Post-intubation dysphagia is a difficulty swallowing that occurs after a patient’s breathing tube (endotracheal tube) is removed, often following mechanical ventilation. The presence of the tube can interfere with the function of the muscles and nerves involved in swallowing. While often temporary, this condition requires careful management to prevent complications like malnutrition, dehydration, and aspiration pneumonia, which occurs when food or liquid enters the lungs.
Diagnostic Evaluation for Swallowing Issues
The first step in addressing post-intubation swallowing difficulties is a thorough evaluation led by a Speech-Language Pathologist (SLP). The process begins with a bedside swallow evaluation (BSE), where the SLP observes the patient managing small amounts of food and liquid. This assessment helps identify obvious signs of dysphagia, such as coughing, choking, or a wet-sounding voice after swallowing.
For a more detailed view of the swallowing mechanism, instrumental assessments are used. One test is the Fiberoptic Endoscopic Evaluation of Swallowing (FEES), which involves passing a thin, flexible tube with a camera through the nose to the throat. This allows the SLP to directly visualize the larynx and pharynx as the patient swallows.
Another diagnostic tool is the Videofluoroscopic Swallow Study (VFSS), also known as a modified barium swallow. During a VFSS, the patient consumes food and liquid mixed with barium, a substance that appears on X-rays. This moving X-ray image allows the medical team to see the entire swallowing process, from the mouth to the esophagus, and to pinpoint where a breakdown is occurring.
Swallowing Rehabilitation and Exercises
After diagnosis, a primary goal is to rehabilitate the muscles and coordination for a safe swallow. An SLP prescribes specific exercises to strengthen the structures affected by intubation. These therapies aim to restore the physiological function of the swallow, not just manage the symptoms.
One exercise is the Mendelsohn maneuver, designed to improve the upward movement of the larynx (voice box) and help open the top of the esophagus. The patient initiates a swallow and consciously holds the larynx in its elevated position for several seconds before completing the swallow. This action helps prolong and strengthen the laryngeal elevation.
Another technique is the effortful swallow, where the patient swallows their saliva or a small amount of liquid as forcefully as possible. This exercise increases the pressure and movement of the tongue base as it pushes food and liquid through the pharynx (throat). The goal is to improve swallow efficiency and reduce residue left in the throat.
The Masako maneuver, or tongue-hold, targets the muscles in the back of the throat. To perform this, the patient gently holds the tip of their tongue between their teeth and swallows. This action forces the pharyngeal muscles to work harder to move food backward, thereby strengthening them.
Compensatory Strategies and Techniques
While exercises restore function long-term, compensatory strategies make swallowing safer immediately. These techniques are adjustments that redirect food and liquid flow to reduce aspiration risk. Unlike exercises, these strategies do not strengthen muscles but work around the existing impairment.
A recommended strategy is the chin tuck, where the patient tucks their chin toward their chest before and during the swallow. This posture narrows the airway entrance, making it harder for food or liquid to enter the lungs. It also widens the vallecular space at the base of the tongue, giving food more time to travel safely through the pharynx.
For individuals with weakness on one side of the throat, a head turn may be advised. The patient turns their head toward the weaker side, which closes off that side of the pharynx and directs food down the stronger side. This postural change can improve the safety and efficiency of the swallow.
Another technique is to alternate solid and liquid swallows during a meal. Taking a sip of liquid can wash down any food residue left in the throat after a bite of solid food. This helps ensure the pharynx is clear before the next bite.
Dietary and Texture Modifications
Managing post-intubation dysphagia involves modifying food textures and liquid thickness to make them safer to swallow. These changes adapt what a person eats and drinks to match their current swallowing ability, as determined by an SLP.
For significant difficulty, a puréed diet may be recommended, with foods blended to a smooth, pudding-like consistency. As function improves, the diet may advance to minced and moist (soft, finely chopped foods) and then to a soft diet of foods that are easy to chew. These modifications reduce the effort and risk of choking.
Liquids are more challenging to control than solids because they move quickly. To slow them down, liquids may be thickened to consistencies like nectar-thick or honey-thick, giving the patient more time to swallow safely. Commercial thickening agents are used to achieve the prescribed consistency for all beverages.
Medical and Surgical Interventions
For patients with severe or persistent dysphagia that does not resolve with therapy and dietary changes, medical or surgical interventions may be considered. These options are for cases where conservative management has not been sufficient. The goal is to improve the swallowing mechanism’s physical structure or provide alternative nutrition.
One medical procedure is pharyngeal augmentation, which involves injecting a substance like collagen into the vocal folds or pharynx walls. This can “bulk up” weakened or atrophied tissues, allowing for better airway closure or improving contact to move food through the throat. This is used when a gap in the vocal folds prevents them from closing completely.
In more complex cases, surgical procedures may be an option to enhance airway protection. These interventions are less common and are tailored to the specific anatomical problem.