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.

Introducing Ben

"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?

  1. Ben's apparent normal vocal cord function and mental status, which you identified during the physical examination
  2. Ben's normal oxygen saturation levels
  3. Ben's apparently stable medical status, given that his doctor was recommending the chance to return to oral feeding
  4. 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?

  1. 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.
  2. 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."

Michael Groher, PhD, F-ASHA

Michael Groher, PhD, F-ASHA, Honors ASHA

Michael Groher is an emeritus professor of the Department of Communicative Disorders at the University of Redlands in Redlands, California. Dr. Groher has spent most of his career working as a medical speech pathologist in acute and long-term care settings. The majority of his hospital work was done for the Department of Veterans Affairs in Seattle/Tacoma, New York, and Tampa. He is best known for his pioneering work with patients who have swallowing disorders.

The majority of his work is summarized in three texts: Dysphagia: Diagnosis and Management (three editions), Introduction to Adult Swallowing Disorders, and Clinical Management of Dysphagia in Adults and Children, second edition. Dr. Groher is an ASHA Fellow and Honors recipient as well as a past founding associate editor for the journal Dysphagia. He is an honorary member of the Japanese Society of Dysphagia Rehabilitation.

  • 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.

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