Clinicians are often faced with the question of whether to allow an acute care patient to return to oral feeding. Historical, physical, and instrumental testing markers can provide guidance so that you can make an appropriate decision as to whether your patient can successfully resume safe oral ingestion.
“Ben” is a 72-year-old male with a past history of congestive obstructive pulmonary disease (COPD). He was recently admitted to the ICU, intubated, and put on a respirator. Unfortunately, Ben failed intubation, and on the third day after he was admitted, he had to be tracheotomized. During this period, Ben has been fed through a nasogastric tube.
By the seventh day of his hospitalization, his doctors call you in for a speech-language pathology consult to see whether he can return to oral feeding.
Before you can make this decision, there are a few details to consider:
- COPD often interferes with swallow safety in the acute exacerbation stage.
- Patients who have COPD are often fragile and may have generalized weakness that affects their swallow function.
- Ben’s tracheotomy tube may interfere with swallow pressures and upper airway sensitivity.
The Physical Examination
Your examination produces the following findings:
- Ben is able to vocalize without occluding his tracheotomy.
- His oral-peripheral and mental status are within normal limits.
- His oxygen saturation levels are at 97 percent.
Based on this information, you decide to send Ben for a videofluorographic swallowing study, where he is given 15 cc of thickened barium and 20 cc of pudding thick barium. You can review Ben’s swallow study below. What do you find?
Videofluorographic Swallow Study Results
The swallow study reveals that:
- On most bolus volumes, there was pharyngeal residue without post-swallow threat to the airway.
- On some boluses, there was airway penetration without aspiration.
- On some swallows, when the material was at the vocal fold level, there was a cough-and-clear response.
- Ben’s laryngeal elevation in the anterior plane was reduced.
- In general, Ben’s swallows became more normal as the study progressed.
Making the Decision
Based on the physical evaluation and the imaging study results, you make the call to start Ben on a soft mechanical diet with thickened fluids.
What markers led you to this decision?
- Ben’s apparent normal vocal cord function and mental status, which you identified during the physical examination
- Ben’s normal oxygen saturation levels
- Ben’s apparently stable medical status, given that his doctor was recommending the chance to return to oral feeding
- The adequate airway protection revealed by the videofluoroscopic swallow study
Ben’s return to oral feeding is a success, and not long after, he is discharged to a skilled nursing facility for post-acute care.
What are the key takeaways from this case study?
- Acute care patients with a tracheostomy may have reduced sensitivity in the upper airway; therefore, they are at a greater risk for events of silent aspiration. This in turn means that it’s important that they receive an instrumental evaluation to rule out any silent aspiration.
- When reinstating oral feeding in patients with COPD, it is important to watch them for an entire meal as the fatigue involved in eating may interfere with normal respiratory cycles and subsequently affect airway protection.
You can learn more about decision-making regarding the return to oral feeding in the MedBridge course, “Medical and Ethical Dilemmas: Nutrition for Adults with Dysphagia.”
- Gross, R. D., Atwood Jr., C. W., Ross, S. B., Olszewski, J. W., & Eichhorn, K. A. (2009). The coordination of breathing and swallowing in chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 179(7): 559–65.
- Crary, M. A. & Groher, M. E. (2006). Reinstituting oral feeding in tube-fed adult patients with dysphagia. Nutrition in Clinical Practice, 21(6): 576–86.