Management of dysphagia

It is gratifying to see attention paid to the nutritional status of stroke patients with dysphagia, an often overlooked aspect of care.¹ However, it is unfortunate that Hillel Finestone and Linda Greene-Finestone promulgate some of the misperceptions that abound in the area of managing patients with a swallowing disorder.

One of the most distressing errors, which often leads to inappropriate management, appears in the article title.¹ Dysphagia cannot be “diagnosed.” Rather, it is a symptom of several hundred conditions and cannot be managed properly without identification of the source. Dysphagia has come to be discussed as though it were a disease in and of itself, which leads to the misperception that there is a standard approach to its management. This has in turn led to various inappropriate strategies for care,² including some that contribute significantly to dehydration,³ as the authors have noted elsewhere.⁴ Where Finestone and Greene-Finestone refer to “overnight intravenous fluid administration,”¹ it is to be hoped that they mean hypodermoclysis, the long-term hydration method of choice.⁵

The case presented¹ illustrates the most problematic of all issues associated with oropharyngeal dysphagia: aspiration. The patient in this case is described as having “pneumonia” in both lungs on the day of admission (also the day of insult). However, this is clearly a case of aspiration pneumonitis, caused by inhalation during the reported vomiting, not bacterial pneumonia requiring antibiotics.^6,7,8,9 Antibiotic therapy, as mentioned in the case description, might well be prophylactic against the secondary bacterial infection that often occurs but would not be effective for chemical pneumonitis. Secondary pneumonia is most often caused by aspiration of saliva, an event that also occurs in healthy adults and that is best avoided by scrupulous mouth care.¹⁰

In the final section, “The case revisited,” the authors state that “Mr. B's pneumonia is a strong indicator that aspiration occurred. His pneumonia is a probable sequela of aspirating saliva. Mr. B is not allowed to have anything by mouth when he is admitted to hospital.”¹ Finestone and Greene-Finestone have missed the obvious at several levels. The patient's “pneumonia” on admission was certainly the result of aspiration but could not have been due to aspiration of saliva (bacterial pneumonia). The solution is not to give him nothing by mouth but instead to identify the real cause of the problem and ensure scrupulous mouth care while maintaining good nutrition and hydration.

Of the remaining misperceptions, one in particular requires mention: there is no relation between the presence or absence of a gag reflex and the ability to swallow.¹¹

Irene Campbell-Taylor Clinical Neuroscientist University of Toronto Toronto, Ont.