statement in the geriatric population and what are other reasons a patient may be exhibiting a cough?

As speech language pathologists, we are all familiar with the word “competence.” After a good deal of time invested in educational pursuits followed by a nine-month period of supervision, we are awarded our Certificate of Clinical Competence (CCC) from the American Speech Language and Hearing Association (ASHA). The reality is, when I received my CCC, I could hardly consider myself competent in any area of practice.