Evaluación y Manejo de la Disfagia

Clasificación y Evaluación Inicial

• La disfagia afecta hasta el 22% de los adultos en atención primaria y es más común en adultos mayores, representando estos últimos hasta dos tercios de todos los casos 1, 2

Evaluación de la Disfagia Orofaríngea

• Evaluar cierre labial, acumulación de saliva, fuerza y movilidad lingual, capacidad de masticación, movimiento palatino, calidad y fuerza de la tos y función foniatría 3
• Utilizar cuestionarios estructurados como el EAT-10, que ofrece alta capacidad discriminatoria para identificar pacientes con aspiración (sensibilidad 86%, especificidad 76%) 3
• Realizar pruebas de deglución con agua o el Test de Volumen-Viscosidad (V-VST), que tiene una sensibilidad del 92% y especificidad del 80% para detectar disfagia en comparación con la videofluoroscopia 3

Evaluación Instrumental

• La videofluoroscopia permite evaluar la manipulación del bolo, movimiento lingual, elevación hioidea, laríngea y faríngea, elevación del paladar blando, movimiento constrictor faríngeo, inclinación epiglótica, penetración laríngea y función del músculo cricofaríngeo 4
• La evaluación endoscópica de la deglución por fibra óptica (FEES) puede realizarse a la cabecera del paciente e implica el paso transnasal de un nasofaringoscopio flexible para observar directamente la faringe y laringe antes y después de la deglución 5, 6

Evaluación de la Disfagia Esofágica

• El esofagograma bifásico permite la detección de anomalías estructurales y funcionales del esófago, incluyendo esofagitis, estenosis, anillos y carcinoma, y tiene una sensibilidad del 96% en el diagnóstico de cáncer de esófago o de la unión gastroesofágica 7
• La gammagrafía puede ser útil para evaluar el tránsito esofágico utilizando sustancias marcadas con Tc-99m en forma líquida, semisólida o sólida 1, 4

Manejo de la Disfagia

• Los pacientes con disfagia deben someterse a evaluación por videofluoroscopia o FEES para identificar el tratamiento apropiado 6
• En pacientes con disfagia leve a moderada, considerar estudios radiográficos no invasivos como el esofagograma de bario para determinar la necesidad de endoscopia 8, 9
• Las indicaciones para endoscopia inmediata incluyen incapacidad para tolerar una dieta líquida suficiente con deshidratación continua, pérdida de peso profunda, y cuerpo extraño o impactación alimentaria con incapacidad para tolerar secreciones 8, 9

Consideraciones Especiales

• Es importante reconocer que una persona puede tener un trastorno de deglución asintomático, y en un estudio de 2,000 pacientes evaluados con exámenes videofluoroscópicos, el 51% aspiraba, pero de estos, el 55% presentaba aspiración silente con ausencia del reflejo de tos protector 1, 4
• En pacientes con disfagia orofaríngea inexplicada, la combinación de videofluoroscopia e imágenes estáticas de la faringe con un examen del esófago tiene un valor diagnóstico más alto que cualquiera de estos estudios por separado 7

Management of Dysphagia

Assessment and Diagnosis

• The American Geriatrics Society recommends that the management of dysphagia requires a comprehensive evaluation followed by targeted interventions, with early involvement of a Speech-Language Pathologist being critical for optimal outcomes 10
• Dysphagia affects up to 22% of adults in primary care settings, with adults over 65 accounting for up to two-thirds of all cases, according to the American College of Radiology 11

Instrumental Assessment

• The American Geriatrics Society suggests that Videofluoroscopic Swallowing Study (VFSS) is the most common instrumental assessment for dysphagia, allowing visualization of bolus manipulation, tongue movement, hyoid/laryngeal elevation, pharyngeal constriction, and aspiration 10, 12
• Fiberoptic Endoscopic Evaluation of Swallowing (FEES) can be performed at bedside and allows direct visualization of pharyngeal and laryngeal structures before and after swallowing, as recommended by the American Geriatrics Society 10, 12

Management Strategies

Compensatory Approaches

• The American Geriatrics Society recommends oral care interventions to reduce the risk of pneumonia and fatal pneumonia in non-ventilated patients with dysphagia, though evidence has high risk of bias 10, 12
• Postural techniques, such as chin-down (chin-to-chest) posture, are beneficial in most cases as they protect airways by opening the valleculae and preventing laryngeal penetration, according to the American Geriatrics Society and Clinical Nutrition 10, 12, 13
• Dietary modifications, such as adapting food textures and using thicker liquids, can compensate for poor oral preparation and ease pharyngeal transport, as recommended by Clinical Nutrition 13
• The International Dysphagia Diet Standardisation Initiative (IDDSI) framework provides standardized food and liquid texture modifications, as recommended by the American Geriatrics Society 10, 12

Rehabilitative Approaches

• Speech-Language Pathologists can provide swallowing maneuvers like effortful swallow to improve pharyngeal pressure generation, as recommended by the American Geriatrics Society 10, 12
• Cognitive-behavioral approaches, such as identifying and challenging beliefs and addressing maladaptive behaviors, may be beneficial for functional dysphagia, according to the Journal of Neurology, Neurosurgery and Psychiatry 14

Special Considerations

• For patients with ALS and dysphagia, fractionating and enriching meals with energy or deficient nutrients, adapting food texture, and using chin-tuck posture can help manage dysphagia, as recommended by Clinical Nutrition 13

First‑Line Management of Dysphagia with Oral Medications

Initial Assessment and Safety Screening

• Screen swallowing function immediately before any oral medication using a validated dysphagia screening tool performed by a speech‑language pathologist or trained provider. This rapid assessment helps identify patients at risk for aspiration prior to drug administration. 15
• Place the patient on strict nil‑by‑mouth status for all oral intake, including medications, until the swallowing assessment is completed. This prevents inadvertent aspiration while the airway safety is being evaluated. 16

Pharmacist Consultation & Alternative Formulations (First Priority)

• Obtain a pharmacist‑led review to identify commercially available alternative dosage forms such as liquid suspensions, elixirs, orally disintegrating tablets, transdermal patches, sublingual formulations, or rectal suppositories. Using these alternatives avoids the dose loss and pharmacokinetic alterations that occur when solid tablets are crushed. 17

Instrumental Evaluation (Third Priority)

• Perform a videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) for patients who, based on bedside screening, are at risk for pharyngeal dysphagia or have poor airway protection. These imaging studies delineate which consistencies can be safely swallowed. 18
• Use the findings from VFSS/FEES to determine safe liquid and solid consistencies and to guide specific compensatory strategies (e.g., postural adjustments, diet modifications). This evidence‑based approach tailors therapy to the individual’s physiologic deficits. 19

Silent Aspiration Risk

• Do not rely on a preserved gag reflex as an indicator of safe swallowing; up to 55 % of patients who aspirate do so silently without a protective cough, highlighting the need for objective screening. 16

Alternative Routes When Oral Administration Is Unsafe

• Initiate nasogastric tube feeding for short‑term (2–3 weeks) medication delivery when oral intake remains unsafe after assessment. This provides a temporary route for essential drugs while the swallowing problem is addressed. 15
• Place a percutaneous endoscopic gastrostomy (PEG) tube for prolonged medication delivery in patients requiring long‑term alternative access; however, clinicians must still select appropriate medication formulations to avoid tube clogging and altered pharmacokinetics. [15][16]