Management of Oropharyngeal Dysphagia with Increased Secretions

Initial Assessment and Referral

The American Thoracic Society recommends referring patients with oropharyngeal dysphagia and increased secretions immediately to a speech-language pathologist for comprehensive swallow evaluation, followed by multidisciplinary team management 1, 2
Patients presenting with coughing or choking during meals should be referred to a speech-language pathologist for oral-pharyngeal swallow evaluation 1
The American Geriatrics Society suggests that patients with wet vocal quality after swallowing, poor secretion management, nasal regurgitation of food, or weak cough should be referred for evaluation 3
Clinical bedside evaluation alone is insufficient, especially in older adults, as silent aspiration occurs in over 70% of patients whose aspiration is detected on videofluoroscopy 4

The American College of Chest Physicians recommends that all patients with dysphagia undergo videofluoroscopic swallow evaluation (VSE) or fiberoptic endoscopic evaluation of swallowing (FEES) to identify appropriate treatment 1, 2, 5
Instrumental studies serve dual purposes: diagnosis and treatment planning, providing critical information that cannot be obtained from bedside evaluation alone 2, 5

A multidisciplinary team approach, including a physician, speech-language pathologist, nurse, dietitian, and physical and occupational therapists, has demonstrated substantial clinical benefit, with reduction in aspiration pneumonia and trend toward decreased mortality 1, 2, 5
The team should include a pharmacist when applicable, and consider early gastrostomy placement in patients with progressive weight decline or uncontrolled aspiration risk 4, 5, 6

Postural maneuvers, such as chin-down position, head rotation, head tilt, and lying down position, can eliminate aspiration in 77% of patients during videofluoroscopic evaluation 2, 5
Dietary modifications, including thickened liquids and standardized texture modifications using the International Dysphagia Diet Standardisation Initiative (IDDSI) framework, can reduce aspiration risk 5, 6
For patients with increased secretions, thickening liquids can address difficulties with thin liquids 4

Patients with reduced level of consciousness should not be fed orally due to high risk of aspiration, and should remain NPO until consciousness improves 1
Monitoring for signs requiring urgent re-evaluation, such as recurrent pneumonia, progressive weight loss, worsening respiratory symptoms, and development of silent aspiration, is crucial 3, 4, 5

Assuming absence of cough means safe swallowing is incorrect, as silent aspiration is common 4
Delaying instrumental assessment in favor of prolonged bedside evaluation alone can lead to inadequate management 3
Implementing dietary modifications without instrumental confirmation of their effectiveness can be ineffective 2, 5
Managing patients in isolation, rather than with a multidisciplinary team approach, can significantly worsen outcomes 1, 2

The American Geriatrics Society recommends referring patients with symptoms such as coughing or choking during meals to a speech-language pathologist for comprehensive evaluation, and considering a pharmacist for medication review, particularly for medications that may worsen dysphagia 7

The American College of Physicians suggests that chin tuck against resistance in addition to conventional dysphagia therapy improves oropharyngeal swallow function and reduces aspiration in poststroke dysphagia, targeting suprahyoid musculature critical for hyoid and laryngeal movement and upper esophageal sphincter opening 8, 9
Respiratory muscle strength training decreases aspiration in patients without tracheostomy by strengthening muscles of respiration through resistance training 8, 9