Modified Mondays: Secretion Depletion
Dried secretions can occur in both the oral cavity and the pharynx. The oral cavity secretions can be directly visualized during a clinical swallow evaluation, but to determine if pharyngeal secretions are present, you need an instrumental swallow evaluation. While FEES has been known to be a better test for assessing secretions, MBSS can sometimes determine if secretions are present as well.
For this Modified Monday we have a patient who was NPO. During the beginning of the test, he complained that his mouth was dry, but he was unaware that it didn’t stop at his oral cavity. He had dried secretions built up in his pharynx as well. The scout image revealed a thickened, shaded area around the NG tube in the pharynx. After water was provided, this shaded area started to change configuration and separated from the NG tube. There was also a diffuse and jagged barium coating in the pharynx. When barium catches like this and isn’t smooth, it can be an indication that barium is coating dried secretions. For this particular person, sips of water assisted in dislodging the secretions, and the patient expectorated and was suctioned. Following this, the majority of the pharynx was clear.
This begs the question, could this patient have had ice chips or sips of water to help prevent the dried thick secretions? We see here the benefit of having water was clearly revealed when the dry material was loosened and expectorated just after a couple sips of liquid. And even though the team also saw trace aspiration of thin liquids (not seen in this clip), dry secretions in the pharynx could significantly harbor harmful bacteria, which poses a risk to the patient. This bacteria could easily migrate into the airway. Is there a better option? Yes, the better option is whichever the patient chooses. The patient should be presented with the fact that strict NPO does not clear him from getting respiratory infections and that there appears to be minimal risk of respiratory issues when having small amounts of water or ice chips (after thorough oral care). Another important point to tell the patient is that if he doesn’t swallow as often, this could lead to further decline. With water or ice available, the patient will be able to swallow with increased frequency. After providing the information, the patient can make an informed decision.
(PDF) The Ice Chip Protocol: A Description of the Protocol and Case Reports (researchgate.net)
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Comparison of outcomes before and after implementation of a water protocol for patients with cerebrovascular accident and dysphagia - PubMed (nih.gov)
Implementation and Analysis of a Free Water Protocol in Acute Trauma and Stroke Patients | Critical Care Nurse | American Association of Critical-Care Nurses (aacnjournals.org)